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the European Commission.
Health of refugee and
migrant children
Technical guidance
The Migration and Health programme
The Migration and Health programme, the first fully fledged programme on migration
and health at the WHO Regional Office for Europe, was established to support
Member States to strengthen the health sector’s capacity to provide evidence-
informed responses to the public health challenges of refugee and migrant health.
The programme operates under the umbrella of the European health policy framework
Health 2020, providing support to Member States under four pillars: technical
assistance; health information, research and training; partnership building; and
advocacy and communication. The programme promotes a collaborative intercountry
approach to migrant health by facilitating cross-country policy dialogue and
encouraging homogeneous health interventions along the migration routes to promote
the health of refugees and migrants and protect public health in the host community.
This project is funded by
the European Commission.
Health of refugee and
migrant children
Technical guidance
Abstract
Between 2015 and 2017, almost one million asylum-seeking children registered in the European
Union, and 200 000 of these arrived unaccompanied by a caregiver. These children faced particular
risks, including being exposed to discrimination, marginalization, institutionalization and exclusion.
When considering health and health care interventions for migrant children, some areas need
specific attention, such as their diverse backgrounds, whether they are unaccompanied and
separated from family, whether they have been trafficked and also if they are children who have been
left behind. Policy considerations include an intersectoral approach to promote good health and
well-being, particularly mental health, in migrant children that target risk factors at the individual,
family and community levels. Particular emphasis is placed on how national/local governments have
an important role in fostering or hindering living conditions for refugee and migrant children in the
areas of housing, health care services and education.
Keywords
CHILD HEALTH, CHILD HEALTH SERVICES, TRANSIENTS AND MIGRANTS, REFUGEES, EUROPE
Suggested citation
Health of refugee and migrant children. Copenhagen: WHO Regional Office for Europe; 2018
(Technical guidance on refugee and migrant health).
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ISBN 978 92 890 5379 2
© World Health Organization 2018
All rights reserved. The Regional Office for Europe of the World Health Organization welcomes
requests for permission to reproduce or translate its publications, in part or in full.
The designations employed and the presentation of the material in this publication do not imply the
expression of any opinion whatsoever on the part of the World Health Organization concerning the
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of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which
there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they
are endorsed or recommended by the World Health Organization in preference to others of a similar
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are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information
contained in this publication. However, the published material is being distributed without warranty
of any kind, either expressed or implied. The responsibility for the interpretation and use of the
material lies with the reader. In no event shall the World Health Organization be liable for damages
arising from its use. The views expressed by authors, editors, or expert groups do not necessarily
represent the decisions or the stated policy of the World Health Organization.
This publication was produced with the financial assistance of the European Union. The views
expressed herein can in no way be taken to reflect the official opinion of the European Union.
Cover © Eray Mert
iii
Contents
Acknowledgements ......................................................................................iv
Abbreviations ................................................................................................v
Summary ......................................................................................................vi
Introduction ...................................................................................................1
Objectives ......................................................................................................................... 2
Methodology ....................................................................................................................2
Overview ........................................................................................................3
Refugee and migrant children in the EU/EEA area ....................................................... 3
Key articles in the CRC with regard to migrant children ..............................................3
Risk factors for health and well-being during migration .............................................4
Risk and protective factors for health and well-being in migrant children ................ 5
Key policies to promote good health and well-being ...................................................5
Evidence .......................................................................................................6
Risk and protective factors for migrant children .......................................................... 6
Health and health care for newly arrived migrant children in Europe ........................ 8
Mental health and psychological well-being ................................................................9
Summary ........................................................................................................................13
Areas for intervention ..................................................................................14
Psychoeducational interventions ................................................................................14
Parenting support programmes ...................................................................................15
School-based health promotion ..................................................................................16
Policy considerations ..................................................................................20
Health promotion strategies ........................................................................................20
Public health strategies ................................................................................................21
References ..................................................................................................22
Recommended reading .................................................................................................28
Annex 1. Child asylum applicants in the EU/EEA during 2015–2017 ............29
Annex 2. Resources ......................................................................................31
iv
Acknowledgements
The technical guidance series on the health of refugees and migrants in the WHO
European Region was produced as part of the WHO Knowledge Hub initiative on Health
and Migration under the aegis of the WHO Regional Office for Europe and the European
Commission collaboration Migration and Health Knowledge Management (MiHKMa)
project.
We would like to thank the MiHKMa project team led by Santino Severoni, who
coordinates and leads the Migration and Health programme within the Division
of Policy and Governance for Health and Well-being of the WHO Regional Office for
Europe, directed by Piroska Östlin.
Anders Hjern (Stockholm University) and Ayesha Kadir (Malmö University) are the
authors of the Technical Guidance on Health of Refugees and Migrant Children.
Guidance and consultation was provided by the Knowledge Management Committee:
Ibrahim Abubakar (University College London), Richard Alderslade (WHO Temporary
Advisor), Guiseppe Annunziata (WHO), Roberto Bertollini (Ministry of Health, Qatar),
Raj Bophal (University of Edinburgh), Jaime Calderon (International Organization
for Migration), Nils Fietje (WHO), Heiko Hering (Office of the United Nations High
Commissioner for Refugees), Anders Hjern (University of Stockholm), Tamar
Khomasuridze (United Nations Population Fund), Monika Kosinska (WHO), Allan
Krasnik (European Public Health Association), Bernadette Kumar (University of Oslo),
Rosemary Kumwenda (United Nations Development Programme), Anne MacFarlane
(University of Limerick), Isabel de la Mata (European Commission), Åsa Nihlén (WHO),
Svetlana Stefanet (United Nations Children’s Fund), Felicity Thomas (University of
Exeter) and Jacqueline Weekers (International Organization for Migration).
The Expert Working Group on Refugee and Migrant Child Health also contributed
technical advice and expertise. Our gratitude goes to Ilse Derluyn (Gent University),
Cetin Dikmen (WHO), Ioannis Micropoulos (WHO), Nick Spencer (International Society
for Social Paediatrics and Child Health), Martin Weber (WHO) and Kolitha Wickramage
(International Organization for Migration). We would like to thank Bente Mikkelsen,
Director of the Division of Noncommunicable Diseases and Promoting Health
through the Life-Course of the WHO Regional Office for Europe and her team for their
contribution.
Acknowledgements are owed to the project manager, Jozef Bartovic, for his work in the
successful coordination and execution of the technical guidance series. Our gratitude
also goes to Hedvig Berry Wibskov, Palmira Immordino, Simona Melki, Kari Pahlman
and Soorej Jose Puthoopparambil for their support with the project.
Finally, the WHO Regional Office for Europe wishes to thank the Consumer, Health,
Agriculture and Food Executive Agency (Chafea) of the European Commission and the
Directorate-General for Health and Food Safety (DG SANTE) for its financial support of
the project, in particular Isabel de la Mata (European Commission) and Paola D’Acapito
(Chafea) for their contribution and support in overseeing the project.
v
Abbreviations
CRC Convention on the Rights on the Child
EEA European Economic Area
EU European Union
UNHCR Office of the United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
vi
Summary
Around one million asylum-seeking children were registered in the European Union
(EU) during 2015–2017, of whom 200 000 (one in five) arrived unaccompanied by a
caregiver. This technical guidance focuses on the initial response of the health care
services to the needs of these and other refugee and migrant children.
