Effect of overseas parental employment migration on healthcare seeking for common childhood illnesses and nutritional status among left-behind young children: A systematic review

Abstract

We aimed to examine the available evidence on the impact of overseas parental migration on healthcare seeking for common childhood illnesses and the nutritional status of children left-behind under five years of age. A systematic review of English language articles was conducted on PubMed, MEDLINE and EMBASE, supplemented by a manual search of grey literature and reference lists. There were no studies examining the association between overseas parental migration and healthcare seeking for common childhood illnesses. We found three cross-sectional surveys examining the association with an indicator of nutritional status. We observed mixed findings from the available studies. The results indicated that children left-behind may have positive, negative or null effects on their nutritional status. There was insufficient information available to draw conclusions on the magnitude and direction of the association between overseas parental migration and its effect on either healthcare seeking for common childhood illnesses or the nutritional status of left-behind children. The association, if any, may be context or country dependent. Prospective studies are needed to address this important knowledge gap.

Keywords

Healthcare illness left-behind children nutrition parental migration

Introduction

International labour migration is defined as the movement of people from one nation to another for employment. Labour migration from low- to high-income countries has sharply increased in recent years. Worldwide 105 million people were working as foreign migrants in 2010, increasing to 150 million by 2013 (International Labour Organization, 2014, 2015). International labour migration plays a crucial role in the global economy. Globally in 2011, about $US440 billion was earned by foreign migrant workers, leading to an estimated $US350 billion in remittances to their home countries (International Organization for Migration, 2011).

Remittances from an international migrant are usually higher than those from an internal migrant. In 2015, international migrants from Bangladesh sent total remittances valued almost 3.5 times higher per migrant to their households of origin compared with internal migrants, and international remittances accounted for 8% of total gross domestic product (GDP) (Rahman et al., 2015; The World Bank, 2016a). Greater income opportunities and substantially larger remittances make international migration more attractive than internal migration for workers in low-income countries such as Bangladesh and Nepal (International Labour Organization, 2010; Rahman et al., 2015). Nepal is a country that highlights the extraordinary role played by international migration in the economy of developing countries. In 2015, overseas remittances accounted for one-third of Nepal’s GDP (The World Bank, 2016b).

When parents undertake international labour migration, children are left-behind in the care of grandparents or a remaining parent. This is a common phenomenon in the developing world (Cortes, 2008; UNICEF, 2007). Available United Nations Children’s Fund statistics in recent years indicate that up to one quarter of children aged less than five years in developing countries have at least one parent living abroad. Migration of fathers (up to 23% of children aged under five years) is more frequent than migration of mothers (up to 2%) (UNICEF, 2014).

International parental migration may have both negative and positive effects on the health and well-being of left-behind children. The remittances sent home can increase the purchasing power of households, making them able to invest in general health and household infrastructure, mitigate the impact of crop failures and improve the consumption of nutritious foods (Azzarri and Zezza, 2011; Jayatissa and Wickramage, 2016). This could ultimately lead to better health and well-being of the left-behind family members. However, parental absence can lead to burdened mothers or carers having reduced time to look after children’s health and well-being (Azzarri and Zezza, 2011; Jayatissa and Wickramage, 2016). Also the burden of loans taken out for migration, and associated interest repayments, may diminish the expected benefits and make household members worse-off (Basa et al., 2012; Frank and Wildsmith, 2005).

In particular, international migration may alter the family’s ability to seek healthcare for common childhood illnesses such as diarrhoea, fever and acute respiratory infections (ARIs) in left-behind children. Globally, 5.9 million children under five years of age died in 2015, and nearly one third of these deaths were due to diarrhoea, pneumonia or malaria (UNICEF-WHO-The World Bank-United Nations, 2015). Improving availability and access to health services and delivery of appropriate healthcare are important pathways to better health outcomes for children experiencing these acute illnesses (Sreeramareddy et al., 2006). Oral rehydration therapy and zinc supplementation can prevent deaths from diarrhoea (WHO, 2005). Appropriate antibiotic treatment and other supportive care can prevent deaths from pneumonia and other ARIs (Sazawal et al., 2003). Similarly, timely treatment with antimalarial drugs can reduce morbidity and mortality from malaria (WHO, 2015).

