Prevalence and predictors of mental health stigma among Greek and Greek-Cypriots residing in the United Kingdom

Prevalence and predictors of mental health stigma among Greek and Greek-Cypriots residing in the United Kingdom | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and predictors of mental health stigma among Greek and Greek-Cypriots residing in the United Kingdom Chris Papadopoulos, Andreas Patikis This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6731958/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Mental health stigma represents a significant barrier to accessing care, particularly within collectivist cultures such as Greek and Greek-Cypriot communities, often tied to concepts of family honour and social standing. This study examined the prevalence and predictors of mental health stigma among Greek and Greek-Cypriot adults in the United Kingdom, focusing on stigma levels, associations with personal and indirect mental health experiences, therapy engagement, perceived cultural importance of therapist alignment, and self-advocacy. Methods A cross-sectional online survey was completed by 162 participants. Mental health stigma was measured using the Reported and Intended Behaviour Scale. Statistical analyses included univariate tests and a Generalised Linear Model; qualitative responses underwent thematic analysis. Results Results indicated moderate to low overall stigma. Univariate analyses revealed significantly lower stigma among individuals with personal mental health experience, knowledge of someone with mental health issues, prior therapy engagement, perceived cultural importance of therapist alignment, and self-advocacy behaviours. Multivariate analysis identified personal experience of mental illness and valuing culturally congruent therapists as independent predictors of lower stigma. Qualitative findings highlighted participants' perceptions of mental health, approaches to supporting others, and sources of mental health knowledge. Conclusion The study concludes that personal experience with mental health issues and the perceived cultural congruence of therapeutic support are crucial factors associated with reduced mental health stigma within this population. Findings underscore the potential value of culturally tailored interventions and services aimed at promoting openness, enhancing help-seeking, and further reducing stigma in Greek and Greek-Cypriot communities. Introduction Mental health stigma represents a significant barrier to accessing care and achieving positive outcomes for people experiencing mental health difficulties across various cultures. However, stigma is neither experienced nor enacted uniformly, with evidence suggesting substantial cultural differences in its nature and intensity (Abdullah & Brown, 2011 ; Papadopoulos, Foster & Caldwell, 2013 ; Papadopoulos et al., 2019 ). Within collectivist cultures, such as Greek and Greek Cypriot communities, the presence of stigma has often been attributed to a cultural emphasis on familial honour, social cohesion, and maintaining one's social standing (Papadopoulos, Leavey & Vincent, 2002 ; Papadopoulos et al, 2013 ; Ran et al 2021 ; Lagunas et al, 2025 ). Consequently, mental illness is frequently perceived not only as an individual's challenge but also as a collective threat to family reputation and social harmony, thus exacerbating negative attitudes and behaviours (Papadopoulos et al, 2013 ; Tzouvara, Papadopoulos & Randhawa, 2016 ; Ran et al, 2021 ). A phenomenological study by Kaite et al. ( 2016 ) supports this, revealing that Greek Cypriot individuals with mental illness often experience their condition as a source of shame and social exclusion, intensifying the cultural pressure to conceal their struggles. Previous foundational studies examining mental health stigma among Greek and Greek Cypriot populations have consistently highlighted elevated stigma compared to more individualistic Western cultures (Papadopoulos et al., 2002 ; Papadopoulos et al., 2013 , Tzouvara & Papadopoulos, 2014 ; Kaite et al, 2016 ). Kaite et al. ( 2016 ) specifically highlight the significant distress experienced by individuals living with severe mental illness within Greek Cypriot communities, emphasising the social stigma associated with psychiatric hospitalisation, medication use, and welfare dependency. These studies demonstrate that stigma persists strongly among diaspora communities, including second-generation Greeks and Greek Cypriots living in the UK, suggesting that cultural transmission of stigma remains potent across generations (Papadopoulos et al., 2002 ). Indeed, stigma within these communities tends to result in concealment of mental health issues, reluctance to seek help, and significant delays in accessing professional support (Amri & Bemak, 2012 ; Tzouvara & Papadopoulos, 2014 ; Altweck et al, 2015). Kaite et al. ( 2016 ) further illuminate this by describing the ‘unbearable’ suffering of individuals, compounded not only by their illness but also by societal labelling and the stigma tied to medication. Collectivist cultural frameworks, particularly the vertical collectivism seen in Greek and Greek Cypriot communities, provide useful insights into understanding stigma dynamics. Vertical collectivism, characterised by high respect for hierarchy, conformity, and maintaining ‘face’ or social reputation, may underpin the pronounced stigma towards mental health issues (Papadopoulos et al., 2013 ). Specifically, the fear of damaging family honour and the broader social image often leads individuals to avoid acknowledging mental health issues publicly or privately, creating a barrier to support and recovery (Aruta et al, 2021 ; Sum et al, 2024 ). Religious and spiritual beliefs prevalent within Greek and Greek Cypriot communities further influence stigma. Greek Orthodox Christianity, deeply embedded within community life, traditionally frames mental illness through spiritual or moral lenses, which may exacerbate stigma and hinder help-seeking behaviours (Economou et al, 2012 ; Tzouvara & Papadopoulos, 2014 ). High religiosity has been associated with greater stigma due to perceptions of mental illness as indicative of moral failure or spiritual weakness, thus amplifying shame and silence around mental health challenges (Economou et al., 2012 ; Fekih-Romdhane et al., 2023 ; Booth et al, 2024 ). Empirical research has indicated that familiarity and personal experience with mental health problems can also moderate stigma levels. Studies reveal that individuals who have either personally experienced mental illness or had close contacts with mental health conditions exhibit reduced stigmatising attitudes (Evans-Lacko et al, 2013 ; Robinson & Henderson, 2019 ; Potts & Henderson, 2020 ). Limited contact and poor mental health literacy are also significant predictors of heightened stigma within the Greek Cypriot diaspora (Papadopoulos et al., 2002 ; Papadopoulos et al, 2013 ; Kaite et al, 2016 ). Given these insights, exploring specific dimensions such as prior therapy experience, the cultural relevance of therapists, and self-advocacy efforts becomes particularly important. Previous therapy engagement might be hypothesised to reduce stigma by increasing familiarity and literacy around mental health issues, thereby nurturing empathy and understanding. The perceived cultural relevance of a therapist - defined by shared language, values, and cultural understandings - could similarly mitigate stigma through improved therapeutic rapport and greater acceptance of mental health support (Truong et al, 2014 ; Smith & Trimble, 2016 ; Huang& Zane, 2016 ). This shared cultural context might facilitate openness, improve communication, and increase trust, ultimately influencing attitudes positively. However, empirical evidence specifically exploring these dynamics in Greek and Greek Cypriot communities remains sparse. Understanding these factors is increasingly pertinent as openness to mental health therapy grows across various communities, including collectivist societies like the Greek and Greek Cypriot populations. Recent studies indicate a gradual shift towards greater acceptance of mental health services among Greek Cypriots, suggesting a positive trend in help-seeking behaviours (Tzouvara & Papadopoulos, 2014 , Alexi et al, 2018 ; Zorba et al, 2019). This evolving landscape underscores the need for culturally sensitive approaches that address unique community dynamics, potentially enhancing the effectiveness of mental health support. Additionally, self-advocacy - the act of speaking out or taking action in support of oneself or others experiencing mental health difficulties - is a promising but under-researched area. Encouraging self-advocacy may enhance empowerment, reduce internalised stigma, and enable more inclusive community attitudes (Corrigan, Kosyluk & Rüsch, 2013 ). Kaite et al. ( 2016 ) suggest potential in this area, as participants expressed a desire to share their experiences during research interviews, hinting at an emerging capacity for self-advocacy that could challenge stigma. However, despite its potential, the link between self-advocacy behaviours and reduced stigma within collectivist Greek and Greek Cypriot contexts has not been explicitly explored, leaving a gap in the literature. Addressing these gaps holds both theoretical and practical significance. Theoretically, further understanding of how specific culturally relevant factors like previous therapeutic experiences, therapist cultural alignment, and self-advocacy influence stigma can refine existing stigma reduction models within collectivist communities. Practically, identifying actionable targets for stigma reduction interventions can directly inform culturally tailored community outreach programmes, educational initiatives, and clinical practices. Furthermore, given the established relationship between stigma, delayed help-seeking, and poorer mental health outcomes, insights from this study could support policy development aimed at improving mental health literacy, enabling culturally sensitive therapeutic services, and encouraging proactive mental health advocacy within the Greek and Greek Cypriot communities. In response to these needs, the current study aimed to explore mental health knowledge and attitudes, particularly stigma, among UK-based Greek and Greek Cypriot adults. Specifically, the research had four primary objectives: (1) to assess levels of stigma within this community, (2) to examine the associations between previous mental health experiences and stigma, including personal history of mental health problems and prior therapy engagement, (3) to evaluate the perceived importance of having a therapist from the same cultural background, and (4) to investigate the potential relationship between self-advocacy behaviours and stigma levels. By addressing these objectives, this study seeks to extend current understanding of stigma within Greek and Greek Cypriot populations and identify potential avenues for culturally informed interventions aimed at reducing stigma and enhancing mental health outcomes. Methods Study design and participants