Nutritional and Immunisation status of Children of Migrants seeking health care in tertiary care hospital – A cross sectional study.

Migration, both internal and international, is a defining phenomenon of the 21st century with significant implications for public health, particularly for children. In India alone, tens of millions of individuals migrate annually in search of livelihood, often settling in urban slums, construction sites, or peri-urban industrial zones. These movements frequently involve families with young children, whose health outcomes are adversely impacted by instability, poverty, and lack of access to consistent healthcare services. Migration is a social determinant of health. The health profile and the care received by migrants are found suboptimal when compared to populations at both origin and destination1.

 

When the migrants move with family, the health and well-being of their children are also affected. India has witnessed increasing trends in internal migration over the last 30 years. It is estimated that 5–9 million people migrate within the country in a year2 and every fifth migrant is a child3.Short-duration rural-to-urban migration is a key livelihood strategy for millions of poor households in India, particularly among historically marginalized groups, who often face chronic poverty4. Migrants typically engage in low-wage, insecure, and informal work environments5,6. Many migrate with their entire families, including children7,8, who then face disrupted education due to frequent relocations8-10, nutrition insecurity due to limited access to subsidized food11, and lower immunization rates stemming from barriers like high costs and limited awareness9-16.

 

Children also face risks to their safety and wellbeing due to exposure to unsafe and unhygienic worksites7.Immunization is the most successful and cost-effective weapon against vaccine preventable diseases. Infectious diseases like tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, hepatitis B, H. Influenza, measles, and rubella can be prevented by immunization. According to the WHO (July 2018), global vaccination coverage among children is 85%. If this is improved, 1.5 million deaths can be avoided17. According to Intensified Mission Indradhanush, vaccination coverage was 65% (2014). India aims to increase full immunization coverage to >90% by December 202018. In India, under-five mortality rate is 39/1000 live births (LB), infant mortality rate 34/1000 LB, and neonatal mortality rate 24/1000 LB. Children suffer from lack of immunization because of frequent shift of places, lack of knowledge, and low socioeconomic status19.Despite its effectiveness, full immunisation coverage remains uneven, particularly among children of migrant populations. Studies have shown that these children are consistently under-immunised compared to non-migrants due to barriers such as lack of awareness, absence of immunisation cards, frequent relocation, and limited access to health infrastructure (Kusuma, 2010; Awoh, 2016; Savani, 2023)20-22. For instance, Kumar (2020)23 reported that only 55.4% of children in brick kiln settlements in Bihar were fully immunised, with a significant proportion either partially or non-immunised, primarily due to lack of knowledge and service inaccessibility.

 

Similarly, Anand (2014)24 found that just 30% of migrant children were fully immunised compared to 50% among non-migrants.Furthermore, the nutritional status of migrant children is deeply concerning. Undernutrition, which includes stunting, wasting, and underweight, is more prevalent among migrant children than their settled counterparts. Studies from various regions in India including Lucknow (Agarwal, 2023)25, Hooghly (Chaudhari, 2024)26, and Delhi (Akkiraju, 2024)27 have reported alarmingly high rates of malnutrition—stunting rates often exceeding 60%, and wasting above national averages. These conditions are often exacerbated by food insecurity, lack of dietary diversity, poor maternal nutrition, and unhygienic living conditions such as open defecation and lack of safe drinking water (Ravindranath, 2019; Ambika, 2025)28,29.The interplay between malnutrition and low immunisation is particularly problematic. Malnourished children have weakened immune responses, reducing vaccine effectiveness and increasing susceptibility to vaccine-preventable diseases.

