CULTURAL BELIEFS AND ATTITUDES TOWARD MENTAL ILLNESS: EVIDENCE FROM JOS UNIVERSITY TEACHING HOSPITAL

CHAPTER ONE

INTRODUCTION

Abstract

In Nigeria, cultural beliefs profoundly shape how mental illness is understood, experienced, and responded to at both individual and community levels. Across diverse ethnic communities served by Jos University Teaching Hospital (JUTH) in Plateau State, mental illness is commonly attributed to supernatural forces, spiritual curses, ancestral displeasure, and witchcraft beliefs that channel help-seeking toward traditional healers and religious practitioners rather than biomedical services. This chapter examines the cultural beliefs and attitudes toward mental illness prevalent among communities in the Jos catchment area, explores their implications for mental health service utilization at JUTH, and provides the conceptual and empirical foundation for the study. The chapter covers the background, problem statement, objectives, research questions, hypotheses, significance, scope, and definitions of key terms.

1.1 Background to the Study

Mental illness is a large public health burden in LMICs and Nigeria accounts for a large proportion of the unmet need for psychiatric service in the world. Only about 20% of mental disorders cases are formally treated in sub-Saharan Africa and Nigeria has one psychiatrist for every 100 000 people (World Health Organisation, 2023), which is one of the lowest in the world. Although funding deficits and poor access to treatment are known barriers to health care, cultural beliefs and stigmatizing attitudes toward mental illnesses are also powerful and frequently dominant factors that limit treatment access.

The Nigerian societies have complex and varied cultures that attribute meaning to health and sickness in cosmological terms. In the many ethnic communities spread throughout the country, mental illness is often thought of as a result of the actions of the supernatural possessing by a spirit, sorcery, transgression of ancestral practices or divine wrath. Qualitative research carried out in the Doma Dara locality (Berom), Zazzau Zaria (Hausa), Ado-Ekiti (Yoruba) and Enugu (Igbo) communities found striking overlaps in the themes of mental illness as a spiritual illness, traditional healing as a primary treatment for mental illness and existential stigma reported in each of the communities (Dada, Yakubu and Adelufosi 2021).

Retired to the north-central region of Nigeria is Plateau State, where more than 50 ethnic groups are found, of which the Berom people of Jos and environs are the biggest. Historically the Berom had an unusual cultural and religious cosmology, which intertwined the behwol, the shrines of the sacred order of the gods, where certain people believed they could find healing and spiritual protection when suffering from mental health issues (Mwadkwon 2010 in Ayiku et al 2022). Despite Christianity and Islam replacing traditional religion as the major religions of the area, syncretistic beliefs, merging biomedical and supernatural factors and orientations, remain and have continued to shape the way Berom families understand and react to mental illness.

In a mixed methods study focused on cultural beliefs and attitudes towards mental health problems (ATMHPs) among the Berom community in Jos, an examination of culture yielded significant findings that cultural identity factors account for religious and ethnic beliefs at the community level which in turn predicted ATMHPs. (Chilaka, Nwachukwu and Ayiku, 2022) (Ethical approval was obtained from both University of East London and Jos University Teaching Hospital). Even although some community members understood that biomedical treatment was effective, those cultural beliefs that deeply rooted in the community still influenced the decision for the individuals or families to consult traditional or faith healers before psychiatric treatment at JUTH.

The impact of culturally caused treatment delay is serious in Nigeria as a whole. Patients who come to the JUTH are usually in the more severe stages of the illness, suffering from either a psychosis or a mood disorder or a drug or alcohol induced psychiatric disorder, after months or years of years of treatment with traditional and faith-based medicines. This late diagnosis leads to higher hospitalization expenses, lowered treatment receptivity and overweighs the disability associated with mental illnesses. Therefore, the knowledge of cultural contexts from which patients are coming is valuable components in culturally competent care at JUTH clinicians and social workers.

Examining the role of mental illness traditional beliefs among rural dwelling women in western Nigeria, Okafor et al. (2022) found that the prevalence of traditional beliefs that are incompatible with biomedical perspectives is significantly higher among women than among men due to their primary role in caregiving, and that communities with high rates of such beliefs tend to have low usage of mainstream mental health care services. In their qualitative study of university health worker students in Nigeria, Pederson et al. (2022/2023) also found that stigmatizing attitude amongst health workers serve as an impediment to cultural factors faced by patients seeking psychiatric help. In total, these studies provide a glimpse into the multi-level nature of cultural beliefs in Nigeria's mental health journey from community, family and patient to provider.

1.2 Statement of the Problem

Although there has been a surge of interest by scholars and researchers into the importance of mental health stigma and cultural attitudes in Nigeria, empirical studies specifically focusing on the attitudes/beliefs of communities provided with mental health services at Jos University Teaching Hospital are limited. Platform cultural diversity, with an increased number of Berom, Hausa, Fulani, Angas, Tarok and other ethnic groups, results in a complex mosaic of mental illness explanatory models which has not been systematically described at institutional level.

Patients come from Jos and Plateau state to the psychiatric department of the Jos University of Health and Technology (JUTH). If the clinician has not knowledge of patients' and families' cultural beliefs and attitudes regarding mental illness, he or she is not in a good position to communicate effectively, minimize treatment delay, facilitate better medication adherence or stop patients from engaging in negative traditional treatments. This study fills the gap by documenting empirically cultural beliefs and attitudes surrounding mental illness among the population in JUTH catchment and their association to mental health service utilization.

1.3 Objectives of the Study

The general objective is to examine the cultural beliefs and attitudes toward mental illness among patients, caregivers, and community members served by Jos University Teaching Hospital.