Adequate nutrition is essential for normal childhood growth and development. International migration may alter families’ resources for providing adequate nutrition for left-behind children. Height for age, weight for height and weight for age are common measures of nutritional status, and values 2 SDs below the World Health Organization (WHO) child growth median standards are defined as stunting, wasting and underweight, respectively. Generally, stunting indicates a long-term nutritional insufficiency. It can be caused by inadequate nutrient intake over a long period or by persistent illnesses and infections. Wasting is a measure of acute malnutrition, mainly due to acute starvation (shortage of food) or severe acute diseases, whereas underweight reflects both acute and chronic under-nutrition (WHO, 2017b). Under-nutrition among children continues to be a major public health problem, particularly in Southern Asia and sub-Saharan Africa (UNICEF-WHO-The World Bank, 2012). Globally in 2016, the prevalence of stunting, wasting and underweight among children aged under five years was 23%, 8% and 14%, respectively (The World Bank, 2016c, 2016d, 2016e). Causes of under-nutrition are multifactorial, including reduced access to food, poor health and inappropriate feeding and caring practices operating at various levels (UNICEF, 1998).

Parental overseas migration may have a positive or negative impact on several underlying causes of under-nutrition for left-behind children, such as access to food and health services, and maternal and child care practices (Cortes, 2008). Mother’s knowledge about child care practices affects the type and amount of care that is provided to children (Amugsi et al., 2014; Popkin, 1980), so mothers staying with children may provide better care than fathers or other family members. A Nigerian study reported relatively poorer psychological well-being of left-behind children when the father was the caregiver, and the mother migrated for work, but no differences were identified in a Ghanaian study, suggesting that such effects may differ contextually (Mazzucato et al., 2015). Vietnamese research has indicated that psychological problems, such as anxiety, hyperactivity, depression and behavioural disorders, are more likely to occur in children whose mother or both parents have migrated abroad for employment (Luot and Dat, 2017).

Healthcare and nutrition are critical for early childhood growth and development (Grantham-McGregor et al., 2007; WHO, 2017c). More than half of under-five child deaths could be avoided or treated with access to simple and affordable interventions (WHO, 2017a). In this systematic literature review, we aim to examine the association between parental overseas migration and (1) healthcare seeking for common childhood illnesses and (2) the nutritional status of left-behind children aged under five years.

Methods

We designed a protocol and registered it in the International Prospective Register of Systematic Reviews (PROSPERO) (Registration number CRD42016049826) (National Institute for Health Research, 2017). This review was conducted and reported according to Preferred Reporting Items For Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009) (Online Supplementary Appendix 1).

Eligibility criteria

A separate systematic literature search was conducted for each study aim. The inclusion criterion for both aims was any study design that examined and reported on care seeking for common childhood illnesses or nutritional status (stunting, wasting or underweight) in children aged under five years (0–59 months) and compared the results for households where at least one parent migrated abroad to households where neither parent migrated abroad for employment.

Information sources and search of the literature

We performed a systematic search of the PubMed, MEDLINE and EMBASE databases in June 2017. To include all potential articles, we used a wide range of Medical Subject Headings (MESH) terms and their combinations (MeSH). The precise search queries for each aim are shown in Online Supplementary Appendices 2 and 3, respectively. For the first aim, the following search terms were used: parent; parental; father; mother; migration; migrant; migrating; migrate; work; labour; labor; employment; job; international; overseas; child; children; health; illness; disease; infection; healthcare; ‘health-care’; fever; diarrhoea; gastroenteritis; and respiratory.

For the second aim, we used the following search terms: parent; parental; father; mother; migration; migrant; migrating; migrate; work; labour; labor; employment; job; international; overseas; child; children; nutrition; ‘nutritional status’; ‘undernutrition’; under-nutrition; growth; ‘physical growth’; malnutrition; stunting; wasting; underweight; ‘anthropometric outcomes’; ‘height for age’; ‘weight for age’; and ‘weight for height’.

