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Research article
Attitudes towards mental illness in Malawi: a cross-sectional survey
Jim Crabb*, Robert C Stewart, Demoubly Kokota, Neil Masson, Sylvester Chabunya and Rajeev Krishnadas
Corresponding author:
Forth Valley Royal Hospital, Stirling Road, Larbert, UK
Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
Scotland-Malawi Mental Health Education Project, c/o Royal Edinburgh Hospital, Edinburgh, UK
Wishaw General Hospital, Netherton St, Wishaw, UK
Sackler Institute of Psychobiological Research, Section of Psychological Medicine, Southern General Hospital, Glasgow, UK
For all author emails, please .
BMC Public Health 2012, 12:541&
doi:10.58-12-541
The electronic version of this article is the complete one and can be found online at:
Received:29 October 2011
Accepted:23 July 2012
Published:23 July 2012
& 2012 Crabb et al.; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background
Stigma and discrimination associated with mental illness are strongly linked to suffering,
disability and poverty. In order to protect the rights of those with mental disorders
and to sensitively develop services, it is vital to gain a more accurate understanding
of the frequency and nature of stigma against people with mental illness. Little research
about this issue has been conducted in Sub- Saharan Africa. Our study aimed to describe
levels of stigma in Malawi.
A cross-sectional survey of patients and carers attending mental health and non-mental
health related clinics in a general hospital in Blantyre, Malawi. Participants were
interviewed using an adapted version of the questionnaire developed for the “World
Psychiatric Association Program to Reduce Stigma and Discrimination Because of Schizophrenia”.
210 participants participated in our study. Most attributed mental disorder to alcohol
and illicit drug abuse (95.7%). This was closely followed by brain disease (92.8%),
spirit possession (82.8%) and psychological trauma (76.1%). There were some associations
found between demographic variables and single question responses, however no consistent
trends were observed in stigmatising beliefs. These results should be interpreted
with caution and in the context of existing research. Contrary to the international
literature, having direct personal experience of mental illness seemed to have no
positive effect on stigmatising beliefs in our sample.
Conclusions
Our study contributes to an emerging picture that individuals in Sub-Saharan Africa
most commonly attribute mental illness to alcohol/ illicit drug use and spirit possession.
Our work adds weight to the argument that stigma towards mental illness is an important
global health and human rights issue.
Background
Stigma can be defined as a sign of disgrace or discredit, which sets a person apart
from others []. The experience of stigma is characterized by shame, blame, secrecy, being the “black
sheep of the family”, isolation, social exclusion and discrimination. The stigma and
discrimination associated with mental illness has been strongly associated by the
World Health Organisation (WHO) with suffering, disability and poverty []. It is a major barrier to treatment and the prevention of suicide [,]. Stigma is also a major reason why sufferers of mental illness fail to acknowledge
their illness and it has been described as the underlying factor mitigating against
the social re-integration of those recovering from mental illness [,].
Early work in the field suggested that stigma might be less common in Africa, particularly
in Muslim countries []. Evidence to discredit this view (or “contrary to this view”) began to emerge from
Islamic states such as Morocco where stigma was found to be a major burden to families
[]. In general there is a paucity of research available concerning attitudes towards
mental illness in Africa and what there is tends to be drawn from vastly different
areas of the continent. It has been suggested that the early observations about a
lack of stigma in Africa were due to a lack of research on the ground rather than
a more culturally receptive attitude to mental illness []. Indeed more recent studies from across Africa have suggested that the experience
of stigma may be prominent in individuals with mental illness, their family and the
community at large. Studies conducted in Ethiopia, in Eastern Africa suggest that
the experience of stigma by people with mental illness may be widespread with three
quarters of family members of individuals with a mental illness experiencing stigma
[]. In surveys of community attitudes to mental illness in South Africa, members of
the general public have been found to attribute mental illness to stress or a lack
of willpower rather than a medical illness [].
Most work on community attitudes has been done in West Africa and has demonstrated
poor knowledge regarding causation, widespread negative views towards mental illness
and an overwhelming majority believe that those with mental illness are dangerous
and unsuitable for normal social contact []. In those attending outpatient clinics in Nigeria ‘supernatural’ reasons were found
to be the most popular explanations for mental illness amongst both carers and patients
whilst ‘psychosocial’ explanations were least popular, a notable difference from international
findings [,]. Family members in Nigeria have also been found to experience a higher frequency
of anger and stigma []. It is difficult to generalise attitudes towards mental illness even within the same
geographical region of the African continent. For example, in nearby Ghana there seems
to be a greater reliance in rural areas on culturally specific explanations allied
with more acceptance and support [].
