1 
 

 
 

Mental Health Literacy: Knowledge and beliefs about mental illness amongst 

indigenous African residents of Dihlabeng Local Municipality in the Free State 

 

By 

Nonhlanhla Faith-Crescentia Matsoele 

 

This dissertation (in article format) is submitted in accordance with the requirements for 

the degree 

 

MAGISTER ARTIUM 

(CLINICAL PSYCHOLOGY) 

 

in the 

 

FACULTY OF THE HUMANITIES 

 

DEPARTMENT OF PSYCHOLOGY 

 

at the 

 

UNIVERSITY OF THE FREE STATE 

 

Supervisor: Dr N.F Tadi 

 

Date of submission:  October 2022



i 
 

 

Declaration 

I, Nonhlanhla Faith-Crescentia Matsoele declare that this dissertation hereby submitted 

by me for the Magister Artium degree (Clinical Psychology) at the University of the 

Free State is my own independent work and has not previously been submitted by me to 

another university/faculty. I furthermore cede copyright of this dissertation in favour of 

the University of the Free State.  

      

__Nonhlanhla Matsoele___   __13.10.2022_______ 

Your Name      Date 

 

  



ii 
 

 

Acknowledgements 

I would like to convey my sincere thanks, appreciation and gratitude to the following 

people: 

I wish to extend my greatest gratitude to the One and Only Mighty God, Jesus Christ my 

Saviour. The one who started a good thing in me and has seen it through to completion. I 

would not be where I am without God. The Great I am. The one who has been sufficient 

and enough for me. Thank You Father. 

 

To each participant who took the time to respond to my survey. Without you, this project 

would not have been possible.  

 

To my two supervisors; Dr. Kometsi, thank you for the conception of the study as well as 

your support and belief in me. Dr. Tadi, thank you for giving me hope, for your guidance 

and consistency for the completion of this study. I appreciate both of you for providing 

me with the space to freely express my ideas and for pushing me towards academic 

excellence. Your dedication to this project kept me inspired and I appreciate your 

comprehensive and constructive feedback throughout the process. Being your supervisee 

has been both an honour and a privilege.  

 

To my mother Ntebaleng Crescentia Magau, thank you for encouraging me and for believing 

in my dreams throughout the years. I appreciate you for never giving up on me no matter the 

struggles. I am who I am and where I am now because of you. I know that you are proud to call 

me your daughter, just as I am proud to call you my mother. 

 

To my unborn child Kaelo, thank you for giving me a purpose that is greater than myself. You 

have been pushing me to keep going when I felt like giving up. You have helped me to believe 

in myself again, not only as a woman, or a mother, but as a psychologist as well.  

 

To my loving partner, close family and friends, thank you for your unending support and 

for believing in me. Because of each one of you, I was able to regain my strength every 

time the journey became difficult.   



iii 
 

 

TABLE OF CONTENTS 

Declaration            i 

Acknowledgements           ii 

Abstract            vi 

1. Introduction           1 

1.1. Research aim and objectives        3 

1.2. Rationale and contribution of the study      3 

2. Literature Review          4 

2.1. The prevalence of mental illness       4 

2.2. Factors that impact access to treatment of mental illness    5 

2.2.1. Lack of resources       5 

2.2.2. Lack of income/finances      6 

2.2.3. Stigma         7 

2.3. Mental health literacy        7 

2.3.1. The importance of mental health literacy     8 

2.3.2. Consequences of poor mental health literacy    10 

2.4. Culture and mental illness        12 

2.5. African worldview         12 

2.5.1. African conceptualisation of health and illness    13 

2.5.2. The African view of mental illness causation    14 

2.5.3. African treatment of mental illness      15 

3. Theoretical Framework         19 

3.1. Explanatory models of mental illness      19 

4. Research Methodology         22 

4.1. Research problem and objectives       22 

4.2. Research design and methodology       22 

4.3. Participants and sampling procedure       23 

4.4. Ethical considerations        24 

4.5. Characteristics of sample        25 

4.6. Measuring instrument        26 

4.7. Pilot study          28 

4.7.1. Pilot location and sample       28 

4.8. Statistical analysis         29 

4.8.1. Descriptive statistics        29 



iv 
 

 

4.8.2. Chi-square analysis        29 

5. Results           31 

5.1. Objective one          32 

5.2. Objective two          37 

5.3. Objective three         44 

6. Discussion           46 

6.1. Conceptualisation of mental illness       46 

6.2. Knowledge and beliefs about aetiology and treatment of mental illness  47 

6.3. Relationship between participants’ aetiological and treatment belief  49 

6.4. Limitations of the study        50 

7. Recommendations          53 

8. Conclusion           54 

References           55 

 

ADDENDUM 

Addendum A Questionnaire         72 

Addendum B Information leaflet and informed consent form     96 

Addendum C Ethics Clearance Certificate        102 

Addendum D Gatekeepers approval letter        103 

Addendum E Proof of language editing       106 

Addendum F   Turnitin Report        107 

 

 

LIST OF TABLES 

Table 1. Sample distribution according to gender, age group, marital status, educational 

level, religion, and home language      25 

Table 2. Reliability of Measuring Instrument      28 

Table 3.  Sample distribution according to gender, age group, marital status, educational 

level, religion, and language spoken at home      31 

Table 4. Categories used to conceptualise mental illness & examples of responses  32 

Table 5.  Percentage of participants conceptualisation of the disorder   33 

Table 6.  Examples used to conceptualize mental disorders     35 

Table 7.  Labels used for mental disorders       36 

Table 8.  Knowledge and beliefs about aetiology of mental disorders    37 



v 
 

 

Table 9.  Percentages of participants on knowledge and belief of aetiology of mental 

disorders          38 

Table 10.  Examples used to describe the knowledge and belief of aetiology of mental 

disorders           39 

Table 11.  Knowledge and beliefs about treatment of mental disorders    40 

Table 12.  Percentage of participants related to knowledge and belief of treatment of mental 

disorders           44 

Table 13.  Examples used to describe the knowledge and belief of treatment of mental 

disorders           43 

Table 14.  Relationship between aetiological and treatment beliefs for mental disorders  44 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



vi 
 

 

Abstract 

 

For many years mental illness has been on the rise globally, internationally and locally. 

This could be attributed to a lack of mental health literacy, which contributes significantly to 

the disease burden and leads to healthcare delays, poor adherence to treatment and patient 

'dropout' from healthcare services. This is true for many indigenous African societies who 

conceptualise mental illness based on their explanatory models of illness rather than according 

to western psychiatric nosology. While research seeks to explore and improve mental health 

literacy among the population, such studies remain limited in Africa. Therefore, this research 

study aimed to investigate mental health literacy among the indigenous African residents of 

Dihlabeng Local Municipality in the Free State. 

 

This study explored conceptions about three mental disorders, namely, depression, 

schizophrenia, and alcohol use disorder, as well as beliefs about their treatment. A quantitative 

design using a survey method was utilised, and a sample was drawn from two towns in 

Dihlabeng Local Municipality (Bethlehem and Fouriesburg). 240 indigenous Africans were 

recruited by the use of a randomised public recruitment strategy using a sample size calculator 

and they completed a self-administered questionnaire. Data were analysed using Statistical 

Package for Social Sciences (SPSS) for Windows, Version 28.0. 

 

In consolidating the findings of this study, the results revealed several explanatory 

models, which included western and traditional explanations. Most participants did not use 

scientifically approved terms to conceptualise mental disorders but phrases relative to their 

respective contexts. The bulk of the participants conceptualised disorders as psychological. The 

results also showed the orderly manner in which the community's conceptualisation of mental 

illness was categorised in terms of psychological, social, medical, traditional and religious 

concepts. The traditional conceptualisation provided an exciting finding for schizophrenia.  

 

In addition, perceptions of mental illness were significantly related to participants' 

treatment beliefs. In terms of treatment, more participants were inclined to seek professional 

help and have someone who would listen to/talk to/support them. Interestingly, participants 

who expressed belief in seeking professional help for mental illness also reported professional-

oriented (medical, social and psychological) causes of mental illness. In contrast, those who 



vii 
 

 

expressed beliefs in traditional forms of treatment for schizophrenia reported on traditional 

causes of mental illness.  

 

Lastly, the study also revealed a positive relationship between etiological and treatment 

beliefs for mental disorders among the participants, indicating a positive relationship between 

what participants believe to be the causes of mental illness. Their belief influences their 

preference of how best to treat mental illness. The outcomes of this study signify the importance 

of mental health literacy campaigns, a collaboration between traditional and medical 

practitioners, and increasing mental health services in communities. Further explorations of 

mental health literacy, specifically from an African indigenous perspective, are recommended 

for future research.  

 

Keywords: African worldview, mental health literacy, alcohol use disorder, depression, 

schizophrenia



1 
 

 

1. Introduction 

The prevalence of mental illness is increasing internationally (Polanczyk et al., 2015) and 

South Africa (Herman et al., 2009). According to the Global Burden of Disease Collaborative 

Network (2018), approximately 970 million people worldwide have a mental illness. The 

prevalence rate of mental disorders in South Africa was 12.78% in 2019 (Onuh et al., 2021), 

with a lifetime prevalence of common mental illness in South Africa being 30.3% (Bhana et 

al., 2019). In a 12-month survey of mental disorders in South Africa, the most common mental 

disorders were anxiety (15.8%), followed by substance use (13.3%) and mood disorders 

(9.8%). Neuropsychiatric disorders rank third in terms of their contribution to the burden of 

disease after human immunodeficiency virus/acquired immune deficiency syndrome 

(HIV/AIDS) and other infectious diseases (Jacob & Coetzee, 2018). 