A cross-sectional study was conducted to explore mental health knowledge and attitudes, with a particular focus on stigma, among UK-based Greek and Greek Cypriot adults. The research employed an online questionnaire survey that gathered data from January 2024 over a period lasting approximately six months. The data collection took place entirely online using various social media platforms, including Facebook, LinkedIn, Instagram, Twitter, and other specialised networks targeting the Greek and Greek Cypriot communities in the UK. Eligibility criteria required participants to be adults aged 18 or older, self-identifying as Greek or Greek Cypriot, and residing within the United Kingdom during the data collection period. Data collection Data were collected via an online questionnaire, initially hosted on Google Forms and subsequently transferred to the Qualtrics platform for secure management and analysis. Mental health stigma, the primary dependent variable, was measured using the Reported and Intended Behaviour Scale (RIBS) (Evans-Lacko et al., 2011 ), consisting of four items scored on a 5-point Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). Possible RIBS scores ranged from 4, indicating high stigma, to 20, indicating low stigma. Independent variables included knowledge about mental health, previous mental health experiences (such as personal mental health issues, previous therapy engagement, and knowledge of someone with mental health problems), and perceived cultural importance of having a therapist from the same cultural background. Additionally, socio-demographic characteristics including age, gender, ethnicity, first language, occupation, marital status, place of birth, educational level, religion, and religiosity were collected. Qualitative data were also gathered through open-ended questions exploring perceptions of good and bad mental health, responses to mental health concerns in children and acquaintances, sources of mental health knowledge, and suggested improvements for mental health understanding. Ethical considerations Participants provided informed consent digitally, confirmed by proceeding past an explicit consent statement presented at the beginning of the survey. Given the sensitive nature of mental health topics, clear trigger warnings and information on accessing support (including contact details for the lead researcher, MIND, and The Samaritans) were provided. Confidentiality was maintained by not collecting any personally identifiable information, ensuring participant anonymity throughout the study. The study received ethical approval from the University of Bedfordshire’s Institute for Health Research Ethics Committee on 28th January 2024 (ref: IHREC1017). All procedures were conducted in accordance with the ethical principles set out in the Declaration of Helsinki. Analysis All statistical analyses were conducted using IBM SPSS Statistics (version 29). The dataset was examined for missing data, and listwise deletion was applied to ensure only cases with complete responses were analysed. Descriptive statistics summarised sample characteristics and the distribution of key variables. The Kolmogorov-Smirnov and Shapiro-Wilk tests, along with skewness and kurtosis values, indicated that the RIBS total score was non-normally distributed, supporting the use of non-parametric statistical methods where necessary. Univariate analyses were conducted to examine the relationship between each independent variable and stigma scores. Mann-Whitney U tests were used for categorical variables, and Spearman’s rank-order correlation for continuous variables. Predictors that showed significant associations were entered into a Generalised Linear Model (GLM) to assess their independent effects. The GLM specified a Gamma distribution with an identity link function, appropriate for the non-normal dependent variable. Wald chi-square tests assessed predictor significance, and model fit was evaluated using Akaike’s Information Criterion (AIC), deviance, and Pearson chi-square statistics. Qualitative data, collected through open-ended survey responses, were analysed using thematic analysis, following the six-phase approach outlined by Braun & Clarke ( 2006 ): (1) data familiarisation, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the final report. Following immersion in the data, initial codes were developed based on participants’ responses using NVivo Software (QSR International Pty Ltd). These codes facilitated the identification of emergent themes across individual responses. A cross-analysis was then conducted, systematically comparing themes across different participants’ responses to identify commonalities and divergences in experiences and perceptions. To enhance rigour and trustworthiness, intra-coder agreement exercises were conducted. The coding process was revisited at multiple intervals to ensure consistency in the application of codes, with comparisons made across a random sample of the dataset. This process confirmed a high level of coding consistency, affirming the reliability of the thematic analysis. Results Descriptive results The study included 162 participants with a mean age of 45.2 years (SD = 14.88, range = 18–83). The sample comprised 111 females and 51 males. The majority were married or in a civil partnership (n = 101), followed by 24.1% single (n = 39), with smaller proportions divorced, widowed, or in other statuses. Greek was the primary language for 53.1% of participants (n = 86), English for 46.3% (n = 75), and one individual (0.6%) spoke another language (n = 1). Regarding birthplace, the majority (60.5%) were born in the UK (n = 98), while 36.4% originated from Greece or Cyprus (n = 59). Education levels varied: 35.8% held undergraduate degrees (n = 58), 22.2% had A-levels or college education (n = 36), 13% completed GCSEs (n = 21), 21.6% earned postgraduate degrees (n = 35), and 6.2% held doctorates (n = 10). The majority (64.8%) identified as Greek Orthodox (n = 105), followed by 13.6% Christian (n = 22), 11.7% Atheist/None (n = 19), and 9.9% Other (n = 16). Religiosity levels included 45.1% as somewhat religious (n = 73), 26.5% as quite religious (n = 43), 9.3% as very religious (n = 15), and 19.1% as not religious (n = 31). Regarding cultural attitudes, 67.3% (n = 109) of participants rated the importance of therapy in their culture as ‘not at all’ or ‘slightly important,’ while 32.7% (n = 53) considered it ‘moderately’ or ‘extremely important.’ When asked about advocating for mental health, the majority (81.5%, n = 132) agreed or strongly agreed that they had spoken up in support of someone experiencing mental health difficulties, while 18.5% (n = 30) disagreed. On the importance of advocacy for improving the situation of people with mental health problems, 57.4% agreed (n = 93) and 41.4% strongly agreed (n = 67), with only 1.2% disagreeing (n = 2). Regarding willingness to support or join a mental health advocacy group or campaign, 65.4% agreed (n = 106) and 22.2% strongly agreed (n = 36), while 12.3% disagreed (n = 20). Finally, 47.5% agreed (n = 77) and 34.0% strongly agreed (n = 55) that they had spoken up for themselves or someone else with a mental health problem in the past year, while 18.5% disagreed (n = 30). The mean stigma score was 15.84 (SD = 3.33), with observed scores ranging from 4 (indicating high stigma) to 20 (indicating low stigma). Over half of the participants (53.7%, n = 87) reported having personally experienced a mental health condition, while 58.6% (n = 95) had previously accessed mental health therapy or counselling. Among those who had received therapy, 44.4% (n = 72) found it helpful, whereas 25.3% (n = 41) did not. The remaining 30.2% (n = 49) had never received therapy. In terms of personal connections to mental health, the majority (79.6%, n = 129) reported knowing someone with a mental health condition, while 11.1% (n = 18) did not, and 9.3% (n = 15) were unsure. Univariate analysis Participants who reported having experienced mental health issues themselves demonstrated significantly lower levels of stigma compared to those who had not (U = 1821.5, Z = -4.895, p < 0.001). Similarly, individuals who had previously visited a psychiatric hospital exhibited significantly lower stigma scores than those who had not visited such facilities (U = 2300.0, Z = -2.032, p = 0.042). Furthermore, participants who knew someone with a mental health problem were significantly less likely to hold stigmatising attitudes compared to those who did not know anyone with a mental health issue (U = 697.5, Z = -2.776, p = 0.006). Additionally, having previously accessed mental health therapy was significantly associated with lower stigma scores (U = 1972.5, Z = -4.162, p < 0.001). Among those who had accessed therapy, participants who found it helpful had significantly lower stigma scores compared to those who did not find therapy helpful (= 1025.0, Z = -2.559, p = 0.010). Furthermore, the cultural importance of having a therapist from the same background was significantly associated with lower stigma scores (U = 1862.0, Z = -3.706, p < 0.001), and participants who had previously spoken up for themselves or others regarding mental health issues also reported significantly lower stigma scores (U = 1425.0, Z = -2.420, p = 0.011). However, there was no significant difference in stigma scores based on gender, age, place of birth, marital status, educational level, religion or religiosity. Multivariate regression analysis Multivariate regression analysis using a generalised linear model revealed independent predictors of mental health stigma when adjusting for all significant variables identified from univariate analyses. The cultural importance of having a therapist from the same cultural background emerged as a significant independent predictor of lower stigma scores (B = 1.483, Wald = 7.858, p = 0.005). Additionally, having personally experienced mental illness was independently associated with significantly lower stigma (B = 1.628, Wald = 5.741, p = 0.017). Although participants who had previously spoken up for themselves or others regarding mental health issues showed a strong trend towards lower stigma, this association narrowly missed statistical significance (B = -1.187, Wald = 3.511, p = 0.061). Variables such as having accessed mental health therapy, knowing someone with mental health issues, and finding therapy helpful did not significantly predict stigma scores when controlling for other variables. The model demonstrated good overall fit, as indicated by the Likelihood Ratio Chi-Square test (χ² = 40.789, df = 8, p < 0.001). Goodness-of-fit indices such as Deviance (value = 6.595, value/df = 0.043) and Pearson Chi-Square (value = 5.829, value/df = 0.038) further indicated strong model adequacy. Qualitative results Qualitative analysis revealed several key themes related to perceptions of mental health. The themes that emerged when asked queried, ‘What is good mental health to you?’ were the effective management of emotions, experiencing happiness, handling stress successfully, and maintaining enjoyment in life. Other themes were healthy balance between work, personal time, and relationships, as well as good physical health and strong interpersonal connections. When asked, ‘What is bad mental health to you’, the themes that emerged were feelings of anxiety, low mood, and being overwhelmed, alongside struggles with daily responsibilities. Social withdrawal, harmful behaviours such as avoiding responsibilities or using unhealthy coping strategies, and feelings of hopelessness, and being stuck were frequently cited as indicators of poor mental health. When asked, ‘What would you do if your child had mental health issues?’ the themes that emerged were the provision of unconditional love and support, and actively seeking professional assistance. While acknowledging potential feelings of sadness or guilt, participants indicated their primary focus would always remain on their child's well-being and recovery. In relation to the question, ‘What would you do if a friend/neighbour showed signs of mental health problems?’, the emergent themes included taking proactive steps such as directly addressing the individual to encourage help-seeking, contacting their family members, and seeking professional help through healthcare providers or mental health services. In severe cases, participants indicated they would engage emergency services such as 111 or 999. When asked, ‘Where do people learn about mental health?’ the key themes were learning from personal experiences, interactions with family and friends, and occupational exposure to mental health issues. Additionally, online resources, media (such as podcasts and television), and formal professional training were identified as significant sources of information. Several themes also emerged when asked ‘What would help them understand mental health better?’ These included better education, exposure to personal narratives, open discussions, and increased visibility of mental health topics across platforms such as television, social media, and schools. Reducing stigma and improving accessibility to mental health resources were also considered critical factors for enhancing public understanding and support. Discussion The findings from this study suggest that mental health stigma remains a notable issue within the Greek and Greek-Cypriot communities in the UK. However, the observed stigma scores, which lean toward lower levels of stigma, indicate a potentially positive shift in attitudes compared to earlier research reporting higher stigma prevalence among these groups (Tzouvara et al, 2016 ). This apparent reduction could reflect generational changes, greater openness to mental health discussions, or increased exposure to mental health education and awareness within the diaspora community. A key finding was the significant relationship between personal experience of mental health issues - either directly or indirectly - and lower levels of stigma. This aligns with previous studies supporting the contact hypothesis, which argues that direct exposure to mental illness typically results in greater empathy, reduced stereotypes, and diminished social distance (Robinson & Henderson, 2019 ; Potts & Henderson, 2020 ). Similar trends have been consistently observed in collectivist cultures, where direct contact effectively diminishes stigmatising attitudes by humanising and normalising mental health experiences, thereby mitigating culturally embedded prejudices (Papadopoulos et al, 2013 ; Lacko et al., 2013; Kaite et al., 2016 ; Tzouvara & Papadopoulos, 2014 ; Robinson & Henderson, 2019 ). Consequently, community interventions promoting personal stories, peer interaction, and open dialogue could effectively reduce stigma within this community. Qualitative findings from this study underscored that participants valued hearing personal experiences and engaging in open discussions, indicating these approaches resonate culturally within Greek and Greek-Cypriot communities. Given the emphasis within Greek culture on close family ties, communal gatherings, and informal social interactions, initiating discussions through trusted community channels such as local churches, Greek community centres, and culturally familiar social events could facilitate greater openness and diminish stigma-related barriers. Thus, culturally appropriate forums that allow individuals to share experiences safely and authentically may significantly advance stigma reduction efforts within these diaspora communities. Another important finding from this study was that participants who placed greater importance on culturally aligned therapists demonstrated significantly lower stigma. This underscores the critical role of culturally congruent mental health services in improving therapeutic engagement and reducing barriers associated with stigma. Previous studies have underscored the positive impact of culturally tailored mental health services in improving access and outcomes among ethnic minorities. For instance, Truong et al. ( 2014 ) found that culturally sensitive interventions significantly improved help-seeking behaviours and reduced stigma-related barriers among Asian-American communities. Similarly, in the UK, culturally congruent mental health services tailored specifically for South Asian populations have been shown to enhance service uptake, improve client engagement, and decrease stigma perceptions (Amri & Bemak, 2012 ). This study’s results extend these findings to the Greek and Greek-Cypriot diaspora, underlining the potential benefit of increasing culturally matched therapeutic services. Such culturally attuned approaches could effectively mitigate fears associated with cultural alienation or misunderstanding, reducing reluctance to seek professional mental health support. This suggests that policy initiatives promoting culturally tailored mental health services could meaningfully address stigma-related barriers and improve mental health care uptake among Greek and Greek-Cypriot diaspora populations. The study also identified a promising, though statistically weaker, relationship between self-advocacy behaviours and reduced stigma. Participants who reported advocating for themselves or others around mental health issues tended to show lower stigma scores, aligning with broader research suggesting that empowerment and advocacy are important tools for stigma reduction (Corrigan et al., 2013 ; Kaite et al., 2016 ). While the evidence from this study is preliminary, encouraging self-advocacy within these communities could strengthen openness, reduce internalised stigma, and enable positive mental health practices. The study’s qualitative findings indicated a clear willingness among participants to advocate proactively for friends and neighbours experiencing mental health difficulties, such as directly addressing concerns, engaging with family members, and facilitating access to professional services. These results suggest that advocacy aligns well with existing cultural norms of community responsibility and care within Greek and Greek-Cypriot communities. Therefore, culturally tailored initiatives designed to enhance practical advocacy skills, such as education on effective communication strategies, navigating mental health services, and recognising early signs of mental distress, could significantly empower individuals and amplify existing community strengths. Several limitations of this study must be acknowledged. Firstly, the use of a cross-sectional design limits the interpretation of causality. Future longitudinal studies would be beneficial to clarify these temporal relationships. Secondly, the sample's representativeness is limited, as participants were recruited online via social media platforms, possibly leading to sampling biases where individuals already open to discussing mental health, females, younger adults, and those with higher educational attainment may be overrepresented. Such sampling imbalances could result in underestimating the true prevalence of stigma in the broader Greek and Greek-Cypriot communities. Self-reported data may have been subject to social desirability bias, with participants possibly underreporting stigma due to perceived social expectations. Furthermore, although the study highlighted culturally aligned therapists as beneficial, it measured perceived importance rather than actual experiences with culturally matched therapy. More objective assessments of culturally matched therapeutic interventions would strengthen these conclusions. Conclusions Despite these limitations, this study provides valuable insights into the current state and predictors of mental health stigma within the Greek and Greek-Cypriot communities in the UK. It highlights the persistent yet potentially declining stigma, driven by personal experiences, the perceived value of culturally congruent therapeutic practices, and potentially, self-advocacy behaviours. These findings carry significant implications for research, policy, and clinical practice. Research should focus on longitudinal studies to clarify causal relationships and comparative studies across other collectivist diaspora groups to broaden understanding of stigma dynamics. In policy terms, the results support advocating for culturally tailored mental health services and community engagement programmes. Policymakers should consider funding initiatives that enhance cultural congruence in mental health care provision, such as bilingual services, culturally matched therapists, and community-based mental health education and advocacy campaigns. Clinically, practitioners serving Greek and Greek-Cypriot populations should prioritise building cultural competence and creating trust through respectful engagement with cultural beliefs and family dynamics. Actively involving families in the therapeutic process and encouraging self-advocacy activities could enhance treatment acceptance, reduce internalised stigma, and promote earlier and more effective engagement with mental health services. Ultimately, addressing stigma within this context requires integrated, culturally informed strategies that respect community values while promoting openness, acceptance, and empowerment around mental health. Declarations Funding statement : No funds, grants, or other support were received for conducting this study. Clinical trial number : Not applicable Human Ethics and Ethics Declaration : The study received ethical approval from the University of Bedfordshire’s Institute for Health Research Ethics Committee on 28th January 2024 (ref: IHREC1017). All procedures were conducted in accordance with the ethical principles set out in the Declaration of Helsinki. Consent to Participate Declaration: All participants provided informed consent to take part in this study, with a clear understanding of its purpose, procedures, and their right to withdraw at any time without consequence. Consent to Publish Declaration: All participants provided explicit consent for their anonymised data to be used in publications arising from this study. They were informed that their confidentiality would be maintained and that no identifiable information would be disclosed in any reports, presentations, or publications. Data Availability: The datasets generated and analysed during the current study are not publicly available due to the inclusion of sensitive information and the terms of participant consent. However, anonymised data may be made available from the corresponding author upon reasonable request and subject to ethical approval. Author Contributions: CP led on writing, data analysis, and interpretation. CP and AP jointly designed the study. AP led on data collection and supported both writing and interpretation. Both authors reviewed and approved the final manuscript. Competing Interests: The authors declare that they have no competing interests. References Abdullah T, Brown TL. Mental-illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Clin Psychol Rev. 2011;31(6):934–48. https://doi.org/10.1016/j.cpr.2011.05.003 . Alexi N, Moore K, Argyrides M. Openness to help-seeking for mental illness among Greek-Cypriots. Health Promot Int. 2018;33(6):990–8. https://doi.org/10.1093/heapro/dax040 . Altweck L, Marshall TC. Mental-health literacy: A cross-cultural approach to knowledge and beliefs about depression, schizophrenia and generalised anxiety disorder. Front Psychol. 