Mental Health Literacy among the Palestinian-Arab Minority in Israel and Its Correlates with Mental Health Service Use

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Introduction
Mental health literacy (MHL) was frst conceptualized and defned by Jorm et al. [1] as knowledge and beliefs about mental health problems, including their recognition, management, and prevention. According to Jorm's (2000) conceptual framework, MHL incorporates six dimensions: (1) ability to recognize disorders, (2) knowledge of risk factors and causes, (3) knowledge of self-treatment, (4) knowledge of professional help available, (5) knowledge of where to seek information, and (6) attitudes that promote recognition or appropriate help-seeking behavior.
Over the decades, MHL has been understood as having a central role in promoting mental health outcomes [2][3][4][5][6]. Studies have shown that MHL is related to help-seeking intentions and behaviors, health-promoting behaviors, and use of mental health services [7][8][9]. Most studies that have examined MHL and its correlates with mental health service use based on Jorm's (2000) framework, however, they have used an overall index. Tis limitation is signifcant, since MHL is essentially a multidimensional concept, so that using an overall index prevents us from concluding about the specifc relationships of the various dimensions to the use of mental health services, and from tailoring interventions accordingly.
In addition, existing studies have been conducted specifcally among samples of Western or majority groups, so that little is known about the relationship between MHL and mental health service use among minorities. Examining MHL among minority groups is essential to address inequalities in mental healthcare [7,10], given that rates of seeking and utilizing mental health services are typically lower among these groups, including even individuals with severe mental illness [11,12]. Indeed, minority group members have reported less overall MHL than have individuals from majority groups [7,13], while lower MHL among minorities is recognized as a barrier to mental health service use [3]. Te current study aims to reduce the knowledge gaps regarding MHL dimensions and their relationship with service use by concentrating on the Palestinian-Arab minority in Israel. To the best of our knowledge, no study has yet assessed MHL within this group.
Palestinian-Arabs represent the largest minority in Israel, with 21% of the population [14]. Tey difer from the Jewish majority in their language, religion, culture, and socioeconomic characteristics. Compared to the individualist Jewish society, the Arab society is considered collectivist and traditional, despite undergoing sociocultural change processes in recent years [15]. In addition, the Palestinian-Arab minority is discriminated against and disadvantaged in terms of income, education, and employment [16]. Most importantly for our purposes, studies indicate higher rates of mental health problems among the Arab minority than among the Jewish majority [17,18]. Still, the percentage of Palestinian-Arabs in Israel who utilize mental health services is considerably lower than among the Jewish population-39% compared to 21% [19].
Based on this literature review, the present quantitative study examines the mental health literacy of the Palestinian-Arabs minority in Israel and its correlates with mental health service use. Informed by Jorm's [20] MHL framework, it does so using a battery of self-report questionnaires.

Participants and Procedure.
Tis cross-sectional research uses a convenience sample of 214 adult Palestinian-Arabs from Israel. Te two inclusion criteria were being a Palestinian-Arab citizen of Israel and being older than 18. Te fnal sample size was determined based on Green's [21] formula-N > 50 + 8p , where p is the number of predictors. Since this study included seven independent variables, the required sample size was 106 and above.
Participants meeting the inclusion criteria were interviewed face-to-face by the frst author, who also sent the survey form as an online link to additional relevant participants. Te participants in the face-to-face meetings completed their survey forms independently, and the frst author intervened only to answer clarifcation questions, taking care to remain objective and not bias their answers. We adopted this combined approach to data collection in order to make sure that not only Internet users completed the survey, but also potentially biasing our fndings. Conversely, we also sought to include participants who might have felt uneasy participating in a study on mental health in a stranger's presence, given the stigma on mental health prevalent in the Arab society [22,23].
Initially, the frst author interviewed participants who varied in age, gender, marital status, area of residence, and education. Subsequently, she asked them to refer her to additional participants (snowball technique). Similarly, she frst sent a link to the online survey to several participants, and asked them to forward it to others. Both interview types used a structured questionnaire form previously piloted with ffteen participants to ensure clarity. Te frst page of both versions provided a description of the study, and included an informed consent form and the authors' contact details. Only those who had signed the form or who had checked a box to indicate agreement to participate could proceed to complete the questionnaire. Note that due to the study's online component, the response rate could not be determined. Data collection occurred between July and October, 2021 and the study was approved by the Human Subjects Ethics Committee of Ben-Gurion University of the Negev, Israel. [24]. Te MHLS consists of 35 items, which examine six dimensions: (1) ability to recognize disorders (8 items), (2) knowledge of risk factors and causes (2 items), (3) knowledge of self-treatment (2 items), (4) knowledge of professional help available (3 items), (5) knowledge of where to seek information (4 items), and (6) attitudes that promote recognition or appropriate help-seeking behavior (16 items). All items related to the ability to recognize disorders, risk factors, and causes, and professional help available were rated on a 4-point Likert scale ranging from 1 � "very unlikely" to 4 � "very likely". Te questions about knowledge of self-treatment were rated on a 4-point Likert scale ranging from 1 � "very unhelpful" to 4 � "very helpful". Finally, the questions about where to seek information and attitudes that promote recognition or appropriate help-seeking behavior were rated on a 5-point Likert scale ranging from 1 � "strongly disagree" to 5 � "strongly agree". Eleven items were reverse-scored.

