Experiences of Mental Health and Functioning Among Conflict-Affected Populations: A Qualitative Study With Military Veterans and Displaced Persons in Ukraine

Abstract

Objective:

This article reports findings from a qualitative study that sought to identify and describe psychosocial and mental health consequences of conflict among internally displaced persons (IDPs) and military veterans in Ukraine. The study was the first phase of a clinical intervention trial and was designed to understand local experiences of mental health problems and function, inform the selection and adaptation of local measures, and guide the modification, and implementation of a psychotherapy intervention that could support conflict-affected persons.

Method:

Free-list interviews (FLs), key informant interviews (KIIs), and focus group discussions (FDGs) were conducted with IDPs, military veterans, and providers working with these two groups. A total of 227 respondents were interviewed from two study regions in eastern Ukraine—Zaporizhia and Kharkiv—including 136 IDPs and 91 military veterans.

Results:

Both IDPs and veterans were described as experiencing high levels of psychological stress symptoms, including depression, isolation, anxiety, and intrusive memories. Although IDPs and veterans were exposed to different traumas, they both identified struggles with social adaptation, including feeling isolated and misunderstood by their communities. Both groups also described relational conflict within and outside the family. Social support mechanisms were considered essential for recovery, and positive social interaction was described as a key example of healthy functioning.

Conclusion:

Findings suggest a need for community-based programming that facilitates social adaptation, supports social network building, and helps engage conflict-affected people into mental health services. Programs that promote greater awareness, interaction, and understanding among the general public, military veterans, and IDPs are also warranted.

Background

Epidemiologic studies have demonstrated that violent conflict is a major cause of death and disability globally and threatens the social and economic stability of affected communities (Haagsma et al., 2016; Kerridge et al., 2012; Mollica et al., 2004). Individuals exposed to violent conflict may experience a range of health-related problems, including disruptions to social systems and networks (Bryant et al., 2017), as well as physical and psychological harm (Murthy, 2007). Much of the research on mental health in conflict-affected populations has focused on post-traumatic stress and depression (Miller & Rasmussen, 2010; Murthy, 2007; Steel et al., 2009). Less attention has been given to other psychological or psychosocial conditions that may be important to affected communities (Murthy, 2007; Tol et al., 2011). It is critical to consider context-specific factors that influence interpretations, norms, and expressions of individual psychological health, as well as communal psychosocial health (Bass et al., 2007; de Jong & van Ommeren, 2002). Understanding these differences is crucial for developing contextually appropriate screening tools, as well as intervention and prevention programs to aid these populations (Carballo et al., 2004). This article reports findings from a qualitative study that examined community perspectives on the mental health impacts of conflict in Ukraine.

Nearly a tenth of the world’s population will be exposed to collective violence in their lifetimes (Benjet et al., 2016). The World Health Organization (WHO, 2001) has estimated that in regions subjected to armed conflict, at least 20% of people exposed will develop mental health problems and/or have difficulty functioning. Military service increases the risk of exposure to life-threatening and traumatic events, including aerial attacks, bombings, direct combat, as well as witnessing injury and death of others. Civilians living amid or exposed to conflict also experience or witness life-threatening and traumatic events and commonly deal with social consequences of conflict, such as food insecurity and displacement. Studies have documented a host of problems that can occur among conflict-affected military and civilian populations, including depression or anxiety (Hollifield et al., 2002; Johnson & Thompson, 2008; Slone & Mann, 2016; Steel et al., 2009), traumatic stress (Charlson et al., 2016), behavioral disorders (Horyniak et al., 2016; Jacobson, 2008), psychosomatic conditions (Prorokovic et al., 2005; Slone & Mann, 2016), and mistrust or hostility/aggression toward others (Begić & Jokić-Begić, 2007; Eggerman & Panter-Brick, 2010; Jakupcak et al., 2007; Keresteš, 2006).

Study Setting

In late 2013 and early 2014, Ukraine underwent a period of escalating political discontent and violence in response to national policies that would have tied Ukraine’s political and economic future more closely to the Russian government than the European Union (EU). Russia’s subsequent annexation of Crimea initiated a prolonged military conflict in eastern Ukraine between Russia-supported separatist fighters and the Ukrainian Army (Reid, 2015; Wood et al., 2016). Since the conflict began, more than 10,000 people have been killed and more than 25,000 wounded (UNHCR, 2017), including many military veterans of the “Anti-Terrorist Operation” (ATO), which sought to remove the Russian military from Ukraine and stop pro-Russian separatists.

The conflict has severely disrupted social and economic life in eastern Ukraine, particularly in the oblasts (i.e., administrative regions) of Donetsk and Luhansk (known as the Donbass), from where hundreds of thousands of Ukrainians have been displaced; many have also been displaced from Crimea. As of April 2019, there are approximately 1.5 million registered internally displaced persons (IDPs) and other conflict-affected persons (UNHCR, 2019)—4% of the total population—living in host communities across Ukraine (Internal Displacement Monitoring Center [IDMC], 2017). The largest populations of IDPs outside of the Donbass are in the national capital region of Kyiv, as well as the eastern oblasts of Kharkiv, Zaporizhia, and Dnipropetrovsk. The number of unregistered IDPs, and thus the total number of persons displaced, is unknown (IDMC, 2017). The Donbass is largely under separatist control, and, given ongoing violence, it remains unclear when the conflict will end (The Economist, 2018). This means increasing numbers of newly displaced persons, no safe prospects for return, and protracted displacement for IDPs displaced earlier in the conflict.

The psychological and psychosocial problems of Ukrainians affected by the conflict are not well understood. Most of what is known comes from a limited number of recent epidemiologic studies. In a cross-sectional survey of approximately 2,200 Ukrainian IDPs over age 18, Makhashvili et al. (2017) and Roberts et al. (2017) estimated the 1-year prevalence of post-traumatic stress disorder (PTSD) to be 32%, depression—22%, and anxiety— 17%. Comorbidities among these problems were common. Analyses of the same survey data suggested IDPs were at increased risk of somatic distress, which was associated with increased functional disability (Cheung et al., 2019). In a screening study of 360 recently displaced persons in the Donbass, Korostiy (2016) found elevated prevalence of acute stress reactions (76%), anxiety disorders (13%), and PTSD (9%). The same study assessed IDPs seeking inpatient and outpatient psychiatric care at a major hospital and found a high frequency of anxiety disorders (33%), depression (53%), and PTSD (24%), although the sampling strategy was not described, and it is not clear if these patients were different from those in the larger assessment. National clinical data from psychiatric facilities were not available.

These findings align with other studies showing elevated psychological problems among conflict-affected populations globally (Porter & Haslam, 2005; Steel et al., 2009). One of the few epidemiologic studies of conflict-affected populations in the region was conducted by Roberts et al. (2014), who conducted survey research with Georgian IDPs displaced in the 1990s and 2008. These findings are useful to consider given the two countries’ geographic proximity and similar experiences of conflict. In one study report, Comellas et al. (2015) found that PTSD, depression, and anxiety were common among a sample of 3,600 IDPs. In the same sample, Roberts et al. found high rates of both hazardous and heavy episodic alcohol use, but only among men. The authors identified barriers to accessing care (Chikovani et al., 2015) and poor coping behaviors, including denial and substance use (Saxon et al., 2017). Qualitative research with IDPs in Georgia (Singh et al., 2018) found that older adult IDPs experienced anxiety-like and depression-like syndromes, as well as psychosocial problems, including family conflicts and difficulty integrating.

