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Abstract

Objective: The aim of this qualitative study was to explore the presence, causes and means of addressing individual and systemic stigma and discrimination against people with mental illness in Zambia. This is to facilitate the development of tailor-made antistigma initiatives that are culturally sensitive for Zambia and other low-income African countries. This is the first in-depth study on mental illness stigma in Zambia. Method: Fifty semi-structured interviews and 6 focus group discussions were conducted with key stakeholders drawn from 3 districts in Zambia (Lusaka, Kabwe and Sinazongwe). Transcripts were analyzed using a grounded theory approach. Results: Mental illness stigma and discrimination is pervasive across Zambian society, prevailing within the general community, amongst family members, amid general and mental health care providers, and at the level of government. Such stigma appears to be fuelled by misunderstandings of mental illness aetiology; fears of contagion and the perceived dangerousness of people with mental illness; and associations between HIV/AIDS and mental illness. Strategies suggested for reducing stigma and discrimination in Zambia included education campaigns, the transformation of mental health policy and legislation and expanding the social and economic opportunities of the mentally ill. Conclusion: In Zambia, as in many other low-income African countries, very little attention is devoted to addressing the negative beliefs and behaviours surrounding mental illness, despite the devastating costs that ensue. The results from this study underscore the need for greater commitment from governments and policy-makers in African countries to start prioritizing mental illness stigma as a major public health and development issue.
ORIGINAL Afr J Psychiatry 2010;13:192-203
African Journal of Psychiatry July 2010 192
Introduction
Mental illnesses worldwide are accompanied by another
pandemic, that of stigma and discrimination. Mental illness
tends to strike with a double-edged sword, with those
affected having to deal with the symptoms and disabilities of
their illness on the one side, and widespread stigma and
discrimination on the other. Evidence from North America
and paralleling findings from research in Western Europe
suggest that stigma and discrimination are major problems in
the community, with negative attitudes and behaviour towards
people with mental illness being widespread.1-6
Stigma and discrimination towards mental illness have
been said to be less severe in African countries.7-8 It is
unclear however whether this finding indicates that Africa
represents a geographical region that does not experience
stigma, or whether there is a dearth of research in these
Mental illness - stigma and
discrimination in Zambia
A Kapungwe1, S Cooper2, J Mwanza1, L Mwape3, A Sikwese3, R Kakuma2,4, C Lund2, AJ Flisher2,5, MHaPP
Research Programme Consortium6
1Department of Social Development Studies, Demography Division, University of Zambia, Lusaka
2Department of Psychiatry and Mental Health, University of Cape Town, South Africa
3Department of Psychiatry, Chainama College of Health Sciences, University of Zambia, Lusaka
4Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, University of Toronto, Canada
5Research Centre for Health Promotion, University of Bergen, Norway
6The Mental Health and Poverty Project (MHaPP) is a Research Programme Consortium (RPC) funded by the UK Department
for International Development (DfID)(RPC HD6 2005-2010) for the benefit of developing countries. The views expressed are not
necessarily those of DfID. RPC members include Alan J. Flisher (Director) and Crick Lund (Co-ordinator) (University of Cape Town,
Republic of South Africa (RSA)); Therese Agossou, Natalie Drew, Edwige Faydi and Michelle Funk (World Health Organization); Arvin
Bhana (Human Sciences Research Council, RSA); Victor Doku (Kintampo Health Research Centre, Ghana); Andrew Green and Mayeh
Omar (University of Leeds, UK); Fred Kigozi (Butabika Hospital, Uganda); Martin Knapp (University of London, UK); John Mayeya
(Ministry of Health, Zambia); Eva N Mulutsi (Department of Health, RSA); Sheila Zaramba Ndyanabangi (Ministry of Health, Uganda);
Angela Ofori-Atta (University of Ghana); Akwasi Osei (Ghana Health Service); and Inge Petersen (University of KwaZulu-Natal, RSA).
Abstract
Objective: The aim of this qualitative study was to explore the presence, causes and means of addressing individual and systemic
stigma and discrimination against people with mental illness in Zambia. This is to facilitate the development of tailor-made anti-
stigma initiatives that are culturally sensitive for Zambia and other low-income African countries. This is the first in-depth study on
mental illness stigma in Zambia. Method: Fifty semi-structured interviews and 6 focus group discussions were conducted with
key stakeholders drawn from 3 districts in Zambia (Lusaka, Kabwe and Sinazongwe). Transcripts were analyzed using a grounded
theory approach. Results: Mental illness stigma and discrimination is pervasive across Zambian society, prevailing within the
general community, amongst family members, amid general and mental health care providers, and at the level of government.
Such stigma appears to be fuelled by misunderstandings of mental illness aetiology; fears of contagion and the perceived
dangerousness of people with mental illness; and associations between HIV/AIDS and mental illness. Strategies suggested for
reducing stigma and discrimination in Zambia included education campaigns, the transformation of mental health policy and
legislation and expanding the social and economic opportunities of the mentally ill. Conclusion: In Zambia, as in many other low-
income African countries, very little attention is devoted to addressing the negative beliefs and behaviours surrounding mental
illness, despite the devastating costs that ensue. The results from this study underscore the need for greater commitment from
governments and policy-makers in African countries to star t prioritizing mental illness stigma as a major public health and
development issue.
Key words: Mental health; Stigma and discrimination; Qualitative study; Zambia
Received: 24-06-2009
Accepted: 09-07-2009
Correspondence:
Ms Sara Cooper
Research Officer, Mental Health and Poverty Project,
Department of Psychiatry and Mental Health, University of Cape Town,
46 Sawkins Road, Rondebosch, 7700, South Africa
email: SD.Cooper@uct.ac.za
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African Journal of Psychiatry July 2010 193
societies.9Indeed, studies elucidating mental illness stigma
and discrimination derive mainly from Western countries,
with a paucity of comprehensive studies having been
conducted in Africa, particularly in Sub-Saharan Africa.7,10
The few studies conducted in Africa have suggested that
the experience of stigma by people with mental illness may
in fact be common.11-12
For example, in their study investigating knowledge and
attitudes of the general South African public towards mental
illness, Hugo and colleagues found that knowledge was low
and stigma was high. Such stigma appeared to be
associated with the fact that mental illnesses were
understood as a lack of willpower, and stress-related, rather
than medical illnesses.13 Another example can be seen in
Nigeria, where the first large-scale, community
representative study of popular attitudes towards mentally
ill, found stigma to be widespread, with most people
indicating that they would not tolerate even basic social
interactions with someone with a mental illness.9These
preliminary findings thus confirm Corrigan and Watson’s
assertion that the lack of empirical data in African countries
may explain the speculation that stigmatisation and
discrimination towards mental illness is less common in
these societies.14 More studies on the continent are needed
in order to avoid ill-informed assumptions, and to prevent
uncritical transposition of findings from western contexts to
Africa, given cultural and structural regional differences.
Besides this geographical gap that appears to
characterize the mental health and stigma/discrimination
literature, other theoretical and methodological biases have
also been noted. From a theoretical perspective, various
scholars have argued that understandings of stigma and
discrimination pertaining to mental illness have been far too
narrow. Most studies tend to understand stigma and
discrimination from an “individual or psychological level”,
that is individual beliefs, attitudes and behaviour that
usually evolve from ignorance and erroneous beliefs.15-16
The focus has thus been on identifying and examining the
nature of the beliefs that come to be associated with
“category members” and the “category label”, and the way
in which such people are treated as a consequence of such
attitudes.1 7
Most certainly, such models have helped to explain
some of the causes and effects of mental illness stigma.15
However, these approaches tend to neglect more macro-
level stigma and discrimination. Thus, various scholars have
argued that understandings of stigma and discrimination
need to be broadened, incorporating structural or systemic
factors that arise at the level of the institution and reflect
economic, political, and historical forces.16,18 Structural or
systemic stigma and discrimination represents the policies
and behaviours of private and governmental institutions that
intentionally or unintentionally hinder the rights and
oppor tunities of stigmatized groups.18 These include for
example, restricting the voting and employment rights of
the mentally ill, as well as structurally disadvantaging
mental health services through its unequal distribution of
resources in health care.19,20
From a methodological perspective, it appears that
studies, globally, which have explored stigma and
discrimination associated with mental illness have been
predominantly quantitative, relying heavily on opinion polls,
surveys and structured questionnaires.21 Very few
qualitative studies have been done on the stigmatization of
and discrimination towards mental illnesses. It has been
argued that given that stigma may be a more subtle and
elusive object of research than commonly assumed,
qualitative methodologies are needed to help tap into the
more nuanced forms of stigma and discrimination.21
Furthermore, it has been argued that survey-type research
may fail to capture the possible social, cultural and political
forces that lie at the heart of mental illness-related stigma
and discrimination.1 6 More qualitative studies are therefore
needed in order to explore some of the more subtle,
complex and multidimensional dynamics possibly at play.
