Challenges of Mass Media Interventions Regarding Mental Health: A Community Exemplar in Kampala Uganda

The Community Psychiatric Support Organization is a registered voluntary not for profit NGO in Uganda working to promote mental health by empowering the community to care for the mentally ill. Mental illness occurring in Uganda is often ‘explored’ or ‘explained’ from non-medical perspectives, including social, cultural, and/or religious belief systems. Over the last two years, the organization has conducted sixty six (66) live radio mental health education talks and twenty six (26) live television talk shows in an effort to reduce stigma towards mental illness. Such campaigns within developing contexts have not be examined extensively, although, in other sectors such as health promotion and disease prevention, it has been found to be highly successful. The retrospective document review of personal journaled materials related to the mental health messaging (radio and television) and responses between 2013 and 2015. These journals captured responses by callers, which were then analyzed using a content analysis methodology. Through this effort, it was recognized that there is an appetite of the public for necessary and appropriate information about mental health in their community. It has also shown the need to more efforts to share information and knowledge about mental health in a manner which reaches the public to reduce misperceptions and misinformation in a manner which is culturally appropriate and social acceptable. This is a major challenge in a context of development which faces various levels of literacy, embedded social/cultural beliefs, religious strengths, and a lack of resources to address mental illness.


Introduction
Mass media is one of the public's primary sources of information about mental health disorders such as bipolar, schizophrenia, and depression [1]. The scientific study of mental health issues in the media began with Nunnally's investigation [2], which compared the views of mental health experts, the general public, and the mass media. The studies [1,[3][4][5][6] emphasize the misrepresentation of mental illness in media and the negative media portrayal of mental illness. Despite new scientific advances in the understanding and treatment of mental illness, it is evident that media depictions of mental illness are as outdated and harmful as ever [7].

Situating mental health stigma within mass media interventions
Mental health-related stigma is a global phenomenon which not only affects those with the mental health problems, but their families, communities, and society as a whole [8]. An international study in 15 countries by Pescosolido [9] found public stigma towards mental health conditions was evident in all countries. Stigma includes elements of ignorance (i.e., knowledge deficit), prejudice (i.e., stigmatizing attitudes), and discrimination (i.e., unfair treatment) [10]. A number of authors [11][12][13] describe the repercussions of stigma on the individuals to include poverty, lack of services for mental and physical health, and a plethora of stereotypical labeling (i.e., dangerous, incompetence, and socially inept). On a societal level, Corrigan emphasizes the loss of opportunity for the mentally ill to contribute as a result of stigmatization [14].
Mass media are channels of communication (such as print; audiovisual media; mobile outreach; digital strategies) reaching out to large numbers, rather than traditional one-to-one or face-to-face contacts [15,16]. Mass media interventions vary as to their target populations (i.e., public, youth, mentally ill clients), sources (i.e., government; community groups), and topic specificity (i.e., mental health generally; specific single mental health condition). These types of interventions are being used globally [17], primarily because of their ease of introduction and potential for scale up to a population level. In addition, mass media campaigns in other fields have been shown to be most effective if they are of more intensive [15] and of longer duration [18].
Rooted in the principles of social marketing [16], mass media targets change in attitudes and behaviors not only at the individual level but within community and policy maker sectors as well [19]. According to Clement et al. [20] anti-stigma strategies such as mass media interventions have not been adequately evaluated for costbenefit, effectiveness, message clarity, and policy impact. As well, these same authors indicated that there have been limited studies in low and middle income countries, where the issues of mental health are often embedded in social and cultural structures that further stigmatize and disenfranchise those afflicted with mental health conditions [21,22] and warn that there is a risk for mass media campaigns to 'backfire' resulting in further stigmatization.
Anti-stigma interventions are often championed by either professionals or by individuals/families with living with mental health-related stigma. According to Clement these groups often present varying perspectives which influence the messaging, so it is critical that multiple perspectives be included in anti-stigma interventions [23].
A number of researchers [24,25] indicated that anti-stigma mass media interventions on mental health have reduced discrimination, as well as increased mental health service utilization and health information awareness on the issues and conditions. However, these results are accompanied by cautionary notes that these approaches are highly complex, may only yield small impacts at high costs [20], and need to appeal to a public with a wide range of opinions, prejudices, and knowledge levels [10].

