Schizophrenia literacy among former Soviet Union immigrants: A cross-generational perspective on knowledge,trust,and stigma

Abstract

Several studies in Western countries have found that first- and second-generation immigrants have an increased risk of developing schizophrenia. Mental health literacy can facilitate help-seeking and prevent chronic mental conditions. This study explores cross-generational differences in schizophrenia literacy among immigrants from the former Soviet Union (FSU) in Israel. Data were collected using a cross-sectional online survey of 405 respondents who self-identified as first-generation, 1.5-generation, or second-generation FSU immigrants. Questions about schizophrenia literacy were adapted from the Australian National Survey of Mental Health Literacy and Stigma, tapping into the recognition of schizophrenia, knowledge of potential helpers, first-aid support, and effective interventions for persons with schizophrenia (PwS) as well as attitudes, measured by personal stigma and trust in the healthcare system. The findings revealed that knowledge was associated with trust in the healthcare system across generations. First-generation immigrants were less likely to correctly identify a distress situation as involving schizophrenia and held more stigmatic attitudes toward PwS. Their utilization of mental healthcare services was lower, compared to the younger generations, which they compensated for by turning to traditional treatment and hypnosis. Lower trust in the mental healthcare system was also found among the first-generation immigrants, as compared to the 1.5- and second-generation groups. In conclusion, lower levels of knowledge and more stigmatizing attitudes toward schizophrenia reflect the lingering effects of living in the Soviet Union, placing first-generation immigrants in a vulnerable position. Implications for culturally adapted interventions aimed at increasing schizophrenia literacy and mental health trust among FSU immigrants are proposed.

Keywords

schizophrenia literacy immigrant generation stigma trust former Soviet Union immigrants

Introduction

Schizophrenia is a severe mental illness (SMI) related to a spectrum of psychotic disorders and is diagnosed among approximately one percent of the global population (McCutcheon et al., 2020). Schizophrenia usually emerges in young adulthood, and its symptoms (e.g., hallucinations, delusions, occupational and social withdrawal) are associated with a high personal, familial, societal, and clinical burden (Fusar-Poli et al., 2017). Therefore, it is crucial to recognize early psychotic symptoms (Lin & Lane, 2019) and provide appropriate bio-psycho-social treatment (Kane & Correll, 2010; Mueser et al., 2013). Schizophrenia literacy can facilitate help-seeking and prevent psychotic experiences, first-episode psychosis, and early schizophrenia from developing into more chronic and severe mental health conditions (Fusar-Poli et al., 2017; Jorm et al., 1997).

Mental health literacy (MHL) refers to “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (Jorm et al., 1997, p. 182). Previous studies on MHL have demonstrated that knowledge about schizophrenia among the public is lower compared to that for other mental disorders, such as depression and anxiety disorders (Knaifel et al., 2023; Reavley & Jorm, 2011a). People with low schizophrenia literacy are unable to recognize psychotic symptoms and are unaware of helpful interventions, treatment, and support (Jung et al., 2017; Thorsteinsson et al., 2019). Stigmatization and negative attitudes toward schizophrenia are additional components of MHL that may influence help-seeking intentions (Corrigan et al., 2014; Soffer & Weinberg, 2023). Stigmatizing attitudes include mistaken beliefs about etiology and recovery from schizophrenia and the perception of persons with schizophrenia (PwS) as unpredictable, aggressive, dangerous, and untreatable (Crisp et al., 2000; Read et al., 2006).

Migration and schizophrenia

Schizophrenia literacy is especially pertinent in the case of immigrant populations from low- and middle-income countries moving to Western societies. Findings from three meta-analyses have shown that first- and second-generation immigrants, mostly from developing countries to Western Europe, were two to three times more at risk for developing schizophrenia and other psychotic disorders than native-born individuals (Bourque et al., 2011; Cantor-Graae & Selten, 2005; Selten et al., 2020). Additionally, the studies consistently showed that immigrants are less likely to seek professional help as compared to native-born individuals, due to various socio-cultural factors such as the level of acculturation, cultural stigma, preference for traditional treatments, and lack of trust in the mental healthcare system (MHCS) (Jarvis, 2025; Kirmayer et al., 2011; Mohammadifirouzeh et al., 2023). Therefore, culturally adapted interventions aimed at reducing stigma and increasing knowledge about schizophrenia and trust in mental health services are particularly essential for immigrant populations.

The current study focused on immigrants from the former Soviet Union (FSU) in Israel. Studies conducted among FSU immigrants in Israel found this group to be at about 1.5 times greater risk for developing schizophrenia than native-born Israelis, and this risk decreased in second-generation immigrants (Eger et al., 2022; Weiser et al., 2008). Concurrently, FSU immigrants display relatively negative attitudes (suspicion and distrust) toward mental health services and utilize them at lower rates compared to long-term Israeli Jews (Mirsky, 2009; Shor, 2006). This low uptake and reserved attitude toward mental health services were found to be associated with comparatively higher levels of mental health stigma, along with a preference for general medical clinics as well as traditional methods of treatment (Dolberg et al., 2019; Jurcik et al., 2013; Leipzig, 2006).

Schizophrenia in the Soviet and post-Soviet periods

Negative attitudes toward mental health and the MHCS in the FSU have been interpreted as being associated with the historical and socio-cultural context of psychiatry in the Soviet and post-Soviet periods (Raikhel & Bemme, 2016; van Voren, 2010). Lavretsky (1998) argues that a prolonged totalitarian regime and oppression in the Soviet period legitimized the political abuse of psychiatry in general, and the biased conceptualization of schizophrenia in particular. The psychiatric diagnosis of “behavior that does not conform to social norm” was defined as a specific type of “sluggish schizophrenia,” and oppositional political views were labelled as “revolutionary delusions”; these have led to the criminalization and overdiagnosis of schizophrenia (Jargin, 2011; Lavretsky, 1998; van Voren, 2010). This policy was mirrored in public perceptions: fear and stigma toward PwS as dangerous and aggressive, and the belief that PwS should be excluded and kept away from Soviet society (Raikhel & Bemme, 2016; Šumskienė & Nemanyte, 2020).

