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Providing responsive primary care for Ukrainian refugees: where are we after a year?

Aaron Poppleton is a GP and Wellcome Trust PhD Fellow in Primary Care at Keele University. He is researching the health needs of Central and Eastern Europeans in the UK. He is on Twitter: @aaronpoppleton

Dennis Ougrin is a Co-director of the Youth Resilience Unit at Queen Mary University of London and a Consultant Child and Adolescent Psychiatrist at East London Foundation Trust. He is originally from Ukraine and is a member of the Ukrainian Medical Association of the United Kingdom. He is on Twitter: @dennisougrin

Pavlo Kolesnyk is a GP PhD and Head of the Family Medicine and Outpatient Care Department at Uzhgorod National University. He is the Director of International Volunteer Family Medicine Clinic ‘InterFamily’, Uzhgorod, Western Ukraine.

Steve Morton is a Public Health Professional leading Health Inequalities & Healthy Places for the Office of Health Improvement & Disparities in North West England. He recently completed a health needs assessment for Ukrainians.

The conflict in Ukraine has displaced over 8.1 million people since February 2022.1 The UK Government has responded by issuing 219 400 visas for Ukrainians through sponsorship schemes, at the time of writing.2 One year on, we feel there is value in reflecting on the health needs of Ukrainians within the UK and the response of primary care.

The health of Ukrainians in the UK

Our previous article explored Ukrainians’ initial health concerns, recommending a culturally-informed and medically sound strategy within UK primary care.3 Empirically, we have observed that many Ukrainians in the UK are now registered with a GP. Clinicians can access tailored health assessment templates and Ukrainian translation services. Repeat prescriptions have been changed to UK equivalents. Local government schemes, community organisations, sponsor families, and churches have developed Ukrainian networks. Ukrainians have reported feeling welcomed within the UK.4

“… many Ukrainians feel their health has worsened since arrival [in the UK].”

For many individuals, remaining in Ukraine would have clear health implications. Ukrainian health services are suffering significant financial, staffing, facility, and material shortages. Yet, despite the comparative safety and stability of the UK, many Ukrainians feel their health has worsened since arrival (unpublished data, Steve Morton, 2023). Three key factors underlie this trend: 1) healthcare accessibility; 2) mental health; and 3) social change and instability.

Healthcare accessibility

As with other Eastern Europeans, Ukrainians have had difficulties knowing which NHS service to access and where and when to access them, alongside language barriers when booking appointments.5 Ukrainians report they would have benefited from more information and education on accessing health services and education (unpublished data, Steve Morton, 2023). While information was available through sponsorship schemes, the format and delivery of this information was not necessarily familiar, accessible, or trusted by Ukrainians. Furthermore, the stress of conflict, displacement, migration, and pressing personal needs (for example, accommodation, financial security, and childcare) impacted individuals’ ability to utilise this information.

Uncertainties with the UK gatekeeper model and generalists’ expertise (including GPs) exist, particularly for women and children’s health, health promotion, and physiotherapy. Primary care being ‘free at the point of use’ is viewed positively; however, dissatisfaction exists around difficulty accessing services and longer appointment waiting times (unpublished data, Steve Morton, 2023). Lack of knowledge, trust, or satisfaction with general practice services risks Ukrainians presenting at crisis point to unscheduled care, including emergency and out-of-hours departments, and a reliance on transnational health care.6 Empirical accounts suggest this is already happening for dental care.

Mental health

Ukrainians in the UK have self-reported a deterioration in their mental health and wellbeing. The ongoing conflict means that Ukrainians experience a trauma triad of personal traumatic experiences, traumatisation through life in a foreign environment, and vicarious trauma through loved ones remaining in Ukraine. Mental health screening suggests underrecognition and underdiagnosis of anxiety (unpublished data, Steve Morton, 2023). Depression and post-traumatic stress disorder (PTSD) are also likely underdiagnosed.

“Ukrainians report they would have benefited from more information on accessing health services and education.”

Ukrainians and British nationals have differing mental health beliefs and culture-bound expressions of symptoms. Historically, mental health care in Ukraine has been institutional rather than community-based.7 Mental health-associated stigma, and delaying help seeking and somatisation are common. Individuals often prefer to discuss ‘real’ physical symptoms rather than psychological disorders.

Social instability

The number of Ukrainians arriving in the UK continues to increase. Many are highly educated individuals who anticipate a short-term stay in the UK and as such delay putting down roots. This has impacted on schooling, building health service knowledge, and employment options. Initial housing agreements are informal and time-limited. Reports of homelessness are increasing, with associated vulnerability and potential for exploitation.8 While host families may become lifelong advocates for Ukrainians, some report an unsustainable care burden, vicarious trauma, and financial/relational strain.