 

Mental health refers to a state of well-being in which an individual recognises their abilities, 

can cope with the everyday stresses of life, work productively and contribute to their 

community (WHO, 2019). On the other hand, mental illness is a syndrome characterised by a 

clinically significant disturbance in a person's cognition, emotional regulation, or behaviour 

that reflects a dysfunction in the psychological, biological or developmental processes 

underlying psychological functioning (American Psychiatric Association [APA], 2013). 

However, Walker (2006) cautions that what may be dysfunctional to a particular group of 

people may be normal to others. Furthermore, their cultural worldviews influence people's 

conceptions of mental illness. Therefore, the cultural and developmental contexts of all health 

issues need to be considered before assigning the constructs of health or illness (Walker, 2006). 

 

According to Bhui and Bhugra (2007), culture is a way of life that includes the values, 

practises, customs and beliefs that form an intricate system. As such, culture encompasses all 

human-constructed ideas, including those of mental illness (Bhui & Bhugra, 2007). More 

specifically, indigenous beliefs about illness influence people's perceptions, experiences and 

ways of coping. Indigenous views play a fundamental role in conceptualising 

psychopathology's aetiology, presentation and treatment outcomes (Mosotho et al., 2011). 

Kometsi et al. (2020) stated that people are not ignorant of mental illness and conceptualise 

mental illness based on indigenous explanatory models informed by their worldview.  

 



2 
 

 

According to the Africentric worldview, individuals' perceptions of reality depend on their 

cultural beliefs, ideas, values, conceptions of time, and cause and effect (Thabede, 2008). 

Therefore, using the biomedical perspective alone is insufficient for clinicians to understand 

people's experiences of mental illness from their worldview, as this can determine individuals' 

behaviour, treatment and response to treatment, argues (Kometsi et al., 2020). According to 

Jorm (2012), improved mental health literacy can indicate the likelihood that individuals will 

access, understand and use the information to promote and maintain good mental health. 

 

The term mental health literacy was first coined by Jorm et al. (2005) and refers to the 

knowledge and beliefs about mental disorders that promote the prevention, recognition and 

treatment of disorders. According to Jorm et al. (2005), this knowledge and beliefs should 

include accurate and appropriate information about mental disorders, such as their aetiology, 

risk factors, recognition, conceptualisation, and methods of treatment and help. Evidence 

shows that most of the public does not correctly recognise the symptoms of mental illness 

(Altweck et al., 2015). Improved knowledge about mental health and awareness of how to seek 

help and treatment leads to the prevention of mental health problems. This can promote early 

detection of mental disorders, which improves mental health outcomes and increase the use of 

health services (Furnham & Swami, 2018). Kometsi et al. (2020) argue that inadequate mental 

health literacy is a serious barrier to care for patients with mental illness. 

 

Swartz and Kilian (2014) point out that the provision of mental health services remains 

inadequate, with only one in four people with a common mental disorder receiving treatment 

(Petersen et al., 2016). Apart from providing mental health services, Jorm (1997) argues that 

better mental health in the community depends on the mental health literacy of the population. 

According to Henderson et al. (2013), a lack of mental health literacy contributes significantly 

to developing countries' disease burden. In addition, inadequate mental health literacy can 

support negative beliefs and stigmatising attitudes towards mental illness (Chipps et al., 2015). 

According to Kutcher et al. (2016), this can lead to mental health patients delaying appropriate 

health care, poor adherence to treatment and dropout from services.  

 

While research continues to seek to explore and improve mental health literacy among the 

population, Atilola (2016) argues that such studies remain limited in Africa. Therefore, this 

research aims to contribute to South African mental health literacy studies. 

 



3 
 

 

1.1.Research aim and objectives 

The proposed study investigates mental health literacy among the indigenous African 

residents of Dihlabeng Local Municipality in the Free State. The following objectives are 

derived from the aims of this study.  

 

1. To investigate participants’ conceptualisation of mental illness. 

2. To investigate the participants' knowledge and beliefs about the aetiology and treatment 

of mental disorders.  

3. To investigate the relationship between aetiological and treatment beliefs. 

 

1.2.Rationale and contribution of the study 

This study will add value to research on mental health literacy among indigenous Africans, 

particularly regarding the conceptualisation of mental illness, knowledge, and beliefs about the 

aetiology and treatment of mental disorders, as well as the relationship between etiological and 

treatment beliefs. The study will further contribute to understanding the presentation of mental 

illness from indigenous South African's explanatory model of illness, an area of study in South 

Africa. It may contribute new insights into less explored areas of mental health literacy, 

particularly from an African perspective. 



4 
 

 

2. Literature Review 

2.1.The prevalence of mental illness 

Globally, mental illness is rising (Jacob & Coetzee, 2018). The World Health Organisation 

(WHO) estimates that in most countries, more than one-third of people meet the criteria for a 

mental illness during their lifetime (WHO, 2011). The Institute for Health Metrics and 

Evaluation (2018) reports that nearly 970 million people worldwide experience mental or 

behavioural disorders. Globally, 264 million people suffer from depression, 50 million from 

dementia, 45 million from bipolar disorder and 20 million from schizophrenia and psychosis 

(WHO, 2019). The prevalence of common mental disorders in developing countries was 

reported by Kutcher et al. (2016) to be similar to those in developed countries.  

 

In Africa, mental health difficulties appear to increase (WHO, 2018). Although between 

2000 and 2015, the African population spread by 49%, the years lost to disability as a product 

of mental and substance use disorders increased by 52%. In 2015, 17.9 million years were lost 

to ill health because of mental health struggles (Sankoh et al., 2018). Such illnesses were almost 

as significant a cause of years lost to disability as were infectious and parasitic diseases (WHO, 

2018). A community study from rural Uganda obtained the following statistics on prevalence: 

Depression 9.3%, Anxiety 8.5%, Bipolar disorder 4.9%, and Schizophrenia 1.5 %. In a study 

of the Kabarole district of Uganda, Kasoro and others discovered that 30.7% of adults had 

psychiatric illnesses (Abbo et al., 2009). In Ethiopia, schizophrenia and depression are rated as 

the top ten contributors to the disease burden (Abera et al., 2014). Nigeria has a global human 

rights crisis in mental health (Ugochukwu et al., 2020). Statistics suggest that roughly 80% of 

people with severe mental health needs do not receive care. This crisis is also seen in South 

Africa, which has more than twice the lifetime prevalence of mental and substance use 

disorders than in Nigeria (12.0%) (Jack et al., 2014). 

 

In 2018, data presented by the South African College of Applied Psychology proposed that 

one in six South Africans experiences depression, anxiety, or a substance use disorder, 40% of 

South Africans living with HIV develop a comorbid mental illness, 41% of pregnant women 

experience depression, approximately 60% of South Africans might be suffering from post-

traumatic stress, while only 27% of South Africans with severe mental disorders receive 

treatment. Despite the rates of mental disorders in South Africa, Mkhize and Kometsi (2008) 



5 
 

 

argue that society still lacks access to mental health services and inadequate mental health 

service provision (Swartz & Kilian, 2014). 

 

Africa has the highest number of low-and middle-income countries, and the disease burden 

of mental health disorders lies more heavily than in the rest of the world (De Kock & Pillay, 

2018). However, more than 85% of people experiencing mental health disorders do not receive 

treatment (De Kock & Pillay, 2018). The fact that only 27% of those with severe mental 

disorders receive treatment is a sign of how mental illness has been overlooked by the health 

system in South Africa (Nguse & Wassenaar, 2021). 

 

2.2.Factors that impact access to treatment of mental illness 

Despite various effective treatments worldwide, more than 70% of people with mental and 

behavioural disorders do not receive professional mental health treatment (Henderson et al., 

2013). Furthermore, approximately 76% of people with severe mental illness in low-income 

countries do not receive treatment for 12 months (Petersen et al., 2017). Therefore, it is 

essential to review factors that may impact access to treatment for those with mental illness to 

address the existing problems (Sarikhani et al., 2021). While there are numerous factors, those 

relevant to the scope of the current study are lack of resources, lack of income or finances, and 

stigma. 

 

2.2.1. Lack of resources  

According to Louw (2019), there is a lack of mental health professionals and training 

facilities for psychiatrists, clinical psychologists, psychiatric nurses, and occupational 

therapists in South Africa. Docrat et al. (2019) found that there is an average of 0.31 public 

psychiatrists per 100 000 uninsured population in the public sector, with the Western Cape 

reporting the highest availability of psychiatrists at 0.89 psychiatrists per 100 000 uninsured 

population and Mpumalanga reporting the lowest rate at 0.08 psychiatrists per 100 000 

uninsured population. Furthermore, there remains a critical shortage of child psychiatrists; only 

three of South Africa's nine provinces, Western Cape, Free State, and Gauteng, have child 

psychiatrists working in the public sector (Docrat et al., 2019). In addition, there were 0.97 

psychologists, senior clinical psychologists, and principal psychologists in the public sector per 

100 000 uninsured residents (Kim et al., 2020). The availability of medical support staff crucial 

to rehabilitative care and support services was also low: 1.53 occupational therapists in the 



6 
 

 

public sector, 1.07 speech therapists and audiologists in the public sector, and 1.83 social 

workers per 100 000 uninsured residents (Kim et al., 2020). Due to a lack of resources, the 

Department of Health is struggling with a shortage of treatment facilities to serve the mentally 

ill population (Louw, 2019).  

 

In addition, mental health services are scarce in rural areas of South Africa (Vergunst, 

2018). The inaccessibility of mental health specialists in various locations is a recurring barrier 

to accessing mental health services (Sarikhani et al., 2021). This situation was described as 

"dehumanising" in the 2015 South African Campaign for Rural Mental Health report 

(Vergunst. 2018). Evidence implies that only 27% of South Africans with severe mental 

disorders receive treatment (Nguse & Wassenaar, 2021). This may be due to the centralisation 

of mental health services in urban centres, specifically tertiary hospitals, resulting in rural 

communities being neglected (Petersen et al., 2012). 

