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Smoothed geographic maps of response to the question "Do you agree that people with MI should be chained, tied and locked in their homes". Left: unadjusted map, deviance explained = 0.887%, p < 0.01; right: adjusted map, deviance explained = 2.11%, p = 0.45.
Source publication
Purpose
This study describes patterns of community-level stigmatizing attitudes towards mental illness (MI) in central Mozambique.
Methods
Data for this study come from a representative community household survey of 2933 respondents ≥ 18 years old in Manica and Sofala Provinces, Mozambique. Six MI stigma questions represented primary research outc...
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Citations
... The mental health treatment gap is exacerbated by the scarcity of resources (professionals, medicines, infrastructure), as well as stigma regarding mental illness. [38][39][40] Many Mozambicans attribute mental disorders to supernatural causes, and in about three-quarters of all cases, consult a traditional healer. 34 Nearly half of the people with these disorders in rural areas were reported as being in poor health. ...
Background:
In Mozambique, the prevalence of common mental illness in primary care is not well established.
Aims:
This study aimed to assess the prevalence of, and associated factors for, common mental illness in patients accessing primary care services in three Ministry of Health clinics in Mozambique.
Method:
Adult patients were recruited from the waiting rooms of prenatal, postpartum and general out-patient consultations. A mental health professional administered a diagnostic interview to examine prevalence of major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence. Generalised linear mixed models were used to examine the odds of each disorder and sociodemographic associations.
Results:
Of 502 patients interviewed, 74.1% were female (n = 372) and the average age was 27.8 years (s.d. = 7.4). Of all participants, 23.9% (n = 120) met diagnostic criteria for at least one common mental disorder; 8.6% were positive for MDD (n = 43), 13.3% were positive for GAD (n = 67), 4.8% were positive for PTSD (n = 24) and 4.0% were positive for any substance misuse or dependence (n = 20). Patients attending prenatal or postpartum consultations had significantly lower odds of any common mental disorder than patients attending out-patient primary care. Age was negatively associated with MDD, but positively associated with substance misuse or dependence.
Conclusions:
Over 20% of patients attending primary care in Mozambique may have common mental disorders. A specific focus on patients attending general out-patient visits, young people for depression, and older people and men for substance misuse/dependence would provide a targeted response to high-risk demographics.
... A third notable theme that emerged from both stakeholder groups was the need to address outer setting related stigma associated with depression if there is to be successful implementation of depression screening within these clinics. Both stakeholder groups remarked that many people in their community associate depression with profound mental illness, which has been reported previously (Zhang et al., 2019). Patients drew a connection between the pervasive stigma towards HIV that exists in their communities and the perceived stigma towards mental illness, potentially from misinformation regarding both conditions. ...
Depression is highly prevalent and, when comorbid with other medical conditions, can worsen health outcomes. Implementing routine depression screening within medical clinics can ensure that patients receive suitable treatment and improve overall health outcomes. Unfortunately, depression screening within medical settings is rare, particularly in low- and middle-income countries. This qualitative study evaluated patient and clinician perspectives on implementing depression screening within HIV and diabetes clinics in Botswana. Seven clinicians and 23 patients within these clinics were purposively selected and interviewed using a guide informed by the Consolidated Framework for Implementation Research (CFIR) to understand barriers and facilitators to depression screening in medical clinics in Botswana. Interviews were recorded, transcribed, and analyzed using NVivo. Three general themes emerged: (1) Appropriateness and Acceptability: attitudes and beliefs from clinicians and patients about whether depression screening should occur in this setting; (2) Stigma as an important barrier: the need to address the negative associations with depression to facilitate screening; and (3) Recommendations to facilitate screening including improving knowledge and awareness about depression, offering incentives to complete the screening, providing staff training, ensuring resources for treatment, the need to preserve confidentiality, and utilizing leadership endorsement. These results offer insights into how to implement depression screening within medical clinics in Botswana. These results can help design implementation strategies to increase depression screening in these clinics, which can be tested in future studies.
Supplementary information:
The online version contains supplementary material available at 10.1007/s43477-022-00062-3.
... Data from the Sigma in Global Context-Mental Health Survey (SGC-MHS) are reported in three publications (Geiger, 2021;Manago et al., 2019;Pescosolido et al., 2015), although these papers used data from different countries out of the 14 countries investigated in this survey. Such cross-national analyses are otherwise rare (Skivenes, 2021), with almost all other papers only using samples from individual countries or specific regions in within a certain country (Akinsulore et al., 2018;Aznar-Lou et al., 2016;Chen et al., 2018;Tesfaye et al., 2020;Xiong et al., 2021) or cities (Laqua et al., 2018;Reta et al., 2016;Rubio-Valera et al., 2016;Steiger et al., 2021;Strike et al., 2016;Zhang et al., 2019). ...