All countries in the WHO European Region have signed and ratified the United Nation’s
Convention on the Rights on the Child (CRC) and have agreed to the obligations
contained in this. This technical guidance identifies a number of areas where the health
situation for migrant children would be improved if countries adhered more closely to
these obligations.
Medical care for chronic disorders and rehabilitation for disabilities are often the
most pressing needs of migrant children, with needs for dental care being the most
common. In addition, migrant children from low- and middle-income countries have a
higher burden of chronic infectious disorders compared with those from high-income
countries, and these disorders need to be identified and treated. Lack of access to
preventive health care in the countries of origin make vaccination programmes a high
priority to prevent outbreaks of measles and other vaccine-preventable disorders.
To address mental health needs, a holistic and family-oriented public health strategy
for promoting mental health and psychological well-being is needed. This should
include collaboration between many different sectors of society, with education in
schools and pre-schools being particularly important. There is some evidence also
to support the effectiveness of more specific interventions to promote well-being, for
example psychoeducational approaches to cope with psychological trauma, culturally
sensitive parent-support programmes and interventions in the school environment.
A general finding in the literature is that differences in health status between children
in different migrant groups are greater than the differences between migrant children
and local populations in Europe. Country of origin is an important predictor here, but
also the social background of the family in the country of origin and the living conditions
in the destination country. Consequently, health assessment/screening procedures
should be individualized. A comprehensive individualized health assessment by a
paediatric nurse or clinician, preferably as soon as possible after the child arrives
in the country of destination, can identify health care needs that might otherwise
go undetected for prolonged periods of time. It also allows screening for potentially
communicable disorders and updating of vaccinations. Such an approach would save
costs by coordinating health care use in an informed manner. The provision of medical
interpreters and cultural mediators is important to make care provision for migrant
children more equitable with that for the host population.
vii
The evidence presented in this technical guidance is primarily based on observational
reports and theory, plus individual evaluative studies. This reflects the lack of evaluative
research of policy and specific interventions on how to facilitate health, well-being
and positive development in migrant children in Europe. There are large knowledge
gaps in research regarding pathways to resilience and for assessing the impact of
specific interventions that may be likely to be effective in improving outcomes. Long-
term follow-up is required to evaluate interventions intended to enhance well-being,
educational outcomes, employment and social inclusion. Close collaboration with
policy-makers and key service providers is essential to ensure optimal translation of
findings into sustainable practice.
© Eray Mert
Health of refugee and migrant children
1
Introduction
In 2017, the Office of the United Nations High Commissioner for Refugees (UNHCR)
estimated that there were around 30 million children in the world living outside their
country of birth, with 13 million being refugees or asylum seekers. The overwhelming
majority of these children reside in countries of low or middle incomes that are
neighbours to zones of armed conflict
(1)
. In recent years, more of these child refugees
have arrived in Europe, with almost one million asylum-seeking children registered in
the EU in 2015–2017, of whom 200 000 were unaccompanied by a caregiver
(2)
.
These children arrive after long and difficult journeys with limited or no access to care.
Some come from countries with collapsed health care systems, overwhelmed by both
victims of conflict and disaster and the consequences of destroyed infrastructure.
Many have been exposed to armed conflict in their country of origin before leaving and
will face new, unfamiliar and often hostile surroundings in the countries of destination.
These circumstances lead not only to accumulated individual health care needs, but
also to a need for effective public health strategies to update preventive child health
programmes and promote positive psychological well-being
(3,4)
.
Children’s right to health care is codified in the CRC, a Convention which has been signed
by all Member States of the WHO European Region. Article 24 recognizes “the right of
the child to the enjoyment of the highest attainable standard of health and to facilities
for the treatment of illness and rehabilitation of health”
(5)
. The Standing Committee
on the Rights of the Child has clarified that “The enjoyment of rights stipulated in
the Convention is not limited to children who are nationals of a State Party and must
therefore, if not explicitly stated otherwise in the Convention, also be available to all
children – including asylum-seeking, refugee and migrant children – irrespective of
their nationality, immigration status or statelessness”
(6)
. The EU Reception Conditions
Directive also obliges Member States to ensure medical or other assistance for asylum
applicants with special needs, which includes children and minors
(7)
.
Two categories of particularly vulnerable migrant children in a social perspective
are asylum seekers and children in an irregular situation. They may be accompanied
or unaccompanied, but they have the same rights as children with legal residency
according to the CRC. Asylum seekers have usually experienced armed conflicts and/
or political persecution in the country of origin. While seeking asylum, they live under
circumstances characterized by temporality and uncertainty about their situation and
future. Children with irregular migrant status are also referred to as “undocumented”
or “unregistered” migrants. These children often live “under the radar” in precarious
situations with no or limited access to basic social rights and exposed to poverty,
exploitation, social exclusion and violence
(8)
.
Technical guidance
2
Objectives
The objective of this technical guidance is to inform national and local health policy
regarding health care for newly arrived refugee and migrant children. This grouping
encompasses children aged 0–18 years who are asylum seekers, in an irregular
situation or in the first two years after obtaining residency in the country of reception.
The guidance, therefore, focuses on the initial health care response to the needs of
these children.
Methodology
This technical guidance reviewed academic literature on migrant child health in a
European context. It built on the WHO Regional Office for Europe’s Child and Adolescent
Strategy for 2015–2020 by combining a child rights approach with an evidence-based
approach
(9)
to put forward practical policy considerations for improving refugee and
migrant child health. The CRC pays specific attention to displaced and unaccompanied
children and so provides a useful framework from which to approach health policy for
migrant children.
Published peer-reviewed literature in English, for the period 2007–2018 was identified
through a comprehensive literature search in EMBASE and PubMed. Search terms
included combinations of terms for children (“child”, “youth” and “adolescent”) with
terms for migrants (“migrant”, “asylum seeker”, “refugee” and “undocumented
migrant”) and terms for countries in the EU/European Economic Area (EEA). The
search was limited to publications covering children from birth to 18 years of age. This
search was complimented by a search in the grey literature from the EU/EEA, UNHCR,
the United Nations Children’s Fund (UNICEF) and WHO during 2013–2018. Extensive
searches were also made by hand from the reference lists of the articles retrieved.
A scoping review was found to best fit the available evidence and a narrative design
was chosen to merge the empirical studies, theory and policy. Policy implications were
based on the policy articles retrieved in this search and documents published by the
EU, UNICEF and WHO.
Health of refugee and migrant children
3
Overview
Refugee and migrant children in the EU/EEA area
In 2015–2017, there were 1 037 440 children applying for asylum in the EU/EEA. Of these
200 550 (19.3%) were unaccompanied (Annex 1). Table 1 gives the EU/EEA countries
hosting the greatest and least number of unaccompanied children, a grouping with
particular health concerns.
