Our study revealed significant differences between Syrian refugee and Turkish resident children. Although non-emergent ED visits were most frequent in both groups, more refugee patients required immediate or urgent care compared to native-born children. In addition, inpatient treatment, ICU admissions (neonatal and paediatric) and hospitalization of neonates were more frequent in refugee children. Respiratory and gastrointestinal system diseases were the most common reasons for presenting to the ED in both groups—75% of these presentations were non-emergent.
Similar to our results, the study by Baykan et. al. conducted in Nevsehir, Turkey, noted that between 2013 and 2017 the number of ED visits by Syrian refugees increased exponentially (12). The fall after 2018 in our centre may be related to the establishment of another state hospital in 2018 near our hospital, where refugee children may also have presented. Also, living conditions of the refugees might have changed, improving their socioeconomic status leading to better integration to the country’s healthcare system. In any case, migration from Syria created a significant overload on Turkey’s emergency healthcare system (16-18).
Our findings showed that although non-emergent visits were high in both groups, immediate and urgent patients were significantly greater in refugee children compared to native children. Consistent with our findings, in a study from Italy looking at the utilization of emergency services by migrant children under the age of one was more frequent for both non-urgent and very urgent visits, and ED visits of immigrant children were more likely to be followed up by hospitalization as they presented with more severe and complex conditions (19). Another study from Turkey reported higher utilization of resources among refugee children presenting to the ED due to presentation with more severe disease (20). Higher representation of refugee children with more acute conditions may be related to delayed presentation, caregiver’s inability to recognize and accurately judge serious medical conditions, language barriers, or cultural predilection of traditional care-seeking practices (5,9,21-23). Other reports have identified that insurance status may affect the pattern of ED utilization of refugees, with overrepresentation of high acuity conditions due to delayed presentation (24-26). However, this specific reason does not apply to Syrian refugees in Turkey as all health costs are covered by Ministry of Interior Disaster and Emergency Management Presidency according to the Temporary Protection Regulation (27). Further research is needed to better elucidate factors other than financial issues that are related to the frequent use ED visits among refugee children in Turkey.
This study also identified a greater number of infant ED visits among Syrian children as compared to native children. This has also been identified in a previous study (19). Consistent with other studies, our research found an increased frequency of hospitalization among refugee children compared to the resident children (12,20). Increased hospitalization was particularly observed among refugee neonates. This is in line with another study showing that infants born from immigrant women were more likely to be admitted into neonatal intensive care unit when compared to the native-born infants born in Canada (28). We did not investigate the reasons for the higher proportion of Syrian infant ED visits and neonatal inpatient admissions, but it may be possible these children have not acquired primary preventive care or general healthcare services that would protect them to some extent from more serious conditions requiring hospitalization (29). Policies and education to increase primary health care seeking practices of refugee families are necessary to expand preventive health care approaches and improve the health of neonates and infants.
Rates of intensive care unit hospitalizations were observed to be higher in refugee children, particularly related to NICU hospitalizations. This again emphasizes the need for preventive services focused on neonates. Labelling all refugee births as high-risk and providing them with frequent appointments in the well-child clinic can help in detecting medical issues earlier, thus improving their health status and decreasing their ED usage. Over representation of immigrant children in paediatric intensive care unit is common among other immigrant communities as well. (30). Factors, including language or cultural barriers, and financial difficulties while accessing health care such as cost of transportation should be further explored. Efforts to overcome these factors would improve access to preventative services.
Similar to other studies globally, the most common reasons for admissions to the ED were respiratory diseases and gastrointestinal system disorders in both refugee and resident children (31,32). When the neonatal period is excluded, acute respiratory infections and diarrheal diseases remain the leading cause of death among children under 5 years of age (33,34). As these are preventable and treatable causes of death, it is important to increase preventive and curative interventions targeting this most vulnerable age to reduce child mortality, such as vaccination, improved nutrition, sanitation, hygiene and altered health care seeking behaviour. Similarly, increasing preventive measures for communicable diseases will also help to reduce the burden on ED services as these were the most common reasons for ED arrivals in our study. Alternatively, appropriate management of minor illnesses related to respiratory and gastrointestinal system diseases in the primary care settings will reduce overcrowding in our hospital ED.
Our study, with the largest sample size to the best of our knowledge, adds to the limited information about ED utilization of refugee children. Choosing a control group allowed us to conduct a comparative study across refugee and local groups of children in a single tertiary hospital setting across time. The use of registered data and large sample sizes strengthened our study. However, our study has several limitations. The study is cross-sectional in design and from a single facility, limiting its generalizability to all refugee children. In addition, we did not evaluate the effects of the components of the socioeconomic status (SES), such as parental educational level and income, on ED utilization, since hospital medical record system was lacking this data. Maternal education level has been shown to be inversely related with higher ED utilization rate (21). However, given the location of our hospital and considering that the hospital is a state hospital, we presume that most of the Syrian and Turkish patients originate from middle and low SES. Another limitation is that the clinical information available in this study is limited to the ED visit records which may provide mis-entered data especially regarding ICD-10 diagnoses. Finally, our analysis does not include information regarding how long Syrian refugees were living in Turkey when they presented to the ED. This may have effects on patterns of ED utilization, since length of stay in the newly settled country may impact parents’ language, and the level of information they know about the services offered.
In conclusion, our findings show the significant impact of paediatric Syrian refugee child admissions to the paediatric emergency health care services at tertiary level. These ED admissions were primarily for respiratory and gastrointestinal infections. ED services might be reduced by improving access to primary preventive health care services that specifically focus on Syrian refugee children under five years of age. Despite governmental efforts to ensure equal health services for Syrian refugees in Turkey, the health care needs of refugee children may remain unmet as we showed in differences in utilization of ED services. Reasons for higher ED utilization of younger Syrian children, presentation with more acute conditions and higher hospitalization rates compared to the resident children should be further investigated to develop new health policies and approaches to refugees’ unmet health needs. Knowledge of and access to primary health care should be improved to improve health outcomes and decrease the burden on hospital emergency units. The findings of our study should be used to guide policy decision-making and hospital funding. Health policy strategies to promote health of refugee children should be developed and implemented by intersectoral coordination, including governments, civil protection authorities, paediatric societies, families, and children.