Applying the Health Stigma and Discrimination Framework to psychosis stigma in Malawi

Psychotic disorders are highly stigmatized across the globe, negatively impacting people with psychosis and their families. However, little is known about stigma faced by people with psychosis in sub-Saharan Africa. We developed semi-structured qualitative guides based in a constructivist epistemology and formative research methodologies and conducted 36 in-depth interviews (IDIs) and two focus-group discussions (FGDs) with 12 people with lived experience (PWLE) with psychosis; 12 caregivers of PWLE; six traditional healers; six medical providers; six community leaders (1 FGD); and six religious leaders (1 FGD) in Blantyre, Malawi. We drew from the Health Stigma and Discrimination Framework to delineate the stigmatization process. Participants described key drivers of stigma as lack of awareness, prejudice, stereotypes, and fear. Manifestations included experienced, anticipated, witnessed, perceived, internalized and secondary stigma in the form of insults, gossip, abuse, physical violence, restraints, social exclusion, and employment-based discrimination from family and community. With respect to negative outcomes and health and social impacts, stigma impacted quality of care, resilience, mental health, morbidity, social inclusion and quality of life. In Malawi, stigma is pervasive challenge for PWLE, with severe implication for their health and social wellbeing. In partnership with PWLE, investment into the integration of evidence-based stigma reduction activities into existing psychosis management programs is warranted.