Introduction

While there has been great attention given internationally to the dangers of getting infected by COVID-19 and to the associated morbidity and mortality risks, there has been growing awareness of associated risks to mental health, both short-term and long-term [1, 2]. Mental health concerns should be viewed not only as a consequence of the threat of the COVID-19 pandemic, but also as a concurrent epidemic [3]. There is a need for policy-makers to consider enhanced mental health services and to increase initiatives to improve mental health outcomes [3].

The risks to the mental health of COVID-19 have been found in Israel as well [4, 5]. These risks have been found to be greater among vulnerable populations including immigrants and/or racial and ethnic groups [4, 6]. The risk for suicide has been disproportionately high among ethnic minority groups during COVID-19, especially among those who experience discrimination [7, 8]; they are especially vulnerable because of distinctive language, culture, race, and immigrant characteristics. Although research so far is limited, there is reason to be concerned that ethnic groups have been at especially high risk for suicide because of the COVID-19 pandemic [8, 9]. Attention to the mental health needs of Ethiopian-Israelis, many of whom are immigrants as well as being a racial and ethnic minority, may be especially important. For example, higher suicide rates have been found among this group [10], a risk that can potentially be exacerbated by the various stresses of COVID-19.

It is not only mental health status and stressors but utilization of mental health services which can be affected by cultural factors and migration status [4, 11, 12]. Among immigrant and other underserved populations, there is usually a higher risk and need for mental health services, on the one hand, yet on the other hand, access to information and utilization of these services is often limited [12].

Stigma and inadequate mental health literacy (MHL) are examples of important barriers to the public in consuming appropriate mental health services. The lack of knowledge in the field of mental health can make it difficult for people suffering from mental illness to identify mental health problems or to locate a suitable source of treatment after identifying a problem [9]. This may especially be true for Ethiopian immigrants in Israel who are both an ethnic and racial minority and may have distinctive health-related perceptions as well as facing discrimination. However, little has been studied about how Ethiopians in Israel have been faring during COVID-19, both in general and in particular about mental health.

To fill this gap, this study analyzed a sample of Ethiopian-Israelis in order to examine both the mental-health challenges experienced by this community during COVID-19 and barriers to appropriate utilization of mental health care services. Specifically, it examined: the extent of mental health stressors and issues related to COVID-19 among Ethiopian-Israelis, the extent of stigma and lack of mental health care knowledge among this group during the period of COVID-19, whether results vary by immigration generation, and what information sources can potentially be used to help improve the situation.

Background

Ethiopian Immigrants in Israel

Migration is considered to be a significant turning point in life, and the greater the country of origin is different from the host country in its physical, social, and cultural environment, the greater the chance of mental and psychological disorders because of some of the following reasons. Many immigrants, including those from Ethiopia, experience trauma during the process of migration to Israel [13]. The longer and more difficult the adjustment process is for these immigrants, the more this experience is linked to the extent of cultural competence and appropriate staff training within its health-related institutions [14]. Feelings of discrimination can also affect the mental health of immigrants such as conflict, stress, fear, and social isolation often impact psychological well-being [15]. These factors can lead to poorer mental health and even suicide among Ethiopian-Israelis [10].

While common to all immigrants, the path of adaptation and absorption of a racial and/or ethnic minority in the country is an important factor affecting mental stability. There are distinctive characteristics of Ethiopian-Israelis which suggest a need to focus on this population separately. As noted below, these include special challenges for access to care, differing levels of health beliefs, and discrimination because they are both a racial and ethnic minority group of immigrants. They come from a non-Western country with many different cultural characteristics. Further, differences in the physical environment between the country of origin and the host country may cause stress during the adaptation process [16].

Approximately 50,000 Ethiopian Jews immigrated to Israel between 1981 and 2013 in primarily three waves [12, 17]. At the end of 2021, the population of Ethiopian origin in Israel was about 1.8% of the overall population, numbering 164,400 residents, including 90,600 who were born in Ethiopia [18].

Ethiopian-Israelis and Mental Health

Mental health and health care is an important issue in Israel, both in general and for Ethiopians specifically. Almost one in five Israelis surveyed reported feeling mental distress within the prior 12 months that was difficult for them to deal with on their own, yet only 36% of them sought treatment from a mental health professional, 47% turned to other sources for help, and 23% did not seek treatment at all [17]. A lack of appropriate mental health services utilization in Israel has especially been found among minority groups such as Ethiopians [19].

Although Ethiopian immigrants make up a low percentage of the population (1.8%), psychiatric hospitalization and suicide rates are high, even compared to other immigrant groups such as those from the Former Soviet Union [10, 20, 21]. However, in general, there has not been a high rate of mental health service utilization among those in need of mental health care within this group [16, 22].

There are several possible barriers to utilization. A common one is the challenge of language and access to mental health care services. Israel has universal health insurance. and Israeli citizens are entitled to a comprehensive “basket” of health care services provided by health plans (called kupot in Israel, which are similar to health maintenance organizations). The basket includes mental as well as physical health. Mental health caregivers within the health plans include psychiatrists, psychologists, and social workers [23].

