Author: Dami Song, RN2, 3EH/3W Medical/Neuroscience, Harborview Medical Center
Academic Supervisor: Tamara Cyhan Cunitz, MN, RN, Executive Director Nashi Immigrants Health Board, Affiliate Assistant Teaching Professor University of Washington
Site Supervisor: Ehsan Shayegan, EthnoMed, Harborview Medical Center, University of Washington

Background and Methods

With the war in Ukraine and President Biden’s announcement in 2022 sponsoring resettlement for 100,000 Ukrainians, approximately 14,000 refugees have entered Washington State. However, there has been insufficient research on the needs specific to this community, such as differing vaccination practices in their home country stemming from inadequate vaccine procurement and mistrust in vaccinations among the general population. Mental health issues also pose a concern in Ukrainian refugees who will need care for PTSD, anxiety, and depression to prevent long-term consequences.

The aim of this project was to create a cultural profile for Ukrainian immigrants and refugees for EthnoMed, an ethnic medicine resource website by the University of Washington and Harborview Medical Center to inform healthcare providers in delivering culturally-appropriate care. In exploring the experiences of the community with the U.S. healthcare system and services in Washington, the project involves identification of community approaches to healthcare and barriers to care, as well as background information about Ukrainian values, beliefs, and perceptions that impact their approaches to health.

Research was conducted in the form of a literature review, conversations with community members, and a review of community surveys conducted by students from the University of Washington in partnership with Nashi Immigrants Health Board – a registered non-profit organization serving Ukrainian communities in Washington – and the WA Department of Health Former Soviet Union workgroup. This EthnoMed profile and will provide healthcare workers with guidance regarding cultural considerations and needs of the community with input from community members. The work is intended to improve the community’s use of the healthcare system and services leading to improved health outcomes, and identify barriers that may be improved to support the community’s resettlement in the U.S.

NASHI Immigrants Health Board website: www.nashisupport.com

Geography

Ukraine is the second largest country in Europe about the size of the U.S. state of Texas, with a population of about 43.8 million as of 2021 (World Health Organization. Regional Office for Europe, 2019b). Situated at the crossroads of Europe and Asia, the country shares borders with Belarus, Hungary, Moldova, Poland, Romania, Russia, and Slovakia (Caston, 2022). The country is divided into 27 administrative regions, with 69% of the population residing in urban areas (Caston, 2022). The eastern regions are the most urbanized, whereas the western regions are more agricultural.

Map of Ukraine: https://www.britannica.com/place/Ukraine

Regional Characteristics

The climate in Ukraine is moderate with subtropical conditions in the southern shores of the Crimean Peninsula (World Health Organization. Regional Office for Europe, 2004). The summers are typically warm and winters cold, at times snowy. Western Ukraine has a milder climate than the east, and southern Crimea is the warmest region (Kent, 2015).

The land in Ukraine includes the Pripyat Marshes, one of the largest wetlands in Europe that extends into Belarus, a plateau region between mountain ranges, and the Central Carpathians, part of a long mountain chain in central and eastern Europe, with Mount Hoverla being the highest peak in Ukraine at 6,762 feet (2,061 meters). The Dnipro in Ukraine is Europe’s fourth longest river with a length of about 1,370 miles (2,200 km). Many cities are built along the river, including the capital of Kyiv. There are around 3,000 lakes within the country, the largest of them being Yalpug, Cahul, Kugurluy, and Katlabush, and most being relatively small and shallow (Kent, 2015).

Ukraine’s rich soil has contributed to its reputation as one of the world’s leading producers of wheat. Fertile black soil called chornozem is abundant – a rare type of soil that has a high proportion of humus, which is made from decaying grasses. Chornozem is excellent for producing crops, earning Ukraine the nickname “the Breadbasket of Europe” for its prosperous harvests (Kent, 2015). The use of chornozem also reduces the need for fertilizer and enables organic farming methods without the use of artificial chemicals, which allows crops from Ukraine’s farms to be sold at a higher price in European markets.

Demographics

The main ethnic groups in Ukraine include Ukrainian (78%) and Russian groups (17%) (World Health Organization. Regional Office for Europe, 2004). The remainder of the population includes Belarusians, Moldovans, Bulgarians, Poles, Hungarians, Romanians, Roma, the Crimean Tatars, and other groups (Ukraine | History, Flag, Population, President, Map, Language, & Facts, 2023). The total population has experienced a significant decline since the country’s independence, with much of the decline occurring between the mid-1990s to the mid-2000s. Part of this is due to the low birth rate, which has overall remained low. The fertility rate was 1.16 in 2021, according to national statistics (Home | State Statistics Service of Ukraine, n.d.), which is significantly lower than the replacement rate of 2.1, which is the average number of babies per family that is needed to keep a population steady (Nadworny & Harbage, 2023). The rates were worrisome even before the Russian invasion in 2022, and with the mass exodus of more than 8 million people during the war (Ukraine Data Explorer, n.d.), there are concerns of a dwindling number of potential parents that may render a baby boom unlikely even if the war comes to an end.

According to the Centre for Eastern Studies (OSW), post Russian full-scale invasion depopulation statistics include estimates of 15-17,000 Ukrainian soldiers killed and estimate 500,000 military and 2.7 million civilians are disabled. At the start of the full-scale war an estimated 8.2 million people (about half the population of New York) were displaced from Ukraine. Over 2.8 million refugees (about the population of Mississippi) from Ukraine now reside in Russia and the United Nations is not able to specify exactly how many were forcibly deported by Russia.

Although the low birth rates appear to be a pattern that is seen across Europe as part of modernization and change in family dynamics, the pattern seen in Ukraine is not that families are deciding not to have children, but to have less children, having only one child as opposed to two or three. Focus groups in eastern Ukraine have shown that the one-child norm has largely been driven by the increasing political uncertainty leading to decreased feelings of safety and stability, as well as the rising costs of living and raising children (Nadworny & Harbage, 2023).

Languages Spoken

Due to Russification both Ukrainian and Russian are spoken and widely understood in Ukraine, and it is not uncommon to hear conversations in which one person speaks in Ukrainian, and the other answers back in Russian. About 67% of the population considers Ukrainian to be their first language, while 30% speak Russian as their first language. Ukrainian is the dominant language spoken in western and central Ukraine, whereas Russian is more commonly spoken in eastern and southern Ukraine (Cultural Orientation Resource Exchange, 2023). Demographic data on Ukrainian refugees in Washington State display similar findings, with approximately 68% speaking Ukrainian and 31% speaking Russian (WA DOH).

Ukrainian As The Official Language

Ukrainian became the country’s official language in 1989 and was reaffirmed in the nation’s constitution as the only official language of Ukraine in 1996. The matter of language is part of an effort of Ukrainians to distance themselves from the shared Soviet past, a tendency which is reinforced by the fact that Russia uses this past as a propaganda tool for a war that may not be named. The Ukrainian government has taken formal action to revitalize the use of the Ukrainian language as the country’s primary language, passing the State Language Law in 2019 to establish Ukrainian as the country’s primary language of communication in businesses, schools, and the media (Caston, 2022). In light of the recent war in Ukraine, policies surrounding language in the country have become important politically as well as personally. Debates have erupted on social media about the importance of speaking Ukrainian over Russian and renouncing Russian language and culture, as it is, as one community member expressed, “the language of the oppressor”. Many are announcing their intent to switch to speaking only in Ukrainian

The “Russification” of Ukraine

“Russification” is defined as “a combination of informational, cultural, academic, diplomatic, military, and general social trends aimed at forcing the transition to the Russian language and the reproduction of Russian imperial myths, customs, and world views”, as well as “a set of aggressive and concealed actions, narratives, and environments aimed at strengthening Russian autocratic national and political superiority in countries that are part of the Russian Federation and/or are affected by its colonial policies” (Kateryna, 2022). Russia’s war on Ukraine that began in 2014 is fueled by Russian propaganda that reinforces the idea of Russians and Ukrainians being “one people”, promoting the superiority of Russian culture and justification for the consistent banning of the Ukrainian language, education, and arts in a move toward “a complete return under Moscow’s influence” (Kateryna, 2022).

Russia has been implementing aggressive policies toward the territories of the Donetsk and Luhansk regions in eastern Ukraine for centuries in an attempt to “erase” their Ukrainian identity and destroying the local population, enlisting methods of deportation, genocide, mass issuing of Russian passports (“passportisation”), and forced Russian language introduction (Kateryna, 2022). Its influence extends beyond regional conquest and aims to destroy Ukraine’s culture and identity, investing millions in media propaganda to promote its imperialist ideals.

Russian president Vladimir Putin’s speech declaring Russia’s “special military operation” in Ukraine in 2022 laid out a long list of grievances including the expansion of the North Atlantic Treaty Organization (NATO) and the fundamental issue of the legitimacy of Ukraine as an independent country with its own culture and heritage, suggesting that modern Russia, Ukraine, and Belarus should “share” a political destiny (Mankoff, 2022). Russia’s policy toward Ukraine and Belarus has been largely based on the assumption that the two countries’ identities are “artificial” and should be unified under Russia in an “unchanging historical essence” (Mankoff, 2022). Its efforts extend beyond preventing Ukraine’s NATO membership to attempt to dominate Ukraine politically, militarily, and economically (Mankoff, 2022).

Romny, Sumy region, Ukraine. Youth Day, June 29, 2014. People in traditional Ukrainian clothes at the Youth Day of Ukraine. Photo by: Volodymyr Chmut, editorial use only.

Ukrainian National Identity

Despite Russia’s attempts to reject and delegitimize Ukraine’s identity, Ukraine has successfully consolidated a shared civic identity, with many citizens identifying as first and foremost Ukrainian (Mankoff, 2022). The number of Ukrainian speakers has outnumbered Russian speakers by 2001 with the exception of Crimea, Donetsk, and Luhansk, and more than two-thirds of citizens designate Ukrainian as their native language (Mankoff, 2022). Religious affiliation also suggests Ukraine’s distinction from Russia, with more Orthodox Christians in Ukraine starting to identify with the Kyiv-based Orthodox Church of Ukraine over the Ukrainian Orthodox Church of the Moscow Patriarchate (Mankoff, 2022). In addition, calls for Ukraine’s integration into the European Union and NATO have grown substantially, despite Russian opposition (Mankoff, 2022).