Situating mental health stigma within community
Mental illness occurs in Ugandan communities, but is poorly understood. It is variably perceived according to ones' belief systems, which are frequently rooted in social, religious, and/or cultural practices -each of which firmly holds to their precepts respecting the causes and manifestations of mental illness. With these influencers come campaigns, programs, and rituals that offer 'solutions' and 'cures' to mental illness. As a result there is often a dilemma of choice between traditional and medicalized approaches to treatment; hence, mentally ill clients are frequently undiagnosed, undertreated, and lack adequate professional care. This dilemma is further reflected in the mass media messaging to the community which highlight the differing and divergent belief systems causing confusion and controversy, at best, and mistreatment and conflicts, at worst.
The use of mass media interventions to reduce mental health related stigma, discrimination, and prejudices in developing countries is in its earliest stages. The challenges of using such strategies in developing contexts are rooted in social and cultural practices and beliefs respecting mental health.
This article therefore reveals the challenges encountered while disseminating health education messages about mental illness using mass media as experienced by the Community Psychiatric Support Organization in Kampala, Uganda.

Methods
The Community Psychiatric Support Organization is a registered voluntary not for profit NGO in Uganda since 2009, whose mission is to promote mental health by empowering the community to care for the mentally ill. In an effort to attain its objectives, the organization has conducted sixty six (66) live radio mental health education talks on five radio stations (Radio Simba FM, Impact FM, Family Radio FM, Beat FM and Top Radio) and twenty six (26) live television talk shows on three local stations (Uganda Broadcasting Corporation TV (UBC TV), Star TV and Top TV) in Uganda between January 2013 and September 2015. At times, co-presenters, including members of the public, spiritual pastors, and traditional healers, joined for the live programs.
Program topics included what mental illness is, signs and symptoms of mental illness, what causes mental illness, and treatments for mental illness. During these programs, the public was invited to call in or send short text messages (SMS), as well as ask questions after the live programs were completed. Although some of the queries were responded to on air, the majority were managed off air.
This study is, a retrospective document review of personal journal materials related to mental health mass media messaging and responses during the aforementioned series of talk show (radio and television) events hosted by the Community Psychiatric Support Organization. The review included records of 132 calls and 44 SMS text messages that contained criticism or content critiques related to the presenter message, while eliminating any compliments or appreciative comments, as well as any messages requesting treatment or further information.
In this consideration, we were interested in revealing the presence or absence of words, scenarios, and dialogues indicative of challenges to the mass media intervention. Hence, content analysis, in accordance with a conceptual approach, was undertaken adapting steps described by Carley. The focus was on identifying existence and types of challenges rather than enumeration of these concepts. Further, it was felt that full understanding was only achieved at the phrase or word cluster level for the text while entrusting selective reduction to the coding level.

Results and Discussion
Conflicting authorities: The bible meets medicine A highly controversial topic was 'hearing voices' , which is a wellknown primary symptom of a major mental illness -schizophrenia. While the main message from the mass media intervention was that this symptom was part of a mental health condition, the religious pastors labelled the presenter's statement as 'an abomination towards God' . They quoted the Bible verses where God talked to Adam & Eve (Genesis 3: 8-13), Abraham (Genesis 22: 1-4), and Moses on Mount Sinai (Exodus 3: 1-21), as evidence that God used His voice only to impart important information. Members of the public cited that Socrates was said to have heard such voices for religious insights, as did Mahatma Gandhi.
It became apparent that this dialogue created confusion and conflict for the listeners as the pastors were quoting an authentic book -'The Bible'; whereas the presenter could only cite authors of psychiatric and medical books unknown to the public. It was important for the presenter in his responses to provide a logic trail as to the difference between the Voice of God and the voices of mental illness. The Bible was acknowledged as a unique book which described miracles and experiences that captured God's Voice, which is not connected to the experiences being described in the mental health scenario. Another spiritual pastor who reported that he had gone to Heaven and come back to earth told of his own experiences hearing voices and having Godly visions. Again, given the authority of this individual and the Biblical citations of Jesus' resurrection, the conflicting evidences require unique therapeutic approaches. Although the mental health provider provided a clinical explanation, since the pastor had severe malaria and was febrile (likely resulting in a delusional episode), he was met with resistance and criticism respecting his cynicism and rebuttals.

