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How can we meet the health needs of child refugees, asylum seekers and undocumented migrants?
  1. Amy Jane Stevens
  1. The School of Public Health, Health Education England Yorkshire and the Humber, Leeds LS2 9JT, UK
  1. Correspondence to Dr Amy Jane Stevens, Health Education England Yorkshire and the Humber, Leeds LS2 9JT, UK; amyjanestevens{at}doctors.org.uk

Abstract

The numbers of people forcibly displaced from their homes because of conflict, persecution, natural disasters and famine is increasing globally, reaching 68.5 million at the end of 2017. Over half of the world’s refugees are children. Child refugees, asylum seekers and undocumented migrants are exposed to multiple risk factors for poor physical and mental health throughout their migration experience. International treaties and national legislation recognise child migrants’ ‘right to health’ and equitable access to healthcare, yet restrictive immigration policies, health system challenges and service provider barriers to care impede translation into practice. This review explores how the experiences of child refugees, asylum seekers and undocumented migrants in England impacts on their health and presents recommendations as to how their health needs can be met.

  • general paediatrics
  • children's rights
  • health service

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What is already known?

  • Child refugees, asylum seekers and undocumented migrants are at increased risk of poor physical and mental health.

  • They have a right to equitable access to disease prevention, health promotion and healthcare.

What this study adds?

  • Restrictive immigration policies, health system challenges and service provider barriers to care are having a negative impact on their health.

  • Immigration policy review and well-informed service providers would better enable the health needs of these child migrants to be met.

Introduction

The numbers of people forcibly displaced from their homes because of conflict, persecution, natural disasters and famine is increasing globally, reaching 68.5 million at the end of 2017.1 Fifty-two per cent of the world’s 25.4 million refugees are children with 173 800 of them being unaccompanied or separated.1 In 2017 the UK ranked as the eleventh largest recipient of new individual asylum claims.1 Of the 14 767 asylum seekers granted asylum, protection or resettlement in the UK that year, 5866 (40%) were children.2 The total number of undocumented child migrants in England is estimated to be over 120 000.3

Though frequently discussed in the same context there are important differences between refugees, asylum seekers and undocumented migrants in terms of legal rights.4 This is significant as legal rights determine immigration policy application and public service entitlement which impact health indirectly via influence on the wider determinants of health and directly via healthcare access. Population definitions are given in table 1.

Table 1

Population definitions52

The life experiences of child refugees, asylum seekers and undocumented migrants through all stages of migration make them more vulnerable to physical and mental health problems than children in the host population.5 While there has been research examining the health of child migrants, there has been limited critical evaluation of whether their needs are being met. This article seeks to address the evidence gap through literature review and evaluation of policy in England.

Although healthcare entitlements and support for child refugees, asylum seekers and undocumented migrants vary between countries, the health-influencing premigration and transit experiences of this population is comparable across Europe. Similarly, many European countries share England’s political and socioeconomic context of rising anti-immigration sentiment, nationalist values and social discontent in a time of austerity and public service cuts.6 Learning points from this article have international relevance.

Understanding life experiences to identify health needs

Child refugees, asylum seekers and undocumented migrants may be exposed to many factors that influence their health needs (table 2).7 8

Table 2

Factors influencing child health needs throughout all stages of migration

Box 1 highlights common physical and mental health needs based on an unpublished review of the literature (AJ Stevens, Masters dissertation, University of Manchester, 2018). While child refugees, asylum seekers and undocumented migrants experience some universal needs, each child’s own life narrative and personal resilience will uniquely impact on their individual requirements. They are not a homogenous group and service providers must recognise this.

Box 1

Common physical and mental health needs of child refugees, asylum seekers and undocumented migrants

  • Communicable diseases. These include communicable diseases associated with the asylum seeker’s originating country, those they migrated through and the living conditions they were exposed to. Parasitic disease, gastroenteritis, cholera, bacillary dysentery, typhoid, fungal infections, scabies, meningococcal disease, influenza, measles, varicella, louse-borne diseases, diptheria, typhoid fever, cholera, hepatitis A, B, C and E, helminthiasis, leishmaniasis, schistosomiasis, HIV, malaria, measles and TB are among the most commonly cited.

  • Incomplete immunisation history. This may be due to low immunisation rates in the country of origin; interruption of vaccine schedules during transit; lack of records of immunisation status and absent communication between public health authorities of transit countries; and failure of many child migrants to register with a general practitioner in England.

  • Non-communicable diseases. Complications of undiagnosed and poorly managed non-communicable diseases contribute to preventable mortality, morbidity and disability.

  • Malnutrition and micronutrient deficiencies. This occurs as a consequence of food insecurity at any stage of migration including postmigration.

  • Obesity. Postmigration risk of obesity is due to food unfamiliarity and the introduction of highly refined foods to their diet.

