Main findings
This systematic review identified 107 studies reporting on healthcare use of migrant children, published from 2006 to 2016. To the best of our knowledge, it is the first attempt to systematize scientific knowledge on patterns of healthcare use among migrant children, a growing group with specific health and healthcare needs. The identified studies originated mostly from Europe and North America, with only 7% of studies coming from other regions. While these two regions host just over half of global international migrants [
42], among children the distribution is different: three out of five child migrants live in Asia and Africa [
10]. There is a clear lack of studies from these regions with large migrant populations.
Methodologically the studies appear strong, with 87% categorized as meeting good quality criteria. Most studies had large sample sizes, one third of them were nationally representative, and a large majority adjusted for important confounding variables. However, majority of studies did not adjust for socioeconomic status, which could be problematic. Even fewer studies adjusted for indicators of need, such as health status, which should be considered when interpreting the results: migrant and native children may have differing healthcare needs, leading to different utilization patterns.
The studies focused on a few main themes, such as vaccinations, and oral and mental health, exploring both primary and specialized care use. Studies from the US frequently assessed existence of a usual source of care. Besides vaccinations and dental check-ups, no other aspects of preventive care or health promotion were studied. This is particularly noteworthy, since some migrant children in Europe have higher rates of risk factors such as obesity and physical inactivity than native children, which highlights the importance of health promotion in these groups [
18]. Among migrant women, attendance to prenatal check-ups has been studied extensively and found generally to be lower than in native populations [
16], and therefore preventive care use merits attention among migrant children as well.
Only 9% (8 studies) of the identified studies focused on refugees, and three additional studies included refugees. One of these studies was carried out in Asia [
43], one in Australia [
44], three in North America [
37,
45,
46] and six in Europe [
47‐
52]. In total, four studies found higher use of health services among refugees, four found lower service use and three found either no difference or they did not compare. As refugee children are a very specific and growing group [
10], and findings regarding health service use among other type of migrants may not be applicable to them, the low number of studies on refugees brings to question what is really known about health service use of this particular group of children.
When analysing the main results by healthcare theme, the most striking difference is the relatively frequent finding of “higher use or access” in the category hospital and emergency room services. Majority of the studies that found higher use in this category originated from Europe [
53‐
59], while two studies originated from North America [
45,
60]. Two of the studies included refugees only, and three examined risk of hospitalization among children with type 1 diabetes [
54,
55,
57]. A Swiss study found that migrants were overrepresented at the paediatric intensive care unit [
59]. Therefore, several of these studies appear to indicate delayed care or problems in accessing routine treatment, rather than overuse.
Possible reasons to reduced utilization and access
Cultural norms, explanatory models of disease, lack of safety networks, language barriers and economic and social adversity all interplay in migrants’ decision to seek and use health services [
61]. The reasons for differing use of health services among migrant children could be categorized into family-related (such as fear, stigma, lack of trust, financial difficulties, problems in navigating new healthcare systems, lack of awareness of rights); those related to health professionals (communication problems, misconceptions, cultural barriers), and structural problems related to healthcare systems (lack of entitlement to care or restrictions to use, problems in physical access) [
62].
These factors affect migrant families of different characteristics to varying degrees: Among migrants with undocumented immigration status, lack of awareness of their rights and functioning of health care systems, fear, and economic reasons may be the most important [
63]. For refugees and asylum seekers, barriers to care are often related to legal entitlement, but organizational barriers and lack of provider expertise also influence their access to care [
64]. Other barriers identified as important for labour-migrants in particular include lack of health insurance, lack of awareness about occupational health and safety regulations, and documentation status [
62]. Several other issues have also been identified as influencing access among migrants: physically moving from one place to another, thereby discontinuing any on-going treatment or vaccine series; lack of coordination among the health authorities inside and between countries; and lack of resources in the hosting countries [
24].
A potential factor influencing access of all migrants and ethnic minorities are health care professionals’ skills and attitudes. A systematic review identified three main components of this barrier: biases, stereotypes and prejudices; language and communication barriers, and cultural misunderstandings [
65]. Another systematic review concludes that this type of implicit bias is likely to influence clinical decisions [
66].