These stigmatic and xenophobic attitudes, along with the lack of human rights for people who were genuinely suffering from schizophrenia, characterized the Soviet and beginning of post-Soviet periods (Lavretsky, 1998). In the 2000s, mental health services in Russia began to shift from the bio-medical, paternalistic paradigm to a more integrative, social approach, which emphasized not only the provision of institutional care for PwS but also development of social and occupational rehabilitation (see Jenkins et al., 2010; Shek et al., 2016). It appears that the implementation of community rehabilitation approaches toward PwS and anti-stigma campaigns have taken hold faster among FSU countries with a more Western orientation such as Georgia and the Baltic states (Šumskienė & Nemanyte, 2020), while knowledge and perceptions toward schizophrenia in contemporary Russia have remained vague and stigmatic (Kolpakova, 2019; Shek et al., 2016). For example, recent studies on MHL among the Russian population indicated that they still have higher levels of stigmatic attitudes toward PwS and lower trust in mental health professionals than their Western counterparts (Cavanagh et al., 2022; Nersessova et al., 2019).

The cross-generational perspective of the present study

The present study examined schizophrenia literacy among three generations (first, 1.5, and second) of FSU immigrants in Israel. Most of them immigrated to Israel after the collapse of the Soviet Union in the early 1990s: first generation (Gen 1.0) immigrated as adults, 1.5 generation (Gen 1.5) as teenagers or children, and second generation (Gen 2.0) were born after migration (Knaifel, 2022; Remennick & Prashizky, 2023). All three generations comprise the largest immigrant community in Israel over the last 35 years, constituting 12% of the general and 15% of the Jewish population (ICBS, 2023; Remennick, 2025). To date, more than 1.2 million FSU immigrants live in Israel, among them about 910,000 of the first and 1.5 generations and 326, 000 of the second generation (ICBS, 2023).

FSU immigrants generally have high levels of education (over 60% hold an academic degree) and professional qualifications, which have helped many integrate into Israeli society (Knaifel, 2022; Kushnirovich, 2018). However, more than 35 years after the beginning of mass emigration from the FSU, those who immigrated to Israel as adults and teenagers still differ from the Israeli-born population in certain cultural-lingual and sociodemographic characteristics; they speak Hebrew with an accent, practice more traditional parenting styles, celebrate Russian-Soviet holidays, and a significant portion reside in geographically peripheral areas with high concentrations of immigrants (Knaifel, 2022; Remennick, 2025).

People who were born in the FSU and immigrated to Israel and other Western countries are simultaneously affected by the culture of their origin and the more liberal and democratic values of their host country (Dolberg & Amit, 2023; Remennick & Prashizky, 2023). An example for the liberal practices in the mental healthcare context is person-centered and recovery-oriented services for people with SMI, established in 2000 within the Rehabilitation Act in Israel (Aviram et al., 2023). As part of rehabilitation and subsequent mental health insurance reform, the Ministry of Health in Israel initiated campaigns and programs aimed at reducing mental health stigma and promoting the social inclusion of people with SMI into Israeli society (David et al., 2022; Steiman & Ben-Dor, 2022). However, in a multicultural country such as Israel, the level of public stigma also depends on the specific population segment, and previous studies have consistently documented high levels of stigma and lower MHL among ethnocultural minorities (Natan et al., 2017; Shapiro et al., 2024; Struch et al., 2007), including Russian-speaking immigrants (Dolberg et al., 2019; Nakash et al., 2020; Shor, 2006).

In contrast to the first-generation immigrants from FSU who tend to preserve lingual-cultural characteristics of their country of origin, including healthcare attitudes and practices (Kostareva et al., 2020; Shapiro, 2022), cultural changes in the Russian-speaking community are particularly noticeable among 1.5- and second-generation immigrants (Knaifel, 2022). Indeed, the recent sociological study showed that the 1.5 and second generations manifest more diverse cultural outlooks and liberal social attitudes toward various minority groups in Israeli society (e.g., Arab citizens of Israel, Ethiopian Jews, and the LGBTQ community) compared to their parents (Remennick & Prashizky, 2023). However, their knowledge and attitudes toward PwS remain unstudied.

The purpose of the present study is to fill this gap, examining schizophrenia literacy—knowledge and the attitudes of stigma and trust—among three generations (first, 1.5, and second) of FSU immigrants in Israel. The objectives of the current study are: 1) to assess schizophrenia literacy among FSU immigrants in Israel in its knowledge and attitudinal dimensions; and 2) to examine differences in schizophrenia knowledge and attitudes between three generations of FSU immigrants.

Methods

Participants

This article is part of a larger study on MHL among different groups in Israeli society (Knaifel et al., 2023; Piterman et al., 2025). While previous publications have addressed different mental disorders, the current analysis focused specifically on schizophrenia literacy (including stigma) and mental health trust among FSU immigrants and their descendants. Our sample included 405 adults who responded to an online survey (n = 470), completed the survey (n = 420), and had no missing values in the section on schizophrenia. Inclusion criteria were: (1) personal or parental history of migration from the FSU to Israel; (2) age of 18 years or older; and (3) able to read Hebrew.

The sample comprised three immigration generations: first generation (born in FSU and immigrated to Israel in their late adolescence or as adults (16+), 1.5 generation (born in FSU and immigrated to Israel in their childhood or early adolescence (0–15 years old)), and second generation (born in Israel to one or two immigrant parents from the FSU). The rationale for conducting a survey in Hebrew was to create language unity across generations, as recent studies have reported that 1.5 and second generations read Hebrew better than Russian (Dolberg & Amit, 2023; Remennick & Prashizky, 2024). Because the survey was conducted in Hebrew, it may not have reached recent immigrants, but rather veteran immigrants, most of whom lived in the Soviet Union and immigrated to Israel in the 1990s.

Design and procedure

The design was cross-sectional, and data were collected between May and September 2021. Convenience and snowball sampling methods were utilized to recruit study participants. The samples were recruited for an online survey using Qualtrics software. The online survey included questions on socio-demographics, MHL (including stigma), and trust. Some participants were recruited by a polling firm called Panel4all (https://www.panel4all. co.il), while others were recruited through postings on social media networks such as Facebook and WhatsApp.

The study was approved by the Institutional Review Board of Ruppin Academic Center (#2021–82). Participants signed an informed consent form before responding. Their anonymity was assured: there was no identifying information in the survey.

Measures

All measures were translated from English to Hebrew and back and tested on a small number of participants using cognitive interviewing (French et al., 2007) .

Socio-demographic characteristics

Socio-demographic characteristics included sex, age, country of birth, country of parents’ birth, age upon immigration, years lived in Israel, level of education, perceived income adequacy, and self-rated health status.

