Authors:  Anastasiya-Mariya Asanov, Igor Asanov, Guido Buenstorf

Armed conflicts cause considerable suffering for the affected populations - especially for the refugees. According to UNCHR, there are approximately 43 million refugees worldwide and 64 million internally displaced persons. This means that more than one in every 69 people on Earth had to flee their homes. We know that refugees have higher levels of distress and depression than internally displaced and non-displaced conflict-affected populations (Asanov et al., 2023). Moreover, their access to psychological support in the host country is often limited. In response to the existing bottlenecks, the World Health Organisation (WHO) has developed scalable psychological interventions to reduce stress and improve the mental health of refugees, e.g., Self-Help +. This is a group intervention for coping with stress based on acceptance and commitment therapy. It was developed specifically for situations of extreme adversity, including armed conflict and displacement. It has been shown to reduce psychological distress and improve the well-being of refugees (Tol et al., 2020).

In the Russian invasion of Ukraine, more than 5 million Ukrainians were displaced within the country, and more than 8 million Ukrainians had to seek refuge abroad in 2022. It has been shown that the war in Ukraine caused alarming rates of stress, depressive symptoms, anxiety, and post-traumatic stress disorder (PTSD), particularly among refugees and internally displaced persons (Asanov et al., 2023; Ben-Ezra et al., 2023).

Given the large number and wide geographical distribution of Ukrainian refugees in Europe, we tested whether and how Self-Help+ could be adapted to the cost-effective and even more scalable format of an online course. We decided to test this delivery method because meta-analyses suggest that online-based mindfulness interventions for the general population decrease depression and anxiety, improve well-being and mindfulness, and are particularly effective in reducing stress (Galante et al., 2023). Our Self-Help Online (SHO) intervention was explicitly designed as an early first-aid help for large, highly geographically dispersed war-affected populations. It was developed to be easily and quickly translated into other languages and rapidly launched if necessary. We built this online course based on the illustrated guide “Doing What Matters in Times of Stress” from the Self-Help+ intervention, released and endorsed for online adaptation by the WHO (WHO, 2020). The program materials can be viewed at https://www.sho4ukraine.com/.

Our randomized controlled trial of this intervention is unique as it includes recently displaced refugees across 17 European countries as well as internally displaced and non-displaced Ukrainians. Additionally, this is the first trial of a mental health online intervention for these groups less than six months after the invasion. The Self-Help Online program was advertised to adult Ukrainian refugees in the European Union. Participation was also open to adult internally displaced and non-displaced Ukrainian citizens and residents. The research team advertised the Self-Help Online program among adult Ukrainians for two weeks, from June 22nd to July 6th, 2022. The program was delivered through Ukraine’s largest free online learning platform, Prometheus. We used online advertising, social media groups, and the online learning platform user base to reach out to Ukrainians living abroad and invite them for a study. 

The program began in July 2022 with 652 participants, including Ukrainian refugees, internally displaced, and non-displaced Ukrainians. The online course consisted of five sections: grounding, unhooking, acting on your values, being kind, and making room. The sections were split into short videos with audio and written self-reflection exercises. Additionally, we offered information on free opportunities and services available to Ukrainian refugees at that time in European countries, in Ukraine, and online. Participants could browse through the following categories: financial support, accommodation, educational opportunities for adults and children, daycare, job opportunities, free local language courses, online portals from local authorities, and psychological help, including several free 24/7 hotlines.

Illustrations from the Self-Help Online video materials

Our analysis of the effect of this first-aid online self-help intervention focused on 292 participants who completed the final survey. We used the Kessler-6 Distress Scale, Mental Health Inventory, and the WHO-5 Wellbeing Index (also measured at the beginning and one week after the intervention) to assess the participants' mental well-being.

Our results show that the online intervention significantly reduced distress among refugees, while internally displaced and non-displaced participants did not benefit to the same extent. The stress reduction in refugees was comparable to similar interventions but at a lower average cost. We conclude that Self-Help Online is an effective psychological intervention for reducing stress in geographically dispersed refugees at a low cost. We also show that online delivery methods can reach other conflict-affected groups – non-displaced and internally displaced people living in the country during the war. However, due to different circumstances and the nature of the stressors, the materials developed for the refugees might not be effective for the populations still located in conflict-affected areas. Future research could discover which type of treatment could be adapted to the online delivery method to alleviate the long-term negative consequences of displacement and war on health and mental health. 

The study was registered registry in the ISRCTN registry: https://doi.org/10.1186/ISRCTN96282810  

The course materials in a format similar to the one presented on the learning platform for the study can be viewed in Ukrainian on the following website: https://www.sho4ukraine.com
References

Asanov, A.M., Asanov, I. and Buenstorf, G., 2023. Mental health and stress level of Ukrainians seeking psychological help online. Heliyon, 9(11).

Asanov, A.M., Asanov, I. and Buenstorf, G., 2024. A low-cost digital first aid tool to reduce psychological distress in refugees: a multi-country randomized controlled trial of Self-Help Online in the first months after the invasion of Ukraine. Social Science & Medicine, p.117442.

Ben-Ezra, M., Goodwin, R., Leshem, E. and Hamama-Raz, Y., 2023. PTSD symptoms among civilians being displaced inside and outside the Ukraine during the 2022 Russian invasion. Psychiatry Research, 320, p.115011.

Galante, J., Friedrich, C., Dalgleish, T., Jones, P.B. and White, I.R., 2023. Systematic review and individual participant data meta-analysis of randomized controlled trials assessing mindfulness-based programs for mental health promotion. Nature mental health, 1(7), pp.462-476.

Tol, W.A., Leku, M.R., Lakin, D.P., Carswell, K., Augustinavicius, J., Adaku, A., Au, T.M., Brown, F.L., Bryant, R.A., Garcia-Moreno, C. and Musci, R.J., 2020. Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial. The Lancet global health, 8(2), pp.e254-e263.

World Health Organization, 2020. Doing what matters in times of stress: an illustrated guide.