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.
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.
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).
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
