Between trauma and resilience - an ecological model of the determinants of mental health among Ukrainian war refugees in Europe: a cross-sectional study

BACKGROUND: The full-scale invasion of Ukraine has generated the largest refugee crisis in Europe since the Second World War, exposing civilians to trauma, displacement, and prolonged uncertainty. Refugees face stressors across multiple ecological levels, making Bronfenbrenner's model a suitable framework for understanding mental health determinants. This study examined multilevel predictors of psychological distress among Ukrainian war refugees in Europe. METHODS: A cross-sectional study was conducted in 2025 across eight European countries. A total of 1,622 adult refugees completed standardized questionnaires. Psychological distress was assessed with the Refugee Health Screener-15 (RHS-15), and cultural trauma symptoms with the Cultural Symptoms of Trauma Scale (CSTS). Sociodemographic, relational, economic, institutional, cultural, and temporal variables were organised within Bronfenbrenner's ecological model. Group comparisons were conducted using non-parametric tests, and predictors of distress were identified through logistic regression. RESULTS: Higher distress was associated with poorer self-rated health, weaker family and social relationships, unemployment, economic strain, and contact with family in war-affected areas. The strongest predictors were macrosystem factors, including emotional, cognitive, existential, and agency-related trauma symptoms (OR 1.40-2.78). Protective factors included better health, stronger family relationships, employment, and favourable economic conditions. Refugees who left Ukraine later in the conflict showed lower distress risk. CONCLUSIONS: Mental health outcomes among Ukrainian refugees reflect interactions across ecological levels. Interventions should integrate individual, relational, community, economic, and culturally informed components to address the multifaceted nature of refugee distress.