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  • NATURE CAREERS PODCAST

Science in Africa: tackling mistrust and misinformation

Judy Baariu giving a presentation with a red overlay and speaker icon

Credit: Falling Walls Foundation

Mary Bitta describes how working with local communities in Kenya can destigmatise mental health.

Mental-health researcher Mary Bitta uses art and artistic performance to tackle public mistrust in science across communities in Kilifi, Kenya.

This distrust can extend to procedures such as taking blood and saliva samples, and also to mental-health problems, which many people think are caused by witchcraft — evil spirits or curses from parents or grandparents, she says.

Such beliefs account for mental health not being prioritized by policymakers, she adds. But change is afoot.

“In the last five years alone, we’ve had policy documents specifically for mental health. There’s also been progress in amending legislation. For example, there has been a recent lobby to decriminalize suicide because, as we speak, suicide is illegal in Kenya,” she says.

Bitta tells Akin Jimoh, chief editor of Nature Africa, how she uses a form of participatory action research — in which communities are involved in song, dance, video and radio productions — to change attitudes to mental health.

This is the final episode of an eight-part podcast series on science in Africa.

doi: https://doi.org/10.1038/d41586-022-01154-8

Transcript

Mary Bitta describes how working with local communities in Kenya can destigmatise mental health.

Akin Jimoh: 00:10

Welcome to Science in Africa, a Nature Careers podcast series. I am Akin Jimoh, chief editor of Nature Africa. I work and live in Lagos and I'm passionate about promoting science and public health journalism in my native Nigeria, and across Africa.

In this series, we've been exploring the practice of science in this wonderful continent, the progress, the issues, the needs, and in the words of the African scientists who are based here.

In this eighth and last episode, we look at science communication in Africa, and hear about some creative solutions to promote science to the general public. Let's meet our researcher.

Mary Bitta 00:58

I'm Mary Bitta. I am a mental health researcher, based at the Kenya Medical Research Institute Wellcome Trust program in Kilifi, Kenya.

And my research develops and tests interventions that aim to address stigma in mental health in this setting.

There are so many problems with mental health in Kenya. First of all, we do not even have a national survey. So we do not even know the precise burden of mental disorders in Kenya.

And because of this, there are so many problems, all the way from individual interpersonal community organizational level.

But one key problem that is cross cutting is stigma, and stigma at all these levels, at all the levels that I've mentioned, and mainly at, for example, at individual level, this comes because of cultural beliefs about the causes of these disorders.

Some people think that mental health problems are caused by witchcraft, or by evil spirits, or by curses from parents or grandparents. Whereas others think that some mental illnesses like depression, are just a sign of laziness.

Or some people even believe that neurodevelopmental disorders like autism and attention deficit hyperactivity disorders, commonly called ADHD, are just defiant behaviour from a child whereas in fact, most of these children really struggle to cope.

And then this cascades down, cascades up I would say, goes all the way up to for example, the policy level, where there are misconceptions about the low priority of mental health because of data. So they do not prioritize mental health. And what this leads to is lack of resource allocation to mental health.

So, and then this, again, goes down to the community level and organizational levels where now, for example, we don't have community mental health units in Kenya. We do not have drugs, we always have shortage of psychiatric drugs at the facility levels. Just because of the lack of, you know, attention for mental health at the policy level.

Interventions try to intervene at different levels. As you can, you can hear it's not possible to intervene at all the levels at any one time. But I think one of the key things is usually to want to try and address stigma at individual interpersonal and community levels, and two, to just try and lobby at a policy level so that across the different sectors or levels, the matter is taken up.

In the last five years alone, we've had policy documents specifically for mental health. For example, there has been a national mental health policy and a national mental health action plan. And this has been developed and adopted at like national level and regional level. And then there's also been progress in, like, amending legislation. For example, there has been a recent lobby to decriminalize suicide because as we speak, suicide is illegal in Kenya.

Speaking of regional, here in Kilifi there's been tremendous progress, I guess, partly influenced by the presence of a research institute that's generating evidence. So compared to when I started working in Kilifi in 2015 there's been a lot of progress in every level of care.

