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Social Psychiatry and Psychiatric Epidemiology

, Volume 54, Issue 11, pp 1391–1410 | Cite as

Geographic distribution and determinants of mental health stigma in central Mozambique

  • Yue ZhangEmail author
  • Orvalho Augusto
  • Kristjana Ásbjörnsdóttir
  • Adam Akullian
  • Vasco Cumbe
  • Deepa Rao
  • Sarah Gimbel
  • Kenneth Sherr
  • Bradley H. Wagenaar
  • with input from the INCOMAS Study Team
Original Paper

Abstract

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 outcomes. Bivariate and multivariable analyses examined the relationship between key explanatory factors and each stigma question. Spatial analyses analyzed the smoothed geographic distribution of responses to each question and explored the association between geographic location and MI stigma controlling for individual-level socio-demographic factors.

Results

Stigmatizing attitudes towards MI are prevalent in central Mozambique. Analyses showed that males, people who live in urban places, divorced and widowed individuals, people aged 18–24, people with lower education, people endorsing no religion, and people in lower wealth quintiles tended to have significantly higher levels of stigmatizing attitudes towards MI. Individuals reporting depressive symptoms scored significantly higher on stigmatizing questions, potentially indicating internalized stigma. Geographic location is significantly associated with people’s response to five of the stigma questions even after adjusting for individual-level factors.

Conclusion

Stigmatizing attitudes towards MI are common in central Mozambique and concentrated amongst specific socio-demographic groups. However, geographic analyses suggest that structural factors within communities and across regions may bear a greater influence on MI stigma than individual-level factors alone. Further implementation science should consider focusing on identifying the most significant modifiable structural factors associated with MI stigma in LMICs to inform the development, testing, and optimization of multi-level stigma prevention interventions.

Keywords

MI stigma Geographic information systems Spatial analysis Determinants of stigma Mozambique 

Notes

Acknowledgements

INCOMAS Study Team includes João Luis Manuel, Leecreesha Hicks, Arlete Mahumane, James Pfeiffer, Stephen Gloyd, Fatima Cuembelo, Miguel Nhumba, Joaquim Lequechane, Alfredo Covele, Manuel Napua, Lucia Vieira, Nelia Manaca, Falume Chale, Alberto Muanido, and Cathy Michel.

Author contributions

BHW and YZ conceived the idea and analyzed the data. YZ wrote the initial draft of the paper under mentorship by BHW. VC, AA, OA, KA, SG, DR, and KS provided creative input on analyses and paper writing. All authors approved the final submitted manuscript.

Funding

This study was supported by the African Health Initiative of the Doris Duke Charitable Foundation. BHW was supported by grant number K01MH110599 from the US National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with ethical standards

Ethical approval

This study was approved by the Institutional Review Board of the National Institute of Health in Mozambique.

Conflict of interest

The authors report no conflicts of interest.