Mental health literacy

The Australian National Survey of Mental Health Literacy and Stigma (Reavley & Jorm, 2011a, 2011b) was adapted and the vignette of a young person with schizophrenia (Alex’s case story) was used (see Supplementary Material). Following the vignette, participants were asked to identify: (1) the mental disorder; (2) potential suitable helpers; (3) effective interventions; (4) helpful first-aid support; and (5) personal stigma.

Schizophrenia identification was assessed by asking the participants for the correct label in the ‘Alex’ case vignette, using the following options of psychiatric diagnoses: social phobia, PTSD, depression, schizophrenia, and others.

Knowledge of potential helpers (9) and interventions (12) was assessed by a list of 21 statements, as presented in Table 3. The participants were asked to indicate whether each option was “helpful,” “harmful,” “neither,” “depends,” or “do not know.” To explore the unique cultural dimensions of FSU respondents’ knowledge of potential helpers and interventions, the research team added specific items of folk healers such as “alternative healer” and “getting traditional treatment.” These items were based on Jurcik et al., (2013) observations regarding help-seeking intentions among FSU immigrants and refer to culturally specific helpers such as Znahari (traditional healers that may use herbs), Babki (old women that remove sglaz (the evil eye)), and Ekstrasensy (psychics who claim to possess extrasensory abilities and use hypnosis alongside spiritual or ritual elements) (see also Brown & Rusinova, 2002).

Knowledge of first-aid support was assessed as a summary of nine types of action (see Supplemental Material). Participants were asked to indicate whether each option was suitable with a dichotomous answer category of ‘yes’ or ‘no’. The sum of correct responses was computed for all knowledge questions, with higher scores indicating better MHL (potential helpers, interventions, first-aid support).

The coding process for all MHL items was conducted by two researchers with clinical backgrounds (Author 1, a clinical social worker; and Author 2, a senior clinical psychologist). They judged independently, coded the answers to each item, and then compared their coding. In divergent responses, a discussion between all authors followed until an agreement was reached.

Personal stigma

Stigmatizing attitudes were assessed using eight statements that evaluated the participant's personal attitudes toward the person described in the schizophrenia vignette (Griffiths et al., 2006; Reavley & Jorm, 2011b). Ratings of each statement were made on a 5-point Likert scale ranging from 1 = 'strongly disagree” to 5 = 'strongly agree.” The internal reliability coefficient (Cronbach's alpha) was .72.

Trust

Respondents were asked how much they trust information about HCS from each of the following information sources: a physician, governmental health organizations, and mental health non-governmental organizations (NGOs). The item was adapted from the HINTS study (Blake et al., 2016). The response was on a 4-point scale, ranging from 1 = “not at all” to 4 = “very much.” An index of trust in mental care was constructed by averaging trust in physicians, governmental health organizations, and mental health NGOs; the reliability of this scale was 0.69.

Data analysis

First, sociodemographic characteristics of the sample and MHL were examined, using descriptive statistics, including correlations among key variables across generations. Second, MHL indices of knowledge (identification, potential helpers, effective interventions, and suitable first-aid support) and attitudes toward schizophrenia were compared between the immigration generations using a chi-square test. In the index of trust and stigma, a one-way ANOVA with bootstrapping of 5,000 samples was used, due to violation of normality among items comprising the index (Krishnamoorthy et al., 2007; Sainani, 2012). Third, a multivariate logistic regression model examined whether the identification of schizophrenia was associated with immigration generation, demographics variables, knowledge (potential helpers, effective interventions, and suitable first-aid support), or stigma. Data were analyzed using the IBM-SPSS 28.0 software (Armonk, NY, USA: IBM Corp) and R studio version 4.3.1.

Results

Participants’ characteristics

Socio-demographic characteristics of the participants are presented in Table 1. The three FSU generations comprised 405 respondents (64% women): 105 persons in the first generation (61% women) and 164 (61.6% women) and 136 (69.1% women) in the 1.5 generation and second generation, respectively. Participants’ ages ranged from 18 to 79 years (M = 39.96, SD = 15.11). The first-generation sample was older (M = 56.25, SD = 11.79) than the 1.5 (M = 41.57, SD = 10.48) and second generation (M = 25.63, SD = 4.63). The mean time since immigration for the first generation was 27.71 years (SD = 6.71), and the mean age at immigration was 28.36 years (SD = 10.17). The first and 1.5 generations attained higher education than the second generation (χ2 = 97.66, p < .001) and also viewed their income as addressing their needs more adequately (χ2 = 17.11, p < .01).

Table 1.

Socio-demographic characteristics of all generations of FSU immigrants (n (%) or mean (SD)).

Characteristics	Gen 1.0N = 105	Gen 1.5N = 164	Gen 2.0N = 136	TotalN = 405	Statistics(χ² or F)
Sex
Men	41 (39%)	63 (38.4%)	42 (30.9%)	149 (36%)	χ² = 2.32
Women	64 (61%)	101 (61.6%)	94 (69.1%)	259 (64%)
Age
Mean (SD)	56.25 (11.79)	41.57 (10.48)	25.63 (4.63)	39.96 (15.11)	χ² = 452.899**
18–30	1 (1%)	9 (5.5%)	127 (93.4%)	137 (33.8%)
31–45	19 (18.1%)	117 (71.3%)	9 (6.6%)	145 (35.8%)
46–65	56 (53.3%)	32 (19.5%)	0	88 (21.7%)
66–79	29 (27.6%)	6 (3.7%)	0	32 (8.6%)
Time from immigration (years)
Mean (SD)	27.71 (6.71)	30.88 (5.76)	None	None
Age at immigration
Mean (SD)	28.36 (10.17)	7.76 (3.97)	None	None
Education
Primary and secondary	10 (9.5%)	19 (11.6%)	40 (29.4%)	69 (17%)	χ² = 97.66**
Post-secondary/college	16 (15.2%)	24 (14.6%)	24 (17.6%)	64 (15.8%)
BA student	1 (1%)	7 (4.3%)	33 (24.3%)	41 (10.1%)
BA degree	41 (39%)	61 (37.2%)	33 (24.3%)	135 (33.3%)
MA degree and higher	37 (35.2%)	53 (32.3%)	6 (4.4%)	96 (23.7%)
Income
Finding it very difficult	2 (1.9%)	2 (1.2%)	9 (6.6%)	13 (3.2%)	χ² = 17.11*
Finding it difficult	122 (11.4%)	29 (17.7%)	33 (24.3%)	74 (18.3%)
Coping	58 (55.2%)	77 (47%)	62 (45.6%)	197 (48.6%)
Living comfortably	33 (31.4%)	56 (34.1%)	32 (23.5%)	121 (29.9%)
Self-rated health
(Mean, SD)	3.32 (0.814)	3.66 (0.838)	3.99 (0.830)	3.69 (0.866)	F(2,402) = 19.36**

Note. *p < .01, **p < .001.