Religion

The predominant religion in Ukraine is Eastern Orthodoxy, which is practiced by nearly half the population (Ukraine | History, Flag, Population, President, Map, Language, & Facts, 2023). Other minority religions in Ukraine include Protestantism, Roman Catholicism, Islam, and Judaism (Ukraine | History, Flag, Population, President, Map, Language, & Facts, 2023).

Historically, many belonged to the Ukrainian Orthodox Church-Kyiv Patriarchate, with others belonging to the Ukrainian Orthodox Church-Moscow Patriarchate and the Ukrainian Autocephalous Orthodox Church (Ukraine | History, Flag, Population, President, Map, Language, & Facts, 2023). In 2019, the Kyiv Patriarchate and Autocephalous groups were merged into the Orthodox Church of Ukraine, formalizing the independence of the Ukrainian Orthodox community that had previously been under the jurisdiction of the patriarchate of Moscow (Ukraine | History, Flag, Population, President, Map, Language, & Facts, 2023). There is little difference between the two churches in terms of religious practice and doctrine, but one’s association with either church has played a part in the parishioners’ identities in relation to the divide between Ukraine and Russia (Santora, 2022).

People leaving ukraine via train due to russian invasion. Refugees leaving Lviv or Kiev, ukrainian state train is seen in the background on the station of Lviv. Photo by: Anze Furlan / psgtproductions ,

The Ukrainian Healthcare System

Ukraine has a universal healthcare system that has undergone a number of reforms to increase healthcare access and streamline care for its citizens. Before the outbreak of the war in 2022, significant progress in primary care was seen, with a substantial part of the population enrolling in a contract with a family doctor, and efforts were made to curb some of the inefficiencies and lack of transparency in the healthcare system (WHO, 2023). Patients in Ukraine can self-refer to specialists, but a third of these patients refer themselves to the wrong specialist and have to be redirected, adding to the inefficiencies in the system (WHO Country Office in Ukraine, unpublished data, 2021).

Challenges surrounding the healthcare system have been around for over 30 years with the inheritance of an under-financed system plagued by bureaucratic inefficiencies and special interests from the Soviet era (Dickinson, 2020b). Structural inefficiencies, fragmentation, and lack of transparency in the healthcare system have given way to lack of accountability, corruption, artificial price markups, and the use of informal payments, making affordability of services and pharmaceuticals a barrier to access (Dickinson, 2020c). The distribution of budget funds to healthcare facilities also relied more on the size of the hospitals and the influence of the politically powerful, rather than on the needs of patients (T Dickinson,2020b). Medical bribes and “charity donations” to clinics and hospitals, as well as physicians at private practices, were common, putting the financial burden on the patients in order to receive quality care (Dickinson, 2020b).

Healthcare financing reforms

Much progress has been made in consolidating previously fragmented sources of government healthcare financing into one program (Bredenkamp et al., 2022). In 2017, ambitious reforms in the healthcare system were driven by the health ministry with the creation of a new single-payer agency called the National Health Service of Ukraine (NHSU).

Increased primary care access

Increasing access to primary care for Ukrainians has been a priority goal for the recent healthcare reforms. In an effort to ensure that all Ukrainians are enrolled with a family doctor, the NHSU distributes payment to doctors to deliver free, basic health services to patients who have signed a contract with a primary care doctor of their choice, allowing private facilities to compete with state facilities for funding and widening the array of choices for patients (Dickinson, 2020b). The benefit package guaranteed to Ukrainian residents is not yet fully funded, leading to eligible services being limited to point-of-care services (Bredenkamp et al., 2022). In 2020, the number of packages was expanded to 31, including inpatient and outpatient hospital care, diagnostics, emergency medical services, and COVID-19-specific care (Bredenkamp et al., 2022).

Designating a primary provider is designed to be flexible, however, allowing patients to enroll with any family doctor as long as the doctor has an active working agreement with a primary health care facility that has a contract with the NHSU (Centre for Primary Health Care (KAZ) (PHC), 2023). Changing doctors is also possible, adding to the flexibility of the system (Centre for Primary Health Care (KAZ) (PHC), 2023). Primary care enrollment has increased to include more than 70 percent of the population since the reforms, although the COVID-19 pandemic has delayed the implementation of some other aspects of the reforms (Bredenkamp et al., 2022).

Streamlining and consolidation of healthcare information

The adoption of an electronic health information system provides continuously updated, transparent data on financing of care and adherence to standards, greatly reducing opportunities for corruption and leading to increased satisfaction on the part of both patients and providers (Dickinson, 2020b).

Prior to the reforms, there was also no comprehensive registry of the number of medical facilities in the country, with different registries listing different facilities that provided inconsistent data (Dickinson, 2020b). The NHSU now publishes the contracts with each facility and the services performed at each hospital, including the outcomes (Dickinson, 2020b).

Reforms in hospital funding

As of 2020, hospitals are reimbursed based on the conditions that are actually treated, forming an incentive structure that is conducive to better care and outcomes (Dickinson, 2020b). This leads to hospitals with more patients and higher quality standards to receive more funding over hospitals with fewer patients and less-than-quality standards. The re-profiling of institutions in order to prioritize and direct funding to facilities that meet these standards will also lead to the authorities to determine which facilities to invest in, merge, and close – which has sparked a fuel of social media posts and protests from staff of the facilities with the largest cuts in funding, denouncing the reforms (Dickinson, 2020b).

Challenges to increasing primary care in Ukraine

The historic model of care involves narrow specialists who manage many of the chronic patient conditions rather than family doctors, resulting in primary care doctors who have limited experience caring for patients with multiple conditions (Centre for Primary Health Care (KAZ) (PHC), 2023). Traditionally, preventative care has not been the main focus of primary care in Ukraine, and technology for early detection and treatment are commonly not available in primary care offices (Centre for Primary Health Care (KAZ) (PHC), 2023). Although the scope of primary care providers is expanding and services now require them to better inform and involve the patient in making decisions related to their health and have preventative conversations regarding lifestyle and behavioral changes, educational support for healthcare workers is needed for primary care staff to meet this expansion of roles (Centre for Primary Health Care (KAZ) (PHC), 2023).

Psychiatric conditions are outside the scope of family medicine, and the lack of input from social workers in healthcare practices is limiting the current reforms involving mental health care. The healthcare reforms of 2017 addressed the lack of community-level mental health care, integrating mental health into primary care services (Vitruk, 2023), but the scope of mental health services that could be provided by primary care practices remains undefined (Centre for Primary Health Care (KAZ) (PHC), 2023). The WHO’s Mental Health Gap Action Programme establishes clinical protocols for primary care doctors and nurses for them to serve as the first point of contact with patients with mental health care needs, thereby increasing access to basic mental health care (Vitruk, 2023).

The use of bribes and informal payments

According to the 2018 Informal Payments Survey in Ukraine conducted by the United States Agency for International Development HIV Reform in Action project, 56% of 4000 patients had made at least one informal payment in the past year (World Health Organization. Regional Office for Europe, 2019b). According to conversations with community members in Washington State, the use of bribes and informal payments is still common in Ukraine, and small gifts or treats may be delivered to providers as part of an attempt to ensure quality of care.

Although the idea may be foreign to those in the U.S., conversations with community members have shown that many Ukrainians do not consider the practice to be of significant concern. They claim that many physicians are government employees and are struggling with low wages, and that the small gifts and payments serve as tokens of appreciation for the care they provide. Some even reasoned that the ability to offer bribes to physicians can be convenient because it offers patients more pathways to receiving quality care, especially during times when good care is urgent. Because gifts and bribes are common in Ukraine with the underlying issues of low wages and structural inefficiencies in the Ukrainian healthcare system (World Health Organization. Regional Office for Europe, 2015), it is good for providers to be aware of the possibility of patients trying to offer them bribes in return for services and understand the cultural context behind the practice.

The rise of vaccine-preventable diseases

There has been a drastic decline in immunizations in Ukraine since 2009 when the death of a child was incorrectly blamed on the measles-rubella vaccine the year before, fueling anti-vaccine sentiments in the media and public distrust of vaccination (Khetsuriani, et al. 2022). This led to a precipitous fall in vaccination levels, dropping the rate of children receiving the complete series of the MMR vaccine from 95% in 2008 to 31% in 2016 (Green, 2017b). Although the rates are back on the incline, the latest 85% measles vaccination rate recorded by the WHO still remains below the level needed for herd immunity (Green, 2017b). The drastic decline in Ukraine’s immunization coverage has led to concerns about the potential resurgence of vaccine-preventable diseases, such as diphtheria and tetanus, and has led to an outbreak of measles in 2012 and 2016 through 2019, as well as vaccine-derived poliovirus type 1 in 2015 (Khetsuriani et al., 2022).

Managing HIV, tuberculosis, and viral hepatitis has been a priority in Ukrainian public health but has been challenging at the primary care level (Centre for Primary Health Care (KAZ) (PHC), 2023). With the current efforts by the government to increase access to primary care and provide screening for communicable diseases at the primary care level, it is important for primary care offices to ask the appropriate screening questions and provide adequate guidance and education regarding testing and treatment options. Challenges remain, however, with the insufficient capacity of primary care staff to identify high-risk patients, lack of knowledge on treatments and prophylaxis for individuals with HIV/AIDS, insufficient time to conduct rapid diagnostic tests, difficulty of primary care facilities to transport blood samples, the cost of testing, gaps in data systems during the transition to electronic immunization registers, and stigma toward patient populations that have or are at risk of contracting HIV and tuberculosis (Centre for Primary Health Care (KAZ) (PHC), 2023).

