Mental health and its associated wellbeing constitute central elements of individual functioning and are key determinants of quality of life. In health policy practice, however, mental health is often reduced to the absence of a diagnosed disorder, which diminishes its broader meaning. The holistic approach promoted by the World Health Organization (WHO) emphasizes that health encompasses interconnected psychological, physical, and social dimensions, and that wellbeing cannot be equated solely with the absence of pathology. Contemporary global challenges—including dynamic social change, economic instability, climate-related stressors, and, above all, armed conflicts—have further underscored the complexity of mental health and its determinants. Armed conflicts exert particularly profound psychological effects, generating both direct trauma among affected populations and wider feelings of insecurity within societies (1, 2).

The war between Ukraine and Russia, which began in 2014 and escalated into full-scale armed conflict in 2022, has created one of the largest humanitarian crises in modern Europe. Millions of Ukrainians have been displaced and forced to seek safety in other countries, making the provision of adequate support and integration resources a priority across Europe. While the consequences of war are most severe among those directly exposed to violence, displacement itself introduces significant psychological burdens, including insecurity, grief, chronic stress, and uncertainty about the future (2, 3). These experiences highlight the importance of understanding factors that protect or undermine mental health in displaced populations.

Emerging evidence from studies conducted since 2022 indicates a substantial mental health burden among Ukrainians affected by the full-scale invasion, including those who fled to European host countries. Recent surveys and cohort studies have reported elevated rates of trauma-related symptoms as well as anxiety and depressive symptoms among Ukrainian refugees across Europe, with a sizeable proportion screening positive for probable PTSD and clinically relevant psychological distress (4–7). Acute stress reactions have also been documented in the early phase of displacement, highlighting the need for timely identification of vulnerable individuals (5).

These findings support the use of brief, standardized screening tools that capture both general psychological distress and trauma-related symptomatology in refugee populations. In this study, we therefore assessed distress using RHS-15 and HSCL-25, complemented by a checklist of DSM-5 trauma-related symptoms, and examined protective and adaptive processes through resilience and coping measures. This broader assessment framework is aligned with public health recommendations emphasizing both risk indicators and psychosocial resources in forced migration contexts (8).

Migration under conditions of forced displacement is closely tied to acculturation processes that may heighten perceived threat and stress, as individuals must navigate unfamiliar sociocultural norms, values, institutional structures, and—often—religious contexts. Challenges such as limited language proficiency, barriers in the labor market, and insufficient social support can intensify feelings of isolation, sadness, and loss associated with leaving one's previous life behind. These obstacles may negatively affect overall wellbeing and hinder effective adaptation to the host environment (9–11).

Importantly, although institutional and structural factors (e.g., welfare systems, access to healthcare, and legal protections) shape refugees' living conditions, the present study operationalizes psychological adaptation at the individual level, focusing on psychological distress, resilience, and coping strategies as measurable outcomes and potential protective factors in the context of forced displacement.

In this context, resilience has emerged as a key construct in understanding individual differences in psychological functioning during and after adversity. Although definitions vary, resilience generally refers to the capacity to maintain or regain psychological balance in the face of stress, using personal and environmental resources to support adaptation. It encompasses processes that help individuals minimize the negative impact of stressors, recover from adversity, and maintain relatively stable functioning. As such, resilience plays a crucial role in preventing more severe psychological difficulties and supporting positive adjustment among individuals exposed to trauma and displacement (10–13).

The diversity of national responses to the Ukrainian refugee crisis across Europe offers a unique opportunity for comparative research. Countries differ substantially in their welfare systems, migration policies, and integration infrastructures—from more centralized, state-led systems (e.g., Poland, Slovenia) to decentralized, NGO-driven models (e.g., Spain, Cyprus). Federal structures, such as in Germany, produce additional regional variation in access to services, whereas countries like Portugal combine inclusive policies with capacity limitations. Serbia, as a non-EU transit and temporary host country, operates largely outside EU protection mechanisms and relies more heavily on humanitarian support. These divergent institutional ecologies provide a valuable comparative lens for examining how societal contexts interact with individual psychological resources to shape refugees' mental health trajectories (14, 15). While these institutional differences are not directly measured in the present study, they provide the contextual backdrop for interpreting cross-national patterns. Accordingly, we focus on individual-level psychological distress, resilience, and coping strategies. In addition, we included internally displaced persons residing in Ukraine as a distinct analytical group to provide a reference point for individuals exposed to ongoing war-related stressors within the country of origin; Ukraine is therefore not treated as a host country but as a separate context of internal displacement. The aim of the study was to identify and compare cross-national differences in levels of psychological distress, resilience, and coping strategies among Ukrainian war refugees residing in seven European host countries and internally displaced persons in Ukraine.

