Qualitative Research with Ukrainian Refugees and Health Care Workers to Inform Interventions to Increase Vaccination and Access to Primary Health Care Services in Estonia

"...it seems to me that there are more high-quality vaccines here [than in Ukraine]... In general, you know, when I gave birth to a child here, it seems to me that the system here is a little different. More honest... That is why I have more trust in this medicine [Estonian medical system]." - caregiver

Due to the Russian Federation's military offensive against Ukraine that began on February 24 2022, over 7.5 million people have fled to nearby countries, including Estonia. This qualitative study is motivated by the belief that understanding how to better support these refugees is essential for tailoring primary healthcare services, including vaccination. The study explores the barriers and drivers experienced by the following groups: caregivers from the Ukrainian refugee community (in terms of having their children vaccinated in Estonia), older adults from the Ukrainian (in terms of receiving influenza vaccination in Estonia), and healthcare workers, or HCWs (in terms of providing primary healthcare services, including vaccination, to the Ukrainian refugee community). The study was published by Think Tank Praxis, the World Health Organization (WHO), Sociologist, and Valid Research Limited.

The theoretical framework underpinning this research and analysis is the capability-motivation-opportunity for behaviour change (COM-B) framework, modified for vaccination behaviours. This framework identifies interlinked factors of capability, physical opportunity, social opportunity, and motivation as influencing individuals' vaccination behaviours, providing a holistic approach to exploring barriers and drivers to positive vaccination behaviours (recommending, delivering, receiving vaccination). The interview guides were organised by the four COM factors and used to investigate the individual and contextual barriers/drivers to receiving and delivering primary healthcare services, including vaccination.

The study was conducted from February to April 2024 in three cities: Tallinn, Tartu, and Pärnu. Ten mothers of children aged 6-24 months and nine older adults who had not received influenza vaccination in the winter of 2023/24 were interviewed in Ukrainian by telephone or online. Five HCWs were interviewed in Estonian by telephone or online. Data were analysed using a rapid approach to framework analysis.

Results indicate that caregivers and older adults were generally confident in finding health information and accessing the healthcare system in Estonia, although two caregivers reported challenges in registering with a primary healthcare facility. All the caregivers and most older adults knew of the health portal. Caregivers with fully vaccinated children had used it, but only two older adults had used it. The HCWs emphasised they treat Ukrainian patients the same as Estonian patients. They communicate in Russian, Ukrainian, and English, and so they do not need interpretation services. The process for refugees registering with primary healthcare facilities was generally viewed as well organised. Limited or no access to medical records was seen to complicate care.

The childhood vaccination programme in Estonia is delivered in the same way to Estonian and Ukrainian children. These caregivers knew about the programme, and most could confidently access it. Both caregivers and HCWs noted the lack of an automated reminder system. Caregivers with fully vaccinated/postponed vaccination children trusted Estonian HCWs and had discussed vaccination with them. Those refusing vaccination for their children had not received any information from HCWs about vaccination, relying on their social circle and social media who held similar beliefs. They stated they do not trust HCWs in Estonia (only their general practitioner in Ukraine), and they were surprised that HCWs in Estonia do not try to persuade them to vaccinate. There was mixed evidence of HCWs tailoring their vaccination conversations to the different needs of hesitant and refusing caregivers, and potential language barriers were recognised. A key barrier for HCWs was the absence of a child's documented vaccination history, meaning they rely on caregivers for this information.

The adult influenza vaccination programme in Estonia is the same for Estonians and Ukrainians. None of these older adults had seen any "official" information about the programme or been invited for influenza vaccination and most did not know it is free for adults aged 60+ years. They demonstrated many knowledge gaps and misperceptions. Many said community norms for vaccination influence their own decisions; however, they (particularly those refusing) perceived low levels of influenza vaccination among the Ukrainian community in Estonia. Those postponing vaccination wanted information and a direct recommendation from a HCW to be vaccinated (seen to be lacking in Estonia compared to Ukraine). HCWs confirmed this less proactive approach to inviting or persuading adults to be vaccinated, respecting patient choice. Some described tailoring their vaccination conversations to the different needs of hesitant and refusing caregivers, mentioning potential language barriers.

In May 2024, the study's findings were taken to a stakeholder workshop in Tallinn, supported by the Ministry of Social Affairs, the Health Board, and WHO country and regional offices. A communication and intervention plan was developed based on the gathering; it isavailable from Kristina Köhler, WHO Country Office, Estonia (kohlerk@who.int).