A low-cost digital first aid tool to reduce psychological distress in refugees: A multi-country randomized controlled trial of self-help online in the first months after the invasion of Ukraine

Armed conflicts increase distress levels among affected populations, particularly impacting refugees who often face barriers to accessing psychological support. We evaluate an online version of a previously tested in-person and endorsed for online adaptation by the WHO Self-Help Plus (SH+) program among Ukrainian refugees dispersed across 17 countries, internally displaced and not displaced Ukrainians. This is the first randomized controlled trial to test an online psychological intervention simultaneously on refugees, internally displaced, and non-displaced conflict-affected populations. This study is an online two-arm, individually randomized controlled trial among participants above 18 years old in Ukraine or EU countries who were randomly assigned to receive either the Self-Help Online (SHO) intervention and passive informational resource or the passive informational resource alone. We recruited 652 participants starting the program on July 7th, 2022. The analysis focused on 292 participants who completed the final survey one week after the end of the program. Results indicated significant distress reduction among refugees (β -2.16, 95% CI -4.17 to -0.16; p = 0.03; d -0.47) but not among internally displaced in Ukraine (β 0.56, 95% CI -1.1 to 2.99; p = 0.17; d 0.2) or non-displaced participants in Ukraine (β 0.2, 95% CI -0.95 to 1.35; p = 0.73; d 0.08). The effect size in stress reduction for refugees was comparable to other similar interventions but with lower average costs. The average cost per participant was €11, with €46.16 for each benefiting (refugee) participant, suggesting cost-effectiveness for scale-up. These findings suggest that Self-Help Online is an effective psychological intervention for reducing stress among geographically dispersed refugees at a low cost. We also find that the online delivery format of psychological interventions is feasible for internally displaced and non-displaced conflict-affected populations.