Finally, different use of health services may also result from different needs. While this is likely not true for lower vaccination rates or lower use of dental care, it may explain to some extent lower use of other services, where the need appears to be less than in native populations. The ‘healthy migrant effect’ has been observed in rates of asthma, some mental problems and risky health behaviours, which all appear to be lower than among native populations [
13,
67].
Comparison to other studies
Another systematic review on adult migrants’ health service use, limited to use of somatic services and the European region [
23], found more varying results than our review. Use of preventive services such as mammography screening was lower, whereas use of general practitioners’ services and rate of hospitalizations was higher. A recent systematic review focused on the use of emergency department services in Europe found higher and sometimes inappropriate use among migrants [
68]. One explanation proposed by the authors is difficulties in accessing more appropriate sources of health care.
Also in line with our findings, a systematic review on vaccination coverage of rural-urban migrant children found a lower rate among migrants than the general population [
69]. Similarly, a systematic review on vaccine coverage of migrant and refugee adults in Europe found lower coverage than among native populations [
24].
Strengths and limitations
To our knowledge, this is the first effort to systematize published research on the use of health services of international migrant children. We used a broad search strategy and found a large number of studies, reporting on more than 10 million children.
However, the study has certain limitations that should be considered. The identified studies were heterogeneous, which makes interpretation of the results more challenging, and also prevented us from carrying out a meta-analysis. Unfortunately, information on countries of origin of the migrants was not available for many studies, and it was not possible to analyse studies by subgroups based on country of origin. Also analyses by type of migrants were not possible because this information was frequently lacking, and number of studies in each group was small. Our review was limited to literature published between 2006 and 2016 and to two databases, and therefore possibly relevant literature could have been missed. Findings published in reports or in languages other than the ones included could also be relevant, and were not included in this study. Most studies originated from Europe and North America, and therefore we cannot draw firm conclusions on migrant children settled in other regions of the world. Some studies were not originally designed to address research questions about migrants or not focused on children, which could also be considered a limitation.
Additionally, it should be noted that the comparison between migrants and native populations does not take into account suboptimal access of native children [
70‐
72]. Nevertheless, in a review the comparison to native populations is the clearest method to point out inequalities in service use between these two groups, even though both may have problems in accessing health care. Further, this study only addressed health service use in the post-migratory situation, leaving out many significant variables that affect why, how and when they migrated, as well as what patterns of access to healthcare existed in their countries of origin. By systematizing several studies, this review overlooks the unique characteristics of individual studies and contexts. To include these complexities would be very hard to disentangle in a single systematic review, and therefore this study can be considered a baseline for further studies, and as such aims to analyse the general tendencies of patterns of use of healthcare among migrant children. International migration should be studied at the local, national, regional and global scales, as this phenomenon responds to complex and dynamic processes of globalization, international labour stratification, poverty and conflict. This paper is unable to mirror all these factors, but they could be studied using different methodologies than a systematic review.
Implications
Migrant children have reduced use of many types of health services. According to our findings, only the use of emergency and hospital services was found to be higher than native populations, which appears to indicate problems in accessing care at earlier stages or more appropriate places.
Targeted policies could help overcome these barriers in access to healthcare. For example, improving health literacy seems to have the potential to empower patients and reduce health inequalities, and there are effective interventions to improve health literacy among migrants [
73]. Regarding health providers, some of the identified barriers could be ameliorated with system changes, such as utilization of interpreters, whereas others would require specific interventions such as cultural competence education for health professionals [
74]. Recently, interventions to improve immigrant health were reviewed, and many specific policies for adult migrants were identified. However, only 11% of the results were policies directed to children [
75]. There appears to be a need to develop and document policies to improve access to care for child migrants.
Future research should extend beyond Europe and North America to the regions with most child migrants: Asia, Africa and South America. Moreover, while the identified studies were large and used reliable methods, the majority did not control for measures of socioeconomic status, and few were able to control for indicators of need, such as health status. It is important to develop study methodologies that can better control for confounding factors, and more precisely measure the impact of migration on service use. Since migrant groups are different in terms of their health care needs, reasons for migration, region of origin and time since arrival should be documented more carefully both in registers and in studies, to identify and analyse groups that have a particularly high risk of underuse of services. Finally, the reasons and mechanisms for foregone and delayed care should be also evaluated in epidemiological studies.