To address the mental health and psychosocial support (MHPSS) needs of conflict-affected groups in Ukraine, we conducted a large clinical training and intervention study, the first phase of which was a qualitative investigation. This article reports findings from this qualitative study. Specifically, we aimed to: (1) identify major MHPSS problems affecting IDPs and military veterans of the ATO; (2) identify commonalities and differences in the experiences of IDPs and veterans; (3) describe key elements of healthy functioning in the local context. We highlight psychological problems affecting IDPs and military veterans that are related to clinical forms of mental illness, including symptomology, perceived causes, and impacts. These problems were assessed in a subsequent instrument validation study (Doty et al., 2018) and targeted by the selected intervention (Murray, Haroz, et al., 2018).

Methods

Project Background

The larger study was a multi-year and multi-site project designed to implement and test a community-based, transdiagnostic psychotherapy approach called the Common Elements Treatment Approach (CETA; Murray et al., 2014) in the Ukrainian context. CETA has been shown to be effective in other low- and middle-income country settings, including in Iraq (Weiss et al., 2015), Thailand (Bolton, Lee, et al., 2014), Zambia (Murray et al., 2020), Colombia (Bonilla-Escobar et al., 2018), and Ethiopia (Murray, Hall, et al., 2018), however, prior to this project, it had not been used in the former Soviet Union region. The project addressed priority MHPSS problems among IDPs, veterans, and their families. This study followed the DIME (Dissemination, Implementation, Monitoring, and Evaluation) process (Applied Mental Health Research Group, 2013; Bolton, Bass, et al., 2014; Bolton, Lee, et al., 2014; Weiss et al., 2015), the first stage of which is a qualitative phase intended to understand local needs and inform selection and adaptation of assessments and interventions suited for the local context. A qualitative approach is useful for uncovering local patterns of functioning and adaptation and for describing context- and group-specific mental health symptomology and terminology. Qualitative methods also allow for assessments of local attitudes toward formal services. The qualitative phase took place in 2016. Findings were used to develop study measures, as well as to inform intervention selection, adaptation, and implementation.

Field Team

Field activities were implemented by a local research partner, the state-run National University of Kyiv—Mohyla Academy (KMA). We also partnered with regional state universities: Zaporizhia National University and Classic Private University and Kharkiv University. The field team was led by core study staff and included a study coordinator and two senior field supervisors from KMA, as well as a field supervisor from each of the regional institutions. Graduate students were recruited from each institution to serve as interviewers and coders. A total of five supervisors and 22 data collectors (12 from Zaporizhia and 10 from Kharkiv) were trained, for a total of 27 field staff. The training materials and curriculum were primarily designed by the Johns Hopkins Bloomberg School of Public Health (JHSPH) team, with adaptations made by the KMA team. Training took place during a 2-week data collection trip in each site and combined didactic and interactive techniques to address research ethics, qualitative methods, interviewing skills, and data coding procedures. Training was provided in Russian and English with consecutive oral translation.

Ethical Approval and Informed Consent Process

All procedures were approved by the Institutional Review Board of Johns Hopkins Bloomberg School of Public Health, Protocol #6764, for the study, “Enhancing Torture Survivor Mental Health Services: A qualitative study of mental health and psychosocial problems among IDP and veteran families in east Ukraine.” Oral informed consent from adult respondents, and oral assent and parental permission from youth respondents and their parents, was received before data collection.

Study Population

The qualitative study was conducted with adult and youth IDPs, demobilized soldiers (including former volunteer fighters) in the ATO and their family members (spouses and children), as well as psychosocial service providers working with these groups. This article reports findings from adult respondents; youth data are presented in a forthcoming manuscript. All respondents were living in Zaporizhia and Kharkiv oblasts in Eastern Ukraine at the time of fieldwork. Zaporizhia and Kharkiv were selected as sites for the qualitative study given their proximity, respectively, to Donetsk and Luhansk oblasts, both of which are within the Non-Government Controlled Area (NGCA) and contain significant numbers of IDPs and demobilized soldiers. Initial site visits and stakeholder consultations suggested that there were comparatively fewer MHPSS services available for IDPs and veterans in Zaporizhia, and thus significant levels of need, and comparatively more MHPSS programs and service capacity in Kharkiv. This provided an opportunity to compare perceptions of MHPSS services across different levels of availability.

Sampling Strategy

The sample strategy employed two purposive sampling approaches: maximum variation sampling and chain sampling. Maximum variation sampling (Patton, 1990) was used to ensure coverage of: IDPs, veterans, veterans’ family members; adult and youth respondents; different residence types for IDPs; and geographic spread. Youth sampled were restricted to 8–17 years for free-listing interviews (FLs) and 12–17 years for key informant interviews (KIIs). Different residences for IDPs included settlements or transit shelters for IDPs, as well as private accommodation. Geographic spread included the urban areas of Zaporizhia City and Melitopol, as well as the smaller town of Volnyansk outside of Zaporizhia City. In Kharkiv, respondents were recruited from Kharkiv City and the smaller town of Chuguiv. A chain sampling approach was also used, where community stakeholders and FL respondents identified potential other respondents. In each study region, we aimed to sample approximately 60 FL respondents, 30 KIIs, and 20–30 FGD respondents. These sample size ranges were based on qualitative research conventions regarding saturation (Sandelowski, 1995), a point after which common themes and information from local respondents tend to converge, specifically the guideline of at least 30–60 respondents with semi-structured approaches (Morse, 2000).

Qualitative Methodology

This study utilized the qualitative methods of FLs, KIIs, and FGDs. This methodology (JHSPH Applied Mental Health Research Group, 2013) has been employed by the project team in other sites to describe community perceptions of problems, and to identify terminology used to describe mental health and psychosocial problems. A rapid approach to coding was used to facilitate the adaptation of symptom and functioning measurement instruments (see Doty et al., 2018) and intervention design (Murray, Haroz, et al., 2018).

Free Listing Interviews.

We used FLs to identify salient problems, experiences, and behaviors that could be further investigated through KIIs and addressed with a community-based intervention. FLs produce brief textual responses, which are conducive to rapid coding and analysis in the field. Questions were the same for both IDPs and veterans but were worded differently for adults and youths (See Table 1). Initial questions asked generally about problems to elicit a wide range of responses. Additional questions asked about respondents’ self-care and care-giving behaviors to identify local conceptions of healthy functioning. A final question asked respondents about desired characteristics of mental health services and providers (reported in Haroz et al., 2019).

Table 1.