The specific objectives are:

1. To identify the dominant cultural and supernatural explanatory models for mental illness held by the JUTH patient population and their caregivers.
2. To assess attitudes toward mental illness including stigma, social distance, and willingness to seek professional treatment among the study population.
3. To examine the relationship between cultural beliefs and the time elapsed between symptom onset and first presentation at JUTH.
4. To compare cultural beliefs and attitudes across ethnic, religious, gender, and educational subgroups in the study population.
5. To recommend culturally sensitive strategies for improving mental health literacy and service utilization in communities served by JUTH.

1.4 Research Questions

1. What are the dominant cultural beliefs about the causes, nature, and appropriate treatment of mental illness among the JUTH study population?
2. What attitudes toward persons with mental illness including stigma, avoidance, and social exclusion prevail in the study population?
3. Is there a significant relationship between holding supernatural explanatory models for mental illness and delay in seeking psychiatric treatment at JUTH?
4. Do cultural beliefs and attitudes toward mental illness differ significantly by ethnicity, religion, gender, and educational level?
5. What culturally appropriate interventions can reduce stigma and improve pathways to psychiatric care in the Jos catchment area?

1.5 Research Hypotheses

H1: Individuals who attribute mental illness to supernatural causes are significantly more likely to have sought traditional or faith healing before presenting at JUTH.

H2: Negative attitudes toward mental illness including stigma and social distance are significantly associated with lower utilization of JUTH psychiatric services.

H3: Level of formal education is inversely associated with adherence to supernatural explanatory models for mental illness in the study population.

1.6 Significance of the Study

This study is of considerable significance for psychiatric clinical practice, mental health policy, and community health education in Plateau State and Nigeria. For JUTH clinical staff, the findings provide an empirical foundation for developing culturally sensitive patient communication strategies, caregiver counselling programmes, and community outreach initiatives. For Plateau State mental health policymakers, the study illuminates specific cultural barriers that policy must address to improve treatment uptake. For Nigerian mental health academia, the study contributes an ethnographically grounded dataset from one of Nigeria's most culturally diverse regions, enriching the national literature on cultural determinants of mental health care. Internationally, the study adds to comparative research on the role of culture in mental health help-seeking in sub-Saharan Africa, a domain identified as requiring sustained research investment.

1.7 Scope and Limitations of the Study

The study focuses on adult patients (18 years and above), caregivers of patients, and community members within the JUTH catchment area in Plateau State. Both qualitative and quantitative methods will be employed: the Cultural Explanatory Model Interview Catalogue (CEMIC) and the Community Attitudes towards Mental Illness (CAMI) scale will be used alongside semi-structured interviews. Limitations include the social desirability bias that may lead participants to underreport stigmatizing attitudes, the challenge of ensuring representativeness across Plateau State's diverse ethnic communities, and the potential influence of the interview setting on responses given in a hospital environment.

1.8 Definition of Terms

Cultural Beliefs:

Shared values, norms, worldviews, and explanatory frameworks held by members of a cultural group that shape how they interpret, respond to, and make meaning of health and illness.

Attitude toward Mental Illness:

A learned predisposition to evaluate persons with mental illness, mental health services, and mental health treatment in a positive or negative manner, reflecting cognitive, affective, and behavioural components.

Mental Illness:

A broad category of health conditions characterized by disturbances in an individual's cognition, emotion regulation, or behaviour that reflect a dysfunction in psychological, biological, or developmental processes underlying mental functioning (APA, 2022).

Stigma:

A social process involving labelling, stereotyping, separation, status loss, and discrimination applied to individuals identified as having mental illness, operating at structural, social, and self-directed levels.

Explanatory Model:

An individual's or community's framework for understanding the cause, course, and appropriate treatment of a specific health condition, which may be biomedical, psychological, supernatural, or a synthesis thereof.

Help-Seeking Pathway:

The sequence of actions taken by an individual or family in response to perceived illness, including consultation with traditional healers, religious leaders, and/or biomedical practitioners.

Traditional Healer:

A practitioner who uses herbs, rituals, divination, spiritual intercession, or other indigenous therapeutic techniques to treat health conditions within a cultural framework recognized by the community.

References

Aluh, D. O., & Caldas de Almeida, J. M. (2023). The need for mental health research in Nigeria. The Lancet Psychiatry, 10(5), 310–311. https://doi.org/10.1016/S2215-0366(23)00077-5

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., Text Revision). APA Publishing.

Ayiku, M., Nwachukwu, I., & Chilaka, M. A. (2022). Berom cultural beliefs and attitudes towards mental health problems in Nigeria: A mixed-methods study. Journal of Mental Health, 31(4), 504–518. https://doi.org/10.1080/13674676.2021.2019205

Dada, M., Yakubu, A., & Adelufosi, A. (2021). Nigerian cultural beliefs about mental health conditions and traditional healing: A qualitative study. Journal of Mental Health, Culture, Mind and Brain. https://doi.org/10.1108/JMHCMB-2021

Okafor, I. P., Oyewale, D. V., Ohazurike, C., & Ogunyemi, A. O. (2022). Role of traditional beliefs in the knowledge and perceptions of mental health and illness amongst rural-dwelling women in western Nigeria. Primary Health Care Research and Development, 14(1), e3547. https://doi.org/10.4102/phcfm.v14i1.3547

Pederson, A., Nwachukwu, I., & Sampson, N. (2022). Perspectives of university health care students on mental health stigma in Nigeria: Qualitative analysis. Transcultural Psychiatry, 60(2), 272–285. https://doi.org/10.1177/13634615211055007

Uwakwe, R., Udofia, O., Nwefoh, E., & Chukwujekwu, D. C. (2020). Mental health stigma among university health care students in Nigeria: A cross-sectional observational study. BMC Psychiatry, 20, 399. https://doi.org/10.1186/s12888-020-02798-2

World Health Organization. (2022). Mental health atlas 2020. WHO Press.