However, this does not mean that those who are in need of mental health care all receive appropriate access, and this may especially be true of a racial/ethnic minority. There is a severe shortage of Ethiopian mental health care providers and/or providers who speak Amharic in Israel [21]. Although the Israeli Ministry of Health has adopted policies to try to improve such access, there is still a lack of legislation that explicitly regulates the linguistic accessibility and cultural adaptation of the health system to different populations [21]. In addition to linguistic access, immigrant patients need to be better trained and empowered to be able to interact with and ask questions of their providers[24]

Economic and cultural challenges are also reflected in reduced accessibility, with barriers existing even though basic medical services are provided free of charge because of the universal health insurance. For example, many families find it difficult to use the services due to transportation challenges and dependence on public transportation [25]. Different conceptions of time can also make it difficult for many Ethiopian immigrants to arrive on time for therapy appointments [14, 17].

However, there are important reasons beyond access that affect utilization and which have been given less attention. Stigma, both external and internal, is potentially an important barrier to people receiving needed mental health services. Developed from Goffman’s pioneering work [26], stigma is conceptualized as a complex social process of labeling, othering, devaluation, and discrimination involving an interconnection of cognitive, emotional, and behavioral components [27]. Mental illness-related stigma reduces people’s willingness to seek out needed mental health care services and creates serious barriers to access and quality care [27, 28]. Stigma can be related to a number of aspects of lives, including those especially important to Israeli society such as the military [29].

Stigma has been found to be related to another problem that can be especially prevalent among immigrants, mental health literacy, or the lack of knowledge about identifying mental health issues and where and when to seek appropriate care for them[30, 31]. The connection between stigma and lack of knowledge is complex and can be bidirectional [32].

Stigma and lack of mental health knowledge may be especially common among minority groups in Israel [28]. Patterns of utilization of mental health services have been found to be different among Ethiopian immigrants, who may have distinctive challenges and a need for culturally sensitive programs addressing them [10, 22, 33]. For example, the traditional Ethiopian mental health approach includes natural healing methods and mystical rituals [34]. Therefore, there can be suspicion towards the use of mental health services and mental health problems are not thought to warrant psychiatric treatment [34].

In addition to stigma, there may be differing perceptions related to mental health that can potentially affect the need for culturally competent care among Ethiopian-Israelis [35]. Different interpretations of symptoms and beliefs about mental health can cause misunderstandings between doctors and patients and lead to dissatisfaction with treatment. There can be sociocultural differences between immigrants from Ethiopia, a non-Western country, and Israeli mental health professionals that have been found to influence rates and patterns of mental health-related hospitalization [36]. Further, Ethiopian-Israelis may have differing spiritual and religious beliefs that can be related to health [37]. Ethiopian-Israelis, in particular, face discrimination in Israeli society, both at the individual and institutional levels [38, 39] This discrimination from various sectors of society may lead this population to have a greater need for mental health care yet also a greater reluctance to use the mental health care system.

COVID-19 and Mental Health Among Ethiopian Immigrants in Israel.

In general, migration can impact mental health and utilization for the first generation of immigrants, those who leave their home country, including those who have emigrated as children or adolescents, or what is often referred to as generation 1.5. This is because they maintain some host country characteristics and are not fully acculturated, with potential negative impacts on mental health [10, 33, 40]. Migration can also impact the second generation, those born to the first generation. For example, the influence of culture and/or of parents can have a great effect on how their children’s mental health services are consumed. Therefore, mental health stigma and lack of knowledge in one generation can potentially affect the mental health of other generations of Ethiopian-Israelis.

The topic of mental health among Ethiopians and other immigrants in Israel is especially relevant since the start of COVID-19, both in terms of the pandemic’s impact on mental health status and on mental health care utilization. As noted, COVID-19 can be a threat to mental health, not just physical health. There has been great stress, anxiety, and risk of depression found among Israelis during COVID-19, with variations observed by demographic groups, especially immigrants [4, 5, 41]. Although there is a paucity of research about Ethiopian immigrants’ mental health during COVID-19, one study during the early period of COVID-19 found that immigrants to Israel, albeit mainly from North America, were more likely to report anxiety than residents born in Israel [4]. Only a small percentage of the sample received mental health care from a professional, although native-born Israelis were less likely than recent immigrants to receive such care.

During COVID-19, there has been lowered access to mental health care services as a result of restrictions on travel and people’s fears of exposure to the virus. While some providers offered virtual services, not all did and not all patients had the technical capacity to receive care virtually [4]. This may be especially true among immigrants such as Ethiopians who are disproportionately from lower socioeconomic strata [18]. There may also be a shortage of mental health providers because of increased demand since the outbreak, with recent reports indicating this is a problem for immigrants in particular [42].

However, beyond access, there are other issues which could affect mental health care utilization during COVID-19. There exist different cultural attitudes towards mental health that can affect utilization not just mental health status [43]. This may be especially true among immigrants such as those from Ethiopia who are from non-Western cultures where mental health care is less prevalent and, again, are an ethno-racial minority that may face discrimination. This effect may be magnified during a crisis such as COVID-19 and research in other countries has found a disproportionately negative impact on mental health care utilization among immigrants because of COVID-19 [6].