The human rights of people with mental illness are constantly threatened. We conduct a scoping review showing how public attitudes towards protecting human rights have so far been
examined and providing an overview of our present knowledge of these attitudes, and present novel findings from a trend study in Germany over nine years, reporting attitudes elicited in 2020 and examining whether these attitudes have changed since 2011. Few studies address attitudes towards human rights explicitly, but several studies contain single items on either first generation human rights, mainly concerning involuntary admission, or civil liberties like the right
to vote, or second generation human rights, mainly with regard to funding for healthcare, but also for example regarding career choice. Recent data from Germany showed little improvement in attitudes towards protecting human rights over the last decade and particularly high support for restricting job opportunities for people with mental illness. Although generally, most restrictions were supported by a minority of respondents only, both our data and our scoping review indicate substantial support for several restrictions in several countries, showing that public attitudes pose a challenge to the human rights of persons with mental illness. We discuss possible
lines of future research.
... In 2014, Mozambique achieved its goal of having at least one psychiatric technician providing outpatient mental healthcare in each of the 128 districts of Mozambique [18]. However, existing evidence suggests that the quality of mental healthcare in Mozambique remains low [42] due to limited financial and human resources, few opportunities for supportive supervision, training, and re-training [18], stock-outs of essential mental health medications [43], and mental health stigma [44] among other challenges [25]. In central Mozambique, over 98% of formal health services are offered through the public sector [45], improving the potential for population-level impacts for supply-side systems interventions. ...
Background
Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique.
Methods
Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels.
Discussion
This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs.
Trial registration
ClinicalTrials.gov; NCT05103033 ; 11/2/2021.
... Moreover, although stigma is a universal phenomenon, local traditions and cultural beliefs play an important role in determining stigmatizing behavior and its enactment. That stigma varies within communities and across regions is illustrated by data from a recent study in which the distribution and determinants of stigma around mental health were mapped in two provinces (Sofala and Manica) in central Mozambique (Zhang et al., 2019). The authors observed that higher levels of stigmatizing attitudes are held by persons aged 18-24, males, divorcees and widows/ers); low levels of education and wealth, urban life, as well as lack of religious beliefs are also associated with higher levels of stigmatizing attitudes towards persons with mental health problems. ...
Labels serve as identifiers and convenient descriptors of inanimate and animate objects. In humans, given labels can easily become part of an individual’s self-perceived identity. Negative labels ascribed to a person can result in internalized stigma , a state that will shape the subject’s biography. This can ultimately impact the person’s mental and physical health since perceived and/or anticipated stigma discourages the use of social and health services. Per definition, stigma involves labeling of persons with physical, mental, or social characteristics that do not match the observer’s arbitrarily conditioned and calibrated sense of norms ( public stigma ); such labeling may eventually become embedded in rules, regulations, and laws ( structural stigma ). Internalized stigma projects onto a person’s emotions and actions. Public (enacted) stigma results from stereotyping (collectively agreed-upon notions about a group of persons that are used to categorize these people) and devaluation, which subsequently leads to social distancing, discrimination, and blatant abuse of human rights. Much of what we know about stigma results from research in the psychosocial sciences and, more recently, from social neuroscience. The stigma around mental health has generated much attention in the field of psychiatry where, to date, most research has focussed on epidemiology and anti-stigma interventions. This essay intends to stimulate thought, debate, and research within the behavioral neuroscience community and, therefore, to inform evidence-based design and implementation of neuroscience-based approaches by other professionals working towards the elimination of the stigma attached to mental illness. The article starts by considering the concept of stigma and the psychological processes that give rise to the phenomenon; it also considers how projected and perceived stigma are multiplied. Finally, after a brief review of the few existing neuroscientific explorations of stigma, gaps in our knowledge of the neurobiological basis of stigma are identified and discussed.
... Another Brazilian study did not find any association between household income and stigma toward schizophrenia (Loch et al., 2014). Nevertheless, in other studies in high-and middle-income countries, wealth was associated with less stigmatizing attitudes (Aznar-Lou et al., 2016;Crisp et al., 2005;Zhang et al., 2019). Although years of education were initially associated with some stigma outcomes, after multiple regression analysis, only the association with the belief that "one of the main causes of psychiatric illness is a lack of willpower" and with the secondary outcome "to have answered at least one stigmatizing belief in the questionnaire" remained significant. ...
Background
Stigmatizing attitudes against individuals diagnosed with mental illness could increase the severity of psychiatric symptoms, lead to delay in getting medical support, and decrease adherence to treatments. Identifying the groups most associated with stigmatization could orientate actions to reduce this prejudice and improve patients’ prognosis.