Furthermore, it has been argued that globally, most
studies have tended to focus on the attitudes and
behaviours of the general community, whilst neglecting the
views and actions of specific population groups.7One
particular group that has been largely ignored is that of
health care professionals, both in the general and mental
health fields.7,22 This is cause for concern, as the few studies
that have explored this area have found that such
professionals frequently hold negative attitudes towards
mentally ill patients which can have a material effect on the
quality and quantity of services that are offered.20,2 3,24 In
addition, stigma as experienced by those who suffer from
mental illness has been inadequately explored.16 This may
be one of the reasons why many anti-stigma programmes
and initiatives have, in part, been criticized for being
largely uninformed by the lived realities of people with
mental illness.20
Putting these geographical, theoretical and
methodological gaps aside, it is also impor tant that
increased attention is given to researching and addressing
the stigmatization of mental illnesses and the discrimination
of those affected. Stigma and discrimination towards the
mentally ill have pernicious implications for prevention and
treatment of mental illnesses, as well as the rehabilitation
and quality of life of those who suffer from mental
disorders.14,25,26 There is much evidence to suggest that
stigma and discrimination ensuing from it can have adverse
effects on those with mental disorders’ willingness to access
appropriate care and adhere to treatment regimes.20,27 The
personal and social costs that result from untreated mental
disorders are also considerable, including lost employment
and reduced productivity, together with possible suicide,
homelessness and the disruptive influence on family life.21,28
In addition, stigmatization and discrimination of those
suffering from mental disorders hinders their ability to
integrate into society and ultimately recover from their
illness, due to the frequent personal harassment, social
isolation and economic exclusion they experience.5,13
Forms of structural and systemic discrimination, such as
limited allocation of resources to psychiatry, also hinder
advances of the profession.2All of these issues in turn pose
major barriers to alleviating the already significant public
health burden of mental health.29-31
A promising sign is that in recent years, the elimination
of stigma and discrimination of mental illness has been
taken on board as a central target by various agencies and
governments internationally. The World Psychiatric
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African Journal of Psychiatry July 2010 194
Association has recently initiated a global programme
against stigma and discrimination, and twenty countries are
participating in the programme.20 The European Union’s
recent consultation about mental health promotion
identified the fight against stigma as an important area of
work for European countries, and the World Health
Organization has highlighted the need to combat stigma
and discrimination.22,32 More initiatives, particularly in Africa
are however urgently needed.
The aim of this qualitative study was to explore the
possible presence, likely causes and potential means of
addressing stigma and discrimination against the mentally
ill in Zambia. In line with approaches proposed by
Thornicroft et al and Link and Phelan, the current study
employed a broad understanding of stigma and
discrimination in relation to mental illness, including
individual attitudes and behaviours, as well as more
macrosocial systemic stigma and discrimination.16,27 These
issues were explored by assessing the views and attitudes
of a number of specific population groups, including mental
and general health care providers, policy makers, users of
psychiatric services, teachers, police officers, academics,
and traditional healers. Being based in Sub-Saharan Africa,
utilizing qualitative methodologies, performing micro- and
macro-level analyses, and focussing on specific
populations, this study speaks directly to many of the
geographical, theoretical and methodological gaps
germane to the contemporary mental health stigma
literature. Based on the insights drawn from this study,
recommendations will be provided on how such stigma
could be addressed in Zambia and other low income
African countries.
Method
The data collection for this study formed part of a situation
analysis of the current status of mental health policy,
legislation and services in Zambia which was conducted as
part of the first phase of the Mental Health and Poverty
Project (MHaPP). The MHaPP, which is being conducted in
four African countries, Ghana, South Africa, Uganda and
Zambia, aims to investigate the policy level interventions
that are required to break the vicious cycle of poverty and
mental ill-health, in order to generate lessons for a range of
low- and middle-income countries.33
This particular study focuses on the qualitative data
obtained from the MHaPP situation analysis. Fifty semi-
structured interviews and six focus group discussions were
held with policy makers (from the Ministry of Health and
elsewhere), health and mental health care professionals,
users of psychiatric services, teachers, police off icers,
academics, members of three NGOs and traditional healers.
In total, the study sample was 65 respondents, who were
sampled from three districts in Zambia (Lusaka, Kabwe and
Sinazongwe). The fieldwork for the study was conducted in
2005 and 2006.
The sampling of respondents for the semi-structured
inter views and focus group discussions was purposive.
Respondents were selected mostly because they were
known to be resourceful people and had the experience
that was particularly relevant to the study. The participants
were also selected based on the principle of maximum
variation, in order to provide as wide a range of
perspectives as possible on mental health policy
development and implementation in Zambia.
The duration of the interviews and focus group varied
between 45 – 120 minutes. Six focus group discussions
were conducted with no less than six participants and not
more than eight at the most. A focus group consisted of
homogenous participants (with nurses alone, clinical
officers alone and patients alone), although in two instances
focus group discussions were conducted in the company of
nurses and clinical officers. Clinical officers are front line
staff in the delivery of mental health care in primary health
care units in both long stay facilities and daily outpatient
facilities. Such staff members are at a level higher than
nurses but lower than doctors, with the law inhibiting them
from administering psychotropic drugs.
The participants who were interviewed individually
included stakeholders from various sectors as follows:
Directors: Ministry of Health: 5
Directors: Ministry of labour: 1
Director: Ministry Home affairs: 1
Director: Education: 1
Director: Ministry Community Development & Social
Services: 1
Director: Ministry Local Government & Housing: 1
Commission of Prisons: 1
HMIS specialist: 1
Director (DHMT) Lusaka: 1
Provincial clinical care specialist: 1
Medical doctors: 4
Clinical psychologists: 1
Clinical officers: 4
Nurses: 6
Mental health NGOs: 5
Family members: 3
Users: 3
Social workers: 1
General psychologist: 1
Teachers: 3
Policemen: 2
Traditional healers: 1
Prison warden: 2
The interviews were loosely structured, consisting of open
ended questions that broadly defined the area to be
explored, and from which the interviewer or interviewee
could diverge in order to pursue an idea on a specific issue
in more detail.34,35 The semi-structured inter views and focus
group discussions were tailored according to the specific
individual being interviewed. The following generic areas
were mostly covered in both the semi-structured interviews
and focus group discussions:
1. The general health context in Zambia
2. Key challenges facing the health system
3. Perceptions of mental health and persons with mental
disorders
4. Mental health needs and priorities in Zambia
5. Key challenges facing the mental health system
6. The general policy making processes
7. Process of mental health policy development.
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African Journal of Psychiatry July 2010 195
8. Role of various stakeholders in mental health policy
9. Content of the current mental health policy and
legislation
10. Mental health policy implementation
11. Mental health research
Various scholars emphasize that the major advantage of
focus groups lies in their ability to mobilize participants to
generate their own questions in their own vocabulary and to
respond to and comment on each other’s contributions on
their own terms.36 Statements are challenged, extended,
developed, undermined and qualified in a way that
generates rich and in-depth data. This is particularly
pertinent for the current study because as highlighted
earlier, stigma research has tended to ignore the social and
structural underpinnings of stigma. Thus, the utilization of
focus groups allowed the researchers to tap into how
representations and meaning systems in relation to mental
illness are articulated, formed, changed, negotiated,
censured, justified, diversified and jointly constructed within
social networks and social interactions. Fur ther more, the
focus groups may shed light on certain shared norms and
communal understandings, as well as discrepant and
divergent views. For this reason, the data collected from the
focus groups both enhanced and expanded upon some of
the issues that emerged within the individual interviews.37,38
Permission to conduct the study was obtained from the
Ethics Committee of the School of Medicine, University of
Zambia and the Research Ethics Committee of the Faculty of
Health Sciences, University of Cape Town, South Africa. We
provided detailed information to participants concerning
participation and the consequence of the study, and thus
participation was voluntary. With the consent of individual
participants, all sessions were digitally recorded and
transcribed verbatim. All digital recordings were erased
following transcription, and all identifying information was
removed from all transcripts. Confidentiality and anonymity
was thus ensured. Transcripts were entered into Nvivo 7
which was used for coding and analysis.