HIV epidemic

Ukraine bears the second largest HIV epidemic in eastern Europe and central Asia, behind Russia (Green, 2017b). According to 2017 UNAIDS estimates, there were 238,000 people living with HIV in Ukraine, its prevalence being highest in people who inject drugs (Green, 2017b). Meeting the needs of the population that is affected has largely fallen into the hands of the international community and local groups supported by international donors, although the Ukrainian government has proposed healthcare reforms in recent years to take over many of the responsibilities (Green, 2017b).

People with HIV in Ukraine are still plagued by stigma, and there are few opportunities for testing, treatment, and prevention services regarding the disease. With the ongoing war beginning in 2014, it has been increasingly difficult to deliver antiretroviral drugs and clean injection products to various regions in Ukraine, leading to concerns of rising HIV incidence (Green, 2017b).

Concerns regarding confidentiality of health information and trust

In conversations with community members, it has been said that it is not always easy to discuss sexual and reproductive health with Ukrainian patients. It is advised to normalize the process of screening and testing to be included in primary care visits and ensure confidentiality with any screening results and health-related information. In conversations with former healthcare professionals from Ukraine, the concern is great for people who inject drugs, who experience significant social stigma and often have less awareness and knowledge of HIV prevention, whereas MSM (men who have sex with men) tend to be more aware of prevention and treatment methods.

Health Beliefs, Attitudes and Preference

Medical decision-making and self-referrals

Although Ukrainian citizens have the right to access health information and services available to them, the methods of accessing this information are not always clear or transparent, leading many to rely on personal recommendations and informal networks in making healthcare-related decisions (Dickinson, 2020c). Individuals may opt to self-refer and pay out-of-pocket for services in an attempt to exercise some degree of choice in their healthcare, but nearly half of the patients who self-refer end up with specialists who treat conditions that are not compatible with what they are looking for and must be transferred to a different facility (Dickinson, 2020c). Some community members have shared that this is not as stressful as it may seem, because appointments are made rather quickly in Ukraine, and it is not considered very difficult to see a different provider soon after the original appointment. Compared to their experience with the U.S. healthcare system and its referral process, they note that they find their self-referral norms to be more convenient and appreciate the sense of control they feel when they seek care for themselves.

Mental Health

Russia’s military invasion of Ukraine in 2022 has significant implications for Ukrainian citizens and refugees arriving in the U.S. The Ukrainian immigrant and refugee community has social and cultural characteristics that uniquely impact the mental health of its members and their engagement with mental health professionals and resources.

Depression, anxiety, and post-traumatic stress disorder (PTSD) are common in many recent arrivals to the U.S. and could affect future generations due to the impact of the war, the COVID-19 pandemic, and resettlement efforts (Vitruk, 2023). Increased feelings of anxiety, depression, loneliness, and hazardous drinking have been reported since the war (Hyland et al., 2022), and many people also experience sleeping issues, fatigue, and somatic symptoms (Kluge & Habicht, 2022). Despite the prevalence of these issues, research conducted prior to 2023 shows that 75% of people in Ukraine did not access care for mental health and alcohol use disorders (Vitruk, 2023).

The following page has additional details regarding mental health care for Ukrainians and Ukrainian refugees by Olga Vitruk, an MPH student from the University of Washington: Ukrainian Refugee Mental Health Profile

Ukrainian refugee woman with Ukrainian flag in the background
Ukrainian Refugee, iStock (cc license)

Mental health, historical and political context

Although the political situation has become more well-known globally with the onset of Russia’s full-scale military invasion in February 2022, the military conflict began in 2014 with Russia’s annexation of the Crimean peninsula. Ukrainians have been fighting for independence for centuries prior to these conflicts, and many older as well as younger Ukrainians have family members who were persecuted or killed (Farmer & Kritovich, 2022).

It is important to be aware of the long-standing generations of oppression and loss in their lives (Farmer & Kritovich, 2022), and be tactful in the way that the Russia-Ukraine relations are approached. In conversations with community members, some have noted that at times it is best not to bring up the political situation at all and avoid over-empathizing about the war. They have mentioned that refugees arriving in the U.S. have many practical things to take care of in their resettlement, and bringing up the political situation back home could not only take the focus away from the immediate context but serve as a potential trigger for past trauma and concern for their loved ones back home.

Mental health care in Ukraine during wartime

Along with the general healthcare system in Ukraine, access to mental health services has been difficult during wartime. Since the conflict in Eastern Ukraine in 2014, civil organizations and international groups stepped in to provide mental health support for people affected by the conflict, providing telephone hotlines manned by volunteers trained in psychological first aid, and mobile crisis intervention stations (Shevlin et al., 2022).

In 2016, a new model of mental health care was launched with the support of the World Health Organization, including Community Mental Health Teams (CMHTs) that provided care for people with mental disorders in remote regions with limited access to mental health services. Since the war in 2022, the Ukrainian government and more than 200 partner groups have increased delivery of mental health support, and civil society organizations have increased their presence in the country, providing mental health services for people who have been affected by the war (Vitruk, 2023). CMHTs have also rapidly adjusted to wartime conditions, providing support for people in and out of the country (Kluge & Habicht, 2022). Ukraine’s First Lady Olena Zelenska initiated the creation of the National Mental Health and Psychosocial Support Program “How are you?” in order for Ukrainians affected by the aggressor to have full and effective access to psychological assistance.

Stigma and cultural perspectives on seeking mental health care

Stigma is a major barrier for Ukrainians that may prevent them from seeking care for their mental health issues. Ukrainians have a lot of empathy when it comes to people with mental health issues, but according to an online survey conducted in Ukraine in 2020, the stigma persists in that many of them would prefer to have friends or colleagues who do not have mental disorders (Quirke et al., 2021). This may have historical implications dating back to the Soviet era, when people who opposed Soviet rule were seen as mentally ill and were sent to psychiatric institutions (Van Voren, 2013). Many Ukrainians may fear that a mental illness diagnosis will lead to them becoming ostracized, and that it would make them unfavorable candidates for potential employers (Weissbecker at al., 2018). The idea seems to be more prevalent in older generations than the younger, but the use of words like “depression” or “mental health care” is discouraged when discussing the issue with Ukrainian populations (Vitruk, 2023), in hopes of reducing the potential impact of stigma that may prevent people from meaningful engagement.

Limited knowledge of mental health issues

In addition to the stigma surrounding the issue of mental health, there is a general lack of awareness that leads to misconceptions about diagnoses and treatment options. Ukrainians may have more extreme perceptions about what they think might happen during a mental health appointment or assume that any diagnosis could result in psychiatric hospitalization (Weissbecker et al., 2018), or pose some kind of disadvantage to them in future employment opportunities.

In conversations with community members, it has been mentioned that many Ukrainians may not take their own mental health issues seriously and recognize the need to seek help. They may have limited experience with mental health services and think they can deal with their mental health issues on their own, so it may be less common for them to seek care independently. According to a community survey of Ukrainians in the greater Seattle area in 2022, however, mental health care was listed as one of the highest priority needs of the community (Ekaterina’s community survey, 2022).

Lack of trust in mental health care

A lack of trust in mental health care and the public healthcare system serves as another barrier to Ukrainians seeking mental health care services (Weissbecker et al., 2018). They are often concerned about privacy and may fear that their mental health information will be shared with others (Weissbecker et al., 2018). They may also perceive the qualifications and expertise of mental health professionals to be inadequate, which could deter them from seeking continuous care or following through with referrals to psychologists or psychiatrists (Hook et al., 2021). The perception may stem from treatment and interventions by psychotherapists that may not always be evidence-based (Hook et al., 2021). State universities do not offer training in evidence-based treatment for common mental disorders Weissbecker et al., 2018) and psychotherapists are not required to complete medical degrees (Hook et al., 2021), which may not only limit the kinds of effective interventions available to people with mental disorders but contribute to the skepticism that Ukrainians may have toward mental health professionals.

From conversations with community members, it has been noted that many mental health care professionals in Ukraine may also be very specialized in certain kinds of treatment and interventions, rather than being trained in a variety of mental health disorders and interventions. This makes it difficult for people to seek care because they may start by seeing a psychotherapist who is specialized in one group of interventions and is unable to provide counsel on other types of treatments, potentially leading to more trial-and-error methods than necessary before settling on an effective treatment option for each patient’s condition.

Psychological first aid

Psychological first aid (PFA) is a direct response and form of psychosocial support that addresses both the emotional and social needs of the person, while helping them to meet immediate needs and connect them to resources (Guhle, 2022). It involves calming and supporting the person and providing practical assistance during times of crisis but could also be used to address needs in the weeks and months following a major distressing event as the individual’s reactions to the event continues to change and they must adapt to changing realities. Anyone can provide PFA at any time and in any setting – even members of the general public who are non-experts in healthcare or mental health. The goal is to provide immediate comfort and emotional support, assess their needs and concerns, help them to address immediate basic needs such as food and water and a place to stay, and link them to information and resources (Guhle, 2022).

Andrew Kritovich, LMHC from the Ukrainian Community Center, and Beth Farmer, LCSW from the International Rescue Committee, have hosted a course on PFA to help increase awareness of cultural and contextual factors related to Ukrainian refugees (EthnoMed, 2023):
Psychological First Aid Webinar Recording
Webinar Slides
Webinar Resources

The IFRC Reference Centre for Psychosocial Support also provides a guide to PFA in English, Ukrainian, and other languages:
Guide to Psychological First Aid

Mental health coping strategies

Individual coping mechanisms, such as meditation, diet, distraction, breathing techniques, and physical activity are some ways in which Ukrainians may address stress (Vitruk, 2023). Valerian root is a common herbal medicine that is also used to calm the nerves (Vitruk, 2023). Hazardous alcohol use has also been seen in 14.3% of men and 1.7% of women, which is expected to be intensified by trauma (Vitruk, 2023).

The role of community and religion in mental health

A sense of community is important in Ukrainian society. Many people rely on time with friends and other community members to talk about their concerns (Vitruk, 2023), making community support and connection to other Ukrainians in the U.S. an important part of resettlement efforts. Religion is also an important part of life for many Ukrainians. Attending weekly church services and connecting with church members can be a helpful source of mental health support (Vitruk, 2023). Spiritual leaders can serve as unofficial therapists, as the idea of receiving professional mental health care could be frowned upon by church members as an indication of lack of faith, with praying more and fasting serving as more acceptable responses to address mental health issues (Vitruk, 2023).