 

In contrast to those with more rural districts, provinces with more urban districts have a 

high percentage of mental healthcare professionals working in the public sector (De Kock & 

Pillay, 2018). Geographic inequalities of this nature are continually reinforced and intensified 

by the movement of healthcare specialists, particularly from rural to urban centres. The 

geographical distribution of the healthcare workforce governs accessible services and their 

quantity and quality (Van Rensburg, 2016). People in need of healthcare are, of necessity, 

referred to the nearest city, which has a cost and transport implications.   

   

Many patients cannot afford to travel to access care due to their already existing burden of 

low socio-economic status (Syed et al., 2013). These imbalances contribute to problems of 

equity or efficiency and effectiveness of services, plus the satisfaction of users (Dussault & 

Franceschini, 2006). Therefore, the consequences of the lack of mental health facilities in terms 

of providing care for patients with mental health disorders in rural areas are extensive. The 

effects of a lack of mental health care are personal suffering, premature mortality, poor physical 

health, experiences of stigma and discrimination, poverty, and abuse (Abera et al., 2014). 

 

2.2.2. Lack of income/finances 

A correlation between poverty and mental health has been noted, with mental illness more 

prevalent among the poor (Mungai & Bayat, 2019). Due to the high unemployment rate, many 



7 
 

 

South African households rely solely on social grants as their only source of income (Ragie et 

al., 2020). Healthcare facilities are often out of reach for many patients who lack personal 

transportation or access to affordable public transportation (Syed et al., 2013). The facilities 

usually within reach include high consultation fees, making them inaccessible for most South 

Africans. The high transportation costs and the distances involved lead to patients presenting 

late with mental disease because they seek help from informal sources that are considered 

affordable (Syed et al., 2013). This theme supports the argument in the theory of planned 

behaviour that external control factors, such as finances, can impact professional help-seeking 

behaviour (Ajzen, 2020). Not only does the poverty increase the risk of mental illness, but it 

also includes a discriminatory factor that further increases the risk of stigmatising attitudes in 

communities due to the inaccessibility of treatment (Shrivastava et al., 2012). 

 

2.2.3. Stigma 

Thornicroft et al. (2007) argue that stigmatising people with mental disorders can result in 

a family's reluctance to take them for treatment at specialised mental health care facilities, 

fearing that they will be labelled negatively based on association. Stigmatising public attitudes 

negatively impacts the prevention, treatment, rehabilitation, and quality of life of those affected 

by mental disorders (Barke et al., 2011). Society and mental health professionals similarly 

stigmatize people with mental health disorders (Kaur et al., 2021). The most consistent 

stereotype expressed by health professionals was that of mentally ill patients presenting as 

aggressive, violent, dangerous, and lacking self-control (Shrivastava et al., 2012). In addition, 

some health professionals do not consider specific categories of mental illness, such as alcohol 

use disorder, anxiety, and depression, as psychiatric diagnoses because they are so common 

(Koschorke et al., 2021). Consistent with undermining certain mental illnesses, some 

professionals deem mental illness incurable (Koschorke et al., 2021). This is due to the belief 

that pharmacological treatment is ineffective as most patients are on lifelong treatment 

(Carvajal, 2022). Mohamed-Kaloo and Laher (2014) maintain that limited mental health 

literacy among health professionals perpetuates the stigmatisation of mentally ill patients in 

global communities. 

 

2.3.Mental health literacy  

Mental health literacy is the knowledge and beliefs about mental health disorders that can 

be applied to preventing, recognising, and treating mental disorders (Jorm et al., 1997). This 



8 
 

 

knowledge and belief should incorporate accurate and adequate information regarding mental 

disorders, such as their aetiology, risk factors, recognition, conceptualisation, treatment, and 

help-seeking methods. Mental health literacy also promotes early identification of mental 

disorders by presenting knowledge of signs and symptoms contributing to preventing mental 

health issues (Bonabi et al., 2016). In addition, understanding mental disorders increase 

awareness of how to seek help and treatment from health services (psychological and 

pharmacological) to maintain positive health (Brijnath et al., 2016). Finally, mental health 

literacy should be based on practical knowledge that can be effectively integrated into existing 

social and organisational structures, such as schools and community organizations (Kutcher et 

al., 2016). Therefore, mental health literacy is critical because it seeks to empower people to 

take appropriate action to maintain their mental health or assist others in need (Jorm & 

Kitchener, 2011). 

 

2.3.1. The importance of mental health literacy  

Jorm et al. (2005) indicate that higher levels of mental health literacy are associated with 

less stigma attached to mental illness or directed at those who are mentally ill. Mental health 

literacy can increase the public's confidence in their ability to recognise mental illness, seek 

professional help, and assist other people with mental health problems (Hagen et al., 2020). A 

high level of mental health literacy can significantly contribute to closing the mental health 

treatment gap (Weiss et al., 2005).  

 

Mental health literacy could have a positive impact on policy creation. An example of the 

desired impact has occurred in Australia's National Mental Health Plan, which now includes 

the Key Action of "Work with schools, workplaces, and communities to deliver programs to 

improve mental health literacy" (Jorm, 2015). Mental health literacy also features in plans for 

other jurisdictions (BC Mental Health and Substance Use Services, 2013; Queensland 

Government, 2008). The Australian government has also supported the national monitoring of 

mental health literacy with subsequent surveys in 2011. This monitoring, provided since 1995, 

has demonstrated substantial improvements in the population's mental health literacy, and 

considerably reduced gaps between public and professional views (Reavley & Jorm, 2011). 

This may be beneficial in the South African context. Implementation of adequate monitoring 

could reduce the rates of mental illness, and increased mental health literacy could ensure that 



9 
 

 

individuals have access to, understand, and use information in ways that promote and maintain 

good mental health (Jorm, 2000). 

 

In addition, mental health literacy is a necessary foundation for mental health promotion 

and interventions (Bjørnsen et al., 2017). Exposing people to effective mental health literacy 

programs can be a fundamental first step in addressing various mental health-related 

interventions (Mcluckie et al., 2014). From a public health perspective, interventions that 

prevent mental disorders and promote mental well-being are essential for reducing mental 

disorders' health and social and economic burden (Arango et al., 2018). An ideal setting for 

interventions would be schools because most children and young people spend a large amount 

of their time at school, and school staff is often the first connection for children and young 

people seeking help for mental health concerns (Abdinasir, 2019). Schools can also reach 

people in communities with marginalised groups who experience higher rates of mental 

disorders (McGinnity et al., 2005) and improve the overall accessibility of mental health 

services (Thorley, 2016). 

 

An example would be Mental Health First Aid, a training intervention modelled on physical 

first aid training designed to increase the public's mental health literacy. Numerous evaluation 

studies have proven that the program improves mental health literacy (Jorm & Kitchener, 

2011). In addition, the program has been successful in its rollout, with over 1% of the 

Australian adult population trained, and the program has spread to over 20 other countries 

(Jorm & Kitchener, 2011).  

 

Mental health literacy can also tailor measures to meet intervention aims (Nobre et al., 

2021). This creates domain-specific assessments, which are critical in evaluating interventions 

(Simkiss et al., 2020). When an intervention is developed to improve some aspect of mental 

health literacy, it needs to be evaluated with measures relevant to the intervention's specific 

aims. A generic measure of health literacy will generally not meet this requirement (Simkiss et 

al., 2020).  

 

Overall, improved mental health literacy contributes to a better quality of life (Nobre et al., 

2021). This is especially true if acquired at a young age, as it has a direct and positive impact 

on adult life. It enables people to acquire knowledge and define the attitudes and behaviors that 

will accompany them throughout their lives (Simkiss et al., 2020). Specifically, it provides 



10 
 

 

individuals with the ability to positively manage their thoughts and emotions to build healthy 

social and family relationships, all based on a strong, positive sense of identity. Therefore, a 

good level of mental health literacy is essential to ensure that individuals will be supported to 

develop a healthy life (Nobre et al., 2021).  

 

2.3.2. Consequences of poor mental health literacy 

Lack of mental health literacy poses challenges to the provision of care to patients (Ganasen 

et al., 2008). According to Henderson et al. (2013), a lack of mental health literacy is a 

significant cause of disease burden in most countries. Failure to recognise mental illness in 

oneself, or others, may result in delayed or inappropriate help-seeking (Cotton et al., 2006). 

The results of a lack of knowledge are that seeking mental health professional services is 

delayed, usually, until significant impairment or severe clinical symptoms are experienced; 

regrettably, managing the condition is difficult and costly. Early detection is essential in 

financial oversight; preventing severe symptoms reduces medical costs for patients and health 

facilities. Once the condition escalates, and this holds for all chronic conditions, medical 

intervention is costly. The benefits of early detection are delivering adequate treatment, care 

and support while avoiding admission to tertiary care institutions (Henderson et al., 2013). This 

is particularly true in developing countries with grossly inadequate mental healthcare services 

and a lack of health promotion and prevention of ill health (Ganasen et al., 2008). The 

inadequate mental healthcare services have led to the use of several mechanisms to compensate 

for mental illness services, which include information that is often misleading (Choudhry et 

al., 2016).  

 

Poor mental health literacy incorporates poor knowledge about using mental health services 

(Hernan et al., 2010). This could be due to the lack of knowledge concerning the role of 

psychologists and psychiatrists in mental health care which might increase doubt about the 

effectiveness of professional help, leading to a preference for informal support (Yap et al., 

2011). Lack of knowledge also contributes to patients' resistance to attending mental health 

appointments and adherence to recommended illness management. Such patients are more 

inclined to discuss mental health difficulties with family members and friends rather than with 

professionals (Wilson & Deane, 2012). Due to this, appropriate professional help is not sought 

by people with mental illness (Jorm et al., 2005).  