References

  1. 1.
    Bass JK, Bornemann TH, Burkey M, Chehil S, Chen L, Copeland JR, Eaton WW, Ganju V, Hayward E, Hock RS, Kidwai R, Kolappa K, Lee PT, Minas H, Or F, Raviola GJ, Saraceno B, Patel V (2012) A United Nations General Assembly Special Session for mental, neurological, and substance use disorders: the time has come. PLoS Med 9(1):e1001159.  https://doi.org/10.1371/journal.pmed.1001159 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Disease GBD, Injury I, Prevalence C (2017) Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 390(10100):1211–1259.  https://doi.org/10.1016/S0140-6736(17)32154-2 CrossRefGoogle Scholar
  3. 3.
    DALYs GBD, Collaborators H (2017) Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 390(10100):1260–1344.  https://doi.org/10.1016/S0140-6736(17)32130-X CrossRefGoogle Scholar
  4. 4.
    Patel V, Maj M, Flisher AJ, De Silva MJ, Koschorke M, Prince M, Zonal WPA, Member Society R (2010) Reducing the treatment gap for mental disorders: a WPA survey. World Psychiatry 9(3):169–176CrossRefGoogle Scholar
  5. 5.
    Sartorius N (2007) Stigma and mental health. Lancet 370(9590):810–811.  https://doi.org/10.1016/S0140-6736(07)61245-8 CrossRefPubMedGoogle Scholar
  6. 6.
    Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, Group IS (2009) Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 373(9661):408–415.  https://doi.org/10.1016/S0140-6736(08)61817-6 CrossRefGoogle Scholar
  7. 7.
    Reta Y, Tesfaye M, Girma E, Dehning S, Adorjan K (2016) Public stigma against people with mental illness in Jimma Town, Southwest Ethiopia. PLoS One 11(11):e0163103.  https://doi.org/10.1371/journal.pone.0163103 CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Pescosolido BA, Medina TR, Martin JK, Long JS (2013) The “backbone” of stigma: identifying the global core of public prejudice associated with mental illness. Am J Public Health 103(5):853–860.  https://doi.org/10.2105/AJPH.2012.301147 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Rusch N, Angermeyer MC, Corrigan PW (2005) Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur Psychiatry 20(8):529–539.  https://doi.org/10.1016/j.eurpsy.2005.04.004 CrossRefPubMedGoogle Scholar
  10. 10.
    Henderson C, Noblett J, Parke H, Clement S, Caffrey A, Gale-Grant O, Schulze B, Druss B, Thornicroft G (2014) Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry 1(6):467–482.  https://doi.org/10.1016/S2215-0366(14)00023-6 CrossRefPubMedGoogle Scholar
  11. 11.
    Henderson C, Evans-Lacko S, Thornicroft G (2013) Mental illness stigma, help seeking, and public health programs. Am J Public Health 103(5):777–780.  https://doi.org/10.2105/AJPH.2012.301056 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    World Health Organization (WHO) (2005) Mental health evidence and research, 2005. Mental Health Atlas 2005. https://www.who.int/mental_health/evidence/atlas/global_results.pdf
  13. 13.
    Corrigan PW, Mittal D, Reaves CM, Haynes TF, Han X, Morris S, Sullivan G (2014) Mental health stigma and primary health care decisions. Psychiatry Res 218(1–2):35–38.  https://doi.org/10.1016/j.psychres.2014.04.028 CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Mai Q, Holman CD, Sanfilippo FM, Emery JD (2011) The impact of mental illness on potentially preventable hospitalisations: a population-based cohort study. BMC Psychiatry 11:163.  https://doi.org/10.1186/1471-244X-11-163 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Ungar T, Knaak S, Szeto AC (2016) Theoretical and practical considerations for combating mental illness stigma in health care. Commun Ment Health J 52(3):262–271.  https://doi.org/10.1007/s10597-015-9910-4 CrossRefGoogle Scholar
  16. 16.
    Stuart H, Chen SP, Christie R, Dobson K, Kirsh B, Knaak S, Koller M, Krupa T, Lauria-Horner B, Luong D, Modgill G, Patten SB, Pietrus M, Szeto A, Whitley R (2014) Opening minds in Canada: background and rationale. Can J Psychiatry 59(10 Suppl 1):S8–S12CrossRefGoogle Scholar