LGBTIQ rights

With the toppling of the Russia-backed government in 2014, the LGBTIQ human rights movement in Ukraine has gained significant momentum, leading to the prohibition of employment discrimination based on sexual orientation and gender identity, and legal gender recognition for transgender individuals in Ukraine (Ukraine | Outright International, n.d.). Same-sex relations for men and women are legal in Ukraine (Ukraine | Outright International, n.d.), although negative societal attitudes toward LGBTIQ people still exist in the country. Violence, discrimination, and hate crimes against LGBTIQ communities remain issues in the country, and anti-queer demonstrations are often seen during pride events and gatherings.

Impact of Russia’s invasion on the LGBTIQ rights movement in Ukraine

Russian president Vladimir Putin has tried to back his decision to invade Ukraine as a last-ditch effort to put a stop to the West’s hostile expansion nearing Russia’s borders (Fisher, 2022). Putin has long portrayed the LGBTIQ rights movement as a threat to traditional, right-thinking Christian values, claiming that this cultural celebration and acceptance of LGBTIQ peoples in Western nations is being imposed on Russia and Ukraine – “attitudes that are directly leading to degradation and degeneration” (Fisher, 2022). Putin has made this a part of his attempt to justify his attack on Ukraine, which may have been an effort to bolster the support of conservative Ukrainian groups – a part of Russia’s strategy to gain support over the past decade (Fisher, 2022). However, this seems to have fueled the LGBTIQ rights movement in Ukraine even further in 2022.

An inclusive queer patriotism

The LGBTIQ community in Ukraine has demonstrated unprecedented visibility in Ukraine during the war, largely thanks to social media highlighting the contributions of queer peoples to the fight against Russian forces (Opinion | How Russia’s War Against Ukraine Is Advancing LGBTQ Rights, 2023b). Many queer soldiers have come out and are fighting in the military to defend Ukraine’s democracy, and public opinion has rapidly grown more supportive of reforms to recognize the rights of these individuals (Opinion | How Russia’s War Against Ukraine Is Advancing LGBTQ Rights, 2023b). During this time of crisis, less importance has been attributed to differences in gender identity and sexual orientation, and more attention is being paid to the fact that soldiers are fighting side-by-side to protect Ukraine, regardless of how they may identify. Many LGBTIQ organizations in Ukraine have also been active in providing humanitarian relief during the war, providing food, medicine, and resources to those who are displaced and in need of assistance (Opinion | How Russia’s War Against Ukraine Is Advancing LGBTQ Rights, 2023b)

Ukrainian Refugees

Impact of the Martial Law on Refugee Populations

Refugees who have fled the country and have scattered across Europe are mostly women and children, as men of age 18 to 60 are prohibited from leaving the country in anticipation of being called to serve in the military (Harlan, 2022). There are exceptions, however, with fathers with three or more children being exempt, as well as individuals with medical issues who are unable to fight (Harlan, 2022). Men of serving age also sneak out through other means – by bribing border guards, for example – or sneaking across the border in areas of comparatively reduced security (Harlan, 2022).

As Ukrainian refugees seek safety, there have been widespread reports of human trafficking and exploitation, including sex and labor trafficking (Cultural Orientation Resource Exchange, 2023). As mentioned above, many who are fleeing Ukraine are women and children, which makes them vulnerable to these issues and lead to trauma that have long-term mental health consequences.

Ukrainian Refugees in Europe

Over 8 million people have fled Ukraine since the Russian military invasion in February 2022 (UNHCR – The UN Refugee Agency, 2023), triggering the largest refugee exodus in Europe since World War II, many fleeing to nearby countries such as Poland and Germany (Montoya-Galvez, 2023). Another 5 million Ukrainians have also been internally displaced inside Ukraine to flee war-ravaged parts of the nation (Montoya-Galvez, 2023). Some have sought resettlement in a third country, whereas others have decided to stay close to home, waiting to return to Ukraine once it is deemed safe (Cultural Orientation Resource Exchange, 2023).

As Ukrainian refugees seek safety, there have been widespread reports of human trafficking and exploitation, including sex and labor trafficking (Cultural Orientation Resource Exchange, 2023). As mentioned above, many who are fleeing Ukraine are women and children, which makes them vulnerable to these issues and lead to trauma that have long-term mental health consequences.

Ukrainian Refugees in the U.S.

The U.S. Department of Homeland Security (DHS) has made an effort to provide humanitarian relief to Ukrainian refugees since Russia’s war on Ukraine in 2022. In April 2022, President Biden announced plans to welcome 100,000 Ukrainians and others fleeing the war into the U.S. through various legal pathways, notably through the Uniting for Ukraine program, which supporters of Ukrainian or family members residing in the U.S. can file to sponsor Ukrainian refugees fleeing the war. The objective was reached in just 5 months, reaching 100,000 refugee admissions since the president’s pledge. DHS confirmed the number of arrivals to the U.S. and expressed that the number of 100,000 was “never a cap” (Montoya-Galvez, 2023), indicating the government’s intent to receive even more refugees in the coming days.

As of February 2023, citizens in the U.S. have applied to sponsor more than 216,000 Ukrainian refugees displaced by the war, and more than 115,000 refugees have already arrived under President Biden’s sponsorship program (Montoya-Galvez, 2023). Government officials have expressed that they expect most of these refugees to seek temporary refuge from the war, but with the uncertainty surrounding the duration and future of the situation in their home country, immigrant experts expect that many will decide to settle in the U.S. if the war were to continue (Montoya-Galvez, 2023).

In conversations with newly-arrived Ukrainians in Washington in 2022, a number of refugees have voiced concerns of having to “start life all over again” and weighing heavily the decisions surrounding resettlement such as looking for long-term work, schools to enroll their kids in, and finding long-term housing options, in the event that they end up settling long-term or permanently in the U.S. if the war back home were to continue. Many refugees find it difficult to obtain jobs, given that many are having to look for positions that may be unrelated to their jobs back home due to language barriers and lack of credentials or work experience in the U.S. Individuals that were formerly on professional career paths in Ukraine often must find lower-paying jobs that they may have no prior experience in, significantly impacting their already-strained economic status.

Cultural adjustment

Ukrainians come from a society with traditional views on identity roles, family dynamics, and religious and social norms. Interacting with people from different ethnic or racial backgrounds may pose difficulty in some refugees, including engaging with the LGBTQIA+ community in a culturally sensitive manner, which may be due to lack of knowledge and experience, or because of homophobic or transphobic perceptions (Cultural Orientation Resource Exchange, 2023).

Ukrainian refugees in Washington

Washington State is one of the top 10 states for refugee arrivals in the U.S. More than 30,000 refugees from over 70 countries have resettled in WA State during the past decade. As of February 2023, nearly 16,000 Ukrainian refugees have resettled in WA State since the war (Wilkinson, 2023), and more are still actively arriving through varying pathways, many through the Uniting for Ukraine program that allows family members and supporters of Ukraine to sponsor the refugees’ applications to travel to the U.S. The program is unprecedented in that it allows Americans to facilitate the entry of an unlimited number of refugees through a free application system that is entirely online, determining the status of the cases in just days to a few weeks (Montoya-Galvez, 2023).

No path to permanent U.S. residency

Uniting for Ukraine has become the largest private refugee sponsorship program in U.S. history in less than a year of its launch (Montoya-Galvez, 2023). Although the program – in addition to other legal pathways to enter the U.S. – allow refugees to flee immediate persecution, they are not granted official refugee status that offers a path to permanent residency in the U.S., instead being granted permission to live and work in the U.S. for two years under parole (Montoya-Galvez, 2023). This is a source of considerable anxiety and stress for these refugees, who must not only seek immediate living situations and employment upon arrival, but are burdened with the uncertainty of what might become of their status in the U.S. near the end of the two-year period.

Common Refugee Pathways to Washington State

Uniting for Ukraine (Humanitarian Parole)

Uniting for Ukraine is a way for Ukrainians to apply for humanitarian parole in the U.S. Eligibility requirements include residency in Ukraine as of February 11, 2022, someone to sponsor them in the U.S., vaccination requirements, biometric and biographic screenings, and vetting security checks. Any U.S. citizen can sponsor Ukrainian applicants and are required to declare their financial support of the applicants and pass background checks administered by the Department of Homeland Security.

Ukrainian applicants that are approved through this process will be permitted to travel to the U.S. and be considered for parole for a period of up to 2 years. Becoming a parolee through this process allows you to apply for work authorization to work in the U.S. (WA DSHS).

Because refugees entering the U.S. through Uniting for Ukraine are not having their arrival and resettlement coordinated through an agency, they are left to figure out their bearings in the new country on their own with their sponsors. Finding housing, jobs, navigating the healthcare system and benefits available to them are overwhelming, especially because many are not comfortable using English, making connections to community groups and resources vital to their resettlement.

Vaccination requirements for newcomers arriving through Uniting for Ukraine are not always fulfilled, and this is something that should be followed up with by providers when conducting their physical exams upon arrival. Although refugees are required to sign an attestation to meet medical requirements of their parole including immunizations, these guidelines are not always clear or closely enforced, leading people to forego vaccinations or struggling to meet the requirements last-minute when they try to enroll their children in school. Community members have communicated that vaccinations are often the last thing on their minds when they are struggling to find housing and food to eat, especially because the guidelines are so unclear, and they aren’t sure where to start.

Asylum seekers

Asylum seekers are people who make their own way to the U.S. border and claim asylum to Customs and Border Patrol personnel. Once they pass a credible fear interview, these individuals must apply for asylum within one year of arrival, during the period of which they are permitted to stay in the U.S. while they await federal review. Asylum seekers are not eligible for refugee services or many public benefits until their case has been approved in federal immigration courts, but they are able to apply for work authorization (WA DSHS). Ukrainian nationals who are currently in the U.S. who are unable to return to Ukraine due to fear of persecution may also apply for asylum with the USCIS (EthnoMed, 2023a).