However, despite the importance of better understanding stressors on mental health and barriers to appropriate mental care service use among Ethiopian-Israelis, and despite the importance of finding solutions to these challenges, there has been a paucity of research on the topic. This lack is even more problematic since the start of COVID-19, as there may be an increased need for mental health care services yet decreased availability of them.

Research Questions

  1. 1)

    To what extent are there mental health stressors and issues related to COVID-19 among Ethiopian-Israelis?

  2. 2)

    What is the extent of stigma and lack of mental health care knowledge among Ethiopian-Israelis during the period of COVID-19?

  3. 3)

    Do results for questions 1 and 2 vary by immigration generation?

  4. 4)

    What are the preferred sources of information about mental health-related topics among Ethiopian-Israelis?

Methods

Sample

The sample for this cross-sectional study consisted of 251 Ethiopian-Israelis between ages 18–55 who either migrated to Israel or whose parents migrated to Israel. Data was collected from October to December 2020, between lockdown periods in Israel. Shortly before the start of the study period, Israel had one of the world’s highest rates of per capita coronavirus cases and deaths. Even without a lockdown, there were severe restrictions in place including masking, social distancing, school and businesses closings, and limitations to the size of both indoor and outdoor gatherings. The severe physical threat of COVID-19 continued during the study period, with over 3000 new cases daily and an over 5% test positivity rate for COVID-19 by the end of it [44].

Participants were partly recruited using a “snowball” method, as the use of a random sample was especially challenging during the COVID-19 period. In an effort to maximize sample representativeness and validity, the survey was disseminated electronically by posting in social media/WhatsApp groups, among students, family, friends, and immigrant groups, and among professional groups of doctors, nurses, social workers, and psychologists serving the Ethiopian community in Israel. A link to the survey was disseminated by the primary investigator, student research assistants, nonprofits who focus on Ethiopian immigrants and leading mental health professionals in the community. The study was approved by the university ethics committee and all participants consented in writing to participate in the study.

Research Instrument

Respondents filled out a 49-question survey that was developed by the research team and implemented using Qualtrics XM software. The digital questionnaire used for this study was answered and commented on by a pilot group of 10 Ethiopian-Israelis. It was modified based on pilot results, to improve survey clarity and reduce the survey length, in an effort to increase the quality and number of responses. For example, an explanation of schizophrenia was added as well as an added assurance of the anonymity of responses before questions about mental health status deemed especially sensitive by those in the pilot.

The questionnaire included several components: mental health status and care utilization, mental health stressors related to COVID-19, mental health knowledge, external and self-stigma, and demographics. Previously validated questions were used to the extent possible. The sources for these questions are listed below.

The full six-question knowledge portion of the Mental Health Knowledge Scale (MAKS) was used [45]. MAKS is a knowledge-specific instrument that can be used to better understand how improvements in mental health-related knowledge might lead to changes in attitudes or behaviors. Respondents are read a series of questions related to knowledge about and treatment options for mental health illness. For each question read, they were asked to state whether they: “Strongly agree, slightly agree, neither agree nor disagree, slightly disagree or strongly disagree.” The tool’s authors stated that it was not developed to function as a scale and questions were analyzed separately. A study tested internal consistency for the MAKS and found a Cronbach’s alpha of 0.65. Overall test–retest reliability was 0.71 and item retest reliability, based on a weighted kappa, ranged from 0.57 to 0.87, suggesting moderate to substantial agreement between the two time points. Feasibility was rated as good based on time to complete the questions, range of scores, and use of a full range of response options.

We also used the Community Attitudes Towards Mental Health (CAMI) scale. The standard CAMI is a tool containing 40 items on a 5-point Likert scale, designed to assess community attitudes toward the mentally ill through four different dimensions, authoritarianism, benevolence, social exclusion, and community mental health ideology [46], and which has commonly been used to measure stigma [47]. Respondents are read a series of questions related to attitudes towards people with mental health illness and asked to state whether they “Strongly agree, slightly agree, neither agree nor disagree, slightly disagree or strongly disagree.”

We used a six-question version of the social exclusion portion of the CAMI. This scale is very widely used to measure stigma and its properties evaluated in several studies [47]. Internal consistency has generally been found to be good, with a Cronbach’s Alpha as high as 0.80 [46]. Test–retest results were more mixed, with some but not all studies showing acceptable scores. Correlations between the CAMI and other potentially related constructs were statistically significant and in the expected directions, partially supporting the scale’s construct validity.

The scale was adapted for Israeli society, including adding two questions about military or national service and about studying in religious institutions. The revised scale was found to still be reliable, with a Cronbach’s alpha of 0.74.

Individual questions about mental health status and services utilization as well as demographic questions were taken from an earlier survey on the topic performed by the Myers-JDC- Brookdale Institute [19]. A nationally representative sample of Israelis was surveyed in 2013 about a range of mental health status conditions as well as general distress and sought to determine to what extent professional care was sought and received. The survey also asked about confidence in the health care system. Questions on this survey were taken from earlier validated surveys in Israel when possible. Several additional questions in our study related to mental health stressors were taken from another survey conducted in Israel at the beginning of the COVID-19 period [4].