In order to best protect the rights of those with mental disorders and to sensitively
develop services, it is vital to gain a more accurate impression of the frequency
and nature of stigma across Sub-Saharan Africa. Our study aimed to explore the frequency
and characteristics of stigmatising beliefs towards mental illness in Malawi, a country
in South East Africa.
The most up to date figures from the World Health Organisation suggest mental disorders
are the forth most common cause of disability in Malawi after HIV/AIDS, cataracts
and malaria []. To meet this need the country has a mental health provision of 2.5 psychiatric nurses
and less than 1 psychiatrist per 100,000 population []. The overwhelming majority of mental health treatment is provided in primary care.
Practitioners working in primary care in Malawi are paramedics who are known as medical
assistants and clinical officers. Medical Assistants undergo two years of medical
training i.e. one year of theory and one year of clinical attachments and graduate
with a certificate in medicine. They are the backbone of primary care in Malawi. As
part of their undergraduate training medical assistants undergo two weeks of theory
teaching in psychiatry and two weeks of clinical attachment at the main psychiatric
hospital [].
The study was conducted in Queen Elizabeth Central Hospital, a tertiary teaching hospital
in Blantyre, the second most populous city in Malawi.
A cross-sectional survey was conducted over a 2-week period. A single member of the
research team recruited participants (DK). All participants were given an information
sheet and written informed consent was obtained before entry to the study. Participants
self-completed the questionnaire. Data was collected from consecutive attendees (patients
and their carers) in the waiting room of epilepsy, psychiatry, general medical and
surgical outpatient clinics. Carers and patients were surveyed individually (carers
did not complete the questionnaire on behalf of patients). Those individuals unable
to read or write, or who were too unwell to complete the questionnaire, were excluded.
The study was approved by the College of Medicine Research Ethics Committee (COMREC),
University of Malawi.
Participants were interviewed using the questionnaire developed for the World Psychiatric
Association Program to Reduce Stigma and Discrimination Because of Schizophrenia []. This tool was developed to measure stigma internationally. It consists of 17 dichotomous
questions regarding the causes of mental illness, views about mental illness and social
distance practices related to mental illness. As with other published studies we adapted
the questionnaire for use across the spectrum of mental illness by replacing the term
‘schizophrenia’, with ‘mental illness’ []. The questionnaire was translated into local dialects and approved by a local panel
of mental health professionals and service users. Although interviewees were anonymous,
their demographic details were recorded.
Data was analysed using SPSS. The questionnaire used in our study does not produce
a total score for stigma therefore analysis focused on the outcome of individual questions
as has been the case in other published work []. Chi-square tests were performed on categorical data and independent student’s t-tests
on continuous outcomes.
A total of 210 participants completed our survey. Three people refused, 15 did not
have the capacity to complete the questionnaire due to the severity of their illness
and 15 were non-literate. The mean age of the sample was 33.9 years (SD 13.5). The
gender distribution was 42.4% male and 57.6% female. See Tables
for further clinical and demographic details.
Description of those attending clinic and type of clinic attended
Demographic details of participants
Most participants attributed mental disorder to alcohol and illicit drug abuse (95%).
This was closely followed by brain disease (92.8%), spirit possession (82.8%) and
then by psychological trauma (76.1%). Other factors, whilst potentially important
were attributed as causes of mental illness by less than half of our sample. Results
regarding the cause of mental illness, views about mental health and social distances
practices in our sample are summarised in Tables ,
Perceived causes of mental illness
Views about mental health
Social distance practices and mental illness
There were no significant differences in stigmatising beliefs according to gender,
education and whether the subject was a patient or carer. Those participants defined
as experiencing poverty were more likely to attribute mental illness to trauma or
shock than their more affluent counterparts (84/91 versus 76/119 p & 0.001). Those
attending non-mental health clinics were less willing to marry someone who had experienced
mental illness compared to those at the psychiatric and epilepsy clinics (12/111 versus
27/99 p = 0.02). There were no other significant differences in responses between
those attending psychiatry/ epilepsy and non mental health related clinics. Younger
patients were significantly more likely to attribute mental illness to illicit drugs
and alcohol (mean age 28.4 years versus 35.7, p = 0.001) and as God’s punishment (30.5 years
versus 35, p = 0.04). Older participants were more likely to consider those with mental
illness a public nuisance (37.8 years versus 32.9, p = 0.03).
Discussion
This was the first study of attitudes toward mental illness to be conducted in Malawi.