 



11 
 

 

In addition, poor mental health literacy in people leads to inappropriate help-seeking 

behaviour (Angermeyer & Matschinger, 2005). Research indicates that most mental health 

patients' initial consult is with either general medical practitioners or complementary-

alternative medical providers (Kometsi, 2016). A significant problem with this model is the 

tendency of general practitioners in public or private care settings to underdiagnose mental 

conditions, resulting in delays in patients consulting with mental healthcare professionals 

(Seedat et al., 2009). Due to this, people with mental illness receive limited information 

resulting in inappropriate interventions for dealing with mental illness.  

 

Another growing trend in mental health treatment is for people to use self-help resources 

(Naslund et al., 2020). However, psychologists have reported self-help interventions in a study 

by Papworth (2015) to be harmful to patients. In addition, Firth et al. (2019) reported the use 

of dietary supplements like vitamins and minerals to treat mental illnesses from self-help 

interventions, even though their role in clinical care is highly controversial. Such findings are 

a concern because mental health literacy influences numerous aspects of the help-seeking 

process, such as attitudes toward mental health practitioners, stigma, treatment knowledge and 

choice, and compliance (Furnham & Swami, 2018).  

 

Poor mental health literacy contributes to widespread stereotypes and prejudice against 

patients with mental illness (Shah et al., 2022), leading to a perception of people with mental 

illness as dangerous, incompetent, unpredictable, and to blame for their illness (Marie & Miles, 

2008). Discrimination, as described above, poses a significant barrier to mentally ill patients 

accessing treatment (Phelan & Link, 2004). Specifically, 'if an individual has little capacity to 

recognise symptoms or has a negative view of mental health problems and mental health 

services, they are unlikely to refer themselves to a mental health service if they develop a 

mental health problem' (Choudhry et al., 2016). To remedy the situation, WHO (2019) 

recommends that community awareness interventions can reduce the stigma and discrimination 

faced by people with mental disorders. It is thought that improved public mental health literacy 

would presumably lessen stigmatisation and encourage the use of currently available and 

effective interventions (Hugo et al., 2003). 

 

 

 

 



12 
 

 

2.4.Culture and mental illness 

Cultural constructions of mental illness influence people's perceptions, experiences, and 

coping skills (Gopalkrishnan, 2018) and the boundaries between normality and pathology 

differ across cultures for certain behaviors (APA, 2013). Deciding that a particular behaviour 

is atypical and requires clinical care depends on cultural norms adopted by the individual and 

employed in their environment (Altweck et al., 2015). Swidler (1986) argues that culture offers 

an interpretive framework that outlines the experience and manifestation of symptoms, signs, 

and behaviours, which are crucial in diagnosing mental and behavioural problems. Due to 

cultural specificities, many mental illnesses are expressed in diverse ways (Gopalkrishnan, 

2018).  

 

For instance, particular symptoms such as hallucinations and delusions have distinctive 

meanings in various cultures. Similarly, depression in some cultures is not necessarily 

expressed in the mood but somatic symptoms (Mosotho et al., 2008). From a Western 

perspective, depression can also be viewed as a dysfunction in a person's physical or 

psychological structures. On the other hand, in several sub-Saharan African societies, the 

conceptualisation of depression also considers cultural, spiritual, and social factors (Sodi, 

2009). Interestingly, specific symptoms and syndromes may not be present in some cultures, 

according to Gopalkrishnan (2018), and their intensity varies (Mosotho et al., 2008). This is 

possible because culture performs a valuable and vital role in the inclusive development and 

manifestation of behaviour (Mosotho et al., 2011). 

 

Specific culturally determined presentations are difficult to explain with standard 

diagnostic terminology (Janse van Rensburg, 2009). In such contexts, mental health 

professionals must deliberate whether a person's experiences, symptoms, and behaviours 

deviate from sociocultural norms and advance into difficulties linked to adapting within their 

culture of origin and specific social contexts (APA, 2013). Due to the emphasis on context, it 

can be concluded that mental illness is relative and depends on the individual's worldview 

(Opare-Henaku & Utsey, 2017). 

 

2.5.African worldview 

The conceptualisation of mental illness depends on the individual's worldview (Opare-

Henaku & Utsey, 2017). Barker (1999) defines worldview as how people understand their 



13 
 

 

relationship with societal institutions: spirituality, nature, other people and objects. The 

Africentric worldview states that how a person sees reality depends on cultural ideals, beliefs, 

conceptions of time, values and cause and effect (Thabede, 2008). As much as Africans share 

commonalities in culture, it is significant to mention that not every African sees the world 

according to a single African worldview (Kometsi, 2016). It is evident that African culture is 

not homogeneous (Gopalkrishnan, 2018).  

 

Contact with multiple worldviews entails that there cannot be a simple one-to-one 

correspondence between a meaning system and its application in real life (Sodi, 1998). 

Therefore, it is anticipated that various African cultures will have distinct ideas about the 

causation and treatment of disease and that there will be alterations in how the disease is 

conceptualised and treated (Honwana, 1998). Thabede (2008) contends that each culture has 

its own theoretical or explanatory model for health and illness. It also assumes that visible and 

invisible worlds are intimately connected and influence each other (Nwoye, 2015). This reflects 

the principle of cosmic unity, meaning that everything is constantly in motion and influences 

the other (Chuwa, 2014).  

 

According to Maffi (1998), indigenous societies do not see the world as cause and effect 

mechanically. Instead, they take a holistic view of the world in which the units of analysis are 

not removed from their context (Nwoye, 2015). In this holistic conception of life, the central 

tenets are belief in God, the universe, and notions of causality, person, and time from a 

traditional African perspective (Mbiti, 1969). Traditional African societies, for example, 

believe that there should be harmony and interdependence between the elements of the cosmos. 

  

2.5.1. African conceptualization of health and illness 

African conceptions of health and disease are embedded in the African worldview 

(Bojuwoye & Moletsane-Kekae, 2018). For Africans, good health entails mental, physical, 

spiritual, and emotional stability for themselves, family members, and the community. This 

integrated outlook of health is grounded on the unified African view of reality (Mokgobi, 

2014), which is consistent with the World Health Organization (WHO) perspective that views 

health holistically (WHO, 2019). According to Swartz & Kilian (2014), ethnic African 

communities in South Africa view coherence between individuals and ancestors as significant 

to sustaining sound mental health. This harmony exists when the individual and their family 



14 
 

 

have fulfilled their socio-spiritual commitments to their ancestors. Certain mental disorders are 

believed to arise when this balanced relationship between the ancestors and those living is 

disrupted (Sodi & Bojuwoye, 2011). For illnesses resulting from disharmony, treatment by a 

traditional healer aims to restore the equilibrium between one's family and ancestors (Sodi & 

Bojuwoye, 2011). Severe mental illness is regarded as metacommunication to be "read" and 

deduced rather than categorised or classified, as underlined in the Western Diagnostic and 

Statistical Manual of Mental Disorders 5 (Nwoye, 2015). By identifying such illnesses as 

"symbolic illnesses" or representations with hidden connotations, indigenous African seniors 

recognise that they should go beyond the surface expressions of illness to discover "who" is 

communicating through such illnesses and what these actors aim to convey (Nwoye, 2015). By 

discovering who or what is behind the hidden meanings of mental illness, African elders can 

be guided to the root cause of the illness, eventually leading to proper treatment (Sodi, 1998). 

 

2.5.2. The African view of mental illness causation  

Africans view the cause of mental illness based on their worldview (Chong et al., 2016), 

thus leading to many causal attributions (Picco et al., 2016). Mabvurira (2016) stated that 

indigenous Africans were more likely to attribute the root of mental illnesses to external 

influences such as possession by ancestral spirits, life stressors, generational curses, witchcraft, 

and religion. It is believed that the basis of ancestral spirit possession is that individuals do not 

honour their ancestral spirits by following specific rules and rituals (Mabvurira, 2016). This is 

corroborated by Sodi (1998), who reports that ancestors, when angered, can inflict illness and 

bad luck on their living relatives. The ancestors can also cause disease in an individual they 

want to make a diviner. Such a disease is called ukuhlanya. Another observation from the study 

findings is that stressful situations are also responsible for causing mental illness (Moelsae et 

al., 2012). This observation is confirmed by Sorsdahl et al. (2010), who identify psychosocial 

factors, especially stress, as the leading cause of mental disorders. Sorcery, or 'Ubuthakathi' 

referred to as witchcraft, is also considered a common cause of the disease (Petrus, 2009). It is 

considered to be performed by anyone and utilised when an individual has a grudge against 

another. In the Northern Sesotho culture, it is also believed that the transgression of diseases 

or senyama can cause mental illness. This is considered to be instigated by someone evil who 

locates a disease in the victim's path in the form of medicine (Sodi, 1998). Opare-Henaku and 

Utsey's (2017) study showed that many individuals considered their illness based on the 

premise that everything happens for a reason or purpose and that nothing happens by chance. 



15 
 

 

Such views imply that people with mental illness deserve their fate in some way, which has 

significant implications for people's use of medical care. An example in the Zulu culture in 

South Africa is a group of diseases such as umkhuhlane, diseases that 'just happen' (Ngubane, 

1977). 

 

These observations imply that the Africentric paradigm, in contrast to the Eurocentric 

perspective, recognises the likelihood that the basis of psychopathology is not merely in the 

infirmity of the body, mind or social setting, as emphasised in the west (Engel, 1977), but is 

sometimes rooted in the spiritual or ancestral upbringing of the individual exhibiting the illness 

(Engel, 1977). This is because, in the Africa-centered paradigm of mental illness, the 

unhappiness can be located past the visible-to the invisible world of ancestors, the concept 

being to find the cause of the crisis and seek treatment at the source of origin (Mkhize, 2003). 

