Introduction

Migrant groups often have lower vaccination rates for routine immunisations than non-migrants [1, 2], a pattern also observed for COVID-19 vaccination [3, 4]. Access to vaccination became especially critical during the COVID-19 pandemic. Available data show that migrants have been disproportionately impacted by the COVID-19 pandemic [5–7]. They were significantly more prone than their non-migrant counterparts to experience SARS-CoV-2 infection, severe health complications, and elevated risk of mortality. Previous stu­dies show that migrants face multiple barriers to vaccine uptake, including language barriers, low literacy, communication challenges, and practical and regulatory challenges. These factors negatively affected the provision and utilisation of vaccination services, compounded by service-related issues such as the absence of specific guidelines [8]. It is evident that the existence of access barriers resulting in under-representation of vaccinated migrants in the general population constitutes a substantial threat to public health.

In recent years, several European countries, including Poland and Norway, have been confronted with a public health challenge due to the rapid influx of migrants from war-torn Ukraine. Although Poland and Norway possess distinct public health structures and migrant populations, their shared challenge of migrants’ access to health information makes a comparative analysis of the intervention projects interesting and important for identifying universally effective practices. Additio­nally, to the best of our knowledge, no similar comparative studies have been published to date.

The Norwegian intervention was implemented during the COVID-19 pandemic. Despite the different context in terms of migrant populations, but also with an expressed goal of equity in health [9], migrants in Norway were also overrepresented in hospital admissions, COVID-related deaths, and overall infectious rate [10]. To alleviate the situation, the Norwegian Directorate of Integration and Diversity (IMDi) supported projects aimed at reaching the migrant population on pandemic-related topics. One of the funded projects was the Health Ambassador Project, which aimed to reach migrants with pandemic information through the inclusion of “ambassadors” and by prioritising an open dialogue among all actors involved. The Health Ambassadors (HAs) were key persons in migrant communities in Bergen with either a health background or established involvement in communicating information regarding the COVID-19 pandemic to immigrants.

The Norwegian project became a model for intervention designed in Poland. The methodology was slightly modified to fit the project’s specific context. In October 2022, the number of Ukrainian citizens residing in Poland stood at 2.2 million, with 1 million having arrived in the country in connection with the ongoing war [11, 12]. This rapidly growing number of immigrants posed a challenge for vaccination against COVID-19 and other diseases. Access to vaccinations for migrants, guaranteed by the Polish state as in other countries, has been found to be insufficient [9]. Scepticism and the low proportion of vaccinated migrants represent a significant threat to public health. A previous study on Ukrainian migrants found that they experienced challenges accessing credible online vaccination information in Ukrainian, and no official local health authority vaccination materials existed, except for information about measles [13]. To mitigate this problem, an intervention project aiming to involve the Ukrainian migrant community in joint public health activities (prevention of infectious diseases such as tuberculosis, diphtheria, measles, rubella, or coronavirus) was developed. The project was implemented in the Tri­city area (Gdansk, Sopot, Gdynia), where a large community of Ukrainian migrants lived. It involved the Migrant Ambassadors (MAs), the key representatives of the Ukrainian community in Tricity, who were willing to participate in the relevant project activities.

The paper partly uses data already published in “Migrants’ experiences as health ambassadors during the COVID-19 pandemic in Norway – a qualitative study” [10]. The results of the Norwegian study showed that participation in the HAs project was perceived as having a predominantly positive effect; however, the role proved challenging due to considerable psychological distress stemming from pressure to convey accurate health information and combat misinformation. In this article, Norwegian data are used to compare two interventions implemented in different contexts, highlighting key lessons for future public health initiatives targeting migrant populations.

Material and methods

Norway

Context of interventions and recruitment

The Health Ambassador Project lasted from spring 2021 to fall 2022 and took place in Bergen, Norway, and the surrounding municipalities. The initial phase in 2021 involved digital meetings, and HAs worked on a voluntary, unpaid basis. The second phase, starting in early 2022, marked a significant change by expanding the project to include Ukrainian refugees. The Pandemic Centre (an interdisciplinary centre at the University of Bergen) had overall responsibility for organising the meetings during the project. Caritas Bergen (a nongovernmental humanitarian organisation for migrants) was responsible for the logistics of the project, the recruitment of HAs, and the organisation of meetings and facilities. Bergen municipality had a coordination function within its own sector authorities and other organisations, as well as responsibility for the execution and facilitation of vaccination for undocumented migrants.