The analysis was undertaken using a grounded theory
approach. As the name implies, grounded theory refers to
generating theory and understandings which are ‘grounded’
or which emerge from the data that is systematically
gathered and analyzed.39 The objective is to build and
expand, rather than test theory, allowing for the discovery of
new insights and enhanced understandings that are derived
from the coded categories, themes and patterns. Grounded
theory is useful in undertaking local research where it may
not be wise to transfer theory generated in more western
settings onto an African context.40
Grounded theory enabled the researchers to inductively
identify categories, themes and patter ns that emerged from
the data, as well as interpreting and contextualizing the text
at greater depth to uncover deeper meanings and themes. A
broad generic coding list was created by the study team,
where after more refined codes were formulated inductively.
Results
Widespread stigma and discrimination
The results revealed that mental illness stigma and
discrimination is widespread in Zambian society. This
surfaced in three different ways. For the most part, this
emerged when participants were asked directly whether
stigma and discrimination of mental disorders occurs. On
other occasions, a number of the stakeholders
spontaneously volunteered their thoughts on these issues.
Finally, when reading each interview as a whole, in their
entirety, it became clear that some of the interviewees
themselves had certain stigmatizing tendencies. Discourses
of stigma seemed to speak through the participants’ talk of
mental health.
Within the general community:
“This is a mad person, so what is he doing in
the community...”
An overriding theme amongst participants from all of
stakeholder groups interviewed was that stigma towards the
mentally ill is rife in Zambia. The interviews were saturated
with comments that people with mental disorders are
“stigmatized”, “feared”, “marginalized” and “labelled in
exclusively negative ter ms”. It was emphasized that such
people were commonly seen as “rejectees”, “stupid”
“embarrassments in the community” or the “laughing stock
of the community”, and thus relegated to the identity of “just
a Chainama case”. Chainama is the main psychiatric
hospital in Lusaka. The list of the negative ways in which the
mentally ill appear to be perceived in the general
community was incessant. One mental health nurse most
succinctly captured community attitudes when she
articulated:
‘You know a mentally ill patient is always
stigmatised, wherever she goes, whenever she
does anything, people in the community would
say cofuntha [you are mad].’
These views were confirmed by some of the mental health
service users themselves that were inter viewed. For
example, one mentally ill patient, who suffers from
depression lamented:
‘My association with Chainama aggravated the
stigma in the community. So, I came in contact
with stigma and discrimination and that
introduced me to life of misery, you know you
can’t get a job...you can’t be accepted. I
couldn’t see hope and my future was chopped
off. I live a life of loneliness’.
This patient highlights some of the kinds of discrimination
that appears to ensue from such widespread community
stigma. Indeed, a number of respondents indicated how the
mentally ill are frequently “discharged from their duties”
and “kicked out of employment”. Furthermore, a social
worker explained that “You find people with mental
problems are attacked, and then you find the community just
stands around cheering, bullying and throwing stones at
them”.
Many participants emphasized that such widespread
stigma in the community also frequently extends to
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African Journal of Psychiatry July 2010 196
everything that is associated with mental illness. Family
members of the mentally ill were perceived by many of the
respondents to experience stigma themselves, as articulated
by a member of a mental health NGO:
Stigma associated with mental illness is
transferred to their afflicted family members.
They too are affected in a big way... it is
assumed that the whole family is mad.
Similarly, a social worker explained, ‘The community also
rejects the family. The whole family is seen as tainted, so the
community does not accept the family and the individual’.
It seems that the Chainama mental hospital is itself a
source of widespread negative attitudes. As a general
medical doctor explained:
‘Some patients have told me that they would
love to change the name Chainama into
something else like probably Kenneth Kaunda
Hospital. Why do they say this? Because
Chainama has always been stigmatized...Just
the name is seen as negative’.
The all-embracing nature of mental illness stigmatization in
Zambia was most aptly revealed by a general nurse’s
comment that even a neighbourhood can be stigmatized if a
patient is known to have lived there:
‘You will find that once there is an illness in the
neighbourhood, the neighbour s will not want to
stay there, because they will be saying that
“apa pali cimunthu cofunta”, meaning there is a
mad person here’.
Amongst family members of the mentally ill:
“Family members themselves are indeed
culprits in this area...”
Although widely acknowledging that the relatives of those
suffering from mental disorders are frequently stigmatized,
many respondents also suggested that family members
themselves often hold very negative views about mental
illness, and treat their family members affected very badly.
Many allied mental health professionals indicated that the
mentally ill are frequently “viewed as subhuman by their own
flesh and blood” and “discriminated against by their closest
friends and family”.
It seems as if abuse of the mentally ill within the family is
widespread, as indicated by this social worker:
‘You find that even in their own homes they are
being troubled by their relatives. I remember
when I was called to go and see a patient who
was kicked up within the home once he was
discharged’.
Many respondents highlighted how many mentally ill
persons are “abandoned by their relatives” or “not
accepted by their family”. A mental health service user said
that “I experience discrimination, especially from my
relatives”. A similar view was expressed by another mental
health service user:
‘To some extent, they [family members] also
promote this human rights violation. I
remember when we had a focus group
discussion and a lot was coming out that family
members themselves are indeed culprits in
this’.
It seems that a mentally ill child suffers particularly
pernicious stigma by their family. One policy-maker in
government movingly stated that if a parent has a mentally
disabled child, and you ask them how many children they
have, it is common for them to reply “we have three and then
there is that unusual one”. Similarly, a school teacher
remarked:
‘Some parents wouldn’t want to be recognised
that they have such children. These children are
unwanted. These days...they wouldn’t want to
keep their children and not wanting to be seen
that they have such people in their homes’.
Amid general health care providers:
“Why are we occupying mental patients
because it is said that an idle mind is the devils
workshop...”
In the interviews and focus group discussion with general
health care practitioners, it became clear that these
individuals may possess cer tain, albeit more subtle,
stigmatizing tendencies. Stigmatizing discourses appeared
to seep through some of the stories that they told, and the
remarks that they made. For example, the above quote by a
general health nurse illustrates this point while talking about
the under-staffed and over-burdens hospitals in Zambia. In
expressing her frustration over her own workload, the
negative views this nurse holds about mental patients is
clearly revealed. Similarly, when talking about a meeting she
attended with mental health patients, another general health
nurse ar ticulated:
‘I attended a workshop run by _______ [NGO]
and like, we look at these people [people with
mental illness] as if they can't do anything. But at
this meeting, I mean I forgot that we were
dealing with mental patients, they came up with
ideas, a lot of ideas. I was so surprised at how
intelligent they actually are...’
Although this nurse is providing an account of a situation
where her negative views about mentally ill people were
challenged, the denigrating assumptions she usually holds
about such individuals is starkly revealed. One is struck by
the surprise she displays in relation to how “intelligent” this
group of mentally ill people were. Similarly, when talking
about how she sympathizes with families who have a
mentally ill relative, another nurse emphasized:
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African Journal of Psychiatry July 2010 197
‘They are a burden to their relatives...if they can
be more independent, they will be respected as
human beings’.
The negative views that some general medical practitioners
appear to hold was confirmed by comments made by other
stakeholders who were interviewed. For example, in
describing a situation when he had to take a person with a
mental illness to a general hospital, a prison warden
exclaimed:
These patients are rarely attended to when they
go to general hospitals. All of the staff their will
just say, “nichofunta ichi chiyende ku Chainama”
meaning that’s a mad person let him/her be
attended to by the Chainama guys’.
This view was shared by a few mental health nurses, who
said that when they have taken a mental patient to the
general hospital, the staff there “don't want mental patients”,
“are rude to them”, remark that “this is a Chainama case so
it’s not there problem” and thus frequently “do not attend to
the person”.
This lack of care afforded to people with mental illness in
general hospitals was reiterated by a mental health user
suffering from depression, when he described an incident
when he went to get medicine at a general hospital:
‘I went to ______ clinic, and oh dear me, a nurse
came out so strong and said ‘who told you that
we stock medicines for mad people here’?
Amongst mental health care staff:
“It’s like they don't see that you are a person like
everybody else...”
Although expressing great uneasiness with the way in which
many general health practitioners’ appear to perceive and
treat the mentally ill, it became apparent that some mental
health care professionals themselves may not be exempt
from possible stigmatizing tendencies. At times, this was
revealed in quite an overt manner. For example, when
describing some of the staff in the mental hospital, a
psychologist exclaimed:
‘If their relatives bring them food, they can't put
it in fridges, because they are perceived that
they are sub-human. If they look at them, they
are perceived that they cannot even suffer from
malaria hence, no mosquito nets in those wards’.