Where questions were based on an English language tool, previously validated translations were used when possible. When translations were not available, such as with the CAMI and MAKS, questions were translated professionally for this survey and then by a second translator and compared, with any differences between translations discussed. It was then pilot tested to confirm that the questions and answers were clear.

Analyses

Because the main focus of the study was differences between first and second generation, only respondents who provided country of birth were included, for a sample size of 225. Question responses were dichotomized when possible, which helped to increase analytic power given the relatively small sample size. Responses of “do not agree or disagree (neutral) and either disagree or agree” were typically grouped together, depending on the question, which has been indicated in the tables. Univariate and bivariate analyses were performed.

Bivariate analyses were performed using crosstabs to examine whether there was an association between immigrant generation, based on country of birth, and mental health-related outcome measures. These outcomes included a variety of stressors and types of knowledge; the variables are found in Tables 2, 3, and 6. Additional bivariate analyses were performed for types of stigma, found in Tables 4 and 5. Those born outside of Israel were considered first-generation immigrants and those born in Israel were second-generation immigrants. Note that all those born in Ethiopia were termed “first generation,” regardless of age of migration. The extent to which they may sometimes be considered to be generation 1.5 because of migration at a young age and the implications of this are discussed below. A Pearson’s chi-square test was performed to determine to what extent differences between generations were statistically significant. Analyses were performed using SPSS version 23.

Multivariate analyses were not performed, as on a theoretical basis, our interest was in determining if there were differences by immigrant generation so they could be appropriately targeted through public health initiatives, whether or not they were also associated with other variables. In addition, the relatively small sample size limited our ability to detect differences between groups in multivariate analyses.

Results

Sample Description

Table 1 presents statistics for sample demographics with breakdowns by immigrant generation. The sample represented a diversity of demographic characteristics: The range of ages was 18–55, with an average age of 35. In terms of gender, 31% of the sample was male and 54.2% of the sample was married. In terms of their religious identity, 27.9% defined themselves as secular, 49.3% as traditional, 20.5% as religious, and 1.4% as Haredi (often called ultra-orthodox). In terms of the level of education, 74.5% of the sample had some academic education, although were not necessarily college graduates.

Table 1 Demographic characteristics of the sample
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About 64% of the sample immigrated to Israel, with virtually all born in Ethiopia. Of the 82 respondents born in Ethiopia, all but one person arrived by age 18 and all but three by age 15, so, while definitions vary, virtually all of the sample born in Ethiopia would likely be considered immigrant generation 1.5, having arrived as children or adolescents.

Mental Health and Stressors

Table 2 presents findings for mental health status and COVID-19 stressors, including differences by immigrant generation. Overall, respondents generally reported good health and wellness but also experienced important levels of stress, both during their lifetimes and during the period since the COVID-19 outbreak.

Table 2 Measures of mental health status and COVID-19 stressors by immigrant generation
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Respondents were asked to rate their happiness on a scale from 1 to 7 and the average score was 5.66, with 20.8% reporting the highest level of happiness. In terms of overall health status, 60.9% reported that their health was at least very good and only 5.8% reported health as fair or below. Slightly over half of respondents, 51.8%, reported having ever experienced mental distress in their lifetimes, such as anxiety, depression, stress, etc.

The situation has worsened since the start of COVID-19. About 40% of respondents said they had experienced greater mental health distress since the outbreak in March 2020, while only about 6% felt less distress. Slightly more than 75% experienced increased worry about their and their family’s health and 38% of respondents experienced greater economic stress since the outbreak. Respondents typically felt they had social support, as only 13.3% did not report having someone they could rely on in a crisis.

There were some variations by immigrant generation. Compared to those born in Israel, those born in Ethiopia had higher levels of happiness, 24.4% vs 14.4%. They also felt greater concern about their health and their family’s health, 84.6% compared to 69.6%. These differences were statistically significant (p < 0.05).

Mental Health Care Utilization Attitudes and Knowledge

Table 3 describes findings for mental health care utilization and related knowledge and attitudes about the health care system, including differences by immigrant generation. In general, respondents showed a lack of readiness to receive mental health care when needed. for a number of reasons. One obstacle was a general lack of confidence in the health care system, with 42.9% saying they were not confident they would receive the best care. There was a lack of knowledge about where to get care, with only about 35% of respondents aware of the 2015 Israeli reform shifting mental health care provision from the government to the HMOs. Almost 23% of the sample said they did not know how to distinguish between different types of mental health care providers. Only 35.7% of the sample agreed that “Most people with mental health problems go to a healthcare professional to get help.” However, only 6.6% of the sample said that they personally would not seek professional help if they had a mental illness.

Table 3 Mental health care utilization and related knowledge and attitudes about the health care system
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The COVID-19 period had somewhat of a positive impact on readiness to use mental health care services, with 23% of respondents saying they were more willing to get professional mental health care. The only significant difference between immigrant generations was in the degree of confidence in the health care system, with 46.6% of those born in Ethiopia expressing confidence in it as opposed to 37.1% of those born in Israel (p < 0.05).