Free Listing Interview Questions

Adult Free Listing Interview Questions

1. What are all of the problems facing (IDP/Veteran) adults?

2. What are all of the problems facing families of (IDPs/Veterans)?

3. What are all of the problems facing children of (IDPs/Veterans)?

4. Please list all of the activities that (IDPs/Veterans) perform to care for themselves

5. Please list all of the activities that (IDPs/Veterans) perform to care for their families

6. Please list all characteristics of a mental health service that people in your community would choose to go to if they needed help

Youth Free Listing Interview Questions

1. What are all of the problems facing IDP/Veteran youth?

2. What are all of the problems facing the families of IDP/Veteran youth?

3. Please describe a child who is doing well. How does such a child behave? What do they do? Please list all the behaviors and activities you can think of for such a child

Key Informant Interviews.

FLs were followed up by KIIs and FGDs to explore emergent priority topics in more depth. The top FL responses related to psychosocial or mental health experiences were selected as topics for the KIIs (see Table 2). We selected these priority MHPSS topics based on the following criteria: They were mentioned at least four times, they could be targeted with a feasible and community-based clinical intervention program, and they were new problems for the study team that required further investigation. Key informants (KIs) were community providers or administrators primarily serving veterans or IDPs, and accordingly, were asked about problems named by veterans or IDPs. KIs were asked to provide more information on each selected problem by describing: (a) symptoms and signs; (b) perceived causes; (c) coping behaviors or treatments; (d) services available or actions taken to address the problem. KIs who provided mental health and psychosocial services were also asked about their experiences working in that sphere.

Table 2.

Free Listing Interview Mental Health and Psychosocial Support (MHPSS) Problem Categories^* Facing Adults and Explored in KII Interviews (Presented in Descending Order of Frequency)

IDPs		Veterans
	Zaporizhia
Difficulties in adapting		Conflict with family
The community doesn’t accept us		Problems with alcohol
Conflicts within the family		The psyche of veterans has changed
Missing home		People don’t understand veterans and/or are against them
Damaged psyche
	Kharkiv
Psychological problems/Fear		Relationships in the family: with wives and with children/Lack of understanding in the family
Bad relationship with Kharkiv residents		Aggression
Conflicts in school among children		Alcohol and drugs
Difficulties adapting to a new place		Nervous system is damaged

Note.

^*Problem categories are summaries of respondents’ listed problems that are grounded in respondents’ words.

Focus Group Discussions.

Continuing with this inductive, iterative approach, FGDs were separately conducted with IDPs, veterans, and service providers working with IDPs or veterans. From the free listing data, we selected functioning behaviors and desired characteristics of mental health services that were frequently mentioned or about which we sought additional information. Behaviors and characteristics named by either IDPs or veterans were separately presented to members of either group or to providers working primarily with either group. FGDs were primarily used to confirm findings from FLs and KIIs, and thus, FGD content is not presented separately here. FGDs were also utilized to gather feedback on vignette descriptions of mental health services. These vignettes were developed for use in the next stages of the overall project (see Haroz et al., 2019, for a discussion of the vignette development process and presentation of FGD data).

Recruitment

Respondents were primarily accessed through a network of service providers serving target communities in each site. Community stakeholders acted as gatekeepers and seeds for the chain sampling approach. These stakeholders included staff from local community-based organizations (CBOs) providing MHPSS services to IDPs and veterans, international organizations providing humanitarian assistance to IDPs, grassroots veterans’ associations, and independent practitioners such as a lawyer serving veterans or a psychologist volunteering for a non-profit organization.

In Zaporizhia, respondents were recruited from three sites: Zaporizhia City, Melitopol, and Volnyansk. Zaporizhia City is the largest city in the oblast population-wise and houses the largest number of IDPs in the oblast as well. Melitopol is a smaller city an hour south of Zaporizhia City and also contains large numbers of IDPs and veterans. Both cities have MHPSS or social services available for these two groups, and Melitopol in particular contained several veterans’ associations. Volnyansk, a small town outside of Zaporizhia City, was selected to balance out these larger urban centers, allowing for recruitment of IDPs from a peri-urban environment. IDPs were recruited from three settlements, including two that were run by the state and one that was privately run by a religious organization. In Kharkiv, respondents were recruited from two sites: Kharkiv City and Chuguiv, a modular town designed for shelter of IDPs and located outside of the city, allowing for recruitment of IDPs from a peri-urban environment.

Data Collection Procedures

Recruitment took place by phone using an approved script. Oral consent or assent was received in person prior to commencing interviews. Data collection was carried out by pairs of interviewers, where one interviewer led the interview and the other took hand-written notes using data collection forms and paper notebooks. Interviewers were instructed to record respondents’ responses verbatim and not to summarize, paraphrase, or translate responses. Interviewers switched roles with each respondent. No audio recordings were made given the sensitive nature of the study topic and population, and since the analysis methods did not require full transcripts. Interviews lasted around 45 min to 1.5 hr, and FGDs lasted from 1 to 2 hr. Data collection was conducted in Russian or Ukrainian, depending on respondents’ stated preference. Interviews were translated by a local translation company, and translations were reviewed by the local lead.

Data Analysis

Blank data matrices for coding were developed in Microsoft Excel with separate worksheets created for each FL or KII question. Data were extracted by segment, with each selected phrase corresponding to an individual problem (this might be a symptom, behavior, characteristic, or other descriptive factor). KII interview data were additionally sorted by problem description, perceived causes/effects, and coping behaviors. Coding involved assigning domain names or themes to interview text and running frequencies for each code. The coding process emphasized using or adapting words and phrases from interview data to better capture respondents’ vernacular. For example, during the FLs, interviewers were instructed to record respondents’ listing of problems verbatim, as well as to record respondents’ brief descriptions of each problem verbatim. During the coding, verbatim listings of problems were inductively grouped into categories of problems by the field team using category labels that integrated respondents’ wording wherever possible. Field interviewer pairs carried out these steps on their own FL and KII interviews immediately after data collection.

Data matrices completed by field interviewer pairs were compiled and integrated into master data matrices by senior members of the field team; these were then sent for translation into English and reviewed by the larger team. Data were initially reviewed to identify interview topics for KIIs and FGDs. Matrices were reviewed again after fieldwork to adapt the project’s treatment manual and assessment instruments. Subsequent integrative analyses involved compiling frequency tables and systematically reviewing frequency tables and data matrices to draw connections and make comparisons across study populations and experiences.

Dependability and trustworthiness (Creswell, 2007; Maxwell, 2013) were established through several measures, including: triangulation, peer review, expert analysis, member checking, debriefing, and audit trials. Triangulation of findings across sites and data collection methods strengthened data integrity. Initial rapid analyses of data took place in the field by data collectors based in each site—this helped ensure that local terminology was interpreted accurately. Data were also reviewed by local experts on the team, as well as core study staff, so that a range of perspectives were drawn on during analysis. A form of member checking took place through the iterative design of data collection so that with each step, respondents had the opportunity to respond to earlier findings. Finally, data collectors were carefully debriefed after data collection, and steps taken were documented in study files.

Results

Demographic Profile of Respondents

The study sample included 227 participants, including 123 FL respondents, 57 KIs, and 47 FGD respondents, across both sites. The sub-sample from Zaporizhia contained more IDPs than veterans due to difficulties with accessing the veteran population through service networks, our primary source for the chain sampling approach. Consequently, we targeted recruitment in the veteran community in Kharkiv and sampled more veterans than IDPs to balance the overall sample (See Table 3).