Descriptives and bivariate association among MHL indices and trust

As can be seen in Table 2, the trust toward the HCS is moderate and so is the stigma toward PwS across generations. The knowledge indices indicate higher knowledge on first aid than on potential helpers and effective interventions. A repeated ANOVA with pairwise comparison with Bonferroni correction was performed. A significant difference between knowledge indices was documented (F(1.94,809.41) = 270.15, p ≤ .001, η² = .392), with first aid (M = 7.53, SD = .09) higher than potential helpers (M = 5.46, SD = .096) and effective interventions (M = 5.50, SD = .11). Table 2 indicates that the knowledge indices of MHL across generations are associated among themselves, with the significant correlations ranging between 0.29 and 0.57. The attitudinal dimension of stigma was only weakly significantly associated with knowledge of potential helpers (r = −0.11, p = .027), and trust toward the HCS was weakly positively associated with two knowledge indices of MHL (r ranging 0.16 to 0.29), but not with stigma or knowledge on first aid.

Table 2.

Means, standard deviations, range, and correlations of study variables.

	Trust in HCS	Potential helpers	Effective interventions	First aid	Schizophrenia stigma
Trust in HCS
Potential helpers	.29**
Effective interventions	.16**	.57**
First aid	.09	.42**	.37**
Schizophrenia stigma	−.03	−.11*	−.09.	−.08
Mean	2.92	5.46	5.50	7.52	2.57
(SD)	.65	1.97	2.15	1.84	.60
Potential range	1–4	0–9	0–12	0–9	1–5
Range	1–4	0–9	0–12	0–9	1–4

Note. *p ≤ .05; **p ≤ .01.

Trust in HCS = Trust in healthcare system.

Knowledge MHL indices by immigration generations

Identification of schizophrenia

Identification of distress situations is one of the indices of MHL. Most respondents accurately labeled the distress situation as schizophrenia (N = 307, 75.8%), with the first generation displaying a lower level of correct identification (N = 63, 60%), compared to younger generations (1.5 generation N = 131, 79.9%; second generation N = 113, 83.1), χ2(2) = 19.72, p ≤ .001. With respect to the incorrect responses, social phobia emerges as the second highest label of distress (N = 44, 10.9%), with the first generation being more prone to this misidentification (N = 17, 16.2%), and lower misidentification was observed among the 1.5 (N = 16, 9.8%) and second generations (N = 11, 8.1%), although these generational differences were not statistically significant, χ2(2) = 4.37, p = .113. A similar pattern was observed for the label of depression (see Supplementary Figure 1).

Knowledge of potential helpers, interventions, and first-aid support

FSU immigrants across generations had mostly similar views regarding potential helpers: mental health providers (psychiatrists, psychologists), general practitioners, and family/friends (see Table 3). The only significant difference between generations concerned telephone counselling: the first generation perceived it as significantly less helpful (17, 16.2%) compared to the 1.5 (52, 31.7%) and second generations (40, 29.4%) (χ2(2) = 8.485, p = .014).

Table 3.

Frequency of schizophrenia correct identification and potential helpers and interventions rated as ‘helpful’ (%) by immigration generation.

Knowledge items	Gen 1.0N = 105N (%)	Gen 1.5N = 164N (%)	Gen 2.0N = 136N (%)	TotalN = 405N (%)	χ2
Schizophrenia identification	63 (60%)	131 (79.9%)	113 (83.1%)	307 (75.8%)	19.72**
Potential helpers
Close family member	27 (25.7%)	50 (30.5%)	40 (29.4%)	117 (28.9%)	.737
Close friend	29 (27.6%)	52 (31.7%)	38 (27.9%)	119 (29.4%)	.721
General practitioner (GP)	50 (47.6%)	88 (53.7%)	64 (47.1%)	202 (49.9%)	1.584
Psychologist	81 (77.1%)	130 (79.3%)	112 (82.4%)	323 (79.8%)	1.036
Psychiatrist	94 (89.5%)	146 (89%)	112 (82.4%)	352 (86.9%)	3.758
Mental health providers	75 (71.4%)	136 (82.9%)	111 (81.6%)	322 (79.5%)	5.754
Phone counselling	17 (16.2%)	52 (31.7%)	40 (29.4%)	109 (26.9%)	8.485*
Alternative healer	18 (17.1%)	27 (16.5%)	27 (19.9%)	72 (17.8%)	.623
Social club	19 (18.1%)	39 (23.8%)	32 (23.5%)	90 (22.2%)	1.4
Effective interventions
Looking for information	71 (67.6%)	120 (73.2%)	94 (69.1%)	285 (70.4%)	1.10
Becoming physically active	24 (22.9%)	53 (32.9%)	47 (34.6%)	125 (30.9%)	4.352
Reading a self-help book	26 (24.8%)	44 (26.8%)	43 (31.6%)	113 (27.9%)	1.54
Only sharing the feelings	34 (32.4%)	61 (37.2%)	58 (42.6%)	153 (37.8%)	2.69
Reading the Bible	8 (7.6%)	7 (4.3%)	13 (9.6%)	28 (6.9%)	3.34
Dealing alone	10 (9.5%)	9 (5.5%)	9 (6.6%)	28 (6.9%)	1.65
Finding new hobbies	37 (35.2%)	63 (38.4%)	58 (42.6%)	158 (39%)	1.40
Drinking alcohol to relax	1 (1%)	1 (0.6%)	1 (0.7%)	3 (0.7%)	.102
Undergoing hypnosis	24 (22.9%)	27 (16.5%)	13 (9.6%)	64 (15.8%)	7.96*
Getting traditional treatment	39 (37.1%)	50 (30.5%)	30 (22.1%)	119 (29.4%)	6.66*
Admitted to psychiatric ward	53 (50.5%)	88 (53.7%)	68 (50%)	209 (51.6%)	.471
Praying with a religious leader	7 (6.7%)	4 (2.4%)	11 (8.1%)	22 (5.4%)	5.04

Note. *p ≤ .05; **p ≤ .001

As for effective interventions, traditional treatment was perceived as “helpful” by respondents from the first generation (39, 37.1%), but less among respondents from the 1.5 and second generations (N = 50, 30.5% and N = 30, 22.1%, respectively) (χ2(2) = 6.66, p = .036). Another intervention that was endorsed as helpful among the first generation (N = 24, 22.9%) was hypnosis, and similarly, this was less endorsed by respondents from the 1.5 and second generations (N = 27, 16.5% and N = 13, 9.6%, respectively) (χ2(2) = 7.96.74, p = .019). There were no differences among the immigrant generations for other items or in first-aid knowledge (see Supplemental Material 2).

