Study population and measures
For the purpose of this study, we selected women with tertiary education as they accounted for most respondents (about 70%) and also restricted the sample to women at productive age (18–64 years). The resulting data was therefore based on the answers of 919 Ukrainian women refugees.
The perceived state of health of the Ukrainian refugees was based on the question “How do you rate your overall state of health?” with five possible answers – very good, good, neither good nor bad, bad, very bad. For the analyses, we dichotomized the perceived state of health as good (very good, good) and poor (neither good nor bad, bad, very bad). The outcome was defined as reporting poor health.
As we selected highly educated women, the sociodemographic variables used in the analysis were merely age applied as a continuous variable from age 18 to 64 years.
Based on the framework of Dahlgren and Whitehead [
34] and Marmot and Wilkinson [
35] determinants were grouped into five domains: (1) self-reported diseases and healthcare factors (number of barriers to healthcare access, number of diseases, lack of medicine, depression symptoms); (2) lifestyle (smoking, alcohol, body mass index); (3) social factors (close people, interest of others, get help, children in household, contact in Czechia prior to arrival, household size, knowledge of language, housing quality); (4) economic factors (job, material deprivation); (5) migration characteristics (return intentions, arrival time, husband in Ukraine, and geographical region).
Self-reported diseases and healthcare factors variables included the number of diseases, the number of barriers to healthcare access, lack of medicines and depressive symptoms. The number of diseases was determined with a set of questions asking whether respondent suffered from 12 listed (plus any other opened to specify) diseases during the past 12 months, including high blood pressure, heart attack, stroke, high level of cholesterol, diabetes, cancer, chronic respiratory diseases, depression and anxiety, diseases of the spine, covid (or post-covid), HIV/AIDS, tuberculosis, and other. The number of diseases was created as a sum of given comorbidities and categories into five groups: (1) no disease, (2) 1 disease, (3) 2 diseases, (4) 3 diseases, and (5) 4 and more diseases. The number of barriers to healthcare access was assessed by asking question “Did you encounter the following barriers when looking for a doctor in Czechia?”. The four following barriers were considered – (1) language barrier, (2) respondent does not know how the system works in Czechia, (3) respondent does not know what to do, how and where to register, and (4) respondent does not know if he/she would have to pay for it. The number of barriers were summed up and the combination of given barriers divided into four groups: (1) no barriers, (2) 1 barrier, (3) 2 barriers, and (4) 3 and 4 barriers. The number of lacking medicines was defined from question “Do you access to all medicines, and do you use them also in Czechia?” including medicines for diseases indicated above. This variable was dichotomized including (1) no lack of medicines, and (2) 1 and more lacking medicines that needed. Depressive symptoms were assessed by a widely used Patient health questionnaire depression scale (PHQ-8) related to selected depressive symptoms in the last 14 days, which assesses depressive symptoms in individuals. The PHQ-8 scale is the sum of the 8 items and measure of current depressive symptoms and the maximum score of PHQ-8 is 24 points. More information on PHQ-8 scale tool can be found in literature [
36]. Ukrainian version of PHQ-8 scale used in the survey was proven to have a good internal consistency (Cronbach’s alpha = 0.87). The study conducted in 2023 suggests a high prevalence of and a strong link between symptoms of depression and anxiety among Ukrainian refugees in Czechia accompanied by a very low help-seeking [
37]. Based on the given score, the depressive symptoms variable was categorized into four groups: (1) no depression (0–4 points), (2) mild depression (5–9 points), (3) medium depression (10–14 points), and (4) severe depression (15 + points).
Lifestyle variables included smoking, alcohol consumption, and body mass index (BMI). Smoking status was assessed by asking question “Do you currently smoke any tobacco products? If yes, how often?” Women were divided into three categories according to the smoking status: (1) smoke daily, (2) smoke occasionally, and (3) never. Alcohol consumption was measured combining two questions “How often do you drink alcoholic beverages?” and “When you drink an alcoholic beverage, how many glasses do you usually drink?”. Women were divided according to the alcohol consumption into three groups: (1) do not drink alcohol, (2) 1–2 glasses of alcohol, (3) 3 and more glasses of alcohol. BMI was measured based on self-reported height in cm and weight in kg and categorized into four groups defined by the WHO: 1) underweight (BMI < 18.5 kg/m2), healthy weight (BMI > = 18.5 kg/m2 & BMI < 25 kg/m2), overweight (BMI > = 25 kg/m2 & BMI < 30 kg/m2), obesity (BMI > = 30 kg/m2).