 

This creates a dangerous cycle of infection, undernutrition, and poor developmental outcomes, especially in settings where health services are inaccessible or underutilised (Prusty,2015; Shankar Mishra, 2022)30,31.Migration also introduces systemic barriers to healthcare delivery. Health records are rarely portable across states or regions, and migrant families often lack formal residence proof, impeding access to government schemes such as the Universal ImmunisationProgramme (UIP) and the Integrated Child Development Services (ICDS). Cultural and language barriers, discrimination, and a lack of trust in healthcare systems further discourage utilisation (Bouaddi, 2024; Ambika, 2025)29,32. Even large-scale initiatives like Mission Indradhanush have faced challenges in effectively reaching migrant populations, despite their considerable progress in improving overall immunisation coverage (Jain, 2024; Lyons, 2024)33,34.International evidence supports these trends. A meta-analysis by Rojas-Venegas (2022)35 found that globally, migrants are half as likely to be vaccinated as non-migrants.

 

These disparities are often entrenched by structural inequities and a lack of targeted interventions for transient populations.Given this complex and multifaceted problem, it becomes crucial to explore the current landscape of immunisation and nutritional status among migrant children, identify existing gaps in services and policies, and recommend actionable strategies. This literature review aims to synthesise evidence from recent studies to understand the scale of the problem, its determinants, and potential solutions. In doing so, it will offer a foundation for informed policymaking, health system improvements, and inclusive child health programming that accounts for the needs of migrant populations. The  present study aims (i) to  assess the nutritional status of children enrolled in the study using appropriate tools and methodology.(ii) To ascertain immunisation rates and dropout % among migrant children and reasons for it and to assess correlation between %dropout with duration since migration.(iii) Assess factors affecting nutritional status of children like initiation of exclusive breastfeeding and its duration, usage of prelacteal feeds, practices of compliment feeding using questionnaire and interviews and  also  use this as a platform to bring change in the knowledge, attitude and practice among the migrants.

A Cross-sectional study for  theperiod  of18 months (May 2023 to October 2024) was conducted  at  Dept of  Paediatrics,  Vani Vilas hospital, BMC&RI ,Bangalore .The study population were  Children of migrants who have migrated to Bangalore attending Vani Vilas hospital, department of paediatrics, Bangalore. The  Sample size was estimated by using Master software Version 2.0 by applying following details in the above formula. The sample size was calculated using from the  formula

n=(〖Z_α〗^2  P(1-P))/d^2 = n=(〖1.96 〗^2  0.50 (1-0.50))/〖0.10〗^2 =100

Inclusion Criteria

Children of migrants who have migrated to Bangalore

Children of parents willing to give informed consent

 

Exclusion criteria

Children with any endocrinological diseases, HIV, TB and other chronic diseases .Anexcluded  mothers who cannot comprehend the questions asked by the investigator 

 

Data Collection Methods

After obtaining approval and clearance from the institutional ethics committee, eligible patients meeting the inclusion criteria will be enrolled in the study following informed consent (Annexure-1). Data will be collected through interviews with mothers of children under two years admitted to the wards and outpatient department (OPD) of Vani Vilas Hospital.

 

Assessment tools

Appropriate WHO charts

Preformed questionnaires

In-person interview

Weighing scale

Measuring tape

 

Outcome measures

Nutritional and immunisation status of children of migrants

Percentage ofImmunised and dropout % will be calculated and compared against national average along with along with native state Percentage.

Immunization and nutritional status will be correlated with duration since migration

Percentage of children malnourished will be assessed

Variation among siblings assessed

 

Statistical methods

Data was collected and compiled in MS Excel. Statistical analysis was performed using SPSS for windows version 26.0. The description of data will be in the form of mean  (±) SD for quantitative data and frequency and proportion for qualitative data. Student t-test/ chi-square test will be used to determine significant difference between two groups. P value of <0.05 will be considered significant.

Table 1: Age Distribution

 

 

 

 

The study included a total of 119 migrant children attending a tertiary care hospital. Age distribution indicates that the majority of the children (42.9%) were in the neonatal to infant age group. The second highest group was preschool-aged children (3–5 years), accounting for 20.2%, followed by toddlers (1–2 years) at 16.8%, and school-age children (6–10 years) at 13.4%. Only 6.7% were adolescents (11+ years).

 

Male children constituted a significantly higher proportion (64.7%) compared to females (35.3%). An overwhelming majority (94.1%) of children were born in hospitals, while only 5.9% were delivered at home.