Attitudes toward schizophrenia by immigration generations

Trust in HCS

A one-way ANOVA with bootstrapping of 5,000 samples test was employed to test for differences between the three generations in trust. There were no differences among the immigration generations in the trust index in HCS. However, the 1.5 and second generations demonstrated higher levels of trust toward NGOs providing mental healthcare (M = 2.87, SE = .04 and M = 2.99, SE = .07, respectively) compared to the first generation (M = 2.70, SE = .09) F(2,402) = 3.165, p ≤ .05, η² = .016 (see Table 4).

Table 4.

ANOVA for trust in healthcare system by immigration generations.

	Gen 1.0		Gen 1.5		Gen 2.0
Trust items	M (SE)	Bootstrap for mean 95% CI	M (SE)	Bootstrap for mean 95% CI	M (SE)	Bootstrap for mean 95% CI	F (df)
Physicians	3.27 (.06)	[3.14, 3.39]	3.29 (.06)	[3.18, 3.41]	3.17 (.07)	[3.04, 3.30]	1.145 (2, 402)
Governmental health organizations	2.74 (.08)	[2.59, 2.89]	2.73 (.07)	[2.59, 2.86]	2.55 (.04)	[2.40, 2.69]	2.031 (2, 402)
Mental health NGOs	2.70 (.09)	[2.52, 2.88]	2.87 (.04)	[2.74, 2.99]	2.99 (.07)	[2.85, 3.14]	3.165* (2, 402)
Index trust	2.90 (.06)	[2.78, 3.03]	2.96 (.05)	[2.85, 3.06]	2.90(.056)	[2.79, 3.01]	.370 (2, 402)

Note. *p ≤ .05.

NGOs = non-government organizations.

Personal stigma

A one-way ANOVA with bootstrapping of 5,000 samples test was employed to test for differences between the three generations in stigma toward PwS. Each item was tested separately, followed by the index. The results are displayed in Table 5. A significant difference in three stigma items was found, and a pairwise comparison with Bonferroni correction was performed on these items to test the differences between generations. Participants across generations evaluated differently the item “the problem is not a real medical illness”, F(2,402) = 7.21, p ≤ .001, η² = .035. Post-hoc comparisons revealed that the first generation (M = 2.1, SE = 1.21) considered the problem as “not a medical illness” more than the second generation (M = 1.6, SE = .89). Another difference between generations was found in social distancing, F(2,402) = 8.04, p ≤ .001, η² = .04. Specifically, while the first generation believed it is better to avoid individuals with this condition (M = 2.15, SE = .95), respondents from the 1.5 generation felt less this way (M = 1.82, SE = .91) and the same held for the second generation (M = 1.7, SE = .81, p ≤ .001). Additionally, first-generation respondents were more likely not to vote for a politician with this condition (M = 3.51, SE = 1.06), compared to second-generation respondents (M = 3.08, SE = 1.24, p = .014), F(2,402) = 4.05, p = .018, η² = .02. Finally, looking at the index of stigma, first-generation respondents held more stigma toward schizophrenia (M = 2.74, SE = .57) compared to the 1.5 generation (M = 2.5, SE = .59) and second generation (M = 2.48, SE = .061), F(2,402) = 6.1, p = .002, η² = .032.

Table 5.

ANOVA for schizophrenia stigma in immigration generations.

	Gen 1.0		Gen 1.5		Gen 2.0
Stigma items	M (SE)	Bootstrap for mean 95% CI	M (SE)	Bootstrap for mean 95% CI	M (SE)	Bootstrap for mean 95% CI	F(df)
Alex's problem is a sign of personal weakness	2.16 (.11)	[1.95, 2.36]	1.94 (.72)	[1.80, 2.09]	1.93 (.08)	[1.77, 2.10]	2.03 (2, 402)
Alex’ problem is not a real medical illness	2.1 (1.21)^b	[1.87, 2.35]	1.8 (1.05)	[1.64, 1.96]	1.6 (.89)	[1.44, 1.74]	7.21** (2, 402)
People with a problem like Alex's are dangerous	2.99 (1.02)	[2.79, 3.18]	2.87 (.98)	[2.72, 3.01]	2.9 (.91)	[2.74, 3.05]	.545 (2, 402)
It is best to avoid people with a problem like Alex’s so that you don’t develop this problem	2.15 (.95)	[1.98, 2.34]^a,b	1.82 (.91)	[1.68, 1.97]	1.7 (.81)	[1.56, 1.83]	8.042** (2, 402)
People with a problem like Alex's are unpredictable	3.42 (1.08)	[3.21, 3.62]	3.38 (.97)	[3.23, 3.52]	3.5 (1.01)	[3.32, 3.66]	.48 (2, 402)
If I had a problem like Alex's I would not tell anyone	2.51 (1.03)	[2.32, 2.72]	2.33 (1.02)	[2.18, 2.49]	2.36 (1.10)	[2.18, 2.55]	1.062 (2, 402)
I would not employ someone if I knew they had a problem like Alex's	3.05 (.96)	[2.87, 3.23]	2.87 (1.06)	[2.71, 3.04]	2.77 (1.10)	[2.58, 2.96]	2.05 (2, 402)
I would not vote for a politician if I knew they had suffered a problem like Alex's	3.51 (1.06)^b	[3.31, 3.72]	3.28 (1.19)	[3.10, 3.46]	3.08 (1.24)	[2.88, 3.29]	4.05* (2, 402)
General stigma	2.74 (.57)^a,b	[2.62, 2.85]	2.53 (.59)	[2.44, 2.63]	2.48 (.61)	[2.38, 2.58]	6.101* (2, 402)

Note. *p ≤ .01; **p ≤ .001

significant difference between Gen 1 and Gen 1.5.

significant difference between Gen 1 and Gen 2.