Table 1. Countries of the EU/EEA with the highest and lowest percentages of unaccompanied
child asylum seekers in 2015–2017
Country All children
2015–2017
Unaccompanied/
separated
children
Unaccompanied/
separated (%
total children)
More than 30% of children unaccompanied
Bulgaria 13 270 5 005 38
Croatia 665 215 32
Denmark 9 905 3 770 38
Italy 33 975 20 095 59
Netherlands 21 080 6 740 32
Norway 12 700 5 235 41
Slovenia 1 020 675 66
Sweden 90 265 37 740 42
United Kingdom 25 445 8 635 34
Less than 5% of children unaccompanied
Czechia 810 015 2
Estonia 215 000 0
France 50 300 1 385 3
Lithuania 420 005 1
Malta 1 315 055 4
Poland 13 825 405 3
Spain 15 490 075 1
Source:
Eurostat, 2017
(2)
.
Key articles in the CRC with regard to migrant children
Article 2.1. Parties shall respect and ensure the rights set forth in the present
Convention to each child within their jurisdiction without discrimination of any kind,
irrespective of the child’s or his or her parent’s or legal guardian’s race, colour, sex,
language, religion, political or other opinion, national, ethnic or social origin, property,
disability, birth or other status.
Technical guidance
4
Article 24 1. Parties recognize the right of the child to the enjoyment of the highest
attainable standard of health and to facilities for the treatment of illness and
rehabilitation of health. States Parties shall strive to ensure that no child is deprived of
his or her right of access to such health care services.
Article 39. Parties shall take all appropriate measures to promote physical and
psychological recovery and social reintegration of a child victim of: any form of neglect,
exploitation, or abuse; torture or any other form of cruel, inhuman or degrading treatment
or punishment; or armed conflicts. Such recovery and reintegration shall take place in an
environment which fosters the health, self-respect and dignity of the child.
Risk factors for health and well-being during migration
Figs. 1-3 outline risk and protective factors for health and well-being in child migrants.
Fig. 1. Risk factors for health problems and poor well-being during the different phases of
migration
Pre-migration
• Chronic infectious
agents
• Violence (including
armed conflict and
political persecution)
• Lack of health and
dental care
• Food insecurity
During the journey
• Exposure at sea
• Injuries
• Hunger
• Acute infectious
disorders
• Food insecurity
• Incarceration
• Separation from
caregivers
• Trafficking
• Exploitation
• Violence
• Lack of health and
dental care
In country of destination
• Barriers to accessing
care
• Barriers to accessing
education
• Social marginalization
and isolation
• Inadequate and
unstable housing
• Daily stressors
• Discrimination/bullying
• Threat of deportation
• Children left behind
• Caregivers' mental
health problems
• Exploitation
Return/deportation
Health of refugee and migrant children
5
Risk and protective factors for health and well-being in migrant
children
Fig. 2. An ecological model of risk and protective factors to be targeted in a public health
strategy for promoting well-being in migrant children
Context
Legal situation
Socioeconomic living
conditions
Daily stressors
Social support
Social network
Family
Individual stress
Trauma
Uprooting
Source
:
Hjern & Jeppson, 2005
(10)
.
Key policies to promote good health and well-being
Fig. 3. Key policies to promote child health and well-being
G
o
o
d
c
h
i
l
d
h
e
a
l
t
h
a
n
d
w
e
l
l
-
b
e
i
n
g
Child
Avoid detention of children
Provide child-friendly spaces
Treat trauma with sensitive care and education
Ensure early entry into pre-school and school
Provide continuity of care for unaccompanied minors
Use a holistic age assessment policy
Family
Provide culturally sensitive parent-support
programmes
Avoid relocation
Ensure parental access to psychiatric care
Have family reunification policies that minimize
children becoming left behind
Community
Facilitate contacts with families/children with the
same origin
Provide basic material resources
Prevent xenophobia
Technical guidance
6
Evidence
Risk and protective factors for migrant children
The health of migrant children is related to both their state of health before their journey
and the risks they face at all phases of their journey and settlement in the country
of destination; it is also linked to the health of their caregivers (Fig. 1). Consequently,
risks for a child will vary according to the child’s particular experiences in the home
country, during travel and after arrival at the destination country
(3,11)
.
Health risks associated with the country of origin
There may be multiple underlying reasons for children’s departure from the country of
origin. They may be escaping war and conflict, have suffered human rights abuses such
as torture or sexual violence, or have been living in extreme poverty. In conflict zones,
health care is often disrupted and has other priorities than prevention; therefore,
children may have been without access to health care for prolonged periods of time
(12)
and may be vulnerable to vaccine-preventable diseases
(13)
. They may also have
increased rates of dental caries because of inadequate dental care
(14)
. Nutritional
deficiencies, chronic infections and noncommunicable diseases may also affect
migrant children, although the epidemiology varies by social background, exposures
and experience in the country of origin
(13)
.
Health risks during the journey
Depending on the route, and the method and length of travel, the journey presents
the migrant child with different challenges. During the crossing of the Aegean Sea
between Turkey and Greece and the Mediterranean Sea between Libya and southern
Europe, many children have drowned when overcrowded boats have capsized
(15)
.
Infants born during the journey are at increased risk of severe and life-threatening
illnesses, including hypothermia, septicaemia, meningitis and pneumonia
(16)
.
These infants may also suffer from poor nutrition, particularly as breastfeeding is a
challenge for mothers during their journey. A recent survey of rescue ships found that
dehydration and dermatological conditions associated with poor hygiene and crowded
conditions were common, as well as new and old traumatic injuries from both violence
and accidents
(17)
. There has been a dramatic increase in recent years in the number
of children migrating to southern Europe who have been subjected to incarceration,
sexual violence and kidnapping during their journey, increasing the risk of both mental
and physical health problems
(4,15)
. Another common risk is the separation of children
from their caregiver during the journey.
Children may spend time in overcrowded accommodation with inadequate hygiene
and sanitation facilities, which places them at risk for diarrhoeal diseases, respiratory
infections, skin infections and other communicable diseases
(16)
. This is particularly
Health of refugee and migrant children
7
the case for children who are trapped for long periods of time in transit accommodation,
without being able to reach their final destination.
Risks in the country of destination
After reaching the country of destination, asylum seekers have a prolonged period of
uncertainty while their application for asylum is being processed. The living conditions
of children and families during this period is often stressful, including frequent housing
relocations, lack of toys or spaces to play, limited access to school, social isolation
from peers, and caregivers under pressure. A recent survey of children living in refugee
camps in Germany also pointed to the risk of injuries in the newly settled children, for
example falls while playing and burns
(18)
.
Children experiencing these conditions may enter a kind of survival mode, making
it difficult for them to envisage their futures
(19)
. At the same time, daily stressors
related to the struggle to make ends meet with minimal allowances and the possible
encounters with xenophobia from local populations and peer groups also take their toll
(20,21)
.
Migrant families may struggle to access education. This challenge places children at
risk for delayed learning and also serves as a barrier to integration into age-appropriate
schooling
(3)
. Migrant children with chronic health problem and disabilities are at
particularly high risk for exclusion from education and may have lower levels of
participation in society than other disabled children
(22)
.
Language barriers, cultural differences and the new and unfamiliar environment
in the country of reception may lead to delayed presentation for health care or the
inappropriate use of health services. Populations at particularly high risk include
migrants in an irregular situation, who may fear being reported to migration authorities,
and unaccompanied minors, who lack information about their health rights and
guidance in seeking health care
(22)
.