IFA supplementation status showed that 81.5% of children received supplementation for the recommended 6 months. Another 16.0% received IFA for 3–4 months, while only 2.5% did not receive any supplementation.

 

Table 2: Breastfeeding & Feeding Practices (n=117)

 

Breastfeeding practices were largely appropriate, with 75.6% of mothers exclusively breastfeeding their children for the first six months. Only 0.8% of children received pre-lacteal feeds. However, only 54.6% initiated complementary feeding at the recommended age of 6 months, while 43.7% had delayed introduction.

 

Table 3: Immunisation Status

 

Immunisation coverage showed that 51.3% of children were up-to-date with vaccinations, while 48.7% were partially immunised. Of the 58 partially immunised children, 25 (43.1%) had primary immunisation failure and 33 (56.9%) had secondary immunisation failure.

 

Table 4: Reason for Non-immunisation

 

Among partially immunised children, 62.0% of caregivers believed immunisation was unimportant, 31.1% were unaware of available facilities, and 6.9% thought vaccines were harmful.

 

Table 5: Nutritional Status (Under 5 Years)

 

 

 

Nutritional assessment using MUAC for children under 5 years revealed that 16.36% of children were moderately to severely malnourished (MUAC <11.5 cm), while 83.64% had measurements ≥11.5 cm.

Migration duration showed that 51.3% had been in the current location for 2–3 years, 28.0% for up to 1 year, and 20.7% for more than 3 years.

 

BMI distribution showed that 78.0% of children had a normal BMI, whereas 9.8% were underweight and 12.2% were severely underweight.

 

Table 6: Action Taken (Health Education & Follow-up)

 

Health education (Knowledge, Attitude, Practice or KAP) was provided to 92.4% of families. A small subset (7.6%) received both education and immunisation services.

Children who do not receive timely and complete immunization are often linked to lower socioeconomic backgrounds, residence in rural areas, and limited access to healthcare services111. A study conducted in Saudi Arabia revealed that (37.5%) of parents held negative attitudes toward immunization, believing it to be unnecessary. Additionally, (25%) of respondents expressed concerns regarding the components of vaccines. Other contributing factors to vaccine refusal included inadequate communication and guidance from healthcare professionals, as well as external influences such as social media, religious beliefs, family opinions, and extended waiting periods at public health centers112. In the present study, a total of (n=119) children of migrant families were assessed, with nearly half (49.6%) belonging to the neonatal to infant age group. This indicates a significant proportion of very young children among those seeking healthcare services. The next largest groups were preschool-aged (22.7%) and toddlers (20.2%), while school-age children and adolescents comprised smaller proportions, whereas Sharma et al116. 

 

conducted an in-depth qualitative study with only 17 caregivers of under-five children in an urban resettlement colony in Delhi. Similarly, the Agarwal et al103.  study among their 400 study participants revealed that the majority (55.8%) of children fell within the 6-12 months age group, followed by more than 12 months (24.3%) and 0 to 6 months (20%) respectively. This age distribution may reflect the increased vulnerability and healthcare needs of younger children, prompting their families to seek medical attention more frequently. Similar  studydone  byKurkuri et al81., involved 500 children aged 12–36 months from migrant worker families in urban Bangalore East with a mean age of 25.23  8.42 months where 36.8% were in the 31 to 36 months age group. At the same time, Abdalla et al113. focused on parental demographics rather than direct child age distribution but noted that 83.1% of respondents had children, with 67% having 1–5 children among their sample of 436 study population. Also, Kusuma et al13. in their study involved a sample of 746 mothers—with differentiation between recent and settled migrants. However, Mishra et al107. used a large, nationally representative sample of 199,448 children aged 12–59 months from the NFHS-4 data, where 33.1% were from

migrant families and 67% were non-migrants in their study.