Human and social capital variables were represented by the number of close persons, interest of others, ability to get help if needed, household size, contact persons in Czechia prior arrival, knowledge of Czech language and housing quality. The number of close persons was assessed by asking question “How many people are so close to you that you can count on them in case of serious personal problems?”. According to the indicated number of persons, women were divided into three categories: (1) no close person, (2) 1–2 close persons, (3) 3 and more close persons. Interest of other people was measured by question “How much are other people around you interested in what you do? What interest do they show?”. Women were grouped into three groups based on perception of interest shown from other people: (1) great interest and some interest, (2) neither great nor little interest, and (3) only little and no interest at all. The ability to get help if needed was assessed by asking question “How easy it is for you to get help from other people if you need it?” Based on provided answers women were divided into three groups: (1) very easy and easy to get help, (2) possible, and (3) difficult and very difficult to get help. The indicator for the household type was constructed from a set of questions in the household grid (number of household members, age of given household member and his or her relationship to the respondent). Based on the answers the respondents were divided into four groups: (1) single member, (2) two and more members without children, (3) single parent with children, and (4) family with children. Social contacts in Czechia prior to arrival were measured by asking question “Did you have any contacts with people living in Czechia before your arrival?” including family members and relatives, other Ukrainian and Czechs. Here women were divided into two groups: (1) with previous contacts, and (2) no previous contacts. Knowledge of Czech language was determined based on question “What are your language skills in Czech language?” based on language proficiency according to the Common European Framework of Reference for Languages (CEFR) organized in six levels from A1 to C2. Women were divided into three groups according to their language knowledge: (1) level A1 and lower, (2) level A2, (3) level B1 and higher. Housing quality was assessed by asking question “Where do you currently live?” grouping women into three categories: (1) lodging house, (2) rental accommodation, (3) other, including solidarity housing.
Economic characteristics were assessed by economic status and material deprivation. Women activity at the labour market was asked by question “Are you currently in paid work?” including job in Czechia or remotely in Ukraine or elsewhere abroad. Women were divided into two groups according to their labour status: (1) yes, or (2) no. For the measurement of material deprivation, we used the adopted EU indicator constructed from 13-item set of questions [
38]. The scale was measuring if the household could afford covering selected everyday and extraordinary expenses. The respondents were asked if their households could afford covering 13 types of expenses (listed in rotation): (1) some unexpected expenses of approx. 500 Euros, (2) paying annually for at least a week’s vacation outside your current Czechia home for all household members, (3) eating meat, poultry, or fish (or their vegetarian replacements) at least every other day, (4) heating the flat sufficiently, (5) replacing worn furniture with new one, (6) replacing worn-out clothes with at least some new pieces (not second-hand), (7) having at least two pairs of well-fitting shoes for each household member, (8) meeting with friends at a café, restaurant, bar, or at home several times a month, (9) regularly engage in a paid leisure activity (sports, going to the cinema, etc.), (10) spending a set amount on yourself every week (e.g. a cinema ticket, a small gift, etc.), 11) using a private car, 12) paying for your housing costs (rent, utilities, etc.), and 13) paying for internet access. Based on provided answers women were divided into three groups according to their level of deprivation: (1) no material deprivation, (2) some material deprivation, and (3) severe material deprivation. Those who could not cover up to 4 out of the 13 mentioned expenses were described as those not suffering from material deprivation; respondents who could not afford 7 and more expenses were treated as those with severe material deprivation.
Migration-related variables included plans for return to Ukraine within next 2 years, time of arrival in Czechia, if women had husband/partner in Ukraine, and geographical region of origin. Return to Ukraine was asked by question “Do you want to return to Ukraine within the next 2 years?” and divided in three groups: (1) with plans for return (definitively and rather want to return), (2) with no plans for return (definitively and rather want to stay abroad, in Czechia or other country), and (3) not decided (do not know or not sure). Time of arrival to Czechia was assessed by asking question “When did you come to Czechia?” and grouped into two categories: (1) February-March 2022, and (2) April-June 2022. The series of questions concerning close family members who stayed in Ukraine were used to calculate the predicator signifying women had spouse or partner left back home. Here we differentiated only those who mentioned that their spouse or partner stayed back in Ukraine from the rest, i.e., we combined women with no partner with those who had partner in other country abroad. Geographic region of origin was determined based on question “In which region of Ukraine did you live for a long time before coming to Czechia?”. The 25 regions of Ukraine were divided into four main geographical areas – West (regions of Volyn, Zakarpattia, Ivano-Frankivsk, Lviv, Rivne, Ternopil, Khmelnytskyi, Chernivtsi), Center (regions of Kyiv City, Vinnytsia, Zhytomyr, Kyiv, Kirovograd, Poltava, Sumy, Cherkasy, Chernihiv), South (regions of Dnipropetrovsk, Zaporizhia, Mykolaiv, Odesa, Kherson) and East (regions of Donetsk, Luhansk, Kharkiv).