General practitioners’ assessment of Ukrainian refugees arriving in Denmark

By June 2024, more than 31,391 Ukrainian refugees resided in Denmark [1, 2]. Ukrainian refugees receive temporary residence permits granting full access to Danish healthcare, including general practitioners (GPs). The literature on Ukrainian refugees in European host countries documents high rates of chronic diseases and infections, low vaccination uptake and mental health problems [3-8]. To mitigate these health challenges, the Danish Health Authority, guided by a professional working group, issued Guidelines for healthcare professionals on displaced Ukrainians in Denmark in June 2022 [9]. The guidelines state that GPs should conduct a general health assessment (GHA) at one of the first contacts with Ukrainian refugees. The GHA should include a detailed examination of chronic diseases, vaccination status, infectious diseases, mental health, pregnancy and vulnerable citizens. GHAs have been offered to other refugee groups, documenting both physical and mental health needs and suboptimal vaccination coverage [10, 11]. The main aim of this study is to explore how this health policy initiative has been put into practice by GPs and which factors influence the provision (or lack thereof) of health assessments in primary care for newly arrived Ukrainian refugees.

Methods

This was a cross-sectional study with a self-administered online questionnaire in SurveyXact, taking approximately 5-7 minutes to complete. The questionnaire was developed and pilot tested as the joint effort of two GPs and our research team, including a Ukrainian medical researcher. (Supplementary material). The survey collected information on four main areas: i) GPs’ knowledge of the guidelines; ii) practical conditions affecting implementation; iii) GPs’ experiences with patients traumatised by war; and iv) intersectoral cooperation. The survey was distributed in collaboration with the Danish Organisation of General Practitioners (PLO) through the web-based PLO Newsletter; questionnaire distribution was followed by a written encouragement from the chair of the PLO. The survey was open for six weeks, from 11 May to 22 June 2023. Reminders were sent in the newsletter a total of three times. In DK there are 3,488 GPs; 3,284 are members of the PLO and were therefore possible participants. Statistical analyses included frequency distributions and logistic regression analyses. We calculated odds ratios (OR) with confidence intervals (CI).

Trial registration: The Regional Data Protection Centre (P-504-0406/23-5000) approved this research project.

Results

In total, we had 55 GP respondents. However, we excluded four respondents who did not complete the questionnaire and seven who had no contact with Ukrainian patients. Thus, the study had 44 respondents, and the largest subgroup (35%) was from the Capital Region of Denmark. In total, the participating GPs had seen approximately 450 displaced Ukrainian patients. Sixty-five per cent had limited or no knowledge of the Guidelines for Healthcare Professionals on Displaced Ukrainians. Only 6% had detailed knowledge of the guidelines, 29% had “fairly good” and 47% “moderate” knowledge, and 18% did not know the guidelines. Despite knowledge of the guidelines, only about a third of the GPs had performed a GHA.

Table 1 shows the association between familiarity with the recommendations and whether the recommended practices were adhered to. GPs with no knowledge of the guidelines formed the reference group. GPs with some degree of familiarity of the guidelines were significantly more likely to ask both adults (OR = 4.0; 95% CI: 2.12-7.92) and children (OR = 4.7; 95% CI: 1.4-16.1) about vaccination status and to test for infectious disease (OR = 5.0; 95% CI: 3.6-19.3) than were those who did not have any familiarity with the guidelines.

Figure 1 shows the barriers that GPs experienced that prevented them from following the guidelines. Language barriers related to booking and the consultation itself were an obstacle, as was a lack of knowledge about trauma and refugee health.

Our results further showed that 98% (n = 43) of GPs answered that they were “always” or “occasionally” in need for interpretation during the consultation with Ukrainian refugees, but only 23% (n = 11) “always” had access to interpreters when needed. If the GP could get an interpreter, 50% (n = 22) performed a health assessment at the first consultation, whereas only 26% (n = 12) did so if they could not get an interpreter.

Finally, GPs were asked how they experienced the intersectoral cooperation regarding Ukrainian refugees (data not shown). A majority responded that they did not know where to refer displaced Ukrainians for municipal rehabilitation (50%, n = 22), psychological help (43%, n = 19) or psychiatric evaluation (45%, n = 20). From the open-ended questions, interesting remarks were made: “The Ukrainian refugees are very poorly prepared and informed about how Danish healthcare works. Don't get the impression they know how to approach a GP. I do not have the impression that the municipality supports them in this process …”. Another GP remarked: “…it would be a dream scenario with more support from the municipalities and housing units. Maybe an initial screening could have been done there, maybe a nurse from the municipality could have provided more training for the Ukrainians to teach them about Danish healthcare”.

Conclusions

Despite knowledge of the guidelines, we found that only about a third of GPs performed a GHA. Even so, GPs who were knowledgeable about the guidelines were significantly more likely to ask about vaccination status and infectious diseases as part of a GHA than GPs who were unaware of the guidelines. In GPs’ experience, language barriers and a lack of knowledge about refugee health and trauma were obstacles to implementing guidelines. GPs also found that displaced Ukrainians had a high need for interpreters and lacked competencies in navigating health care. Lastly, GPs lacked intersectoral cooperation and referral possibilities.

Our study is limited by the low number of respondents, despite having structural backup from the PLO and sending out reminders. GPs are limited due to their work conditions, which likely hampered participation. Furthermore, due to the General Data Protection Regulation (GDPR), we were not allowed to contact GPs directly, which might have increased participation. Additionally, our study might have been affected by selection bias as GPs with a special interest in Ukrainian refugees might have been more likely to participate.

Our study contributes to understanding the transition from policy to practice in refugee health. The National Health Authority made specific guidelines for Ukrainians, which are unique for this refugee group, i.e. similar guidelines were not prepared for Syrians or evacuated Afghans. Thus, the guidelines were prepared as one of several unique initiatives for Ukrainian refugees, including special acute clinics for Ukrainians in the Capital Region, hotlines and translated material on mental health and general healthcare provided by the Danish Health Authority, the five Danish national Regions and non-government organizations (NGOs). The guidelines for GPs were in line with the recommendation of Danish refugee health experts [11]. They also aligned with European Centre for Disease Prevention and Control recommendations [12]. Our study shows that not all GPs were aware of the guidelines, and those who were experienced several barriers related to interpretation, resources and knowledge about refugee health when trying to transition from policy to practice. Some of these barriers relate to well-known challenges of providing care for refugees and minority groups. However, our impression is that the specific awareness and structural framework currently in place are insufficient to allow GPs to help Ukrainian refugees successfully. Furthermore, the many special health initiatives for Ukrainian refugees showed that it was possible for national authorities to optimise and upscale initiatives to facilitate healthcare for new refugee groups arriving in Denmark. Our study, with all its limitations, underscores the importance of providing structural support and evaluation to ensure that migrant health policies effectively impact the target groups in practice.