Preliminary analyses examined the effects of selected sociodemographic variables on psychological distress (RHS-15). One-way ANOVA results indicated significant main effects of age group (F₍₅, _{1, 625)} = 4.09, p = 0.001) and employment status (F₍₅, _{1, 625)} = 6.03, p < 0.001) on distress scores. In contrast, no significant effects were observed for gender (F₍₃, _{1, 627)} = 0.25, p = 0.860) or marital status (F₍₂, _{1, 627)} = 0.51, p = 0.600). These findings indicate that age and employment contribute to variability in psychological distress and were therefore considered in subsequent analyses.

To further examine the independent contribution of sociodemographic factors, a univariate general linear model was conducted including host country, gender, marital status, employment status, and age as predictors of psychological distress (RHS-15). After controlling for sociodemographic variables, country of residence remained a significant predictor of distress, F₍₇, _{1, 611)} = 38.79, p < 0.001, partial η² = 0.144. Marital status (p = 0.003) and employment status (p = 0.004) also showed significant independent effects, whereas gender and age were not significant predictors in the adjusted model. The overall model explained 16.2% of the variance in psychological distress (R² = 0.162).

A one-way ANOVA revealed statistically significant differences in psychological distress levels across the examined countries. These differences were observed for all assessed indicators—RHS-15, HSCL-25 (anxiety and depression), and the four DSM-5 trauma-related symptom clusters (intrusion, avoidance, negative alterations in cognition and mood, and arousal)—all p < 0.05.

Table 2 presents the mean scores obtained by participants in each host country, demonstrating clear variation in psychological burden. The highest levels of distress were reported in Slovenia, Ukraine, Portugal, Spain, and Germany, where mean RHS-15 scores and HSCL-25 and DSM-5 subscale scores were consistently elevated. For example, DSM-5 total scores in these countries ranged from 2.017 to 2.246, indicating more pronounced trauma-related symptoms.

In contrast, the lowest distress levels were observed in Cyprus and Poland, where mean scores on all measures were markedly lower. RHS-15 scores in these countries were 0.760 and 1.293, respectively, and DSM-5 total scores were 1.400 and 1.673, reflecting substantially reduced symptom severity compared with higher-distress countries.

Games–Howell post hoc tests indicated that distress levels in Cyprus were significantly lower than in most other countries, and that Poland also differed significantly from several higher-distress country groups (p < 0.05). Overall, significant cross-national differences in psychological distress were observed across host countries (Table 2).

A one-way ANOVA revealed significant differences in resilience levels across host countries (F = 22.01, p < 0.001). Table 3 presents the country-level means, standard deviations, and confidence intervals for the RS-25 resilience scores. The results demonstrate marked variation in resilience among Ukrainian refugees residing in different national contexts (η² = 0.087).

The highest resilience levels were observed in Poland (M = 5.417) and Germany (M = 5.447), where participants reported the strongest perceived personal competence and acceptance of self and life. Confidence intervals for both countries (Poland: 5.335–5.498; Germany: 5.253–5.641) were narrowly distributed, indicating relatively stable and elevated resilience scores.

In contrast, the lowest resilience levels were found in Spain (M = 4.409, 95% CI = 4.202–4.617), where scores were consistently lower than in all other host countries. Participants in Slovenia (M = 4.778), Ukraine (M = 4.733), and Portugal (M = 4.724) reported intermediate resilience levels, reflecting moderate perceived adaptive capacity. Cyprus (M = 5.111) and Serbia (M = 5.192) also fell within the mid-range but showed relatively higher means within this group.