 

Savani et al98.  studied (n=110) children and divided them into recent migrants (n=56) and settled migrants (n=54), where (41.81%) were in the age group of 12 to 24 months and remaining (58.2%) in the range of 24 to 60 months respectively. Comparative Demographic Characteristics of Children in Migration-related Immunization and Health Studies. In our study, there was a clear male predominance, with (64.7%) of the participants being boys and only (35.3%) girls, whereas Sharma et al116.  study had a more concordant  sample (n=8 males, n=9 females) and the Agarwal et al103. study also found a male predominance, but with a smaller difference (55.5%) males compared to 44.5% females). Kurkuri et al81. and Savani et al98. in their respective studies also had a male preponderance of (52.4%) and (56.36%) respectively. This skew could reflect either a higher number of male children in migrant families or possibly a gender bias in health-seeking behavior, where male children are prioritized for medical attention. In our study, migration patterns revealed that over half of the families (51.3%) had migrated within the last 2–3 years, while 28% had migrated within the past year, and 20.7% had been settled for over three years. The Agarwal et al103. study, on the other hand, showed that a significant proportion of migrants (51.5%) have been away from their native places for over 5 years followed by 2 to 5 years (26%) and less than 2 years (22.5%). The relatively recent migration status of most families may contribute to barriers in accessing consistent healthcare, including immunisation and nutritional services. In the current study, the majority of children (94.1%) were born in hospitals, and only a small proportion (5.9%) were delivered at home. This suggests that institutional deliveries are relatively well-utilized among migrant populations, possibly due to improved healthcare access, awareness, or governmental support for safe deliveries. Comparatively, in the Kusuma et al13. study, hospital deliveries were associated with higher immunization uptake, with children born in hospitals having an Adjusted Odds Ratio (AOR) of 1.95 for being fully immunized against seven VPDs compared to home births, whereas Savani et al98. observed institutional deliveries among 93.6% and remaining of home deliveries (6.4%) respectively which was consistent with our study.

 

In the present study, iron and folic acid (IFA) supplementation was fairly well covered, with (81.5%) of children receiving supplementation for six months as recommended. An additional 16% received IFA for a shorter period of three to four months, while only (2.5%) had not received any supplementation at all. This reflects good adherence to nutritional supplementation protocols among the majority of the study population. In our study, exclusive breastfeeding for the first six months was reported by (75.6%) of mothers, indicating a positive practice in line with global health recommendations, while in Sharma et al116. study, 58.8% of caregivers practiced exclusive breastfeeding for 6 months and Agarwal et al103. in their study observed 84% of children under two years of age were exclusively breastfed for the first six months. Pre-lacteal feeding was nearly nonexistent, with only one case reported in our study. However, timely initiation of complementary feeding at six months was observed in just over half (54.6%) of the children, while 43.7% experienced delayed introduction, potentially putting them at risk of nutritional deficiencies during a critical period of growth. Comparatively, 70.4% of caregivers initiated complementary feeding at or after 6 months, however, bottle-feeding was common, with (64.7%) in the Sharma et al116. study. In the current study, immunisation coverage was found to be suboptimal, with only 51.3% of children being up-to-date on their vaccines, and a significant (48.7%) being only partially immunised. The reasons for partial or non-immunisation revealed that (30.30%) of caregivers perceived vaccines as unimportant, 15.1% were unaware of available facilities, and 3.4% believed vaccines to be harmful. These findings underscore the urgent need for targeted educational interventions to improve immunisation awareness and acceptance in this community. Similarly, Abdalla et al113. reported a high coverage of immunisation, where (96.7%) children were up-to-date, 42.9% of non-compliance was due to belief that vaccines were unimportant and others cited side effects (14.3%) and parental refusal (14.3%) in their study respectively. At the same time, Kurkuri et al81.

 

observed 88.6% fully immunized, (11.40%) partially immunized, and no child was unimmunized, according to their study findings and multiple factors were identified as key reasons for partial immunization among children of migrant workers in their study. The most frequently cited barrier was the inconvenient timing of immunization sessions, reported by (80.7%) of parents, making it difficult for working families to access services. A significant proportion (77.19%) of respondents also demonstrated a lack of awareness about the overall need for immunization, indicating a critical gap in health education. Additionally, (75.44%) of parents reported that their busy work schedules prevented them from bringing their children for vaccination. Furthermore, (71.93%) were unaware of the importance of returning for subsequent doses, which highlights a breakdown in follow-up communication. Migration-related issues also played a substantial role, with (59.65%) citing frequent movement as a reason for missed immunizations in their study respectively.