Temporary Protected Status (TPS)

Ukrainian citizens who have been present in the U.S. before the war are not considered for parole under Uniting for Ukraine but may be eligible for Temporary Protected Status (TPS) for 18 months. They may also request employment authorization along with their application (USCIS). Unlike individuals arriving through Uniting for Ukraine who are required to undergo a TB screening and receive certain immunizations, people under TPS have no immigration medical requirements.

Public benefits for Ukrainian refugees in WA

As of May 21, 2022, the Office of Refugee Resettlement (ORR) was authorized to provide resettlement assistance and other benefits for Ukrainian and non-Ukrainian populations that were displaced from Ukraine as a result of the war. If eligible, these benefits include Temporary Assistance for Needy Families, Medicaid, Supplemental Nutrition Assistance Program (SNAP), Supplemental Security Income, resettlement assistance, and other benefits (Dept of Health & Human Services).

People arriving in Washington from Ukraine may be eligible for a variety of public benefits programs and services, including eligibility for cash, food and medical assistance based on immigration status, income, and available resources. Not everyone may be eligible for these benefits and services, however – working with resettlement agencies is advised to determine eligibility based on individual status (Dept of Health & Human Services).

Health insurance for Ukrainian refugees in WA

Apple Health is the name of the Medicaid program in Washington and offers free or affordable healthcare coverage for qualifying individuals. Covered services include primary care, emergency visits, maternity services, pediatric care, dental services, vision care, prescription medications, etc. There is no designated enrollment period and coverage can be obtained at any time throughout the year.
In May 2022, Apple Health eligibility was expanded to Ukrainians and non-Ukrainian individuals who had resided in Ukraine and were paroled into the U.S. between February 24, 2022, and September 30, 2023(WA Healthcare Authority). Refugees that are not eligible for Apple Health may still be eligible for a qualified health plan with financial assistance through Washington Healthplanfinder.
Ukrainian refugees who are eligible for Apple Health include:

  • Parolees: Individuals granted parole before February 24, 2022
  • Humanitarian Parolees: Individuals granted parole on or after February 24, 2022, through September 30, 2023
  • Temporary Protected Status (TPS): Individuals granted TPS who have been continuously physically present in the U.S. since April 19, 2022

The International Rescue Committee has launched a Uniting for Ukraine Support Line (U4USL) to help Ukrainian humanitarian parolees to access resources and resettlement benefits, including employment assistance and medical benefits. The number below is available for Ukrainian humanitarian parolees in the U.S.:
Uniting for Ukraine Support Line (U4USL): (407) 591-3963 (M-F, 9am-5pm EST)

Challenges adjusting to the U.S. healthcare system

The U.S. healthcare system is complicated for many new arrivals to navigate, and this is no exception for Ukrainian arrivals. Ukrainian community members have shared their frustrations with U.S. healthcare and the medical insurance system, claiming that physicians and healthcare workers in Ukraine usually serve as both the patient consultant and healthcare system navigator, whereas in the U.S., patients are expected to largely navigate the system themselves and figure out what services and benefits work for their insurance plans. They are also not familiar with the need for a referral to see a specialist, as patients are used to self-referrals and being able to see specialists directly in Ukraine.

In conversations with community members, people have expressed frustrations with how processes for insurance coverage and physician referrals are unclear and difficult to navigate for people who are used to a different healthcare system. They explain that in Ukraine, physicians’ offices take care of these activities and appointments are expected to be available in a matter of days, or even the next business day. They are also unfamiliar with prescription requirements from doctors when going to the pharmacy, as many medications are available over the counter in Ukraine without a prescription.

Additionally, vaccination is not always an easy topic of discussion with Ukrainian patients. Some may be reluctant to discuss vaccinations due to religious beliefs, or from negative things they have heard in the media. U.S. vaccination recommendations and requirements also differ from the standard vaccines administered in Ukraine, so education and increasing health literacy in these individuals may be necessary.

Mental health is also an area of healthcare that is often stigmatized and less trusted by patients in Ukraine due to less evidence-based practice and fragmented mental health care specializations. Avoiding the use of words like “depression” or “mental health care” is advised (Vitruk, 2023), to increase the chances of meaningful engagement. Connection to community resources, religious organizations, and other Ukrainian community members is also important because many Ukrainians prefer peer and family support over seeking help from mental health specialists.

Establishing trust in U.S. healthcare and healthcare providers

Ukrainians come from a healthcare system that is riddled with inefficiencies and characterized by a popular mistrust of physicians and healthcare professionals by the general public (World Health Organization. Regional Office for Europe, 2015). The U.S. healthcare system is a complex system that is difficult for Ukrainian arrivals to navigate, and providers should be mindful of the challenges to adjustment that they are facing and take special care to establish trust before moving forth with interventions and treatment. It is important to take the time to explain what is included in the appointment and health services to refugees upon arrival, including dental care. Being clear about processes, expectations, and timelines for care and referrals is key in minimizing their anxiety and uncertainties regarding care.
With the recent widespread integration of primary care services in Ukraine as part of the healthcare reforms of 2017, recent arrivals from Ukraine may have had more exposure to primary care services. Primary care in Ukraine, however, has traditionally differed from what is commonly seen in the U.S., leading to patients seeking care from narrow specialists for chronic disease management, screening, and diagnostics. Efforts are being made to increase these kinds of services at primary care offices, but many individuals from Ukraine may still be used to receiving care from specialists, whom they also may refer themselves to. Because of these differing ideas of what primary health care looks like, it may be helpful to inform Ukrainian patients of the scope of practice of primary care clinics in the U.S. and the reasons for screening for certain diseases.

Advice for providers

Manage expectations and inform Ukrainian patients of what is included in the visit. Review the process and timeline for receiving medical care and referrals in the U.S. and inform them that appointments may not always be made on the same day and could take time for non-urgent cases.

Involving the patient in healthcare decisions

Members of the Ukrainian community have expressed their frustrations regarding the amount of time that physicians spend with their patients and the lack of clarity and transparency in their conversations during appointments. New arrivals to the U.S. may have more questions regarding health and vaccination requirements and test results, and some report not having enough time during the appointment to have all their questions answered. Some also report that patients in Ukraine typically receive detailed patient health records and diagnostic results from physicians’ offices and are at liberty to take them to other physicians for a second opinion and feel that the amount of information and records they have access to in the U.S. is not always adequate or accessible to the patient. One individual noted that it seemed at times that providers and healthcare teams make healthcare decisions on their behalf without patient input, or the patient may not be provided an adequate explanation for certain decisions, making the patient feel like they are left in the dark. It is important to take the time to explain the reasons behind the decisions and be transparent in interacting with these patients.

Advice for providers

Allow adequate time to have a conversation with the Ukrainian patient and be clear about expectations. Allow the patient to ask questions and understand the next steps before the end of the visit and be clear about which members of the care team will be handling which aspects of care, since duties and expectations for people in certain positions vary in the Ukrainian healthcare system (e.g. primary care provider, nurse, mental health specialist, etc.).

Advice for providers

It is important to confirm the preferred language of communication with refugees from Ukraine and ensure appropriate choice for language interpretation for refugees that are arriving from different regions of Ukraine. Also consider that some Ukrainians may find it traumatic or even offensive to communicate using Russian but may not directly voice these concerns.

Importance of Providing care in patient’s preferred language

Language is one of the most significant barriers for Ukrainian patients in receiving adequate care. Inquiring about the patients preferred language is essential, don’t make assumptions about their language choice. Although some Ukrainians may speak a moderate level of English, providers who are able to speak Ukrainian or Russian are helpful in establishing trust and helping Ukrainian patients to better communicate their concerns, especially when mental health issues are concerned. Community members have indicated that mental health is a difficult topic to open up about for Ukrainians, and that the language barrier makes it even less likely for some patients to speak up about them.

The following are lists of Ukrainian and Russian-speaking providers in Washington and Oregon:
List of Ukrainian and Russian-speaking Providers in WA and OR (English) List of Ukrainian and Russian-speaking Providers in WA and OR (Russian)

The role of a community health board in building trust

Family and community play a key role in Ukrainian culture and provide feelings of security and safety in the historical context of persecution and political instability. Community health boards are led by community members who are community leaders, advocates, or experts in healthcare or public health (Utilizing Community Health Boards to Build Community Capacity | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM), n.d.). These boards work with various groups and professionals to reduce health disparities in their community, partnering with organizations and agencies to advocate for changes to the existing systems that are needed by their community, and serving as a bridge between the community and health system to facilitate community outreach events and culturally relevant programs. They also serve as a trusted resource for health education and information, often through social media, trusted providers, and community leaders (Utilizing Community Health Boards to Build Community Capacity | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM), n.d.).

Health Board in Washington State serving Ukrainian communities

The Washington State Department of Health (WA DOH) works with Nashi Immigrants Health Board, a community health board for Ukrainian communities in Washington that was formed in the early phase of the COVID-19 pandemic when there was a lack of culturally and linguistically-appropriate resources regarding vaccination (Utilizing Community Health Boards to Build Community Capacity | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM), n.d.).

The WA DOH found that one of the key reasons for lower COVID-19 vaccination rates in these communities was that public health decisions were being made without community input, making the health board’s role key in providing a space for the community to advocate for their health needs (Utilizing Community Health Boards to Build Community Capacity | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM), n.d.).

Nashi Immigrants Health Board works to build the capacity of  Ukrainian-speaking communities to provide accurate, trusted information to their members, and engages with the community through community health fairs, social media, a podcast on a Slavic radio channel discussing healthcare issues, a weekly health column in a Russian language newspaper in Seattle, and creating and managing Vax4School, a website that provides translations of Ukrainian vaccination records for Ukrainian refugees (Utilizing Community Health Boards to Build Community Capacity | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM), n.d.).

Advice for providers:

Community engagement and input are essential in establishing trust within the Ukrainian communities. Nashi Immigrants Health Board is a community health board that works to reduce health disparities in these communities by partnering with local healthcare entities to provide culturally-appropriate care and communicate community healthcare needs. Partnering with trusted community health boards such as this would be effective in disseminating public health and health-related information and obtaining community input.

