Narratives Against Stigma: The Walking Tour at a Neuropsychiatric Hospital with a Baseline Assessment of Public Attitudes and Stigma

To the Editor,

The term stigma refers to an “attribute that is deeply discrediting” and can be conceptualized as consisting of “problems of ignorance, prejudice and discrimination.”^1–3 Negative perceptions and attitudes toward persons with mental illness (PWMI) have been rooted in our communities since the Vedic ages, when mental illness was considered as an interface between man and the supernatural powers of nature. Till about the 17th century, abnormal behavior was believed to be an act of the “devil,” that is, “against God,” and PWMI were likely to be considered “evil” or described as “witches.” They were often placed in jails or “asylums.” These closed spaces physically separated the PWMI from the rest of the community. Although they aimed to possibly correct their condition, they became breeding grounds for human exploitation and mistreatment. Despite the scientific advancements in the late 19th century and considerate changes adapted into professional care for PWMI, images of past treatment methods, related attitudes, and discriminatory behaviors still seem to prevail in the minds of the public.^5–8

Interventions targeted to address such stigmatic beliefs thus need to be an essential part of efforts to bridge the existing treatment gap in mental healthcare services. ⁹ Existing evidence reports that social contact plays an important role in reducing prejudice minimizing stigma and discrimination, among low and middle income countries.^8–10

This study, conducted at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India, talks about an innovative community-based public health initiative titled Stories against stigma: A walking tour of NIMHANS. It employed “in-person” social contact in combination with the educational strategy of stigma reduction by organizing a guided tour across different neuropsychiatric, educational and rehabilitation settings. It was a baseline assessment study conducted on the premises of the National Institute of Mental Health and Neuro Sciences, Bengaluru, India. Forty participants completed the initial assessment and the feedback form designed to assess the impact of the tour experience. Mass advertising of the event was done through the departmental social media platforms, and the institute’s website. A local radio channel was roped in as an organizing partner for the said event, and it was publicized in national newspapers and local dailies. The socio-demographic data sheet was used to collect the details of participants, and an initial assessment form comprising of ten items designed on a five-point Likert scale was administered to assess the participants’ level of awareness about mental illness, treatment, and services at the mental health institute before the tour. After the completion of the tour, a semi-structured feedback form was provided to assess the overall usefulness of the tour. The tour covered movement through different departments and facilities at the institute (Table S1) within 3 hours, involving a faculty member from each department/facility/center joining the group at a specific stop and time to explain the functioning, the research work conducted in their facility, and also to respond to any of the questions by participants. Ethical clearance was obtained from the Institute Ethics Committee.

The socio-demographic details of the participants suggested 60% of them were in the age group of 26–55 years, and the remaining 40% were below the age of 25. It showed almost equal participation among both genders (men [54.5%] and women [45.5%]). Graduates comprised 45.5% of the group, followed by postgraduates (36.4%), which indicated that the majority of the participants were well educated.

The initial assessment suggested that around 36.4% took part in the tour to know more about mental illness, about 27.3% were interested in knowing about NIMHANS, and the remaining 27.3% wanted to improve their knowledge about mental health.

The feedback form was designed to assess the impact of the tour experience and ask for suggestions that could be incorporated into future tours. The majority (79.4%) agreed that the tour was responsible for bringing about a positive shift in their attitude toward mental health and an appreciation for the opportunity to address various misconceptions about PWMI via direct interactions with professionals at every stop of the tour. The entire tour was covered well by various media houses.^11–13

Some of the limitations observed in the study were: the participants registered for the tour shared multiple commonalities in terms of their educational backgrounds and areas of residence, making our findings less generalizable. The tools used were not standardized, and the initial assessment and feedback designed for this tour were not tested for their reliability and validity.

The stigma attached to mental health institutions contributes to the increased treatment gap when it comes to mental illness in our country. Hence, it is necessary to deal with it by employing novel techniques. Walking tours such as this can be organized at various historical mental health establishments across the country to address the stigma attached to the institution, professionals, and PWMI.

The response to the tour showed that partnering with community members to enhance mental health literacy would be an effective way of combating stigma. Individuals who had a positive impact through this program are likely to take it forward to their respective communities, thus exponentially expanding the initial impact.

A walking tour is feasible in tertiary healthcare centers like NIMHANS, where a dedicated team of members could help organize visits to various facilities and engage in discussion with participants. This paper talks about the experiences of the first walking tour. However, this will be an ongoing initiative by the department, and more such tours will be conducted in the near future with a robust methodology and standardized tools, aimed at evaluating the expected change in stigma. More such efforts could be an important step towards improving mental health literacy and reducing stigma.

Supplemental Material

Supplemental material for this article is available online.