Our analyses were guided by the System Innovation Approach (12).

This approach acknowledges that implementing new approaches to service delivery, such as task-shifting from specialists to trained community-based providers, often challenges existing systems and requires coordinated responses across multiple levels. The framework identified multiple relevant levels including culture, structures, practices of existing subsystems, and landscape, which shape their overarching systems, aiming to explore the broader system changes necessary for the sustainable and culturally appropriate integration of services into routine care for FDPs (20). Figure 1 presents a visual representation of the levels identified within the System Innovation Framework.

This study employed a two-step qualitative design to identify and understand the needs of FDPs. The study protocol was pre-registered and described in detail on the Open Science Framework (https://osf.io/tmsk7) (21). The study was conducted between April 2023 and January 2024 and consisted of a two-step interview process. The first round of semi-structured free list (FL) interviews aimed to identify frequently encountered difficulties faced by FDPs in their host countries since leaving Ukraine. Recruitment occurred until no new themes emerged during FL interviews. Twelve participants were recruited as a convenience sample, using a maximum variation sampling method, by balancing participants on gender and host country, to ensure diverse representation (22). The recruitment was conducted through U-RISE’s project partner non-governmental organisations (NGOs): International Medical Corps (Poland), Phoneo (Romania), and TENENET (Slovakia).

The second round of semi-structured interviews, which constituted the data for the present study, focused on the nature, causes, and consequences of previously identified problems in greater depth, as well as potential solutions to overcoming the identified barriers within the host countries. Snowball sampling was used to recruit Key Informant (KI) interview participants from the FL interview participants (23).

The interview questions and topic guide were developed by the research team (MB, MP, IF, NM), and culturally adapted by research team members with Ukrainian background (IF, NM). Translation of the interview transcripts followed rigorous procedures, where text was translated from English to Ukrainian by two independent bilingual Ukrainian team members (IF, NM). Afterwards, the text was back-translated and checked for meaning (24).

Based on the guidelines for qualitative assessments of the Applied Mental Health Research Group (25) and World Health Organization (26), we aimed to recruit 18 participants for the FL interviews, and at least 10 participants for the KI interviews. Prior to the interviews, participants were informed about the study aims and characteristics. Participants signed an electronic informed consent form for study participation and personal data processing. Interviews with FDPs residing in Poland and Romania were conducted via Zoom by a pair of interviewers, each spanning 40 to 50 minutes, whereas in Slovakia, interviews were conducted in person and lasted between 30 to 40 minutes each.

Interpreters were included in the interviews where necessary. The study was approved by the Institutional Review Board Committee at the University of Verona (Study ID: 12a/2023).

To ensure the relevance of the interview findings, we conducted a Zoom-based focus group in November 2024 with seventeen female Ukrainian FDPs. Participants were members of the U- RISE Advisory Group and were recruited through the project’s mailing list. The session lasted one hour and was moderated by a Ukrainian researcher (IF). The Advisory Group was formed to advise on points of improvement during the implementation of psychological interventions that could impact cultural acceptance and sustainability. The Advisory Group comprises a combination of forcibly displaced persons from Ukraine with and without mental health background mental health professionals, researchers and MHPSS advisors who were forcibly displaced from Ukraine, now residing in Poland, Romania, Slovakia, Denmark, and the Netherlands. During the focus group session, results from the KI interviews, along with relevant non-identifiable quotes and interpretations of the data, were presented to participants in English by EO and KW, with simultaneous Ukrainian interpretation (presentation slides were translated to Ukrainian).

Participants were invited to participate in a moderated discussion to confirm the quotes and provide feedback on the authors’ interpretations of the interview results, identify needs that should be further emphasised, and assess the relevance of the findings with the current challenges faced by the Ukrainian FDP community. These insights were used to ensure that the authors have accurately and respectfully captured FDPs’ perspectives. The meeting was recorded, transcribed, and summarised in the form of meeting notes, which were then sent to all participants of the focus group for review and feedback. Additionally, during the summary process, notes were used for consensus agreement with researchers (EO, KW, IF), to enhance credibility and interpretive accuracy.

All KI interviews were audio-recorded, transcribed, and pseudonymised (MB). The data collection and analysis employed various credibility strategies to ensure methodological integrity, including methodological and investigator triangulation (17). All decision-making processes were discussed and verified in small-group meetings with experienced researchers, who also supervised the data analysis process (IF, EVV, MS). For data analysis, combined consensus and split coding was used. Data was coded independently by two researchers (EO, KW) using Atlas.ti (27) (Version 24.1.1.30813), with regular meetings with expert researchers (IF, EVV, MS). Discrepancies were resolved using consensus discussions to ensure full alignment.