  • Anaemia. Causes include malnutrition, parasitic infections and haemoglobinopathies.

  • Musculoskeletal complaints. This may occur as a consequence of the physical stress endured during the migration journey, injuries from torture or violence, or malnutrition.

  • Oral disease.

  • Sexually transmitted infections. Some asylum seekers may have been raped or forced into commercial sex work prearrival or postarrival in England. Consequences of untreated sexually transmitted infections include infertility, poor obstetric outcomes, neonatal infections, anogenital cancers, and heightened risk of acquiring and transmitting HIV.

  • Adolescent pregnancy. Limited sexual health awareness, low rates of contraception use and vulnerability to sexual abuse increases pregnancy risk. Adolescent pregnancy is associated with adverse maternal and neonatal health outcomes including antenatal complications, premature birth and maternal and neonatal death.

  • Female genital mutilation. This is common in some African and Middle Eastern countries where some asylum seekers originate from. It is associated with transmission of bloodborne viruses, menstrual problems, recurrent urinary tract infections, psychological problems, sexual dysfunction problems, infertility and adverse obstetric outcomes.

  • Psychological disturbance. Post-traumatic stress disorder (PTSD), anxiety with sleep disorders, and depression are commonly reported.

In England it is a legal requirement that all unaccompanied asylum seeking children (UASC) receive an initial health assessment (IHA) within 28 days of registration with the local authority.9 This is usually carried out by a community paediatrician and followed up with annual physical and mental health assessments. While there is no official health pathway for other child refugees, asylum seekers and undocumented migrants, general practitioners (GPs) are encouraged to carry out targeted new patient checks including immunisation review and communicable disease screening as appropriate.10 Unfortunately lack of capacity means long delays in IHAs, and GP registration challenges coupled with an overstretched service means targeted patient checks are not routine practice.9 Many of these children first present to health professionals in an acute situation, at which point an opportunistic holistic assessment is warranted. While there is National Health Service (NHS), government and Royal College of Paediatrics and Child Health (RCPCH) guidance for health professionals on assessing and meeting the health needs of refugees and asylum seekers, service providers have articulated that they feel clinically and emotionally ill-equipped to manage this group.10–14 Inexperience among GPs and paediatricians has been highlighted as a contributor to England’s inability to meet the mental health needs of UASC.15 Understanding a child’s life experiences, the cultural context, their sociopolitical environment and the immigration legislation they are subject to is important in identifying their needs.

Alarmingly it is claimed that many asylum seekers arrive in the UK in relatively good physical health but health problems may quickly develop as a consequence of immigration policy, barriers in healthcare access and unawareness of entitlement.10 16

Policy and legislation

The ‘right to health’ is enshrined in numerous international treaties including the United Nations Convention on the Rights of the Child (UNCRC), the European Convention on Human Rights, and the International Covenant of Economic, Social and Cultural Rights. In accordance with the principle of universal health coverage all children should be provided with equitable access to disease prevention, health promotion and healthcare. However, a global rise in populist radical right politics is in conflict with commitments to human rights and vulnerable populations. Migration is high on the political agenda as an issue of public concern across Europe, North America and Australia, with consequent introduction of some laws and policies that impose additional life stressors on migrants and potentially exacerbate existing health problems.5 17 Being both children and migrants, this doubly vulnerable group is subject to conflicting legal and policy frameworks in a situation where international responsibilities and national priorities are not always aligned.3

Immigration policies and the wider determinants of health

Children in England are not exempt from national ‘hostile environment’ policies (box 2), made law in the Immigration Acts of 2014 and 2016.18 These policies are designed to deter illegal immigration by (1) Limiting migrants’ rights, access to services and welfare benefits. (2) Integrating immigration controls into public services.18 Social inequalities cause health inequalities. Immigration policies relating to housing, financial support, parental right to work, access to education, enforced dispersal, detention, healthcare charges, community integration and public service/Home Office data sharing for immigration enforcement all influence health outcomes. Undocumented migrants and asylum seekers are most affected by these policies but delays in document issues for refugees and entitlement confusion due to policy complexity means a large number of children are indirectly affected.19 20

Box 2

Examples of government 'hostile environment' policies in England

  • Identification checks and upfront charging of undocumented migrants for hospital treatment and National Health Service (NHS)-funded community health services.

  • No recourse to public funds for asylum seekers and undocumented migrants.

  • Banks and building societies prohibited from opening accounts for undocumented migrants.

  • Criminalisation of letting to undocumented migrants and asylum seekers awaiting a decision on their case as they are disqualified from renting.

  • Criminalisation of employing undocumented migrants for whom it is illegal to work.

  • Data sharing for immigration enforcement purposes between

    • the Home Office and Department for Education.

    • the Home Office and banks and building societies.*

    • the Home Office, Her Majesty’s Revenue and Customs, the Department for Work and Pensions for immigration.