We also conducted a manual search of the grey literature using Google web search, and the terms used were parental; labour; overseas; international; migration; children; left-behind; health; illness; health-care; nutrition; nutritional status and undernutrition. In addition, a manual search was performed on all references listed in relevant articles.

Only articles published in the English language were included. There were no limits concerning the country of study or date of publication. Where necessary, corresponding authors were contacted for clarification of study results.

Study selection

Titles from the database searches were reviewed to identify and remove duplicate studies. All searches were carried out by author RK, and all titles and abstracts were screened independently by authors RK and PL. The same authors independently reviewed full-text articles, and the final eligibility decision was made on the basis of inclusion and exclusion criteria.

Data extraction

Our data extraction form included the following information: author and publication year, study design, study place and calendar year(s), sample size, age of the study group, parental migration status, study outcome (healthcare-seeking behaviour, stunting, wasting or underweight) in migrant and non-migrant households, statistical test and study quality. Data extraction was performed independently by authors RK and PL. Any disagreement between the authors was resolved by discussion with the remaining authors.

Risk of bias in individual studies and quality assessment

The Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices tool designed by The CLARITY Group at McMaster University was used to assess the risk of bias in individual studies. We assessed the risk of bias for five study attributes, that is, the representativeness of the sample, the adequacy of response rate, the extent of missing data, whether the survey was ‘clinically sensible’ and whether the survey instrument was valid (CLARITY Group, 2017).

Authors RK and PL independently performed a quality assessment of the articles using the National Heart, Lung, and Blood Institute’s Quality Assessment Tool for Observational Cohort and Cross-sectional Studies (National Heart Lung and Blood Institute, 2014). Any disagreement was resolved with the assistance of the other authors. The tool evaluates the quality of articles according to the research question or objective, study population, study design, the presence of eligibility criteria, the rate of participation, sample size justification, variance and effect estimates, confounders, exposure measures and outcome measures. Each study was given an overall rating on a three-category scale (good, fair, and poor), based on the rating of each methodological component (National Heart Lung and Blood Institute, 2014).

Statistical analysis

For the nutritional status aim, we extracted, where available, the mean for height for age z-score, weight for height z-score, weight for age z-score and prevalence of stunting, wasting or underweight in children aged under five years in the comparison families and performed a narrative synthesis.

Results

Study selection

Healthcare seeking for common childhood illnesses

We identified 697 articles through the electronic database searches. An additional 39 potentially relevant titles were identified by manually searching the grey literature and reference lists. Twenty-eight full-text articles were assessed for eligibility after screening titles and abstracts. We found only one study from Tajikistan which reported on the healthcare-seeking behaviour for children in households with at least one parent migrated abroad (migrant households) compared to households where neither of the parents migrated abroad (non-migrant households) (Catrinescu et al., 2011). However, the study was excluded as it reported only on children under 18 years of age. The results of our study selection processes are shown in Figure 1.

Figure 1.

Flow diagram showing study selection process to examine the association between parental overseas migration and healthcare seeking for common childhood illnesses in left-behind children.

Nutritional status

We retrieved 210 titles through our database search and an additional 34 potentially relevant titles by manual searching (Figure 2). After removing duplicates, the title and abstracts of 181 articles were screened. Of the 33 articles undergoing full-text evaluation, 3 articles met our inclusion criteria (Davis and Brazil, 2016; Jayatissa and Wickramage, 2016; Wickramage et al., 2015).

Figure 2.

Flow diagram showing study selection process to examine the association between parental overseas migration and nutritional status in left-behind children.