Multivariate analysis on correct identification of schizophrenia

As can be seen in Table 6, we regressed immigration generation, demographic variables, other knowledge indices, and stigma on correct identification of schizophrenia. Generation was split into two dummy variables where first generation was the comparison group. Education and socioeconomic status were inserted once as continuous and once as categorical variables and both yielded nonsignificant results. The overall model was significant, χ2(9) = 44.92, p < .001, and explained 16% (Nagelkerke R2) of the variance in correct identification. Only knowledge on effective interventions (OR = 1.23, p = .005) and immigration generation were significantly associated with correct identification, so that the 1.5 (OR = 2.82, p ≤ .001) and second generations (OR = 3.87, p ≤ .001) had higher odds of identifying schizophrenia compared to the first generation.

Table 6.

Logistic regression on correct identification of schizophrenia; examining background characteristics and MHL indices.

Variables	B	SE	OR	95% CI for OR	p
Sex	.47	.26	1.6	[.96, 2.65]	.071
SES	.221	.17	1.25	[.89, 1.74]	.192
SRH	0.09	1.6	.914	[.67, 1.24]	.562
Education	.031	.08	.69	[.67, 1.2]	.690
Gen 1.5	1.04	.30	2.82**	[1.57, 5.08]	.001
Gen 2.0	1.35	.37	3.87**	[1.88, 7.98]	.001
Potential helpers	.091	.09	1.096	[.94, 1.28]	.242
Effective interventions	.206	.07	1.23*	[1.07, 1.46]	.005
First aid	.18	.10	1.19	[.98, 1.46]	.083
Schizophrenia stigma	.03	.21	1.03	[.68, 1.56]	.901

Note. *p ≤ .01; **p ≤ .001.

Discussion

The current study adopted a cross-generational perspective and examined schizophrenia literacy among three generations of FSU immigrants in Israel (first, 1.5, and second generations), focusing on knowledge, stigma, and trust. The findings show that first-generation FSU immigrants exhibited lower schizophrenia literacy and trust in mental health services, along with higher levels of personal stigma, compared to the 1.5 and second generations.

These results indicate that when interpreting mental health conditions such as schizophrenia, older and less acculturated first-generation immigrants, even many years after immigration and despite having higher levels of education, continue to rely on values and practices from their country of origin. Schizophrenia literacy was relatively low in the Soviet Union, access to Western models of mental illness was limited, and psychiatry was often associated with political control rather than care (Kolpakova, 2019; Raikhel & Bemme, 2016). As a result, mental disorders were frequently expressed through physical symptoms or understood through folk beliefs—such as moral failings or supernatural causes—which contributed to the continued use of traditional healing practices and the persistence of stigmatizing attitudes toward PwS (Brown & Rusinova, 2002; Jurcik et al., 2013). In contrast, the 1.5 and second generations, who are younger and more acculturated to the person-centered values of Israeli society, demonstrated greater familiarity with Western, evidence-based models of mental health and held more tolerant attitudes toward PwS. Despite these cross-generational differences, our findings indicate that schizophrenia literacy across all FSU generations is relatively high, in comparison to other international studies focused on schizophrenia (Reavley & Jorm, 2011a; Thorsteinsson et al., 2019) as well as previous studies focused on health literacy among FSU immigrants (Kostareva et al., 2020; Nakash et al., 2020).

Knowledge of schizophrenia

Identification

A lower rate of respondents who labeled the distressing situation as schizophrenia was found among first-generation immigrants, compared to the 1.5 and second generations. Schizophrenia was mislabeled most often as social phobia or depression across all generations. This may stem from a difficulty to acknowledge the relatively severe and uncommon condition and a probable confusion between psychotic and neurotic symptoms. Historical Soviet-Russian paradigms and perspectives that viewed mental distress as indicating personal frailty and a morally questionable conduct could have added to this misdiagnosis (Jargin, 2011; Nersessova et al., 2019).

Helpful interventions and potential helpers

Knowledge of helpful interventions and potential helpers for PwS is mixed, including endorsement of both standard (seeking information, being admitted to hospital) and non-standard interventions (more physical or social activity) across all generations. First-generation immigrants reported more beliefs in hypnosis and traditional healing as effective treatments for schizophrenia, possibly a reflection of using more traditional Russian healing practices (Brown & Rusinova, 2002). For example, in Soviet and post-Soviet society, hypnosis occupies a more ambiguous space between formal treatment and folk healing, as evident in the famous mass hypnosis sessions carried out by Anatoly Kashpirovsky and Allan Chumak on TV for physical and mental health problems (Huxtable, 2017). In addition, traditional treatments such as “evil eye” removal by folk healers are also commonly used in mental health crises among older FSU immigrants (Jurcik et al., 2013). The transition toward Western values in mental health utilization is observable among 1.5- and second-generation respondents, who endorsed more sharing experiences and emotions and employing self-help modalities as compared with the first FSU immigrant generation.

FSU immigrants across generations held similar views regarding potential helpers, both formal (mental health professionals and general practitioners) and informal (family and friends). The findings contradict previous evidence which reported FSU immigrants’ tendency to cope with crises and distress within the family space, and to be less likely to seek formal support (Leipzig, 2006; Polyakova & Pacquiao, 2006). The only differences found between the generations is with respect to telephone counseling, probably reflecting less inclination among the first generation to disclose mental distress without a face-to-face encounter with a health professional. These findings align with previous studies that highlighted suspicion and mistrust among ex-Soviet citizens shaped by their country-of-origin experiences where mental health services were often characterized by a lack of ethics, transparency, and privacy (Cavanagh et al., 2022; Shor, 2006).

First-aid support

The findings on high knowledge of first-aid support in our study are aligned with findings that laypersons possess a reasonable understanding of appropriate courses of action within such critical occasions (Loureiro et al., 2015; Tissera & Tairi, 2020). The high level of first-aid knowledge across FSU generations could also be explained by socio-demographic and contextual factors. For example, higher educational attainment and personal or family experience with immigration-related stressors may have made participants in our cohort more familiar with mental health concerns (Mirsky, 2009; Polyakova & Pacquiao, 2006).

Attitudes toward mental health and schizophrenia

Our findings indicate that attitudes toward mental health have evolved toward high trust in HCS across all immigration generations, and a change in stigma toward PwS among the younger generations.

Trust

The level of trust in the HCS was found to be relatively high across all generations. The level of immigrant trust in HCSs is associated with a variety of cultural and contextual factors related to country of origin and host country (Gaebel et al., 2014). The current findings on relatively high trust can be interpreted in the context of immigration from a poorer HCS (Kolpakova, 2019) to one providing more services, to citizenship entitlement upon their immigration (granted by the Israeli “Law of Return”) availing free medical care, and to encountering and being assisted by some medical professionals who are themselves FSU immigrants. These professionals have integrated into the medical system (Clarfield et al., 2017; Knaifel, 2022) and can thus assist when linguistic barriers are encountered. These findings are consistent with a study by Pinchas-Mizrachi et al. (2020), who also found relatively high levels of trust in the HCS among immigrant and minority groups in Israel.