    • the Home Office and NHS digital.*

  • *These policies were revised May 2018 following pressure from lobbyists but data sharing continues between the Home Office and NHS digital in the case of unpaid NHS debts.

Health policy and practice

WHO’s Regional Office for Europe emphasises the importance of responsive, people-centred health systems. It states health systems should be accessible to all migrants throughout the migration trajectory, and in conjunction with health policy must be equipped to manage the varying needs of arriving migrants and respect their human rights and dignity.21 This sentiment is echoed by the European Parliament which urges member states to deliver healthcare in line with fundamental rights; ensure vulnerable groups have equitable healthcare access; guarantee free, universal, quality healthcare to disadvantaged groups; and dissociate health policy from immigration control.22 Aspects of England’s current health policy and practice is contradictory in both enabling and obstructing these goals.

Child refugees and asylum seekers, children looked after by the local authority and detained children are entitled to free healthcare at all levels of care.23 However, confusing eligibility policies and complex procedures negatively impact on the reality of healthcare access for these children. Undocumented child migrants and dependants of refused asylum seekers not entitled to Section 95 or Section 4 support are chargeable for inpatient hospital care and many other services, excluding GP and Accident and Emergency (A&E) services.23 In cases where clinicians deem treatment to be non-urgent, full payment, at 150% of NHS tariff, is required upfront.23 24 Urgent treatment is provided without advance payment but fees are recovered subsequently.23

The impact of NHS overseas visitors charges

Research demonstrates that introduction of healthcare user fees creates a barrier to healthcare access even to those children with entitlement. Service providers have difficulty understanding the frequently changing policies pertaining to refugees and asylum seekers.3 4 25 26 Consequences have included: difficulties registering with a GP as documentation of proof of address or identity are wrongly demanded; eligibility mistakes; and failure to provide urgent and immediately necessary care irrespective of a patient’s ability to pay.3 4 24 27–29

Refugees, asylum seekers, undocumented migrants and their families are deterred from seeking healthcare due to misunderstandings about eligibility; fear of unaffordable costs; and fear of being arrested due to requested disclosure of immigration status and NHS data sharing with the Home Office.3 24 27 30 In the case of undocumented migrants this fear is well founded as NHS data sharing with the Home Office in 2016 led to 5854 people being tracked by immigration officers.24

Failure to seek timely treatment can result in inappropriate use of secondary care.27 Patients access A&E departments for diseases that could be prevented or managed by routine appointments putting increased pressure on already overstretched services.4 27 This results in adverse health outcomes for the patients and negative cost implications for the NHS.4 27

Health workforce attitudes

The core principles on which the NHS is based state that healthcare should address the needs of all, be free at the point of delivery and be based on clinical need—not ability to pay.31 Current policy does not abide by these principles and goes against Article 24 of UNCRC which obliges States Parties to ensure that no child is deprived of his or her right of access to healthcare services.32 The legal obligation to withhold treatment from vulnerable patients ineligible for free treatment until payment is received is morally challenging for doctors whose professional duty is to prioritise patient care. Many health professionals consider policy related to NHS charging of this vulnerable group as unethical and express concerns about the impact on individual and public health with additional doubts as to its cost-effectiveness.33–35

Asylum seekers have described feeling discriminated against because of their immigration status in primary and secondary care settings.36 Stigmatisation by service providers may effect an individual’s right to access good quality care as the literature indicates feelings of discrimination have deterred undocumented migrants from visiting GPs.37

Resources and capacity

To effectively meet the needs of child refugees, asylum seekers and undocumented migrants who may have complex health needs and for whom English is often not a first language, may be resource demanding. The necessity of interpreters and longer, more frequent appointments has resulted in an unwillingness among some GP practices to register refugees and asylum seekers.4 13 However, the expense of interpreter use is balanced by improved service access and patient symptom disclosure; more timely treatment/referral to specialist services; and better patient compliance and health outcomes.4 24 29 38–40

Delayed IHAs and absent or inadequate medical review reduces the opportunity for early intervention to minimise the impact of physical and mental illness. Many vulnerable child migrants require mental health service input but these are often overstretched and specialist culturally appropriate services are lacking.41 42 Long waits for mental health treatment can have a devastating impact and application of Western-derived interventions to populations with differing cultural views on mental illness may be of limited benefit.42 43 Further research is necessary to examine the effectiveness of existing therapies in child migrants accessing mental health services and to understand how to adapt healthcare practice and services to best meet their unique needs.

Health professionals have experienced difficulties referring refugees to other health and social services due to capacity, geographical and administrative barriers.44–46 A better informed and connected workforce incorporating NHS and third sector services would improve health outcomes.

