Research Article: Portrayals of mental illness, treatment, and relapse and their effects on the stigma of mental illness: Population-based, randomized survey experiment in rural Uganda

Date Published: September 20, 2019

Publisher: Public Library of Science

Author(s): Justin D. Rasmussen, Bernard Kakuhikire, Charles Baguma, Scholastic Ashaba, Christine E. Cooper-Vince, Jessica M. Perkins, David R. Bangsberg, Alexander C. Tsai, Charlotte Hanlon

Abstract: BackgroundMental illness stigma is a fundamental barrier to improving mental health worldwide, but little is known about how to durably reduce it. Understanding of mental illness as a treatable medical condition may influence stigmatizing beliefs, but available evidence to inform this hypothesis has been derived solely from high-income countries. We embedded a randomized survey experiment within a whole-population cohort study in rural southwestern Uganda to assess the extent to which portrayals of mental illness treatment effectiveness influence personal beliefs and perceived norms about mental illness and about persons with mental illness.Methods and findingsStudy participants were randomly assigned to receive a vignette describing a typical woman (control condition) or one of nine variants describing a different symptom presentation (suggestive of schizophrenia, bipolar, or major depression) and treatment course (no treatment, treatment with remission, or treatment with remission followed by subsequent relapse). Participants then answered questions about personal beliefs and perceived norms in three domains of stigma: willingness to have the woman marry into their family, belief that she is receiving divine punishment, and belief that she brings shame on her family. We used multivariable Poisson and ordered logit regression models to estimate the causal effect of vignette treatment assignment on each stigma-related outcome. Of the participants randomized, 1,355 were successfully interviewed (76%) from November 2016 to June 2018. Roughly half of respondents were women (56%), half had completed primary school (57%), and two-thirds were married or cohabiting (64%). The mean age was 42 years. Across all types of mental illness and treatment scenarios, relative to the control vignette (22%–30%), substantially more study participants believed the woman in the vignette was receiving divine punishment (31%–54%) or believed she brought shame on her family (51%–73%), and most were unwilling to have her marry into their families (80%–88%). In multivariable Poisson regression models, vignette portrayals of untreated mental illness, relative to the control condition, increased the risk that study participants endorsed stigmatizing personal beliefs about mental illness and about persons with mental illness, irrespective of mental illness type (adjusted risk ratios [ARRs] varied from 1.7–3.1, all p < 0.001). Portrayals of effectively treated mental illness or treatment followed by subsequent relapse also increased the risk of responses indicating stigmatizing personal beliefs relative to control (ARRs varied from 1.5–3.0, all p < 0.001). The magnitudes of the estimates suggested that portrayals of initially effective treatment (whether followed by relapse or not) had little moderating influence on stigmatizing responses relative to vignettes portraying untreated mental illness. Responses to questions about perceived norms followed similar patterns. The primary limitations of this study are that the vignettes may have omitted context that could have influenced stigma and that generalizability beyond rural Uganda may be limited.ConclusionsIn a population-based, randomized survey experiment conducted in rural southwestern Uganda, portrayals of effectively treated mental illness did not appear to reduce endorsement of stigmatizing beliefs about mental illness or about persons with mental illness. These findings run counter to evidence from the United States. Further research is necessary to understand the relationship between mental illness treatment and stigmatizing attitudes in Uganda and other countries worldwide.Trial registrationThe experimental procedures for this study were registered with as "Measuring Beliefs and Norms About Persons With Mental Illness" (NCT03656770).

Partial Text: Mental illness is heavily stigmatized worldwide. In cross-national studies, people with mental illness report experiencing discrimination in most areas of their life, including making friends, keeping jobs, or interacting with their partners and families [1–3]. Available evidence suggests that while beliefs about mental illness vary by country, negative attitudes toward people with mental illness are neither uncommon nor isolated [4,5]. Widespread negative attitudes provide an enabling environment for harmful violations of basic human rights that range in severity from prejudicial behavior and employment discrimination to chaining, caging, and killing [6,7]. These attitudes undercut efforts to improve mental health at a fundamental level because stigma undermines already low rates of mental-healthcare–seeking behavior [8–18]. Compounding this attenuating effect on treatment-seeking, stigma is also associated with reduced public support for funding toward mental health services, which erodes the availability of appropriate care within the mental healthcare system [19–21].

Of the 1,776 participants enumerated and randomized in the 2014–2015 survey, 1,355 (76%) were successfully interviewed in 2016–2018, excluding 10 individuals who were not administered the experiment correctly because of a technical error. Of the remainder, 250 (14%) were known to have emigrated out of the study site, 57 (3%) could not be located, 37 (2%) had died, 42 (2%) refused to participate, and 25 (1%) were ineligible or could not be interviewed for other reasons (for example, incarceration or acute intoxication at each of multiple interview attempts). We summarize participant characteristics in Table 1. Respondents came from all eight villages, and just over half were women (56%). The mean age was 42 years, with good representation from all age groups. Just over half (57%) had completed primary school, and almost two-thirds were married or cohabiting (64%).

In this population-based, randomized survey experiment conducted in rural southwestern Uganda, portrayals of effectively treated mental illness did not appear to reduce endorsement of stigmatizing responses about mental illness. Instead, any kind of mental illness portrayal—whether untreated, successfully treated, or treated with relapse—resulted in an overwhelmingly large proportion of stigmatizing responses. Among those responses, refusal to have a woman with mental illness marry into the family was the most common, though beliefs that her mental illness created shame for the family or was the result of divine punishment were also fairly common. Perceptions of village norms followed similar patterns as individual beliefs.



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