Objective
To investigate variables associated with stigmatization toward psychiatric disorders in Brazil.
Methods
A Web-based survey was sent out to assess the sociodemographic characteristics of the respondents and their perception of mental illness. Included participants were composed of Brazilians aged 18 years or over, with access to the internet and social networks. The questionnaire was available from June to August 2018 on Facebook.
Results
A total of 2414 respondents were included. The majority were female, white, aged between 18 and 29 years, and had more than 10 years of study. The variables associated with stigma were male sex, fewer years of education, lower household income, the presence of a psychiatric disorder in a first-degree relative, and internalized stigma.
Conclusions
The present study identified variables associated with the stigma against psychiatric disorders. Future studies should propose intervention strategies, such as to foster education about mental illness and to promote the importance of seeking help from a mental health professional, to address this problem in Brazil.
... This suggests that a large burden of depression is missed in existing psychiatric care settings [25]. A recent population-based survey of over 3000 households conducted by our group additionally showed the high rates of mental health stigma in central Mozambique, as well as treatment gaps for depressive symptoms and suicidal ideation of almost 70 and 90%, respectively [26,27]. ...
Background:
Depression is one of the leading causes of disability in Mozambique; however, few patients with depression are identified in primary care. To our knowledge, there are no validated tools for depression screening in Mozambique. The aim of this study was to validate the Patient Health Questionnaire-9 (PHQ-9) for use in primary care settings in Mozambique.
Methods:
The PHQ-9 was adapted using a structured multi-phase process led by a team of bilingual experts followed by a review by lay individuals and pilot-testing including cognitive interviews. The final Mozambican PHQ-9 (PHQ-9-MZ) was applied among 502 individuals randomly selected from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary healthcare clinics in Sofala Province, Mozambique. The PHQ-9-MZ was evaluated against the MINI 5.0-MZ as a gold standard diagnostic tool.
Results:
The majority of participants were female (74%), with a mean age of 28. Using the MINI 5.0-MZ, 43 (9%) of the sample tested positive for major depressive disorder. Items of the PHQ-9-MZ showed good discrimination and factor loadings. One latent factor of depression explained 54% of the variance in scores. Questions 3 (sleep) and 5 (appetite) had the lowest item discrimination and factor loadings. The PHQ-9-MZ showed good internal consistency, with a Cronbach's alpha of 0.84, and an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI: 0.73, 0.89). The PHQ-2-MZ had an AUROC of 0.78 (95% CI: 0.70, 0.85). Using a cut-point of ≥9, the PHQ-9-MZ had a sensitivity of 46.5% and a specificity of 93.5%. Using a cut-point of ≥2, the PHQ-2-MZ had a sensitivity of 74.4% and a specificity of 71.7%. Increasing the cut-point to ≥3, the PHQ-2-MZ has a sensitivity of 32.6% and a specificity of 94.6%.
Conclusions:
The PHQ-9-MZ and PHQ-2-MZ emerge as two valid alternatives for screening for depression in primary health care settings in Mozambique. Depending on program needs and weighing the value of minimizing false positives and false negatives, the PHQ-9-MZ can be employed with cut-points ranging from ≥8 to ≥11, and the PHQ-2-MZ with cut-points ranging from ≥2 to ≥3.
... This suggests that a large burden of depression is missed in existing psychiatric care settings (25). A recent populationbased survey of over 3,000 households conducted by our group additionally showed the high rates of mental health stigma in central Mozambique, as well as treatment gaps for depressive symptoms and suicidal ideation of almost 70% and 90%, respectively (26,27). ...
Background: Depression is one of the leading causes of disability in Mozambique; however, few patients with depression are identified in primary care. To our knowledge, there are no validated tools for depression screening in Mozambique. The aim of this study was to validate the Patient Health Questionnaire-9 (PHQ-9) for use in primary care settings in Mozambique.
Methods: The PHQ-9 was adapted using a structured multi-phase process led by a team of bilingual experts followed by a review by lay individuals and pilot-testing including cognitive interviews. The final Mozambican PHQ-9 (PHQ-9-MZ) was applied among 502 individuals randomly selected from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary healthcare clinics in Sofala Province, Mozambique. The PHQ-9-MZ was evaluated against the MINI 5.0-MZ as a gold standard diagnostic tool.
