Pre- and post-migration determinants of self-rated health among Ukrainian refugees in Germany: A cross-sectional comparative analysis with recently arrived refugees from other countries of origin

6.5 million Ukrainian refugees have been displaced globally since 2022, with one million who registered for temporary protection in Germany under the EU Temporary Protection Directive. Unlike other refugee groups, they were granted immediate access to social security and health care. However, little is known about the differences in health determinants for individuals arriving under the EU Temporary Protection Directive versus those seeking protection on the basis of asylum law, limiting the evidence base for policy intervention. Thus, a comparative analysis is needed. We use a representative survey of Ukrainian refugees in Germany (2023) to analyse the effect of pre- and post-migration factors on self-rated health using multiple logistic regression (n = 5943). We contrast these findings with identical analyses among non-Ukrainian refugees who arrived in Germany mainly during 2015/16 and were interviewed within one year after their arrival (n = 1195). In the Ukrainian sample, post-migration factors are particularly critical for health, with those experiencing discrimination (OR: 1.9, 95%CI: 1.6 - 2.3) and social isolation (OR: 2.7, 95%CI: 2.2 - 3.2) affected by ill health, while those attending a German language course (OR: 0.7, 95%CI: 0.6 - 0.9), with "sufficient" German proficiency (OR: 0.7, 95%CI: 0.6 - 1.0), and frequent contact with Germans (OR: 0.7, 95%CI: 0.5 - 0.8) have better health. Pre-migration factors do not affect self-rated health. Among non-Ukrainian refugees, pre- and post-migration factors are not associated with health, apart from social isolation (OR: 2.2, 95%CI: 1.4 - 3.2). Despite favourable legal entitlements, the health of Ukrainian refugees in Germany is shaped by adverse post-migration circumstances. This finding underscores the importance of expanding diversity-sensitive healthcare approaches, including outreach services and medical interpreters. For non-Ukrainian refugees, restrictive legal conditions pose substantial health risks that become more evident over time.