In addition, accounts given by mental health patients and
their families revealed that mental health professionals do not
always think about and behave towards patients in the most
amicable ways, as indicated by a family member of a mental
health service user:
‘He is treated really badly at the hospital... For
instance, he told me how he was being beaten
when he was admitted. These people who work
with the patients should be more
knowledgeable...Even the nurses say iwe yenda
ku Chainama [hay you are just a Chainama
case]’.
Similarly, a mental health service user sadly explained:
‘Sometimes the way we are treated in the wards,
it’s like they don't see that you are a person like
everybody else, sometimes you are even beaten,
we were being beaten and insulted. You can't like
it’.
Some of the negative views certain mental health care
practitioners appear to hold were also revealed in more subtle
ways. For example, when asked whether service users should
be included in policy development, one clinical officer in
psychiatry rather tentatively replied:
‘Well, um, I mean, I suppose, like they are not
always sensible...you know they can't really
function properly, so it will be very difficult for
them to come up with comprehensive ideas’.
Similarly, in answer to the same question, a mental health
nurse exclaimed:
‘I am not sure, but I think as care takers we know
what is good for them and what is not. Often they
choose something that is not good for them, so
they should have a limit there’.
Although submerged in uncertainty, both of these mental
health practitioners’ remarks tend to be to link to the rhetoric
of incapability and powerless so characteristic of views about
people with mental illness.
At the level of government:
“Mental health...is the Cinderella of the health
services, as it is the last aspect of it...”
It became clear that more structural forms of discrimination
are rife at the level of government. This was most aptly
revealed in respondents’ discussions around the current
mental health law, as well as the limited funding allocated to
mental health. A number of respondents indicated that the
mental health law is “old fashioned” and uses “very ancient
and derogatory terms like imbecile and idiot”. It was
emphasized further that this current law “does not protect the
rights of the mentally ill” because the “patient has no say
when it comes to the law”. The degrading nature of the
current mental health law in Zambia was most pertinently
revealed in one mentally ill patient’s narrative about stigma:
‘One of the biggest problems is the law itself...it
actually deposits a person with a mental illness
as a dangerous person, as a person with no
worth. The way law descr ibes me. Who am I? The
identity that I am given by the law is an imbecile,
an idiot...’
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African Journal of Psychiatry July 2010 198
Other health professionals commented on the way in which
psychiatry is sidelined through its unequal or scanty
distribution of resources in health care. During an
interview with a district health officer, the interviewer
remarked that he thought that a certain amount of money
was specifically dedicated for mental health. The
respondent replied:
I have never heard of that money, that is news
to me. I have never come across a budget
allocated to the district for mental health
care... Mental health...is the Cinderella of the
health services, as it is the last aspect of it...
The monies which come here are just not
adequate’.
The limited funds dedicated to mental health was
reiterated by a psychologist when she explained,
‘There is the complete neglecting of mental
health issues. I think we devote less than 1% of
health expenditure to mental health which is a
sad state of affairs’
Possible causes of stigma and discrimination
Having shed light on the omnipresent nature of stigma and
discrimination within Zambian society, we now turn to
exploring some of the possible reasons for such
widespread negative views and behaviours.
Constructions of mental illness aetiology:
“So it all starts with the definition itself...”
It became clear that dominant views around what causes
mental illness in Zambian society may play a significant
role in producing stigmatizing attitudes towards people
with such disorders. Firstly, hegemonic cultural explanatory
models of mental disease aetiology appears to be a major
contributing factor towards mental illness stigmatization
and discrimination, particularly amongst those not in the
fields of general or mental health care. There was a great
deal of consensus amongst respondents that mental illness
in the general community tends to be understood as
“bewitchment”, “Satanism” and “evil spirits” and that the
individual has “been cursed” or “possessed by demons”.
A number of participants explained that it is commonly
believed that the individual has done something wrong in
the community, such as “stealing”, “telling lies”,
“committing atrocities with other innocent people” or
“getting with another man’s wife”, and as a result, the
person or a member of their family, is bewitched. As
described by one mental health nurse,
‘When mental illness is in the family, it is seen
as a sign that one of the relatives in the family
did some thing which is not supposed to be
done. So, its like an omen or an abomination,
so they are punished, bewitched, through poor
mental health, through mental illness. Like a
curse from God’.
As indicated by this nurse, given understandings of mental
illness aetiology, the supposed resulting mental illness is
consequently perceived to be divine punishment for
immorality. A few respondents made the link, explicitly,
between this cultural authority of traditional constructions of
health and illness and stigmatization. For example, after
talking about dominant understandings of the causes of
mental illness, a member of a mental health NGO concluded:
‘So, generally, the picture is that, because of the
way people understand mental illness, the
community has been persecuting the mentally ill
and that is why these people have never enjoyed
the comfortable life’.
In a similar way, a clinical officer in psychiatry remarked:
‘People still think that mental illness is caused by
evil spirits. They believe that any person suffering
from mental illness is demon possessed. And
these explanations affect the way they perceive
mentally disabled people... So it all starts with
the definition itself’.
In addition to dominant cultural explanatory models of mental
disease aetiology, drug and alcohol abuse was highlighted,
particularly amongst participants in the general and mental
health fields, as an additional causative factor for mental
illness. This perception also appears to contribute to the
stigmatization of mental illness.
A number of health professionals explained that drug and
alcohol abuse is a major cause of mental illness. In the
participants’ descriptions, it became clear, that such views
translate into the notion that mental illness is self-inflicted. This
in turn appears to elicit blame, rather than understanding or
compassion. For example, one clinical psychiatric officer
elucidated:
‘So many of the disorders are from substance
abuse...they abuse alcohol, they abuse these
illicit drugs, cocaine and related ones, and then
they wonder why they get mentally ill...’
Through this account, this health care provider implied that
mental illness is a calamity one brings upon oneself, and is
thus condemns mentally ill patients for “inexcusably”
imposing risk upon themselves. Similarly, a mental health
nurse described a patient she knew who “had no direction”
and thus “just sat around smoking dagga” and then
“expected people to feel sorry for him when he fell ill”. The
sentiments of disapproval and blame are clearly revealed by
these remarks. A few other mental health care workers also
recounted stories with similar morally punitive undertones.
Fear:
“People are just scared...and fear always makes
people behave in negative ways”
It became clear that mental illnesses have induced an
emotional context of fear and anxiety in Zambian society.
ORIGINAL Afr J Psychiatry 2010;13:192-203
African Journal of Psychiatry July 2010 199
People within the general community, as well as some
health care practitioners appear to harbour immense fear
towards mental illness. Such trepidations appear to stem
from perceptions that mental illness is contagious and
transmittable, and that mentally ill people are dangerous.
For example, par ticipants described how many people in
society “believe that mental illness is contagious”. As a
member of a mental health organization said:
‘Most of the organizations that we came across
have a belief that a bite from a mental patient
affects the other person to be mentally ill. Now
with such kind of beliefs, do you expect the
community to give proper care to the patient?’
The way in which such fear translates into negative
attitudes and behaviour is clearly revealed by this
respondents comment. Other respondents highlighted that
many people in Zambia believe that mental illness is
genetically transmissible. Consequently, people are afraid
to marry someone from a family where mental illness
exists, in case the new children get ill, as described by a
teacher:
‘Others think it’s an inborn thing that is passed
from generation to generation, meaning that, if
there was a mentally ill patient in a family, then
this will get passed down into subsequent
families...So people are scared...’
Although there most certainly is evidence supporting the
contribution of genetic factors to mental illness, the way in
which this evidence is interpreted and the fears stemming
from this, contributed to the stigmatization of mental
disorders and those affected. In conjunction with fears of
infection and transmissions, other participants, par ticularly
in the general health field, expressed immense fear around
the supposed violent and aggressive nature of people with
mental illness. A few general medical doctors provided in-
depth narratives about how dangerous and risky mentally
ill people can be:
‘It is very risky for you to be working in the
psychiatric ward...you really have to be very
careful because it is risking. Patients can end
up beating you so you need to be very
tactful...Either you will be physically attacked.
Similarly, in talking about why mental health patients should
not be treated in the general health care sector, another
general health officer
‘You see, these mental patients when they get
sick they become violent so they threaten the
people that we keep here...They become so
aggressive...’.
It thus seems that a myriad of fears are associated with
mental illness, which may contribute to the widespread
stigmatization of people with mental disorders. Indeed, as a
man suffering from anxiety explained:
‘People are just scared. I can see that they are
afraid of me, and fear always makes people
behave in negative ways.’