2015;6:1272. https://doi.org/10.3389/fpsyg.2015.01272 . Amri S, Bemak F. Mental-health help-seeking behaviours of Muslim immigrants in the United States: Overcoming social stigma and cultural mistrust. J Muslim Mental Health. 2012;7(1):43–63. https://doi.org/10.3998/jmmh.10381607.0007.104 . Aruta JJBR, Antazo BG, Briones-Diato A, Crisostomo N, Vizconde M. Mental-health stigma among Filipinos: Time for a paradigm shift? Asian J Soc Psychol. 2021;24(1):52–60. (Advance online publication). Booth R, Smith J, Trimble J. Religious framing and mental-illness stigma: A mixed-methods meta-synthesis. J Relig Health. 2024;63(2):215–40. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa . Corrigan PW, Kosyluk KA, Rüsch N. Reducing self-stigma by coming out proud. Am J Public Health. 2013;103(5):794–800. https://doi.org/10.2105/AJPH.2012.301037 . Economou M, Peppou LE, Louki E, Stefanis CN, Stefanis L. Religious beliefs and mental-illness stigma in Greece. J Neuropsychiatry Clin Neurosci. 2012;66(3):196–204. Evans-Lacko S, Rose D, Little K, Flach C, Rhydderch D, Henderson C, Thornicroft G. Development and psychometric properties of the Reported and Intended Behaviour Scale (RIBS): A stigma-related behaviour measure. Epidemiol Psychiatric Sci. 2011;20(3):263–71. https://doi.org/10.1017/S2045796011000308 . Evans-Lacko S, Henderson C, Thornicroft G. Public knowledge, attitudes and behaviour regarding people with mental illness in England 2009–2012. Br J Psychiatry Suppl. 2013;55:s51–7. https://doi.org/10.1192/bjp.bp.112.112979 . Fekih-Romdhane F et al. (2023). Religiosity, mental-illness stigma and help-seeking among Arab Muslims: A multi-country study. BMC Public Health, 23 , Article 16622. Huang CY, Zane NW. Cultural influences in mental-health treatment. Curr Opin Psychol. 2016;8:131–6. https://doi.org/10.1016/j.copsyc.2015.10.009 . Kaite CP, Papadopoulos C, Vivilaki VG. Experiences of Greek-Cypriot individuals living with mental illness. BMC Psychiatry. 2016;16:343. https://doi.org/10.1186/s12888-016-1051-y . Lagunas L, Sörensen T, Choudhury A. Family honour and mental-health stigma: A systematic review in collectivist cultures. J Cross-Cult Psychol. 2025;56(2):212–30. (in press). Papadopoulos C, Foster J, Caldwell K. Individualism–collectivism’ as an explanatory device for mental-illness stigma. Commun Ment Health J. 2013;49(3):270–80. https://doi.org/10.1007/s10597-012-9534-x . Papadopoulos C, Leavey G, Vincent C. Factors influencing stigma: A comparison of Greek-Cypriot and English attitudes towards mental illness in North London. Soc Psychiatry Psychiatr Epidemiol. 2002;37(5):233–44. https://doi.org/10.1007/s00127-002-0560-9 . Papadopoulos C, Lodder A, Constantinou G, Randhawa G. Systematic Review of the Relationship Between Autism Stigma and Informal Caregiver Mental Health. J Autism Dev Disord. 2019;49(4):1665–85. https://doi.org/10.1007/s10803-018-3835-z . Potts LC, Henderson C. Intergroup contact and the moderation of mental-health stigma. Soc Psychiatry Psychiatr Epidemiol. 2020;55(8):945–55. Ran M, Yang L, Liu Y, Huang D, Mao W, Lin F, Thornicroft G. Stigma and stigma reduction in Chinese mental health. Lancet Psychiatry. 2021;8(8):659–70. Robinson EJ, Henderson C. Public knowledge, attitudes, social distance and reported contact with people with mental illness 2009–2017. Psychol Med. 2019;49(16):2717–26. Smith TB, Trimble JE. Foundations of multicultural psychology: Research to inform effective practice. 2nd ed. American Psychological Association; 2016. Sum YY, Chung H, Drapalski AL. Mental-health stigma among Asian-American communities: Cultural influences and implications for intervention. J Community Psychol. 2024;52(1):68–85. Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: A systematic review of reviews. BMC Health Serv Res. 2014;14:99. Tzouvara V, Papadopoulos C. Public stigma towards mental illness in the Greek culture. J Psychiatr Ment Health Nurs. 2014;21(10):931–8. https://doi.org/10.1111/jpm.12146 . Tzouvara V, Papadopoulos C, Randhawa G. Systematic review of the prevalence of mental-illness stigma within the Greek culture. Int J Soc Psychiatry. 2016;62(3):292–305. https://doi.org/10.1177/0020764016629699 . Zorba AB. (2019). Attitudes towards mental illness in Turkish and Greek-speaking Cypriot communities living in Cyprus (Doctoral dissertation). Middlesex University. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 14 Jul, 2025 Editor invited by journal 16 Jun, 2025 Editor assigned by journal 11 Jun, 2025 Submission checks completed at journal 11 Jun, 2025 First submitted to journal 23 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6731958","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485677025,"identity":"2b401c55-f5a4-49b3-8edf-72d8023e7ab5","order_by":0,"name":"Chris Papadopoulos","email":"data:image/png;base64,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","orcid":"","institution":"University of Bedfordshire","correspondingAuthor":true,"prefix":"","firstName":"Chris","middleName":"","lastName":"Papadopoulos","suffix":""},{"id":485677027,"identity":"59a26cf3-fbcd-43c3-be3d-968e3a99d769","order_by":1,"name":"Andreas Patikis","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Patikis","suffix":""}],"badges":[],"createdAt":"2025-05-23 10:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6731958/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6731958/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86834725,"identity":"531eb915-9e7d-443b-bfed-871e032209ce","added_by":"auto","created_at":"2025-07-16 06:58:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":509106,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6731958/v1/a9e74ece-2154-4f8e-b648-b9fb8518063a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence and predictors of mental health stigma among Greek and Greek-Cypriots residing in the United Kingdom","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health stigma represents a significant barrier to accessing care and achieving positive outcomes for people experiencing mental health difficulties across various cultures. However, stigma is neither experienced nor enacted uniformly, with evidence suggesting substantial cultural differences in its nature and intensity (Abdullah \u0026amp; Brown, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Papadopoulos, Foster \u0026amp; Caldwell, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Papadopoulos et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Within collectivist cultures, such as Greek and Greek Cypriot communities, the presence of stigma has often been attributed to a cultural emphasis on familial honour, social cohesion, and maintaining one's social standing (Papadopoulos, Leavey \u0026amp; Vincent, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Papadopoulos et al, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Ran et al \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lagunas et al, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Consequently, mental illness is frequently perceived not only as an individual's challenge but also as a collective threat to family reputation and social harmony, thus exacerbating negative attitudes and behaviours (Papadopoulos et al, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Tzouvara, Papadopoulos \u0026amp; Randhawa, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ran et al, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A phenomenological study by Kaite et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) supports this, revealing that Greek Cypriot individuals with mental illness often experience their condition as a source of shame and social exclusion, intensifying the cultural pressure to conceal their struggles.\u003c/p\u003e\u003cp\u003ePrevious foundational studies examining mental health stigma among Greek and Greek Cypriot populations have consistently highlighted elevated stigma compared to more individualistic Western cultures (Papadopoulos et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Papadopoulos et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, Tzouvara \u0026amp; Papadopoulos, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Kaite et al, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Kaite et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) specifically highlight the significant distress experienced by individuals living with severe mental illness within Greek Cypriot communities, emphasising the social stigma associated with psychiatric hospitalisation, medication use, and welfare dependency. These studies demonstrate that stigma persists strongly among diaspora communities, including second-generation Greeks and Greek Cypriots living in the UK, suggesting that cultural transmission of stigma remains potent across generations (Papadopoulos et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Indeed, stigma within these communities tends to result in concealment of mental health issues, reluctance to seek help, and significant delays in accessing professional support (Amri \u0026amp; Bemak, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Tzouvara \u0026amp; Papadopoulos, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Altweck et al, 2015). Kaite et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) further illuminate this by describing the \u0026lsquo;unbearable\u0026rsquo; suffering of individuals, compounded not only by their illness but also by societal labelling and the stigma tied to medication.