Evaluation of a pilot, community-led mental illness de-stigmatization theater intervention in rural Uganda

Abstract

Background In rural areas of low- and middle- income countries, mental health care is often unavailable and inaccessible, and stigma is a major barrier to treatment. Destigmatization can increase treatment-seeking attitudes, community support, and acceptance of individuals suffering from mental illness. This study’s primary objective was to evaluate the impact of a community-led, theater-based destigmatization campaign for mental illness conducted in the Busoga region of Eastern Uganda. Methods One hundred residents of the Busoga region were randomly selected via cluster sampling to complete a structured questionnaire assessing mental health stigma. Four focus groups were conducted for qualitative data on mental health stigma. Common misconceptions and specific points of stigma were identified from these responses, and local village health team personnel developed and performed a culturally-adapted theatrical performance addressing these points. Changes in perceptions of mental illness were measured among 57 attendees using two measures, the Broad Acceptance Scale (designed to reflect factors that contribute to structural stigma) and Personal Acceptance Scale (designed to reflect factors that contribute to interpersonal, or public stigma), before and after the performance. Results There was a significant increase in acceptance according to the Broad Acceptance Scale (p < .001) and Personal Acceptance Scale (p < .001). Qualitative responses from play attendees also indicated a decrease in stigma and an increased sense of the importance of seeking treatment for mentally ill patients. Conclusion This study shows community-led, theater intervention may be an effective tool for the destigmatization of mental illness in rural areas of Uganda. Larger studies are needed to further test the efficacy of this approach and potential for longer-term scalabilityand sustainability.

Twelve-month Outcomes of a Mental Illness Destigmatizing Theatrical Intervention in Rural Uganda

“…The report on the original study suggested that the intervention cohort demonstrated a greater willingness to live, work, interact, and understand those with mental illness [13]. This follow-up study demonstrated that these attitude shifts persist for at least one year and may even become more pronounced after a substantial period of time, suggesting that this model could be used to enact signi cant, long-term change in attitudes amongst rural Ugandans.…”

“…Outcomes were assessed with a 61-item questionnaire that gathered demographic data and included two stigma-focused batteries, the Personal Acceptance Scale (PAS) and the Broad Acceptance Scale (BAS), described in Lee et al [13]. The PAS targets population stigma, and consists of community-in uenced negative attitudes, beliefs, and behaviors towards people with mentally illness.…”

“…The effectiveness of the intervention likely derives from its theoretical audience-channel-messageevaluation (ACME) framework[15] and its community-based approach, in which community health volunteers devised and performed a play that harmonized existing cultural ideas around the topic with new beliefs and knowledge about mental illness [13]. The intervention was therefore created by individuals with similar cultural perspectives as the target audience.…”

“…While a variety of educational approaches have been designed and tested, approaches to educational interventions using creative arts have been less studied than more didactic approaches [12]. Lee et al in 2022 developed and evaluated the effectiveness of a community-led theatrical performance in the rural Busoga region of eastern Uganda, depicting an individual's progression from intense, debilitating mental illness to establishing care opportunities at a health center, receiving individualized treatment, attaining gainful employment, and achieving reintegration into society [13]. Participants exposed to this intervention showed a signi cant and sizable reduction in mental health stigma from baseline to a oneweek follow-up assessment.…”

“…This study aims to extend the ndings of Lee et al, in an evaluation of the long-term effectiveness of this community-led theatrical intervention in reducing mental health stigma by reporting the results of a oneyear follow-up survey of the initial study participants. A detailed description of the community-led theater intervention, participant selection, and immediate post-intervention results have been reported previously by Lee et al (2022) [13].…”