Mental Health Stigma

Table 4 presents the extent of mental health care stigma towards others, including by immigrant generation. Table 5 presents the extent of mental health care self-stigma and discrimination. We examined six types of stigma towards others, based on the validated CAMI tool questions, with some adapted for an Israeli population. Respondents were read statements expressing stigma. Responses were dichotomized as disagree vs agree/neutral, indicating at least some level of stigma. The least stigma was shown in response to the statement that the mentally ill should be isolated, with over 81% disagreeing with this idea. Almost 72% of the sample did not express reluctance to live next door to someone with mental illness, 73% did not oppose serving in the military or performing national service with someone mentally ill and 86% disagreed with the idea that someone with mental illness should not learn in a religious yeshiva or seminary. Only about 66% of respondents did not think that mental illness should affect the decision to marry someone even when they seem fully recovered and a little over half the sample, 51.6%, thought that people with mental illness should not be given any responsibility. There were no statistically significant differences between generations.

Table 4 Extent of mental health care stigma towards others by immigrant generation
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Table 5 Extent of mental health care self-stigma and discrimination
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In terms of self-stigma, of those who considered the question relevant to them, about 21% agreed with the statement that “stereotypes about the mentally ill applied to me” and 28% thought that their mental illness made them more isolated because of their race or ethnicity. Despite this, only about 7% said that they had definitely experienced discrimination because of mental illness. While 18.5% of respondents said that since the start of COVID they were more concerned of what others will think of them if they have a mental illness, a relatively similar amount, 21%, were less concerned. The only notable difference in the stigma results between immigrant generations was the percent of those feeling that their mental health illness made them more isolated because of their race or ethnicity. Over 10% more of the second generation expressed such a concern as compared to the first generation, although this difference was not statistically significant.

Mental Health and Resources Knowledge

Table 6 presents information about the extent of mental health and health care knowledge, along with differences by immigrant generation. In general, while most respondents knew the correct answers to questions about mental health care or could find them, large minorities did not. Only 68% of the sample were confident that they had access to resources about mental health illness, 66% felt confident that they could identify a mental health problem requiring treatment and virtually the same percentage correctly identified signs that someone had major depression. A similar percentage said they would know what advice to give a friend with a mental health problem. About 81% of respondents thought psychotherapy could be an effective treatment for mental health problems, while over 76% thought medications could be an effective treatment. However, only 46.5% thought people with severe mental health problems can fully recover.

Table 6 Health and health care knowledge by immigrant generation
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There were some significant differences between immigrant generations, with 73.9% of the first generation saying they knew what advice to give friends with a mental health problem and only 56.1% of those born in Israel saying the same thing (p < 0.05). In addition, 8% more of first-generation immigrants correctly identified symptoms someone had major depression, although 11% fewer thought that someone with mental health issues would seek employment, with differences significant at a marginal level (p < 0.10).

Sources of Information

Respondents were asked to rate to what extent they would like to receive mental health information from a variety of potential sources; respondents could select more than one choice. Results are found in Fig. 1. Respondents reported a diversity of preferences. The most popular information sources were family doctors and HMOs, each chosen as at least somewhat desirable by slightly over 75% of the sample. Selected by between 55 and 60% of respondents were: government offices, non-profit organizations, academic institutions, and internet sites; 40% said they would like to receive information from whoever they considered to be spiritual leaders. Almost 14% of respondents suggested an additional source not on the original list, with the most popular ones being the place of work and a specialist doctor.

Fig. 1
figure 1

Desired sources of information about mental health. Note: Respondents can select more than one source

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Respondents were also asked in what form they would like the information (results not shown in tables). Personal consultation at 68% was much more popular than either workshops or receiving printed materials, with 44% and 36% of respondents respectively, indicating they would like information in this form.

Discussion

There is a paucity about studies of the mental health of Ethiopian-Israelis in general and this study is, to our knowledge, the first to examine mental health status and barriers to utilization among Ethiopian-Israeli immigrants during the COVID-19 period. Another contribution is that most studies conducted with this population have focused on first-generation Ethiopian immigrants and not enough is known about mental health among second-generation immigrants. This article adds to the body of knowledge by analyzing differences between generations among Ethiopians in terms of mental health including knowledge, stigma, and help-seeking.

While to our knowledge there have not been other studies about the mental health of Ethiopian-Israelis during the COVID-19 period, a recent study of Russian-speaking Israeli immigrants found a mean emotional distress score of 0.62 out of a maximum of 3.0 among adults in the sample. A study of the general population in the early part of the pandemic found slightly higher levels of risk for depression, also using the PHQ2 tool [4]. Using different scales, however, a study of all Israelis during the early part of the pandemic found a normal level of anxiety, mild level of depression, and normal level of stress [48]. The current study’s results are also consistent with other research finding a general decrease in mental health status and an increase in stressors in Israel for the age group being studied since the start of COVID-19 [49].