The Health Ambassador Project aimed to reach diverse migrant groups by including “Ambassadors”. To be recruited as a HA, the criteria were having prior experience in health-related work and having a migrant background. It was assumed that HAs would be able to communicate information to migrants more effectively and with greater impact. Using their native language was expected to be beneficial both for communication and outreach to the targeted groups. Before the intervention began, the HAs were asked to gather information on pressing pandemic-related issues or questions relevant to the migrants they would be communicating with. Meetings were then scheduled based on the gathered information.

Project execution and evaluation

The meetings lasted approximately one hour and commenced with health experts being interviewed by the Pandemic Centre leader. The interviews were conducted using plain language to facilitate comprehension between all parties involved. It was emphasised that all questions were welcome. Then, the HAs divided themselves into different language groups in digital rooms where they could discuss and process the information in their native language. The language groups were Amharic, Arabic, Filipino, Polish, Somali, and Tigrinya. At the end of each meeting, participants reconvened in a plenary session to discuss the issues raised. The HAs asked health experts and other HAs for guidance on how best to handle challenging situations and counter misinformation when engaging with migrants. Besides the language groups, the meetings were held in Norwegian. This was thought to be beneficial for the independence of the HAs; by learning Norwegian terminology for different health topics, they could locate relevant health information themselves. After the meetings, the HAs were instructed to share the information with migrants in their local communities in their preferred language. The goal was to reach as many migrants as possible.

It is important to distinguish between the early and later stages of the project. While during the early stages of the project meetings were held on digital platforms and the HAs did not receive payment, in the later stages of the project, Ukrainian HAs were included, meetings were held in person again, and the HAs received compensation for participating.

To understand how the HAs themselves were affected by their participation in the project, 7 HAs (from Ukraine, Palestine, Iraq, Eritrea, and Turkey) among the 75 who participated were selected [14]. They varied in age and duration of stay in Norway. Individual interviews were performed in January 2023. The interview guide was designed to examine both positive and negative experiences the HAs had, as well as how they received information from health experts. We also inquired about how the HAs experienced the responsibility of communicating information to migrants in their local communities. In addition, the informants were asked about the social aspects of their experience, as well as the amount of time and effort they dedicated to their roles during the project. Audio recordings were transcribed and anonymised. The transcribed data were stored in SAFE (the University of Bergen’s online data storage program for safe processing of sensitive personal data), and audio recordings were then deleted.

Poland

Context of interventions and recruitment

The Polish project lasted from summer 2023 to summer 2024 and took place in the Tricity area (Gdańsk, Sopot, Gdynia). The project was funded by Polish National Agency for Academic Exchange (Narodowa Agencja Wymiany Akademickiej – NAWA) intervention grants and modelled on the Norwegian intervention methodo­logy, with adaptations to address the project’s specific constraints, including access to beneficiaries, the demographic area, and the timeframe. It consisted of three parts: (1) diagnostic, (2) intervention and inclusive information, and (3) evaluation. The first part included a study visit to the Pandemic Centre in Bergen (a project partner), desk research, and the recruitment of medical doctors and MAs (key representatives of Ukrainian migrants). MAs were recruited via NGOs in the Tricity area and medical doctors in cooperation with the Medical University of Gdansk. In the second part, from February to March 2024, six intervention information meetings were held – three in-person and three online (via the Zoom platform). In contrast to the Norwegian project, where the role of the MAs was to attend information meetings and subsequently communicate the information in their respective language groups, in the Polish project, the MAs were tasked with recruiting migrants to attend the meetings. Migrant Ambassadors recruited meeting participants among a close circle of friends, local communities, NGOs, and social media groups. Before the intervention meetings, they collected questions from participants regarding vaccines and accessing the health services in Poland.

Project execution and evaluation

Each meeting lasted approximately two hours. Two project members moderated the meeting, and two doctors answered previously prepared questions as well as additional questions that arose during the meeting. The events were conducted in Polish; however, if the information was incomprehensible, a dedicated member of the project team explained it at a basic level of Polish. MAs also helped with translation. Following the intervention information meetings, a meeting was held to summarise the project. Two workshops on medical language were organised in May and June. They covered themes related to communication with health personnel and the description of the disease’s symptoms. Lastly, the evaluation part of the project was executed. Seventeen semi-structured interviews were conducted with MAs and meeting participants regarding their project experiences. The interview guide covered the following themes: experiences of intervention meetings, strengths and weaknesses of the project, differences between medical care in Poland and Ukraine, and the approach to the vaccines.

