Our focus groups contained 10 women and 12 men; one was 18 years, eleven were in their 20s, nine in their 30s, one in his 40s (Table 1). Seven had lived in Poland for under 1 year, fourteen 1-4 years and one for 20 years. Six held university degrees and twelve college qualifications. Seven participants had one child, five had two children (a total of 17 children with ages ranging from 6 months to 17 years); ten participants were childless. Participants had a variety of jobs; 6 women were cleaners at a teaching hospital, 4 worked as chefs in a restaurant, 3 were hospital maintenance workers, 3 - construction workers, 2 – packers, 2 – professional volleyball players, one – architect, one – laundry worker.
Table 1. Characteristics of the participants, 2019; n=22.
Eight participants stated that they had incomplete record of routine vaccinations. While one recalled her parents had refused to give her measles and hepatitis B vaccine, the group generally experienced difficulties in naming specific vaccines lacking in their immunisation history. Most of their children living in Poland were completely vaccinated according to the Polish schedule (two were not vaccinated with BCG). One UM reported having two children living in Ukraine who were completely unvaccinated.
3.1 Factors affecting vaccine uptake, delivery and PHC access
- Vaccine delivery and PHC access
Participants reported that it was straightforward and easy to book vaccination appointments for children at General Practitioner (GP) practices. In general, most UMs did not experience communication barriers during PHC consultations due to language similarities.
“ A GP asked about my child’s vaccination record. She did not understand what was written there, so she asked a senior doctor. They figured out that my child had been vaccinated correctly.” (Female#4, aged 34, Group 2)
However, some UMs reported institutional level difficulties in navigating the system, e.g. challenges in registering adult migrants with GPs practices with uncertainty about entitlement and proving residence.
“For 4 days I was trying to get an appointment in the clinic, they did not have time to examine me. They kept saying “come the next day. We do not know what to do then, where to go.” (F#6, aged 28, G1)
Those UMs that had experienced particularly high costs of paid health services in Poland (this mainly referred to dental and gynaecological services) and had quickly accessed much cheaper treatment on presentation to services in Ukraine:
“I called him [a dentist] from Poland to make an appointment, to get in the queue, because it’s cheaper there. I go privately because the state-provided care is not any good.” (Male#9, aged 33, G3)
UM families were also reported to travel to Ukraine with schoolchildren for annual check-ups.
“Either we or someone from the family travels with a child to Ukraine for an annual check-up.” (F#5, aged 30, G1)
In general, all UMs reported difficulty finding vaccination information they trusted and resorted to using a variety of unregulated sources such as Google searches and social media, specifically Facebook.
“Information about vaccines should be provided through the Internet, because everyone is on Facebook. Some advertisements need to be there.” (F#1, aged 23, G2)
Participants advocated more vaccination information being available in Ukrainian language through different means.
“A doctor would be the most trustworthy. He should cover a lot of information: what sort of vaccination is it, where it comes from, what side effects might be developed, etc… A doctor and, for example, a person who has already been vaccinated. Or a person who got sick due to the lack of vaccination.” (F#2, aged 18, G2)
Regarding vaccine administration, it was also noticed by UMs that information about measles vaccination and antibody checking was widely distributed and available in Polish institutions which are obliged to serve Ukrainian citizens.
“Information about measles vaccination was easy to find everywhere - at the Town Hall and the Provincial Migration Office. It was hanging on all doors. What is it, why is it important. In Polish, Ukrainian, even in English.” (M#1, aged 25, G1)
- Trust in state structures, quality of healthcare and vaccination policies
There was a higher level of trust in Polish healthcare system and vaccination policy compared to the Ukrainian one; this was partially shaped by reported differences in the quality of health services. The participants used the Ukrainian system as a point of reference.
UMs blamed the government and politicians for the long lasting healthcare crisis in Ukraine, pointing at rebuilding trust in the state institutions as the most important element to increase confidence in vaccinations.
Public employees were frequently viewed as corrupted and responsible for buying low quality vaccines which resulted in vaccine-related complications or even deaths.
