Mental health conditions and help-seeking among Ukrainian war refugees in Czechia: A cross-sectional study

Background: We aimed to screen Ukrainian war refugees (UWR) in Czechia for depression and anxiety, and to assess their recognition of personal mental health problems and related help-seeking. Methods: We conducted a cross-sectional study on a sample of UWR in Czechia. We used PHQ-8 and GAD-7 to screen for depression and anxiety, SELF-I to assess the recognition of respondents ’ own mental health problems, and a set of questions regarding mental health-related help-seeking. Findings: Our sample consisted of 1,347 UWR. More than 41 % of respondents screened positively for moderate or severe depression and more than 23 % for moderate or severe anxiety. Self-recognition of mental health as well as help-seeking was very low among those who screened positively for moderate or severe depression or anxiety. Interpretation: Even those UWR who report severe symptoms do not identify themselves as potentially having mental health issues and are not seeking help.


Introduction
War and related traumatic, economic and social stressors are strong risk factors for mental health problems, especially for post-traumatic stress disorder (PTSD) and depression (Baxter et al., 2014;Kessler, 2000;Miller and Rasmussen, 2010;Sartorius, 2001;Steel et al., 2009).In 2022, the full-blown war started by Russia on February 24th led to a displacement of more than seven million Ukrainian war refugees (UWRs) into neighbouring European countries.In Czechia, as of May 2022, three months after the start of the war in Ukraine, there were hundreds of thousands of UWRs, with almost 90 % of them being children and women (UNHCR Czech Republic, 2022).To obtain reasonably reliable epidemiological estimates, we aimed to screen UWRs in Czechia for common mental health problems and to assess their recognition of personal mental health problems and related help-seeking.

Participants, sampling and recruitment
This study is based on an online panel that was established in cooperation with the Ministry of Labour and Social Affairs of Czechia (MLSA).All Ukrainian refugees aged 18 and over who arrived in Czechia after the start of the war in Ukraine on 24 February 2022 and who applied for humanitarian financial aid in March through May 2022 were registered by MLSA and eligible to participate in the panel.MLSA approached benefit claimants with an offer to enter the panel, which is managed by the Institute of Sociology of the Czech Academy of Sciences.A sample of 3082 respondents representing 3082 unique households was drawn from those who agreed to participate in the panel survey.Respondents' identities were verified by phone during the recruitment phase to the panel.At the beginning of each data collection wave, respondents were asked to report whether they were still residing in Czechia.
The current survey was the third wave of data collection on the panel.Respondents from the resulting dataset responded from 6 September to 22 September 2022.The survey was conducted using the online survey software NIPO Nfield.In the third wave of data collection, 1347 respondents participated in the survey that focused on mental health and health condition in general.In comparison, the first (June/ July 2022) and second (August 2022) survey waves had 1700 and 2351 respondents, respectively.
Subsequent data weighting was used to ensure that the sample structure matched statistics from the Ministry of Interior of Czechia (data from June) in terms of the region of residence within Czechia, the combination of age and gender within regions, and education.Participants were not compensated directly but were offered that for a completed questionnaire a donation of 50 CZK (2.10 Euro) would be made on their behalf to a charity helping people affected by the war in Ukraine.

Outcomes and covariates
To assess depressive and anxiety symptoms, as well as the participants' perceptions of their own mental health and level of help-seeking, we used PHQ-8 and GAD-7 scales and SELF-i, along with help-seeking related questions.Additionally, we collected demographic data such as age, gender, region of origin in Ukraine, presence of family members in Ukraine and/or Czechia, the state of their house in Ukraine, work status, material deprivation, knowledge of Czech language, and current living situation (i.e., state-funded housing, local host, rental).More details are provided in the Appendix.