For example, they just recently formed Mental Health Technical Working Group, which now oversees all mental health activities.

And then, I think for me, the most promising venture here in Kilifi has been costing the mental health action plan, which means that money will be available for activities. And I think with that, things, things are looking up things will improve greatly.

I think there are challenges that are common to like all fields of research, and then there are challenges that are unique to specific fields. And for me, interestingly, one of my biggest challenges is just language barrier.

And I mean, you know, I conduct research in either Kiswahili or Kikuyu. Swahili is Kenya's lingua franca and then Kikuyu is the most widely spoken language here. And then I, you know, analyze and present my findings in English. Now, my method of working is participatory action research, which means that I involve the target populations in design, implementation and evaluation of interventions. So, this demands that even communicating the I should communicate my results.

Now, for many of my concepts, I do not have equivalent Kiswahili words, Akiyama wants to express this. And so, although I try my best to make as good translations as possible, sometimes a lot of this is lost, so it becomes very difficult to communicate.

I'll give you a recent example, I just concluded research on stigma. And then one of the outcomes I had was changes in attitude, major changes in attitude as one of the many domains. And one of the subdomains I had was an attitude called authoritarianism.

Now I tried to translate this to Kiswahili as best as I could, in a way that could be understood, I'm still struggling with that.

So that's just one of the things, just finding the right words to communicate the concept without losing meaning.

Another one around culture would be, you know, the belief systems about some very critical components of our research, for example, samples.

Here in the Kenya Medical Research Institute, there had been a longstanding suspicion in the community, particularly about around collection of blood samples.

So one of the key pieces of work that we do here is malaria research, which requires collection of blood samples at many intervals.

And there was a time when there was a rumour going on in the community that the blood samples were being like those these huge, within the Kemri logo, the organizational logo, there is a snake, which is usually common in many medical fields of research.

And so there was this rumour that we are collecting blood to feed a certain like demon or something. So there was a suspicious about the number of times we were collecting blood, and where we were taking this blood.

And what happened is that a whole community engagement department had to be set up and and and running the community to try and destigmatize these needs.

And for a long time, and we still have people today who believe that can KEMRI collects blood for demonic reasons.

So that's all there is that suspicion and, and for a long time, even to date, we have international collaborators from all over the world. And so when, you know, they see white people in the organization, and like myself, I'm from a different part of the country, have come here, and we are collecting the samples.

There are those suspicions about, you know, the, the the culture and the belief around blood, and then suspicions about what some of these things are being used for because of lack of clarity, or lack of understanding of scientific concepts.

I'll give a recent example of a study where we had to collect saliva samples for a genetic study. Now, there's a lot of sacredness around our saliva in this community, which is where I work. And there's also a lot of sacredness around genetics, which is you know, passing on information from one generation to another.

So some of the challenges we had to we encountered is trying to demystify the myths that surround passing on genetic diseases, some of which mental health, some of which mental disorders,, psychiatric conditions, like schizophrenia or psychosis, bipolar, mood disorders, and even neurodevelopmental disorders for which there is evidence that there is genetic links.

And just explaining that we would be storing saliva samples for a long time because it has a very personal and a very spiritual meaning for, for some of the people here.

So we really had a challenging time explaining this concept and gaining acceptance from the community. So those are just some of the, you know, challenges that I experienced in communicating this just the complexity even of the concepts of science itself, yeah.

Akin Jimoh: 09:23

The lack of trust is rooted in local belief systems, religion, attitudes to science, and other issues around confidence in the authorities. Mary uses art and artistic performance to get around this.

Mary Bitta: 09:41

I'll give an example from one of my projects called the Default CMO, which means breaking free. So I use actually, mainstream media and alternative media, social media.

And I use art as a method of communication, specifically songs, dance points, and even short participatory to videos and documentaries. Now here in the local culture and I believe in many cultures across the continent, you know, music and dance have been used to preserve history to explain phenomena, and even most importantly, to pass very serious messages in very light moments.