Migrant children in detention
Systematic detention of asylum seekers, often in temporarily constructed structures,
at entry points and/or when they are waiting for deportation is a reality. The
material conditions in detention centres can vary from appalling in some countries
to comparatively better standards in others
(23,24)
. Children can be detained both
in transit countries and in countries that they or their parents see as the ultimate
destination. Immigration detention has negative consequences for the well-being of
all those detained, but studies have found that it is most detrimental to children
(23).
The United Nations Committee on the Rights of the Child has commented on children in
detention: “the leading principles for the use of deprivation of liberty are: (a) the arrest,
detention or imprisonment of a child shall be in conformity with the law and shall be
used only as a measure of last resort and for the shortest appropriate period of time;
and (b) no child shall be deprived of his/her liberty unlawfully or arbitrarily”
(25)
. The
Technical guidance
8
Committee also stated that every child in detention has a right to education and health
care, something that is lacking in many countries in Europe
(25)
. In 2014, the Council
of Europe passed a resolution that strongly opposed the detention of migrant children
(26)
, a call that has been supported also by Caritas, UNHCR and UNICEF.
Health and health care for newly arrived migrant children in Europe
Migrant children have diverse backgrounds, coming from countries with different
socioeconomic living conditions and from different social strata in these countries.
Accordingly, the health status within the population of refugee and migrant children
varies greatly. Nonetheless, their situation and exposure to the risk factors described
above make them vulnerable to the development of health problems. Infectious
diseases have been investigated most frequently in published studies, perhaps
because of fears of transmission of these diseases to others in the population.
Assessment of health care needs
A comprehensive individualized health assessment by a paediatric nurse or physician,
preferably as soon as possible after the child arrives in the country of destination, can
identify health care needs that might otherwise go undetected for prolonged periods
of time. Untreated health problems and unidentified disabilities can have long-term
consequences for well-being, learning and integration into the new country
(27)
.
Health assessments made within a clear structure, with the participation of qualified
medical interpreters and with the collaboration of a network of relevant specialists,
can increase the likelihood of detection of significant health conditions, link newly
arrived migrant children and their families with primary health care and reduce costs
by coordinating care across primary care and specialist services
(28)
.
A survey in 2016 found that in all but four countries in the EU/EEA there were systematic
health examinations of some kind for newly arrived migrants
(29)
. This health
examination was mandatory in most eastern European countries and Germany, while
it was voluntary in the rest of western and northern Europe. All countries that have
a policy of health examination aimed to identify communicable diseases in order to
protect the host population. Almost all countries with a voluntary policy also aimed to
identify a child’s individual health care needs, but this was rarely the case in countries
with a mandatory policy, where the focus was strictly on communicable disorders
(29)
.
Communicable diseases
Increased incidence of infectious diseases has been identified in refugee and migrant
children in the EU in a range of settings. Infections identified include minor infections
as well as more significant diseases requiring hospital admission
(30)
. Inadequate,
overcrowded accommodation and substandard hygiene and sanitation facilities
place children at risk for communicable diseases such as diarrhoeal diseases and
skin infections
(16).
The prevalence of many chronic infections, such as tuberculosis,
Health of refugee and migrant children
9
hepatitis B and C, malaria and intestinal parasites, is more common in middle-income
and, particularly, low-income countries than in the EU/EEA, and this is reflected in a
higher prevalence of these disorders in migrant children
(30,31)
. The European Centre
for Disease Prevention and Control provides information about infectious disorders in
migrant populations
(31)
, as well as guidance for screening and treatment.
Refugee and migrant children arriving in Germany unaccompanied have been found to
have higher rates of colonization with multidrug-resistant bacteria
(32)
. These children
are potentially at risk of morbidity and mortality from contracting clinically important
infections, which would be more difficult to treat and need specialized hospital care.
Outbreaks of measles, a potentially vaccine-preventable disorder, have been reported
in asylum-seeking children. A literature review in 2016 covering publications from 2012
onwards found that outbreaks of measles were linked to lack of protective vaccine-
related antibodies for measles and other main vaccines in a significant proportion of
migrant children in Europe
(33)
. This underlines the importance of establishing public
health routines for vaccination of young migrants entering Europe.
Noncommunicable diseases
Compared with their Swiss peers, migrant children had more dental cavities, twice
the odds of being obese and migrant adolescents seemed more frequently affected by
psychological problems
(14).
Children of migrants may have distinct health needs and
paediatric care and health promotion activities should be aware of these.
Nutrition
The first years in the country of destination may put newly settled children at risk for
the development of obesity; this is linked to issues such as stress and the potential
for replacement of dietary habits in the country of origin with food less suitable for
children, including new breastfeeding patterns
(34)
. The lack of sunshine during the
winter also puts children with dark skin at particular risk for the development of vitamin
D deficiency if this is not supplemented
(35,36)
.
Mental health and psychological well-being
There is abundant evidence showing that newly arrived migrant children are at high risk
for mental and psychosocial problems
(37–39)
, predominately internalizing disorders
– post-traumatic stress disorder, depression and anxiety – associated with exposure
to organized violence and migration stress
(40)
. Externalizing symptoms, however,
appear to be no more common in migrant children than in children in the host majority
population
(39)
. Longitudinal studies of refugee children in Scandinavia during the
1990s showed that the high rate of internalizing symptoms on arrival in the destination
country tended to fade slowly over time, with post-traumatic stress disorder being rare
six or seven years after arrival
(41)
. Risk factors associated with life in the country of
Technical guidance
10
destination, such as socioeconomic deprivation, parental divorce and bullying, were
identified as important determinants of mental health at follow-up
(41)
.
Migrant children often have to cope with parents who themselves are suffering from
stress-related psychological disorders after traumatic experiences and migration
stress. Caregivers with psychiatric disorders may struggle to provide their children
with a sense of security and psychological support
(42)
, as has been shown in studies
of families of Holocaust survivors
(43)
. In combination with socioeconomic deprivation,
these parenting difficulties also increase the risk for child abuse
(44)
.
Unaccompanied/separated children
Around 20% of the asylum-seeking children in the EU during recent years have arrived
unaccompanied by an adult caregiver, most of them boys aged 15–17 years on arrival
(4)
. Unaccompanied or separated children are at high risk for exploitation and trafficking
as they lack the protection and support of a caregiver. Consequently, they are also
particularly vulnerable for the development of poor mental health and well-being.
Large epidemiological studies of unaccompanied teenage asylum seekers in Belgium
and the Netherlands have confirmed this vulnerability, demonstrating high rates of
depression and post-traumatic stress disorder during the first years after resettlement
(21,45,46)
. At the same time, there are also indications that unaccompanied children
often are resourceful and arrive with a clear vision of a positive future in the new country
despite the suffering they may have endured
(47)
. Education and continuity in care so
that relations can be maintained with substitute caregivers during the first years after
resettlement have been identified as key determinants of long-term adjustment of
unaccompanied children
(47)
.
Having an assumed chronological age above or below 18 years determines the support
provided for young asylum seekers in most European countries, despite the fact that
many, particularly unaccompanied children, lack documents with an exact birth date
(48)
. This has led to the use of many different methods to assess age. The majority of EU
Member States rely on medical examinations, primarily in the form of radiograph of the
hand/wrist, collarbone and/or teeth
(49)
; more recently magnetic resonance imaging
has been utilized
(50)
. Factors such as individual variation in age-specific maturity in
later teenagers, and unknown variations between children from high- and low-income
countries, make these methods unreliable for correct assessment of whether a young
person is below or above 18 years of age
(51,52)
.