Overall, the significant ANOVA results and observed mean differences indicate substantial cross-national variation in resilience. These findings indicate significant cross-national differences in resilience among Ukrainian refugees.

Analyses revealed significant cross-national differences in both adaptive coping (F₍₇, _{1, 622)} = 25.85, p < 0.001) and maladaptive coping (F₍₇, _{1, 623)} = 24.85, p < 0.001) (η²_adaptive = 0.100; η²_maladaptive = 0.097). Games–Howell post hoc tests were applied to identify significant pairwise differences due to unequal group sizes. Mean scores and standard deviations for each country are presented in Table 4. The highest levels of adaptive coping were reported in Poland (M = 2.386), Slovenia (M = 2.359), and Germany (M = 2.402), indicating a relatively strong engagement in constructive strategies such as active problem-solving and positive reframing. These countries also demonstrated low variability, suggesting stable patterns of adaptive coping among respondents.

Conversely, the lowest adaptive coping scores were observed in Cyprus (M = 1.801) and Serbia (M = 2.166), indicating reduced reliance on adaptive approaches within these contexts. Spain (M = 2.167), Portugal (M = 2.256), and Ukraine (M = 2.282) fell into intermediate ranges, suggesting moderate use of adaptive coping strategies.

Maladaptive coping showed a similar but less pronounced pattern of cross-national variation. Although differences were statistically significant, mean scores clustered more closely together across countries. Poland, Slovenia, and Germany exhibited slightly higher maladaptive coping tendencies compared with Cyprus and Serbia; however, the differences were smaller relative to those observed for adaptive coping. These results indicate that adaptive coping strategies vary more strongly across countries than maladaptive coping strategies.

The present study demonstrates clear and statistically significant cross-national differences in psychological distress, resilience, and coping strategies among Ukrainian refugees, underscoring the central role of host-country contexts in shaping mental health outcomes during forced displacement. From a public health perspective, these findings confirm that refugee mental health is a population-level issue influenced by structural, institutional, and policy determinants rather than solely by individual exposure to trauma.

Marked cross-national differences in psychological distress were observed. Ukrainian refugees residing in Cyprus and Poland reported notably lower distress, whereas those in Slovenia, Ukraine, Spain, Germany, and Portugal exhibited higher symptom burdens. These patterns are consistent with socio-ecological models of adaptation, which emphasize that mental health outcomes are embedded within broader institutional, cultural, and political systems (13, 28). However, because institutional and political factors were not directly assessed in the present study, these interpretations should be considered contextual and hypothesis-generating rather than causal explanations of the observed differences (29). Importantly, contemporary public health frameworks developed by the World Health Organization and UNHCR similarly conceptualize refugee mental health as shaped by post-migration conditions, access to services, and system-level protection mechanisms, rather than by trauma exposure alone (30).

At the same time, cross-national differences may partly reflect compositional differences between the country samples (e.g., age distribution, gender balance, and employment status), rather than the country context alone. To address this possibility, additional analyses were conducted including sociodemographic variables as covariates. Host country remained a significant predictor of psychological distress after controlling for age, gender, marital status, and employment, indicating that cross-national differences cannot be explained solely by compositional characteristics of the samples. Nevertheless, future studies should further investigate these relationships using multilevel or longitudinal designs to disentangle contextual and individual-level mechanisms more precisely.

Resilience also differed substantially across national contexts, with the highest levels observed in Poland and Germany and the lowest in Spain and Slovenia. Importantly, resilience does not imply the absence of psychological distress; rather, protective resources and symptom burden may co-occur, especially under ongoing adversity (31, 32). From a public health standpoint, resilience should be understood not merely as an individual psychological trait but as an outcome influenced by structural determinants such as legal stability, access to healthcare, labor market inclusion, and social integration. Previous research shows that, beyond exposure to war-related violence, mental health outcomes among refugees are strongly shaped by post-migration stressors, including family separation, financial difficulties, problems with employment or underemployment, discrimination, and limited access to healthcare, all of which have been consistently associated with poorer mental health and increased psychological distress (33). The higher resilience observed in Poland and Germany may therefore reflect the combined effects of cultural proximity, established Ukrainian diasporas, and comparatively well-developed institutional support infrastructures.

