Mental health responses in countries hosting refugees from Ukraine

Assessing the Cultural Fit of a Digital Sleep Intervention for Refugees in Germany: Qualitative Study

BACKGROUND

Digital interventions have been suggested to facilitate access to mental health care for refugees, who experience structural, linguistic, and cultural barriers to mental health care. Sleep-e, a digital sleep intervention originally developed for German teachers, has been culturally adapted for refugees in Germany mainly coming from African and Middle East countries. With the increasing number of refugees from Ukraine and the associated diversity of cultural backgrounds among refugees in Germany, it is essential to assess whether existing digital interventions are culturally appropriate for this target group as well.

OBJECTIVE

The study aimed to investigate the perceived cultural appropriateness of Sleep-e in both its original and culturally adapted versions among refugees in Germany, hereby exploring and possibly contrasting the needs of refugees coming from Ukraine and other countries of origin.

METHODS

Overall, 13 refugees (6 from Ukraine, 23-66 years old; and 7 from other countries, 26-41 years old) participated in the study. Each participant went through parts of the original or culturally adapted version of the digital sleep intervention, with 5 participants going through both versions. A total of 17 semistructured interviews (11 for the adapted, 6 for the nonadapted intervention version) and 9 think-aloud sessions (6 for the adapted, 3 for the nonadapted intervention version) were conducted to assess cultural appropriateness, suggestions for adaptations, and perceived relevance. Data were transcribed, categorized, and analyzed using structured qualitative content analysis.

RESULTS

The findings showed key differences in the perceived appropriateness and identification between the 2 refugee groups and the 2 intervention versions. Ukrainian participants expressed positive (n=70) and negative (n=56) feedback on the adapted intervention version, which revealed identity conflicts, as the adapted intervention version was targeted at a refugee population with whom they could not fully identify (18 negative feedback quotes concerning the refugee example characters). Whereas they identified with the European context in the original version, they found the problems described less relevant to their experiences. In contrast, participating refugees from other countries found the culturally adapted version more comprehensible and culturally appropriate (55 positive and 5 negative feedback quotes). No significant usability issues were reported, but several participants highlighted the need for an individualization of the intervention content.

CONCLUSIONS

Neither the original nor culturally adapted version of the digital sleep intervention fully met the needs of all refugee groups, highlighting the complexity of culturally adapting digital interventions for this population. Particularly, the identity conflict of participating Ukrainian refugees regarding the refugee context suggests that adaptation should go beyond regional considerations and consider the dynamics of social identity. These findings emphasize the relevance of including co-design processes with different refugee populations to ensure broad identification and, herewith, cultural appropriateness of digital interventions.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00036484; https://drks.de/search/de/trial/DRKS00036484.

The plight of Ukrainian refugees staying in Sweden under EU:s mass refugee directive: a brief trauma-focused, participatory, online intervention as a pilot feasibility study

Background

Ukrainians staying in Sweden under the EU mass refugee directive may face challenges due to traumas caused by the invasion that started on February 24, 2022. Part of an European Social Fund (ESF) project, our study showed that a brief trauma-focused group intervention onsite helped to increase health and mental-health literacy. The intervention has not yet been adapted online.

Methods

This pilot study during six months aimed to investigate the feasibility, acceptability and outcome in perceived trust, anxiety/stress, and perceived health after this brief trauma-focused group intervention online. A second aim was to observe perceived acceptability of the group intervention with different ways of online intervention. Local coaches, interpreters, the authors, and local experts participated. A mixed-methods design with participatory methodology and evaluation were used. Data was collected with a short questionnaire in Ukrainian. Additionally, at the end of each set, we orally asked about perceived trust and integrity. There were six sets of five group sessions per set, a total of 30 sessions. Each group met online five times for 2 h, a total of 10 h excluding pre- and post-assessment. Breathing exercises sought to reduce stress among the participants.

Results

The group intervention had both strengths and limitations. Baseline data were obtained from 136 participants, mostly females (75.7%). Answers to pre- and post-questionnaires showed that perceived anxiety/stress was significantly reduced (N = 91, chi-2 20.648, df = 6, p < .02). Perceived health significantly improved between pre- (mean 63.6) and post (77.2) (N = 77, t = -8.08, df = 66, p < .001). Older participants were vulnerable with higher stress and lower mean perceived health after the intervention. Four out of ten needed individual psychosocial support online.The participants' open questions were analyzed with qualitative content analysis, giving five general categories and 25 sub-categories and the theme "Strong efforts to cope with Swedish system".

