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Mental health is slowly gaining global significance as a key health issue. However, the stigma attached to psychosis is still a major problem, especially in low-income countries. In Zimbabwe, most cases of mental health are attributed to cultural and spiritual beliefs, so public conversations around mental health are a cultural taboo.

For Mental Health Awareness Week, we interviewed Denford Gudyanga, University of Zimbabwe, to find out more about the Z factor and a pilot community engagement project that he and his team are working on, as set out in their Study Protocol published on Welcome Open Research. They are investigating whether drama is itself a useful tool to engage communities about mental health, and to learn whether drama can help raise awareness and educate communities about mental health to reduce stigma in Zimbabwe.

Read the interview with Denford to learn more about planning interventions that are not only suited to the local setting but give communities a voice in directing their health initiatives.

How did you get involved in mental health research?

My background is in clinical social work and I’ve moved from child welfare and social development to mental health. The change wasn’t meant to be a long term one, as I used to view the field of mental health from the same perspective as stigmatizing community attitudes. Fortunately, exposure to the field has radically changed my view about mental health and the lack of robust and accessible services, especially for the vulnerable rural communities. I’ve now broadened my research interest into HIV/AIDS field as there often is a strong association between mental health and HIV/AIDS.  

What is the status of mental health awareness and care in Zimbabwe?

Zimbabwe has several mental health services, but they are scattered and often inaccessible to rural and other vulnerable folks. COVID-19 has further worsened the gap, especially if you’re to compare the access to mental health services between rural and urban communities, as well as the difference between the poor and the wealthy members of society.

For example, most mental health service providers tried to go virtual because of COVID-19. However, this approach was inaccessible to rural and poor folk, who have no access to such virtual platforms. But again, communities are rarely consulted as key stakeholders or empowered with the required resources to direct the development of interventions that are accessible, acceptable and useful to them.

Public engagement allowed us to explore this bottom-up approach in mental health service creation, critiquing it and to understand where communities are in terms of mental health needs, expectations, beliefs and knowledge, especially in a society where supernatural causes are often attributed to mental illness, creating wide spread fear and stigmatization of persons with mental illness.

What is the Z Factor project and what inspired its creation?

Having worked in rural communities piloting the Early Intervention in Psychosis project, we came across a general lack of accurate information regarding psychosis and its treatment. We also felt this was further compounded by the traditional and religious explanatory models which largely attribute the causes of psychosis to witchcraft and evil spirits, which in turn maybe responsible for fuelling stigmatization in these communities.

We therefore needed to understand societal beliefs, offer alternative evidence-based explanations for psychosis and provide accurate bio-psychosocial treatment information that would potentially encourage communities to reduce the delay in their help seeking behaviours, as well as pave a way for traditional/ faith-based system to collaborate with a biomedical model.  

Why is drama a useful public engagement tool?

Drama being a socially acceptable medium of community socialization has always played a positive role in people’s life in Zimbabwe. And given how mental illness is a greatly misunderstood and shunned subject in these communities, we wanted to use an already existing medium that is positively associated with community life, and one that is fun and educational to spark conversations around mental illness, which is usually considered a socially unacceptable topic of discussion.

Z factor therefore also sought to pilot how useful drama would be in encouraging mental health conversations. Within similar contexts like Zimbabwe, drama does seem to be a meaningful medium to introduce socially undesirable public health issues. I think the usefulness of drama is its ability to play a dual role as it infuses both education and involvement of communities, but this only works when communities lead the process of engagement rather than being the subject/target of engagement.    

What were the aims of the Z project?

Z Factor’s overall aim was to spark community conversations around mental illness with both service providers and users in mind, as well as the general community and caregivers. It therefore had several objectives and assumptions. One being to engage young adults and their support networks across a variety of socioeconomic groups in a rural district of Zimbabwe and explore the potential for traditional and biomedical service providers to collaborate in mental health treatment with hopes that by providing a fun and interactive platform for public mental health dialogue it may also play a role towards reducing mental health stigma.