  17. 17.
    Kapungwe A, Cooper S, Mwanza J, Mwape L, Sikwese A, Kakuma R, Lund C, Flisher AJ, Consortium MHRP (2010) Mental illness–stigma and discrimination in Zambia. Afr J Psychiatry (Johannesbg) 13(3):192–203Google Scholar
  18. 18.
    Sorsdahl KR, Kakuma R, Wilson Z, Stein DJ (2012) The internalized stigma experienced by members of a mental health advocacy group in South Africa. Int J Social Psychiatry 58(1):55–61.  https://doi.org/10.1177/0020764010387058 CrossRefGoogle Scholar
  19. 19.
    Yap MB, Mackinnon A, Reavley N, Jorm AF (2014) The measurement properties of stigmatizing attitudes towards mental disorders: results from two community surveys. Int J Methods Psychiatr Res 23(1):49–61.  https://doi.org/10.1002/mpr.1433 CrossRefPubMedGoogle Scholar
  20. 20.
    Boysen G, Ebersole A, Casner R, Coston N (2014) Gendered mental disorders: masculine and feminine stereotypes about mental disorders and their relation to stigma. J Soc Psychol 154(6):546–565.  https://doi.org/10.1080/00224545.2014.953028 CrossRefPubMedGoogle Scholar
  21. 21.
    Mutiso VN, Musyimi CW, Tomita A, Loeffen L, Burns JK, Ndetei DM (2017) Epidemiological patterns of mental disorders and stigma in a community household survey in urban slum and rural settings in Kenya. Int J Soc Psychiatry.  https://doi.org/10.1177/0020764017748180 CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Letovancova K, Kovalcikova N, Dobrikova P (2017) Attitude of society towards people with mental illness: the result of national survey of the Slovak population. Int J Soc Psychiatry 63(3):255–260.  https://doi.org/10.1177/0020764017696334 CrossRefPubMedGoogle Scholar
  23. 23.
    Giasuddin NA, Levav I, Gal G (2015) Mental health stigma and attitudes to psychiatry among Bangladeshi medical students. Int J Soc Psychiatry 61(2):137–147.  https://doi.org/10.1177/0020764014537237 CrossRefPubMedGoogle Scholar
  24. 24.
    Ayazi T, Lien L, Eide A, Shadar EJ, Hauff E (2014) Community attitudes and social distance towards the mentally ill in South Sudan: a survey from a post-conflict setting with no mental health services. Soc Psychiatry Psychiatr Epidemiol 49(5):771–780.  https://doi.org/10.1007/s00127-013-0775-y CrossRefPubMedGoogle Scholar
  25. 25.
    Mohamed-Kaloo Z, Laher S (2014) Perceptions of mental illness among Muslim general practitioners in South Africa. S Afr Med J 104(5):350–352.  https://doi.org/10.7196/samj.7863 CrossRefPubMedGoogle Scholar
  26. 26.
    Ng TP, Nyunt MS, Chiam PC, Kua EH (2011) Religion, health beliefs and the use of mental health services by the elderly. Aging Ment Health 15(2):143–149.  https://doi.org/10.1080/13607863.2010.508771 CrossRefPubMedGoogle Scholar
  27. 27.
    Padayachee P, Laher S (2014) South African Hindu psychologists’ perceptions of mental illness. J Relig Health 53(2):424–437.  https://doi.org/10.1007/s10943-012-9646-1 CrossRefPubMedGoogle Scholar
  28. 28.
    Mahajan AP, Sayles JN, Patel VA, Remien RH, Sawires SR, Ortiz DJ, Szekeres G, Coates TJ (2008) Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS 22(Suppl 2):S67–S79.  https://doi.org/10.1097/01.aids.0000327438.13291.62 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Parker R, Aggleton P (2003) HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med 57(1):13–24CrossRefGoogle Scholar
  30. 30.
    Sherr K, Cuembelo F, Michel C, Gimbel S, Micek M, Kariaganis M, Pio A, Manuel JL, Pfeiffer J, Gloyd S (2013) Strengthening integrated primary health care in Sofala, Mozambique. BMC Health Serv Res 13(Suppl 2):S4.  https://doi.org/10.1186/1472-6963-13-S2-S4 CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Fernandes QF, Wagenaar BH, Anselmi L, Pfeiffer J, Gloyd S, Sherr K (2014) Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique. Lancet Glob Health 2(8):e468–e477.  https://doi.org/10.1016/S2214-109X(14)70276-1 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Instituto Nacional de Estatística (INE) (2008) Indicadores Sócio Demográficos Província de Sofala 2007. ​http://www.ine.gov.mz/operacoes-estatisticas/censos/censo-2007/rgph-2007/indicadores-socio-demograficos-provincia-de-sofala-2007.pdf/at_download/file
