Introduction
Poland, with 41 million people, has 1.35 million Ukrainian conflict refugees from the 2014 Russian annexation of Crimea and labor migration, plus 2.38 million who fled the 2022 Russian invasion (the largest European refugee migration since World War II).1-2 Poland implemented a symptom virtual triage and care referral (VTCR) platform in 2021 to improve continuity of afterhours/weekend healthcare access in Polish and Ukrainian. AI-based VTCR assisted users with automated symptom evaluation and referral to acuity level-appropriate telemedical, virtual or in-person care. We examined mental health symptom (MHS) reporting differences between Polish and Ukrainian language patient-users in the war’s first year.
Methods
A cross-sectional study evaluated VTCR utilization during September 2022-August 2023 where MHS were chief complaints. AI-based VTCR conducts evidence-driven analyses of 800 diseases and 200 risk factors, evaluating 1,500 symptoms and suggesting probable conditions matching clinical presentation and history. VTCR conveys an analysis of reported symptoms, and refers to an appropriate level of care acuity: self-care, outpatient or emergency care. Patient-users consented to use of their de- identified data in aggregate analyses, and IRB approval was waived. Results reporting adhered to appropriate guidelines, with P values calculated by Z-tests.
To engender patient-user trust, VTCR did not collect personal identifiers, including when Ukrainians migrated to Poland. However, demographic growth during the study period was driven by war refugees/displaced persons: from 2014-21 mean annual growth of Ukrainians issued Poland residency permits was 162,998/year; in 2022-23 this grew to 1,429,256/year.3 Pre-war Ukrainian migration to Poland largely involved circular mobility of impermanent migrants who retain substantial residential and other ties to Ukraine. This was disrupted by the 2022 invasion, rendering a large majority of Ukrainians in Poland de facto refugee or displaced persons status.
Results
A sample of 12,594 VT encounters were analyzed: 82.0% were in Polish and 17.5% in Ukrainian; 0.5% completed in English were excluded. Ukrainians were more often female (76.8% vs. 62.2%, P<.001) and older (79.7% vs. 84.4% under 45, P<.001), possibly reflecting that younger males remained in Ukraine to fight for their nation.
Ukrainian reporting of anxiety, insomnia, nervousness, gastric symptoms/stress-related, and fear of dying was twice that of Poles (all P<.001 in Table 2). Differences in suicidal ideation and intent were not significant. With respect to VTCR output, Ukrainians were pre-diagnosed almost twice as frequently with generalized anxiety disorder (0.9% vs 0.5%, P<.001), and were 50.0% more likely to have a mental health condition leading the differential diagnosis (4.6% vs 2.9%; P<.001). Ukrainian VTCR utilization was twice expected based on population.
Discussion
Because delay in mental healthcare seeking is often longer than for somatic/physical complaints, MHS are likely under-reported to VTCR.4 These findings align with a three-nation analysis of free public use of the same VTCR platform one year before and following the Russian invasion, where 93,876 Ukrainian, Polish and Italian language users reported MHS. MHS reporting among Ukrainians and Poles increased 11.6% (P=.003) and 3.7% (P<.001), respectively, with little change among Italians. Populations more directly exposed to the war were more traumatized. Ukrainian reporting increased for 10 of 16 MHS, including suicidal thoughts/intent (158.7%, P=.007), sleep disorder (45.7%, P<.001), insomnia (32.9%, p=.03) and irritability (20.7%, P=0.04).
Conclusion
Refugees and conflict migrants are at elevated risk of psychological and somatic problems which are more effectively managed through early detection/treatment than when care is delayed.4-6 This data is instructive for nations facing large dislocations of international refugee or domestic populations. VTCR combined with virtual/telemedical care delivery enable nations to monitor population needs and automate referral to acuity-appropriate care for citizens and refugee populations, and can be valuable in meeting healthcare needs of displaced war and, imminently, climate change refugees