Integrated analysis

Both Polish and Norwegian interview transcripts were analysed using thematic analysis [15]. They were coded for the experiences related to participating in the project. Afterwards, the codes were categorised and clustered into themes. In the subsequent step, the initial themes were examined to ensure that the data within each theme were coherent and that there was clear differentiation between the themes. Then, subthemes were identified within each theme. Finally, the content of the themes and subthemes was combined into generalised descriptions.

Results

Four main themes emerged from the data: experiences related to being an ambassador (HAs and MAs), aspects of the interventions that worked well, aspects of the interventions that required improvement, and the need for reliable information.

Experiences related to being an ambassador

Polish and Norwegian ambassadors reported very diverse experiences, both positive and negative, related to their participation in the interventions. The following subthemes were identified: willingness to help other migrants, meaning and empowerment, burden of responsibility, language, and unclear logistics.

Most of them mentioned the willingness to help other migrants. They wanted to benefit as much as possible from the meetings so they could pass on the knowledge gained to other migrants. One of the HAs in Norway explained:

I was happy because I’m pro-vaccination, and it’s for me to give myself the tools to be able to communicate in a way that can help people make better life decisions, or to kind of protect them, and to feel like it’s uh optional. Something to communicate in a nice way, so this was the case. And I, because it’s paid, you also feel like you want to give something back, because uh yeah. (Norway)

All the interviewed MAs in Poland said they intended to facilitate other migrants’ access to information on vaccinations and healthcare in Poland.

First, I wanted to learn how the healthcare system works in Poland and help others learn and find answers to their vaccination and medical questions. (Poland)

The participant was happy to have been able to recruit migrants for the project, and she found her role very important.

For many MAs in Poland, the topics covered during the meetings were interesting because they had children and wanted to know more about the vaccination system in Poland. One of them explained:

Well, I was curious about this project. I have a teenage daughter. She is 13 years old, and it was interesting to me because in Ukraine we do not have such vaccinations for teenagers. (Poland)

Participation in the project seemed to be also associated with meaning and empowerment. One of the HAs in Norway said:

It was nice, especially since you know you are here in Norway as an immigrant, you don’t have... you don’t have... You don’t feel so privileged. You know what I mean? Like, but then you get this responsibility, and now you say “wow, I have a purpose”. It is very nice. (Norway)

Several participants also pointed out the negative aspects of participating in the project. Some HAs in Norway mentioned the burden of responsibility of providing accurate and timely information to other migrants. It caused stress and was experienced as one of the most negative aspects of their participation in the project. Also, in terms of negative experience, one of the participants mentioned language and unclear logistics that made organising the meeting stressful:

So, it was stressful having challenges related to language, and I think the meeting itself took quite a long time. Yes, this is the only part that was stressful. Getting there, being there for a long time, and some challenges with the language, erm, yes, so and just shared… it feels like I almost took part in organising the event. I didn’t feel like I just came, listened, and had a good time and went home; it was a bit like, okay, we kind of must do something then, it was a bit…Not much, I would say. I was, uh, 70% satisfied with the experience (light laugh). (Norway)

MAs in Poland were directly involved in organising the meetings because they were responsible for recruiting the participants, and they were paid for it. Some MAs found it very stressful because it was difficult to convince migrants to attend the meetings.

Aspects of the interventions that worked well

The interviewed HAs and MAs generally expressed positive views regarding the organisation and conduct of the information meetings. A key perceived indicator of the meetings’ effectiveness was that information was reported to have influenced behaviour, with several migrants in Poland and Norway subsequently being vaccinated. One of the HAs in Norway said:

I felt, yes, they had received the right information; therefore, they had changed, and then they wanted to go vaccinate at the same time. And yes, it happened! There were some people who, yes, changed their minds, so they said, “Yes, we want to go now.” (Norway)

Most HAs and MAs noted the high quality and accessibility of the information provided to meeting participants. One of the MAs explained the potential influence of the meetings on migrant communities, referring to the fact that migrants would spread the information in their communities:

If it’s some kind of leaflet, people don’t always pay attention to it, yes. Because there’s too much, nobody wants to read it. And such seminars are better because people who attended them will pass on this information. They can pass on this information themselves. It will be useful to other people. One person passes it on to five people, and they pass it on. That’s how it works. Even if there were 100 of us at these seminars, the information would reach more people. (Poland)

The MA drew attention to the way information is provided and emphasised the advantages of meetings over information leaflets. She explained it this way: “We often receive leaflets and throw them away without even reading them”. The other MAs also noted the benefits of direct communication with doctors and the ability to ask questions. Most Polish participants thought that in-person meetings were much more effective than online meetings. This was attributed to the perception that in-person meetings facilitate a good atmosphere and asking questions. Only two MAs considered a mix of online and in-person meetings the best possible solution.