Study characteristics

Of the three articles examining the association between overseas parental migration and the nutritional status of left-behind children, all were recently performed cross-sectional surveys. Two were conducted in Sri Lanka (Jayatissa and Wickramage, 2016; Wickramage et al., 2015) and one in Guatemala (Davis and Brazil, 2016). The studies from Sri Lanka measured nutritional status in children less than five years, but the study from Guatemala only included children aged up to three years (Davis and Brazil, 2016). The study characteristics are summarized in Table 1.

Table 1.

Characteristics and results of studies examining the nutritional status of children in international migrant and non-migrant households.

Author (year)	Country	Study design	Participant age	Total sample size	International migrant households							Non-migrant households							Study quality	Main result after adjustment for confounders
					N	Stunting		Underweight		Wasting		N	Stunting		Underweight		Wasting
					N	Prevalence (%)	Mean z-score (SD)	Prevalence (%)	Mean z-score (SD)	Prevalence (%)	Mean z-score (SD)	N	Prevalence (%)	Mean z-score (SD)	Prevalence (%)	Mean z-score (SD)	Prevalence (%)	Mean z-score (SD)
Jayatissa and Wickramage (2016)	Sri Lanka	Cross-sectional study. National nutrition and micronutrient survey (2012)	6–59 months	7306	321	11.5%	−.8 (1.2)	24.30%	−1.2 (1.1)	18.1%	−1.1 (1.1)	6985	14.8%	−.9 (1.1)	26.2%	−1.3 (1.0)	21.5%	−1.2 (1.0)	Good	Stunting was lower in children from migrant households compared to non-migrant households
Davis and Brazil (2016)	Guatemala	Cross-sectional study. ENCOVI (2000)	≤three years	3973	171	NA	−2.30	NA	NA	NA	NA	3802	NA	−1.91	NA	NA	NA	NA	Good	Higher risk of stunting in households with father as a migrant
Wickramage et al. (2015)	Sri Lanka	Cross-sectional survey (2015)	6–59 months	228	114	NA	NA	30%	NA	NA	NA	114	NA	NA	17.7%	NA	NA	NA	Good	No difference in risk of underweight.

SD: standard deviation; ENCOVI: Encuesta Nacional de Condiciones de Vida (National Survey on Living Conditions); NA: not available.

Study quality and risk of bias in the individual studies

The three studies had a low risk of bias and were of good quality. Detailed information about the risk of bias and quality of each study is shown in Online Supplementary Appendix 4.

The three studies had a clearly stated research objective and clearly defined study population, and participants were randomly selected from a specified population within a specified time period (Davis and Brazil, 2016; Jayatissa and Wickramage, 2016; Wickramage et al., 2015). The inclusion and exclusion criteria were pre-specified and were applied consistently. In all studies, pre-validated survey instruments were used. The exposure and outcome variables were also clearly defined and were uniformly ascertained for all study participants. Several potential confounding variables were measured and adjusted statistically in two of the studies (Davis and Brazil, 2016; Jayatissa and Wickramage, 2016). However, in the study by Wickramage et al. (2015) only univariable results are shown for the relationship between parental migration and underweight in left-behind children (Wickramage et al., 2015). Two studies included a sample likely to be nationally representative of the population of interest (no evidence of selection bias) (Davis and Brazil, 2016; Jayatissa and Wickramage, 2016). In the other study, conducted by Wickramage et al. (2015) in Sri Lanka, the study population was drawn from districts with a high prevalence of international migration (Wickramage et al., 2015) and was representative within the selected districts. The response rate was >80% in two of the studies; however, no response rate was reported in the Guatemalan study (Davis and Brazil, 2016). Two studies had minimal missing data (Davis and Brazil, 2016; Jayatissa and Wickramage, 2016), but the extent of missing data was not provided by Wickramage et al. (2015).

Risk of bias across the studies

We could not assess the risk of publication bias or selective reporting bias, as we were unable to conduct a meta-analysis, and there was no relevant registry to identify incomplete or unpublished studies or selective reporting of outcomes.