Analyses
We started by assessing the basic characteristics of UWRs using standard descriptive statistics.For categorical variables, we reported absolute and relative frequencies.To estimate the prevalence rates of depression and anxiety, we used bootstrapping with 10,000 replicates, which allowed us to calculate 95 % confidence intervals (95 % CI).We applied the same method to estimate rates of individuals who did not recognize that they could have a mental health problem (score 5 to 10 on SELF-I) among those who screened positively for moderate to severe depression or anxiety.To identify risk factors associated with moderate to severe depression or anxiety, and help-seeking among those who screened positively for moderate to severe depression or anxiety, we conducted multiple logistic regression analyses.We adjusted all regression models for socio-demographic characteristics.We used IBM SPSS for Windows, version 28, to analyse the data.

Sociodemographic characteristics
A total of 1347 participants responded to the questionnaire, resulting in a response rate of 44 %.Of these, 74 % were women.The majority of participants fell within the age range of 18-49, were unemployed, and had a partner who stayed in Ukraine (see Table 1 in the Appendix for further details).The sample is representative of Ukrainian War Refugees (UWR) in Czechia, as the gender and age distribution align with the data presented by the Ministry of Interior Affairs of Czechia (2022).

Mental health conditions, their recognition and help-seeking
Over two-fifths (41.5 %) of respondents screened positively for moderate or more severe depression (Table 1), while nearly a quarter screened positively for moderate or severe anxiety (Table 2).The rate of depression and anxiety in our sample (at least moderate or severe depression or anxiety) was 43.01 % (95 ).Women and younger individuals were more likely to screen positively for mental health problems.Additionally, our data show a significant overlap between mental health conditions, as indicated in Graph 1 (see Appendix), which demonstrates a linear relationship between symptoms of depression and anxiety with a Pearson Correlation of 0.813 (95 % confidence interval: 0.792-0.831,p<0.001).This finding suggests a strong link between symptoms of depression and anxiety.
We analysed data from the SELF-I scale to determine participants' perceptions and self-identifications of mental health conditions, which we consider as an important prerequisite for seeking help.There were 21.54 % (95CI [17.44,25.91])individuals who screened positively for moderate to severe depression or anxiety and at the same time did not recognize that they could have a mental health problem (score 5 to 10 on SELF-I).Table 2 in the Appendix shows the percentage of individuals with at least moderate levels of depression or anxiety who responded to each SELF-I item.Notably, 298 participants strongly disagreed with the idea that their current problems are signs of mental health issues.However, 18.5 % of these individuals exhibited symptoms of at least moderate depression or anxiety.Similarly, 340 participants considered themselves mentally healthy, yet 18.7 % of them had symptoms of depression or anxiety.
In the Appendix, Table 3 displays the proportions of individuals with and without mental health issues, along with their corresponding responses on the SELF-I scale.As mentioned earlier, a significant proportion of respondents disagreed with the possibility of having a mental health problem, as indicated by their SELF-I score.Nonetheless, they exhibited at least moderate levels of depression or anxiety (21.6 %).

Table 1
Symptoms of depression measured by PHQ-8.

Mild depression
Moderate depression Moderately severe depression Severe depression Total p-value * Regarding seeking professional help, out of our sample of 1347 participants, only 45 sought help for their mental health issues in Czechia.However, among the remaining participants who did not seek help, 41.8 % had symptoms of at least moderate depression or anxiety.No help-seeking among those who screened positively for moderate to severe depression or anxiety was: 93.80 % (95 %CI [88.03,99.85]).Similar results were found when asking participants about seeking help in Ukraine prior to their arrival.When we asked participants if they had thought about seeking help in Czechia for mental health issues since their arrival, 744 answered "no."However, 23 % of those who answered "no" had symptoms of at least moderate depression or anxiety.These outcomes are presented in Table 4 (in the Appendix).We also asked participants what were some of the barriers they faced preventing them from seeking professional help in Czechia.The most frequently stated answer was "I wasn't sure what type of help I needed" reported by 199 participants.The second was "I didn't know where to find information about available options" with 158 participants responding.Graph. 2 (Appendix) shows a distribution of all the responses.