An over whelming majority of participants recruited from mental health and non-mental
health clinics at a large general hospital attributed mental illness to substance
misuse and spiritual causes such as spirit possession and God’s punishment [,,]. Our findings are broadly consistent with those from a large and robust community
survey using the same rating scale conducted in Nigeria. That work found illicit drugs
and alcohol (80.8%), spirit possession (30.2%), psychological trauma (29.9%) and genetic
explanations (26.5%) to be the most common attributions for mental illness []. That such similar results should be found is perhaps surprising considering the
different study designs and samples. The Nigerian study involved multistage cluster
sampling of households across three separate states whilst our work focused on consecutive
attendees at hospital clinics. Though more work is required across Sub-Saharan Africa,
these findings would seem to suggest that views on causation of mental illness maybe
common across the region.
The fact that most of our sample attributed mental illness most strongly to drugs
and alcohol might be considered a positive finding on one level, as it suggests potential
treatability. However only a few mental disorders are known to be aetiologically attributable
to alcohol or illicit drug use, therefore the majority view found in our sample is
not factually correct. In most Sub-Saharan African societies alcohol and illicit drug
use are viewed negatively and are considered due to moral failings on the part of
the user. This may also be why many participants attributed mental illness to spiritual
processes.
More of our sample attributed mental illness to Gods punishment compared to participants
in West Africa (21.9% in Malawi compared to 9.3% in Nigeria). In Nigeria, religious-magical
views of causation have been found to be more associated with negative and stigmatizing
attitudes to the mentally ill compared with biological explanations []. Spiritual explanations have also been found for mental states due to physical illness
such as delirium in this region []. These beliefs may also explain why many cases of mental illness in Sub-Saharan Africa
are treated punitively or outside of the Western Health care systems, for example,
via traditional or faith healers. Our findings regarding drugs and alcohol and spiritual
matters as the most popular causes of mental illness are therefore a concern, as they
reflect a potential for discrimination and non-medical treatment or at its worst,
maltreatment.
One notable difference in our results from other work in West Africa is the more frequent
attribution of mental illness to brain disease (92.8% in Malawi versus 9.2% in Nigeria).
Once again the differences observed between Nigeria and Malawi may reflect the different
populations sampled. Whilst we are not aware of any direct health promotion strategies
regarding mental health and mental illness in the Malawian clinics, it seems reasonable
that a population attending these services will be more attuned to a medical model
of causation. The strong attribution of mental illness to brain disorders does however
appear contradictory considered alongside the equally strong spiritual attributions
given by participants for mental illness (such as spirit possession and mental illness
being a punishment from god). While in Western traditions, the mind and body are traditionally
considered as distinct entities, this may not be true in Malawi. It is possible that
spiritual possession is believed to influence the brain directly. Further qualitative
research is needed to better understand the culturally specific inter relationships
between these explanations for mental illness.
Malawi is currently ranked 153 of 169 on the latest UN Development Index and Category
E (very high mortality) on the WHO mortality register. It is therefore perhaps surprising
that only around half of our sample (43.3%) endorsed poverty as a cause of mental
illness. Furthermore those defined as existing in poverty did not more readily attribute
mental illness to poverty than their more affluent counterparts. The reasons for this
may be two fold. If most of a population exists in relative poverty, then it may be
hard for those within the society to consider poverty as a contributing factor for
an illness which only affects a minority. In developed economies, though a diagnosis
of mental illness can carry stigma, it can also entail sympathy (from some quarters),
treatment from established health services and support from the welfare state. These
factors are far from the established norm in Malawi where destitution may await those
with mental illness. It is possible that those in a state of poverty are reluctant
to consider that they may be at risk of an even worse fate.
Only a quarter of our respondents believed mental illness could be treated outside
of the hospital setting. On one level this is to be expected as around half our sample
consisted of patients and their carers attending established mental health clinics
at a major teaching hospital in an urban centre. The population in our sample may
therefore have been self selected to have a more positive or biased view towards hospital
treatment. However our finding may reflect the reality that there is very little community
mental health care in Malawi. Respondents may simply not have been aware of any alternative
to treatment in a hospital. They may also have had concerns about the reality of treatment
in a less specialised centre.
With regards to social distance and mental illness, very few of our respondents would
have been ashamed if someone in their family experienced mental illness and most were
prepared to maintain a friendship with someone who had been mentally ill. However,
our respondents seemed to be less prepared to consent to increasing social intimacy
with someone who had experienced mental illness. Less than half were prepared to share
a room with someone who had experienced mental illness and only approximately one
in five was prepared to consider marriage. Since genetic factors were believed by
half of our participants to be a cause of mental illness, fears about mental illness
being passed on to future offspring may have influenced these findings.