  33. 33.
    Instituto Nacional de Estatística Ministério da Saúde, Maputo, Moçambique (2013) Moçambique Inquérito Demográfico e de Saúde 2011. https://www.dhsprogram.com/pubs/pdf/FR266/FR266.pdf
  34. 34.
  35. 35.
    Morier-Genoud E, Cahen M, Rosário DMD (2018) The war within: New perspectives on the civil war in Mozambique, 1976-1992. ​Woodbridge, Suffolk: James Currey, an imprint of Boydell & Brewer.Google Scholar
  36. 36.
    World Health Organization (WHO) (2011) Mental Health Atlas 2011. ​https://www.who.int/mental_health/evidence/atlas/profiles/moz_mh_profile.pdf?ua=1
  37. 37.
    Dos Santos PF, Wainberg ML, Caldas-de-Almeida JM, Saraceno B, Mari Jde J (2016) Overview of the mental health system in Mozambique: addressing the treatment gap with a task-shifting strategy in primary care. Int J Ment Health Syst 10:1.  https://doi.org/10.1186/s13033-015-0032-8 CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Wagenaar BH, Cumbe V, Raunig-Berho M, Rao D, Kohrt BA, Stergachis A, Napua M, Sherr K (2016) Outpatient mental health services in Mozambique: use and treatments. Psychiatr Serv 67(6):588–590.  https://doi.org/10.1176/appi.ps.201500508 CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Wagenaar BH, Cumbe V, Raunig-Berho M, Rao D, Napua M, Hughes JP, Sherr K (2015) Health facility determinants and trends of ICD-10 outpatient psychiatric consultations across Sofala, Mozambique: time-series analyses from 2012 to 2014. BMC Psychiatry 15:227.  https://doi.org/10.1186/s12888-015-0609-4 CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Wagenaar BH, Stergachis A, Rao D, Hoek R, Cumbe V, Napua M, Sherr K (2015) The availability of essential medicines for mental healthcare in Sofala, Mozambique. Glob Health Act 8(1):27942.  https://doi.org/10.3402/gha.v8.27942 CrossRefGoogle Scholar
  41. 41.
    Wagenaar BH, Augusto O, Asbjornsdottir K, Akullian A, Manaca N, Chale F, Muanido A, Covele A, Michel C, Gimbel S, Radford T, Girardot B, Sherr K, with input from the IST (2018) Developing a representative community health survey sampling frame using open-source remote satellite imagery in Mozambique. Int J Health Geogr 17(1):37.  https://doi.org/10.1186/s12942-018-0158-4 CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Pescosolido BA (2019) Stigma in global context-mental health survey (SGC-MHS). ​http://www.indiana.edu/~sgcmhs/
  43. 43.
    Tawiah PE, Adongo PB, Aikins M (2015) Mental health-related stigma and discrimination in ghana: experience of patients and their caregivers. Ghana Med J 49(1):30–36CrossRefGoogle Scholar
  44. 44.
    Wu IHC, Bathje GJ, Kalibatseva Z, Sung D, Leong FTL, Collins-Eaglin J (2017) Stigma, mental health, and counseling service use: a person-centered approach to mental health stigma profiles. Psychol Serv 14(4):490–501.  https://doi.org/10.1037/ser0000165 CrossRefPubMedGoogle Scholar
  45. 45.
    Ahmedani BK (2011) Mental health stigma: society, individuals, and the profession. J Soc Work Values Ethics 8(2):41–416PubMedGoogle Scholar
  46. 46.
    Shah A, Wheeler L, Sessions K, Kuule Y, Agaba E, Merry SP (2017) Community perceptions of mental illness in rural Uganda: an analysis of existing challenges facing the Bwindi Mental Health Programme. Afr J Prim Health Care Fam Med 9(1):e1–e9.  https://doi.org/10.4102/phcfm.v9i1.1404 CrossRefPubMedGoogle Scholar
  47. 47.