Parental international migration and nutritional status of children

Jayatissa and Wickramage (2016) reported that the prevalence of stunting, wasting and underweight was slightly lower in children aged 6–59 months in Sri Lankan households with at least one parent migrated abroad (migrant households) compared to non-migrant households (Jayatissa and Wickramage, 2016). Accordingly, the mean height for age z-score, weight for height z-score and weight for age z-score were slightly higher in children of migrant compared to non-migrant households. The study did not report the statistical significance of these crude comparisons. The prevalence of stunting and underweight was higher in children whose mother was the only international migrant compared to children whose father was the only migrant (stunting: 21.7% vs. 9.7%, underweight: 34.8% vs. 22.8%), while the prevalence of wasting was similar (Jayatissa and Wickramage, 2016). However, statistical significance was not reported for these associations. After adjusting for variables at the level of the child and household, father’s migration to overseas was associated with a lower prevalence of stunting (regression coefficient: .686, p < .05), but there was no difference for wasting and underweight (Jayatissa and Wickramage, 2016).

Wickramage et al. (2015) reported the prevalence of underweight in Sri Lankan children aged 6–59 months in households with at least one parent working abroad (migrant household) and households where both parents lived with the children (non-migrant household) (Wickramage et al., 2015). Among left-behind children, 24.5% were underweight, and 5.5% were severely underweight. In non-migrant families, 17.7% of children were underweight, and none were severely underweight, but these differences were not statistically significant (p = .061) (Wickramage et al., 2015).

The study by Davis and Brazil (2016) reported the prevalence of stunting in Guatemalan children aged up to three years in households where the father migrated internationally compared to non-migrant households. They reported that underweight and wasting were not associated with parental migration but did not report any detailed measures. However, irrespective of the amount of remittance received by the households, the difference in mean height for age z-score was statistically significantly (p < .05) lower in children of migrant households compared to non-migrant households, indicating a greater degree of stunting in left-behind children (Davis and Brazil, 2016).

Discussion

In this systematic review, we searched for studies investigating the impact of parental overseas migration on healthcare seeking for common childhood illnesses and on the nutritional status of left-behind children.

International parental migration and healthcare seeking for common childhood illnesses

We did not find any study examining the relationship between parental overseas migration and healthcare seeking for common childhood illnesses. This is an important knowledge gap regarding the health of left-behind children. We identified a Tajikistan study that was ineligible because it examined health-seeking behaviour for any health condition, not just the common childhood illnesses (Catrinescu et al., 2011). It found that during the year before being surveyed, children from non-migrant households were more likely to have consulted a healthcare provider (female = 72%, male = 76%) compared to those from migrant households (female = 68%, male = 63%), but these estimates were not compared statistically. At the same time, the average health expenditure per child during that period was higher in migrant households compared to non-migrant households (Catrinescu et al., 2011). The study reported that 54% of migrant households found it easier to pay for children’s healthcare since their mother or father had migrated abroad. The main reason given for this change was improved financial status from remittances (Catrinescu et al., 2011). The contradiction that more healthcare was sought by non-migrant households is difficult to explain, although it could reflect poorer health status or increased risk of disease among non-migrant households due to poorer circumstances.

International parental migration and effects on nutritional status

We identified studies reporting null (Wickramage et al., 2015), positive (Jayatissa and Wickramage, 2016) and negative (Davis and Brazil, 2016) associations of parental international labour migration with the nutritional status of their left-behind children. Jayatissa and Wickramage (2016) reported the slightly lower prevalence of stunting in Sri Lankan children from migrant households compared to non-migrant households (Jayatissa and Wickramage, 2016), whereas another Sri Lankan study by Wickramage et al. (2015) that only examined underweight found a similar prevalence between migrant and non-migrant households (Wickramage et al., 2015). Although the two Sri Lankan studies were conducted during a similar time frame, the study by Wickramage et al. (2015) was conducted in selected districts with a high prevalence of international labour migration, and they may not be representative of the national population, unlike the study by Jayatissa and Wickramage (2016). The Guatemalan study found a significantly higher prevalence of stunting among children whose father had migrated in the last year (Davis and Brazil, 2016). This study additionally examined the difference in stunting among left-behind children on the basis of whether the left-behind household received remittances, but it did not distinguish whether the remittances received were from a migrated parent or another member of the household. The receipt of remittances was not associated with stunting among the groups studied (Davis and Brazil, 2016). The authors argued that such an observation may be due to the migrant father of young children not being able to achieve economic success in a timely manner (Davis and Brazil, 2016).