Health information

Health information enables stakeholders to monitor health system performance, develop improved health policies and make effective decisions.47 Comprehensive health surveillance data on the health of refugees and asylum seekers in England and Europe are unavailable.48 Health surveillance efforts are impeded by the desire of undocumented migrants to keep ‘under-the-radar’ for fear of deportation, an unintended impact of the ‘hostile environment’ policies. England’s inadequate health information on child refugees, asylum seekers and undocumented migrants impacts on other health system elements including service delivery as the knowledge to inform healthcare policy and provision is inaccessible.

Recommendations for change

Child refugees, asylum seekers and undocumented migrants have many potential health needs but they are also a resilient group with capability to survive and to flourish.7 They have great capacity to benefit from interventions and addressing their health needs should be a priority. The following paragraphs propose recommendations for action to address the health needs of this population in the context of the challenges and barriers discussed above. Paediatricians should be encouraged to take an active role using their positions as clinicians, child advocates, researchers, members of child health professional bodies and health service managers.

The role of child health professionals

Child health professionals can meet the needs of vulnerable child migrants through provision of quality and comprehensive clinical care, maximising use of available resources and advocacy work (box 3).

Box 3

The role of child health professionals

Remove healthcare barriers:

  • Identify the child’s entitlements.

  • Be familiar with RCPCH and government guidance on assessment and management of child refugees and asylum seekers.

  • Understand their life experiences and health needs and the correct technical and cultural approach to address them non-discriminately.

  • Use an interpreter when required and allow additional time for appointments.

  • Support children and their families in navigating the healthcare system and encourage engagement with service providers.

Maximise resources:

  • Collaborate closely with other healthcare providers including third sector organisations to streamline services, improve referral systems, capitalise on expertise and resources, and strengthen professional advocacy for this group.

Advocate:

  • Humanise child refugees, asylum seekers and undocumented migrants through public speaking, media campaigns and engagement with policy makers.

  • In parliamentary and political engagement, convincingly frame policy issues to ensure the health of child refugees, asylum seekers and undocumented migrants is recognised as worthy of government attention and public support.

  • Engage with and support the work of non-governmental organisations such as MedAct, Docs Not Cops and Doctors of The World.

The role of the research community

The health benefits and economic savings associated with investing in research to address the health needs of this group advantages all of society.49 Child health researchers must engage with relevant stakeholders including government, public health, clinical communities, front-line organisations (eg, Doctors of The World), and importantly the children and their caregivers, to identify research priorities for child refugees, asylum seekers and undocumented migrants. Attention should be given to filling the evidence gaps required to inform policy, public health and clinical practice that enables good health. Possible research areas include health impact assessment of current immigration policy; challenges and opportunities to healthcare access; communicable disease control including screening and vaccination programmes; and the effectiveness of Western derived mental health interventions in children from different cultural backgrounds. There is a need to strengthen health information by investing in development of a child refugee and asylum seeker health surveillance systems. European and global collaborations, improved data collection and better data linkage are essential in understanding and meeting the health needs of mobile populations.

The role of child health professional bodies

Child health professional bodies like RCPCH have a responsibility to inform, influence and shape local and national policy to improve child health. Child health professional bodies could use their lobbying and influencing power to recommend that national policies and practices regard child migrants first and foremost as children whose internationally and nationally defined rights must be upheld. RCPCH has already joined other health professional bodies, charities and organisations to call for the suspension of NHS charges to migrants pending an independent review of their effect and publication of existing evaluation.50 Similarly, they could lean on the government to review all national immigration policies that contributes to the health needs of child migrants and widens the inequalities they experience (eg, housing, financial support and detention policies).

The role of health service providers

NHS Trusts in areas serving large refugee and asylum seeking populations (eg, London, port of entry locations and local authority areas participating in the national transfer and dispersal policy schemes) should introduce workforce training and local care pathways to enable optimal evidence-based service provision to refugees, asylum seekers and undocumented migrants. Additionally, Trusts providing UASC IHAs should ensure the service has capacity to deliver these within the 28-day target to enable timely intervention where warranted.

In 2018 Kent Community Health NHS Foundation Trust and Kent County Council received a grant from the Ministry of Housing, Communities and Local Government to improve migrant access to healthcare by reducing local service barriers, providing targeted interventions and delivering cultural competency training to staff.51 Evaluation of this 2-year migrant communities programme project could provide valuable lessons for other health service providers serving large migrant populations.

Conclusion

Restrictive immigration policies, health system challenges and barriers to effective service provision hinders England’s ability to meet the physical and mental health needs of its child refugees, asylum seekers and undocumented migrants. Through cultural awareness and understanding how a child migrant’s life experiences may have impacted on their health, paediatricians can improve the quality of care they deliver. However, child health professionals have a responsibility to respond to a child’s health needs and to act and influence the precipitants. Advocacy, research and engagement with national and local policy makers are ways in which paediatricians globally can enable attainment of the greatest health potential in this population.

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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