Conclusion

Trust and reduced anxiety level changed after the intervention and a combination online of small, closed group meetings with the possibility of personal acquaintance, trust and individual follow-up psychosocial support for those in need to be paid attention to for future refugee support services, particular an online format.

Healthcare provision for displaced people in transit: Analyses of routinely collected data from INTERSOS clinics at the Ukrainian border with Moldova and Poland

Background

The Russian military invasion of Ukraine has sparked Europe's largest forced displacement since World War II, bringing about significant health vulnerabilities for migrants and refugees. European health information systems lack comprehensive data coverage, especially in underrepresented migration stages like transit. This study aims to address this gap by analyzing data from INTERSOS clinics at the Moldovan and Polish borders with Ukraine to identify the common health conditions prompting people to seek healthcare services during transit.

Methods

From 6th March to 31st May 2022, this cross-sectional study observed migrants and refugees receiving INTERSOS services at two mobile clinics in Moldova, and a facility in Poland. We analyzed data by age, sex, nationality, and reported disease frequencies and care provided.

Results

This study used routinely collected data from 1756 patients. The majority of the adult population seeking healthcare were females (76.5 %), 26.1 % were children and 18.7 % were older individuals. Noncommunicable diseases (NCDs) were the primary reason for seeking healthcare at these clinics, with 23.3 % of the study population being diagnosed with at least one chronic disease, and 3.4 % of people having multimorbidity. Mental and behavioural disorders were diagnosed in 12.6 % of the population, and somatoform disorders and related stress (F40-F48) in 10.8 %.

Discussion

Our study indicates the diversity of forcibly displaced populations and the corresponding diversity of their healthcare needs. In the shadow of a forced displacement crises triggered by the conflict in Ukraine, there is an urgent need to give more attention to subgroups of the population that are often neglected in humanitarian crises. These include older adults, females, and ethnic minorities. Additional attention should also be given to NCDs and sexual and reproductive health (SRH) care needs, especially given the high numbers of older adults and females in this population. Early medical support, psychological first aid and interventions in transit centers that promote survivor resilience and recovery are required.

Conclusion

Our findings shed light on the healthcare needs of forcibly displaced populations during transit, a stage often overlooked in migration health research. They underscore the diverse healthcare needs of forcibly displaced populations, emphasizing the necessity for humanitarian aid programs to acknowledge and address this diversity. Accessing data on displaced populations' healthcare needs in transit can help the preparing and planning of healthcare services for these populations in host or destination countries. Ensuring objective anonymization and preventing patient re-identification are essential, particularly in safeguarding refugee privacy and data protection to avoid the misuse of their data.

Social and emotional well-being intervention to reduce stress, anxiety, and depression among Ukrainian refugees resettled in Massachusetts

BACKGROUND

Mental health problems are high among refugees due to their traumatic experiences of fleeing war and witnessing disasters and deaths due to violence and conflict. Refugees are exposed to various socio-cultural stressors during their migration journey before, during, and after arriving at the host country, which may increase their risk of mental health problems. Strength-based interventions may be beneficial to address their socio-cultural and psychological stressors by strengthening individual's strengths to address their problems.

AIMS

This study evaluated the effect of a Social and Emotional Wellbeing intervention on mental health (stress, anxiety, and depression) and emotional health outcomes (coping, self-efficacy, social support, and conflict resolution) among Ukrainian refugees in Massachusetts.

METHODS

We implemented intervention (once-weekly/5-week) among 31 Ukrainian refugees with pre-and post-assessment of mental and emotional health outcomes (2022-2023). The intervention consisted 5-module: managing stress and mind-body exercise, strengthening communication and social networking, problem-solving, and creating a healthy family environment. Validated scales were used to measure mental and emotional health outcomes, such as the Hopkins-Symptom-Checklist-25 for anxiety and depression and the Cohen-Perceived-Stress scale for stress. Paired t-test was used for data analysis.