Ukrainian Health Profile and Screening Guidance

The following is a summary of health concerns and screening guidelines for Ukrainian immigrants and refugees by the Washington State Department of Health Refugee and Immigrant Health Program, based on the medical exam refugees receive within 30 to 90 days of arrival to the U.S. (Ukrainian Health Resources, n.d.). The full PDF can be found below:
Ukrainian Health Profile and Screening Guidance: ADULTS (English) 
Ukrainian Health Profile and Screening Guidance: PEDIATRICS (English) 

The following links are helpful in understanding the different vaccination requirements in Ukraine:
Translation Guide: Ukrainian & Russian Vaccination Records 
Vaccination Coverage Record Translation Guidance for Health Care Providers Serving Ukrainian Newcomers

Additional resources about Ukrainian health,behavioral health, and clinical guidance compiled by the Washington Department of Refugee Health Program can be found on the following page through the EthnoMed website:
Health and Behavioral Health Resources for Ukrainian refugees 

Leading Causes of Death

According to data from 2019, the top 10 causes of death in Ukraine include ischemic heart disease, stroke, cirrhosis, lung cancer, Alzheimer’s disease, cardiomyopathy, colorectal cancer, self-harm, chronic obstructive pulmonary disease, and stomach cancer (Ukrainian Health Resources, n.d.). Highest risk factors for death and disability include high blood pressure, dietary risks, tobacco use, high LDL, high body-mass index, alcohol use, high fasting plasma glucose, air pollution, and kidney dysfunction (Ukrainian Health Resources, n.d.). Community surveys in the greater Seattle area have reflected similarities in the prevalence of chronic health conditions, as well as mental health issues being major concerns for Ukrainian and Russian-speaking community members in the greater Seattle region, indicating the need for relevant screening in these communities.

Substance Use

It was found in a Ukrainian national survey in 2017 that 40% of men and 9% of women in Ukraine were current smokers (Ukrainian Health Resources, n.d.). Hazardous alcohol use was also found in 14.3% of men and 1.7% of women in the 2022 Internally Displaced Persons Mental Health Survey in Ukraine, which is expected to be intensified by trauma related to the recent war (Vitruk, 2023). Alcohol use was also prevalent even before the war in 2022, and community members have shared that some Ukrainians are coping with the trauma and stresses of resettlement with alcohol and marijuana (Vitruk, 2023).

Immunization Coverage in Ukrainian Refugees in Washington

The following is a summary of the rates of immunization coverage upon arrival in Ukrainian refugee adults who have resettled in Washington State from October 2015 to September 2021 (Ukrainian Health Resources, n.d.):

Vaccine          % up-to-date arrival (Adult)
Measles, mumps, rubella                75%
Varicella                                              56%
Tdap                                                     23%
Covid-19 (5/2022)                             9%

The following is a summary of the rates of immunization coverage upon arrival in Ukrainian refugee children who have resettled in Washington State from October 2015 to September 2021 (Ukrainian Health Resources, n.d.):

Vaccine Confidence and Low Immunization Rates in New Arrivals

There has been a drastic decline in immunizations in Ukraine since 2009 when the death of a child was incorrectly blamed on the measles-rubella vaccine, fueling anti-vaccine sentiments in the media and public distrust of vaccination (Khetsuriani et al., 2022b). Although the rates of vaccination are back on the rise, it was not before the resurgence of vaccine-preventable diseases such as diphtheria, tetanus, measles, and vaccine-derived poliovirus type 1 (Khetsuriani et al., 2022b).

According to focus groups and interviews with key informants conducted by the Department of Health, the significantly lower vaccination rates in Ukrainian refugees can be attributed to reasons of language and cultural barriers from providers, fear of adverse events, faith-based fears, suspicion of corrupt government and medical authorities, the lack of support for vaccines by community leadership, and lower adoption of COVID-19 prevention practices (WA DOH). In medical exams among Ukrainian refugees who resettled in Washington from 2015 to 2021, pediatric immunizations were generally low upon arrival, with the measles, mumps, and rubella vaccines being 75% up to date, varicella at 56%, poliovirus at 53%, hepatitis B at 45%, DTaP/Tdap at 23%, and the meningococcal and HPV vaccines at 0% (WA DOH).

In conversations with community members, it has been noted that there is a general distrust of Russian-manufactured vaccines and vaccines or uncertain origin, as well as a need for education regarding the safety and necessity of immunizations. The origins of vaccines and their brand names may be helpful to communicate to the patient to ensure their safety. New arrivals to the U.S. may be overwhelmed with the different immunization requirements for visas and public-school enrollment and may lack health literacy in regard to vaccines and vaccination practices. They may also be hesitant about receiving multiple vaccines at one time, making vaccine safety and information important points of education (Ukrainian Refugee Crisis Response: Actively and Authentically Engaging Communities in Outbreak Response Activities | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM), n.d.)

The following is an e-course training for providers and healthcare workers working with Ukrainian and Russian-speaking populations to better understand vaccine hesitancy in these communities, and learn about strategies to initiate conversations about the COVID-19 vaccine:
Fostering COVID-19 Vaccine Confidence in Russian- and Ukrainian-Speaking Communities 

Additional resources to help Ukrainians learn more about the COVID-19 vaccine in their own language:
COVID-19 Vaccine Resources (in Ukrainian and Russian)

Advice for Providers

Patients from Ukraine may have concerns about vaccinations for various reasons. It is helpful to understand the reasons for their hesitancy and answer questions appropriately. Oftentimes these uncertainties stem from lack of knowledge or misinformation, so it is important to help them to understand how vaccines work and reassure them of their credibility.

Free Vaccination Program in Washington

The Washington State Childhood Vaccine Program offers free vaccines to all children under age 19, including new immigrants from Ukraine (Nashi Immigrants Health Board, n.d.). The vaccines are available at participating doctors’ offices and pharmacies and are covered by most insurance policies. Federally funded clinics also provide them for free to those who are uninsured.

Search for providers in Washington offering free vaccines at no cost:
https://wadoh.maps.arcgis.com/apps/webappviewer/index.html?id=d35642cbbd32419787341d2e27d9a75f

Immunization Requirements for School Enrollment in Washington

All children entering childcare, preschool, and kindergarten through the 12th grade of high school must be vaccinated against tetanus, diphtheria, and pertussis, as well as measles, mumps, and rubella, for both public and private schools and daycare centers (Nashi Immigrants Health Board, n.d.).

Differences in Vaccination Requirements in Ukraine

Childhood immunization requirements and norms in Ukraine differ from those in the U.S. Children from Ukraine may need additional vaccinations to bring them up to date with the vaccination schedule required in the U.S. Some vaccines may be given at different ages or may not be routinely administered in Ukraine. For example, vaccinations against varicella (chicken pox), human papillomavirus (HPV), meningococcus, pneumococcus, as well as rotavirus, are not mandatory in Ukraine (Nashi Immigrants Health Board, n.d.).

Translating Immunization Records

Despite the uncertainties surrounding vaccines, refugees may still need vaccinations to enroll their children in public schools and meet visa immunization requirements. The need to vaccinate children for school should be clarified so that patients do not mistake the provider’s guidance as arbitrary, but something required to enroll their children in school. Washington State regulations allow 30 days for children to receive the required vaccinations, or they will not be permitted to continue studies in school (Nashi Immigrants Health Board, n.d.)

Some Ukrainians may have brought immunization records from Ukraine that will need to be translated into English. Vax4School is an online resource that provides information about childhood vaccines in the Russian language for immigrants from former Soviet Union countries. The website provides translation of vaccine records into English from Ukrainian and Russian, free of charge. The process takes about a week and parents are advised to upload the records onto the website themselves due to privacy concerns.

The following is a translation guide for vaccine records that are in Ukrainian and Russian, for use by school personnel and healthcare providers:
Translation guide for Ukrainian and Russian vaccine records (English) 

Advice for Providers

It is important to help parents from Ukraine to understand that their children must be vaccinated to be enrolled in public schools in the U.S. and their impact on keeping the community safe from vaccine-preventable diseases. Childhood vaccination requirements and schedules differ from those in the U.S., so a translation of Ukrainian immunization records is advised, through Vax4School, which provides free translation of vaccine records that take about a week to process.

Vaccine-Preventable Diseases

People from Ukraine are at increased risk of vaccine-preventable diseases due to low immunization coverage (CDC in Ukraine | CDC, n.d.). National vaccination rates in 2020 were 81% for diphtheria, tetanus, and pertussis; 82% for measles, mumps, rubella; and 84% for polio (CDC in Ukraine | CDC, n.d.). VPDs including pertussis, measles, chicken pox, diphtheria, varicella, hepatitis A, and paralytic polio should be considered (Ukrainian Clinical Guidance Center of Excellence in Newcomer Health – MN Dept. Of Health, n.d.-b).

The national vaccination program in Ukraine follows the World Health Organization recommendations for childhood vaccinations and includes protection against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, and hepatitis B (Nashi Immigrants Health Board, n.d.). Vaccinations against varicella (chicken pox), human papillomavirus (HPV), meningococcus, and pneumococcus are not mandatory in Ukraine (Nashi Immigrants Health Board, n.d.). The rotavirus vaccine is also not included in the routine vaccination schedule in Ukraine, leading to increased risk of diarrheal disease in children. Symptoms that are compatible should be assessed (Ukrainian Clinical Guidance Center of Excellence in Newcomer Health – MN Dept. Of Health, n.d.-b).

Tuberculosis

Providers should be vigilant about examining individuals for possible TB disease in those arriving from Ukraine. In 2020, approximately 30% of TB cases in Ukraine were treated for multidrug-resistant (MDR-TB) or rifampin-resistant TB (RR-TB) (Ukrainian Health Resources, n.d.). 36% of adult Ukrainian refugees arriving in Washington had a positive TB screening test during the period between 2015 and 2021, and 1.7% of pediatric arrivals to Washington had a positive TB screening test (Ukrainian Health Resources, n.d.). CDC recommends that all arrivals from countries with intermediate prevalence of TB (including Ukraine) should be tested for TB with IGRA (>2 years of age) or tuberculin skin test (<2 years of age). Rapid molecular methods for detecting drug resistance are recommended due to TB among Ukrainians having a higher rate of drug resistance than is typically seen in the U.S. (Ukrainian Clinical Guidance Center of Excellence in Newcomer Health – MN Dept. Of Health, n.d.-b).