 

Nath et al117. reported similarly low immunization rates among migrants, with only (24%) of children fully vaccinated and (76%) with partial immunization. The study pointed out that illiteracy (OR: 4.1), lack of awareness (92%) and fear of side effects (74%) were strong predictors of non-immunization, with cultural barriers and sociodemographic factors like religion (i.e., Muslim religion being associated with lower immunization rates) (OR: 4.1) playing a role in their study. At the same time, Similarly, the Agarwal et al103. study found that only (14.8%) of the children had a fully immunized status, and a striking (96.8%) lacked an immunization card. Kusuma et al13.  found 81% full immunization among settled migrants but only (64%) among recent migrants (for six VPDs). This dropped to (60.2%) and (39.7%) respectively when including the 7th VPD. 5% received no vaccines as reported in their study.However, the CES-IMI 2018 survey reported a high full immunization rate of 93.3% among children118 . Similar to our study, Kumar P et al97.  in Bihar recorded a full immunization rate of just (55.43%) among children aged 12–23 months. Similarly, Singh et al119. reported only 34.6% full immunization among children aged 12–60 months, while Gokhale CN et al120.  observed a slightly higher rate of (36.1%). Other studies, such as those by Vaidya et al19., Anand S et al14. , and Sengupta et al15., reported even lower coverage rates of 20%, 30%, and 37.4%, respectively. In Savani et al93.  study, a clear distinction was made between recent and settled migrants, with recent migrants having a significantly lower immunization rate (17.8%) compared to settled migrants (51.9%).

 

The multivariate analysis in Savani et al. (24) study found that recent migrants were 9 times less likely to be fully immunized than settled migrants (AOR 9.211).Regarding partial immunization, Geddam JB et al121. similarly identified lack of awareness as a major contributor to partial immunization, which they found to affect (38.7%) of children. On the other end of the spectrum, Dutta et al122. reported an exceptionally low partial immunization rate of just 0.6%, with the predominant reason being the parents' busy schedules. Fear of adverse reactions (60%) and inconvenient timing (52%) were among the leading reasons for incomplete or missed immunizations in Singh et al119. study. Furthermore, research by Pakhare et al16.  emphasized that among migrant families, the most significant barrier to complete immunization was a lack of knowledge about the timing and location of vaccination services.In a study conducted by Luman et al114. , it was found that (75%) of parents refused immunization due to a belief in alternative treatments such as homeopathy, which they considered more effective than vaccines. Interestingly, some participants noted that these alternative methods often come with side effects themselves.

 

Additionally, a quarter of the respondents expressed doubts about the effectiveness of vaccines112. Other common reasons for vaccine hesitancy included religious convictions, personal or philosophical beliefs, and concerns about vaccine safety115. Moreover, maternal refusal emerged as a significant factor influencing whether children completed their immunization schedules, with this trend often linked to the mother’s socio-demographic background114.In the present study, nutritional status, as measured by Mid Upper Arm Circumference (MUAC), showed that (7.6%) of the assessed children had values indicating undernutrition (<12.5 cm). Although only a portion of the total sample had MUAC measured, this finding suggests the presence of malnutrition within the population. Additionally, BMI assessment in our study revealed that only (26.9%) of children fell within the normal range, while 3.4% were underweight and 4.2% were severely underweight, highlighting the need for continued nutritional support and monitoring.