    Egbe CO, Brooke-Sumner C, Kathree T, Selohilwe O, Thornicroft G, Petersen I (2014) Psychiatric stigma and discrimination in South Africa: perspectives from key stakeholders. BMC Psychiatry 14:191.  https://doi.org/10.1186/1471-244X-14-191 CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Donnell O, World B (2008) Analyzing health equity using household survey data: a guide to techniques and their implementation. World Bank, WashingtonGoogle Scholar
  49. 49.
    Filmer D, Pritchett L (2001) Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India*. Demography 38(1):115–132.  https://doi.org/10.1353/dem.2001.0003 CrossRefPubMedGoogle Scholar
  50. 50.
    Webster T, Vieira V, Weinberg J, Aschengrau A (2006) Method for mapping population-based case-control studies: an application using generalized additive models. Int J Health Geogr 5:26.  https://doi.org/10.1186/1476-072X-5-26 CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/
  52. 52.
    Akullian A, Kohler P, Kinuthia J, Laserson K, Mills LA, Okanda J, Olilo G, Ombok M, Odhiambo F, Rao D, Wakefield J, John-Stewart G (2014) Geographic distribution of HIV stigma among women of childbearing age in rural Kenya. Aids 28(11):1665–1672.  https://doi.org/10.1097/Qad.0000000000000318 CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Ward EC, Wiltshire JC, Detry MA, Brown RL (2013) African American men and women’s attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nurs Res 62(3):185–194.  https://doi.org/10.1097/NNR.0b013e31827bf533 CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Drapalski AL, Lucksted A, Perrin PB, Aakre JM, Brown CH, DeForge BR, Boyd JE (2013) A model of internalized stigma and its effects on people with mental illness. Psychiatr Serv 64(3):264–269.  https://doi.org/10.1176/appi.ps.001322012 CrossRefPubMedGoogle Scholar
  55. 55.
    Kpobi L, Swartz L (2018) ‘That is how the real mad people behave’: beliefs about and treatment of mental disorders by traditional medicine-men in Accra, Ghana. Int J Soc Psychiatry 64(4):309–316.  https://doi.org/10.1177/0020764018763705 CrossRefPubMedGoogle Scholar
  56. 56.
    James CC, Peltzer K (2012) Traditional and alternative therapy for mental illness in Jamaica: patients’ conceptions and practitioners’ attitudes. Afr J Tradit Complement Altern Med 9(1):94–104PubMedGoogle Scholar
  57. 57.
    Mutiso VN, Pike K, Musyimi CW, Rebello TJ, Tele A, Gitonga I, Thornicroft G, Ndetei DM (2018) Feasibility of WHO mhGAP-intervention guide in reducing experienced discrimination in people with mental disorders: a pilot study in a rural Kenyan setting. Epidemiol Psychiatr Sci.  https://doi.org/10.1017/s2045796018000264 CrossRefPubMedGoogle Scholar
  58. 58.
    Musyimi CW, Mutiso VN, Musau AM, Matoke LK, Ndetei DM (2017) Prevalence and determinants of depression among patients under the care of traditional health practitioners in a Kenyan setting: policy implications. Transcult Psychiatry 54(3):285–303.  https://doi.org/10.1177/1363461517705590 CrossRefPubMedGoogle Scholar
  59. 59.
    Mutiso VN, Musyimi CW, Rebello TJ, Gitonga I, Tele A, Pike KM, Ndetei DM (2018) Patterns of concordances in mhGAP-IG screening and DSM-IV/ICD10 diagnoses by trained community service providers in Kenya: a pilot cross-sectional study. Soc Psychiatry Psychiatr Epidemiol 53(11):1277–1287.  https://doi.org/10.1007/s00127-018-1567-1 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Global HealthUniversity of WashingtonSeattleUSA
  2. 2.Health Alliance InternationalSeattleUSA
  3. 3.Universidade Eduardo MondlaneMaputoMozambique
  4. 4.Institute for Disease ModelingBellevueUSA
  5. 5.Mozambique Ministry of HealthMaputoMozambique
  6. 6.Department of Family and Child NursingUniversity of WashingtonSeattleUSA
  7. 7.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleUSA
  8. 8.Department of EpidemiologyUniversity of WashingtonSeattleUSA

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