The imprecision of these methods to assess age raises serious ethical and human
rights concerns and is often experienced as unfair and stressful by the young asylum
seekers themselves. The European Academy of Paediatrics and several national
medical associations have, therefore, recommended their members not to participate
in medical age-assessment procedures for asylum applicants on behalf of the state.
European paediatric associations instead advocate for a holistic age assessment to
allow for the benefit of the doubt that these imprecise methods demand
(53)
.
Health of refugee and migrant children
11
Child trafficking
Refugee and migrant children are at increased risk of being trafficked for sexual
exploitation, labour exploitation, forced criminal activities, illegal adoption and street
begging
(54)
. At particularly high risk are children who become separated from family,
children travelling unaccompanied and children who are left behind
(55)
. Traffickers
exploit young age and the challenges that young migrants face such as unfamiliarity
with new surroundings, separation from family and friends, language barriers and
social isolation
(56)
. In a survey of migrants in Bulgaria, Greece, Hungary, Italy, Romania
and countries of the former Yugoslavia by the International Organization for Migration
in 2017, 88% of children surveyed reported having experienced exploitation in labour,
being locked up and/or being approached with an offer of arranged marriage
(57)
. Even
after arrival at their destination, children continue to be at risk. An estimated 10 000
unaccompanied minors went missing in Europe in 2015, many while in state care
(56)
.
Factors that protect migrant children from trafficking include living in a supportive
and stable family environment, the existence of well-functioning child protection and
social support systems, access to education, access to information on safety and child
rights, access to health care and the existence of intervention strategies aimed at
preventing trafficking
(55)
.
Children left behind
Many adult migrants arrive in a country of destination without their children or
partners. Parents are the main sources of social and physical support for children and
separation from them can be detrimental a child’s health and well-being, particularly
mental health
(58)
. The CRC is very clear on the right of children to be united with their
parents. It requires states to protect children against separation from their parents
against their will (Article 9), and to ensure that applications of a child or his or her
parents for the child to leave a country for the purpose of family reunification are
dealt with “in a positive, humane and expeditious manner” (Article 10, paragraph 1)
(5)
. Migration policy in many European countries today violates this obligation by
creating obstacles for family reunification
(59)
, leaving the children left behind in dire
circumstances without protection of their caregiver.
Promoting mental health and well-being in migrant children
A public health strategy to promote well-being and mental health in migrant children
should have a holistic framework, targeting risk factors for the individual their family
and the community using a mixture of policy-based and more specific interventions
(Fig. 2)
(10)
.
Risk factors at the individual level are primarily targeted by the more specific
interventions described below. Parents are the most important psychological support
children have provided that they are not separated from them. Access to adequate
psychological support for parents suffering from psychiatric disorders is, therefore,
an important part of support for children. Additionally, schools and child care centres
Technical guidance
12
provide a sense of security and help children to develop social support systems. A
beneficial effect has been shown even with only a few hours of school each day
(60)
.
On the level of context, government policy defines many aspects of the socioeconomic
living conditions for asylum seekers, such as material resources and housing. These
are important social determinants of health in general, applying equally to migrant
children
(10)
. The stress associated with the asylum process is profound and has been
shown to increase with time of waiting
(61,62)
; this makes effective administrative
procedures during the asylum process particularly important for children.
The second paragraph of the CRC non-discrimination legislation implies that nations
should provide care on the same terms for both migrant and resident children. However,
a survey in 2016 found that entitlements to care for migrant children varied considerably
between countries in the EU/EEA
(28)
. Migrant children legally categorized as asylum
seekers were more likely to be entitled to health care on equal terms with resident
children than were other migrant children without permanent residency. Only 11 EU
Member States provided similar care arrangements for irregular migrant children from
non-EU/EEA countries.
The system used to fund health care differs considerably across Europe. Some
countries have a tax-based system while others are funded by insurance. Although
the insurance-based system is more administratively complicated in terms of funding
health care for migrant children, the effective working solutions to this challenge in
insurance-funded countries such as France and the Netherlands show that these
obstacles can be overcome.
Health care provided in a primary care setting is, in most societies, the most cost-
effective way of providing psychological support, which is the most pressing health
care need for migrant children, particularly for victimized children who have a specific
right to rehabilitation (CRC Article 39). European governments also have to consider
how health care can be delivered in a context that allows children in an irregular
situation to access care without fear of deportation
(63)
.
Newly settled migrants face numerous barriers for accessing care: unfamiliarity with
rights, entitlements and the overall health system; gaps in health literacy; social
exclusion; and direct and indirect discrimination
(3,64)
. Outreach strategies with
access to services and closely connected with asylum centres and refugee-dense
neighbourhoods are important to overcome these barriers
(27)
. Cultural and language
barriers can also influence the quality of the care received. The use of professional
medical interpreters improves the quality of communication, and studies have found
that using professional interpreters also reduces the cost of care and helps to avoid
unnecessary diagnostic evaluations and treatments. Cultural mediators facilitate the
care process by explaining health concepts and health behaviours, and by helping to
ensure that investigations and treatments take into account culturally specific needs.
Before migrant families find a more permanent home in the country of destination,
they often pass through less than satisfactory transitory housing facilities, including
detention centres. To promote child well-being in these situations, child-friendly
Health of refugee and migrant children
13
spaces have been developed. These are spaces that are designed to promote a sense
of safety and normality in children whose lives have been disrupted
(65)
. They are
used to promote resilience and well-being in children and are, therefore, adapted
to meet their needs, often with colourful decorations, child-sized furniture, simple
toys and structured activities. Child-friendly spaces can be set up virtually anywhere
that is safe, including in asylum centres, government offices that carry out asylum
procedures, health facilities, schools, community settings and even in detention
centres. Child-friendly spaces have been used successfully in psychosocial and
educational interventions to promote child mental health both during and after armed
conflict
(65)
.
Summary
The evidence presented in this technical guidance is primarily based on observational
reports and theory, and on individual evaluative studies, reflecting the lack of rigorous
evaluative research of policies and specific interventions on facilitating health, well-
being and positive development for migrant children in Europe
(66)
. There are large
knowledge gaps in research on understanding pathways to resilience and in assessing
the impact of specific interventions that evidence suggests may be effective in
improving outcomes. Long-term follow-up is required to evaluate interventions that
enhance well-being, educational outcomes, employment and social inclusion. Close
collaboration between policy-makers and key service providers is also essential to
ensure optimal translation of findings into sustainable practice
(21)
.
Technical guidance
14
Areas for intervention
The burden of poor mental health and psychological well-being in refugee and migrant
children has been addressed by interventions specifically developed to target newly
settled refugee and migrant children and families. Three different strategies are
illustrated with case studies: psychoeducation, parenting support and school-based
programmes.
Psychoeducational interventions
Psychological trauma, often associated with conflict and persecution in the country
of origin or events during the migration journey, is an important risk factor for poor
mental health and well-being in newly arrived migrant children. Interventions based
on psychoeducational principles have been developed to help migrant children to cope
with their symptoms (Case study 1)
(67)
.