Aspects of the intervention requiring improvement

MAs and HAs mentioned several issues related to the organised intervention meetings that needed improvement. Language was one of the most frequently mentioned barriers to migrants’ access to health services in the literature. It also proved to be a challenge during the organised interventions [8]. Despite assurances from the organisers of the meetings in Poland that, should language problems arise, questions and answers would be translated into Ukrainian, some participants were still reluctant to ask questions. One of the MAs offered an explanation:

After the meetings, people wrote that they found them helpful. The only thing they said was that sometimes people had a hard time asking a question in Polish. They were worried that it would look bad if they spoke broken Polish. Many people spoke Polish with mistakes, and they didn’t care. But there’s always someone who’s embarrassed. There was a great idea when that Ukrainian doctor was there. At one of the meetings, everyone was told that if they didn’t understand something, they shouldn’t worry, because someone would translate it. But people have lived here for a long time; they should understand the language, and they understand everything by ear. (Poland)

The MA understood the worries and concerns of the Ukrainian migrants, but at the same time, she believed that they should have already understood Polish. In Norway, the combination of Norwegian with the experts and smaller groups in the different languages worked well in the first phase, when all the HAs had a medium level of Norwegian. However, linguistic challenges arose in the final phase of the project when HAs from Ukraine, who had been in the country for only a short time, were included. One of the Ukrainian HAs explained:

So, it was kind of shocking that this sort of uh that this refugee group was invited without them being given the facilities to understand. Because no Ukrainian can understand it after being uh in Norway for four months to participate in a Norwegian speaking somehow... (Norway)

Many of the suggestions on how similar meetings could be better organised concerned practical issues. The Polish MAs experienced many problems before and during the online meetings. Not all migrants knew how to use Zoom. As a result, the recruited migrants could not join the meetings. One of the HAs in Norway missed visual information during the meeting. Another one would have liked some breaks during the meetings:

Maybe it would be good to have some breaks when there are different parts of the seminar… maybe it would be good to have a five-to-ten-minute break so people could feel a bit more relaxed. Because it felt like it was a lecture. So, for it to be more relaxed... so yes. (Norway)

There was also a comment that there was not enough time to answer all the questions:

And there were important people who came to answer important questions. Not only to me, I think everyone got uh enough or important answers, but time was not enough to answer all the questions that all the Health Ambassadors were wondering about. (Norway)

The need for reliable information

In both the Polish and Norwegian interviews, the issue of migrants’ access to reliable information and the consequences of a lack of such access emerged. One of the MAs in Poland explained that finding information related to the healthcare system was challenging. It encouraged her to participate in the project so she could help those who are not familiar with the Polish healthcare system and, therefore, postpone medical visits until returning to Ukraine. Most participants said that receiving information directly from the experts was reassuring and very useful. MAs in Poland noted that participation in the meeting was free, which was strongly appreciated by migrants. They could meet with medical specialists and obtain reliable information instead of seeking it from various sources.

The results of the study indicate that the challenges associated with the interventions carried out both overlapped and differed across countries. The differences were mainly related to the intervention design and the different ethnic structures of the participants. In both countries, similar challenges related to language and practical issues were experienced.

Discussion

The paper presents an evaluation of two interventions aimed at improving migrants’ access to information on vaccines (Poland) and pandemic-related topics (Norway), and thus to make healthcare more equitable.

The interventions were carried out during a public health emergency (a pandemic or war). In both interventions, ambassadors reach out to migrant communities, which, according to a literature review on community-based healthcare for migrants and refugees, is a common practice and a core element of interventions in these communities [16].

The evaluation results show that two approaches significantly benefited public health activities: 1) include migrant representatives (MAs in Poland (PL)/HAs in Norway (NO)), and 2) organise information meetings. The experiences of the ambassadors in the project illustrate the significance of the initiative at multiple levels and highlight the challenges and dilemmas related to the involvement of migrant representatives in interventions.