Our study found less stigmatising beliefs in terms of social distance compared with
Nigerian samples (8.1% of our sample compared with 82.9% in Nigeria). This may be
explained by the fact that half of our sample had either personally experienced mental
illness or were related to someone who had. Promoting direct personal contact between
individuals experiencing mental illness and the general public has been shown to reduce
stigma [-]. Stigma / increased social distance have also been found to be correlated with a
lack of personal contact with mental illness in three Nigerian studies [-]. It is possible that many in Gureje’s Nigerian community sample had not had this
personal experience compared to our population. This does not however explain why
we found no difference in stigma scores between psychiatric and non psychiatric clinic
attendees. According to the available evidence it would be expected that those attending
psychiatric clinics would have had more personal experience of living with mental
illness and so express less stigmatising beliefs than those participants attending
medical and surgical clinics. In Nigeria psychiatric patients have been found to experience
high self stigma rates of up to 21.6% and this phenomenon may explain the lack of
difference in stigma scores found between mental health and non mental health clinic
attendees in our results [].
Our study has some limitations. It is possible that our sample population, consisting
of literate persons attending an urban centre teaching hospital may not be representative
of Malawi as a society and so limits the generalisability of our results. The role
of demographic variables in stigma (and therefore any potential bias in our sample)
is far from clear from the existing research that has been performed in Africa. Studies
from Nigeria, Ghana and Ethiopia suggest that urban dwelling and higher education
correlates with biological/ psychological attributions for mental illness and lower
stigma scores [,,]. However, the most robust study in West Africa by Gureje et al found no correlation
between any demographic variable, including urban, semi rural and rural dwelling []. Any associations between stigmatising beliefs and demographic groupings found in
our study therefore need to be interpreted with extreme caution. Though it is possible
that older participants were indeed more conservative and so were more likely to consider
those with mental illness a nuisance, and that younger participants might have had
more experience of alcohol and illicit drugs as a direct cause of mental illness (as
was shown in our results), it needs to be borne in mind that we found no consistent
differences in stigmatising beliefs between demographic groups, only single question
associations. Ultimately we can only speculate as to why participants held the particular
views or attitudes regarding mental illness they expressed in our study. This is due
to the limitations of a quantitative study design. Whilst our study is an important
first step in clarifying what patients and their carers think about mental illness
in Malawi further qualitative work is required to deepen our understanding of this
important issue.
Conclusions
There is a marked discrepancy in explanatory models of mental illness between Africa
and the other parts of the world. In a review of the literature the general public
internationally were found to prefer psychosocial to biogenetic explanations for mental
illness []. Our study contributes to an emerging picture that this is not the case in Africa
where most individuals attribute mental illness to alcohol/ illicit drug use and spiritual
causes. Our work continues to add weight to the argument that stigma towards mental
illness exists across the globe, including Africa where unique culturally appropriate
interventions will need to be developed.
Abbreviations
UN, United N WHO, World Health Organisation.
Competing interests
Authors of this manuscript have no competing interests.
Authors’ contributions
The study protocol was devised by JC & SC. Ethical approval was submitted by SC. Data
collection was completed by DK and supervised by RS. Data analysis was performed by
JC and RK. The study was written up by JC, RK, RS, DK & NM. All authors have given
final approval of the version to be published.
Authors’ information
Robert Stewart (RS) is a Lecturer and Consultant Psychiatrist at the College of Medicine,
University of Malawi, Blantyre. He is supported in his work helping develop mental
health services in Malawi by the Scotland Malawi Mental Health Education Project (SMMHEP).
The mission of this UK registered charity (Scottish Charity number SC039523) is to
improve the training of mental health workers in Malawi. Demoubly Kokota (DK) is a
psychology graduate of University of Malawi and is currently employed as Research
Coordinator, SMMHEP project in Malawi. Jim Crabb (JC) & Neil Masson (NM), two Consultant
Psychiatrists based in Scotland volunteer with SMMHEP and have visited Malawi to assist
with SMMHEP’s training and research projects. Sylvester Chabunya (SC) is a medical
student who received his undergraduate psychiatry teaching from SMMHEP volunteers.
He displayed an interest and aptitude in mental health after this experience and expressed
an interest in gaining more experience in mental health research. Rajeev Krishnadas
(RK) is a Clinical Lecturer at the University of Glasgow. He has kindly volunteered
his time and expertise in research to assist this paper. All authors have given final
approval of the version to be published.
Conflict of interest
No authors have any conflict of interest to declare.
SMMHEP is a registered charity that receives funding from the Scottish Government
& private donations. DK is employed by University of Malawi with salary funding from
SMMHEP. JC, NM and RS’s flights to Malawi whilst they were volunteering for training
and research projects were reimbursed by SMMHEP. For more information on the work
of SMMHEP please visit the following link
Acknowledgements
The authors would like to thank the management and the staff of QECH outpatient department,
and all those who agreed to participate in the study.
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