The analysis followed a two-step approach to allow for both data-driven insights and alignment with the theoretical framework. First, data was coded inductively based on emerging themes by each coding author separately. Second, emerging themes were synthesised and coded data was reorganised deductively according to the most suitable domains of the conceptual framework; Landscape, Structure, and Culture by each coding author (EO, KW) (20). The pseudonymised coding list is stored securely on the principal investigator’s drive.

Sample characteristics are reported in Table 1 . The FL sample consisted of 18 participants, with a mean age of 41.1 years, and the majority being female. The KI sample consisted of 12 female participants with a mean age of 41.3 years, most of whom had a professional background related to MHPSS. Both samples were evenly distributed across Poland, Romania and Slovakia, all participants were Ukrainian. The frequency of the topics mentioned by interviewees varied among representatives from different countries ( Figure 2 ).

Overall, the identified needs and barriers remained consistent between the initial KI interviews and the focus group meeting. Nonetheless, the focus group provided additional novel insights, including war fatigue, the difficulties of maintaining a household for single parents and specific needs among vulnerable subgroups of Ukrainian FDPs ( Table 2 ).

Access to free language courses, clear length-of-stay policies and recognition of work qualifications, labour market assistance, and financial aid for FDPs may support long-term perspectives and increase integration readiness of Ukrainian FDPs (33). Continued efforts are needed to foster acceptance, support, and security for vulnerable groups, minimising stigma while recognising FDPs’ cultural perspectives on preferred means of seeking support. Psychoeducation, and normalisation of mental health support remain critical (29). Among service providers in host countries, awareness should be raised regarding cultural idioms of distress and the ways in which mental health concerns can manifest, such as somatisation.

Social contact has been shown to be an effective strategy for reducing mental health stigma (34). Barriers to implementing MHPSS could be addressed by systematically building on existing community support structures and integrating online formats and digital tools into mental health services (17). Offering evidence-based, scalable interventions for people experiencing adversity, such as Self-Help Plus (35, 36) in combination with individual interventions (Problem Management Plus; 37), and family-oriented interventions aiming to support positive parenting (Multi-family approach; 38), may facilitate MHPSS uptake. Furthermore, investigations should focus on how to make scalable MHPSS accessible to special needs (39) and minority populations, for example, Ukrainian Roma (40).

Various strengths of our method should be highlighted. Employing the System Innovation Approach to guide our analysis provided a multi-level lens essential for identifying systemic enablers and barriers to sustainable, culturally appropriate implementation of psychosocial services. Additionally, the two-step snowball sampling method leveraged trust within networks to recruit knowledgeable and motivated participants efficiently, ensuring thematic saturation.

However, several limitations must be acknowledged. The snowball sampling method led to a highly educated sample, with many working in fields related to MHPSS, which limits the generalisability of the results to the broader population of Ukrainian FDPs. Additionally, the study’s limited sample, comprising only four female participants per country, limited any analyses of potential gender differences and restricted the generalisability of findings both across and within Poland, Romania and Slovakia’s distinct health and policy contexts. Furthermore, with 75% of the participants aged 36–50, the sample lacked sufficient representation of younger and older age groups. Research suggests that age differences may shape how individuals cope with stressful situations (41, 42). Therefore, future research should aim for gender, and age inclusivity, recruiting a more representative sample of Ukrainian FDPs to ensure a comprehensive understanding of the challenges and barriers they experience. Furthermore, participants were not followed over time. As displacement is a dynamic, ongoing process, rather than a single event (43), the challenges and needs of displaced populations may evolve over time. To provide a clearer picture of emerging needs and areas for intervention, future research should systematically and routinely examine how stressors and coping mechanisms have evolved in the general population of Ukrainian FDPs over time. Finally, although Ukrainian-language materials and interviews were developed with the help of Ukrainian team members to ensure linguistic and cultural appropriateness, several analysis team members were not Ukrainian, which may have introduced subtle interpretive biases. To mitigate this, we used continuous team-based reviewing of meaning with Ukrainian colleagues, and organised a focus-group session to present preliminary findings and ensure interpretation accuracy.