Mental Health Literacy. MHL was assessed by the Mental Health Literacy Scale (MHLS)
In the current study, the items in each dimension were summed, with a higher score in each of the six dimensions representing a higher level of that aspect of MHL. Te scale was translated from English to Arabic using the back-andforth method, and showed high internal consistency for all dimensions (Cronbach's alpha � 0.91, 0.67, 0.91, and 0.90 for dimensions 1, 4, 5, and 6, respectively). For dimensions 2 and 3, a signifcant relationship (p < 0.001) was found between the two items of each dimension (r s � 0.50 and 0.53, respectively).

Psychological Distress.
Psychological distress was assessed using the General Health Questionnaire (GHQ-12) [25], which contains 12 items rated on a 4-point Likert scale. Seven items were reverse-scored. Sample items were "Have you recently lost much sleep over worry?" and "Have you recently been thinking of yourself as a worthless person?" Following the original scoring method, an overall index was calculated by summing the scores of all items, where the scoring method became 0, 0, 1, and 1 instead of 1, 2, 3, and 4, respectively, providing scores ranging from 0 to 12, with higher scores representing higher levels of psychological distress. Te scale is available and validated in Arabic [26]. Te internal reliability of the scale in the current study was high (Cronbach's alpha � 0.89).

Sociodemographic Characteristics.
Te sociodemographic questionnaire referred to age, gender (male and female), marital status (single, married, divorced, and widowed), educational attainment in years, and income (above average, average, or below average in Israel). In addition, participants reported whether they used mental health services.

Data Analysis.
All data were coded and analyzed using SPSS-25 (IBM Corp., 2017). Descriptive statistics were used to describe participants' characteristics and the main variables. To assess diferences in sociodemographic characteristics and psychological distress between participants who reported mental health services use and those who did not, tand χ2 tests were performed according to the type of variable. In addition, t-tests were employed to examine the diference in MHL dimensions between the two groups.
Binary logistic regression analysis was conducted to examine the determinants of mental health service use. In the frst step, two sociodemographic variables found to be signifcantly related to mental health service use at the bivariate level were included as control variables: gender and education years. In the second step, psychological distress was added. Te last step included all MHL dimensions found signifcantly related to mental health service use: knowledge of professional help available, knowledge of where to seek information, and attitudes that promote recognition or appropriate help-seeking behavior. To assess multicollinearity, we examined correlations between all covariates and found no strong associations (r < 0.53).

Sample Description.
Most (68.2%) of the participants were women, with a mean age of 36.40 years (SD � 10.77, range � 18-72), and their years of formal education averaged 14.23 (SD � 4.77). Sixty-fve (30.38%) of the participants reported mental health service use (see Table 1). As can be observed, most of both service users and nonusers were female and married. However, signifcant gender diferences were found between the two groups in that regard. Significant diferences were also found in education, with more education years among those reporting using mental health services. Finally, and expectedly, participants who reported mental health services use had a signifcantly higher level of psychological distress. Table 2 lists the MHL dimensions' ranges, means, and standard deviations for the entire sample. In addition, it lists diferences in MHL dimensions between participants who reported mental health service use and those who did not. As can be observed, compared to participants who did not report mental health service use, those who did had higher levels of MHL in all dimensions. Statistically signifcant diferences (p < 0.001) between the two groups were found in three dimensions: knowledge of professional help available, knowledge of where to seek information, and attitudes that promote recognition or appropriate help-seeking behavior.

Determinants of Mental Health Service Use.
Te results of the binary logistic regression models predicting mental health service use are shown in Table 3. As can be observed, sociodemographic characteristics explained 7% of the variance in mental health service use. Psychological distress added 23% to the explained variance, and together with sociodemographic characteristics, they explained nearly one-third of the variance in mental health service use. With the addition of the three signifcant dimensions of MHL, the Cox R 2 was 0.38, indicating that 38% of the variation of mental health service use was explained by the estimated model. Having a higher education level, higher psychological distress, higher knowledge of where to seek information and higher positive attitudes that promote recognition or appropriate help-seeking behavior, were the most important determinants of mental health service use.