Case study 1. Teaching Recovery Techniques (Sweden, the United
Kingdom)
Teaching Recovery Techniques is a psychosocial intervention for children who
have experienced traumatic events. It was initially developed for children who had
experienced war or disasters, including refugees and asylum-seeking children, but
the programme has since been used for groups of children who have experienced
other kinds of trauma. Children take part in group sessions aimed at enhancing
emotional regulation, coping skills and problem-solving techniques, and in helping
the children to express themselves. A parent component has two parallel sessions
that provide information on the intervention and education on techniques to
support their children.
The Teaching Recovery Techniques approach has been used in numerous contexts
since its first development in 1999 and has been shown to reduce children’s
distress and post-traumatic symptoms and to improve peer and sibling relations
(67,68)
. Recently, it was also adapted to the context of unaccompanied children,
with positive effects on symptom levels
(69)
. A manual for the programme is now
available in 10 languages
(70)
.
Duration
: five sessions, 1.5 hours per session.
Cost
: training programme for trainers £300 per person in the United Kingdom.
Health of refugee and migrant children
15
Parenting support programmes
Caregivers are the main source of support for all children and this is particularly true
for migrant children during the journey and the first phase of resettlement when other
sources of social support are often non-existent. Findings ways of strengthening
parents as a source of support for their children is, therefore, vital (Case studies 2 and
3)
(67)
.
Case study 2. Ladnaan: a culturally sensitive parent-support programme
for Somali-born parents (Sweden)
Ladnaan is a 12-week culturally adapted parenting support programme combined
with civic orientation for Somali-born parents living in Sweden. The programme
builds on the well-established parent-support programme Connec, but was
modified by qualitative interviews with Somali parents in Sweden about the
parenting challenges they experience in the new society
(71)
.
The programme was provided in weekly group-based sessions lasting 1–2 hours
each, facilitated by a trained community educator of Somali origin. In addition to
societal information, parents received educational lectures and participated in
workshops and discussions on the parent–child relationship, attachment, child
development and challenged interactions.
The effect of the programme was studied in a randomized controlled trial of 57
parents of children aged 11–16 years with self-reported stress related to parenting
practices, compared with a control group of 52 parents on the waiting list for
Ladnaan. Children’s behaviour was examined by parent reporting, using the Child
Behaviour Checklist. Parents participating in Ladnaan reported higher efficacy and
parent satisfaction after having participated in the programme, and significant
improvement in behavioural problems in their children two months after completing
the programme
(72)
.
Duration
: 12 weeks.
Cost
: €120 per parent/family included in the programme in Sweden.
Technical guidance
16
Case study 3. Mind-Spring (Belgium, Denmark, the Netherlands)
Mind-Spring is a mental health prevention programme in Belgium, Denmark and
the Netherlands that provides psychoeducation plus psychosocial and parenting
support for asylum-seeking parents in a culturally sensitive manner and in their
own language
(73)
.
Training sessions for parents are carried out by a trainer with a refugee background
and a mental health professional and cover topics such as stress, trauma,
depression, identity, acculturation and mental health care. The programme is
designed to facilitate the sharing of experiences and to empower parents with
knowledge about mental health and the ability to recognize signs of trauma and
mental illness in themselves. It also gives information about where to seek help.
Additionally, parents receive training and support in parenting practices and how
to navigate cross-cultural parenting issues. Participants in the programme report
improved understanding of the effect of migration and trauma on their reactions
and behaviour, improved understanding of mental health and an increased sense
of control.
Duration
: eight sessions, 2 hours per session.
Cost
: €1375 for eight group sessions in Belgium.
School-based health promotion
A growing body of evidence and experience has shown that schools play a critical role
in protecting and promoting the health of refugee and migrant children. Successful
school-based mental health prevention requires professionals trained in cultural
competence, who understand the mental health needs and risks of refugee and
migrant children, and who are able to adapt the learning programme to the needs of
the individual child and family. The literature on school-based programmes is large
and includes programmes that focus on promoting a healthy adaptation to the host
society in a holistic manner (Case studies 4 and 5), plus ones that focus on specific
child mental health issues and that use particular treatment modalities to promote
child mental health
(67,74)
.
Health of refugee and migrant children
17
Case study 4. Hearing All Voices (United Kingdom)
Hearing All Voices was a pilot project undertaken by Child to Child in London,
United Kingdom, in 2013–2016, aimed at enhancing social inclusion, engagement
in educational activities and social participation among vulnerable youth, with a
particular focus on refugee, migrant and asylum-seeking youth
(75)
. The project
used a child rights participatory approach, whereby the students, aged 16–18 years,
identified a social problem that they wished to address, investigated the issue,
designed an intervention, implemented it, evaluated the results and identified
future steps and needs. In order to equip the students for their projects, they were
given training in the English language and in activities designed to enhance agency,
communication and teamwork. Additionally, teachers and teaching assistants
were trained in methods of supporting the participation of young people in the
classroom while being non-directive.
Over the three years, the groups developed projects on a wide range of issues,
including street safety, knife crime, homelessness, bullying in schools and the
care of Ebola orphans. At the end of the project, students reported improved self-
confidence and a sense of self-worth, an increased sense of control over their lives
and improved ability to initiate conversations with adults. The projects created a
space for the young people to speak about their lives and experiences, and teachers
reported that this helped them to better understand the needs of their students.
Teachers noted substantial improvement in the students’ communication, ability
to work in groups and increased solidarity and mutual support, with these effects
apparent from early stages of the project and increasing throughout the project.
Hearing All Voices demonstrates the potential for educational interventions to
promote the social and psychological well-being of youth on the move, and enhance
their language and life skills. The project is also an example of a successful way to
train professionals working with youth on the move to understand and respond to
their needs.
Evaluations of this project showed improved peer relations and life skills among
the students plus enhanced engagement with the wider school and community
(75)
.
Duration
: 19 weeks.
Cost
: £120 per student for the 18-session programme in the United Kingdom.
Technical guidance
18
Case study 5. The Pharos Schools Programme (the Netherlands)
The Pharos Schools Programme provides classroom programmes in the Netherlands
focused on nurturing social participation among migrant children with host society
children and adults while also providing individualized attention according to the
needs of the child
(76)
. The Programme is offered in special primary and secondary
schools for refugee and asylum-seeking children. Teachers are trained in teaching
techniques for children at each developmental level. The techniques include verbal
and nonverbal activities, with attention to past and present life, identity, feelings of
trust and safety, and the development of agency in the children. In a version of the
programme in the United Kingdom, services from refugee community organizations
are also included
(77).
Duration
: primary school programme 8 weeks; secondary school programme 21
lessons.
Cost
: not available; guidance materials are available for teachers and students
which cost €20–34.95 for teachers and €5 for students.
Case study 6. Health assessment in a school setting (Sweden)
In the Swedish city of Malmö, a central unit in the school system screens all children
who have recently arrived with an origin outside Sweden. Screening for infectious
disorders is not included as this occurs at a separate county council unit.
The school nurse meets all children and their caregivers for a health assessment to
broadly define and address each child’s health care needs. An interpreter is used if
needed. For children without their original caregiver, the city provides a substitute
caregiver for the assessment.