Association with HIV/AIDS:
“People’s views about AIDS accounts for a lot of
why mental illness is seen as so negative”
The stigma surrounding mental illness appears to be
buttressed and/or produced, at least in part, by HIV/AIDS
stigmatization. General and mental health practitioners and
policy-makers emphasized a significant link between mental
illness and HIV/AIDS, indicating that many people suffering
from mental disorders are also HIV-positive. As a clinical
officer in psychiatry exclaimed:
‘Nowadays there are so many patients who are
mentally ill with HIV... I would say that from my
own experience, I have seen that many people,
particularly women suffer from HIV/AIDS related
mental disorder’.
This was reiterated by a policy maker in government who
said:
‘With HIV pandemic, there are now a lot of
people with mental disorder due to HIV/AIDS....
lets say 80% of them could be HIV related... AIDS
is a catalyst for mental health so you can’t
separate HIV from mental health’.
It seems that the mental health and HIV/AIDS link is widely
known in the community, with a common prevailing
perception being that HIV/AIDS causes mental illness, as
indicated by this mental health nurse’s remark:
‘Most people think that mental illness is because
of HIV/AIDS, although others think they have just
been bewitched’.
Indeed participants in the general health field indicated that
people “often assume that if one is a mental patient, one also
has HIV”. Given this epidemiological profile, together with the
common assumptions it evokes, a few respondents explained
that mental illness stigmatization is produced by HIV/AIDS-
related stigma. A mental health NGO member argued:
‘I think that people’s views about AIDS accounts
for a lot of why mental illness is seen as so
negative... If people see a patient from
Chianama, they will say, ‘Oh, he must have
AIDS’... And, we still face a lot of stigma with
AIDS...’
Similarly, a psychiatric officer explained:
‘Sometimes they would say mental illness is
because of infections which are HIV related or
other infections like syphilis and you know these
kinds of diseases carry a lot of stigma already...’
ORIGINAL Afr J Psychiatry 2010;13:192-203
African Journal of Psychiatry July 2010 200
Challenging mental illness stigma and discrimination
Respondents from all stakeholder groups interviewed,
emphasized that increased attention and commitment towards
addressing the widespread stigma and discrimination
surrounding mental illness in Zambia is urgently needed.
Community sensitization and public awareness campaigns were
indicated as the primary approaches that should be used. It was
stated that people need education about “the causes of mental
illness”, “how mental illness can affect anyone” and how “with
the right treatment, people can be cured and function as
normal”. It was emphasized that this is essential for people to
“start accepting mental illness” and “perceiving the mentally ill
as human beings”. For example, a general medical doctor
suggested:
‘We need to sensitize people in the community to
make them understand what mental illness is all
about. They need to know that they [the mentally ill]
are sick just like any other illness’.
Other respondents emphasized particular groups that may need
to be targeted for awareness campaigns. For example, a policy-
maker in government highlighted that employers need to be
targeted, so as to avoid inappropriate discrimination:
‘Employers need to be educated that there is a
certain level where someone can continue with his
job and contribute effectively to the organisation. So
I think that the target should be the employers, the
people with the authority to keep someone in the
organisation’.
In addition to awareness campaigns, a number of respondents
indicated that redressing stigma and discrimination requires a
strong and relevant mental health law and policy. As one clinical
psychiatric officer explained:
‘I think that if the government could come in and
strengthen the policy on mental health probably
the stigma would go down.’
This was reiterated by a mental health service user, who
movingly supplicated for policy and law transformation to
promote stigma reduction:
‘Please, plead to pioneers to take the issue of policy
and law very seriously if we are to move... The law
needs to start looking at mental health from the
human rights point of view....’
Other respondents emphasized that appropriate law and policy
is not enough, as reducing stigma and discrimination that ensues
from it requires actually supporting the rights of people with
mental disorders, as one mental health NGO member explained:
‘There is need to actually promote the equalisation
of opportunities. They need to participate in
decision-making, full participation. There is need
for opportunities in employment, education and
rehabilitation services. These steps need to
accompany awareness campaigns.’
Discussion
This study provides qualitative insights into the presence
and possible causes of stigma and discrimination in
Zambian society, as well as shedding light on what key
stakeholders perceive to be the best ways of addressing
such stigmatization. To our knowledge, this is the first in-
depth study on mental illness stigma in Zambia. This study
is also novel in its attempt to explore the attitudes and
beliefs of a number of specific population groups,
including general and mental health staff, family members
of mental patients, as well as government officials. It also
attempts to give agency to the views of those actually
suffering from mental disorders, voices which are
frequently neglected in research. As Link and Phelan argue,
stigma research is frequently conducted by researchers
“who do not belong to stigmatized groups, and who study
stigma from the vantage point of theories that are
uninformed by the lived experience of the people they
study”.16
The results from this study revealed that stigma and
discrimination towards mental illness and those affected
are ubiquitous and insidious across Zambian society,
prevailing within the general community, amongst relatives
of patients, amid general and mental health care providers,
and at the level of government. Such stigma also appears to
be all-embracing, being directed not only towards those
labelled as mentally ill, but also extending to their family
members across generations, and even to the mental
hospitals themselves. This corroborates findings from other
studies, which have also shown that stigma extends to
family members and mental hospitals.2,19,41-42 This picture
thus contrasts with assertions that have been made that
stigma and discrimination of mental illness is less severe in
African countries.7-8
Although mental illness stigma appears to be present
across Zambian society, the nature of such stigma most
certainly differed between different stakeholder groups.
The results revealed that stigma residing within the general
community and amongst family members is extremely
blatant, with a plethora of negative labels being assigned
to, and a range of abusive and neglectful behaviours being
directed towards, the mentally ill. These findings confir m
the results from the few other studies which have been
conducted in Africa, which have also shown community
stigma and discrimination surrounding mental illness to be
overt and per nicious.7,9,11-13
The results revealed that some, although not all, general
and mental health practitioners may also hold certain
negative attitudes towards the mentally ill. Most certainly,
such perceptions appear to be more subtle and less crude
those residing within the general community. Nonetheless,
certain stigmatizing tendencies do appear to be present
amongst health care providers. This was revealed by the
accounts given by service users and their families, as well
as through some of the actual remarks made by such
practitioners in the interviews. Schulze indicates that
possible stigma amongst health care providers has been a
neglected area of research, and a blind-spot in anti-stigma
initiatives.20 A handful of studies that have explored this
area have found that health and mental health professionals
may contribute to the development and reinforcement of
ORIGINAL Afr J Psychiatry 2010;13:192-203
African Journal of Psychiatry July 2010 201
mental illness stigma.22,24,32,43 As was the case in this
current study, these studies also found that such
professionals may use derogatory terms for mental illness,
may refuse to treat physical illness in those with mental
illness and frequently assume that people with mental
illness are incapable and powerless to make decisions.
A disheartening finding from this study concerns the
systemic discrimination that prevails at the level of
government and policy. This study revealed that mental
health legislation contributes to the very disparaging
labels assigned to people with mental disorders in
Zambian society. Furthermore, mental health appears to be
structurally disadvantaged, being allocated inadequate
funding. These findings are confirmed by quantitative
research carried out in Zambia which found the law to be
outdated, and funding insufficient to meet even the basic
mental health needs of the country.44 This situation is not
unique to Zambia. WHO Mental Health Atlas revealed that
many low income countries in Africa have mental health
legislations that are outdated and not in accordance with
inter national human rights standards.45 In addition,
inadequate funding for mental health is an insidious
problem affecting many low-income African
countries.31,46,47
This study also shed light on some of the possible
causes of this widespread stigma and discrimination. For
the most part, respondents were not asked directly, nor did
they spontaneously provide an explanation, as to why such
stigma and discrimination exists. Although a direct link was
not always made, when reading the respondents
narratives, possible rationales for the ubiquitous stigma
materialized. The manner in which stories are told, the
emphases and links made, the morals drawn and the
details, justifications and conclusions made, are all very
revealing often beyond the storytellers’ intent.48 For
example, a respondent may be talking about the link
between mental illness and drug abuse, and then
subsequently conclude with negative characteristics about
the person. Thus, by putting the pieces of data together,
and contextualizing them with the interview as a whole,
more subtle insights can be gleaned.