 

2.5.3. African treatment of mental illness 

Tangwa (2007) confirms that many South Africans see traditional medicine as more 

attractive than mainstream medicine. It has established itself as an accessible and affordable 

means of health care. In addition, it is valued as sensitive to psychological, environmental, and 

spiritual influences (Pretorious, 2004). According to Stott & Brown (1973), the African 

medicine man is seen as one who honors, appeases, or exorcises evil. His treatment is often 

obtained from dreams, and his diagnostic abilities are attributed to psychic powers bestowed 

by ancestral spirits. Shai-Mahoko (1996) concluded that indigenous healers prevent certain 

diseases that the Western-trained health personnel cannot treat; they prevent social conflict by 

performing ritual cleansing and fortifying homesteads; and they repair social relationships by 

performing sacrificial rites to ancestors (Moagi, 2009).  

 

Indigenous Africans are more prone to consulting traditional healers for mental health 

issues than other ethnicities (Chipps et al., 2015). Moagi (2009) classifies a traditional healer 

in the South African setting as an individual who has the gift of obtaining spiritual counsel 

from the ancestors. Occasionally, such a person is chosen by ancestors from a chronological 

family background with a solid ancestral lineage. The Traditional Health Practitioners' Act 

Number 22 of 2007 regulates the happenings of traditional healers in South Africa. It designates 

that traditional healing involves the practice of a function, service, activity, or process that is 

grounded on traditional philosophy and involves the use of traditional medicine (Government 



16 
 

 

Gazette, 2008). South African patients can seek out four categories of traditional healers. These 

include (Setswe, 1999; Truter, 2007): 

 The traditional doctor –inyanga, focus on the use of herbal remedies,  

 The diviner–isangoma, either choose to become fortune teller or is chosen by the 

ancestors.  

 The faith healers – umprofiti or umthandazi, diagnosis is made primarily through 

communication with God and 

 traditional birth attendants. 

Mashamba (2007) notes that dreams, ancestors, and throwing bones are essential in diagnosing 

disease because this study focuses on the applicability of indigenous African practices to 

treating mental illness. Therefore, only the roles of the diviner and the faith healer are discussed 

here. 

 

The diviner  

In most societies in indigenous Africa, the diviner is the competent intermediary (Sodi, 

1998). Divination involves consulting the spirit world (Ezekwesili-Ofili & Okaka, 2019). It is 

a process of obtaining information about a person or a disease state using randomly assembled 

symbols to attain healing knowledge (Ezekwesili-Ofili & Okaka, 2019). It is a transpersonal 

practice in which diviners center their wisdom on communication with spiritual forces such as 

spirits, deities, and ancestors (Olupona, 2004). The "spirit world" is consulted to determine the 

cause and treatment of the illness or to find out if the sick person has violated an established 

order (Ezekwesili-Ofili & Okaka, 2019). This is done by throwing bones, shells, money, dice, 

and other items determined by the diviner and the spirit to embody certain polarities on leather, 

animal skin, or pieces of wood (Omonzejele, 2008). The divining bones, which comprise most 

objects, consist of bones of animals such as lions, hyenas, goats, baboons, crocodiles and 

antelopes. The bones represent all the forces that affect humans, regardless of their culture 

(Cumes, 2014). Because of the enlightening powers of divination, it is generally the first step 

in traditional African treatment (Omonzejele, 2008). 

 

The treatment can also take other forms depending on the information obtained and 

may be used for spiritual protection when the cause of the illness is perceived as an attack by 

evil spirits (Ezekwesili-Ofili & Okaka, 2019). The ill person would be protected by a talisman, 



17 
 

 

amulets, specially designed body signs, or a spiritual bath to drive away the evil spirits 

(Westerlund, 2006). Diviners may also offer sacrifices at the request of the ancestors and spirits 

(Olupona, 2004). These sacrifices would be in the form of slaughtering certain animals with 

the certainty that their spirits are effective to replace life (Olupona, 2004). Sacrifices can also 

appease spirits, ancestors, or the gods if a disease is perceived to be caused by an invocation of 

a curse or violation of taboos (Idowu, 1973). 

 

The Faith-healer 

Communities in South Africa believe that faith healers are led by both the ancestors 

and by God-sent messages (Zuma et al., 2016). Those who are ill consult faith healers for 

treatment to reveal what is hidden in the messages of their illness and what treatment can be 

applied. Faith healers heal through prayer (Adjaye, 2001). Not only is prayer used as a tool to 

investigate the cause but also to intervene in the healing of the individual with the illness. Other 

main methods of treatment include the use of water and minerals such as ash and salt (Zuma et 

al., 2016). The most common treatment for the mentally ill is exorcism, where the healer expels 

evil spirits from people and places (Pfeifer, 1994). Exorcism can only be performed by a faith 

healer who is a religious leader and has the authority to do so. This practice may be 

accompanied by dancing to the beating of drums, singing, and at times flogging the individual 

or touching them with objects, such as animal tails, amongst others, to chase out the spirit 

(Adjaye, 2001).  

 

In the South African context, it is essential to note that some patients, their families, 

and traditional healers consider biomedical interventions necessary to treat the symptoms of 

diseases attributed to bewitchment (Mokgobi, 2014). Some, therefore, recognise psychiatric 

assessments, hospitalisation, and medication as an effective way of treating psychotic 

symptoms believed to be caused by witchcraft. However, it is essential to recognise that 

although these sources are found to be helpful, they are not necessarily the first line of 

treatment. Instead, the help of a psychiatrist or psychologist may be the last option after talking 

to family and friends or seeing a doctor or GP (Rinne, 2001).  

 

Traditional healers provide culturally appropriate health care that is linked to the 

explanatory models of indigenous South Africans (Campbell-Hall et al., 2010). Considering 

that Africans have their way of understanding their universe and illness, it is vital to examine 

how they conceptualise mental illness, precisely the level of their mental health literacy. 



18 
 

 

Therefore, this study aims to examine the conceptualisation of mental illness among a group 

of indigenous Africans in the Dihlabeng Municipality area of the Free State.  



19 
 

 

3. Theoretical Framework 

3.1.Explanatory models of mental illness 

Many African indigenous societies conceptualise mental illness based on their own 

explanatory models of illness rather than according to Western psychiatric nosology 

(Herselman, 2004; Nwoye, 2006). Explanatory models were developed by Kleinman (1978) 

out of a critique of western diagnostic categories, which he called 'category fallacy'. 

Explanatory models of mental illness refer to how people think about mental illness and include 

the origin of the illness, the onset, severity and prognosis of the illness, the type of treatment 

and the treatment provider needed (Kleinman, 1978). These models arise when people ask 

themselves questions such as: What is the nature of the problem, why has it affected me, why 

now, what will happen next? The system thus functions as a product of how people, in tune 

with different social and cultural contexts, understand, label, explain and treat illness 

(Kleinman, 2013). This shows that explanatory models of illness generally help people to deal 

with, and make sense of, an illness as a social construct of reality (Fox et al., 2005).  

 

Kleinman found that patients understand and explain their illnesses using conceptual 

models different from their doctors (Rich et al., 2002). Therefore, disease explanations that are 

not consistent with a preferred explanatory model may not be explored, may seem implausible 

and could be considered less satisfactory than those consistent with the preferred explanatory 

model (Lynch & Medin, 2006). Consequently, it is crucial to elicit specific explanatory models, 

especially when the patient and doctor have different cultural roots. In addition, this could 

encourage physicians to be more open to communication and place their expertise alongside 

the patient's explanations and perspectives (Kleinman & Benson, 2006).  

 

Explanatory models serve as a means to bridge cultural differences between patients and 

doctors (psychiatrists) from different backgrounds, as well as to bridge conceptual gaps and 

generate empathy and a therapeutic connection (Weiss & Somma, 2007). Culture affects how 

clinicians and patients display and understand different types of distress (Bhugra & Gupta, 

2010). This is particularly true in South Africa, where patients come from a variety of cultural 

backgrounds. In addition, individual, family and community perceptions of mental illness may 

differ from those of professionals trained in western biomedical concepts (Opare-Henaku & 

Utsey, 2017). Therefore, using a biomedical perspective alone for clinicians in Africa is 



20 
 

 

insufficient to understand people's experiences of mental illness from their worldview, which 

may influence the patients' behaviour, treatment and response to therapy (Kometsi et al., 2020).  

 

Each patient must be thoroughly aware of their perspective, health beliefs, fears and 

treatment expectations (Nambi et al., 2002). This would mean describing the many causal 

attributions for mental illness that exist in different ethnic groups (Nambi et al., 2002). 

Kleinman (1980) suggested using a mini-ethnography to explore individual questions such as 

"Why me?", "Why now?", "What is going on?" and "Who can intervene or treat the illness?" 

are crucial for treatment. According to Rich et al. (2002), the core idea is that the illness can be 

treated more successfully if the clinician understands what illness means to the patient and the 

tacit beliefs and assumptions the patient brings to clinical treatment. This highlights the 

importance of explanatory models serving as a link between what patients believe about their 

illness and what is considered appropriate and suitable treatment (Laws, 2016). Failure to do 

so may result in patients rejecting help from mental health professionals or failing to comply 

with treatment (Jorm et al., 1997). The explanatory model of illness is also an essential aspect 

of mental health literacy for both professionals and the public (Malla et al., 2015).  

 

Mental health literacy is a relative concept influenced by conceptions of illness, such as the 

explanatory models of patients and healers or professionals (Bhugra & Gupta, 2010). It can be 

assumed that many indigenous Africans lack understanding and awareness of mental health 

problems because their worldview influences their conception of illness (Kometsi et al., 2020). 

According to Atilola (2016), these views assume that a lack of mental health literacy, or worse, 

ignorance, is associated with a mismatch in the biomedical understanding of mental illness. 