Table 3.

Demographic Profile of Respondents (Adults and Youth)

Category	Sample size	IDPs/Providers serving IDPs	Veterans/Providers serving Veterans
Free list participants	n = 123	n = 31 adults, 11 youth in Zaporizhia n = 21 adults, 9 youth in Kharkiv	n = 17 adults, 0 youth in Zaporizhia n = 32 adults, 2 youth in Kharkiv
Key informant participants	n = 57	n = 13 serving IDPs in Zaporizhia n = 19 serving IDPs in Kharkiv	n = 15 serving veterans in Zaporizhia n = 10 serving veterans in Zaporizhia
Focus group discussion participants	n = 47	n = 6 women, 6 men, 4 service providers in Zaporizhia n = 6 men, 5 women, 5 service providers in Kharkiv	n = 3 men, 4 service providers in Zaporizhia n = 8 service providers in Kharkiv
Total sample size	N = 227	n = 136	n = 91

The Zaporizhia sample of FL respondents was majority female, while the Kharkiv sample was majority male. This was due both to larger numbers of veterans recruited in Kharkiv, as well as to an attempt to recruit more IDP men in Kharkiv, given lower numbers of IDP men in Zaporizhia. In both sites, we had no female veterans and few veterans’ wives. Overall, our sample had fewer veteran and IDP youth compared to adults. We had no youth KIs in the sample as none were identified by respondents (See Table 4).

Table 4.

Free List Interview Respondents

Characteristics	Zaporizhia	Kharkiv
Sample size	n = 59	n = 64
Age range (Years)	8–77	9–58
Female (%)	63%	36.5%
Male (%)	37%	63.5%
IDP status (%)	72%	48%
Veteran status (%)	28%	52%
Marital status (%)
Unmarried	8.3%	22%
Married	50%	49%
Divorced	13%	6.4%
Widowed	8.3%	0%
Other	1.7%	4.8%
N/A (Youth)	18%	17%

In Zaporizhia, 28 KIs were interviewed. KIs included: psychologists, social workers, volunteers working with veterans, lawyers, office managers, administrators, state employees, and priests. They worked with a range of community organizations providing services and support to IDPs and/or veterans. In Kharkiv, 29 KIs were interviewed. KIs included: social workers, volunteers working with veterans, office managers, administrators, lawyers, and a sports club director. They also worked with community organizations serving IDPs and/or veterans. We did not collect data on age, gender, or marital status of KIs as their primary role was to report on selected MHPSS problems, not to describe experiences of a personal nature.

In both sites, five FGDs were carried out with: female IDPs, male IDPs, male veterans, providers mainly working with IDPs (e.g., a priest, social worker, manager of an IDP settlement, psychologist, teacher), and providers mainly working with veterans (e.g., a priest, social worker, volunteer, counselor). In Zaporizhia, a total of 23 respondents were interviewed in FGDs, and in Kharkiv, 24 respondents were interviewed. Once again, personal demographic data were not collected on FGD respondents.

Top Problem Categories

In response to Question 1 of the FL, which asked about problems faced by the respondent’s community, the most frequently mentioned problem category for IDPs in both oblasts had to do with economic or financial well-being. In Zaporizhia, the most frequently mentioned problem category had to do with difficulties finding employment, whereas the most frequently mentioned problem category for IDPs in Kharkiv had to do with a lack of housing. In both sites, problems with acceptance from, or interaction with, local residents was also in the top five most frequently mentioned categories. Other problem categories related to social integration and IDP status included difficulties with adapting, inability to return home, and experiencing humanitarian aid or services as humiliation. Psychosocial problems that were mentioned including conflicts in the family, damaged psyche, fear of the future, loneliness/lack of communication, and feeling loss. Each of these psychosocial problems was linked to experiences with living in displacement (See Table 5).

Table 5.

Top Problems^* That IDP Adults Face, Listed by IDP Adults (# Refers to Number of Listings, or Mentions, of the Given Problem)

Zaporizhia		Kharkiv
Problem category	#	Problem category	#
Difficult to find a job	24	Lack of housing	19
There is no help	20	No work	15
The community doesn’t accept us	15	No money	14
It is difficult to adapt	14	Obtaining certificates	13
No finances	12	Bad attitude of Kharkiv residents	12
They don’t give housing for rent	11	Difficulties with benefits	9
Well-being is at zero level	10	Psychological problems/Fear	7
Conflicts in family	5	Difficult to adapt	6
Damaged psyche	5	It is hard to go home	4
Fear of the future	5
Loneliness, lack of communication	5
Feeling of loss	4
Help as humiliation	4
Missing home	9

Note.

^*Problems considered “top problems” are those with at least four listings by respondents. Problem categories are summaries of respondents’ listed problems that are grounded in respondents’ words.

The top problem categories for veterans in both sites had to do with feeling misunderstood or betrayed by the public and government, as well as financial problems such as difficulties finding employment or accessing subsidized property. Other top problems also had to do with feelings of being misunderstood or underrecognized, such as not being respected on public transport. Difficulties with re-integration or adjustment to civilian life extended to the household domain, as respondents also listed changed relationships in the family and a lack of understanding by the family. Psychosocial problems that veterans listed included problems with alcohol and drugs, nervous system disorders, dreams, irritability or aggression, and apathy (See Table 6).

Table 6.

Top Problems^* That Veteran Adults Face, Listed by Veteran Adults (# Refers to Number of Listings, or Mentions, of the Given Problem)

Zaporizhia		Kharkiv
Problem category	#	Problem category	#
Betrayal by the government	14	Public misunderstanding/Low public support	18
Promised land is not given	8	Difficulties in finding employment	18
Many conflict situations in transport	7	Difficulties with adaptation	14
Negative attitude	7	The state doesn’ t support [us]	13
They [other people] understand us in a wrong way	7	Disorders of the nervous system	13
Employers are unfair	7	Irritability/Aggression	12
Legal issues	6	Alcohol and Drugs	12
Not enough money	5	Difficulties with benefits/Getting official status of veteran	10
Bad medical treatment	4	Changed relationship with wife/Lack of understanding in the family	9
Adapting to the new life	4	Dreams	9
Problems with alcohol	4	Diseases	8
		No money	7
		Increased sense of justice	7
		Changed priorities in life	4
		Apathy	4

Note.

^*Problems considered “top problems” are those with at least four listings by respondents. Problem categories are summaries of respondents’ listed problems that are grounded in respondents’ words.

Priority Mental Health and Psychosocial Categories (Aims 1 and 2).