Engagement in the project activities imbued many of the ambassadors with a sense of agency and purpose, effectively transforming their involvement into a mission to help fellow migrants. Although the roles of the HAs and MAs were somewhat distinct during the interventions, both groups felt responsible for the success, which led to a certain degree of stress. The study participants in Norway observed that sharing incorrect or incomplete information among migrants carries a significant responsibility. Consequently, Health Ambassadors sought to gain as much knowledge as possible during the meetings, although some felt that the meetings were too brief and that it was not feasible to pose all the relevant questions. Ambassadors’ concerns show that “deve­loping” MAs is a process that requires regular meetings to provide migrants with updated information [17]. The MAs in Poland reported a high level of stress related to difficulties with recruiting migrants for the information meetings.

The ambassadors’ experience highlighted the importance of having specialists or health professionals serve as the primary sources of knowledge. Ambassadors perceived health professionals as the most reliable source of information on vaccinations and pandemic-related issues. This is particularly important given the disinformation on social media [18]. According to the interviews, the information provided during the interventions persuaded a considerable number of migrants to be vaccinated or to advise their relatives to do so. The opportunity for direct contact with specialists in Poland also permitted participants to pose questions, at times pertaining to their individual circumstances, and this contact proved beneficial for them.

However, the organisation of interventions also faced challenges, particularly related to language barriers. It is important to guarantee that all participants can easily comprehend the information they are required to disseminate to their respective communities. This was of particular importance for the relatively new migrants as the Ukrainian refugees in Poland and Norway. The MAs in Poland have highlighted that Ukrainian migrants frequently perceive their stay in another country to be merely temporary. Consequently, they may not prioritise learning Polish and therefore experience limited access to health information, delaying medical attention until they return to Ukraine. A study on post-accession Polish migrants in Norway revealed a similar relationship between the perception of migration as temporary and the willingness to learn the language and use healthcare [19].

The completion of the project activities prompted several reflections. For public health reasons, it is crucial to provide understandable, reliable information on healthcare and vaccination to all individuals in the population to improve their own health and to consider herd immunity and the protection of the population. However, there is a marked disparity in vaccination coverage, with migrants receiving vaccinations appro­ximately half as frequently as non-migrants [20]. Who should assume responsibility for including migrants in the healthcare system? The question thus arises whether engaging ambassadors from within migrant communities is the optimal means of reaching migrants and providing them with information about the healthcare system. In the context of sometimes traumatic experiences, concerns for loved ones, and an uncertain future, such involvement could result in an additional source of stress for the Migrant Ambassadors [14]. Furthermore, it could be perceived as a transfer of responsibility from the host country to the ambassadors, which could further confuse healthcare access. Despite these concerns, MAs and HAs should be central to future health promotion among migrants. Their integration should transition from a crisis-response model (such as the one used during the pandemic) to a permanent, paid, and perhaps professionalised co-production model. MAs and HAs play a pivotal role in addressing the core barriers that official health systems often struggle to overcome, including trust, cultural nuances, and accessibility. To ensure the well-being of the ambassadors, it is crucial to structure their roles in a way that mitigates the psychological stress and overextension reported by participants in the intervention projects discussed in this paper.

We have presented the results of the evaluation of two intervention projects conducted in two countries, differing in terms of the number and ethnic structure of migrants. Both interventions shared a response to specific crisis situations. From an evaluation perspective, greater comparability between the interventions would have facilitated a clearer understanding of the contextual impact. How­ever, the intervention carried out in Poland was tailored to the Polish context to be as effective as possible.

It is imperative to recognise that migrants cannot be viewed as a homogeneous group. Adapting the format and content of information to align with migrants’ specific circumstances and needs is of great importance. This extends beyond mere provision of information to encompass meaningful assistance and support for migrants as they navigate healthcare systems, a facet often overlooked or treated as an add-on rather than a core aspect.

Conclusions

Health authorities are responsible for ensuring that all members of the community have equitable access to healthcare and that services are culturally and linguistically suitable. The objective of public health interventions is to address perceived health problems or community issues that are identified as requiring attention. The interventions discussed in the paper underscore the necessity of not only providing migrants with reliable health information but also of employing misinformation mitigation strategies within migrant communities.

Disclosures

1. Institutional review board statement: Not applicable.

2. Assistance with the article: AI assistance was used for language editing and grammar correction.

3. Financial support and sponsorship: The Health Ambassador Project was funded by the Directorate of Integration and Diversity (IMDi). The present evaluation was conducted as part of a Master’s thesis at the University of Bergen and received no separate funding. The Polish project was funded under NAWA intervention grants.

4. Conflicts of interest: The authors declare no conflict of interest.

References