Nevertheless, mental health trust was found to be lower among the first generation, compared to the younger generations. This finding is consistent with international studies reporting on difficulties in developing trust in the MHCS among various groups of immigrants in the USA (Mohammadifirouzeh et al., 2023) and in European countries (Sandhu et al., 2013). In the case of first-generation FSU immigrants, they maintain more suspicious attitudes toward mental health professionals, which were prevalent in their country of origin, based on historical abuse of MHCSs in the Soviet period (Cavanagh et al., 2022; Nersessova et al., 2019).

Stigma

The current study also identified a difference between immigrant generations in the stigma index, so that first-generation immigrants exhibit a higher level of stigma than 1.5 and second generations. Schomerus and Angermeyer (2008) suggest that older generations were not exposed to the same level of mental health education and awareness, which has contributed to a more ingrained stigma toward schizophrenia. For many older adults, SMIs such as schizophrenia were often hidden or misunderstood in their formative years. In contrast, younger people may be influenced by more diverse representations of schizophrenia in media and social networks, and therefore exhibit greater empathy and understanding.

These cross-generational differences can also be explained by the internalization of more liberal and tolerant attitudes toward PwS among more acculturated younger generations, who, unlike their parents, have lived all or most of their lives in Israel. This pattern echoes previous research that identified generational gaps among FSU immigrants in their attitudes toward various minority groups in Israeli society, including Mizrahi/Sephardic Jews, Palestinian citizens of Israel, and the LGBT community (Knaifel, 2022; Remennick & Prashizky, 2023). Our findings demonstrate that similar generational shifts occur in the mental health context.

One of the items with a significant difference between the generations was the belief that schizophrenia is not a “real” medical problem, which was endorsed more by first-generation respondents. This may reflect the cohort's experience with the abuse of psychiatry in the Soviet Union. Specifically, schizophrenia was often over-diagnosed in Soviet society, where individuals who were not necessarily ill but expressed different political, social, or religious views were labeled as having schizophrenia (Jargin, 2011).

In comparison to international studies, stigma toward PwS among first-generation immigrants was higher than in Australia's liberal society but lower than in a collectivistic society such as Japan (Griffiths et al., 2006). However, among 1.5- and second-generation FSU immigrants in Israel, stigma is even lower than in Australia (Reavley & Jorm, 2011b), possibly due to socio-demographic differences in the samples (e.g., age, education). The most stigmatizing statements across immigrant generations portrayed PwS as unpredictable and dangerous, aligning with findings from Israeli (Struch et al., 2007) and Australian national surveys (Reavley & Jorm, 2011b).

Associations between MHL indicators

The absence of a significant association between stigma toward PwS and trust in the HCS, and the weak association between stigma and knowledge about schizophrenia, can be interpreted by considering the relative stability of attitudes such as stigma compared with knowledge—highlighting the need for sustained, long-term efforts to address entrenched mental health attitudes (Corrigan et al., 2014). Indeed, although first-generation immigrants demonstrated trust in the HCS, they continued to exhibit higher levels of personal stigma. In our case, this pattern may reflect lingering influences of their Soviet background, as well as age-related attitudes and generational differences in openness to mental health issues (Schomerus & Angermeyer, 2008). In contrast, the stronger associations among knowledge indices (r = .30 – .57) indicate consistency across schizophrenia-related knowledge domains. Moreover, our finding that—along with the immigrant generation—knowledge about effective interventions is associated with accurate identification of schizophrenia suggests possibilities for overcoming stigma in help-seeking intentions by increasing immigrants’ knowledge, which is more amenable to change through targeted education (Thorsteinsson et al., 2019).

Limitations and strengths

This study has several limitations. First, the cross-sectional design of the study prevents establishing a causal relationship between MHL knowledge, stigma toward schizophrenia among FSU immigrant generations, and trust in the HCS. Second, there were two sources of selection bias: the online administration and the survey language (Hebrew). Both factors a priori excluded some first-generation respondents, who are less likely to use digital resources and/or have less proficiency in the Hebrew language at a reasonable level (such as recent immigrants from Russia and Ukraine). Moreover, the present study focused on a particular cultural milieu, which imposes constraints on the extent to which the obtained results can apply to FSU immigrants residing beyond Israel's borders or to immigrant communities of different backgrounds. Another limitation is that the current analysis does not include a comparison with a non-immigrant group.

The primary strength of the study lies in its deliberate focus on three distinct generations of FSU immigrants. This population constitutes approximately 39% of the total immigrant influx into Israel since the nation's establishment in 1948 (Kushnirovich, 2018). Furthermore, the FSU immigrant group ranks among the most substantial immigrant populations globally (Kostareva et al., 2020). Moreover, our study examined various facets of MHL concerning schizophrenia, through the utilization of well-validated measurement tools. Notably, schizophrenia is underrepresented in existing MHL studies among immigrant populations, and the current study focused on the association between schizophrenia literacy and a structural and objective attribute, namely immigrant generation. Lastly, although the use of the Hebrew language in the survey may seem like a limitation, as we did not include first-generation respondents who lacked a reasonable level of proficiency in Hebrew, we view it as a strength. We still identified cross-generational differences, which might be even more pronounced among older and less acculturated first-generation immigrants (Nakash et al., 2020).

In future studies, it would be interesting to explore how the new immigrant groups who arrived since 2014 from post-Soviet regions to Western countries, in so-called “Putin's immigration” (Remennick, 2025), perceive PwS and how they differ from ex-Soviet groups that immigrated in the 1990s. Future studies may examine a broader range of socio-demographic and clinical variables that might also be associated with schizophrenia literacy (e.g., other kinds of health-related literacies), as well as the generalizability of cross-generational transformations in knowledge, stigma, and trust across different cultural and geographical contexts.

Implications

This study has some important theoretical and practical implications. Theoretically, changing attitudes, such as stigma toward PwS, is a slower process, compared to changes that take place following learning practice (e.g., knowledge). However, as there is a weak negative association between knowledge and stigma (specifically ‘potential helpers’), even stigmatic attitudes can be modified, albeit more slowly.