As shown in other studies views about causation were
strongly associated with stigmatizing attitudes towards
people with mental disorders.3,9,49 As with many studies in
the West, this study showed that the associations of mental
illness with drug and alcohol abuse generate sentiments of
blame and condemnation, holding those affected
responsible for their illness.20,32,50 Negative attitudes to
mental illness and associated blame also appeared to be
fuelled by cultural and religious views about disease
aetiology, seeing mental illness as divine punishment for
atrocities committed. This confirms Gureje’s remark that
stigmatization of mental illnesses probably exists
everywhere, even though its causes and manifestations
may be culturally-specific.9More studies are needed to
explore the culturally-specific causes, forms and nature of
mental illness stigma, so that tailor-made educational
campaigns can be more culturally sensitive.26
An unexpected finding from this study, that appears to
not have been shown elsewhere, was the way in which
HIV/AIDS stigma may produce and reinforce mental illness
stigma. This was not a major focus of the study, nor was it
the main theme that emerged. It was thus not fully explored
or unpacked during the interviews. Further probing might
have elicited possible reasons for this finding more
explicitly. It is possible to speculate on the likely
explanations for this relationship. As with mental illness,
HIV/AIDS is highly stigmatized.51 Given that there was
widespread belief in Zambian society that people with
mental disorders are also frequently HIV-positive, such
persons, whether they are positive or not, may suffer twin-
stigmatization: HIV and mental illness-related. This clearly
reflects Treichler’s contention, when talking about AIDS as
an ‘epidemic of signification’, that ‘AIDS is a nexus where
multiple meanings, stories, and discourses intersect and
overlap, reinforce and subvert one another’. More studies
are needed to explore this area further.52
The myriad of fears surrounding mental illness may
also be a contributing factor to its stigmatization. Fears of
contagion and transmission as well as the fears of mental
patients being violent and aggressive were widespread
across the different stakeholders interviewed. Indeed,
stereotypes of the dangerousness of people with mental
illness appear to be common, and a key factor contributing
to stigma and discrimination.21,48,53
Various scholars working within a psychosocial
perspective have argued that fear might be a driving force
under pinning stigma.54-56 It has been suggested that when
people are faced a potential threat, such as mental illness,
in order allay the fear it induces, people frequently ‘other’
or stigmatize the threat and those associated with it. This
process helps people to distance themselves from a sense
of personal risk and vulnerability.57-58 Thus, far from being a
rational and cognitive process, from this perspective,
stigma may rather be a complex unconscious, irrational
and emotional process. Thus, despite various assertions
that knowledge is a protective factor against stigma, this
theory raises questions around the role that information
and education may actually play in preventing stigma.25-26
This understanding of stigma, as related to primal fears and
anxieties rather than knowledge, may help one to
understand why many health care providers in this study
appeared to hold certain, albeit subtle stigmatizing
attitudes.
This psychosocial theory may also help one to
understand why many people who held stigmatizing views,
also emphasized the need for increased attention and
commitment towards addressing the widespread stigma
and discrimination surrounding mental illness. This
apparent contradiction becomes somewhat clearer when
one understands that stigma may be an unconscious and
unintentional process. Indeed, one was constantly struck by
the unawareness so many mental and general health care
providers displayed when making certain derogatory
remarks.
Many different recommendations were put forward
concerning how to address such stigma and
discrimination. Strategies suggested included awareness
raising campaigns and health education programmes. It
was also emphasized that the current mental health law
needs to be revamped and transformed, and the social and
economic opportunities of the mentally ill expanded.
ORIGINAL Afr J Psychiatry 2010;13:192-203
African Journal of Psychiatry July 2010 202
Anti-stigma initiatives globally have tended to focus on
reducing mental illness stigma by changing beliefs and
attitudes through three dominant ways: education (which
replaces myths about mental illness with accurate
conceptions), through contact (which challenges public
attitudes about mental illness through direct interactions
with persons who have these disorders) and through
protest (which seeks to suppress stigmatizing attitudes
about mental illness).21,59-61 The results from this study
indicate that such initiatives need to be broadened and
expanded.
For example, the results suggest that mental and
general health staff should themselves be an important
target for anti-stigma initiatives. The results from this study
shed light on the fact that challenging mental illness stigma
may need to go beyond providing ‘correct’ information and
education, at least amongst health care providers. It may
entail providing a space for people to engage with, and be
open and honest about the fears and anxieties they may
have around mental illness. They need to be encouraged to
reflect on their own fears, separating those that are realistic
from those that are irrational. Such professionals need to be
made aware of, and encouraged to take cognisance of
their own attitudes, and the ways in which they may
produce and reproduce stigma. This is by no means an
easy task, as stigmatization may be serving a deep-seated
and frequently unconscious defensive function.
Furthermore, the findings from this study suggest that
HIV/AIDS-related stigma may need to form an important
component of efforts to reduce mental illness stigma. In
addition, anti-stigma initiatives also need to target the
structural conditions that create and exacerbate stigma and
discrimination. These include developing new legislation,
policies, and programmes that are based on international
human rights standards for people with mental disorders,
securing funding for mental health and promoting the life
opportunities of people with mental disorders. All of this
will require increased political will from government and
relevant stakeholders to promote mental health. These
initiatives are essential if we hope to reduce the
widespread stigma and discrimination surrounding mental
illness in Zambia and other low income countries.
Ultimately, the words of one service-user in this study, as
highlighted in the title of this paper, are an urgent call to
star t placing mental heath stigma on the national agenda:
‘I hope that one day, a person like me could
walk head up into a psychiatry unit and say
‘look doctor, I have not slept for three to four
days please diagnose me’. And I would not
feel afraid to say this’.
Conclusion
Despite the common occurrence of mental health
problems, and worldwide anti-stigma efforts, societies
continue to hold deep-seated and culturally specific,
negative attitudes about mental illnesses. It has been
shown that attitudes and behaviours are not fixed and
concrete attributes, but have the potential for change. The
possibility of reducing stigma thus most certainly exists.
Redressing more structural discrimination may be more
difficult, as it reflect complex socioeconomic and political
forces, directly linked to the wider notions of power,
exclusion and control. Ultimately, it requires that policy-
makers and other relevant stakeholders star t recognizing
the devastating personal, social and economic
consequences of mental illness, and commit to prioritizing
it as a public health and development issue.
Acknowledgements
This research was funded by the UK Department for
International Development (DfID)(RPC HD6 2005- 2010) for
the benefit of developing countries. The views expressed
are not necessarily those of DfID. We would like to
acknowledge the respondents for their valuable
contributions.
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... A lack of training of health-care professionals in a number of LMICs, the stigma associated with mental disorders exacerbated by preconceptions and cultural issues as well as a lack of clear referral systems and support to treat mental disorders, all negatively impact on care provision alongside concerns with access to care and appropriate treatment [3,4,12,16,23,[37][38][39][40][41][42][43][44][45][46][47][48][49]. There is also considerable use of traditional medicines and faith healers in a number of LMICs which may also have a negative impact on patient outcomes; however, this may not always be the case [50][51][52]. ...
... There are a number of common challenges to the management of patients with BD-II in LMICs building on comments in the Introduction and Table 2. In addition to concerns with stigma, common challenges include the use of traditional medicines and faith healers as well as cultural issues associated with the management of patients with mental disorders [16,40,43,44,46,47,49]. Common challenges and themes can be divided into infrastructure and financial issues as well as treatment issues (Box 1). ...
... • The government has also made appreciable strides recently to increase the number of mental health workers through the new specialist training program (STP) for physicians, an undergraduate degree in mental health, and the recently enacted mental health act which passed into Law in April 2019. • Improved patient and physician education can hopefully address current concerns with widespread social stigma and discrimination against people with mental disorders in Zambia [46]. ...
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Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middleincome countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed. Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments. Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients’ rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.
... A lack of training of health-care professionals in a number of LMICs, the stigma associated with mental disorders exacerbated by preconceptions and cultural issues as well as a lack of clear referral systems and support to treat mental disorders, all negatively impact on care provision alongside concerns with access to care and appropriate treatment [3,4,12,16,23,[37][38][39][40][41][42][43][44][45][46][47][48][49]. There is also considerable use of traditional medicines and faith healers in a number of LMICs which may also have a negative impact on patient outcomes; however, this may not always be the case [50][51][52]. ...
... There are a number of common challenges to the management of patients with BD-II in LMICs building on comments in the Introduction and Table 2. In addition to concerns with stigma, common challenges include the use of traditional medicines and faith healers as well as cultural issues associated with the management of patients with mental disorders [16,40,43,44,46,47,49]. Common challenges and themes can be divided into infrastructure and financial issues as well as treatment issues (Box 1). ...
... • The government has also made appreciable strides recently to increase the number of mental health workers through the new specialist training program (STP) for physicians, an undergraduate degree in mental health, and the recently enacted mental health act which passed into Law in April 2019. • Improved patient and physician education can hopefully address current concerns with widespread social stigma and discrimination against people with mental disorders in Zambia [46]. ...