Individuals with diagnosed latent TB should be prioritized for treatment using the following regimen recommended by the WA Department of Health:
DOH Latent TB Infection Treatment Regimens 

The following is the CDC page on screening guidance for TB infection and disease for newly-arrived refugees:
CDC Screening Guidance for Tuberculosis Infection and Disease for Newly Arrived Refugees 

Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV)

HBV and HCV are key public health issues in Ukraine, with prevalence being higher in men and people of older age, as well as risk groups such as people who inject drugs and people living with HIV (Ukrainian Clinical Guidance Center of Excellence in Newcomer Health – MN Dept. Of Health, n.d.-b). HBV vaccination is required in Ukraine, but not many people may have received it (Ukrainian Health Resources, n.d.). 1.4% of adult Ukrainian refugees arriving in Washington had chronic HBV infection during the period between 2015 and 2021, and 1.4% had chronic HCV infection (Ukrainian Health Resources, n.d.).

The HIV Epidemic

Over 250,000 Ukrainians are living with HIV as of 2020 (Ukrainian Clinical Guidance Center of Excellence in Newcomer Health – MN Dept. Of Health, n.d.-b). The country has the second largest HIV epidemic in eastern Europe and central Asia (Green, 2017b), and there is potential for rising incidence due to the war and difficulties delivering clean injection products and antiretroviral drugs to various regions in Ukraine (Green, 2017b). Screening and guidance are recommended for new arrivals and those who are at risk.

Most healthcare providers and clinics provide HIV testing and counseling. Many organizations throughout Washington State offer testing and counseling for free or at a reduced cost, and walk-ins and self-tests may be available.

The following is a list of testing and counseling sites for HIV in various counties of Washington State:
Where to Get Tested for HIV and other Sexually-Transmitted Infections

The Rise of Measles in Ukraine

Since 2018, cases of measles have more than tripled in Europe, with Ukraine representing more than 54,000 cases in 2018 (Wadman, 2019). Corruption, war, lack of governmental prioritization of vaccinations, and anti-vaccine sentiment are to blame, coupled with the failure of the Ukrainian government to order the measles vaccine until 2015 due to the Russian annexation of Crimea (Wadman, 2019). Although the Ukrainian Ministry of Health has been attempting to play catch-up by promoting mobile vaccination and cash incentives for physicians to vaccinate all children in their practices, which have led to the country’s vaccination coverage against measles to jump back up to 93% of infants in 2017, the epidemic continues due to the remaining large proportion of unvaccinated or undervaccinated people (Wadman, 2019).

With Washington State’s recent measles outbreak and many members of the Ukrainian community having been affected, it is important to ensure that newly arriving immigrants from Ukraine be up to date on their immunizations.

References

Afanasiev, I. (2022, June 2). Ukraine agonizes over Russian culture and language in its social fabric. NPR. https://www.npr.org/2022/06/02/1101712731/russia-invasion-ukraine-russian-language-culture-identity

An Inclusive Queer Patriotism Envisioned in Ukraine | Outright International. (n.d.). Outright International. https://outrightinternational.org/insights/inclusive-queer-patriotism-envisioned-ukraine

ArcGIS Web Application. (n.d.). https://wadoh.maps.arcgis.com/apps/webappviewer/index.html?id=d35642cbbd32419787341d2e27d9a75f

Authentically involving Ukrainian communities in public health response activities | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM). (n.d.). https://nrcrim.org/authentically-involving-ukrainian-communities-public-health-response-activities

Bredenkamp, C., Dale, E., Doroshenko, O., Dzhygyr, Y., Habicht, J., Hawkins, L., Katsaga, A., Maynzyuk, K., Pak, K. R., & Zues, O. (2022). Health Financing Reform in Ukraine: Progress and Future Directions. International Development in Focus. https://doi.org/10.1596/978-1-4648-1840-0

Caston, G. (2022, July 26). Cultural Backgrounder: Refugees from Ukraine – RITA. RITA. https://www.ritaresources.org/resource/cultural-backgrounder-refugees-from-ukraine/

CDC in Ukraine | CDC. (n.d.). https://www.cdc.gov/globalhealth/countries/ukraine/default.htm

Centre for Primary Health Care (KAZ) (PHC). (2023). Primary health care in Ukraine: progress review and way forward: assessment and data collection 2020–2021. www.who.int. https://www.who.int/europe/publications/i/item/WHO-EURO-2023-7087-46853-68305

Childhood vaccine program. Washington State Department of Health. https://www.doh.wa.gov/public-health-healthcare-providers/public-health-system-resources-and-services/immunization/childhood-vaccine-program

Cultural Orientation Resource Exchange. (2023, February 23). Working with Ukrainian Refugees Ukrainian Backgrounder – CORE. CORE. https://coresourceexchange.org/ukrainian-backgrounder/

Cyhan, T. (2007). An Exploration of Ukrainian Immigrant Seniors’ Perceptions, Beliefs and Practices Related to Physical Activity as it Pertains to Chronic Disease Management [MS Thesis]. University of Washington.

Dickinson, P. (2020c). Ukraine’s healthcare system is in critical condition again. Atlantic Council. https://www.atlanticcouncil.org/blogs/ukrainealert/ukraines-healthcare-system-is-in-critical-condition-again/

Displaced Children, Youth, and Families Traumatized by War and Violent Conflict in Ukraine and Beyond. (2022, June 9). Yale School of Medicine. https://medicine.yale.edu/news-article/displaced-children-youth-and-families-traumatized-by-war-and-violent-conflict-in-ukraine-and-beyond/

EthnoMed. (2023, February 15). Ukrainian – Health and Culture Resources – EthnoMed. https://ethnomed.org/resource/ukrainian-health-and-culture-resources/

EthnoMed. (2023, August 16). Ukrainian – Ukrainian refugee mental health profile – EthnoMed. https://ethnomed.org/resource/ukrainian-refugee-mental-health-profile/

Fact Sheet: DHS efforts to assist Ukrainian nationals | Homeland Security. (2022, March 31). https://www.dhs.gov/news/2022/03/31/fact-sheet-dhs-efforts-assist-ukrainian-nationals

Finding an LGBTQ+ community in the Ukrainian diaspora. (2022, January 14). KUOW News and Information. Retrieved May 21, 2023, from https://podcasts.apple.com/us/podcast/finding-an-lgbtq-community-in-the-ukrainian-diaspora/id1601751895?i=1000613146711

Fisher, M. (2022, February 25). Read Putin’s Speech and His Case for War in Ukraine. The New York Times. https://www.nytimes.com/2022/02/24/world/europe/putin-ukraine-speech.html

Fostering COVID-19 vaccine confidence • Immunity community. (n.d.). Immunity Community. https://immunitycommunitywa.org/resources-vaccine-confidence/

Fostering COVID-19 vaccine confidence in Russian- and Ukrainian-Speaking communities. (n.d.). Immunity Community. https://immunitycommunitywa.org/courses/fostering-covid-19-vaccine-confidence-in-russian-and-ukrainian-speaking-communities/

Green, A. (2017b). The HIV response in Ukraine: at a crossroads. The Lancet, 390(10092), 347–348. https://doi.org/10.1016/s0140-6736(17)31915-3

Guhle, J. (2022, March 28). A Guide to Psychological First Aid – Psychosocial Support IFRC. Psychosocial Support IFRC – Mental Health Matters. https://pscentre.org/?resource=a-guide-to-psychological-first-aid-for-red-cross-red-crescent-societies&selected=single-resource

Haque, U., Naeem, A., Wang, S., Espinoza, J., Holovanova, I., Gutor, T., Bazyka, D., Galindo, R., Sharma, S., Kaidashev, I. P., Chumachenko, D., Linnikov, S., Annan, E., Lubinda, J., Korol, N., Bazyka, K., Zhyvotovska, L., Zimenkovsky, A., & Nguyen, U. S. D. T. (2022). The human toll and humanitarian crisis of the Russia-Ukraine war: the first 162 days. BMJ Global Health, 7(9), e009550. https://doi.org/10.1136/bmjgh-2022-009550

Harlan, C. (2022, March 9). In a war of terrible choices, these are the fighting-age men who left Ukraine. Washington Post. https://www.washingtonpost.com/world/2022/03/09/ukraine-men-leave/

Home | State statistics service of Ukraine. (n.d.). https://stat.gov.ua/en/home

Home | Washington State Health Care Authority. (n.d.). https://www.hca.wa.gov/

Hook, C. C., Hardee, K., Shand, T., Jordan, S., & Greene, M. B. (2021). A long way to go: engagement of men and boys in country family planning commitments and implementation plans. Gates Open Research, 5, 85. https://doi.org/10.12688/gatesopenres.13230.2

Immunization schedules for 18 & younger. (2023, April 27). Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

Infectious Disease Prevention–DCHS-ID–5620. (n.d.-a). HIV testing. Washington State Department of Health. https://doh.wa.gov/you-and-your-family/illness-and-disease-z/hiv/hiv-testing

Infectious Disease Prevention–DCHS-ID–5620. (n.d.). Tuberculosis (TB). Washington State Department of Health. https://doh.wa.gov/you-and-your-family/illness-and-disease-z/tuberculosis-tb

Javanbakht, A. (2022). Addressing war trauma in Ukrainian refugees before it is too late. European Journal of Psychotraumatology, 13(2). https://doi.org/10.1080/20008066.2022.2104009

Kateryna, M. (2022, December 27). How Russia Russified the east of Ukraine • Ukraїner. Ukraїner. https://ukrainer.net/russia-russified/

Kent, D. (2015). Ukraine: Enchantment of the World. Scholastic.
Khetsuriani, N., Zaika, O., Slobodianyk, L., Scobie, H. M., Cooley, G., Dimitrova, S. D., Stewart, B., Geleishvili, M., Allahverdiyeva, V., O’Connor, P., & Huseynov, S. (2022). Diphtheria and tetanus seroepidemiology among children in Ukraine, 2017. Vaccine, 40(12), 1810–1820. https://doi.org/10.1016/j.vaccine.2022.02.006

Klymanska, L. D., Klimanska, M. B., Herasym, H. Z., Savka, V. Y., Andreichuk, S. K., & Myshok, R. R. (2022). HISTORICAL AND CONTEMPORARY CONTEXTS OF ALCOHOL CONSUMPTION IN MODERN UKRAINE. Wiadomości Lekarskie, 75(8), 1908–1913. https://doi.org/10.36740/wlek202208116

Lekhan V, Rudiy V, Shevchenko M, Nitzan Kaluski D, Richardson E. Ukraine: health system review. Health Syst Transit. 2015 Mar;17(2):1-154. PMID: 26106880.