There is a structured interview and a superficial examination of the body, including
dentition, eyesight and hearing, and the child’s height and weight are recorded.
Structured questions are posed regarding acute symptoms (e.g. diarrhoea, jaundice,
cough, fever, skin problems, fatigue, pallor or nightly sweat) and an immediate
referral is made to a physician in a primary care clinic if any are identified.
Questions are also posed about long-standing health problems (e.g. stunted growth
or disabilities) and medications. Mental health problems are explored using open
questions that explicitly ask about symptoms associated with traumatic events or
sleeping disturbances. These are only recorded if the symptoms are severe enough
to impair the well-being of the child. Vaccination history is taken from documents if
these are available and if not through the use of structured questions.
Health of refugee and migrant children
19
Case study 6. (contd)
Identified health care needs that are not urgent are addressed initially by the school
health team of nurses, physicians, psychologists and social workers. Children with
milder forms of mental health problems are provided with psychoeducational
advice and followed up. Referrals are made if more specialized services are needed.
The results of the interview and the examination are documented in a structured
patient record and statistics are regularly produced based on these records. During
the autumn semester of 2015, 639 children aged 6–18 years who were either asylum
seekers or children in refugee families were screened. Immediate referral to a
physician was needed for 1% of accompanied children and 5% of unaccompanied
children; 20% of accompanied children and 39% of unaccompanied children
needed support from the school health team. Mental health issues were twice as
likely in the unaccompanied children (e.g. 33% with sleep problems and 22% with
post-traumatic stress, compared with 15% and 6%, respectively, in accompanied
children). Almost 50% of children in both groups had untreated caries.
Source
:
Stefan Kling and Anders Hjarn, unpublished information.
Technical guidance
20
Policy considerations
National governments have an important role in the creation of living conditions for
refugee and migrant children. Most newly settled refugee families rely on government
support for housing and living expenses, and governments define the rights of children
to access health care services and education. Local government has an important role
in adjusting services to the special needs of refugee and migrant children. The following
policies considerations are suggested as methods to promote health and well-being,
particularly mental health, which is a major issue, in these circumstances. (Annex 2
lists some resources to support decisions on service provision.)
Health promotion strategies
Access to equitable care and education for all categories of migrant children
Article 2 of the CRC implies that nations should provide care to all categories of
migrant children on equal terms with resident children. Access to education, including
pre-school, is another fundamental right in the CRC that is particularly important
for refugee and migrant children. The provision of medical interpreters and cultural
mediators is important to ensure that care provision for migrant children is more
equitable with that for the majority population. The use of professional interpreters
with medical knowledge improves the quality of translation, and studies have found
that using professional interpreters reduces the cost of care and helps to avoid
unnecessary diagnostic evaluations and treatments.
Provision of psychological support is the most pressing health care need for migrant
children and in most societies the primary health care setting is the most cost-effective
way of providing this. This is particularly important for victimized children (CRC outlines
specific rights to rehabilitation in Article 39).
Individualized health assessment
Most European countries today provide some kind of health screening for newly arrived
migrants but in many this only covers communicable disorders. A comprehensive
individualized health assessment by a paediatric nurse or clinician, preferably as soon
as possible after the child arrives in the country of destination, can identify health care
requirements that might otherwise go undetected for prolonged periods of time. It can
also link newly arrived migrant children and their families with primary health care and
coordination of care across primary health and specialist services, thus reducing costs.
Health of refugee and migrant children
21
Public health strategies
Intersectoral collaboration for promotion of health and well-being
A public health strategy to promote well-being and health in migrant children should
have a holistic framework, targeting risk factors on individual, family and community
levels. Moving children between multiple locations hinders the creation of peer
networks and educational continuity. For unaccompanied children, minimizing
relocation is particularly important to allow them to build good sustainable relations
with substitute caregivers. Before migrant families find a more permanent home in
the country of destination, they often pass through less than satisfactory transitory
housing facilities, sometimes including detention centres. To promote child well-
being in these situations, child-friendly spaces can be developed that are designed to
promote a sense of safety and normality in children whose lives have been disrupted.
A public health strategy to promote mental health and psychological well-being
in migrant children should target the support systems for the children as well as
identifying and treating specific issues. The most important psychological support for
children is their parents. Consequently, early/expedited family reunion, as outlined in
the CRC, is essential for the well-being of refugee and migrant children. Other important
aspects are early access to education for children in pre-school and access for parents
to psychiatric care, trauma-informed care and education.
Avoidance of detention of migrant children
Children are more vulnerable than adults to the negative consequences of detention on
health, particularly their mental health. Consequently, detention should not be used as
a means for control or deportation of migrant children. If such use is unavoidable, the
facilities should include child-friendly areas and access to health care and education.
Holistic age assessment
Many unaccompanied young people lack documents to prove their age. Since children
have additional rights over adults, an assessment of their age is often deemed
necessary. Current evidence indicates that medical methods cannot determine age
accurately in those in their upper teens with the precision needed for this critical
determination. Therefore, a holistic assessment that provides fair benefit of the doubt
is highly preferable.
Technical guidance
22
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Technical guidance
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Recommended reading
European Commission (2016). European Forum on the rights of the child: the protection
of children in migration. Brussels: European Commission (http://ec.europa.eu/
newsroom/just/item-detail.cfm?item_id=34456, accessed 31 August 2018).
Fazel M, Betancourt T (2018). Preventive mental health interventions for refugee
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2(2);121–32.
Issop Migration Working Group (2018). ISSOP position statement on migrant child
health. Child Care Health Dev. 44(1):161–70.
Stubbe Ostergaard L, Norredam M, Mock-Munoz de Luna C, Blair M, Goldfeld S, Hjern A
(2017). Restricted health care entitlements for child migrants in Europe and Australia.
Eur J Public Health. 27(5):869–73.
Tyrer RA, Fazel M (2014). School and community-based interventions for refugee and
asylum seeking children: a systematic review. PLOS One. 9(2):e89359.
WHO Regional Office for Europe (2016). Strategy and action plan for refugee and migrant
health in the WHO European Region. Copenhagen: WHO Regional Office for Europe (EUR/
RC66/8; http://www.euro.who.int/__data/assets/pdf_file/0004/314725/66wd08e_
MigrantHealthStrategyActionPlan_160424.pdf, accessed 30 August 2018).
Woodland L, Burgner D, Paxton G, Zwi K (2010). Health service delivery for newly arrived
refugee children: a framework for good practice. J Paediatr Child Health. 46(10):560–7.
Zwi K, Woodland L, Mares S, Rungan S, Palasanthiran P, Williams K et al. (2018). Helping
refugee children thrive: what we know and where to next. Arch Dis Child. 103(6):529–32.