How should GPs respond?:

Promoting access
Responding to how and why Ukrainians do (or don’t) use GP services could improve their health. Knowledge gaps could be improved by easier and recurring access to linguistically and culturally translated NHS guidance, including via community social media such as Telegram and Viber chats.

“Reports of homelessness are increasing, with associated vulnerability and potential for exploitation.”

Opportunities to speak with and ask questions of health professionals is valued. At a locality level, primary care networks could identify and train community member ‘champions’ to support Ukrainians’ engagement with health, social, and educational services. Further steps are, however, required to overcome cultural and linguistic barriers, including during appointment booking, referrals, screening, and discussion of stigma-bound conditions.9

As with the UK–Polish community, common presentations like child health or musculoskeletal disorders can provide an opportunity for relationship building, health promotion (including immunisation and tuberculosis screening), and sensitive discussion of mental health and social vulnerability.10

Managing care expectations
Communication skills and consultation models used within UK general practice were largely designed for a culturally homogeneous British society. Ukrainians have established health beliefs, experiences, and expectations that may clash with standard communication approaches in UK general practice.

Examples include indications for antibiotics, probiotics, and herbal medications, as well as urgency of childhood illness. Clinicians should not perceive differences as criticism or confrontation, but as an opportunity to pragmatically discuss UK health system norms and find a mutually agreeable management strategy. Flexibility or possibly even reimagination of the consultation may be required to build this trustful and open dialogue.

“GP practices can provide a safe environment for disclosure … “

Cultural competency training is a starting point, providing skills to avoid assumptions and identify how Ukrainians’ health beliefs and expectations shape their help seeking. Significant variations exist in Ukrainians’ health literacy, social connections, and lived experience as refugees in the UK.

Mental health and trauma-informed practice
Managing Ukrainians’ mental health needs, including psychological trauma, necessitates a trauma-informed care approach. Traumatic experiences impact an individual’s ability to feel safe and develop trusting relationships with healthcare professionals. GP practices can provide a safe environment for disclosure, as well as compassionate guidance on support and treatment options. Delivering trauma-informed care requires considering the impact of traumatic exposure/s on an individual’s biological, psychological, and social development, while seeking to avoid further harm to the individual.

Trauma-informed care should also consider the clinician’s own needs and how they can be met to ensure ongoing emotional capacity.11 Resources, including the CALMER Framework, have been developed to support integration of ‘trauma-informed practice’ when supporting Ukrainians (Box 1).12,13 Given the current lack of culturally and linguistically accessible talking therapies or PTSD services for Ukrainians in the UK, additional mental health support should be considered:14

  • Screening for depression, anxiety, or PTSD and offering pharmacological treatment with selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors (when appropriate). Advice and guidance can be sought from community psychiatrists skilled in trauma while waiting for specialist review.
  • Support in registering with and requesting interpreter services for NHS Talking Therapies/social prescribing.
  • Online mental health options, such as private video consultations with Ukrainian- and Russian-speaking professionals, Ukrainian self-directed counselling via chatbot, and social media support groups (Box 1).
  • Signposting to local cultural, community, and church groups for practical and wellbeing support. These groups are often accepted, empowering, and manage subthreshold mental health symptoms.
Box 1. Mental health support tools for Ukrainians in the UK
Trauma-informed care in primary care15
  • The migrant health guide – resources on migrants and the NHS assessing vulnerability, communicable, and non-communicable diseases
  • The British Medical Association toolkit on asylum seekers’ and refugees’ health needs and overcoming common barriers to health care
  • Doctors of the World (UK) – resources for clinicians and practices improving health care for migrants (healthcare professions and medical practitioners)
  • The ‘All Our Health’ inclusion medicine e-learning from the Royal College of General Practitioners and e-Learning for Healthcare.
The CALMER Framework12 C – Consider needs and risks

A – Acknowledge diversity in people’s needs, understanding, and preferences

L – Listen with empathy

M – Manage situations to promote dignity and respect

E – Enable contact with supportive others

R – Resource through the provision of information and remember your own needs.