RESULTS

The pre versus post-intervention proportion reduced for anxiety (61.29% vs. 22.58%) and depression (58.06% vs. 22.58%). The mean scores significantly decreased from pre- to post-intervention by 6.26 points for stress, by 7.07 points for anxiety, and by 6.29 points for depression (both p's < .01). The mean scores significantly increased for coping (by 15.71), emotion-focused engagement (4.48), problem-focused engagement (4.80), social support (8.77), problem-focused coping self-efficacy (14.93), stop unpleasant emotions and thoughts (12.74), and friends networking (3.48; all p's < .01).

CONCLUSIONS

The stress, anxiety, and depression were reduced, and coping, self-efficacy, and social support networking skills were improved among Ukrainians after intervention. This program should be replicated in the larger community for a wider benefit.

"Business as usual won't work … ": Therapists' experiences and preparedness for providing refugees with trauma-related interventions

OBJECTIVE

Worldwide, the numbers of refugees and displaced people being exposed to traumatic and inhumane experiences are escalating, resulting in an enhanced need for appropriate psychological management of trauma in this at-risk group. This study explores therapists' perspectives on and preparedness for supporting adult refugees with trauma-related interventions.

METHOD

Therapists (N = 17), with varying ranges of experiences supporting adult refugee clients, were recruited nationally, and participated in semi-structured interviews, exploring their experiences and preparedness for therapeutically supporting refugee clients with trauma-related interventions. Data were analyzed using reflexive thematic analysis. A Patient Public Involvement (PPI) approach was embedded within this study.

RESULTS

Five major themes were developed throughout the analysis: (i) Therapists' Fears and Apprehensions in Meeting Client Complexities, (ii) Preparation and Support for Competency Development, (iii) Adjusting Preconceptions of the Nature of Therapeutic Work, (iv) Humanity Within the Therapeutic Relationship, and (v) Balancing Therapeutic Meaningfulness and Hardships.

CONCLUSION

Therapist training must reflect trauma-informed care and inter-cultural awareness to allow therapists to feel better prepared within mainstream and specialist services. Further, therapists' well-being needs to be prioritized to prevent vicarious trauma, burn-out and ultimately, improve interventions for clients.

Compounded Effects of Multiple Global Crises on Mental Health: A Longitudinal Study of East German Adults

The early 2020s witnessed an unprecedented overlap of multiple global crises. This longitudinal study examined the compounded effects of multiple intersecting global crises on mental health outcomes in a representative cohort of East German adults. We investigated how perceived threats (PT) from climate change (PT-CLC), COVID-19 (PT-COV), the Russia-Ukraine War (PT-RUW), and rising costs of living (PT-RCL) will impact various aspects of mental health from 2021 to 2022. This research question addresses whether these crises exacerbate mental health issues and how their effects differ across various mental health outcomes. Methods: We conducted a longitudinal study with 319 participants (mean age 49.9 years, 54.5% female) from the Saxony Longitudinal Study. Data were collected in two waves: March-July 2021 and September-December 2022. We used linear mixed-effects models to analyze both unadjusted group trends and adjusted individual-level effects on physical complaints, mental distress, sleep problems, life satisfaction, and self-rated health. Results: Unadjusted analyses revealed significant increases in mental distress and sleep problems over time, whereas physical complaints, life satisfaction, and self-rated health remained stable at the group level. Adjusted analyses showed that higher PT-RCL and PT-COV were significantly associated with increased physical complaints, mental distress, sleep problems, and decreased life satisfaction, even when group-level changes were not significant. Conclusions: This study highlights the complex impact of intersecting global crises on mental health, emphasizing the importance of considering both population-level trends and individual perceptions. The findings suggest that economic and pandemic-related stressors have more immediate effects on mental health outcomes compared to more distant threats, such as climate change or geopolitical conflicts.

Coping and emotions of global higher education students to the Ukraine war worldwide

Trauma scientists have raised the alarm about the devastating consequences of the Ukraine war on mental health. We examined how higher education students-as indirect victims-coped with this conflict and how they emotionally reacted during 2022. We involved 2314 students from 16 countries through an online survey. A structural equation model indicated significant relations between war-related worry about military and macroeconomics domains and two coping strategies (opposition, support giving), in turn significantly linked with six emotions. The model was strongly invariant across gender, study field, and geographic area. The most frequent emotions were anger and anxiety, followed by two future-centred emotions (hopelessness and hope). Emotions were more frequent for females and students of the countries geographically close to the war region. Our findings call for evidence-based policy recommendations to be implemented by institutions to combat the negative short and long-term psychological sequelae of being witnesses of armed conflicts.