\u003c/p\u003e\u003cp\u003eCollectivist cultural frameworks, particularly the vertical collectivism seen in Greek and Greek Cypriot communities, provide useful insights into understanding stigma dynamics. Vertical collectivism, characterised by high respect for hierarchy, conformity, and maintaining \u0026lsquo;face\u0026rsquo; or social reputation, may underpin the pronounced stigma towards mental health issues (Papadopoulos et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Specifically, the fear of damaging family honour and the broader social image often leads individuals to avoid acknowledging mental health issues publicly or privately, creating a barrier to support and recovery (Aruta et al, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Sum et al, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eReligious and spiritual beliefs prevalent within Greek and Greek Cypriot communities further influence stigma. Greek Orthodox Christianity, deeply embedded within community life, traditionally frames mental illness through spiritual or moral lenses, which may exacerbate stigma and hinder help-seeking behaviours (Economou et al, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Tzouvara \u0026amp; Papadopoulos, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). High religiosity has been associated with greater stigma due to perceptions of mental illness as indicative of moral failure or spiritual weakness, thus amplifying shame and silence around mental health challenges (Economou et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Fekih-Romdhane et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Booth et al, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEmpirical research has indicated that familiarity and personal experience with mental health problems can also moderate stigma levels. Studies reveal that individuals who have either personally experienced mental illness or had close contacts with mental health conditions exhibit reduced stigmatising attitudes (Evans-Lacko et al, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Robinson \u0026amp; Henderson, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Potts \u0026amp; Henderson, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Limited contact and poor mental health literacy are also significant predictors of heightened stigma within the Greek Cypriot diaspora (Papadopoulos et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Papadopoulos et al, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Kaite et al, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGiven these insights, exploring specific dimensions such as prior therapy experience, the cultural relevance of therapists, and self-advocacy efforts becomes particularly important. Previous therapy engagement might be hypothesised to reduce stigma by increasing familiarity and literacy around mental health issues, thereby nurturing empathy and understanding. The perceived cultural relevance of a therapist - defined by shared language, values, and cultural understandings - could similarly mitigate stigma through improved therapeutic rapport and greater acceptance of mental health support (Truong et al, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Smith \u0026amp; Trimble, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Huang\u0026amp; Zane, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). This shared cultural context might facilitate openness, improve communication, and increase trust, ultimately influencing attitudes positively. However, empirical evidence specifically exploring these dynamics in Greek and Greek Cypriot communities remains sparse. Understanding these factors is increasingly pertinent as openness to mental health therapy grows across various communities, including collectivist societies like the Greek and Greek Cypriot populations. Recent studies indicate a gradual shift towards greater acceptance of mental health services among Greek Cypriots, suggesting a positive trend in help-seeking behaviours (Tzouvara \u0026amp; Papadopoulos, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e, Alexi et al, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Zorba et al, 2019). This evolving landscape underscores the need for culturally sensitive approaches that address unique community dynamics, potentially enhancing the effectiveness of mental health support.\u003c/p\u003e\u003cp\u003eAdditionally, self-advocacy - the act of speaking out or taking action in support of oneself or others experiencing mental health difficulties - is a promising but under-researched area. Encouraging self-advocacy may enhance empowerment, reduce internalised stigma, and enable more inclusive community attitudes (Corrigan, Kosyluk \u0026amp; R\u0026uuml;sch, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Kaite et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) suggest potential in this area, as participants expressed a desire to share their experiences during research interviews, hinting at an emerging capacity for self-advocacy that could challenge stigma. However, despite its potential, the link between self-advocacy behaviours and reduced stigma within collectivist Greek and Greek Cypriot contexts has not been explicitly explored, leaving a gap in the literature.\u003c/p\u003e\u003cp\u003eAddressing these gaps holds both theoretical and practical significance. Theoretically, further understanding of how specific culturally relevant factors like previous therapeutic experiences, therapist cultural alignment, and self-advocacy influence stigma can refine existing stigma reduction models within collectivist communities. Practically, identifying actionable targets for stigma reduction interventions can directly inform culturally tailored community outreach programmes, educational initiatives, and clinical practices. Furthermore, given the established relationship between stigma, delayed help-seeking, and poorer mental health outcomes, insights from this study could support policy development aimed at improving mental health literacy, enabling culturally sensitive therapeutic services, and encouraging proactive mental health advocacy within the Greek and Greek Cypriot communities.\u003c/p\u003e\u003cp\u003eIn response to these needs, the current study aimed to explore mental health knowledge and attitudes, particularly stigma, among UK-based Greek and Greek Cypriot adults. Specifically, the research had four primary objectives: (1) to assess levels of stigma within this community, (2) to examine the associations between previous mental health experiences and stigma, including personal history of mental health problems and prior therapy engagement, (3) to evaluate the perceived importance of having a therapist from the same cultural background, and (4) to investigate the potential relationship between self-advocacy behaviours and stigma levels. By addressing these objectives, this study seeks to extend current understanding of stigma within Greek and Greek Cypriot populations and identify potential avenues for culturally informed interventions aimed at reducing stigma and enhancing mental health outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and participants\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted to explore mental health knowledge and attitudes, with a particular focus on stigma, among UK-based Greek and Greek Cypriot adults. The research employed an online questionnaire survey that gathered data from January 2024 over a period lasting approximately six months. The data collection took place entirely online using various social media platforms, including Facebook, LinkedIn, Instagram, Twitter, and other specialised networks targeting the Greek and Greek Cypriot communities in the UK. Eligibility criteria required participants to be adults aged 18 or older, self-identifying as Greek or Greek Cypriot, and residing within the United Kingdom during the data collection period.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected via an online questionnaire, initially hosted on Google Forms and subsequently transferred to the Qualtrics platform for secure management and analysis. Mental health stigma, the primary dependent variable, was measured using the Reported and Intended Behaviour Scale (RIBS) (Evans-Lacko et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), consisting of four items scored on a 5-point Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). Possible RIBS scores ranged from 4, indicating high stigma, to 20, indicating low stigma. Independent variables included knowledge about mental health, previous mental health experiences (such as personal mental health issues, previous therapy engagement, and knowledge of someone with mental health problems), and perceived cultural importance of having a therapist from the same cultural background. Additionally, socio-demographic characteristics including age, gender, ethnicity, first language, occupation, marital status, place of birth, educational level, religion, and religiosity were collected. Qualitative data were also gathered through open-ended questions exploring perceptions of good and bad mental health, responses to mental health concerns in children and acquaintances, sources of mental health knowledge, and suggested improvements for mental health understanding.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e Participants provided informed consent digitally, confirmed by proceeding past an explicit consent statement presented at the beginning of the survey. Given the sensitive nature of mental health topics, clear trigger warnings and information on accessing support (including contact details for the lead researcher, MIND, and The Samaritans) were provided. Confidentiality was maintained by not collecting any personally identifiable information, ensuring participant anonymity throughout the study. The study received ethical approval from the University of Bedfordshire\u0026rsquo;s Institute for Health Research Ethics Committee on 28th January 2024 (ref: IHREC1017). All procedures were conducted in accordance with the ethical principles set out in the Declaration of Helsinki.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eAll statistical analyses were conducted using IBM SPSS Statistics (version 29). The dataset was examined for missing data, and listwise deletion was applied to ensure only cases with complete responses were analysed. Descriptive statistics summarised sample characteristics and the distribution of key variables.\u003c/p\u003e\u003cp\u003eThe Kolmogorov-Smirnov and Shapiro-Wilk tests, along with skewness and kurtosis values, indicated that the RIBS total score was non-normally distributed, supporting the use of non-parametric statistical methods where necessary.\u003c/p\u003e\u003cp\u003eUnivariate analyses were conducted to examine the relationship between each independent variable and stigma scores. Mann-Whitney U tests were used for categorical variables, and Spearman\u0026rsquo;s rank-order correlation for continuous variables. Predictors that showed significant associations were entered into a Generalised Linear Model (GLM) to assess their independent effects.\u003c/p\u003e\u003cp\u003eThe GLM specified a Gamma distribution with an identity link function, appropriate for the non-normal dependent variable. Wald chi-square tests assessed predictor significance, and model fit was evaluated using Akaike\u0026rsquo;s Information Criterion (AIC), deviance, and Pearson chi-square statistics.