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Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed. Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments. Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients’ rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.
... However, when placed in the context of the personal accounts of the participants, additional aspects of the meaning of these results emerged. The understanding of the term mental health itself was not straightforward for many of them, and appeared to be associated with prevailing cultural prejudices in Zambia which characterise it as 'madness' or 'demon possession' (Aidoo and Harpham 2001;Kapungwe et al. 2010). There could also have been other sensitivities with the concept in a country where homosexuality itself is still considered a mental health pathology (ASSA 2015). ...
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Current law in Zambia criminalises same-sex sexual contact while strong socio-cultural values drive a profoundly negative view of the moral status of gender and sexual minorities. Despite this, Zambia's national HIV programme has recently identified the predominantly young population of men who have sex with men as a priority group for HIV and other sexual health programming. Research in other African settings has shown how the sexual health of these young men is affected by mental health. This mixed-methods study, which drew on the minority stress model as an analytical framework, sought to explore mental health as an initial step towards understanding its influence on other health domains. Findings describe the tension, and its psychological effects, surrounding the trajectory of discovering and affirming same-sex sexuality in an environment replete with social, physical and emotional risks, but one in which young men must nevertheless seek to create and maintain a meaningful, if precarious, social existence. To achieve this, in the absence of supportive mental health services or other programmatic responses, they adopt numerous risk-mitigation or coping strategies to attempt to build resiliency and to preserve their psychological and emotional well-being.
... The causes of stigma associated with mental disorders and the way in which it is manifested differ across the globe, but within Africa its sources are generally consistent and identifiable. High levels of stigma are predominantly attributed to fear and hostility arising from culturally informed beliefs regarding the aetiology of mental disorders, e.g., beliefs about spiritual causes such as witchcraft, demonic possession, retribution or the view that symptoms and behaviours are deliberate or indicate weakness or incorrigibility ( Egbe et al., 2014, Kapungwe et al., 2010, Gureje et al., 2005, Shibre et al., 2001, Shah et al., 2017, Opare-Henaku and Utsey, 2017, Palk and Stein, 2020. External factors and notions of responsibility thus play an important role in stigmatizing ascriptions in these contexts. ...
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Neuroimaging genetics is a rapidly developing field that combines neuropsychiatric genetics studies with imaging modalities to investigate how genetic variation influences brain structure and function. As both genetic and imaging technologies improve further, their combined power may hold translational potential in terms of improving psychiatric nosology, diagnosis, and treatment. While neuroimaging genetics studies offer a number of scientific advantages, they also face challenges. In response to some of these challenges, global neuroimaging genetics collaborations have been created to pool and compare brain data and replicate study findings. Attention has been paid to ethical issues in genetics, neuroimaging, and multi-site collaborative research, respectively, but there have been few substantive discussions of the ethical issues generated by the confluence of these areas in global neuroimaging genetics collaborations. Our discussion focuses on two areas: benefits and risks of global neuroimaging genetics collaborations and the potential impact of neuroimaging genetics research findings in low- and middle-income countries. Global neuroimaging genetics collaborations have the potential to enhance relations between countries and address global mental health challenges, however there are risks regarding inequity, exploitation and data sharing. Moreover, neuroimaging genetics research in low- and middle-income countries must address the issue of feedback of findings and the risk of essentializing and stigmatizing interpretations of mental disorders. We conclude by examining how the notion of solidarity, informed by an African Ethics framework, may justify some of the suggestions made in our discussion.
... Para ahli memperkirakan 15% populasi global akan memiliki masalah gangguan jiwa tahun 2020 (Harpham, et al., 2003). Orang dengan gangguan jiwa (ODGJ) tidak hanya mengalami dampak akibat gejala dan penyakit, tetapi juga stigmatisasi (Kapungwe, 2010). Prevalen-si ODGJ berat di Indonesia adalah 1,7 per 1000 dan ODGJ ringan sekitar 6% dari total populasi (Kemenkes, 2013). ...
... including schizophrenia, bipolar disorder and depression. This finding was similar to a study performed in Zambia, where most respondents knew that mental disorders could be transmitted 22 . Unlike this study, a previous study performed in Kaduna State, Nigeria, showed that most of the respondents (89.2%) did not know that mental disorders can be transmitted genetically 18 . ...
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Background Mental disorders are one of the most ignored public health issues worldwide. However, the burden associated with mental disorders is ever increasing and poses a major threat to health, social interactions and the economy of both developed and developing countries.Aim To assess the knowledge of adults residing in an urban local government area in Lagos, south-west Nigeria, with regards to mental health and investigate their attitudes towards this condition.Methods This was a descriptive cross-sectional study. Multi-stage sampling was used to select 242 adults who were subsequently interviewed with a structured questionnaire. Data was collected and analysed using Epi Info statistical software version 7. Associations between socio-demographic variables and the knowledge and attitudes of subjects with regards to mental disorders were assessed using chi-square tests at a significance level of 0.05. ResultsAlmost all respondents (95.5%) in this study were aware of mental disorders while 31.0% were related to someone with a mental disorder. Approximately half of the respondents (51.2%) had poor knowledge of mental disorders while the majority (90.0%) had positive attitudes. There was a significant and positive association between having a relative with a mental disorder and the level of knowledge (P=0.010).Conclusion Analyses identified knowledge gaps in the community in terms of mental disorders in the community. We recommend that health workers should develop ways to educate the community with regards to the causes, symptoms, effects and treatment options for mental disorders.
... Staff shortages make it difficult for one to screen for, diagnose, initiate on treatment and provide psychoeducation to individuals with mental illness including depression. Moreover, the low levels of mental health literacy [45,46], high stigma levels [47,48] and negative explanatory models of mental illness in SSA [49][50][51] are significant barriers to treatment uptake and adherence to treatment. And yet, depressed patients need to adhere to prescribed treatment over long period of time in order for them to achieve symptom remission and attain adequate social and occupational functioning [52,53]. ...
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Background: About 20-40% of patients with diabetes mellitus (DM) suffer from depressive disorders (DD) during the course of their illness. Despite the high burden of DD among patients with DM, it is rarely identified and adequately treated at the majority of primary health care clinics in sub-Saharan Africa (SSA). The use of peer support to deliver components of mental health care have been suggested in resource constrained SSA, even though its acceptability have not been fully examined. Methods: We conducted qualitative interviews (QI) to assess the perceptions of DM patients with an experience of suffering from a DD about the acceptability of delivering peer support to patients with comorbid DM and DD. We then trained them to deliver peer support to DM patients who were newly diagnosed with DD. We identified challenges and potential barriers to a successful implementation of peer support, and generated solutions to these barriers. Results: Participants reported that for one to be a peer, they need to be mature in age, consistently attend the clinics/keep appointments, and not to be suffering from any active physical or co-morbid mental or substance abuse disorder. Participants anticipated that the major barrier to the delivery of peer support would be high attrition rates as a result of the difficulty by DM patients in accessing the health care facility due to financial constraints. A potential solution to this barrier was having peer support sessions coinciding with the return date to hospital. Peers reported that the content of the intervention should mainly be about the fact that DM was a chronic medical condition for which there was need to adhere to lifelong treatment. There was consensus that peer support would be acceptable to the patients. Conclusion: Our study indicates that a peer support program is an acceptable means of delivering adjunct care to support treatment adherence and management, especially in settings where there are severe staff shortages and psycho-education may not be routinely delivered.
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Depression is defined as a condition when people has a prolonged feeling of uselessness and a thought of suicide, and hard to expressed their feelings. Based on pre-research data, it was found that the age of 12 – 24 is an age where symptoms of depression appear, and potentially lead to suicide. This is due to the lack of literacy and public awareness of depression, which has eventually led to various stigma in public, thus cause the community's function as a support system was not going well. Communities in this case are people who are close to people with depression has strong influence to help them through the healing process. One important role of the community is providing accompaniment and mental support for people with depression, so they do not feel alone. Therefore, a good understanding and awareness is needed for the community to become a good support system for people with depression. In order to increase the public awareness and convey messages related to depression, the creator of the work did a campaign "Kenali Aku" that used The Nine Steps for Strategic Planning of Public Relations concept by Ronald D. Smith. This campaign has several activities such as education through social media, social experiment, and seminars (education that conducted in three regions in DKI Jakarta).
