Can simple information interventions reduce mental health stigma?
Misperceived social norms and access to mental health services in Kenya
Nicholas Otis (PhD student in Health Policy and Economics, UC Berkeley) describes preliminary findings from a pilot study on mental health and stigma in Kenya supported by CEGA’s Psychology and Economics of Poverty Initiative.
Depression is an important cause and consequence of poverty, with debilitating effects on health and economic productivity (Kremer et al., 2019; Ridley et al., 2020). In Kenya, the prevalence of depression is estimated to be as high as 40% (Ndetei et al., 2008; Osborn et al., 2020). While an increasing number of nonprofit and private firms have begun offering counseling services in Kenya, demand for these services remains low. This blog post describes results from qualitative interviews and pilot surveys (conducted in conjunction with the Busara Center for Behavioral Economics) exploring the effect of beliefs on the demand for mental health services.
Do psychological biases suppress the demand for mental health services?
Our initial scoping interviews identified perceived stigma as a barrier to seeking treatment. For example, when asked why more people don’t talk to a counselor, one interviewee responded: “People fear being seen as weak or childish, or as a person who always complains. They are afraid people will look down on them.”
Stigma and beliefs
To better understand concerns about stigma, we created simple survey questions to capture (a) attitudes toward treatment for depression, and (b) perceptions of other people’s attitudes towards treatment.
We designed the following question to measure stigma about using mental health services: If I learned someone was seeking support for depression or sadness (through a counselor or using other services), I would judge them negatively. {No, Yes}.” Through qualitative interviews, we confirmed that this question captures people’s main concerns about stigma. Of the sample of 81 people, only 7% of respondents answered “Yes” (that they would judge someone negatively), indicating low levels of stigma. This is not surprising given the high burden of depressive symptoms among the respondents.
Individuals overestimate the prevalence of stigma from seeking treatment. These private judgements diverge sharply from individuals’ perceptions of stigma. To capture misperceptions, we elicited predictions of how many people responded “Yes” to the stigma question above: “Now we want to ask you about a group of 100 people in your community who responded to the previous [stigma] question. How many of these respondents do you think answered “Yes (I would judge them negatively)?”
Pilot results indicate that on average individuals overestimate stigma by more than a factor of five; respondents predicted that 40% of (other) respondents would hold stigmatizing views towards treatment (compared to the observed 7%), and 66% of participants overestimated the frequency of negative judgements for seeking care.
Why do misperceived social norms persist?
Depression influences behavior through negative beliefs about the self, the world, and the future (Beck, 1979). This may lead people to have overly pessimistic expectations about the level of stigma associated with seeking treatment. The persistence of stigma in a context where a large proportion of the population is depressed can be explained by the idea of pluralistic ignorance, a state where most people privately reject an attitude or judgement (i.e., holding stigmatizing attitudes), but incorrectly believe that others accept it, and as a result conform to and perpetuate the misbelief (Bursztyn et al., 2020).
Correcting misperceived social norms
The pilot results also demonstrate that individuals’ beliefs can be changed by simply providing them with information on the number of people (out of a random sample of twenty respondents) who answered “No (we would not judge them negatively)” to our stigma question. We then re-elicited individuals’ predictions of the average level of stigma for the full sample. This simple information intervention reduces the overestimation of stigma by 25%, suggesting a potentially powerful tool for correcting biased beliefs.
Ensuring service quality
Correcting misperceived social norms is just one part of improving welfare. The quality of service providers is of particular concern in low- and middle-income countries (LMICs). Through recent scoping activities, we had research assistants contact several local mental health services to provide a minimal quality assessment: checking if it was possible to book an appointment. Results ranged from having a volunteer hotline worker try to provide our caller with a loan, to being placed on hold and asked to call back each day for almost a week, after which the counseling line was disconnected. While high-quality services and practitioners may exist in Kenya, these results emphasize the importance of running quality checks on service providers.
Mental health is a first-order concern in many resource-constrained settings like Kenya. My piloting suggests that misperceived stigma is an important barrier to treatment. Yet, supply-side constraints further limit the provision of high-quality care. In future work, I plan to extend these pilot results by referring people to effective psychological services.
Bursztyn, L., González, A. L., & Yanagizawa-Drott, D. (2020). Misperceived social norms: Women working outside the home in Saudi Arabia. American economic review, 110(10), 2997–3029.