Further, keeping in mind that we were piloting the usefulness and acceptability of drama as a public engagement tool we also wanted to come up with a context specific and community acceptable mental health public engagement model for low resource settings. Z factor therefore had several aims which were all intertwined.

Why is public engagement and creative projects like this an important approach to help tackle health issues?

As clinicians, researchers and service providers, we are guilty of often approaching mental health services from a biased clinical perspective and expect communities to embrace whatever treatment ideology we find useful. Which in most cases aren’t actually useful or acceptable to local communities, hence end up being a waste of human and financial resources.

In my opinion, this not only invalidates community beliefs but also perpetuates mental health stigmatization as we have an inherent tendency to look down upon cultural and social values and treatments around mental health, which I feel is promoting hostilities between biomedical and traditional practitioners in most African communities. It doesn’t mean that all cultural and social beliefs around mental health treatments are useful or agreeable, but providing platforms where there can be dialogue to influence mental health policies without belittling community knowledge would go a long way, not only in ending mental health stigma but the creation of responsible and community acceptable mental health services.

Creative projects are therefore needed to foster the spirit of engagement by bringing communities, service users, providers and policy makers together in ways that encourage development rather than perpetuating a biased viewed of public health. A lot of trial-and-error projects will need to be implemented, as well as encouraging similar works to publish their protocols and findings to the wider field of public engagement.   

How can this empower communities and help raise awareness of mental health?

I feel that more public engagement work that encourages community participation and provides them with a voice to actively shape responsive mental health services, especially for vulnerable and often overlooked segments of the Zimbabwean communities, would go a long way in improving mental health service delivery. It allows both the service user and providers to share expectations as well as improving on already existing services, while at the same time promoting the creation of new and context based mental health policies that better address community needs rather than being prescriptive. Public engagement is useful in empowering communities, providing them with sufficient knowledge, resources and platforms to interrogate their own biases, shortcomings and strengths in the fight to end stigma, and promote services in ways that support their rights and aspirations towards living a full and meaningful life.   

What changes do you hope to see in behaviour and policy?

We hope that more mental health service providers and researchers will adopt public engagement as a key component of their service delivery as it’s a great learning curve. At the same time, we hope that communities that benefited from the project will continue to have and promote more conversations around mental health. This is important, as the more mental health becomes a topic of daily conversation, the less stigma will be attached to it as well as exerting pressure on policy makers to come up with and adopt more inclusive and responsive programs.

We hope that more universities and other research institutions will encourage and promote the growth of mental health public engagement, as this field of work is currently seen as waste of time or not deemed a scientifically rigorous enough type of enquiry. This is despite the gains we’re seeing, considering the role public engagement has played in yielding more than any other form of enquiry at the same time as empowering the target audience. We sincerely hope that there will be more research funding to increase public engagement activities, as well as encouraging global collaboration between well-established scholars from developed nations and scholars in low-income settings.   

What are the next steps?

We hope to refine the Z factor public engagement model, making it more responsive to community needs by incorporating community feedback and recommendations. We would like to explore, in greater detail, the various aspects of the project in urban settings, as well as at a policy/national level roping in more policy makers as well as giving mental health service users and their caregivers a louder voice.

Public engagement around mental health is still a new activity for researchers like me. Initially, my team and I felt a little like we were stumbling in the dark, as we started to learn about the processes and developed our skills during this project. We therefore plan to disseminate as many outputs from Z factor as possible, to help other researchers and practitioners, enabling them to learn from our experiences and providing them with springboard to carry out their own investigations.   

“This article makes a valuable contribution to the field of community engagement, and community-based approaches to addressing mental health, particularly in lower and lower middle-income settings,” explains Mary Chambers, Oxford University Clinical Research Unit, University of Oxford, Vietnam, in her review of the article.

You can read the Study Protocol and the peer review reports via Wellcome Open Research, ‘Z Factor: Drama as a tool to tackle mental health stigma: study design and protocol for community and public engagement in rural Zimbabwe’