Health of refugee and migrant children
29
Annex 1. Child asylum applicants in the EU/EEA
during 2015–2017
Country 2015 2016 2017 All children
2015–2017 (% of
total applicants)
Unaccompanied
and separated
children (% of
total in country)
Austria 32 225 17 865 12 020 62 110 (6.0) 13 525 (21.8)
Belgium 13 630 5 690 5 535 24 855 (2.4) 4 300 (17.3)
Bulgaria 5 495 6 575 1 200 13 270 (1.3) 5 005 (37.7)
Croatia 020 465 180 665 (0.1) 215 (32.3)
Cyprus 530 685 690 1 905 (0.2) 545 (28.6)
Czechia 270 275 265 810 (0.1) 015 (1.9)
Denmark 6 320 2 410 1 175 9 905 (1.0) 3 770 (38.1)
Estonia 070 065 080 215 (0.0) 000 (–)
Finland 7 625 1 740 1 350 10 715 (1.0) 3 080 (28.7)
France 14 020 15 285 20 995 50 300 (4.8) 1 385 (2.8)
Germany 148 170 268 195 96 585 512 950 (49.4) 67 275 (13.1)
Greece 2 500 19 720 19 785 42 005 (4.0) 5 225 (12.4)
Hungary 45 895 8 550 1 595 56 040 (5.4) 10 255 (18.3)
Iceland 090 275 175 540 (0.1) 035 (6.5)
Ireland 385 580 840 1 805 (0.2) 100 (5.5)
Italy 7 295 11 170 15 510 33 975 (3.3) 20 095 (59.1)
Latvia 085 125 135 345 (0.0) 025 (7.2)
Liechtenstein 040 015 050 105 (0.0) 010 (9.5)
Lithuania 070 165 185 420 (0.0) 005 (1.2)
Luxembourg 780 625 630 2 035 (0.2) 205 (10.1)
Malta 395 455 465 1 315 (0.1) 055 (4.2)
Netherlands 10 580 6 220 4 280 21 080 (2.0) 6 740 (32.0)
Norway 10 370 1 250 1 080 12 700 (1.2) 5 235 (41.2)
Poland 5 570 5 920 2 335 13 825 (1.3) 405 (2.9)
Portugal 145 360 560 1 065 (0.1) 115 (10.8)
Romania 295 530 1 595 2 420 (0.2) 365 (15.1)
Slovakia 105 035 035 175 (0.0) 015 (8.6)
Slovenia 085 425 510 1 020 (0.1) 675 (66.2)
Spain 3 720 3 740 8 030 15 490 (1.5) 075 (0.5)
Sweden 70 385 10 875 9 005 90 265 (8.7) 37 740 (41.8)
Technical guidance
30
Country 2015 2016 2017 All children
2015–2017 (% of
total applicants)
Unaccompanied
and separated
children (% of
total in country)
Switzerland 11 425 9 245 6 990 27 660 (2.7) 5 420 (19.6)
United
Kingdom
8 280 9 505 7 660 25 445 (2.5) 8 635 (33.9)
Total 406 870 409 045 221 525 1 037 440 (100) 200 550 (19.3)
Source
:
Eurostat, 2017
(2)
.
Health of refugee and migrant children
31
Annex 2. Resources
Clinical care
Caring for Kids New to Canada
The Canadian Paediatric Society through its website Caring for Kids New to Canada
provides guidance to help health professionals providing care to refugee and migrant
children, youth and families.
The website provides information on when and how to use cultural mediators and
language interpreters in the care of migrant children. This includes guidance on the
role of the interpreter and on how to work with interpreters during a medical encounter.
Ite also provides guidance on the needed skills of the interpreter, risks and pitfalls of
using untrained interpreters and further literature on using language and culture-
incongruent health encounters.
Paediatric-focused guidance on medical assessment as well as information on
migration patterns to Canada and relevant health risks and needs for migrant children
is also provided.
Canadian Paediatric Society (2018). Caring for Kids New to Canada [website]. Ottawa:
Canadian Paediatric Society (https://www.kidsnewtocanada.ca/, accessed 25
September 2018).
The Migrant-friendly Hospitals initiative
The EU Migrant-friendly Hospitals initiative was developed to enhance health service
needs for migrant populations. A study was conducted in Switzerland to examine how
such initiatives might address specific needs during hospital-based care of migrant
children. This study identified a need for the development of migrant-sensitive
approaches suitable for children. Specific areas of focus include support and training
of staff, the availability of interpreters, and allotting adequate time for consultation.
Hudelson P, Dao MD, Perneger T, Durieux-Paillard S (2014). A “migrant friendly
hospital” initiative in Geneva, Switzerland: evaluation of the effects on staff knowledge
and practices. PLOS One. 9(9):e106758.
Jaeger FN, Kiss L, Hossain M, Zimmerman C (2013). Migrant-friendly hospitals: a
paediatric perspective: improving hospital care for migrant children. BMC Health Serv
Res. 13:389.
Krajic K, Stramayr C, Karl-Trummer U, Novak-Zezula S, Pelikan JM (2005). Improving
ethnocultural competence of hospital staff by training: experiences from the European
“Migrant-friendly Hospitals” project. Diversity Health Social Care. 2(4):279–90.
Technical guidance
32
Child and adolescent health promotion
Becoming Adult
The Becoming Adult project that explores the transitions of unaccompanied young
migrants, including the perspective of transitions from youth to adulthood as well
as the social processes of migration and resettlement in a new country. The study
involves young people from Afghanistan, Albania, Eritrea and Vietnam and involves
three distinct work packages: Young people’s conceptions of futures and wellbeing,
Cultural conceptions of futures and wellbeing and Policy conceptions of futures and
wellbeing.
The Becoming Adult Project (2018). Becoming adult: conceptions of futures and
wellbeing among migrant young people in the UK (https://becomingadult.net/about-
becoming-adult/, accessed 25 September 2018).
Classroom programme of creative expression workshops for refugee and
migrant children
Numerous governmental and nongovernmental programmes have incorporated
artistic expression in programmes for forcibly displaced children and for children who
have experienced adverse events. In spite of its broad use, there are few studies that
evaluate the effectiveness of this approach. A study from Montreal, Canada, found
that migrant children who participated in a 12-week creative expression programme
reported fewer internalizing and externalizing symptoms, independent of gender, age,
or fluency in the mainstream language. Additionally, students participating in the
programme reported higher self-esteem, with a particularly strong effect for boys.
Rousseau C, Drapeau A, Lacroix L, Bagilishya D, Heusch N (2005). Evaluation of a
classroom program of creative expression workshops for refugee and immigrant
children. J Child Psychol Psychiatry. 46(2):180–5.
Resources on migrant health policy
Investing in children: the European child and adolescent health strategy
2015–2020
This report highlights the importance of early child development and access to health
services for migrant children. The report calls for evidence-informed policies for
migrant child health.
WHO Regional Office for Europe (2014). Investing in children: the European child
and adolescent health strategy 2015–2020. Copenhagen: WHO Regional Office for
Europe (http://www.euro.who.int/__data/assets/pdf_file/0010/253729/64wd12e_
InvestCAHstrategy_140440.pdf?ua=1,. accessed 25 September 2018).
The WHO Regional
Office for Europe
The World Health Organization (WHO) is a
specialized agency of the United Nations created
in 1948 with the primary responsibility for
international health matters and public health.
The WHO Regional Office for Europe is one of
six regional offices throughout the world, each
with its own programme geared to the particular
health conditions of the countries it serves.
Member States
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czechia
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
The former Yugoslav
Republic of Macedonia
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
World Health Organization Regional Office for Europe
UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01
Email: eurocontact@who.int
Website: www.euro.who.int