Below, we present the top-listed MHPSS problems among IDP and veteran adults in either study site. This article is specifically concerned with presentations of problems related to mental health, as these were targeted by a subsequent measurement validation study (Doty et al., 2018) and the trial of the clinical intervention (CETA; Murray, Haroz, et al., 2018). Therefore, we also present a summary of KIs’ descriptions of such psychological problems, with focus given to perceived causes and impacts. The problem categories and functioning behaviors presented below are summaries of respondents’ listed problems/responses generated by the field team and often integrate respondents’ own words and phrasing. What is presented in quotation marks are verbatim statements from respondents. In some cases, respondents from different groups identified similar problems, for example, struggles with employment or family conflict, however, the problem category labels use different wording. This is because the problem categories were inductively derived summaries of respondents’ own words. Wherever possible, the field/data analysis team was instructed to integrate respondents’ wording so that category labels were grounded in each group’s vernacular. This was important for the later instrument and intervention adaptation processes where intervention components were tailored to meet different groups’ needs.

IDPs in Zaporizhia.

Zaporizhia IDPs largely named social problems that had to do with relating to host communities and struggling with social adaptation and feeling accepted. That is, IDPs described obstacles with both directions of relational interaction—outward connection to new communities and places, as well as reception from others. IDPs in Zaporizhia also described challenges getting along with their families. In other words, difficulties with social relationships not only had to do with integrating into new environments but also reflected other emotional impacts of exposure to conflict and the displacement process (See Table 7).

Table 7.

Psychosocial Problems^* Facing IDP Adults & Their Families, Listed by IDP Adults in Zaporizhia (# Refers to Number of Listings, or Mentions, of the Given Problem)

Problem category	Examples from interviews*	#
Difficulties in adapting	“For many people it appeared stressful to find self-realization. The person rolls down the career ladder. Nervous breakdowns. New place, new social problems.   Looking for doctors, clubs, social connections. No stability, possible need to leave this place.” “Absence of own corner is stressful, our home is not where we are rooted, but where we are safe, stable living conditions, that will not turn over tomorrow, work and housing.”	27
The community doesn’t accept us	“There is a wall around us, people forget about us, it’s very hard psychologically, hopelessness.” “Neighbors look askance. We feel whispering.”	23
Conflicts within the family	“Conflicts with parents, children don’t understand, start yelling, we don’t hear and don’t see each other, adults are nervous.”	17
Damaged psyche	“You don’t understand what is happening, there is endless depression.” “Conflicts happen, psyche is unstable. The son was killed at the age of 26 (before the war)—can’t sleep because of it.”	5
Missing home	“It appeared to be the most difficult. Isolation from home, a sense of detachment. Uselessness, the broken links. It is a big problem. After 1–2 years longing is not the same. There’s all that I have amassed there. For many people it is in the first place [a top priority].” “All want to return to their walls, where the house is. In the house I am my own boss, many people think so. You will not do what you don’t want to do. Under the supervision of the prison camp.”	4

Note.

^*Problems considered “top problems” are those with at least four listings by respondents. Problem categories are summaries of respondents’ listed problems that are grounded in respondents’ words. What is presented in quotation marks are verbatim statements from respondents.

Damaged Psyche.

This category included a range of symptoms and behaviors that IDPs described as resulting from traumatic events and as having a negative impact on their psychological well-being. IDPs described several behavioral problems, such as enuresis, sleep disturbances, tics, and eating disorders. One IDP described the connection among depression, anger, and conflict-seeking or avoidance: “People are racing at each other, very conflicting, everyone with their ‘cockroaches in their heads.’ Depression and anger, anger at all. They avoid each other. Everyone needs a psychologist, everyone, even if they say that they do not need it.” KIs described damaged psyche in terms more related to PTSD: “The effects of stressful experiences, unhealed wounds that can last for years”; “Not often, but sometimes—PTSD.” Depressive and anxiety symptoms were identified as having resulted from losing homes, close relatives, social environments, and from uncertainty about the future: “You don’t understand what is happening, there is endless depression.”

IDPs in Kharkiv.

Kharkiv IDPs similarly focused on psychosocial problems related to adapting to their host communities. IDPs in Kharkiv specifically pointed to negative social interactions within these new environments. This included negative encounters with local residents and being perceived as separatists. These dynamics influenced both local and IDP children, and conflicts in school was another feature of tension between IDPs and local Kharkiv residents (See Table 8).

Table 8.

Psychosocial Problems^* Facing IDP Adults & Their Families, Listed by IDP Adults in Kharkiv (# Refers to Number of Listings, or Mentions, of the Given Problem)

Problem category	Examples from interviews*	#
Bad relationship with Kharkiv residents	“Neighbors saw Lugansk numbers, called the police, searched the car, the house—attitude, as to the separatists.” “We do not mix up with separatists.”	12
Conflicts in school among children	“At school may be a mockery of a child from Lugansk, for example: “Separatists! It’s your fault.” “Can snub the child for the fact that he separatist.”	11
Difficulties adapting to a new place	“Difficult to adapt, all thoughts are there, do not see perspectives here, between two worlds, no taste of life.” “Difficult in a strange city. Nothing was taken, came from the ground. There is an anxiety—do not know what to expect.”	9
Fear	“General injury of people who have served. Many of them are going crazy. The death of friends.” “Fears: under the bombs, in the cellar, beat in the city—horror, everyone shakes. React to the noise. The mind is disturbed, the problems with the head.”	9

Note.

^*Problems considered “top problems” are those with at least four listings by respondents. Problem categories are summaries of respondents’ listed problems that are grounded in respondents’ words. What is presented in quotation marks are verbatim statements from respondents.

Fear.

IDPs also identified feeling fear as a significant problem. KIs highlighted two major reasons for experiences of fear among IDPs: Traumatic experiences and feeling uncertain about the future. One KI explained: “The fear that the war will come here, and that we are close to the conflict zone. Because of the experience that [IDPs] survived, they are afraid of falling back into a similar situation of losing everything. Posttraumatic symptoms—after a loud noise.” Other KIs described the lack of stability that IDPs experience after displacement: “I had to break out of a stable life. I do not know what will happen next. Fear of a new life, of all new.” These feelings of fear were described as contributing to a range of other psychological problems:

• Psychosomatic problems: “A lot of serious diseases, that they didn’t have. Psychosomatics, up to enuresis including with children”;

• Panic attacks: “They [IDPs] are afraid of going out, that someone can die or fall ill. Fear of everything”;

• Depression: “People become extremely anxious and depressed”;

• Problems with functioning: “The fear of turning to organizations. Don’t apply for the job. If you work here, you’ll not come back.”

• Fear and uncertainty were also said to lead to family conflict and negatively impact children’s well-being: “The psyche of the child suffers. The child is constantly [returning to bad memories and fears from the past] due to conversations within the family and the excitement [emotions and fear] of parents.”

Veterans in Zaporizhia.

Similar to IDPs, veterans in Zaporizhia identified challenges in interacting both with local residents and with their families. In both cases, veterans described incidents of conflict or tension, as well as feeling generally misunderstood or attacked. In terms of family relationships, veterans felt that their family members, particularly spouses, could not relate to or understand their combat experiences, and thus did not know how to interact with or support them. When it came to interactions with community members, however, veterans described a greater sense of antagonism and feeling of being blamed for the conflict (See Table 9).

Table 9.