\u003c/p\u003e\u003cp\u003eQualitative data, collected through open-ended survey responses, were analysed using thematic analysis, following the six-phase approach outlined by Braun \u0026amp; Clarke (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2006\u003c/span\u003e): (1) data familiarisation, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the final report. Following immersion in the data, initial codes were developed based on participants\u0026rsquo; responses using NVivo Software (QSR International Pty Ltd). These codes facilitated the identification of emergent themes across individual responses. A cross-analysis was then conducted, systematically comparing themes across different participants\u0026rsquo; responses to identify commonalities and divergences in experiences and perceptions.\u003c/p\u003e\u003cp\u003eTo enhance rigour and trustworthiness, intra-coder agreement exercises were conducted. The coding process was revisited at multiple intervals to ensure consistency in the application of codes, with comparisons made across a random sample of the dataset. This process confirmed a high level of coding consistency, affirming the reliability of the thematic analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive results\u003c/h2\u003e\u003cp\u003eThe study included 162 participants with a mean age of 45.2 years (SD\u0026thinsp;=\u0026thinsp;14.88, range\u0026thinsp;=\u0026thinsp;18\u0026ndash;83). The sample comprised 111 females and 51 males. The majority were married or in a civil partnership (n\u0026thinsp;=\u0026thinsp;101), followed by 24.1% single (n\u0026thinsp;=\u0026thinsp;39), with smaller proportions divorced, widowed, or in other statuses. Greek was the primary language for 53.1% of participants (n\u0026thinsp;=\u0026thinsp;86), English for 46.3% (n\u0026thinsp;=\u0026thinsp;75), and one individual (0.6%) spoke another language (n\u0026thinsp;=\u0026thinsp;1). Regarding birthplace, the majority (60.5%) were born in the UK (n\u0026thinsp;=\u0026thinsp;98), while 36.4% originated from Greece or Cyprus (n\u0026thinsp;=\u0026thinsp;59). Education levels varied: 35.8% held undergraduate degrees (n\u0026thinsp;=\u0026thinsp;58), 22.2% had A-levels or college education (n\u0026thinsp;=\u0026thinsp;36), 13% completed GCSEs (n\u0026thinsp;=\u0026thinsp;21), 21.6% earned postgraduate degrees (n\u0026thinsp;=\u0026thinsp;35), and 6.2% held doctorates (n\u0026thinsp;=\u0026thinsp;10). The majority (64.8%) identified as Greek Orthodox (n\u0026thinsp;=\u0026thinsp;105), followed by 13.6% Christian (n\u0026thinsp;=\u0026thinsp;22), 11.7% Atheist/None (n\u0026thinsp;=\u0026thinsp;19), and 9.9% Other (n\u0026thinsp;=\u0026thinsp;16). Religiosity levels included 45.1% as somewhat religious (n\u0026thinsp;=\u0026thinsp;73), 26.5% as quite religious (n\u0026thinsp;=\u0026thinsp;43), 9.3% as very religious (n\u0026thinsp;=\u0026thinsp;15), and 19.1% as not religious (n\u0026thinsp;=\u0026thinsp;31).\u003c/p\u003e\u003cp\u003eRegarding cultural attitudes, 67.3% (n\u0026thinsp;=\u0026thinsp;109) of participants rated the importance of therapy in their culture as \u0026lsquo;not at all\u0026rsquo; or \u0026lsquo;slightly important,\u0026rsquo; while 32.7% (n\u0026thinsp;=\u0026thinsp;53) considered it \u0026lsquo;moderately\u0026rsquo; or \u0026lsquo;extremely important.\u0026rsquo; When asked about advocating for mental health, the majority (81.5%, n\u0026thinsp;=\u0026thinsp;132) agreed or strongly agreed that they had spoken up in support of someone experiencing mental health difficulties, while 18.5% (n\u0026thinsp;=\u0026thinsp;30) disagreed. On the importance of advocacy for improving the situation of people with mental health problems, 57.4% agreed (n\u0026thinsp;=\u0026thinsp;93) and 41.4% strongly agreed (n\u0026thinsp;=\u0026thinsp;67), with only 1.2% disagreeing (n\u0026thinsp;=\u0026thinsp;2). Regarding willingness to support or join a mental health advocacy group or campaign, 65.4% agreed (n\u0026thinsp;=\u0026thinsp;106) and 22.2% strongly agreed (n\u0026thinsp;=\u0026thinsp;36), while 12.3% disagreed (n\u0026thinsp;=\u0026thinsp;20). Finally, 47.5% agreed (n\u0026thinsp;=\u0026thinsp;77) and 34.0% strongly agreed (n\u0026thinsp;=\u0026thinsp;55) that they had spoken up for themselves or someone else with a mental health problem in the past year, while 18.5% disagreed (n\u0026thinsp;=\u0026thinsp;30).\u003c/p\u003e\u003cp\u003eThe mean stigma score was 15.84 (SD\u0026thinsp;=\u0026thinsp;3.33), with observed scores ranging from 4 (indicating high stigma) to 20 (indicating low stigma). Over half of the participants (53.7%, n\u0026thinsp;=\u0026thinsp;87) reported having personally experienced a mental health condition, while 58.6% (n\u0026thinsp;=\u0026thinsp;95) had previously accessed mental health therapy or counselling. Among those who had received therapy, 44.4% (n\u0026thinsp;=\u0026thinsp;72) found it helpful, whereas 25.3% (n\u0026thinsp;=\u0026thinsp;41) did not. The remaining 30.2% (n\u0026thinsp;=\u0026thinsp;49) had never received therapy. In terms of personal connections to mental health, the majority (79.6%, n\u0026thinsp;=\u0026thinsp;129) reported knowing someone with a mental health condition, while 11.1% (n\u0026thinsp;=\u0026thinsp;18) did not, and 9.3% (n\u0026thinsp;=\u0026thinsp;15) were unsure.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUnivariate analysis\u003c/h3\u003e\n\u003cp\u003eParticipants who reported having experienced mental health issues themselves demonstrated significantly lower levels of stigma compared to those who had not (U\u0026thinsp;=\u0026thinsp;1821.5, Z = -4.895, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, individuals who had previously visited a psychiatric hospital exhibited significantly lower stigma scores than those who had not visited such facilities (U\u0026thinsp;=\u0026thinsp;2300.0, Z = -2.032, p\u0026thinsp;=\u0026thinsp;0.042). Furthermore, participants who knew someone with a mental health problem were significantly less likely to hold stigmatising attitudes compared to those who did not know anyone with a mental health issue (U\u0026thinsp;=\u0026thinsp;697.5, Z = -2.776, p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e\u003cp\u003eAdditionally, having previously accessed mental health therapy was significantly associated with lower stigma scores (U\u0026thinsp;=\u0026thinsp;1972.5, Z = -4.162, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among those who had accessed therapy, participants who found it helpful had significantly lower stigma scores compared to those who did not find therapy helpful (=\u0026thinsp;1025.0, Z = -2.559, p\u0026thinsp;=\u0026thinsp;0.010). Furthermore, the cultural importance of having a therapist from the same background was significantly associated with lower stigma scores (U\u0026thinsp;=\u0026thinsp;1862.0, Z = -3.706, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and participants who had previously spoken up for themselves or others regarding mental health issues also reported significantly lower stigma scores (U\u0026thinsp;=\u0026thinsp;1425.0, Z = -2.420, p\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e\u003cp\u003eHowever, there was no significant difference in stigma scores based on gender, age, place of birth, marital status, educational level, religion or religiosity.\u003c/p\u003e\n\u003ch3\u003eMultivariate regression analysis\u003c/h3\u003e\n\u003cp\u003eMultivariate regression analysis using a generalised linear model revealed independent predictors of mental health stigma when adjusting for all significant variables identified from univariate analyses. The cultural importance of having a therapist from the same cultural background emerged as a significant independent predictor of lower stigma scores (B\u0026thinsp;=\u0026thinsp;1.483, Wald\u0026thinsp;=\u0026thinsp;7.858, p\u0026thinsp;=\u0026thinsp;0.005). Additionally, having personally experienced mental illness was independently associated with significantly lower stigma (B\u0026thinsp;=\u0026thinsp;1.628, Wald\u0026thinsp;=\u0026thinsp;5.741, p\u0026thinsp;=\u0026thinsp;0.017). Although participants who had previously spoken up for themselves or others regarding mental health issues showed a strong trend towards lower stigma, this association narrowly missed statistical significance (B = -1.187, Wald\u0026thinsp;=\u0026thinsp;3.511, p\u0026thinsp;=\u0026thinsp;0.061). Variables such as having accessed mental health therapy, knowing someone with mental health issues, and finding therapy helpful did not significantly predict stigma scores when controlling for other variables.\u003c/p\u003e\u003cp\u003eThe model demonstrated good overall fit, as indicated by the Likelihood Ratio Chi-Square test (χ\u0026sup2; = 40.789, df\u0026thinsp;=\u0026thinsp;8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Goodness-of-fit indices such as Deviance (value\u0026thinsp;=\u0026thinsp;6.595, value/df\u0026thinsp;=\u0026thinsp;0.043) and Pearson Chi-Square (value\u0026thinsp;=\u0026thinsp;5.829, value/df\u0026thinsp;=\u0026thinsp;0.038) further indicated strong model adequacy.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQualitative results\u003c/h2\u003e\u003cp\u003eQualitative analysis revealed several key themes related to perceptions of mental health. The themes that emerged when asked queried, \u0026lsquo;What is good mental health to you?\u0026rsquo; were the effective management of emotions, experiencing happiness, handling stress successfully, and maintaining enjoyment in life. Other themes were healthy balance between work, personal time, and relationships, as well as good physical health and strong interpersonal connections.\u003c/p\u003e\u003cp\u003eWhen asked, \u0026lsquo;What is bad mental health to you\u0026rsquo;, the themes that emerged were feelings of anxiety, low mood, and being overwhelmed, alongside struggles with daily responsibilities. Social withdrawal, harmful behaviours such as avoiding responsibilities or using unhealthy coping strategies, and feelings of hopelessness, and being stuck were frequently cited as indicators of poor mental health.\u003c/p\u003e\u003cp\u003eWhen asked, \u0026lsquo;What would you do if your child had mental health issues?\u0026rsquo; the themes that emerged were the provision of unconditional love and support, and actively seeking professional assistance. While acknowledging potential feelings of sadness or guilt, participants indicated their primary focus would always remain on their child's well-being and recovery.\u003c/p\u003e\u003cp\u003eIn relation to the question, \u0026lsquo;What would you do if a friend/neighbour showed signs of mental health problems?\u0026rsquo;, the emergent themes included taking proactive steps such as directly addressing the individual to encourage help-seeking, contacting their family members, and seeking professional help through healthcare providers or mental health services. In severe cases, participants indicated they would engage emergency services such as 111 or 999.\u003c/p\u003e\u003cp\u003eWhen asked, \u0026lsquo;Where do people learn about mental health?