Results: The majority of participants were female (74%), with a mean age of 28. Using the MINI 5.0-MZ, 43 (9%) of the sample tested positive for major depressive disorder. Items of the PHQ-9-MZ showed good discrimination and factor loadings. One latent factor of depression explained 54% of the variance in scores. Questions 3 (sleep) and 5 (appetite) had the lowest item discrimination and factor loadings. The PHQ-9-MZ showed good internal consistency, with a Cronbach’s alpha of 0.84, and an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI: 0.73, 0.89). The PHQ-2-MZ had an AUROC of 0.78 (95% CI: 0.70, 0.85). Using a cut-point of ≥9, the PHQ-9-MZ had a sensitivity of 46.5% and a specificity of 93.5%. Using a cut-point of ≥2, the PHQ-2-MZ had a sensitivity of 74.4% and a specificity of 71.7%. Increasing the cut-point to ≥3, the PHQ-2-MZ has a sensitivity of 32.6% and a specificity of 94.6%.
Conclusions: The PHQ-9-MZ and PHQ-2-MZ emerge as two valid alternatives for screening for depression in primary health care settings in Mozambique. Depending on program needs and weighing the value of minimizing false positives and false negatives, the PHQ-9-MZ can be employed with cut-points ranging from ≥8 to ≥11, and the PHQ-2-MZ with cut-points ranging from ≥2 to ≥3.
... This suggests that a large burden of depression is missed in existing psychiatric care settings. A recent population-based survey of over 3,000 households conducted by our group additionally showed the high rates of mental health stigma in central Mozambique, as well as treatment gaps for depressive symptoms and suicidal ideation of almost 70% and 90%, respectively (24,25). ...
Background: Depression is one of the leading causes of disability in Mozambique; however, few patients with depression are identified in primary care. To our knowledge, there are no validated tools for depression screening in Mozambique. The aim of this study was to validate the Patient Health Questionnaire-9 (PHQ-9) for use in primary care settings in Mozambique. Methods: The PHQ-9 was adapted using a structured multi-phase process led by a team of bilingual experts followed by a review by lay individuals and pilot-testing including cognitive interviews. The final Mozambican PHQ-9 (PHQ-9-MZ) was applied among 503 individuals randomly selected from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary healthcare clinics in Sofala Province, Mozambique. The PHQ-9-MZ was evaluated against the MINI 5.0-MZ as a gold standard diagnostic tool. Results: The majority of participants were female (74%), with a mean age of 28. Using the MINI 5.0-MZ, 43 (9%) of the sample tested positive for major depressive disorder. Items of the PHQ-9-MZ showed good discrimination and factor loadings. One latent factor of depression explained 54% of the variance in scores. Questions 3 (sleep) and 5 (appetite) had the lowest item discrimination and factor loadings. The PHQ-9-MZ showed good internal consistency, with a Cronbach’s alpha of 0.84, and an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI: 0.73, 0.89). The PHQ-2-MZ had an AUROC of 0.78 (95% CI: 0.70, 0.85). Using a cut-point of ≥9, the PHQ-9-MZ had a sensitivity of 46.5% and a specificity of 93.5%. Using a cut-point of ≥2, the PHQ-2-MZ had a sensitivity of 74.4% and a specificity of 71.7%. Increasing the cut-point to ≥3, the PHQ-2-MZ has a sensitivity of 32.6% and a specificity of 94.6%. Conclusions: The PHQ-9-MZ and PHQ-2-MZ emerge as two valid alternatives for screening for depression in primary health care settings in Mozambique. Depending on program needs and weighing the value of minimizing false positives and false negatives, the PHQ-9-MZ can be employed with cut-points ranging from ≥8 to ≥11, and the PHQ-2-MZ with cut-points ranging from ≥2 to ≥3.
Background
Mental illness stigma is universally prevalent and a significant barrier to achieving global mental health goals. Mental illness stigma in Bangladesh has gained little attention despite its widespread impact on seeking mental health care in rural and urban areas. This study aimed to investigate mental illness stigma and the associated factors in rural and urban areas of Bangladesh.
Methods
The study areas were divided into several clusters from which 325 participants (≥18 years) were recruited with systematic random sampling. The Bangla version of the Days’ Mental Illness Stigma Scale was used to collect data. Independent-samples t -test, ANOVA, and multiple regression were performed.
Results
Results suggest that gender, age, geographical location, socioeconomic status, and occupation significantly differed across subscales of stigma. Age, gender, seeking treatment of mental illness, having knowledge on mental health, and socioeconomic status were predictive factors of mental illness stigma. The results also showed a high treatment gap in both rural and urban areas.
Conclusion
This study supports that mental illness stigma is prevalent in Bangladesh, requiring coordinated efforts. Results can inform the development of contextually tailored mental health strategies to reduce stigma and contribute to the promotion of mental health of individuals and communities across Bangladesh.