Acute Stress Disorder among 2022 Ukrainian war refugees: a cross-sectional study

Introduction

Fleeing from war can be terrifying and result in Acute Stress Disorder (ASD), a mental health condition that can occur in the first month after a traumatic event. The study aimed to identify the prevalence of ASD among Ukrainian refugees and identify its risk factors to create a profile of the most vulnerable refugees.

Methods

This cross-sectional study of 637 Ukrainian war-displaced persons and refugees in 2022 used the Acute Stress Disorder Scale.

Results

The prevalence of ASD among participants was high (93.5%). Several factors increasing the risk of developing ASD in the sample were identified, e.g., witnessing Russian attacks (OR 2.92, 95% CI 1.26-6.78), insufficient financial resources (OR 3.56, 95% CI 1.61-7.91), and feeling of loneliness in the host country (OR 3.07, 95% CI 1.58-8.69). Pre-existing depression and the death of a close person, among others, were found to significantly (p < 0.05) exacerbate the ASD symptoms. At the same time, neither age, the distance traveled, time spent on fleeing the country, nor the type of companionship during refuge (escaping alone, with children, pets or the older adults) correlate with the severity of symptoms.

Conclusion

The study shows extreme levels of trauma among Ukrainian war refugees and displaced persons. Knowledge regarding ASD vulnerabilities in the present conflict may facilitate prompt and adequate psychological help. Since ASD can be an antecedent of PTSD and several autoimmune disorders, these results may also serve as a predictor of future challenges for Ukrainian society.

Half a Century of Research on Posttraumatic Stress Disorder: A Scientometric Analysis

We conducted a scientometric analysis to outline clinical research on posttraumatic stress disorder (PTSD). Our primary objective was to perform a broad-ranging scientometric analysis to evaluate key themes and trends over the past decades. Our secondary objective was to measure research network performance. We conducted a systematic search in the Web of Science Core Collection up to 15 August 2022 for publications on PTSD. We identified 42,170 publications published between 1945 and 2022. We used CiteSpace to retrieve the co-cited reference network (1978-2022) that presented significant modularity and mean silhouette scores, indicating highly credible clusters (Q = 0.915, S = 0.795). Four major trends of research were identified: 'war veterans and refugees', 'treatment of PTSD/neuroimaging', 'evidence syntheses', and 'somatic symptoms of PTSD'. The largest cluster of research concerned evidence synthesis for genetic predisposition and environmental exposures leading to PTSD occurrence. Research on war-related trauma has shifted from battlefield-related in-person exposure trauma to drone operator trauma and is being out published by civilian-related trauma research, such as the 'COVID-19' pandemic impact, 'postpartum', and 'grief disorder'. The focus on the most recent trends in the research revealed a burst in the 'treatment of PTSD' with the development of Mhealth, virtual reality, and psychedelic drugs. The collaboration networks reveal a central place for the USA research network, and although relatively isolated, a recent surge of publications from China was found. Compared to other psychiatric disorders, we found a lack of high-quality randomized controlled trials for pharmacological and nonpharmacological treatments. These results can inform funding agencies and future research.

Practical approaches to conducting biopsychosocial research with refugee and internally displaced communities