The study also found that about half of Ethiopian-Israelis had experienced mental health distress over their lifetimes and about 40% had greater mental health distress since the start of COVID-19. A study during the early part of COVID-19 among the general population in Israel found. relatively high levels of perceived stress and corona-related worries, but low levels of anxiety [50]. This is consistent with other literature finding that in general there are greater mental health issues among immigrants as compared to non-immigrants, in Israel and elsewhere, including both first and second generations of immigrants. [43, 51]. Reviews of the literature have found immigrants to be at greater risk of mental illness because of a number of factors including traumatic events [52, 53]. The higher general risk of mental health distress is true among Ethiopian-Israelis. For example, immigrants from Ethiopia in Israel in general were at much higher risk of schizophrenia [54] and of suicide [10], when compared to both native-born Israelis and other immigrant groups, including those from the Former Soviet Union.

Few of the study respondents said they had experienced discrimination as a result of their mental distress yet over a quarter of respondents with mental illness said they felt more isolated because of their race or ethnicity. A similar phenomenon has been found among English-speaking immigrants in Israel and Blacks, Latinos, and Asians in the U.S. during COVID-19 with a negative impact on both their mental health status and mental health care, leading to mental health disparities [55,56,57]. It appears that being an Ethiopian-Israeli, both a racial and ethnic minority, can play a negative role in how one deals with mental health problems, even if it does not always lead to overt discrimination, through mechanisms such as the immigration process or cultural beliefs [58]. To what extent this finding is unique to COVID-19 or exacerbates a tendency that already exists, however, is unclear from the existing literature.

Dealing with the COVID-19 virus requires increased co** and awareness of and use of mental health services [59]. Our study found that there are still barriers to the appropriate use of mental health services among Ethiopian-Israelis beyond just access. Psychosocial factors, in particular stigma, can impact the appropriate use of mental health care services even when there is access among immigrants and/or racial and ethnic minorities.[60, 61]. Differences among cultural attitudes towards mental health issues may lead to differences in the level of stigmas felt by and expressed towards different groups in a society [60]. This is true not only of first-generation migrants but also of their children [62]. This stigma has led to worsened mental health among immigrants [61].

Interestingly, while almost one in five respondents said they were more concerned about what others will think of them if they have had a mental illness since the start of COVID-19, a relatively similar amount said they were less concerned. The reasons for this are not clear but it may be that there are differing effects of the pandemic on different subgroups. One hypothesis is that there can be increased community resilience and support in times of crisis despite sometimes lacking information about mental health and services, but not for all groups [4]. This topic should be explored further.

Some Ethiopian-Israelis may also not be receiving appropriate mental health care services when they have a need because of the lack of knowledge about how to identify mental health issues or where to receive care. The substantial lack of mental health literacy (MHL), especially when compared to non-immigrants is something that has been found among other immigrants as well. This is true among both among immigrants to countries in other regions such as North America, Europe, and East Asia as well as among Israeli immigrants from other areas, such as countries of the Former Soviet Union (FSU) [63,64,65]. We did not find an impact in MHL among generations, similar to what a recent study also found among FSU immigrants to Israel [33].

We found a relatively low level of confidence in receiving the best treatment among the study sample, 42.9%, although there was not a great gap between Ethiopian-Israelis and the confidence level of the rest of the Israeli population, 46% [66]. Surprisingly, significantly more of those in the sample born in Ethiopia have confidence in receiving optimal care than those born in Israel. One hypothesis is that a group of immigrants is more likely to trust the receiving country in relation to those born in it, feeling gratitude to the government who enabled their emigration while the younger generation did not experience this and may also be more willing to protest what they see as governmental and societal injustices. A similar phenomenon has been found among other Israeli immigrant groups such as those from the Former Soviet Union [67].

On the other hand, the COVID-19 period seems to have had a positive impact on readiness to use mental health care services, with almost twice as many respondents saying they were more willing to get professional mental health care than those less willing, although it is unclear if the greater readiness to get care will translate to changes in behaviors in the long-term. Perhaps stresses from COVID-19 as the pandemic continued raised awareness of the impact of social isolation and other stresses from COVID-19 and the need for care. There is support in the literature for a connection between social isolation and stress among racial/ethnic minorities, although not in all cases. A sco** review of literature about immigrants in Europe during COVID-19 found social isolation to be an important factor as many of the immigrants are removed from their families[68]. On other hand, a study in the USA found a connection between a greater need for social interaction and greater stress during COVID-19 because of the increased isolation but did not find that it varied by race.

Overall, there were few differences found when comparing the 1.5th and 2nd generations of immigrants in the sample. To our knowledge, a quantitative comparison of mental health status, stressors, stigma, or knowledge between 1 the 1.5th and 2nd generations of Ethiopian-Israelis has not been performed, even before COVID-19, making our study unique.

However, based on research among other immigrant groups in other countries, one might have expected differences in both mental health status as well as utilization of mental health care services between generations, with those in the 1.5th generation expected to be less likely than the 2nd generation to have mental health problems but more likely to use mental health services when they do have a need [11, 40, 69]. This may be because of reasons such as greater stress of immigration and less acculturation and adaptation to the dominant culture’s values and systems. One possible reason that, contrary to expectations, our study did not find such differences between these generations may be because Ethiopian families are especially close-knit and parents have a strong influence and pass on culture and values even to those born in Israel. There is support for this idea in the literature [70]. However, more research is needed.

