Providing responsive primary care for Ukrainian refugees

BACKGROUND

The conflict in Ukraine has displaced millions of people, creating a new refugee crisis. A formal route exists for Ukrainians to reside and access health care in the UK, including primary care. In this article we explore the health of refugees from Ukraine before, during, and after their migration to the UK, with a particular lens focusing on how UK primary care can seek to meet these needs.

BEFORE TRANSIT

Ukraine is a lower middle-income country in Eastern Europe. It is predominantly Slavic in culture (Ukrainian/Russian-speaking) with a number of ethnic minority groups. Culturally, a comparatively high proportion of Ukrainians identify with a religion, particularly Christianity. Over the past three decades, community health care in Ukraine has expanded to include GP-led primary care services alongside district physicians within multidisciplinary Semashko polyclinics.¹ The private healthcare sector is robust, with direct access to specialists, diagnostics, and treatment for those who can afford it.

Rates of cardiovascular disease and associated risk factors, including diabetes, cholesterol, and hypertension are high. Prevalence of thyroid disease and malignancy are high in some parts of Ukraine, a legacy of the Chernobyl nuclear disaster of 1986. Lifestyle choices, limited health literacy, and frequent use of herbal and alternative remedies complicate chronic disease management.²

Rates of excess alcohol consumption and certain infectious diseases are higher than in the UK, particularly tuberculosis and HIV due to intravenous drug use. Individuals may choose not to openly disclose these conditions to a doctor. Mental health stigma exists, in part a legacy of questionable management of many mental health conditions within large residential care centres (‘internats’). The prolonged conflict in Eastern Ukraine has led to an increased prevalence of post-traumatic stress disorder.³ COVID-19 vaccination rates in Ukraine are currently around 35%, in part due to significant vaccine hesitancy.⁴

DURING CONFLICT AND TRANSIT

The conflict has disrupted supply chains, meaning many individuals have had difficulty accessing essential medications, including thyroxine and insulin. Medical facilities have been damaged, with personnel killed, injured, or redeployed. The rapid and potentially unplanned migration stemming from the conflict has put individuals’ health at risk, with specific vulnerabilities according to an individual’s sex, ethnicity, and age. The majority of refugees from Ukraine are women and children. Individuals may have undergone long journeys under precarious conditions, with limited access to medication, health care, translation, finances, and social support. Criminal, physical, and sexual exploitation of Ukrainians is already being reported.⁵

IN THE HOST COUNTRY

Universal health coverage does not necessarily ensure equality of care. Health capacity and capabilities in some European transit countries are becoming overstretched. Lessons for the NHS can be learned from other Central and Eastern Europeans’ experiences of migration to the UK, including the social and environmental factors that have compromised their physical and mental health.^6,7 Prevalence of mental health conditions and alcohol overuse are concerningly high.^7,8 Delayed primary care registration and presentation is common. Unfamiliarity with UK clinician communication approaches including telephone consultations, short consultation durations, and shared and self-care has led to disengagement. Refugees from Ukraine are likely to share many of these characteristics. Their engagement with primary care may be complicated by a limited number of Ukrainian healthcare staff/translators and the impact of trauma. Furthermore, Ukrainians are not familiar with waiting lists for specialist review — expectations and needs will need to be sensitively managed.

THE RESPONSE OF PRIMARY CARE

Providing effective primary care for refugees from Ukraine will require a culturally-informed and medically sound approach. Suggestions include:

1. Review access to primary care services, including registration, appointment booking, and translator access. Printable resources are available in Ukrainian and Russian on how the NHS works.⁹ Feedback and input from Central/Eastern European and refugee patients could inform this process.

2. Implement structured health and social screening within practice registration including immunisation status, infectious (TB, hepatitis C, and HIV [when indicated]), nutritional, metabolic, and mental health disorders. Creating a patient record template will ease this process.¹⁰

3. Assess for ‘red flags’ within consultations, including psychological trauma and exploitation (modern slavery, sexual trafficking, and child exploitation). E-learning resources are available to support post-war mental health care for Ukrainian adults and children.^11,12

4. Considering culturally tailored strategies to meet complex health and social needs. This will require ongoing compassion, patience, and recognition of a shared humanity. Management options may include liaising with local and national support organisations for Ukrainians and refugees (see below).

RESOURCES

Local and national organisations supporting Ukrainians in the UK include:

MEDICAL

• The Ukrainian Medical Association of the United Kingdom: https://www.facebook.com/groups/umauk

SOCIAL, CULTURAL, AND RELIGIOUS

• The Association of Ukrainians in Great Britain: https://www.augb.co.uk

• Ukrainian and Russian-speaking churches (various): http://www.ukrainiansintheuk.info/eng/01/orglist-e.htm#church

• Ukrainian Institute London: https://ukrainianinstitute.org.uk

• British-Ukrainian Aid: https://british-ukrainianaid.org

• PLAST — Ukrainian Scouting Organisation in Great Britain: http://www.plast.org.uk/eng/default.aspx

• Ukraine Charity: https://www.ukrainecharity.org

• Medical Aid Ukraine: https://www.facebook.com/groups/758994511751010

ADVOCACY, COUNSELLING, AND DOMESTIC VIOLENCE

• Europia (empowering, supporting, training, and representing European nationals in Greater Manchester): https://europia.org.uk

• East European Resource Centre (London): http://www.eeac.org.uk

• Feniks (counselling, personal development and support services ltd, Edinburgh): https://www.feniks.org.uk