In practice, more accepting and compassionate attitudes among immigrants from FSU, especially among the first generation, can be realized by developing and implementing special interventions aimed at both expanding the knowledge and softening the attitudes toward mental health conditions such as schizophrenia and psychosis. Culturally adapted interventions and psycho-educational programs can play a key role in this effort, specifically with highly educated first-generation FSU immigrants who, despite being accustomed to learning, experience a mental health knowledge gap with younger generations. Such programs may include information about the interaction between biological and social factors involved in the onset and relapse of psychotic symptoms, as well as evidence-based approaches to effective treatment and recovery-oriented rehabilitation. From the cross-cultural perspective, it is essential to highlight that only licensed medical, dental, and expert psychology professionals can legally perform hypnosis in Western mental healthcare and this method may be an effective treatment for anxiety disorders but can be harmful for psychotic conditions (Walker, 2016).

These psychoeducational efforts are particularly valuable in family counseling centers, which often serve as a first point of contact for individuals and families dealing with emotional or mental difficulties, including FSU immigrant families (Knaifel, 2023). Alongside this, culturally adapted psychoeducation can also be delivered through a range of other health and social settings such as general health clinics, primary care physicians, hospitals, and traditional healers who may provide first-aid support for FSU immigrants. In the case of PwS, these providers can play a mediating role by facilitating access to mental health services (Jarvis, 2025).

To enhance the trust of FSU immigrants in mental health services, it is important to communicate information about professional ethics among psychiatrists and other health professionals. Specifically, it is crucial to explain the commitment of mental health providers to maintaining the confidentiality and autonomy of PwS, as well as to clarify the recovery-oriented values, laws, and policies, and the limited practice of compulsory treatment. In Israel and other liberal countries, these policies protect the civil rights of people with SMIs (Aviram et al., 2023) and greatly limit the possibilities of forced hospitalization and social control, which were easily implemented in the Soviet Union (van Voren, 2010).

Henderson (2023) suggests leveraging social media to develop public campaigns aimed at guiding appropriate responses to SMI and changing attitudes toward PwS. However, for the FSU immigrant population, particularly older and less acculturated individuals, public education efforts must be delivered through venues that are both accessible and culturally appropriate. To address this need, Russian-language media can be engaged, including television channels and online platforms, which remain more popular and trusted sources of information among FSU immigrants (Remennick, 2025). In this context, the recovery narratives of FSU immigrants with schizophrenia who have gone through a rehabilitation process and achieved significant professional and social roles in their lives may especially contribute to alleviating stigma. For example, the Ministry of Health in Israel initiated the special project “Peer for Rights” (“Amitim le-Zhuyot”) in which mental health consumers with lived experience share their recovery stories to reduce public stigma toward SMIs (Steiman & Ben-Dor, 2022); it is vital to implement such practices among the Russian-speaking community.

Conclusion

This is the first study to examine schizophrenia literacy from a cross-generational perspective. Lower knowledge and more stigmatic attitudes toward schizophrenia are the lingering effects of living in the Soviet Union, putting first-generation immigrants in a vulnerable position, compared to 1.5 and second generations. Despite these cross-generational differences, the findings demonstrate that schizophrenia literacy across all FSU generations is relatively high, and in some dimensions of knowledge and trust there were no differences between generations. That may reflect the acculturative changes experienced by immigrants moving into a more pluralistic society.

Supplemental Material

sj-docx-1-tps-10.1177_13634615251409636 - Supplemental material for Schizophrenia literacy among former Soviet Union immigrants: A cross-generational perspective on knowledge, trust, and stigma

Supplemental material, sj-docx-1-tps-10.1177_13634615251409636 for Schizophrenia literacy among former Soviet Union immigrants: A cross-generational perspective on knowledge, trust, and stigma by Evgeny Knaifel, Rafael Youngmann, David Piterman and Efrat Neter in Transcultural Psychiatry

Footnotes

ORCID iDs

Evgeny Knaifel

Rafael Youngmann

David Piterman

Efrat Neter

Ethical considerations

The study was approved by the Institutional Review Board of Ruppin Academic Center (#2021–82). All respondents signed an informed consent form before their participation.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant awarded to the first author from the Institute of Immigration and Social Integration, Ruppin Academic Center, Emek Hefer, Israel.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

Author Biographies

Evgeny Knaifel, PhD, is a lecturer in the Faculty of Social Work at Ashkelon Academic College, Israel. He is a social worker specializing in mental health care and a training consultant at the community-based Yahel family centers, part of the non-profit organization Eychut Beshikum (AEPR). Dr. Knaifel previously completed postdoctoral research at the Institute for Immigration and Social Integration at Ruppin Academic Center and at the Department of Public Health at Ben-Gurion University of the Negev. His research examines the intersection of immigration and mental health, especially among immigrants from the former Soviet Union in Israel. His publications address health inequalities, mental health literacy, family caregiving, and the development of culturally adapted interventions and policies for immigrants and minorities.

Rafael Youngmann, PhD, is a Clinical Psychologist and retired Senior Lecturer from the Clinical Psychology Department at Ruppin Academic Center, Israel. He is a member of the Israel Association of Analytical Psychology (IAAP) and an IAAP Training Analyst. For the past 35 years, Dr. Youngmann has been deeply involved in research and consultations on culture and mental health issues in immigrant populations, particularly Ethiopian immigrants, refugees, and asylum seekers in Israel. Recently, his research has focused on mental health and human rights, and mental health literacy among immigrants and minorities. His publications cover topics such as idioms of distress, mental health services research, suicidal behavior, patterns of success in immigrants, and mental health literacy.

David Piterman, MA, PhD candidate, is a psychologist who currently serves as Research Lead at NATAL, where he oversees research on trauma, PTSD interventions, and the integration of digital evaluation tools in clinical settings. Mr. Piterman holds a master's degree in Clinical Psychology from Ruppin Academic Center, Israel and he is currently pursuing a PhD at the University of Haifa. His doctoral research focuses on the application of large language models (LLMs) in psychological training.

Efrat Neter, PhD, is a professor of Psychology in the Department of Behavioural Sciences at Ruppin Academic Center, Israel. Dr. Neter researches health behaviors, goal adjustment in the context of illness, digital health literacy in the context of the digital divide, and mental health literacy among ethnic populations in Israel. She is currently co-editor-in-chief of Health Psychology and Behavioural Medicine, and she served as a secretary for Psychology Coalition at the United Nations (2022–2024). Her published works focus on health behaviors and attempts to change behaviors, and on disparities in digital health literacy and mental health literacy.

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