There were still some differences between generations related to mental health and these are noteworthy. For example, although levels of mental health distress during COVID-19 are similar between the first and second generations in general, the level of concern about personal and family health in the COVID-19 period was notably higher among first-generation Ethiopians. We hypothesize that this is because of a heightened sense of responsibility from those who helped to bring their families to a new country and settle the family members there.

Implications

There are a number of important implications to this study, for both the Israeli health care system and groups external to it. There may be opportunities to improve the mental health of the Ethiopian-Israeli community during COVID-19 and beyond. A variety of potential solutions to reduce mental health stressors and overcome barriers to utilization that were identified, such as the initiatives mentioned below. Although there may be greater awareness in the population of mental health issues because of the stresses of COVID-19, policies to improve systems and organizations and to reduce barriers and improve access to services for racial/ethnic minority groups may still be needed [71, 72].

While barriers for Ethiopian-Israelis identified in the study were not always worse than those for the general population, differing solutions may be called for based on their distinctive cultural and contextual characteristics. Therefore, a need for increased cultural competence in mental health promotion and treatment is needed. We found that over half of the respondents do not believe that it is possible to “recover” from a mental illness. Recovery generally means that people can live a full and meaningful life even if not necessarily cured in the sense that some physical diseases can be [73]. Steps should therefore be taken to try to mitigate the effects of mental illness by increasing the level of awareness of the potential effectiveness of therapies and confidence in the success of treatments.

The findings suggest that the platform of HMOs and government institutions should be used to pass on the information regarding treatment options for mental illness. This may especially be needed among Israelis born in Ethiopia. For example, the traditional approach to mental health among Ethiopians includes natural healing methods and there can be suspicion towards mental health services as mental health problems are not thought to warrant psychiatric treatment such as medications [34, 37].

There is a shortage of mental health professionals from the Ethiopian community in Israel. Recruitment of more professionals such as social workers, psychologists, and psychiatrists from the Ethiopian-Israeli community is needed. There is also a need to help find solutions to mediating language difficulties and cultural disparities during care, and in general to strengthen trust in the health care system [14, 20]. Using intermediaries for translation and mediation between patient and therapist is a common means to expand the linguistic accessibility of medical services [20, 74, 75]. While the use of interpreters has been shown to improve communication and increase satisfaction among patients [76], such use is not without problems and enabling language-concordant encounters for immigrant mental health patients may be especially important [77].

There may be inadequate awareness in the Israeli mental health community about Ethiopian cultural issues which can affect stigma and greater cultural competence training needed among mental health providers may be needed to increase such awareness [20, 34]. Interestingly, survey respondents still preferred personal consultations with health care providers over the internet or printed materials despite the challenges of the COVID-19 period and lack of confidence in the health care system. Mental health care providers and educators at the health plans should be trained to better understand the distinctive needs and beliefs and barriers related to improving mental health literacy (MHL) and thereby mental health status among Ethiopian-Israelis [30].

It is vital that culturally responsive initiatives for populations with lower levels of MHL be developed to increase relevant knowledge and help-seeking behaviors. A sco** review of the literature about Asian immigrants in the USA stressed the importance of increasing the ability to identify the causes of mental health issues and when care is needed as well as a better understanding of treatment options for immigrants, while taking into account culturally different attitudes towards mental health [31]. A recent article highlighted the differential impact of COVID-19 on mental health based on ethnicity [9].

Appropriate support and training should also be given to non-profit organizations which provide often anonymous assistance and/or referrals for mental health issues to make sure they understand and meet the needs of the Ethiopian-Israeli community. These organizations are often trusted resources and can also organize workshops within the community to increase MHL.

Printed materials can still play a role in improving MHL as well as enabling the use of the internet to find appropriate knowledge about mental health [30]. Increased teaching of self-help strategies for dealing with mental health stressors may be useful for those unwilling or unable to turn to others for support when facing a mental health issue [31]. It should also be noted that programs should be targeted to adolescents, not only adults; there are examples of low-cost successful school-based initiatives for this age group that can be replicated [30, 78].

There is a need to increase trust in the health care system and our study found this to be especially true among the second generation of Ethiopian-Israelis. A recent article examined the Ministry of Health’s success in increasing trust between Israel’s Ministry of Health and the Haredi religious community regarding COVID-19 guideline adherence and vaccination [79]. It suggested that similar initiatives could be successful among other minority groups in Israel and other areas of health; and such an initiative related to mental health should be considered for the Ethiopian-Israeli community.

Our findings generally suggest a need to increase knowledge about mental health issues and the mental health care system from a diverse body of information sources, which may in turn serve to reduce stigma. Further, because of differences in the types of knowledge lacking that exist between generations, the development of separate programs for each may be warranted.

While respondents preferred family doctors and HMOs as information resources. there may be less access to the health care system during crises such as COVID-19 and/or a shortage of providers so other sources may need to play a more prominent role in disseminating information. For example, respondents in a study during the early part of COVID-19 viewed multiple elements of their social community as important resources and reported an increase in the importance of community since the start of the crisis [4]. Social support has been found to improve mental health literacy among minority groups [31].