Psychosocial Problems^* Facing Veterans & Their Families, Listed by Veterans in Zaporizhia (# Refers to Number of Listings, or Mentions, of the Given Problem)

Problem category	Examples from interviews*	#
People don’t understand veterans/People are against them	“A minibus driver said rudely: “We didn’t send you there.” “People tried to humiliate my friend, but he reacted well, rebuffed back. Many look as if we were persecutors.”	23
Conflict with family	“Problems in family. Because they [veterans] went to the front voluntarily … It is difficult to overcome for wives. No connection. [Wives say:] “If you go there again–I’ll divorce you.”” “Families don’t understand what veterans did and what was happening.”	10
Problems with alcohol	“Alcoholism here and there. A lot of beer every day is needed.” “They think nobody understands them, and they try to drown it all with alcohol.”	10
The psyche of veterans has changed	“Obsessed with war, all thoughts are about it. [Conflicts] grow in relation to the family. Every day I have memories, we don’t talk about today, all the talks are about the past.” “Tendency for suicide; fear of death disappears; many use alcohol.” “Manifestation of past events both witnessed and experienced. The boys start binge drinking, the psyche is exploded. Nightmares. When you restrain the lump in your throat, it becomes easier. Psychologically easier.”	8

Note.

^*Problems considered “top problems” are those with at least four listings by respondents. Problem categories are summaries of respondents’ listed problems that are grounded in respondents’ words. What is presented in quotation marks are verbatim statements from respondents.

Problems with Alcohol.

KIs described various reasons for substance use and problems with alcohol among veterans. Some veterans were alcohol dependent before the war and experiences in the war worsened dependence: “If there was a tendency for alcohol before the war, the military situation was only exacerbated.” Others began using substances to cope with traumatic memories: “They are trying to stifle the memories about the war.” Or, substances were used as an attempt to resolve social conflicts and rid themselves of feelings of isolation: “They think nobody understands them, and they try to drown it all with alcohol.” Such behaviors led to substance abuse and dependence among veterans and worsened existing psychological problems: “Those who use alcohol get crazier.”

Substance use was described as negatively influencing all aspects of social life. This included family life, where “families break up, because [his] wife was not used to seeing him in this state,” and other social relationships. As one respondent explained, addiction leads to the “destruction of the individual, [who] cannot find himself in society.” Substance use was also described as leading to poor mental health outcomes, including: “hopelessness, frustration, confusion, and inability to find a way.” When discussing how veterans took care of this problem, they explained that: “Veterans do not realize that they abuse alcohol, so they don’t address [this problem].” Even if veterans seek treatment, it is very difficult to find appropriate, acceptable, and effective services: “There is a small number of centers for ATO fighters who have problems with alcohol”; “No centers, sanatoriums where people can be treated with the whole family. Alcoholism is a complex problem.”

The Psyche of Veterans Has Changed.

Many veterans felt different after returning home, including being preoccupied about the war: “Obsessed with war, all thoughts are about it. Snowball in relations in the family. Every day I have memories, we don’t talk about today, all the talks are about the past.” Veterans described experiencing “nightmares,” “[having a] tendency to suicide,” “pain in the soul,” “[inability to] sleep anymore.” When asked about changed psyches of veterans, KIs described this as: “aggressiveness,” “becoming more irritable,” “heightened sense of [desire for] justice,” and ‘’emotional dullness, absence of emotions.” The main cause of these symptoms was identified as war trauma: “It’s psychologically traumatic to see people who have been killed; the realization of yourself being at the front line, where people die, greatly affects the psyche.” The negative effects of mental health problems were described as causing increased social conflict.

Veterans in Kharkiv.

Veterans in Kharkiv described similar problems as veterans in Zaporizhia. However, “aggression” was a more salient problem among these respondents. Veterans in Kharkiv seemed to experience greater levels of tension after returning home than those in Zaporizhia. While veterans in Zaporizhia described difficulties with re-integration mostly linked to the government, veterans in Kharkiv described difficulties connected to social interactions with community residents and a perceived lack of understanding (See Table 10).

Table 10.

Psychosocial Problems^* Facing Veterans & Their Families, Listed by Veterans in Kharkiv (# Refers to Number of Listings, or Mentions, of the Given Problem)

Problem category	Examples from interviews*	#
Relationships in the family: With wives and with children/Lack of understanding in the family	“After returning I want to be alone–the wife does not understand, children need attention, but you want to be alone, to think. Frequent quarrels, the wife is difficult to understand that I want to be alone. She wants to communicate, and I need privacy.” “Man returns from the front as a different person. After these events the person cannot be the same.”	36
Aggression	“It is easier to kill a man than to sort out whether he is right or wrong. It doesn’t take long to make a decision, to solve their problems.” “These effects are residual. Switches. React in advance. Sometimes lose control. This switching is dangerous. Can cause specific harm to another person. There are many nervous guys. After returning from there, they have the impression that everyone owes them. Because of this, they rage. It hasn’t come to the grenade yet … ”	22
Alcohol and drugs	“Many people drink, but cannot cope with injuries” “Every day guys have a bottle of vodka. They cannot relax or relax permanently … ”	18
Lack of understanding in the community	“Public misunderstanding. People think that we were playing toys there. And there are different attitudes to the war in our city: People who are against veterans perceive us as punitive forces.” “Misunderstanding, constant psychological and social pressure, acts of aggression and accusation, saying that we are the reason of the war. ” “The feeling of being unwanted, offended, lonely. The feeling of being offended, because you are abandoned.”	18
Nervous system is damaged	“I know the incidents where people didn’t survive. Suicide at home after demobilization. Psyche didn’t stand, there were problems with family.” “I can’t relax. No relaxation. I cannot sleep until I have a shot.” “Post-war syndrome. Contusions, acts of aggression … ”	13

Note.

^*Problems considered “top problems” are those with at least four listings by respondents. Problem categories are summaries of respondents’ listed problems that are grounded in respondents’ words. What is presented in quotation marks are verbatim statements from respondents.

Alcohol and Drugs.

Patterns of alcohol use among veterans in Kharkiv were similar to those of their peers in Zaporizhia. KIs explained that many veterans were drinking before the war began and during it: “People who drank alcohol in the ATO zone continue to use [in] peaceful life.” After combat, veterans use alcohol to try to relieve stress: “They try so to cope with stress, but it only aggravates.” Alcohol use led to veterans behaving in more aggressive and passive ways. For the latter, alcohol use allowed for the avoidance of problems and a feeling of indifference to family, children, and work. Family life was particularly damaged by such behavior, as compared to other social spheres: “Scandals in the family. Children run away from home, his wife drove into the street, fighting, destruction of the family.” KIs also explained that Kharkiv veterans showed less interest in seeking professional help for alcohol problems: “Men do not recognize this problem and do not seek help.”

Nervous System is Damaged.

Many of the psychological symptoms that Kharkiv veterans experienced appeared to correspond to post-traumatic stress symptoms, for example: “Injuries impact on the psyche of man”; “Suicide at home after demobilization”; “Post-war syndrome.” Sleep disturbances were often mentioned: “Cannot fall asleep. No sleep but only nervousness”; “Wake up, trying to escape.”; “Bad sleep, conversations at night”; “Nightmares, insomnia, when he cannot get away from it, when he jumps up and fights in the dream.” Symptoms of intense fear, anxiety, reactivity, and aggression also negatively affected family stability and disrupted children’s well-being: “Children are afraid [of] their father’s reactions.”