And the issue that I'm trying to tackle, which is stigma is a very contentious one, particularly in the context of mental health, because of the cultural associations and beliefs.

And so that's why I chose art because one, it brings people together, and then in add this freedom of expression, which is very critical, and which gives us an opportunity to to address those really contentious issues.

So like, when we have the mass, the mass campaigns at the community level, we actually get our artists to perform the songs, which are in most occasions, formatted as question and answer.

So the artists will sing a song asking the population a question. And then the population will give an answer. I'll give an example. You know, the artists will sing and ask, “What do you think causes depression” as a song, and then maybe a member of the community will say, “I don't know, thinking too much, or maybe stress or something.” And then the artists will reply in song and say, “Would you like to come and dance with me to, you know, to demonstrate how you can like stop depression or be happy or something like that.”

So it's usually very participatory and interactive. But within the song, there are messages about what causes these illnesses and what someone can do when they have these disorders. And we even sometimes communicate our findings, like, “Did you know that there is a cure for depression? Do you know that if you suffer from this, you can get help here.” They're all that is usually entailed in the song.

So we do so what the design of for example, the first thing was such that we were working with people across all the levels, including like the administrators, etc.

So when we have an event, we just usually advertise it through the administrators for the different like regions.

And then we set a date and we send out the message and then people just show up, people just come. And then yeah, we perform and we share the messages. We have some events inside, we have some events outside.

Sometimes we attract. So, well, the pandemic brought challenges in terms of the number of people you could gather together, but pre-pandemic, it would be like in I don't know, in hundreds, maybe at any one gathering.

That's the whole point. Yes, we focus on the entertainment to attract the crowds, because we want people to you know, we do not want the seriousness that's usually attached to you know, research and health science that will not attract the crowd.

So we value the entertainment value of the of the songs, but we also ensure that, you know, once people are settled and the crowd is calm, we now engage in not only an entertaining way, but also a college knowledge exchange, not just educating because educating sounds like one way we like engaging like in knowledge exchange, but we use the entertainment component to attract the crowds.

The program uses a concept called participatory action research, which means that the target population or the stakeholders in whatever issue you're trying to address are involved in the conceptualization, development, implementation and evaluation of the interventions.

So in our case, the stakeholders at the centre of it are people with lived experience in mental illness and their caregivers.

And then we also have healthcare providers which could include biomedical healthcare providers, traditional healers, spiritual healers. And then we also have representatives from the administrative units etc.

And the idea is that concept development is shared. So in the case of Difisimo, it is people with lived experience and traditional healers and spiritual healers, who suggested the use of songs and music and dance essentially as a tool or as a method of communicating.

Because like I said, mental health is a very sombre topic, I think all over the world and even in this setting and it is surrounded with a lot of myths and misconceptions.

And so, you know, they suggested that to address this, we would use something that is light and where we will be allowed to express ourselves because, you know, music allows, you know, jokes and, you know, etc.

So that is how we chose music and dance as a method of communicating. Discussing stigma and mental health essentially.

A lot of our work is audio visual. And so we, we also rely on, you know, pictures and videos and music to disseminate the information because when we go for like community outreaches we usually film you know some of the stories that we collect in the field.

And so, one prominent work that we did was a documentary called The Man in Chains, which was about a person who had lived with schizophrenia for 25 years.

And the community believed that this person possessed supernatural powers, and they saw he never sought any form of treatment for his illness, and he deteriorated. And he started wandering away and getting lost, and then they would chain him to a tree in his home state.

And that's how we coined the name Man in Chains. And so we've used this documentary to speak about stigma around mental illness, beliefs and myths and misconceptions about the causes of mental illness.

And I think it has always been very emotive, while we've in most circumstances received overwhelmingly positive reception and people have opened up about, for example, people that they're hiding at home because of stigma.

And they've really expressed gratitude for showing that film because they've seen avenues which they can help their own people back at home.

So yeah, so we use documentaries, we've posted them on us on our website and our social media platforms. But when we go to the field, we actually carry filming and screening equipment.