Online mental health support in Ukrainian
  • ‘Коло сім’ї’ (‘family circle’) – Website with a range of resources for mental health-related issues in Ukrainian – https://k-s.org.ua/resources
  • ‘Friend. First Aid’ – Telegram-based self-help chatbot simulating dialogue with a specialist using the World Health Organization’s psychological first aid and stress management – https://t.me/friend_first_aid_bot
  • Чат ‘Як ти?’ (chat ‘how are you?’) – Telegram group offering psychological help and conversational support for people experiencing complex emotions – https://t.me/yaktuzaraz
  • ‘ПсихБатальон’ Чат (‘PsychBattalion’ Chat) – Telegram group offering counselling, psychological support, and relaxation techniques – https://t.me/PsycheBattalion
  • ‘Розірви коло’ (‘Break the Circle’) – Instagram group supporting and empowering women who have experienced or are at risk of violence – https://rozirvykolo.org

Conclusions

Despite the initial NHS response, many Ukrainian refugees feel their health has deteriorated since arrival in the UK. Ukrainians are often unsure how and when to access NHS services. Cultural adaptation of information on accessing the NHS, GP consultation approaches, and discussions around mental and social wellbeing would improve relevance and quality of primary care for Ukrainians. Longer-term consideration of how UK primary care can support the health of those returning to Ukraine and the rebuilding of the Ukrainian health system would be of added value.

References
1. United Nations High Commissioner for Refugees. Operational data portal: Ukraine refugee situation. 2023. https://data.unhcr.org/en/situations/ukraine (accessed 7 Mar 2023).
2. Home Office, UK Visas and Immigration. Ukraine Family Scheme, Ukraine Sponsorship Scheme (Homes for Ukraine) and Ukraine Extension Scheme visa data. 2023. https://www.gov.uk/government/publications/ukraine-family-scheme-application-data (accessed 7 Mar 2023).
3. Poppleton A, Ougrin D, Maksymets Y. Providing responsive primary care for Ukrainian refugees. Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp22X719633.
4. Adams C. Ukrainian refugees are now living in the UK – so how is it going? BBC News 2022; 28 May: https://www.bbc.co.uk/news/uk-61548979 (accessed 7 Mar 2023).
5. Pope C, McKenna G, Turnbull J, et al. Navigating and making sense of urgent and emergency care processes and provision. Health Expect 2019; 22(3): 435–443.
6. Poppleton A, Howells K, Adeyemi I, et al. The perceptions of general practice among Central and Eastern Europeans in the United Kingdom: a systematic scoping review. Health Expect 2022; 25(5): 2107–2123.
7. Wong BHC, Chkonia E, Panteleeva L, et al. Transitioning to community-based mental healthcare: reform experiences of five countries. BJPsych International 2022; 19(1): 18–21.
8. Crisis. Cross-party MPs urge UK Government to act as homelessness amongst Ukrainian refugees increases sixfold in a year. 2023. https://www.crisis.org.uk/about-us/media-centre/cross-party-mps-urge-uk-government-to-act-as-homelessness-amongst-ukrainian-refugees-increases-sixfold-in-a-year (accessed 7 Mar 2023).
9. Kolesnyk P, Frese T, Vinker S, et al. Steps towards implementing evidence-based screening in family medicine in Ukraine: SWOT-analysis of an approach of multidimensional empowerment. BMC Fam Pract 2021; 22(1): 20.
10. Madden H, Harris J, Blickem C, et al. “Always paracetamol, they give them paracetamol for everything”: a qualitative study examining Eastern European migrants’ experiences of the UK health service. BMC Health Serv Res 2017; 17(1): 1–10.
11. Pollard T, Howard N. Mental healthcare for asylum-seekers and refugees residing in the United Kingdom: a scoping review of policies, barriers, and enablers. Int J Ment Health Syst 2021; 15(1): 60.
12. British Red Cross. Homes for Ukraine: how to support Ukrainian guests in your home. 2023. https://www.redcross.org.uk/stories/health-and-social-care/health/homes-for-ukraine-how-to-support-ukrainian-guests-in-your-home (accessed 7 Mar 2023).
13. Scottish Government. Trauma-informed practice: toolkit. 2021. https://www.gov.scot/publications/trauma-informed-practice-toolkit-scotland (accessed 7 Mar 2023).
14. Javanbakht, A. Addressing war trauma in Ukrainian refugees before it is too late. Eur J Psychotraumatol 2022; 13(2): 2104009.
15. Office for Health Improvement and Disparities. Assessing new patients from overseas: migrant health guide. 2021. https://www.gov.uk/guidance/assessing-new-patients-from-overseas-migrant-health-guide (accessed 7 Mar 2023).

Featured photo by Max Kukurudziak on Unsplash.

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