Loboda, A. (2020). Child healthcare system in Ukraine. Türk Pediatri Arşivi. https://doi.org/10.14744/turkpediatriars.2020.82997

Ludvigsson, J. F., & Loboda, A. (2022). Systematic review of health and disease in Ukrainian children highlights poor child health and challenges for those treating refugees. Acta Paediatrica, 111(7), 1341–1353. https://doi.org/10.1111/apa.16370

Mankoff, J. (2022). Russia’s War in Ukraine: identity, history, and conflict. https://www.csis.org/analysis/russias-war-ukraine-identity-history-and-conflict

Measles, war, and health-care reforms in Ukraine. (2018). The Lancet, 392(10149), P711. https://doi.org/10.1016/S0140-6736(18)31984-6

Ministry of Health of Ukraine (2022, June 20). Office of First Lady, Ministry of Health and partners launch National Mental Health and Psychosocial Support Program. https://www.kmu.gov.ua/en/news/ofis-pershoyi-ledi-moz-ta-partneri-zapuskayut-nacionalnu-programu-psihichnogo-zdorovya-ta-psihosocialnoyi-pidtrimki

Mogilevkina, I., & Khadzhynova, N. (2022). War in Ukraine: Challenges for women’s and perinatal health. Sexual &Amp; Reproductive Healthcare, 32, 100735. https://doi.org/10.1016/j.srhc.2022.100735

Montoya-Galvez, C. (2022, September 14). 5 states account for half of 123,962 requests to sponsor Ukrainian refugees in U.S. CBS News. https://www.cbsnews.com/news/ukrainian-refugees-sponsors-5-states-applications/

Moser, M. (2022). Geschichte und Gegenwart des Russischen in der Ukraine. Ein Überblick. Die Welt Der Slaven, 67(2), 393–423. https://doi.org/10.13173/ws.67.2.393

Nadworny, E., & Harbage, C. (2023, February 22). Ukraine’s birth rate was already dangerously low. Then war broke out. KNKX Public Radio. https://www.knkx.org/2023-02-22/ukraines-birth-rate-was-already-dangerously-low-then-war-broke-out

Nashi Immigrants Health Board. (n.d.). Navigating Vaccination Differences: A Guide for New Immigrants from Ukraine Moving to Washington State [Press release]. https://drive.google.com/file/d/1xBdQDC3YJzdez6mkgaaHlaIQVlqrT64A/view

Nashi – Vaccination – registration, translation, vaccination and other resources. (n.d.). Nashi – Vaccination. https://vax4school.org/

Opinion | How Russia’s War Against Ukraine Is Advancing LGBTQ Rights. (2023b, March 7). POLITICO. https://www.politico.com/news/magazine/2023/03/07/russias-war-ukraine-advancing-lgbtq-rights-00085841

Peterson, S. (2018, March 29). About PFA. The National Child Traumatic Stress Network. https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for-psychological-recovery/about-pfa

Podolskyi, V., Gemzell-Danielsson, K., & Marions, L. (2018). Contraceptive experience and perception, a survey among Ukrainian women. BMC Women’s Health, 18(1). https://doi.org/10.1186/s12905-018-0651-8

Roberts, B., Gilmore, A., Stickley, A., Rotman, D., Prohoda, V., Haerpfer, C., & McKee, M. (2012). Changes in Smoking Prevalence in 8 Countries of the Former Soviet Union Between 2001 and 2010. American Journal of Public Health, 102(7), 1320–1328. https://doi.org/10.2105/ajph.2011.300547

Romanenko, L., Shlemkevych, O., & Arendt, M. (2023). Lactation Newsmakers: Documenting our History–The Current State of Breastfeeding in Ukraine: An Interview With Lidiia Romanenko and Olha Shlemkevych. Journal of Human Lactation, 39(1), 15–21. https://doi.org/10.1177/08903344221136477

World Health Organization. Regional Office for Europe. (2015). Ukraine: health system review. https://apps.who.int/iris/handle/10665/176099

Santora, M. (2022, December 3). Zelensky proposes banning Ukrainian Orthodox Church led by Putin ally. The New York Times. https://www.nytimes.com/2022/12/02/world/europe/zelensky-ukraine-orthodox-church.html

States with religious and philosophical exemptions from school immunization requirements. (2023, September 25). https://www.ncsl.org/health/states-with-religious-and-philosophical-exemptions-from-school-immunization-requirements.aspx

Supporting LGBTIQ Ukrainians, Inside And Outside Ukraine | Outright International. (n.d.). Outright International. https://outrightinternational.org/insights/supporting-lgbtiq-ukrainians-inside-and-outside-ukraine

Tuberculosis: Domestic Guidelines | CDC. (n.d.). https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/tuberculosis-guidelines.html

Ukrainian Clinical Guidance Center of Excellence in Newcomer Health – MN Dept. of Health. (n.d.). Minnesota Department of Health. Retrieved October 17, 2022, from https://www.health.state.mn.us/communities/rih/about/ukrainian.html#NaN

Ukrainian Health Resources. (n.d.). Washington State Department of Health. https://doh.wa.gov/about-us/programs-and-services/executive-office-health-and-science/disease-control-and-health-statistics/refugee-and-immigrant-health-program/ukrainian-health-resources

Ukrainian Refugee Crisis Response: Actively and Authentically Engaging Communities in Outbreak Response Activities | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM). (n.d.). https://nrcrim.org/ukrainian-new-arrivals/ukrainian-refugee-crisis-response-actively-and-authentically-engaging

Ukraine Data Explorer. (n.d.). https://data.humdata.org/visualization/ukraine-humanitarian-operations/

Ukraine | History, flag, Population, President, Map, Language, & Facts. (2023, July 18). Encyclopedia Britannica. https://www.britannica.com/place/Ukraine/People

Ukrainian Clinical Guidance Center of Excellence in Newcomer Health – MN Dept. of Health. (n.d.). https://www.health.state.mn.us/communities/rih/about/ukrainian.html

UNHCR. (2022, October 26). Displacement Patterns, Protection Risks and Needs of Refugees from Ukraine [Press release]. https://data.unhcr.org/en/documents/details/96447

UNHCR – The UN Refugee Agency. (2023, February 23). UNHCR: One year after the Russian invasion, insecurity clouds return intentions of displaced Ukrainians. UNHCR. https://www.unhcr.org/news/unhcr-one-year-after-russian-invasion-insecurity-clouds-return-intentions-displaced-ukrainians

Utilizing Community Health Boards to Build Community Capacity | National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM). (n.d.). https://nrcrim.org/utilizing-community-health-boards-build-community-capacity

Vasylieva, I. V., Hololobova, K. O., Tsymbaliuk, R. S., Nechushkina, O. V., Kobrzhytskyi, V. V., Kiriienko, S. V., & Laputko, A. V. (2021). ARTIFICIAL TERMINATION OF PREGNANCY IN UKRAINE: BIOETHICAL, PHILOSOPHICAL AND RELIGIOUS ASPECTS. Wiadomości Lekarskie, 74(3), 731–735. https://doi.org/10.36740/wlek202103231

Wadman, M. (2019, February 19). Measles cases have tripled in Europe, fueled by Ukrainian outbreak. Science. Retrieved July 18, 2023, from https://www.science.org/content/article/measles-cases-have-tripled-europe-fueled-ukrainian-outbreak

Weissbecker, I., Hanna, F., El-Shazly, M., Gao, J., & Ventevogel, P. (2018). Integrative mental health and psychosocial support interventions for refugees in humanitarian crisis settings. In Springer eBooks (pp. 117–153). https://doi.org/10.1007/978-3-319-72914-5_6

Wilkinson, E. (2023, February 23). One year after Russian invasion, Washington still welcoming Ukrainian refugees. KING5. Retrieved March 16, 2023, from https://www.king5.com/article/news/nation-world/ukraine/one-year-later-washington-welcoming-ukrainian-refugees/281-0d1a61b9-7439-47e5-9786-cab2dbcecfaa

World Health Organization. Regional Office for Europe. (2004). Health care systems in transition: Ukraine. https://iris.who.int/handle/10665/107604?locale-attribute=es&mode=full

World Health Organization. Regional Office for Europe. (2019). Ukraine: review of health financing reforms 2016–2019: WHO–World Bank joint report: summary. https://iris.who.int/handle/10665/346330

World Health Organization: WHO. (2022, October 24). Accessing health care in Ukraine after 8 months of war: The health system remains resilient, but key health services and medicine are increasingly unaffordable. World Health Organization. Retrieved November 15, 2022, from https://www.who.int/europe/news/item/24-10-2022-accessing-health-care-in-ukraine-after-8-months-of-war–the-health-system-remains-resilient–but-key-health-services-and-medicine-are-increasingly-unaffordable

World Population Review. (n.d.). Alcohol Consumption by Country 2023. https://worldpopulationreview.com/country-rankings/alcohol-consumption-by-country

Zeller, J. P. (2022). Attitudes on languages, identities and politics at the Ukrainian Black Sea coast in 2020/21. Russian Linguistics, 46(3), 291–311. https://doi.org/10.1007/s11185-022-09264-7