So we will carry the projector and laptop, widescreen speakers and everything. And we'll select a venue with access to electricity.

And we plug in our our equipment and show the population.

So with the radio events, what we actually do is just, we do we book slots for just discussing mental health. And it's usually advertised on the radio pages, their web pages and everything.

And then it's just mostly to show you around primetime. So maybe eight in the morning or 8pm. So yeah, we'll just get people listening in and calling in live to ask questions and sometimes to to challenge some of the things that we have said and then we usually just answer and have discussions usually moderated by like, the radio presenter for that particular show.

Yeah, we have had metrics we've attracted a million listeners and remember with the radio shows, it's not regional it's people are listening from different parts of the country. So we have had large listenership for some of the programs as high as a million people. Yeah.

Akin Jimoh 18:05

I'm personally very interested in Mary Bitta’s innovative strategy to improve the care of mental health, patient and care. As a science communicator in Nigeria, I well understand the challenges of trying to overcome cultural barriers, and the multifaceted approach you need to work on them.

In 2013, I undertook a task for UNICEF, Nigeria, to increase vaccine uptake in children. The Muslim population of northern Nigeria became suspicious of an immunization program.

Polio, measles, diphtheria, and other childhood immunizable diseases, they began to believe misinformation that the vaccines affected fertility.

We launched various myth busting campaigns about our vaccines are developed and manufactured. We engage communities or religious leaders, recruited thousands of volunteers to knock on people's doors, and organized national fascination days.

We use all forms of media, newspapers, radio, television, and community theatre to educate the public.

And it worked. In 2020. Nigeria, the last polio endemic country in Africa, was officially certified free from polio. After marking three consecutive years since the last case of wild polio was reported. Mary Bitta came up against a similar wall of misconceptions was used a different approach, participatory action research in order to educate. Did it work?

Mary Bitta 19:47

The quantitative results of our analysis are showing that it's working. Yes, we are seeing an improvement in levels of knowledge in changes in attitude and improvements in reported and intended behaviours.

But of course, what we are observing so far is in the short term. So we are yet to see whether these effects will be sustained in the long term.

But, again, just to say that our campaigns have been very targeted. The campaigns that we've evaluated, empirically have been very targeted to specific groups.

So again, you know, you're asking a very difficult question about whether this works for large mass populations. That is something that we're yet to see.

But just to say, I'm sure everyone appreciates that change takes time, we are asking people to change their long held beliefs and attitudes and behaviour, that is something we have to wait and see.

For me, one big outcome of this work is that we are opening avenues for dialogue. I think for me that's a big change because mental health stigma has been a taboo subject for the longest time.

And so just the fact that they are these avenues for dialogue for me is evidence that we are one step in the right direction. As long as it's contextually relevant.

The idea of I think the idea of participatory action research is long overdue, because when you use participatory approaches, you actually address what matters the most to that target population, which varies from from population to population.

And then also there's a there's a problem researchers refer to as type three error, which essentially means challenges with problem conceptualization.

But if you use participatory action research, you actually conceptualize the problem correctly. For instance, in most cases mental health is conceptualized biomedical, which means that people think of schizophrenia, depression, those categorical, you know, categorization of mental illness, but that's what we've learned for the facilities. That that's not how people understand mental health in this setting.

Some people actually understand it as a blessing in disguise in the instances where they believe someone possesses supernatural powers, whereas a doctor would call those hallucinations and delusions.

So I think they are sustainable if they're locally adapted, and if they are participatory so that when you're addressing a problem, you address what matters most to the population you're targeting.

Akin Jimoh: 22:16

Misinformation about science, whether it's mental health or immunization programs, is a global challenge, not just Africa.

The recent divided opinions about COVID vaccines is a case in point. Good science communication is critical to preserving and improving the health of society.

Thankfully, there are positive stories like Mary Bitta’s, but much more needs to be done.

Well, that's all for this episode and the series Science in Africa, a Nature Careers podcast. I am Akin Jimoh, chief editor of Nature Africa. I hope you've enjoyed the journey. Thank you for listening.

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