A Community Health Worker model can also be a cost-effective option in situations where there is a lack of manpower and trust in the system among immigrants and useful across a wide range of health conditions [80]. While more widely used in other countries such as the USA, they have been used in an earlier initiative among Ethiopians in Israel [75] and may be useful for mental health programs. Israeli HMOs have started using liaisons to the Ethiopian community (called “megashrim” in Israel) regarding mental health issues but there may be a need for more of them, an idea also recommended in the literature to increase health literacy among Ethiopian-Israelis [30].

It is noteworthy that about 40% of respondents said they would like to receive information from a spiritual leader, almost twice the percentage of those in the sample identifying themselves as religious. This is not necessarily surprising, however, as there is a connection between religious beliefs and health among Ethiopian-Israelis as well as distinctive spiritual beliefs [37]. There is evidence that even non-religious Israelis sometimes turn to independent rabbis (sometimes called “rabbanim askanim” in Israel) for referrals for physical health issues [81] and there may be an opportunity to use them to increase needed use of mental services among many Ethiopian-Israelis. Religious leaders, kessim, play a prominent role for Ethiopians and can increasingly serve as trusted sources of mental health information for Ethiopian-Israelis. However, appropriate training must be given to increase religious or spiritual leaders’ mental health literacy and ensure they know when and where to refer people to the mental health care system and even sometimes disseminate mental health knowledge themselves [82].

Limitations

There are a number of limitations to the study. The sample is not fully representative of all Ethiopians. It is disproportionately educated and female compared to the overall Ethiopian population and there were also differences in these characteristics between generations. For example, in our study, almost three-quarters of the sample had at least some college education while in the general population, only a little over half of Ethiopians had even matriculated from high school [18]. While there is no reason to conclude that the underrepresentation of some subgroups necessarily negates our major findings and additional bivariate analyses we performed found that gender and education were associated with few of our outcome measures, results of the survey should still be interpreted with appropriate caution. However, because there is so little research about the topic of our study, we think it still makes a valuable contribution despite any potential limitations in generalizability.

The survey sample is not necessarily representative of Ethiopian-Israelis do not have a high level of Hebrew or who were not computer literate since the survey was given only in Hebrew and distributed online. However, we consulted with Ethiopian-Israeli key informants about the language of the survey and they thought that given the target range of the survey, there was not a need to translate it into Amharic so it is unlikely that this is a major problem.

Studies addressing our research questions using larger and more representative samples of Ethiopian-Israelis across several generations should be conducted when feasible, to better enable additional subgroup analyses as well as multivariate analyses. The first-generation immigrants in the study emigrated at a young age, or what is sometimes called generation 1.5. Results would likely be magnified had the study population consisted of older first-generation immigrants, who arrived in Israel at an older age, where there was likely a larger home country impact, as has been found in some studies with other groups [43].

It is not clear to what extent findings are generalizable to non-Jewish Ethiopians or Ethiopian Jews who migrated to other countries. Additional research about these groups is needed as well.

Due to the sensitivity of the topic of mental health, there may have been social response bias that affected the veracity of answers. Therefore, the extent of stigma found may actually be higher than what was reported, although the survey was anonymous in an effort to keep such bias to a minimum.

Those who were neutral were typically categorized together with those who agreed for dichotomized variables for questions about stigma as well as some other questions. To make sure this categorization did not change results, we reran the analyses comparing generations using agree, disagree, and neutral as separate categories. We found that this did not change key findings through shifts in what is statistically significant. However, additional research, perhaps on a qualitative basis, is needed to probe what neutrality represents and a larger sample size could facilitate detecting differences between those who were neutral and those who agree or disagree.

The study was conducted at a certain point in time during the COVID-19 in Israel, and it is possible that following additional waves of COVID-19 as well as vaccination, the severity of the mental distress, the stigma, and the knowledge about mental health services and the connections between them, may have changed.

Comparisons between Ethiopian-Israelis and non-Ethiopian-Israelis for physical measures of health and their connection to mental health differences were beyond this study’s scope but would complement and build upon the study’s findings. We also recommend conducting research into feelings toward the host country between first- and second-generation Ethiopian immigrants in Israel, which would test some of our hypothesized reasons for some of the findings.

Conclusion

Mental health has a very broad meaning both in the functioning of the individual and in its implications for family and the upbringing of the next generation as well as potentially providing resilience during crises such as COVID-19. Mental health treatment options should be made available and familiar to everyone. Increasing knowledge related to mental health among the Ethiopian community in Israel can contribute to the mental health and wellness of the community and thus strengthen overall well-being.

However, there are excessive levels of external and internal stigma as well as a lack of relevant knowledge that can be barriers to the appropriate use of mental health services among the Ethiopian community in Israel, so there is a need to take steps to increase mental health literacy. These problems are especially important in light of COVID-19, when there may be a greater need for treatment but they have relevance during other periods as well.

This study sheds light on potential means to try to overcome these barriers and potentially reduce disparities. The Ethiopian-Israeli community is characterized by a strong and distinctive cultural tradition and a willingness to provide help to community members when needed but there should also be culturally appropriate support from sources from both within and external to the formal mental health care system.