Exploring socio-ecological context and mental health of Ukrainian refugees in Italy through eco-map: a mixed-methods study

Background: Following the humanitarian crisis in Ukraine, an estimated 8,174,189 refugees have fled (April 2023). Refugee status leads to a higher prevalence of mental illness, which may also arise or be worsened by post-migration stressors. Although a growing literature on the social determinants of mental health, little is known on the Ukrainian refugee population. Thus, this study aims to analyse the association between mental health and the socio-ecological context of Ukrainian refugees. Methods: A mixed-methods study was conducted involving Ukrainian refugees hosted in the province of Verona (Italy) from November 2022 to April 2023. Mental health (MH) was assessed through the International Trauma Questionnaire (ITQ) and the General Health Questionnaire-12 (GHQ-12). The socio-ecological context was explored through a semi-structured ecomap distributing individuals into ecomap clusters. Logistic regression was used to explore association between mental health outcomes and ecomap clusters adjusting for sex, age, and chronic diseases. Results: A total of 224 refugees were recruited (F = 80.8 %; median age=35.5 years, IQR 24.7-44.0). At the GHQ-12, 119/214 (55.6 %) individuals were found to be at risk for psychological distress; at the ITQ, 86/211 (40.8 %) tested positive for post-traumatic stress disorder (PTSD) and 28/211 (13.3 %) for complex PTSD.Five clusters of stressful edges were identified: none (53.4 %), family (15.5 %), social network (12.1 %), public services (9.7 %), school/work (9.2 %). Refugees from the stressful clusters social network, public services and school/work had an odds ratio of PTSD 1.24 [0.95CI 1.01-1.53, p = 0.049], 1.41 [0.95CI 1.12-1.78, p = 0.031] and 1.46 [0.95CI 1.15-1.85, p = 0.002] times higher than none. The risk of a positive GHQ-12 was 1.29 [0.95CI 1.02-1.62, p = 0.031] and 1.46 [0.95CI 1.14-1.87, p = 0.003] times higher in the public services and school/work clusters compared to none. Conclusions: MH distress was high in our sample and was associated with having stressful edges with public services and school or work in the resettlement country. Ecomap proved to be a useful tool to explore the social network of refugees. Reducing the stressors of refugees' social context could contribute to improving their MH.