 

Comparatively, in the Agarwal et al103. study, among interstate migrant children, (31.7%) were underweight, and (25.7%) had Severe Acute Malnutrition (SAM), while 33.6% of intrastate migrants were underweight in their study. Also, in Chaudhari and Bandyopadhyay’s104 study, malnutrition emerged as a major concern, with stunting in (64%), underweight in (45%), and wasting in (26%) of children, whereas in the Ambika et al105. study, malnutrition remained a major concern, with 24% of children severely stunted, (16%) severely underweight, and (12%) severely wasted, according to WHO growth standards. However, Mishra et al107.  found a notable and somewhat counterintuitive pattern in child malnutrition, revealing that non-migrant children experienced higher levels of undernutrition compared to their migrant counterparts. Specifically, the prevalence of stunting was 44.2% among non-migrant children, significantly higher than the (37.4%) observed among migrant children. Similarly, underweight status was more common among non-migrants at (39.5%), compared to (32.8%) among migrant children in their study.

 

In the current study, health education through knowledge-attitude-practice (KAP) interventions was provided to (92.4%) of the participants. Only a small proportion (7.6%) received both health education and immunisation services during the visit. While the provision of education is a vital step, the low proportion of children receiving immediate immunisation highlights a gap in service delivery that requires attention through improved follow-up and outreach. Comparatively, Sharma et al116. in their study observed high levels of awareness (88.2%) and utilization (64.7%) of ICDS services and Nath et al117. also emphasized the importance of health education, but they found that only 46% of mothers in their survey utilized immunization services. Similarly, the Agarwal et al103. study reports low utilization of government health facilities, with only (2.2%) of interstate migrant families utilizing these services.

 

However, the majority of families in their studies relied on unqualified practitioners (50.8% in interstate migrants), showing a significant barrier to accessing proper healthcare and services. Despite (72%) of migrant families being aware of their nearest Anganwadi, only (42%) utilized growth monitoring services and 49% received nutritional supplements in the Ambika et al105. study. At the same time, Kusuma et al13. observed that postnatal visits by health workers significantly improved immunization outcomes (AOR = 3.16 for 7 VPDs) and Savani et al98. found that health worker visits during pregnancy were common, with over (89%) of recent migrants receiving such visits, indicating the importance of health workers in promoting immunization. In the present study, the findings collectively point to a complex interplay of adequate awareness in certain domains—such as breastfeeding and institutional deliveries alongside significant gaps in immunisation coverage, complementary feeding practices, and nutritional status. These insights emphasize the importance of tailored, sustained public health interventions that specifically address the needs of migrant populations and bridge the healthcare access gap for their children.

The present study highlights key health concerns among children of migrant families attending a tertiary care hospital. While encouraging trends were observed in institutional deliveries (94.1%) and exclusive breastfeeding practices (75.6%), significant challenges persist. Nearly half (48.7%) of the children were only partially immunized, with common reasons including lack of awareness (15.1%), belief that vaccines are unimportant (30.3%), and fear of harm (3.4%). Nutritional assessments showed that (7.6%) had MUAC values indicating undernutrition, and 7.6% were underweight or severely underweight based on BMI. These findings underscore the ongoing vulnerabilities faced by migrant children and point to a need for strengthened outreach, education, and continuity of care.

 

Study limitations

Our study had some limitations. Firstly, it was conducted in a single tertiary care hospital, which may limit the generalizability of the results to the broader migrant population in other regions or healthcare settings. Additionally, recall bias could have influenced responses related to breastfeeding, immunization history, and IFA supplementation, especially when caregivers were asked to recall events from several months or years earlier. Lastly, the study did not evaluate the socioeconomic status or parental education levels, which could be significant determinants of healthcare access and child health outcomes in migrant populations.

 

Recommendations

Based on the study findings, several key recommendations can be made. Firstly, targeted immunization drives should be conducted within migrant communities to address misconceptions and improve coverage. Mobile health units and outreach camps can help bridge the access gap, particularly for newly settled or frequently migrating families. Secondly, regular nutritional screening and supplementation programs should be strengthened, especially for children under five. Incorporating community health workers to provide door-to-door education on breastfeeding, complementary feeding, and vaccine awareness can foster sustained behavior change. Finally, the integration of migrant health needs into broader national child health programs and policies is crucial to ensure

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