Healthy Functioning Behaviors (Aim 3)

FL respondents were asked to describe activities they engage in to take care of themselves and their families. These activities approximate healthy functioning behaviors and contribute to an understanding of what healthy functioning means for IDPs and veterans in Ukraine. The tables below present the top (four or more listings) functioning behaviors mentioned in FLs. During FGDs, respondents were asked to reflect on these behaviors. IDPs in both sites named employment or earning money as the top activity they engage in to take care of themselves and their families. IDPs in Zaporizhia also named improvement of living conditions and learning to live in a new place as important for daily functioning. These behaviors included household chores such as cleaning and cooking and taking care of the physical appearance of living spaces: “Create coziness, a homey atmosphere. Family traditions, events, walks and homemade craftworks.” Both receiving and giving help were described as contributing to well-being. It was not only important to receive social support but to actively build and strengthen social connections and relationships. Given the dislocation of social networks that typically results from displacement, proactively engaging in social network building is adaptive (See Table 11).

Table 11.

Top Functioning Behaviors^* Among IDPs

Activities that IDPs do to take care of themselves		Activities that IDPs do to take care of their families
	Zaporizhia
Earn money		Looking for employment
Improvement of living conditions		Improvement of living conditions
Leisure activities		Receive help
Getting help		Leisure
Communication		Care of children
Care for others		Learning to live in a new place
Receive education		Support for each other
Sports
	Kharkiv
Working		Working
Training		Child development
Art
Visit humanitarian aid centers
Self-employment/Owning business

Note.

^*Behaviors/Activities are summaries grounded in respondents’ words.

As with IDPs, veterans in both Zaporizhia and Kharkiv named employment or earning money as the top activity they engage in to promote healthy functioning. This included registering for social benefits provided because of their military service. Although veterans in Kharkiv identified “getting help” as an important functioning behavior, for the most part, veterans in both sites identified social support mechanisms as helping and spending time with other veterans and their families. Veterans described helping “people like us,” in other words, other veterans, as well as their families, as well as spending time with veterans “like us” and with family. Other activities named had to do with re-integration, such as “establishing everyday life,” personal development and training, and leisure activities. Several veterans also identified consulting a psychologist as a healthy behavior: “Psychological therapy helped me to understand myself” (See Table 12).

Table 12.

Top Functioning Behaviors^* Among Veterans

Activities that veterans do to take care of themselves	Activities that veterans do to take care of their families
Zaporizhia
Earning money/Work	Earning money
Being socially active	Registering for social and living benefits
Helping people like us	Establishing everyday life
Being with people like us	Communicating with the family
Kharkiv
Working	Working
Getting help	Spending time with family and children
Helping each other [other veterans]/Establishing connections	Helping in the house
Sports	Getting benefits for the family
Social activity	Helping each other
Personal development/Training	Leisure time/Attending cultural events
Hobbies
Housework
Consulting a psychologist
Parenting

Note.

^*Behaviors/Activities are summaries grounded in respondents’ words.

Discussion

Research Implications

This article has presented qualitative data on mental health symptoms or other relational/social problems, as well as healthy functioning behaviors, among adult IDPs and military veterans of the ATO (anti-terrorist operations) living in two communities in eastern Ukraine. These data were collected to understand local experiences of mental health problems and function, inform the selection and adaptation of local measures, as well as to guide the modification, and implementation of a psychotherapy intervention that could support conflict-affected persons. Specifically, new survey items based on the problems and functioning behaviors identified in the qualitative study were integrated into the psychometric scales, functioning measures, and dissemination-and-implementation measure that make up the assessment instrument used in the broader study; these adapted measures were validated with conflict-affected communities in Ukraine (see Doty et al., 2018 and Haroz et al., 2019). Additionally, findings from the qualitative study were used to adapt and tailor the CETA psychotherapy intervention components to the specific needs and experiences of Ukrainian IDPs and veterans, which were the target populations for the intervention. This included prioritizing mental health problems and symptoms of distress identified in the qualitative study, as well as using preferred characteristics of mental health providers identified in the qualitative study to inform provider selection.

The design and implementation of the intervention study and trial are described in depth elsewhere (see Murray et al., 2011; Murray, Haroz, et al., 2018). Findings from the trial will be reported in a forthcoming article. Overall, the project has increased the availability of Ukrainian community-based mental health providers trained in cognitive-behavioral therapy methods. A cadre of CETA counselors, supervisors, and trainers now work in several regions of Ukraine in a range of clinical and community settings (for more, see http://www.ceta.org.ua/ and https://www.cetaglobal.org/).

The study’s first two aims were to (1) identify major MHPSS problems affecting IDPs and military veterans of the ATO and (2) identify commonalities and differences in the experiences of IDPs and veterans. Findings suggested that both IDPs and veterans experienced high levels of psychological stress symptoms, such as: depression, feeling isolated, anxiety, and intrusive memories. Overall, veterans appeared to be coping with anxiety, aggression, and PTSD-like symptoms caused by exposure to traumatic events during military activities. Alcohol use was also identified as a significant problem among former soldiers, although some may have experienced alcohol dependence before the ATO began. These findings contribute to the limited, but growing, body of evidence on high comorbidity of mental health problems, such as depression or anxiety, and substance use in low-and-middle-income countries (Kane et al., 2018). IDPs appeared to be coping with depressive symptoms due to losing homes and feeling uncertain about the future. These symptoms are likely related to difficulties with social integration into host communities and for some, could be manifestations of pre-existing mental illnesses, but seem less likely to reflect post-traumatic stress.

Although IDPs and veterans had unique experiences in the conflict and were exposed to very different traumas, they both identified struggles with social adaptation and integration. For both, feeling misunderstood and socially isolated were central experiences; while IDPs in particular described feeling mistrusted by local residents, veterans described feeling underappreciated or even under attack. This suggests how critical strong social connections and a sense of community support are in the recovery of groups affected by conflict (Hynie, 2018). Both groups, despite their differences, also experienced profound identity shifts and lifealtering experiences during displacement or combat. As such, they have also struggled with either readjusting to daily life in new communities or returning to homes and communities once familiar.

Findings also suggested differences in how relational conflict emerges among IDPs and veterans. Conflicts among IDPs were described as being rooted in poor living conditions, while conflict among veterans was connected to feeling misunderstood by the public or family members. Both groups described feeling that their rights were not well protected by the government. We theorize that such perceptions and experiences of alienation are likely to produce feelings of helplessness, as well as cause a shift in aggression onto real or imagined enemies within families and communities. Living in unpredictable circumstances and with ongoing armed conflict may draw individuals’ attention to external sources of conflict and threats. It is possible that the impulsivity and reactivity displayed by some veterans in response to conflict is due to psychological trauma experienced while serving or to learned and reinforced behaviors within the military that promote using physical force to resolve conflicts.