Mental health conditions associated risk factors
We used a logistic regression to arrive at adjusted estimates of sociodemographic factors and their link to mental health conditions (Table 5 in the Appendix shows basic descriptive characteristics).For age, the lower the age the higher the odds of depression or anxiety.Participants who are 18-29 years old have 1.6 times higher odds to have moderate depression or anxiety than 30-39 years old, 2.2 higher than 40-49-yearolds and 2.8 higher than 50-59 year olds.Women have 1.77 times higher odds for depression or anxiety than men.If the participants' partner stayed in Ukraine, odds ratio (with regard to the reference category partner in Czechia) was 1.46.The odds ratio for people without a partner was 1.45 (detailed results are provided in the Table 6 in the Appendix).

Discussion
Our results indicate that the prevalence of depression and anxiety symptoms among UWR in Czechia is high, with women and young adults under the age of 30 being significantly more likely to experience mental health issues.A significant proportion of refugees who experience symptoms of moderate or severe anxiety or depression do not recognize their mental health issues as problems and are therefore less likely to seek help.
Our findings are consistent with previous studies examining mental health in conflict and post-conflict settings.A recent meta-analysis of 129 studies looking at the prevalence of various mental health conditions among conflict-affected populations showed a higher prevalence of depression, anxiety, and PTSD (Charlson et al., 2019).Similarly, a study conducted with UWRs in Poland found similar levels of depression and anxiety, albeit on a smaller sample (Rizzi et al., 2022).Another study conducted in Germany also found similar outcomes, with higher levels of depression and anxiety among UWR living in Germany (Buchcik et al., 2023).
The reported barriers to accessing treatment by respondents in our study were similar to those reported in other studies, indicating the need for education on different types of help available and when to seek it (Byrow et al., 2020).

Limitations
There are limitations to our study.Our cross-sectional design only allows for a limited generalisations about the relationship between mental health outcomes and war or refugee related experiences, which means that we are not able quantify a causal influence of war or other factors on mental health outcomes of Ukrainian refugees.Furthermore, we were not able to gather data on potentially important covariates, such as length of stay of participants in Czechia.Regarding the measures used, while we back-translated the PHQ-8 and GAD-7 scales, the SELF-I scale and questions regarding treatment utilisation were only translated by a native speaker and not thoroughly validated for use in Ukrainian, we cannot rule out a potential bias stemming from this.Moreover, all the measures are self-reported, which makes them prone to social desirability bias.In addition, our sampling method may introduced a selection bias, since it relies on participants willing to take part in online surveys, which might further limit the generalizability of our findings Most importantly, the response rate of under 50 % may appear low and insufficient for making robust generalizations.However, it is crucial to consider the unique circumstances of the population under study.The nature of their situation is marked by high levels of uncertainty and a sense of 'permanent temporality' in terms of their place of stay.Since virtually all Ukrainian war refugees (UWR) were registered by the MLSA, the panel from which our sample was derived might be considered as reasonably representative of the entire UWR population in Czechia.In light of these factors and the absence of more robust evidence, we argue that our estimates offer valuable insights for informed decision-making in terms of addressing the mental health needs of UWR, but we also highlight the need for more research to understand the true extent of mental health problems among UWR populations across Europe.

Table 2
Symptoms of anxiety measured by GAD-7.

Conclusion
The results of this study offer initial insights into the mental health of UWRs residing outside of Ukraine, and they reveal a high prevalence of depression and anxiety, which is accompanied by very low help-seeking among this group.Ultimately, our study highlights the need for increased mental health literacy within the UWR population, in order to better inform help seeking and support those in need.

Declaration of generative AI and AI-assisted technologies in the writing process
During the preparation of this work corresponding author used ChatGPT (GPT-3.5) in order to improve language and readability.After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.