This conceptualization helps explain seemingly paradoxical patterns such as the co-occurrence of elevated distress and relatively high resilience in some contexts (e.g., Germany). In line with the two-continua perspective on mental health, positive psychological resources and mental health symptoms represent related but distinct dimensions; individuals may therefore report substantial distress while simultaneously maintaining resilience-related capacities for adaptation and functioning (32). For refugees, this may reflect simultaneous exposure to persistent post-migration stressors (e.g., uncertainty, bureaucratic demands, and separation from family) alongside access to supportive resources and community networks that sustain resilience (29).

Cross-national variation in coping strategies further reinforces the importance of post-migration environments for public mental health. Refugees residing in more structured and coordinated reception systems, such as Poland, Germany, and Slovenia, reported higher levels of adaptive coping, whereas lower levels were observed in Cyprus and Serbia. Previous research demonstrates that adaptive coping among refugees is closely linked to integration-related conditions, including access to employment, education, and psychosocial services (21, 28). In line with WHO and UNHCR guidelines on mental health and psychosocial support (MHPSS), these findings suggest that strengthening everyday functioning and social participation may be as important as clinical interventions for promoting adaptive coping in displaced populations (30).

A closer examination of these cross-national patterns highlights the decisive role of institutional ecologies in shaping psychological adaptation. Lower distress levels in Poland and Cyprus appear consistent with reception systems characterized by greater predictability and clearer administrative pathways. In contrast, higher distress in Spain and Slovenia coincides with fragmented reception structures, administrative delays, and limited psychosocial capacity. Elevated distress in Germany and Portugal may reflect, respectively, the heterogeneity of federal reception frameworks and capacity constraints within welfare-oriented systems. Serbia, operating largely outside the EU protection regime and relying primarily on humanitarian rather than integration-oriented provision, exhibited moderate distress alongside comparatively lower adaptive coping resources (34). These findings align with comparative analyses showing that restrictive or unstable integration policies are associated with poorer mental health outcomes among refugees and migrants (35).

More broadly, the results are consistent with European public health evidence documenting persistent inequalities in access to healthcare and mental health services among refugee populations. Recent reports from Eurofound and the European Center for Disease Prevention and Control highlight substantial cross-national disparities in healthcare access, service continuity, and mental health provision for refugees within the European Union, particularly during periods of rapid displacement and system overload (36). Such inequalities likely contribute to the observed variation in distress, resilience, and coping across host countries.

Taken together, these findings demonstrate that institutional architectures are not passive contexts but active determinants of mental health trajectories among forcibly displaced populations. From a public health perspective, strengthening reception systems, reducing administrative barriers, and ensuring equitable access to mental health and social services are critical for mitigating long-term psychological distress and supporting resilience at the population level.

Given the broad age range of the participants (18–65 years), age-related differences in psychological distress, resilience, and coping may have influenced the observed cross-national patterns; however, age did not remain a significant independent predictor of psychological distress after adjustment for other sociodemographic variables in the multivariable model (37–39). For example, older adults may differ from younger adults in both exposure to cumulative stressors and preferred coping strategies. Although the present study focused on country-level comparisons, age-related mechanisms may still interact with contextual factors, even though age was not an independent predictor in the adjusted analyses. Future research should therefore examine potential age-by-country interactions and longitudinal age effects to clarify whether age moderates psychological adaptation across different institutional settings.

Future research should extend cross-national analyses to additional host countries and apply longitudinal designs to examine how changes in institutional arrangements influence mental health trajectories over time. Such evidence is essential for informing public health strategies and policy reforms aimed at promoting sustainable psychological adaptation during prolonged displacement.

This study demonstrates substantial cross-national differences in psychological distress, resilience, and coping strategies among Ukrainian refugees across European host countries and internally displaced persons in Ukraine, highlighting the importance of a public health perspective on forced displacement.

The findings underscore the potential importance of institutional, social, and policy environments in shaping psychological adaptation during forced displacement. Although institutional and policy environments were not directly measured, host country remained a significant predictor of psychological distress after adjustment for key sociodemographic variables, suggesting that cross-national differences are unlikely to be explained solely by sample composition. Future public health research should explicitly integrate system-level indicators to empirically test these contextual influences.