Assumptions about a lack of mental health literacy ignore that clinical phenomena are socially 

produced and that different civilisations derive their knowledge from different worldviews 

(Kleinman, 1980). This affects the explanatory models of disease (Kometsi et al., 2020). A 

culturally sensitive approach to treatment that focuses on exploring explanatory models during 

assessment and treatment is an effective way to deal with the complexity of patient and family 

needs by placing culture and narratives at the centre of care. This could be used to enhance 

community mental health programmes, improve service delivery, educate the public and 

ultimately improve the quality of life for people with mental illness (Arthur & Whitley, 2015).  

 

In summary, understanding the public's explanatory models of mental health literacy can 

help achieve better mental health outcomes. According to Kometsi et al. (2020), exploring each 



21 
 

 

patient's explanatory model would be helpful as it may lead to developing culturally appropriate 

treatment plans that address patients' concerns and priorities in the cultural context of their 

daily lives. Apart from these clinical benefits, increased awareness of explanatory models 

related to mental health literacy could positively impact mental health decision-makers, 

training health professionals and public education campaigns (Wei et al., 2015). 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



22 
 

 

4. Research Methodology 

4.1.Research problem and objectives 

The study aims to investigate mental health literacy among the indigenous African residents 

of Dihlabeng Local Municipality in the Free State. The following objectives were derived from 

the aims of this study.  

 

Research Objective 1 

 To investigate participants’ conceptualisation of mental illness. 

 

Research Objective 2 

 To investigate the participants' knowledge and beliefs about the aetiology and treatment 

of mental illness.  

 

Research Objective 3 

 To investigate the relationship between participants' etiological and treatment beliefs.  

 

4.2.Research design and methodology 

A quantitative approach was used to achieve the objectives of this study. A quantitative 

approach uses numerical data collected and analysed using statistical methods (Apuke, 2017). 

Quantitative studies emphasise the measurement and analysis of relationships between 

variables (Yilmaz, 2013). An advantage of the quantitative approach is its usefulness in 

studying many individuals, its relatively time-saving data analysis using statistical software, 

and its relatively rapid data collection (Eyisi, 2016). This quantitative-based study was 

conducted in the form of a survey. A survey is a structured series of questions or statements 

asked of a group of people to measure their attitudes, beliefs, values, or action tendencies 

(Goodwin, 2005). For this study, a survey design was considered because it is flexible and best 

suited to explore people's opinions, attitudes, beliefs, and values at a given point in time 

regarding a wide range of topics (Ponto, 2015). In addition, survey research is best suited when 

the researcher wants to gain a representative picture of the attitudes and characteristics of a 

large group (Nardi, 2018).  

 

In addition to the current study being a quantitative survey approach and cross-sectional 

design, correlational design was also used. Correlational research describes the intensity and 



23 
 

 

direction of the relationship between two or more variables (Rindfleisch et al., 2008; Stangor, 

2014). Yilmaz (2013) supports this idea by stating that the essence of quantitative research is 

the study of relationships between variables. Therefore, correlational design was used to 

determine if any relationship exists and the strength and direction of the relationship between 

variables (Yilmaz, 2013). In addition, this study also employed a cross-sectional design 

because data were collected at one point in time (Muijs, 2004), and no follow-up surveys were 

conducted (Bryman, 2012). Cross-sectional studies are also helpful for public health planning, 

understanding disease aetiology, and hypothesis generation (Mamady, 2016).  

 

4.3.Participants and sampling procedure 

The study was conducted in the Free State province in South Africa, Thabo Mofutsanyana 

District Municipality, and the sample was drawn from two towns, Bethlehem and Fouriesburg. 

In order to recruit a sample size of 240 participants, a randomised public recruitment strategy 

was adopted using a sample size calculator. Data were collected in November 2021. 

Participants in this study were randomly recruited in public places with large numbers of 

people, such as taxi or bus stations, on township streets, and sometimes in their homes. Only 

indigenous African participants over 18 were included in this study. No participants were 

excluded based on their education level, gender, financial situation, or marital status. 

Participants were recruited using probability sampling, known as multistage cluster sampling, 

followed by simple random sampling using a computer programme called a randomiser 

(Saghaei, 2004). For example, the randomiser generated sets of random numbers to select 

participants. Some individuals were skipped to select the next participant based on the 

following random number. On each day of data collection, a randomiser was calculated to 

generate six new sets of ten unique integers each, with each integer having a value between 

one and five. According to Adwok (2015), in probability sampling, each member of the target 

population has a known chance of being included in the sample. This increases the likelihood 

that the sample is representative of the population and the possibility of drawing inferences 

about the population from the sample (Stangor, 2014).  

 

Before completing the questionnaire, a fact sheet outlining the aim of the study and an 

informed consent form were discussed with potential participants. Each participant was 

randomly given a questionnaire representing only one of the three vignettes for depression, 

schizophrenia, or alcohol use disorder. The participants read and completed these 

questionnaires with support from the research assistants. 



24 
 

 

4.4.Ethical considerations  

Permission to conduct this study was obtained from the Research Ethics Committee of the 

Faculty of the Humanities at Free State University and the Dihlabeng Local Municipality. The 

university granted ethics clearance: UFS -HSD2020/0391/21, and the Dihlabeng Municipality 

provided written permission. Participants signed informed consent forms. Information leaflets 

explaining the study, including risks and voluntariness, were distributed to all participants so 

they could give and sign their consent to participate. They also had the opportunity to ask 

questions or withdraw from the study at any time. 

 

Under the Health Professions Act (1974), researchers must protect confidential information 

obtained during the research. Participants were informed that all identifiable information would 

be kept strictly confidential and that the only individuals/organisations in possession of the data 

would be the researcher, the research director, and the University of the Free State. In addition, 

only the final results of the study will be published. The results will be made available to the 

participants upon their request. In addition, the anonymity of the participants was maintained 

by ensuring that no personal information, such as their first and last names, was provided on 

the questionnaires. This ensured that participants were as honest and protected from bias. 

Questionnaires were provided to participants and completed in either English or Sesotho, 

depending on which language participants preferred.  

 

It took about 40 minutes to complete the questionnaires. The researcher and research 

assistants were available to answer and clarify participants' questions. The ethical principle of 

justice refers to participants' fair, objective and unbiased treatment (Allan, 2015). This was 

achieved by ensuring participants' anonymity throughout the process and ensuring that the 

information they provided could not be traced back to the participants. Another ethical 

principle followed in this study was nonmaleficence, which means avoiding harming the 

participants (HPCSA, 2016). The study was structured so that no physical, social, 

psychological or economic harm was caused. However, participants were informed that if they 

felt harmed, they could be referred to the nearest clinic or counselling centre offering 

psychological services. 

 

 

 

 



25 
 

 

4.5. Characteristics of sample 

The biographical variables in the study were gender, age group, level of education, marital 

status, religion, and language spoken at home. A nominal scale was utilised to measure all the 

biographical variables. Data on the distribution of the 240 participants concerning the six 

biographical variables were calculated using the SPSS version 28.0 computer software and are 

presented in Table 1 (below). 

 

Table 1 

Sample distribution according to gender, age group, marital status, educational level, 

religion, and home language 

Demographics N % 

Gender   

Male 118 49.2 

Female 122 50.8 

Age group   

18-34 158 65.8 

35-49 54 22.5 

50-64 23 9.6 

65+ 5 2.1 

Marital status   

Single 139 57.9 

Married 38 15.8 

Separated/Divorced 14 5.8 

Widowed 19 7.9 

Living with a partner 30 12.5 

Educational level   

Never went to school 8 3.3 

Primary 23 9.6 

Secondary 85 35.4 

Tertiary 124 51.7 

 

Religion   



26 
 

 

Atheist 6 2.5 

Christian 164 68.3 

Jehovah’s Witness 12 5.0 

African religion 42 17.5 

Hindu 1 0.4 

Non-Religious 12 5.0 

Other 1 0.4 

Not indicated 2 0.8 

Language spoken at home   

Afrikaans 1 0.4 

isiZulu 30 12.5 

Sepedi 4 1.7 

Swati 1 0.4 

English 2 0.8 

Sesotho 200 83.3 

isiXhosa 2 0.8 

Total 240 100 

 

Of the total group, 50.8% were females, while 49.2% were male. Concerning age, most 

participants were between 18-34, with 65.8%. Regarding marital status, the majority were 

single, at 57.9%. Furthermore, the majority of the population's educational level was tertiary, 

at 51.7%. In addition, concerning religion, most of the population reported being Christian, 

68.3%. Finally, the language spoken in the area was Sesotho, 83.3%. 

 

4.6.Measuring instrument 

The instrument used to collect data was the shorter version of The Attitudes and Beliefs 

about Mental Health Problems: Professional and Public Views’ Questionnaire (Jorm et al., 

1999). The questionnaire comprises three sections. The first section of the questionnaire 

contains information explaining the survey and questions asking participants to consent to 

participate in the study. In addition, this section required simple demographic information such 

as age, gender, marital status, education level, religion and language spoken at home. The 

second section of the questionnaire contained vignettes of various individuals who meet the 

diagnostic criteria under the Diagnostic and Statistical Manual of Mental Disorders, Firth 

Edition DSM-5: American Psychiatric Association, (2013) for depression, schizophrenia, and 



27 
 

 

alcohol use disorder. Each of these vignettes contains information on the onset, duration, 

frequency, progression, and severity of the individual behaviours exhibited by each person per 

vignette (Zanele). In addition, the impact(s) of the mental illness on the vignette character is 

also supplied in the vignettes. The third part of the questionnaire contained questions to elicit 

understanding, attitudes, and perceptions of mental illness. The first questions are open-ended, 

allowing participants to freely express their opinions and use personal phrases, which allowed 

the researcher to gain a deeper understanding and comprehensive information from their 

answers. Most of the questions in the questionnaire consisted of Likert scales, and some 

required a "yes" or "no" response. In summary, these questions captured 'participants' 

perceptions of the cause of mental illness, their thoughts regarding various professionals and 

helpful treatments, the likelihood of their recovery, social distance and attitudes toward people 

with mental illness, likely sources of knowledge about mental illness, and knowledge of 

available treatment facilities. According to the study by Kometsi (2016), a Pearson's correlation 

coefficient was employed to test the questionnaire used in his study, and a result of .85, using 

a sample of South African adults, indicated that the questionnaire was reliable for use with the 

participants in this study.  