\u0026rsquo; the key themes were learning from personal experiences, interactions with family and friends, and occupational exposure to mental health issues. Additionally, online resources, media (such as podcasts and television), and formal professional training were identified as significant sources of information.\u003c/p\u003e\u003cp\u003eSeveral themes also emerged when asked \u0026lsquo;What would help them understand mental health better?\u0026rsquo; These included better education, exposure to personal narratives, open discussions, and increased visibility of mental health topics across platforms such as television, social media, and schools. Reducing stigma and improving accessibility to mental health resources were also considered critical factors for enhancing public understanding and support.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from this study suggest that mental health stigma remains a notable issue within the Greek and Greek-Cypriot communities in the UK. However, the observed stigma scores, which lean toward lower levels of stigma, indicate a potentially positive shift in attitudes compared to earlier research reporting higher stigma prevalence among these groups (Tzouvara et al, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). This apparent reduction could reflect generational changes, greater openness to mental health discussions, or increased exposure to mental health education and awareness within the diaspora community.\u003c/p\u003e\u003cp\u003eA key finding was the significant relationship between personal experience of mental health issues - either directly or indirectly - and lower levels of stigma. This aligns with previous studies supporting the contact hypothesis, which argues that direct exposure to mental illness typically results in greater empathy, reduced stereotypes, and diminished social distance (Robinson \u0026amp; Henderson, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Potts \u0026amp; Henderson, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similar trends have been consistently observed in collectivist cultures, where direct contact effectively diminishes stigmatising attitudes by humanising and normalising mental health experiences, thereby mitigating culturally embedded prejudices (Papadopoulos et al, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Lacko et al., 2013; Kaite et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Tzouvara \u0026amp; Papadopoulos, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Robinson \u0026amp; Henderson, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Consequently, community interventions promoting personal stories, peer interaction, and open dialogue could effectively reduce stigma within this community. Qualitative findings from this study underscored that participants valued hearing personal experiences and engaging in open discussions, indicating these approaches resonate culturally within Greek and Greek-Cypriot communities. Given the emphasis within Greek culture on close family ties, communal gatherings, and informal social interactions, initiating discussions through trusted community channels such as local churches, Greek community centres, and culturally familiar social events could facilitate greater openness and diminish stigma-related barriers. Thus, culturally appropriate forums that allow individuals to share experiences safely and authentically may significantly advance stigma reduction efforts within these diaspora communities.\u003c/p\u003e\u003cp\u003eAnother important finding from this study was that participants who placed greater importance on culturally aligned therapists demonstrated significantly lower stigma. This underscores the critical role of culturally congruent mental health services in improving therapeutic engagement and reducing barriers associated with stigma. Previous studies have underscored the positive impact of culturally tailored mental health services in improving access and outcomes among ethnic minorities. For instance, Truong et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) found that culturally sensitive interventions significantly improved help-seeking behaviours and reduced stigma-related barriers among Asian-American communities. Similarly, in the UK, culturally congruent mental health services tailored specifically for South Asian populations have been shown to enhance service uptake, improve client engagement, and decrease stigma perceptions (Amri \u0026amp; Bemak, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). This study\u0026rsquo;s results extend these findings to the Greek and Greek-Cypriot diaspora, underlining the potential benefit of increasing culturally matched therapeutic services. Such culturally attuned approaches could effectively mitigate fears associated with cultural alienation or misunderstanding, reducing reluctance to seek professional mental health support. This suggests that policy initiatives promoting culturally tailored mental health services could meaningfully address stigma-related barriers and improve mental health care uptake among Greek and Greek-Cypriot diaspora populations.\u003c/p\u003e\u003cp\u003eThe study also identified a promising, though statistically weaker, relationship between self-advocacy behaviours and reduced stigma. Participants who reported advocating for themselves or others around mental health issues tended to show lower stigma scores, aligning with broader research suggesting that empowerment and advocacy are important tools for stigma reduction (Corrigan et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Kaite et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). While the evidence from this study is preliminary, encouraging self-advocacy within these communities could strengthen openness, reduce internalised stigma, and enable positive mental health practices. The study\u0026rsquo;s qualitative findings indicated a clear willingness among participants to advocate proactively for friends and neighbours experiencing mental health difficulties, such as directly addressing concerns, engaging with family members, and facilitating access to professional services. These results suggest that advocacy aligns well with existing cultural norms of community responsibility and care within Greek and Greek-Cypriot communities. Therefore, culturally tailored initiatives designed to enhance practical advocacy skills, such as education on effective communication strategies, navigating mental health services, and recognising early signs of mental distress, could significantly empower individuals and amplify existing community strengths.\u003c/p\u003e\u003cp\u003eSeveral limitations of this study must be acknowledged. Firstly, the use of a cross-sectional design limits the interpretation of causality. Future longitudinal studies would be beneficial to clarify these temporal relationships.\u003c/p\u003e\u003cp\u003eSecondly, the sample's representativeness is limited, as participants were recruited online via social media platforms, possibly leading to sampling biases where individuals already open to discussing mental health, females, younger adults, and those with higher educational attainment may be overrepresented. Such sampling imbalances could result in underestimating the true prevalence of stigma in the broader Greek and Greek-Cypriot communities.\u003c/p\u003e\u003cp\u003eSelf-reported data may have been subject to social desirability bias, with participants possibly underreporting stigma due to perceived social expectations. Furthermore, although the study highlighted culturally aligned therapists as beneficial, it measured perceived importance rather than actual experiences with culturally matched therapy. More objective assessments of culturally matched therapeutic interventions would strengthen these conclusions.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite these limitations, this study provides valuable insights into the current state and predictors of mental health stigma within the Greek and Greek-Cypriot communities in the UK. It highlights the persistent yet potentially declining stigma, driven by personal experiences, the perceived value of culturally congruent therapeutic practices, and potentially, self-advocacy behaviours.\u003c/p\u003e\u003cp\u003eThese findings carry significant implications for research, policy, and clinical practice. Research should focus on longitudinal studies to clarify causal relationships and comparative studies across other collectivist diaspora groups to broaden understanding of stigma dynamics. In policy terms, the results support advocating for culturally tailored mental health services and community engagement programmes. Policymakers should consider funding initiatives that enhance cultural congruence in mental health care provision, such as bilingual services, culturally matched therapists, and community-based mental health education and advocacy campaigns.\u003c/p\u003e\u003cp\u003eClinically, practitioners serving Greek and Greek-Cypriot populations should prioritise building cultural competence and creating trust through respectful engagement with cultural beliefs and family dynamics. Actively involving families in the therapeutic process and encouraging self-advocacy activities could enhance treatment acceptance, reduce internalised stigma, and promote earlier and more effective engagement with mental health services. Ultimately, addressing stigma within this context requires integrated, culturally informed strategies that respect community values while promoting openness, acceptance, and empowerment around mental health.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding statement\u003c/u\u003e\u003c/strong\u003e: No funds, grants, or other support were received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eClinical trial number\u003c/u\u003e\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eHuman Ethics and Ethics Declaration\u003c/u\u003e\u003c/strong\u003e: The study received ethical approval from the University of Bedfordshire\u0026rsquo;s Institute for Health Research Ethics Committee on 28th January 2024 (ref: IHREC1017). All procedures were conducted in accordance with the ethical principles set out in the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent to Participate Declaration:\u003c/u\u003e\u003c/strong\u003e All participants provided informed consent to take part in this study, with a clear understanding of its purpose, procedures, and their right to withdraw at any time without consequence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent to Publish Declaration:\u003c/u\u003e\u003c/strong\u003e All participants provided explicit consent for their anonymised data to be used in publications arising from this study. They were informed that their confidentiality would be maintained and that no identifiable information would be disclosed in any reports, presentations, or publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Availability:\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe datasets generated and analysed during the current study are not publicly available due to the inclusion of sensitive information and the terms of participant consent. However, anonymised data may be made available from the corresponding author upon reasonable request and subject to ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor Contributions:\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCP led on writing, data analysis, and interpretation. CP and AP jointly designed the study. AP led on data collection and supported both writing and interpretation. Both authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting Interests:\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbdullah T, Brown TL. Mental-illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Clin Psychol Rev. 2011;31(6):934\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cpr.2011.05.003\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2011.05.