Refugees and internally displaced people comprise one percent of the world population. Forced migration involves a multitude of ongoing stressful and traumatic experiences, often resulting in lasting psychological symptoms for people resettling as refugees. Despite these risks, the underrepresentation of refugee populations in research-particularly in biological sciences-has impeded the allocation of effective resources and the development of novel interventions for these groups. This paper identifies and addresses key methodological challenges to successfully and appropriately conducting research with refugee and internally displaced communities, many of which have served as barriers to improving research representation for these populations. Methodological challenges discussed include language and literacy barriers; political fears; differing cultural dynamics between participants and researchers; and others. We provide practical recommendations for overcoming each challenge, often sourced from our experience conducting multi-year studies and interventions in refugee mental health. Several key strategies include the recruitment of researchers and research assistants from similar cultural and linguistic backgrounds as participants; providing detailed, ongoing communication about informed consent; avoiding assumptions regarding participants' understanding of concepts that may vary based on culture or experience (e.g., "voluntary" research; confidentiality); and adopting flexible data collection procedures compatible with participants' needs and restrictions. Finally, we discuss the role of the researcher in regard to cultural competencies and partnering with the refugee community. Given the increasing global population of refugees, the strategies discussed in this paper are suggested in order to encourage future research in this underrepresented population and empower investigators to logistically carry out studies with refugees.

Mental health and stress level of Ukrainians seeking psychological help online

Due to the Russian invasion of Ukraine on February 24th, 2022, more than 8 million Ukrainians have been displaced from their homes. Ukrainians exposed to armed conflict and migration are likely to have low levels of mental health status and seek help. We provide a uniform quantitative assessment of the mental health conditions of Ukrainians seeking help soon after the invasion and resettlement. We screen the mental well-being and psychological distress of 1165 refugees, migrants, internally displaced, and non-displaced individuals from Ukraine who seek psychological help online in Ukraine and across 24 countries of the European Union. We surveyed participants in the study as a part of our online program for adult Ukrainians from June 22nd to July 6th, 2022. We report descriptive results of mental-health status for the aggregate sample and the sub-groups. More than half of the respondents exhibit low levels of mental well-being and high psychological distress, with 81 % being at risk of depression; 57 % having severe psychological distress. Refugees and internally displaced participants show a particularly high risk of depression and severe psychological distress in our sample. Many Ukrainians seeking psychological help work, study, or volunteer, and those who engage in these activities have relatively alleviated mental well-being. Our results indicate a considerable psychological burden on Ukrainians. Although our analysis focuses on Ukrainians seeking help, it shows that the displaced soon after resettlement require particular attention and can be reached in a short time across borders, irrespective of their (officially documented) migration status.

Response to provide key health services to Ukrainian refugees: The overview and implementation studies

BACKGROUND

The outbreak of war in Ukraine has contributed to the largest migration crisis in this part of Europe since the Second World War. In a short period of time, several million refugees of different ages and with different health needs have arrived in Poland. This study aims to assess the health problems of Ukrainian refugees, evaluate the barriers faced by primary care physicians (PCPs), and analyse and evaluate the system solutions available (including the use of modern information technology) to address them.

METHODOLOGY

For this purpose, an original questionnaire distributed to PCPs in Poland was created and a literature review of implemented system solutions was conducted. The survey was conducted between the 3rd-10th April 2022-45 days after the outbreak of the war. The survey was repeated between 20th January and February 15, 2023.

RESULTS

The survey was completed by 402 physicians who provided health care to refugees at that time. There were 252 respondents in the first stage of the study while 150 PCPs took part in the repeat survey. The findings of the survey revealed that the most common health problems among refugees were infections, regardless of age. The biggest barrier to providing care to refugees was the lack of available medical records and language difficulties. During the first months of the refugee influx in Poland, many - both systemic and grassroot - solutions were implemented to improve the quality of health care for refugees.

CONCLUSIONS

According to PCPs, the language barrier and the lack of previous medical records are key constraints when providing medical care to refugees. The health needs of refugees and the difficulties in providing care for them require constant monitoring and implementation of appropriate systemic solutions that can reduce the limitations in the daily work of medical staff.

Global Mental Health: Where We Are and Where We Are Going

PURPOSE OF REVIEW

To summarize recent findings in global mental health along several domains including socioeconomic determinants, inequities, funding, and inclusion in global mental health research and practice.

RECENT FINDINGS

Mental illness continues to disproportionately impact vulnerable populations and treatment coverage continues to be low globally. Advances in integrating mental health care and adopting task-shifting are accompanied by implementation challenges. The mental health impact of recent global events such as the COVID-19 pandemic, geo-political events, and environmental change is likely to persist and require coordinated care approaches for those in need of psychosocial support. Inequities also exist in funding for global mental health and there has been gradual progress in terms of building local capacity for mental health care programs and research. Lastly, there is an increasing effort to include people with lived experiences of mental health in research and policy shaping efforts. The field of global mental health will likely continue to be informed by evidence and perspectives originating increasingly from low- and middle-income countries along with ongoing global events and centering of relevant stakeholders.