Discussion
Tis study examined Jorm's [20] six dimensions of mental health literacy (MHL) among the Palestinian-Arabs minority in Israel to determine their contribution to explaining mental health service use. Overall, we found an intermediate level or above in all MHL dimensions. Tese fndings were somewhat surprising given that several studies had indicated low MHL levels among ethnic minorities [7,13,27], as well as among the general public in several Arab countries [28,29]. Tree explanations may account for our fndings. First, the process of modernization in the Arab society in Israel has been shown to positively afect prevailing attitudes to mental illness, treatment, and stigma [22,23] and may therefore have also afected MHL positively. Second, most of our participants are women, with educational attainments higher than the average for the Arab society in Israel [30]. According to the literature, gender and education are signifcantly associated with MHL, with women and better educated individuals both reporting higher MHL [31,32]. Tird, the gap in MHL levels between the present study and previous ones may be the result of using diferent MHL measures.
Such gaps emphasize the need for a clear conceptual defnition and for standardized MHL measures. Our empirical fndings support the multidimensional concept of Perspectives in Psychiatric Care MHL [3], as it presents dimensions that have diferent relationships with mental health service use. Te fndings theoretically demonstrate that multidimensional scales should be used, as opposed to the tendency of most studies to examine MHL using vignettes that do not address MHL aspects and have psychometric validation issues [24]. Tis insight is critical at this point, given the growing interest in developing MHL-based psychoeducational programs in Israel.
Tis study corroborates the fndings of studies that have shown MHL to be related to mental health service use [32,33], but also extends them by addressing the specifc efects of each MHL dimension on mental health service usage. Two dimensions in particular have been identifed as signifcant service use determinants. Te frst is knowledge of where to seek information. According to [3], information is an important element in providing mental health frst aid and in reducing disparities in the use of mental health services. Our study highlights the importance of enhancing the ability to fnd mental healthrelated information, similar to fndings regarding the importance of concrete knowledge of mental illness and treatments as major predictors of both help-seeking behavior and disclosure of mental illness [34]. Accordingly, intervention programs need to provide information and teach users how to obtain it.
Te second MHL dimension found to be a signifcant determinant of using mental health services is attitudes that promote recognition or appropriate help-seeking behavior. Note that whereas other studies have explored mental attitudes and stigma attached to help-seeking behaviors and intentions, our study adds to the literature by directly linking attitudes to actual service use. Tese fndings are particularly important for groups with high negative attitudes towards mental disorders and their treatment, such as Arab societies [35], and for groups with low rates of mental health service use, such as various ethnic minorities [11]. Tey are consistent with recent studies showing that attitudes and perceptions in general are related to health outcomes and behaviors [36][37][38], and highlight the need for intervention programs to seriously consider improving attitudes and reducing stigma, alongside addressing barriers associated with minority service users' disadvantaged socioeconomic status.
Finally, previous fndings regarding the association between psychological distress and mental help-seeking behavior [38,39], have been confrmed. Tis means that even among societies with instrumental and cultural barriers to mental health service use such as the Palestinian-Arab minority in Israel, psychological distress may potentially overcome these barriers and motivate individuals to seek mental health services. Tis fnding emphasizes the importance of raising literacy regarding the identifcation of psychological distress, even though this study has not found the MHL dimension of ability to recognize disorders to be a signifcant determinant of service use.

Limitations.
Despite its contributions, the current study also has several limitations. First, the use of a convenient and culturally homogeneous sample limits the generalizability of our results and conclusions. Te sample includes only Palestinian-Arabs from central and northern Israel. Hence, the fndings may not be applicable to the Bedouin Arabs in the south. Second, our observational, cross-sectional design prevents us from inferring causal relationships. Tird, our data are based mostly on self-report measures administered online, which have several limitations such as preselection of high Internet users and the potential for inaccurate interpretation of certain questions. Finally, some of our data have been collected in face-to-face interviews, which might have involved social desirability bias.

Conclusions and Implications for Nursing Practice
Minorities may be more vulnerable to mental health issues but are at the same time less likely to seek help from mental health services. Our fndings broaden the existing knowledge regarding factors that infuence mental health service use among ethnic minorities, indicating that it is not determined only by the participants' sociodemographic and clinical characteristics. Instead, the MHL dimensions of knowledge of where to seek information and attitudes that promote recognition or appropriate help-seeking behavior are signifcant determinants as well. Tese fndings inform professionals and policymakers about the crucial role of MHL with relation to mental health service use and may provide the foundation for strategies to promote greater usage of such services by minority populations. Tey stress the need to develop tailored intervention programs that target MHL, particularly the dimensions found signifcant, in order to increase mental health service use. In addition, our fndings expand the existing knowledge regarding MHL among minorities, and non-Western ethnic minorities particularly. However, we recommend additional, qualitative studies to explore whether Jorm's [20] MHL framework is also suitable for these minorities, especially as Jorm [3] and others [39] have suggested that MHL should be understood based on individuals' cultural background and ethnic identity. Such future studies would enable to ethnoculturally adapt the framework to non-Western groups, and thus contribute further to understand the relationship between MHL dimensions and the use of mental health services and other health-related outcomes. [40].

Data Availability
Te data used in this study are available on request from the corresponding author.

Conflicts of Interest
Te authors declare that they have no conficts of interest.