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlexi N, Moore K, Argyrides M. Openness to help-seeking for mental illness among Greek-Cypriots. Health Promot Int. 2018;33(6):990\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/heapro/dax040\u003c/span\u003e\u003cspan address=\"10.1093/heapro/dax040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAltweck L, Marshall TC. Mental-health literacy: A cross-cultural approach to knowledge and beliefs about depression, schizophrenia and generalised anxiety disorder. Front Psychol. 2015;6:1272. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2015.01272\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2015.01272\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmri S, Bemak F. Mental-health help-seeking behaviours of Muslim immigrants in the United States: Overcoming social stigma and cultural mistrust. J Muslim Mental Health. 2012;7(1):43\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3998/jmmh.10381607.0007.104\u003c/span\u003e\u003cspan address=\"10.3998/jmmh.10381607.0007.104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAruta JJBR, Antazo BG, Briones-Diato A, Crisostomo N, Vizconde M. Mental-health stigma among Filipinos: Time for a paradigm shift? Asian J Soc Psychol. 2021;24(1):52\u0026ndash;60. (Advance online publication).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBooth R, Smith J, Trimble J. Religious framing and mental-illness stigma: A mixed-methods meta-synthesis. J Relig Health. 2024;63(2):215\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCorrigan PW, Kosyluk KA, R\u0026uuml;sch N. Reducing self-stigma by coming out proud. Am J Public Health. 2013;103(5):794\u0026ndash;800. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2105/AJPH.2012.301037\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2012.301037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEconomou M, Peppou LE, Louki E, Stefanis CN, Stefanis L. Religious beliefs and mental-illness stigma in Greece. J Neuropsychiatry Clin Neurosci. 2012;66(3):196\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans-Lacko S, Rose D, Little K, Flach C, Rhydderch D, Henderson C, Thornicroft G. Development and psychometric properties of the Reported and Intended Behaviour Scale (RIBS): A stigma-related behaviour measure. Epidemiol Psychiatric Sci. 2011;20(3):263\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S2045796011000308\u003c/span\u003e\u003cspan address=\"10.1017/S2045796011000308\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans-Lacko S, Henderson C, Thornicroft G. Public knowledge, attitudes and behaviour regarding people with mental illness in England 2009\u0026ndash;2012. Br J Psychiatry Suppl. 2013;55:s51\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1192/bjp.bp.112.112979\u003c/span\u003e\u003cspan address=\"10.1192/bjp.bp.112.112979\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFekih-Romdhane F et al. (2023). Religiosity, mental-illness stigma and help-seeking among Arab Muslims: A multi-country study. BMC Public Health, \u003cem\u003e23\u003c/em\u003e, Article 16622.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang CY, Zane NW. Cultural influences in mental-health treatment. Curr Opin Psychol. 2016;8:131\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.copsyc.2015.10.009\u003c/span\u003e\u003cspan address=\"10.1016/j.copsyc.2015.10.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaite CP, Papadopoulos C, Vivilaki VG. Experiences of Greek-Cypriot individuals living with mental illness. BMC Psychiatry. 2016;16:343. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12888-016-1051-y\u003c/span\u003e\u003cspan address=\"10.1186/s12888-016-1051-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLagunas L, S\u0026ouml;rensen T, Choudhury A. Family honour and mental-health stigma: A systematic review in collectivist cultures. J Cross-Cult Psychol. 2025;56(2):212\u0026ndash;30. (in press).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePapadopoulos C, Foster J, Caldwell K. Individualism\u0026ndash;collectivism\u0026rsquo; as an explanatory device for mental-illness stigma. Commun Ment Health J. 2013;49(3):270\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10597-012-9534-x\u003c/span\u003e\u003cspan address=\"10.1007/s10597-012-9534-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePapadopoulos C, Leavey G, Vincent C. Factors influencing stigma: A comparison of Greek-Cypriot and English attitudes towards mental illness in North London. Soc Psychiatry Psychiatr Epidemiol. 2002;37(5):233\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00127-002-0560-9\u003c/span\u003e\u003cspan address=\"10.1007/s00127-002-0560-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePapadopoulos C, Lodder A, Constantinou G, Randhawa G. Systematic Review of the Relationship Between Autism Stigma and Informal Caregiver Mental Health. J Autism Dev Disord. 2019;49(4):1665\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-018-3835-z\u003c/span\u003e\u003cspan address=\"10.1007/s10803-018-3835-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePotts LC, Henderson C. Intergroup contact and the moderation of mental-health stigma. Soc Psychiatry Psychiatr Epidemiol. 2020;55(8):945\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRan M, Yang L, Liu Y, Huang D, Mao W, Lin F, Thornicroft G. Stigma and stigma reduction in Chinese mental health. Lancet Psychiatry. 2021;8(8):659\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRobinson EJ, Henderson C. Public knowledge, attitudes, social distance and reported contact with people with mental illness 2009\u0026ndash;2017. Psychol Med. 2019;49(16):2717\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith TB, Trimble JE. Foundations of multicultural psychology: Research to inform effective practice. 2nd ed. American Psychological Association; 2016.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSum YY, Chung H, Drapalski AL. Mental-health stigma among Asian-American communities: Cultural influences and implications for intervention. J Community Psychol. 2024;52(1):68\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTruong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: A systematic review of reviews. BMC Health Serv Res. 2014;14:99.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTzouvara V, Papadopoulos C. Public stigma towards mental illness in the Greek culture. J Psychiatr Ment Health Nurs. 2014;21(10):931\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jpm.12146\u003c/span\u003e\u003cspan address=\"10.1111/jpm.12146\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTzouvara V, Papadopoulos C, Randhawa G. Systematic review of the prevalence of mental-illness stigma within the Greek culture. Int J Soc Psychiatry. 2016;62(3):292\u0026ndash;305. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0020764016629699\u003c/span\u003e\u003cspan address=\"10.1177/0020764016629699\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZorba AB. (2019). \u003cem\u003eAttitudes towards mental illness in Turkish and Greek-speaking Cypriot communities living in Cyprus\u003c/em\u003e (Doctoral dissertation). Middlesex University.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6731958/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6731958/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMental health stigma represents a significant barrier to accessing care, particularly within collectivist cultures such as Greek and Greek-Cypriot communities, often tied to concepts of family honour and social standing. This study examined the prevalence and predictors of mental health stigma among Greek and Greek-Cypriot adults in the United Kingdom, focusing on stigma levels, associations with personal and indirect mental health experiences, therapy engagement, perceived cultural importance of therapist alignment, and self-advocacy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional online survey was completed by 162 participants. Mental health stigma was measured using the Reported and Intended Behaviour Scale. Statistical analyses included univariate tests and a Generalised Linear Model; qualitative responses underwent thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eResults indicated moderate to low overall stigma. Univariate analyses revealed significantly lower stigma among individuals with personal mental health experience, knowledge of someone with mental health issues, prior therapy engagement, perceived cultural importance of therapist alignment, and self-advocacy behaviours. Multivariate analysis identified personal experience of mental illness and valuing culturally congruent therapists as independent predictors of lower stigma. Qualitative findings highlighted participants' perceptions of mental health, approaches to supporting others, and sources of mental health knowledge.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study concludes that personal experience with mental health issues and the perceived cultural congruence of therapeutic support are crucial factors associated with reduced mental health stigma within this population. Findings underscore the potential value of culturally tailored interventions and services aimed at promoting openness, enhancing help-seeking, and further reducing stigma in Greek and Greek-Cypriot communities.\u003c/p\u003e","manuscriptTitle":"Prevalence and predictors of mental health stigma among Greek and Greek-Cypriots residing in the United Kingdom","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-16 06:42:17","doi":"10.21203/rs.3.rs-6731958/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-07-14T13:14:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-16T09:41:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T22:52:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T22:51:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-05-23T10:15:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f375726-f0dc-4d97-a143-42ead7209e6f","owner":[],"postedDate":"July 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-16T06:42:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-16 06:42:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6731958","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6731958","identity":"rs-6731958","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}