Negotiating powers: cultural challenges
While the presenter focuses on clarifying mental illnesses and interventions from a biomedical lens, traditional healers describe the cause of mental illness as due to 'supernatural powers' . They refer to the 'powers' as useful for healing, but can be dangerous if disobeyed or disregarded. Good powers can be used to direct chosen people to identify unknown medicinal trees & shrubs and/or how to perform rituals that help the mentally ill patient to rid themselves of their affliction. The good powers as well prevent disasters like mud slides, drought, famine, wars, and floods. One traditional healer stated that most of the challenges and devastations in today's world are because people have become more educated and adopted Western culture and religion which encourage disobedience and defiance of the supernatural powers. Further, the healer indicated that these behaviors have made the local spirits angry bringing on plagues such as mental illnesses.
Some of these powers are bad (also called Kitambo) and, according to a traditional healer, these powers make people eat human flesh. He then gave an example of the spirits in one place called Bukunja where individuals have powers and herbs that they put on the grave which awaken the dead body to allow them to be eaten. It is difficult for the mental health practitioner to refute such beliefs without becoming critical or appearing ignorant of cultural practices. However, this conjecture lead to a subsequent caller who threatened to kill and take the presenter's, dead body to dig in his garden and eat it thereafter. He ordered the presenter to send him his recent photograph that would be used to perform rituals that would kill the presenter. This caller indicated that these bad powers are the same powers that, if out of control, cause mental illness. On a subsequent follow up 'off air' contact, the caller recanted his intent to participate in performing such rituals publically because they are intended for survival and he would risk losing this power if he was involved in a public display.

Interpreting dreams: challenging the message
In another encounter, one traditional healer who is well known for communicating with supernatural being and interpretation of dreams revealed that failure to attend to one's dream can be punishable by suffering mental illness. He said dreams are a communication from the supernatural powers and in most cases people dreams at night and the dreams are ignored, yet they have special messages and instructions to be followed. It is therefore important that whoever dreams at night takes a step to look for anointed people like this traditional healer for dream interpretation in order to not annoy the supernatural powers and cause mental illness. He also encouraged the public to work hard in order to be able to pay for the costs of interpreting the dreams such that their communication with God is understood to avert such conditions. The mental health provider challenged the need for dream interpretations by traditional healers as opposed to medical healers. It was clear that the motivation for dream interpretations was more rooted in financial gain than affecting the desired change in the patients.