“They are buying a cheaper substitute for a vaccine, on this basis we do not really know what we get in this vaccine. Is there saline or something else?” (M#4, aged 27, G3)
“Many people do not believe what they are told about vaccines. My friends are afraid that they are carrying out experiments on us. They [the government] are crooks, they steal all the time.” (M#9, aged 33, G3)
The commonly held view was that pharmaceutical companies promote specific vaccines to increase profits.
“These vaccines are for the companies that produce them to make a lot of money, so people think.” (M#5, aged 25, G3)
The high profile of vaccination in the media was well recognised with it frequently viewed as being important in fuelling fears and mistrust in vaccination.
“It was blown out on television… showing children who died after vaccination.” (M#4, aged 27, G3)
“There was a programme where they said that there were some cases when a child dies. So people are afraid.” (M#5, aged 25, G3)
Several participants contrasted the negative reporting in the media and were appreciative of the TV approach of showing the Ukrainian Minister of Health promoting child vaccinations and also vaccinating himself.
“In one TV programme the Minister of Health said it [vaccination] was necessary and showed that he was doing it. He said that you had to vaccinate your children.” (M#8, aged 24, G4)
- Trust in the vaccination provision
UMs discussed between-country differences regarding vaccine administration. In Poland vaccines are administered by nurses, after a physical examination done by a doctor, while in Ukraine this depends on the region. In some regions the decision on whether a certain vaccination should be given was placed on the parent, who was asked whether a child was healthy; the vaccination is performed by nurses. In many other regions, like in commonly Poland, the patient is examined by a doctor before vaccination.
“I think there are cases that people can die, but it can be, for example, the fault of the doctor – they do not carry out thorough examinations, they do not check the child's condition, although there might be some contraindications [for vaccination]. But in general, vaccines help people and they need to be given.” (M#9, aged 33, G3)
“In Ukraine when we went to the GP clinic with the child - the doctor did not carry out a thorough examination. The child could have been ill, though this seemed unimportant. The doctor said: "Do it today, because we do not know when the next vaccine supply will arrive." (F#9, aged 35, G1)
Additionally, Polish doctors were thought to be better and UMs were vocal and sceptical about the quality of medical training at some Ukrainian universities. Most UMs were not confident in Ukrainian health care workers (HCWs), however, they generally trusted Polish HCWs advice.
“Everyone can be a doctor in Ukraine, because you may pay, then buy and have a diploma. I have more confidence in the doctors in Poland, they are trained, and they study medicine for several years.” (M#9, aged 33, G3)
Lack of trust in healthcare professionals was dominant regarding access to all levels of services in Ukraine.
“Where I live, when you go to the doctor, he does not see a sick person, he wants to get as much money as possible from you.” (M#7, aged 45, G4)
“They [doctors] say: Give us money and we will sell you a better product. If there is a thorough control over doctors, it would not be possible. But there is no control and money goes to them.” (F#10, aged 21, G2)
Most UMs stated that in Ukraine false vaccination certificates can be readily obtained by bribing HCWs and were well known as a fact of life.
“You can go to the GP clinic, to the hospital, give a bribe and they will write that all vaccinations have been completed and the child can go to school.” (M#10, aged 38. G3)
“If you pay you can get it [vaccination].” (F#9, aged 35, G1)
- Trust in the vaccines provided (vaccination safety/quality/importance)
There was a uniform, strongly stated opinion expressed that the Ukrainian state-funded vaccines were inferior to those in Poland in many aspects.
“I think vaccines are safer in Poland than in Ukraine.” (F#7, aged 21, G1)
“In the EU the quality of vaccines is better.” (F#8, aged 20, G1)
“Ukrainians don't trust vaccines. They think the vaccines are not safe and don't help.” (M#12, aged 35, G4)
Respondents backed up comments about Polish vaccines being better with the evidence that family members were vaccinated in Poland while they had not been in Ukraine because of vaccine safety concerns.
“My friend, an Ukrainian mother of a young child follows the vaccination program here in Poland. But she did not vaccinate her child while they were living in Ukraine. There are lots of mums like her.” (F#1, aged 23, G2)
“My brother received all vaccinations here, in Poland, he has not been vaccinated in Ukraine. He felt well after receiving vaccinations.” (F#2, aged 18, G2)
One respondent presented clear evidence that medical staff may not be recommending state provided vaccines in Ukraine.
