Healthcare Professionals' Perspectives on the Challenges in the Vaccination of Ukrainian Child Migrants and War Refugees: Findings from a Qualitative Study in Poland

"[T]he study results could inform the application of behavior change interventions among HCPs [healthcare professionals], patients, and parents/caregivers to facilitate optimal preventive care services and increase vaccination rates among Ukrainian children in the host country."

Despite the availability of publicly funded vaccines, Ukrainian migrant and refugee children in Poland still show suboptimal vaccination coverage and enrollment in immunisation registers. Healthcare workers are crucial in increasing vaccination rates among migrants: They can address vaccination hesitancy, contribute to policy formulation, and garner support for policy initiatives. The aim of this qualitative research study was to explore the barriers encountered by Ukrainian war migrants and refugees in accessing vaccinations in Poland and the challenges related to delivering vaccinations observed by healthcare professionals (HCPs).

The study was based on an analysis of data from 18 in-depth interviews with HCPs working with Ukrainian refugees conducted in Poland in July and August 2023. The authors analysed the data using the United Nations Children's Fund (UNICEF) Journey to Health and Immunization (JHI) framework in order to identify bottlenecks and possible interventions that could solve existing problems in preventive healthcare for migrants. The JHI framework identifies 6 key steps in the vaccination process: knowledge, awareness, and beliefs; intent; preparation, cost, and effort; point of service; experience of care; and after service.

Factors at the individual, community, societal, and political levels impact vaccine access, confidence, and demand at each of these stages. The concept of JHI invited HCPs participating in the study to walk in the shoes of the Ukrainian migrant and war refugees population in their journey to vaccination, recognising their unique experiences. 

This qualitative study revealed that at each stage of the JHI, there were challenges related to vaccinating Ukrainian children in Poland, which were similar to those experienced in other countries: gaps in routine immunisations and the need to fill these gaps by ensuring refugee populations are fully included in routine immunisation in the host country. Here are some examples from each JHI stage:
 

• Knowledge, awareness, and beliefs: Participants emphasised the role of their own knowledge in supporting vaccinations in the following areas: understanding the needs and rights of refugees related to health care; knowledge of the culture, language, and experiences of Ukrainian citizens; knowledge and awareness of services supporting refugees; and practical knowledge in creating individual vaccination schedules for Ukrainian children. However, most HCPs stated they have not received any formal training for working with Ukrainian migrants and war refugees or the necessary materials. They expressed a strong desire to increase their expertise and confidence in managing the immunisation process among migrant and war refugees.
• Intent: Health decisions in general, and vaccination decisions in particular, can be significantly influenced by patients' trust in the healthcare system and healthcare workers. "We need to talk to them so they know we want to help them..."
• Preparation, cost, and effort: According to the HCPs, Ukrainian mothers face competing priorities, so convenience of access points was a key factor in vaccination decision-making. It is important to improve training and awareness of healthcare workers and other frontline workers about the needs and cultural, religious, and social perspectives of refugees and migrants.
• Point of service: Many participants noted that systems and processes, such as opening hours, recall systems, and administrative processes (e.g., phone bookings), created barriers to healthcare utilisation for Ukrainian families. The standard consultation time for immunisation events with refugee children was perceived as too short due to complex health needs, large family sizes, and language barriers. Communication challenges were recognised as one of the most significant barriers. Sometimes due to language barriers or lack of time, information about vaccination was not transmitted.
• Experience of care: A need for patient education has been stressed, including informal education, to improve their ability to use the Polish healthcare system, preventive vaccinations, and enhance their satisfaction with received medical care. "But when you talk to parents in a non-judgmental, caring atmosphere, they sometimes decide to vaccinate their children..." The participants pointed out that refugees chose to travel further to access more culturally appropriate practices where staff spoke similar languages or were of similar backgrounds.
• After service: Mothers felt reassured after being informed about the symptoms that their child might experience, situations that should be alarming and require medical help and situations when they can manage health issues on their own. It is important to ensure precise information about the next steps (e.g., the next vaccination appointment) and to schedule the date. It was noted that conventional methods of sending reminder letters and phone calls were ineffective.

In short, the work environment, training, and communication with Ukrainian mothers contribute to HCPs' engagement in increasing vaccine uptake among their patients. The HCPs' attitudes, skills, and experiences impacted their interactions with patients and participation in the immunisation process. HCPs observed that the mother's journey was influenced by vaccine literacy level, competing priorities, individual barriers of access (e.g., language barriers, costs), and feelings associated with the decision to vaccinate a child, including worries about vaccine safety. The surrounding cultural norms, social support, and past experiences with the Ukrainian health system also influenced decisions on vaccinations.

The study revealed that the success of HCPs in achieving high vaccination coverage among Ukrainian patients is determined by the healthcare system. There are numerous factors in the healthcare system and broader socio-political system that can either strengthen or mitigate challenges faced by both HCPs and patients. The findings underline the need to review barriers faced by healthcare workers and provide them with training on migrant health and medical care. The more awareness practitioners have about their patients' cultural backgrounds, the higher the quality of care they can provide.

In conclusion: "Overcoming barriers related to vaccinations for migrant and war refugee populations requires a comprehensive approach, including building HCPs' knowledge about migrants' rights to healthcare services and vaccinations, improving communication between patients and HCPs, enhancing vaccine literacy, implementing informational campaigns to build trust in vaccinations and achieving vaccination coverage through flexible, tailored systemic solutions."