Ritualizing death: from beyond the grave
According to traditional healers, another cause of mental illness and other conditions (such as epilepsy) was failure to respect the dead. He said people who died before their stipulated time in traumatic event, like accidents, disasters (floods, fires), and wars, must be respected, given special consideration among the dead and so special rituals must be performed in their honor because they should still be alive. These distinctive rituals are prescribed and conducted by designated people, and if they are not done, the spirits will display their anger by causing mental illness in those who knew them before they died or were involved in terminating their lives. For example, people are to share alcohol with clan members who have died or they will suffer the risk of acquiring mental illnesses. This logic indicates that alcohol does not cause a mental illness but failure to perform rituals involving alcohol do, which is in direct conflict with the mass media messaging of the mental health provider. The healer also indicated that people today are ignoring the local brew and use unacceptable imported brews, thus violating the norms of spirits of the deceased, again accelerating the occurrence of alcohol-related mental illnesses.
The community perceives that mental illness occurs when the spirits of those who have died in a traumatic event wish to pass on the messages to those who are living through the ordeal. According to the traditional healers, there is an imperative to undertake bloody sacrifices to help mediate this interaction; whereas the spiritual pastors decree a need to cast out demons. The mental health practitioner indicated that these forms of treatment result in little or no improvement and leave the afflicted individuals without a path to wellness. In response to this statement, the traditional healers intimated that by delivering such messages and public utterance against the spirits would result in the presenter being the target of the spirits' displeasure.
Discovering fire: refuting the plagues During one show, a discussion ensued related to the destruction by fire of a historical landmark in Kampala called Kasubi Tombs. A caller explained the event was due to extreme anger from the dissatisfied spirits of the deceased kings of Buganda Kingdom, and was predicated on local plague-like conditions of extreme poverty, incurable diseases, and mental illness. The caller indicated that the neglect or nonacknowledgement of these catastrophes lead to the extreme response of the spirits in the form of the destructive fire on the Kasubi Tombs. From the presenter, the response was clearly that fire is caused by an inalienable triad of oxygen, fuel, and heat rather that the wrath of spirits. It is noteworthy that this response catalyzed a number of caller responses demanding the talk show moderators stop bringing 'confused people like the presenter' on air to mislead the public. Some suggested that the presenter was mentally ill and should take his own medicine. As a result of this scenario, the relationship between the presenter and the radio station management deteriorated and has since been severed.

Confusing the issues: sarcasm, intimidation, and innuendos
Over the course of the multiple mass media interventions, there were a range of comments and suggestions which led to confusion and disruption in the positive messaging. Many of these comments were in the realm of spiritual healing and divinely inspired healing of mental health conditions. Although the presenter continually sought to clarify the causes and pathologies of mental health, these pastors and traditional healers would refute and 'utter' threats against his own wellbeing. Others offered traditional remedies for mental illnesses such as hanging a piece of the dried nose of a dead pig above the main door of the house wrapped in black cloth or burning the bones of a pig along with snake scales to chase away the causative demons. As per the comment of one traditional healer, demons dislike pork products, so by using these elements will never come to the home and consequently cure the person with the mental illness. Again, the presenter emphasized the medical/pharmaceutical treatments available to manage mental health conditions and tried to present the evidence of the effectiveness of a range of 'proven' treatments. The mass media interventions were often met with threats to the presenter and a curse on future family generations because of the utterances against the spirits. As well many hinted that the presenter himself must be mentally ill as he was unable to see the powers or the spirits impacts in his life.

Implications for practice and research
Mental health practitioners and researchers in developing countries have a major challenge in dealing with mental health clients, public education respecting mental health, and bring the issues of mental health to the global health agenda. This experience in Uganda has demonstrated the appetite of the public for necessary and appropriate information about mental health in their community. The public is in critical need of appropriate, accurate, and accessible information about mental illness as part of the health information for all agenda [26]. It has also shown the need for more efforts to share information and knowledge about mental health in a manner which reaches the public. Mass media interventions have been shown to reduce discrimination and stigma related to mental health albeit at a relatively limited level.
The strengths of such interventions should be used to the advantage of mental health information campaign; however, these should be coupled with other approaches which reach the target populations in order to overcome dissenting and confusing messaging. Regardless, it is clear that message content and repetitive messaging (extended involvement) are the critical elements to ensuring effectiveness and potential successful mass media interventions. There is a need for mental health practitioners and researchers to work collaboratively to reduce misperceptions and misinformation in a manner which is culturally appropriate and socially acceptable. This is a major challenge in a context of development which faces various levels of literacy, embedded social/cultural beliefs, religious strengths, and a lack of resources to address mental illness. Practitioners and researchers must work with government officials on a mental health agenda which ensures appropriate and consistent messaging for the public and those afflicted by mental health issues, such that the information is evidencebased, and accessible to all.