“My friend took her neonate child to the vaccination unit. Her colleague who was a paediatrician and was working there, warned her not to immunize a child against poliomyelitis due to the poor quality of a vaccine. When my child was born I refused to vaccinate him with that vaccine. I told my GP the story I’d heard before. She did not vaccinate him, however she made a note that he was vaccinated.” (F#5, aged 30, G1)
Some UMs stated confidently that in Ukraine vaccines could be falsely labelled and then administered under the public system.
“They produce everything in Odessa, in Ukraine, but they can give vaccines false labels, like “produced in Germany” or “produced in England.” (M#9, aged 33, G3)
“We have a lot of black market vaccines.”(M#6, aged 36, G1)
There were also concerns that some children had been vaccinated at clinics that experienced frequent power outages with no generator. Concern was raised that others had been vaccinated with vaccines which were past the expiration date or from a poorly stored multi-dose vial.
“In our village three children aged about 1 year were given vaccines and died. The vaccines were poorly stored, and out of date. After that, everyone stopped vaccinating children.” (F#8, aged 20, G1)
“They keep vaccines in a regular fridge, in which a vaccine and a doctor's sandwich is kept.“ (F#3, aged 31, G2)
“The vials are left opened after administration for 2-3 days after which other children are vaccinated with the same vial. A child could be vaccinated on the third day [from the same vial], and could become sick. There have been many reports of this kind of behaviour. Therefore, there are refusals“. (F#9, aged 35, G1)
UMs often sought branded vaccinations which were thought to be a “better choice”, although needing to be purchased by the parent.
“A friend came for a vaccination to the doctor, they gave her child a bad vaccine and it was sick. But you could pay and the child would get a better vaccine.” (F#9, aged 35, G1)
“Good-quality vaccines are being sold for money.” (F#2, aged 18, G2)
UMs mostly reported accepting mandatory vaccines according to the Polish schedule and generally thought that vaccines administered in Poland are safe.
“I have two children, they live here. They were vaccinated here and they feel good. When my sister was at their age she was vaccinated, and then she was sick even more than before vaccination, my mother told me.“ (F#1, aged 23, G2)
“Vaccinations are better here because there is a regulation.”(M#11, aged 27, G3)
Some vaccines were considered less important than others and it was a common argument that there is no uptake of self-founded vaccines in Ukraine due to their costs, low salaries and difficult life conditions.
“People in Ukraine do not earn enough, it is better to spend money on life. Everyone thinks what he will eat tomorrow, therefore, he does not think about [self-founded] vaccines at all.” (M#7, aged 45, G4)
About a half of participants considered influenza vaccine important. However, this was the dominant vaccine that UMs reported struggling with the vaccination decision-making process, which involved the evaluation of perceived potential benefits and risks. Arguments against were mainly based on the perception that this vaccine is unnecessary. Influenza was considered less serious compared with other vaccine-preventable diseases (VPD). Some participants voiced higher concern around this non-mandatory vaccine that was considered not to be safe when administered in Ukraine.
“I wouldn't get vaccinated against flu in Ukraine. It's better to take a lemon, I would figure out some natural things, it's safer than risking my health and have experiments made on me”. (M#1, aged 25, G1)
It was also reported that no information, both on national and provincial level, was provided regarding influenza vaccination; no interventions oriented to high risk groups, e.g. pregnant women, to increase the uptake were provided either.
“I was pregnant, I had the flu but I didn't hear about any vaccination from the doctor.” (F#8, aged 20, G1)
Several UMs also reported concerns that having the vaccine during pregnancy could cause harm for a foetus.
None of participants was aware of the Human Papilloma Virus (HPV) vaccine, which has been widely available in Poland  but was not universally offered in Ukraine.
“If I had heard about it [HPV vaccine] earlier, I might get my daughters vaccinated.” (M#2, aged 35, G1)
“I haven't heard anyone in Ukraine at school, on television talking about HPV vaccination.” (F#4, aged 34, G2)