 

The 'Attitudes and Beliefs about Mental Health Problems: Professional and Public Views' 

questionnaire was initially designed for a population different from South Africa's. The 

questionnaire was translated into the Sesotho language, spoken in the Dihlabeng community. 

The three vignettes on depression, schizophrenia and alcohol abuse, as well as the 

questionnaire, were translated into Sesotho. The translation guidelines suggested by Babbie 

and Mouton (2001), Guillemin et al. (1993) and Rosnow and Rosenthal (1996) were followed. 

Two experienced Sesotho translators were engaged in translating the questionnaire. The first 

person translated the English questionnaire into Sesotho, and the other translated the Sesotho 

version back into English without seeing the English version. A challenge for the translators 

was the lack of consistent Sesotho words for medical and psychiatric terminology, which they 

acknowledged. Where equivalent Sesotho words could not be identified, other words which 

were similar in meaning were used to form a sentence but still convey the essence of the 

meaning. 

 

The reliability coefficients of the respective measuring instruments were calculated using 

Cronbach's coefficients. This is displayed in Table 2.  

 



28 
 

 

 

Table 2  

 

Reliability of Measuring Instrument  

 

The reliability coefficient obtained from Cronbach's alpha analysis was 0.65 (approx. 0.7), 

indicating a good internal consistency level of the items in the data collection tool used in the 

study. Reliability coefficients of 0.7 or higher are deemed acceptable in studies within the 

context of the social sciences (Lance et al., 2006).  

4.7.Pilot study 

A pilot study was conducted to address Stopher (2012) suggestion that the questionnaire, 

survey designs and procedures should be tested before conducting the primary survey. 

According to Clark-Carter (2010), this is particularly important when the researcher uses an 

existing questionnaire for a new population. In addition, according to Kim (2011), since the 

wording of a questionnaire is crucial in any survey, a pilot study is conducted to identify and 

correct ambiguities and to determine whether the instructions are clear and whether there are 

any procedural difficulties in administering the questionnaire in the current study (Kim, 2011).  

 

According to In (2017), pilot studies are also helpful for training research assistants. A total 

of six research assistants were recruited and trained to collect data for this study. They all 

resided in Bethlehem and had completed Grade 12, meaning they completed their high school 

education. The researchers assumed that participants in the Free State region would speak 

Sesotho; therefore, two of the six research assistants were fluent in Sesotho, and the other four 

had a good command of the language. The pilot study was conducted for one day; after that, 

data collection for the main study commenced. 

 

4.7.1.1.Pilot location and sample 

The pilot sample of 24 people (10% of the main study), of whom 47.2% were male and 

52.8% female, were recruited in Paul Roux, a small town of 6,152 people in the Free State 

 

Cronbach's Alpha N of Items 

.651 16 



29 
 

 

province. The black African population comprised 91.6%, with Sesotho being the predominant 

first language at 88.3% (Stats, 2011). Paul Roux is located in Thabo Mofutsanyana District, 

which is part of Dihlabeng Municipality. The town was chosen because the researcher believed 

that the population were similar to Bethlehem and Fouriesburg, which are part of the same 

district. The steps used to recruit the pilot sample were the same as those used to recruit the 

sample for the main study. However, the data collected during the pilot study were not included 

in the results of this study, as the aim of the pilot study was only to test the data collection 

methods (In, 2017). 

 

4.8.Statistical analysis 

Data were collected and analysed using the Statistical Package for Social Sciences for 

Windows (IBM SPSS Statistics) version 28.0. Data analysis uses statistics to organise, 

summarise and interpret the data (Mishra et al., 2018). Therefore, descriptive and inferential 

statistical analyses were conducted to achieve these goals. 

 

4.8.1. Descriptive statistics 

Descriptive statistics provide numerical and graphical methods to summarise the collected 

data clearly and understandably (Franzese & Iuliano, 2019). Descriptive statistics are used to 

reduce the data to a more straightforward summary and to identify patterns in the data. This 

includes calculating various descriptive measures such as averages and percentages (Isotalo, 

2009). Inferential statistics make inferences about collected data or studied populations 

(Franzese & Iuliano, 2019). This form of statistical analysis includes methods such as interval 

estimates and hypothesis testing (Isotalo, 2009). The two inferential statistical methods used in 

this study were chi-square analysis and regression analysis. 

 

4.8.2. Chi-square analysis 

Chi-square analysis is a non-parametric statistical test comparing categorical information 

with expected information (Jackson, 2012). It does not measure the value of a set of items but 

compares the frequencies of different categories of items in a sample. According to Nihan 

(2020), the chi-square statistic can be used to test the hypothesis that there is no relationship 

between two or more groups, populations or criteria. However, according to Gavin (2008) and 

Jackson (2012), the following assumptions must be met before the chi-square test can be used: 

1) the sample must be randomly selected, 2) the data must be in raw frequencies, not 

percentages, 3) the variables measured must be independent, 4) the values or categories of the 



30 
 

 

independent and dependent variables must be mutually exclusive and complete, and 5) the 

observed frequencies should be greater than five. Nevertheless, Chi-square analysis was 

conducted to test the relationship between some demographic data or variables and the 

questions examined in this study. 



31 
 

 

5. RESULTS 

This section presents the findings of the study based on the data generated and analysed 

using SPSS version 28. Both descriptive and inferential statistics (Chi-Square test) were 

conducted to address the study objectives. The results obtained are presented below. 

 

Table 3 

 

Sample distribution according to gender, age group, marital status, educational level, 

religion, and language spoken at home 

Demographics N % 

Gender   

Male 118 49.2 

Female 122 50.8 

Age group   

18-34 158 65.8 

35-49 54 22.5 

50-64 23 9.6 

65+ 5 2.1 

Marital status   

Single 139 57.9 

Married 38 15.8 

Separated/Divorced 14 5.8 

Widowed 19 7.9 

Living with a partner 30 12.5 

Educational level   

Never went to school 8 3.3 

Primary 23 9.6 

Secondary 85 35.4 

Tertiary 124 51.7 

Religion   

Atheist 6 2.5 

Christian 164 68.3 

Jehovah’s Witness 12 5.0 



32 
 

 

African religion 42 17.5 

Hindu 1 0.4 

Non-Religious 12 5.0 

Other 1 0.4 

Not indicated 2 0.8 

Language spoken at home   

Afrikaans 1 0.4 

isiZulu 30 12.5 

Sepedi 4 1.7 

Swati 1 0.4 

English 2 0.8 

Sesotho 200 83.3 

isiXhosa 2 0.8 

Total 240 100 

Results of the descriptive statistics presented in Table 3 showed that a total of 240 

participants aged 18 years and above participated in the study. There was a relatively even 

distribution of the participants across gender. The participants aged between 18 and 34 years 

were the majority in terms of age groups in the sample at 65.8%. The results also showed that 

many of the participants, 57.9%were single. Statistics relating to the distribution in terms of 

educational level revealed that the majority had tertiary education at 51.7%. People that 

practised Christianity constituted a majority in terms of religion, with 68.3%. Finally, most 

participants reported Sesotho as their language of communication at home, at83.3%. 

 

5.1.Objective one 

To investigate participants' conceptualisation of mental illness. 

Table 4 

 

Categories used to conceptualise mental illness and examples of responses 

Category of explanation Examples of responses 



33 
 

 

Medical Weak mind, mental illness, overworked, going through personal 

things and now that is making her feel worthless, lacks sleep 

and her brain is lacking proper function 

Psychological Suffering from grief, lacks confidence, need to accept self, 

problems with her inner self, a mind disturbed situation, 

overwhelmed and has depression, crazy 

Social Lacks love, being alone, heaping up of a lot of circumstances, 

always stressing, never speaking with anyone, lack of support 

Traditional Has a calling, spiritual ancestral, visions, ancestors are bothering 

her 

Religious Spirit is troubled 

Not indicated Did not answer this question 

 

The conception of mental illness was assessed among the study participants with an 

item requesting them to describe what they think is wrong with a person presented in a 

Vignette. Table 4 presents the various responses the participants provided them, and to be 

meaningful, they were placed under different categories, including medical (e.g. brain 

malfunctioning), psychological (e.g. lack of confidence, grief), social (e.g. stress, loneliness), 

traditional (e.g. spiritual, ancestral calling), religious (e.g. spirit is troubled), and not indicated 

(to indicate that the question was not answered)  

 

Table 5 

 

Percentage of participants' conceptualisation of the disorder 

Disorder, N (%) 

Category of 

explanation 

Depression Schizophrenia Alcohol use 

disorder 

Total 



34 
 

 

Medical 10 (12.5) 1 (1.3) 1 (1.3) 12 (5.0) 

Psychological 53 (66.3) 52 (65.0) 68 (85.0) 173 (72.1) 

Social 15 (18.8) 16 (20.0) 11 (13.8) 42 (17.5) 

Traditional 0 (0.0) 8 (10.0) 0 (0.0) 8 (3.3) 

Religious 1 (1.3) 0 (0.0) 0 (0.0) 1 (0.4) 

Not indicated 1 (1.3) 3 (3.8) 0 (0.0) 4 (1.7) 

Total 80 80 80 240 (100) 

X 2 (10) = 38.79, p < .001 

 

Table 5 reveals the percentage of responses regarding the conceptualisation of mental 

illness. The majority (n = 173, 72.1%) of the participants conceptualised the conditions 

presented on the vignettes as psychological problems, followed by those that thought the 

problems were social (n = 42, 17.5%), medical (n = 12, 5.0%), traditional (n = 8, 3.3%). Only 

a handful of the participants (n = 1, 0.4%) conceptualised the cases as religious, and a few (n 

= 4, 1.7%) did not indicate a specific nature for the presented cases. Further observation of the 

results showed that for depression, more than half of the sample (n = 53, 66.3%) conceptualised 

the case as psychological, followed by those who explained the conditions in the vignette as a 

social problem (n = 15, 18.8%), then medical (n = 10, 12.5%). Only 1 (1.3%) person 

conceptualised the case as a religious problem and no specific problem. For schizophrenia, the 

majority (n = 52 (65%) of the participants described the condition in the vignette as a 

psychological problem, followed by those conceptualising schizophrenia as social (n = 16, 

20%). The results, however, showed that it was only in the schizophrenia vignette that 

participants (n = 8, 10%) conceptualised the condition as a traditional problem. No participant 

attributed the conditions in the schizophrenia vignette to a religious problem, while 3 (3.8%) 

did not indicate the case as a specific problem. The majority of the participants (n = 68, 85.0%) 

explained the conditions of alcohol use disorder as a psychological problem, followed by 11 

(13.8%) who explained the condition as a social problem, and only 1 (1.3%) indicated alcohol 

use disorder as a medical problem.  