The Social Determinants of Mental Illness: A Rapid Review of Systematic Reviews

Previous research agendas have prioritised the role of biological determinants in mental illness aetiology. This is of particular concern, as endorsing biological determinants has been shown to promote negative attitudes towards people with mental illness. The aim of this review was to provide an overview of high-quality evidence of the social determinants of mental illness. A rapid review of systematic reviews was conducted. Five databases were searched: Embase, Medline, Academic Search Complete, CINAHL Plus, and PsycINFO. Systematic reviews or meta-analyses that described any social determinant of mental illness, were published in peer-review journals in English, and focussed on human participants were included. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were applied for the selection procedure. Thirty-seven systematic reviews were deemed eligible for review and narrative synthesis. Determinants identified included conflict, violence and maltreatment, life events and experiences, racism and discrimination, culture and migration, social interaction and support, structural policies and inequality, financial factors, employment factors, housing and living conditions, and demographic factors. We recommend that mental health nurses ensure adequate support be provided to those affected by the evidenced social determinants of mental illness.

Thinking about young refugees' mental health following the Russian invasion of Ukraine in 2022

The Russian invasion of Ukraine on 24th February 2022 has prompted this article to summarise some of the salient mental health issues experienced by young asylum seekers and refugees focussing on resettlement countries, drawing on the substantial literature, for Child and Adolescent Mental Health Practitioners. Firstly, the various UNHCR categories of persons affected by war and persecution and statistics are described. By July 2022, over 100 million people globally were of concern to UNHCR, a number increased by the many millions of refugees fleeing Ukraine to neighbouring countries. Selected findings on the psychiatric epidemiology of young refugees are summarised, and some principles of Child and Adolescent Mental Health Service delivery and treatments are outlined. The research on Ukrainian refugees' mental health is limited and this is an area that requires further investigation alongside active attempts to meet their mental health needs.

Stressors related to the Covid-19 pandemic, climate change, and the Ukraine crisis, and their impact on stress symptoms in Germany: analysis of cross-sectional survey data

BACKGROUND

Climate change, the Covid-19 pandemic, and the Ukraine crisis are considered unprecedented global stressors, potentially associated with serious health consequences. However, simultaneous effects of these stressors are not yet understood, making it difficult to evaluate their relative contribution to the population burden and potential future manifestations in clinically significant psychiatric disorders. This study aimed at disentangling the relative contribution of the three stressor groups on current sub-clinical stress symptoms.

METHODS

A cross-sectional, representative survey study was conducted two months after the outbreak of the Ukraine war in Germany. Proportional quota sampling was applied for age, gender, income, and regional characteristics. Data were recruited by means of an online survey. 3094 data sets (1560 females) were included. Age ranged from 18-89 (M: 50.4 years; SD: 17.2). The Subclinical Stress Questionnaire (SSQ-25) served as main outcome measure. In collaboration with a professional media agency, 20 items were generated to capture salient population stressors. A three-factor exploratory structural equation model confirmed the appropriateness of this scale.

RESULTS

(1) Differences in subjective rankings revealed that stressors related to the Ukraine crisis were rated as most worrying, followed by climate change, and the Covid-19 pandemic (Generalized-Linear-Model: Epsilon = .97; F(1.94, 6001.14) = 1026.12, p < .001; η_p² = .25). (2) In a linear regression model (R² = .39), Covid-19 pandemic stressors were the only meaningful predictors for current ill-health (standardized β = .48). Ukraine crisis did not predict stress symptom profiles in the present sample. (3) Older and male individuals report less and/or less severe stress symptoms, although effect sizes were small (range: η² .11-.21). An older age also reduced the impact of Covid-19 stressors.

CONCLUSIONS

Researchers from the health sciences must consider overlapping effects from population stressors. Although the Ukraine crisis and climate change mark salient stressors, including economic threats, the Covid-19 pandemic still has a profound effect on ill-health and must be considered as a relevant factor in future manifestations of psychiatric and associated health consequences.