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ABSTRAK Perilaku kekerasan dan perasaan ketakutan serta stigma dan proses stigmatisasi terkait orang dengan gangguan jiwa (ODGJ) banyak dilaporkan. Penelitian ini bertujuan memahami dampak stigma dan proses stigmatisasi terhadap perilaku kekerasan oleh ODGJ dan perilaku kekerasan terhadap ODGJ dan untuk mengetahui ketakutan yang dirasakan oleh ODG serta ketakutan orang lain terhadap ODGJ. Penelitian menggunakan metode ry Charmaz Constructivist Grounded Theo (CCGT) dengan 30 pasien dan perawat yang bekerja di RS. Marzoeki Mahdi Bogor sebagai partisipan. Metode pengumpulan data dilakukan dengan wawancara semi-terstruktur, dokumen review, memo dan catatan lapangan dan dianalisis dengan analisis. Penelitian ini menghasilkan dua tema utama: 1) perilaku kekerasan dan Paille grounded theory 2) perasaan ketakutan; serta sembilan sub-kategori. Hasil penelitian menunjukkan bahwa perilaku kekerasan dilakukan oleh pasien termasuk terhadap diri sendiri, keluarga, masyarakat, dan tenaga kesehatan. Kekerasan juga dialami oleh penderita dari orang lain. Akibat stigmatisasi, ketakutan dirasakan oleh penderita dan orang lain tehadap penderita. Dampak stigmatisasi dimanifestasikan dengan perilaku kekerasan dan ketakutan yang dialami oleh penderita sendiri, keluarga, dan masyarakat. ABSTRACT Violent behavior, feeling of fear, stigma, and stigmatization process associated with people with mental illness (PWMI) are widely reported. This research aims to understand the impact of stigma and stigmatization process towards violent behavior by PWMI and violent behavior towards PWMI and to know the fear felt by PWMI and fear of others to PWMI. This study used Charmaz Constructivist Grounded theory (CCGT) method with a total of 30 participants consisting patients and nurses who work in Marzoeki Mahdi Hospital Bogor. Data collection method was done by semi-structured interviews, document reviews, field notes, and memos. Paille's grounded theory was used for data analysis. This study indicated two major categories, i.e. 1) violent behavior and 2) feeling of fear; as well as nine sub-categories. Study results showed that violent behavior is conducted by patients, including to themselves, families, communities, and health professionals. Violence was also experienced by patients conducted by others. As a result of stigmatization, fear was experienced by patients, and it was also felt by others toward patients. This stigmatization is manifested by violent behavior and fear experienced by patients themselves, family, and community.
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Abstrak Sampai saat ini masih sedikit informasi dari hasil-hasil penelitian tentang pemanfaatan terapi tradisional dan alternatif oleh para penderita gangguan jiwa di Indonesia. Penelitian ini bertujuan untuk melihat bagaimana pemanfaatan terapi tradisional dan alternatif di antara penderita gangguan jiwa di Indonesia. Metode penelitian ini menggunakan Charmaz Constructive Grounded Theory untuk mengeksplorasi pemanfaatan terapi tradisional dan alternatif di antara pasien yang menderita gangguan jiwa. Metode pengumpulan data termasuk interaksi langsung (wawancara semi-terstruktur), document review, catatan lapangan dan memo. Data analisis menggunakan pendekatan Paille data analisis. Penelitian menghasilkan lima kategori: 1) kerasukan oleh setan atau roh; 2) penyakit akibat berdosa; 3) Berobat ke tradisional dulu baru akhirnya ke rumah sakit jiwa; 4) kekerasan; 5) takut dengan pengobatan. Hasil penelitian menunjukkan bahwa terapi tradisional dan alternatif dan orang pintar (dukun, para pemimpin agama Islam, pendeta, paranormal dan pengobatan tradisional Cina) memiliki peran sentral dalam mendukung dan menawarkan solusi ketika seseorang memiliki gangguan jiwa di Indonesia. Para terapis atau 'orang pintar' biasanya merupakan pilihan pertama dari keluarga dan anggota 'masyarakat lainnya jika berhubungan dengan terapi yang orang yang menderita gangguan jiwa. Penelitian lanjut diperlukan untuk melihat efektivitas terapi tradisional dan alternatif ini yang masih kurang diteliti dan didokumentasikan di Indonesia. Penelitian lebih lanjut juga perlu dilakukan untuk memahami sikap atau perspektif keluarga, masyarakat dan staf lembaga pemerintahan sebagai partisipan terkait dengan pengobatan tradisional dan alternatif ini. Penelitian ini menggunakan pendekatan kualitatif, penelitian kuantitatif diperlukan untuk meneliti faktor-faktor yang mempengaruhi pemanfaaatan terapi tradisional dan alternatif oleh penderita gangguan jiwa di Indonesia. Kata kunci: Gangguan jiwa, terapi, tradisional-alternatif. Traditional and Alternative Therapies Usage by Psychiatric Patients: A Grounded Theory. Abstract Until recently, little information is known from studies regarding the use of traditional and alternative therapies by people with mental illness in Indonesia. This study explored the use of traditional or alternative therapies among mentally ill sufferers in Indonesia. A Charmaz's Constructivist Grounded Theory method was used to explore the use of traditional or alternative therapies among patients as a result of suffering from mental illness. Data collection method involved direct interaction (semi-structured interviews), mute evidence (document review), field notes and memos. Paillé (1994) data analysis was employed to organize and manage data. Study has led to five categories: 1) possessed by Satan or spirit; 2) sinful illness; 3) treatment at traditional before going to the hospital; 4) violence; 5) fear of treatment. Study results indicated that complementary-alternative treatments and 'smart people' (shamans, Islamic leaders, chaplains, paranormal and traditional Chinese medicine) have a central role in supporting and offering solutions when someone has a mental illness in Indonesia. Visiting therapists or 'smart people', is usually the first choice of patients, families and other community members when dealing with the mentally ill treatments. Further research is needed to see the effectiveness of traditional or alternative therapy which is still poorly researched and documented in Indonesia. It is also needed to understand the attitude or perspective of the family, the community and government staff as participants regarding traditional or alternative therapies. This study used a qualitative approach, thus quantitative research is needed to examine the factors that affect the utilization of traditional or alternative therapies by mentally ill people in Indonesia..
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‘Medicine is a social science, and politics nothing but medicine on a grand scale.’ (Rudolph Virchov, 1848, quoted in Link & Phelan, 1996) Discrimination and prejudice against people with mental illnesses is ubiquitous, pernicious and wrong. The overwhelming case against such stigma has been recognised by initiatives from the UK government, the Royal College of Psychiatrists, the US Surgeon General, the World Psychiatric Association and many other organisations
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People with serious mental illness no longer spend years of their lives in psychiatric institutions. In developed countries, there has been a major shift in the focus of care from hospitals into the community. However, while it means those with mental illness are not confined, it does not guarantee they will be fully integrated into their communities. The barriers to full citizenship are partly due to the disabilities produced by their illnesses and partly by stigmatizing and discriminatory attitudes of the public. This book analyzes the causes of these barriers and suggests ways of dismantling them. The book is constructed in two parts: the first relates to social inclusion and the second to occupational inclusion. Throughout, the text is annotated with quotes from consumers to illustrate their experience of the issues discussed. The innovations outlined are described in sufficient detail for the reader to implement them in their own practice. © J. Leff and R. Warner 2006 and Cambridge University Press, 2009 and Cambridge University Press, 2009.
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This study expands on earlier research by our group that has shown that contact with people with mental illness has significant effects on changing stigmatizing attitudes. Two factors that affect contact are examined in this study: the medium through which contact is experienced, and the level of stereotype disconfirmation engendered in contact. One hundred sixty-four individuals were randomly assigned to one of five conditions. Three of the conditions allowed us to examine the effects of medium: no stigma-control, in vivo contact with moderate disconfirmation, and videotaped contact with moderate disconfirmation. Along with the moderate disconfirmation videotape, two additional videotaped conditions - little or no disconfirmation and high disconfirmations-defined the three groups for our second set of hypotheses on disconfirmation. Research participants completed the Social Distance Scale prior to being assigned to condition and im mediately upon completion. In terms of the medium of contact, results showed that both videotaped and in vivo contact led to significant change in stigmatizing attitudes. Two interesting results were found in terms of level of disconfirmation. First, viewing a videotape of a person with mental illness that does not disconfirm the stereotype (e.g., the person is manifestly psychotic) does not change stigmatizing attitudes. Second, videotapes of people who moderately and highly disconfirm the stereotype lead to significant improvement in attitudes, with nonsignificant trends suggesting that moderate disconfirmation yields better effects. Implications of these findings for future work on changing public attitudes are discussed.