Several other studies described the nutritional status of children aged under five years in households with at least one migrant but did not distinguish whether the migrant was a parent or another household member. Those studies reported mixed results (Antón, 2010; Azzarri and Zezza, 2011; Carletto et al., 2011). The study by Azzarri and Zezza (2011) reported that the prevalence of severe stunting was higher in Tajikistan children of non-migrant households compared with migrant households (19.31% vs. 14.72%, p < .05) (Azzarri and Zezza, 2011). Antón (2010) reported that wasting and underweight were significantly lower in Ecuadorian children under five years of age in remittance-receiving households compared to non-remittance-receiving households, but stunting was similar (Antón, 2010). Another study from Guatemala examined the relationship between migration and child growth in children under 30 months and found the prevalence of stunting and mean HAZ level was significantly lower in children of migrant households compared to non-migrant households (Carletto et al., 2011).

A challenge in interpreting the results of these cross-sectional studies is that poor health or children’s nutritional status could contribute to the decision of a parent to migrate. The need to fund better healthcare may provide motivation to seek improved household financial status through migration. This possible confounding factor has also been described as a problem of endogeneity. Endogeneity is a term used to describe the presence of an endogenous explanatory variable. The problem of endogeneity occurs when an explanatory variable is correlated with the error term (Wooldridge, 2012). Unpredictable shocks such as high rainfall, crop failures, droughts, floods and so on may affect children’s health and thus the decision of parent to migrate in a hope to improve the health and nutritional status of their children (Antón, 2010; Davis and Brazil, 2016). Most studies use a statistical method using an instrumental variable in order to minimize the potential endogeneity. An instrumental variable is a third variable that is not associated with the outcome except through its association with an exposure variable (Greenland, 2000). In this case, this means identifying an instrumental variable that is correlated with migration but not a child’s nutritional status. Davis and Brazil (2016) used unexpected rainfall shocks as an instrumental variable for migration with an assumption that unexpected drops in rain levels decrease agricultural production and income, thus motivating people to migrate (Davis and Brazil, 2016). Another instrumental variable used in the studies was a measure of a network effect of migration within a community; more migrants in a community can encourage and help others from that same area to migrate and seek opportunities (Antón, 2010; Davis and Brazil, 2016). These approaches, however, do not explain whether any association is confounded by pre-existing poor health status of children prior to a parent’s migration. Hence, longitudinal studies measuring the health status of children at the time of migration with a suitable follow-up period are needed to estimate any change in health status associated with remittances or loss of parental presence.

Conclusion

Our review demonstrates that there has been little research on the impact of parental overseas migration on healthcare seeking for common childhood illnesses and nutritional status, despite the important contribution of international labour migration to developing economies. There is insufficient research using suitable study designs to draw a conclusion on the impact of international parental migration on healthcare seeking for common childhood illnesses or on the nutritional status of left-behind children. Longitudinal study designs that are able to evaluate the health status of children at early and later stages of parental migration are needed. Also needed is information on remittance amounts and the proportion allocated to child welfare needs.

Supplemental material

Supplemental Material, Online_Appendix - Effect of overseas parental employment migration on healthcare seeking for common childhood illnesses and nutritional status among left-behind young children: A systematic review

Supplemental Material, Online_Appendix for Effect of overseas parental employment migration on healthcare seeking for common childhood illnesses and nutritional status among left-behind young children: A systematic review by Ritu Kunwar, Prabhat Lamichhane, Claire Vajdic, and David J Muscatello in Journal of Child Health Care

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by an Australian Government Research Training Program (RTP) Scholarship to RK.

Supplemental material

Supplementary material for this article is available online.

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