Both sets of respondents also experienced high levels of social conflict. Respondents described conflict within families and public spaces such as schools, workplaces, and public transportation. This suggests that exposure to armed conflict has psychosocial effects that are transferred onto other social spaces, leading to relational conflict. Societal and political conflict thus appears to correspond to aggression at relational, household, and community levels. Other empirical and conceptual research with conflict-affected groups has suggested that new social dynamics that emerge within or postdisplacement complicate the psychosocial and psychological effects of war exposure (Miller & Rasmussen, 2017; Silove et al., 2017). Therefore, the relational experiences and needs of conflict-affected groups should not be understood within the context of trauma exposures alone but should also account for the stressors and disruptions inherent in social adaptation trajectories.

The study’s third aim was to (3) describe key elements of healthy functioning in the local context. Both groups identified positive social interaction as supportive and an example of healthy functioning. Prosocial behavior and social support mechanisms are wellstudied protective factors (Durkheim, 1951; Kawachi & Berkman, 2001). Social support has also been found to mitigate the negative consequences of trauma (Pine & Cohen, 2002; Trickey et al., 2012) and of displacement and war exposure (Hartwig & Mason, 2016; Oppedal et al., 2018), as well as to aid in mental illness recovery (Mak et al., 2009). However, increased symptom intensity and contextual factors may limit individuals’ ability to access and engage with social networks. For example, respondents explained that leisure activities were difficult to engage in given disruptions in social networks after displacement or demobilization. IDPs also identified their temporary living conditions as limiting possibilities for social engagement. Veterans’ experiences of feeling misunderstood by both family and the larger community may help explain why they identified socializing with other veterans, specifically, as important. Psychosocial interventions must be designed with such barriers in mind so as to intentionally provide opportunities for social interaction and support, including via therapeutic settings.

Strengths and Limitations

Study conclusions are limited by the comparatively smaller sample sizes of veterans and men. We faced challenges in recruiting veterans, given limited entry into this population via service providers, compared to IDPs. It was also challenging to recruit male IDPs, in part because there were more women registered as IDPs than men, as men may migrate elsewhere or between the government and non-government-controlled areas for income generation. We used hand-written notes, as they allowed for more efficient processing of data and might have offset respondent concerns around recording sensitive discussions. However, this may have resulted in some lost or distorted data. It may have been challenging for some respondents to name stigmatized topics during the free-listing exercise. However, the KIIs provided an opportunity for more in-depth elicitation of sensitive topics.

This study was one of the first of its kind to qualitatively examine the psychosocial and psychological experiences of Ukrainians directly affected by conflict in east Ukraine. Data were collected from both IDPs and veterans in two sites, allowing for wider exploration into the experiences and needs of conflict-affected groups in Ukraine. The use of multiple qualitative methods provided triangulation of findings. Further, collecting data on both psychological and social problems allowed for better contextualization of mental health problems and adaptation of the intervention to the local context. Findings are likely to be applicable to other IDPs and veterans of the ATO in Ukraine and may also shed light on the experiences of other IDP and veteran populations. As this was exploratory research, similar studies are needed to understand the mental health needs of conflict-affected Ukrainians more comprehensively and to determine the transferability of these findings across settings. The findings have broad implications for improving our understanding of how violent conflict affects psychological and psychosocial health, particularly in the study region.

Prevention and Policy Implications

Based on our findings, we make the following recommendations for programming serving conflict-affected persons in Ukraine. We recognize that some of these efforts are already underway.

Mental Health and Psychosocial Services for Affected Communities.

We recommend that concrete program inputs be developed that facilitate social (re) integration, including recreational events and activities that support social network building and help engage more people affected by the conflict into mental health services. Given respondents’ experiences with social integration and adaptation, we recommend developing programs or community events that promote greater awareness, interaction, and understanding, among the general public, ATO veterans, and IDPs. It is also important that decision-makers understand the needs and experiences of conflict-affected communities. We suggest program funds be used to create or support opportunities where IDPs and veterans can share their priorities and feedback to policy-makers, media, advocates, and service providers. More comprehensive community outreach materials and campaigns that increase community mental health literacy and promote helpseeking behaviors should also be developed. We also suggest establishing programs to support women and children living in situations of domestic violence, as well as more appropriate and accessible community-based rehabilitation programs for alcohol and drug addiction with behavioral components.

Training for Psychosocial Providers.

Both IDPs and veterans described experiences with, and concerns over, feeling blamed or misunderstood by psychosocial providers themselves. Therefore, we recommend implementing awareness and sensitivity trainings for service providers to avoid stigmatization or re-traumatization. Stronger supervision and quality assurance mechanisms and initiatives should be put in place. This helps address clients’ expressed need for higher professionalism and qualification of mental health providers. Social workers and psychologists, or others, who have been serving conflict-affected groups and who themselves may have been directly impacted by the conflict should also be supported with services and education to decrease burn-out or secondary traumatization.

Media Campaigns.

In addition to the program inputs recommended above, we suggest that public media campaigns be used to better promote collective understanding and recovery. For example, an informational campaign for the broader Ukrainian community might be developed that could: Highlight veterans’ and IDPs’ experiences; explain challenges these groups face as well as their social behaviors; emphasize the value of dialogue; and promote increased social support. It is also critical that media training programs be provided to state representatives and journalists on how to talk about veterans’ and IDPs’ psychosocial needs. Similarly, brief trainings for others who regularly interact with or provide services to affected groups, such as volunteer staff in IDP settlements or public transportation workers, might be considered.

Financial Support.

We recognize the ever-expanding demands of international donors to assist emerging humanitarian crises. To more effectively achieve collective recovery, rehabilitation, and stability, we urge international donors to continue financial support of MHPSS programs to ensure ongoing availability of these programs. We also recommend funding programs that promote local capacity building and training of local providers to better achieve sustainability of results. Subsidy programs to support IDPs and veterans accessing mental health services should continue. The financial problems of IDPs and veterans are significant, and most cannot pay for mental health services; it is unlikely that this situation will change in the near future. A more coherent and coordinated approach is needed to link various international training schemes that have been implemented in Ukraine in the area of MHPSS. Finally, validated symptom and functioning measures should be disseminated to non-governmental organizations, CBOs, and other providers. Our study team has made our validated measures (Doty et al., 2018) publicly available and continues to promote their dissemination and use.

Conclusion

This qualitative study examined the psychological and psychosocial needs and experiences of two conflict-affected groups in Ukraine: IDPs and military veterans and their families. Findings demonstrated commonalities across the two groups including depression, anxiety and substance use, as well as challenges in social adaptation or integration, receiving social support, and relational conflict. Differences were also apparent as both groups experienced unique psychosocial challenges and psychological symptomology. A range of recommendations for programming is provided.

Public Policy Relevance Statement.

When designing mental health interventions for conflict-affected persons, it is critically important to assess and integrate contextually specific experiences and local conceptions of healthy functioning. Findings from this study highlight the relevance of community-based programming that can facilitate social adaptation and link affected persons to formal mental health services. Programs that promote greater awareness and interaction among the general public and conflict-affected groups are also warranted.