 



35 
 

 

The chi-square analysis results showed significant differences in how the participants 

conceptualised the different mental illnesses X 2 (10) = 38.79, p < .001. For instance, most of 

the sample in the alcohol use disorder category explained the condition as a psychological 

problem, while all the participants that conceptualised mental illness as a traditional problem 

were in the sample that responded to schizophrenia. 

 

 

Table 6  

 

Examples used to conceptualise mental disorders 

Disorder    

Category of 

explanation 

Depression Schizophrenia Alcohol use disorder 

Medical Maybe pregnant, going 

through personal things 

and now that is making 

her feel worthless, 

lacks sleep and her 

brain is lacking proper 

function 

Weak mind, mental 

illness,  

overworked,  

Psychological going through 

something (trauma), 

hurt in the past, lacking 

sleep which causes 

unusual behaviour, 

personal insecurity of 

seeking approval, 

childhood trauma, 

depressed 

Suffering from grief, 

problems with her 

inner self, judging 

self, lack of 

motivation, crazy 

has addiction on 

alcohol, stressed, 

creating a bad habit 

for herself, using 

alcohol as an escape 

and that's wrong, 

relied on being given 

a certain feeling by 

alcohol 



36 
 

 

Social hurting from something 

it can be break up, 

might be dealing with 

rejection or she feels 

unwanted or maybe not 

enough,  

lacks love, being 

alone, lack of 

support, feels lonely 

lots of problems in 

her life, being 

pressured from her 

family, has a lot of 

things going on in 

her life, 

overwhelmed by 

either work or her 

life 

Traditional  Has a calling, 

spiritual ancestral, 

visions 

 

Religious Her spirit is troubled   

Not indicated Unable to finish her 

work 

No problem, 

poverty, and 

suffering 

 

 

The results presented in Table 6 showed the different examples of explanations or 

descriptions used to explain schizophrenia, depression, and alcohol use disorder across 

different categories of conceptualisation. For example, conceptualising depression as a medical 

problem, the individual in the vignette was thought to be pregnant. Also, “problem with inner 

self” was an example of a description used to capture schizophrenia as a psychological 

problem, and “pressure from the family” was an example of the expression used to 

conceptualise alcohol use disorder as a social problem. 

 

Table 7 

 

Labels used for mental disorders 

Label used   

Depression Schizophrenia Alcohol use disorder 

Abuse Anxiety Addiction 



37 
 

 

Alcoholic 

Anxiety 

Depression 

Ill 

Unlovable 

Depressed 

Evil spirit 

Fatigue 

Hangover 

Isolation 

Lack of interest and pleasure 

Lacking sleep 

Mental illness 

Lonely 

Overthinking 

Phobia  

pregnancy 

Stress 

Calling from ancestor 

Crazy 

Depression 

Emotional 

Grief 

Family issues 

Insecurity 

Isolation 

Lack of satisfaction 

Low self-esteem 

Madness 

Mental illness 

Mental weakness 

Overthinking 

Paranoia 

Peer pressure 

Spiritual 

Stress  

Alcohol abuse 

Alcohol addiction 

Alcoholic 

Drinking unreasonably 

Hangover 

Heart problems 

Insecurity 

Drunkenness 

Lie 

Lack of satisfaction 

Low self-confidence 

Negative use of alcohol 

Peer pressure 

Selfish 

Substance abuse 

Stress 

Unbalance 

 

A summary of different labels used by participants for each of the three disorders was 

presented in Table 5. It was observed that the participants provided numerous labels for the 

mental disorders presented in the vignettes, with only a few labels (anxiety, depression, stress) 

used for all three disorders. The results also showed that labels, such as addiction and 

drunkenness, were only used to describe alcohol use disorder. In addition, labels, such as 

callings and visions, were used only for labelling schizophrenia, and physical/medical-inclined 

labels, such as pregnancy and sleep, were specific to depression. 

 

5.2.Objective two 

To investigate the participants' knowledge and beliefs about aetiology and treatment of 

mental disorders. 

Table 8 

 

Knowledge and beliefs about aetiology of mental disorders 



38 
 

 

Aetiology of mental 

disorders 

Examples of responses 

Medical By her heart, morning sickness, being tired, chemical 

imbalance, hangover 

Psychological overthinking because of no time to mourn for her loss, 

imagining a lot, low self-esteem and anxiety, lost her self-

confidence, needing the presence of a parent or a loved one, 

grief, being overwhelmed and doesn't know how to deal with it 

Social may have enemies because of her position at work, family 

situation, staying alone, always listening to people, not getting 

enough love and support, no support and lack friends, life 

issues, pressure from the family,  

Traditional her ancestors are calling her to do their duties on their behalf, 

not following traditional ways of doing things 

Religious The devil is attacking,  

Table 8 presents results on the knowledge and belief about the aetiology of mental 

disorders assessed among the participants. Again, many responses were provided to describe 

what participants believed to be the cause of the conditions presented in the vignettes. For this 

study, the responses provided were classified into medical (e.g. chemical imbalance), 

psychological (e.g. overthinking, low self-esteem), social (e.g. lived events, lack of support), 

traditional (e.g. spiritual, ancestral calling), and religious (e.g. devil's attack). 

 

Table 9 

 

Percentages of participants on knowledge and belief of aetiology of mental disorder 

Disorder, N (%) 

Category of 

aetiology 

Depression Schizophrenia Alcohol use 

disorder 

Total 



39 
 

 

Medical 9 (11.3) 1 (1.3) 1 (1.3) 11 (4.6) 

Psychological 53 (66.3) 41 (51.2) 52 (65.0) 146 (60.8) 

Social 17 (21.3) 32 (40.0) 27 (33.8) 76 (31.7) 

Traditional 0 (0.0) 6 (7.5) 0 (0.0) 6 (2.5) 

Religious 1 (1.3) 0 (0.0) 0 (0.0) 1 (0.4) 

Total 80 80 80 240 (100) 

X2 (8) = 32.06, p < .001 

 

The results in Table 9 present the percentage of responses regarding knowledge and 

beliefs of the aetiology of mental disorders across the three disorders assessed in this study. 

Many (n = 146, 60.8%) of the participants expressed that mental disorders are caused by 

psychological factors, followed by those that ascribed the causes of mental disorders to social 

(n = 76, 31.7%), medical (n = 11, 4.6%), traditional (n = 6, 2.5%), and religious (n = 1, 0.4%) 

factors. Most of the participants that believed medical factors caused mental disorders were in 

the sample for the depression vignette, while all the participants that believed that traditional 

conditions cause mental illness were in the sample for the schizophrenia vignette. 

 

The results of the chi-square analysis showed significant differences in the participant's 

belief in the aetiology of mental disorders across the three disorders assessed X2(8) = 32.06, p < 

.001. For instance, the majority of the sample in the alcohol use disorder category explained 

the condition as a psychological problem, and the category with the least attributions to all 

three disorders was that of religion. 

 

Table 10  

 

Examples used to describe the knowledge and belief of aetiology of mental disorders 

Disorder    



40 
 

 

Category of 

aetiology 

Depression Schizophrenia Alcohol use disorder 

Medical Being tired, morning 

sickness, chemical 

imbalance, lack of 

sleep, exhausted, 

consistent fatigue 

By her heart,  Hangover 

Psychological Past trauma, 

overthinking and 

expecting approval, 

pilling up her 

sadness, personal 

problems, being 

hurt, previous 

insecurities, 

overthinking, 

hopelessness 

Not have time to 

mourn and 

overthinking, 

imagining a lot, 

thinking a lot, low 

self-esteem and 

anxiety, lost self-

confidence 

stressed or might be 

experiencing 

anxiety, being 

overwhelmed and 

doesn’t know how to 

deal with it, too 

much stress, got 

hooked on drinking 

to create a specific 

effect 

Social Family issues, a 

break up (cheated 

on) or family always 

comparing her to 

someone, loneliness, 

overwhelmed by 

work,  

Affected because of 

her working 

position, family 

situation, staying 

alone, not getting 

enough love and 

support, not 

speaking to anyone 

Life issues, pressure 

from the family, too 

much workload and 

expectations from 

the family, too much 

pressure on self, 

negative peer 

pressure,  

Traditional  ancestors are calling 

to do their duties on 

their behalf, not 

following traditional 

 



41 
 

 

ways of doing 

things, lack of belief 

Religious The devil is 

attacking,  

  

The results in Table 10 showed the various examples used to describe the aetiology of 

mental disorders across different disorders. For example, participants that believed that medical 

factors cause depression used expressions such as "morning sickness", "exhausted", and 

"chemical imbalance" as causes of depression. Expressions such as "imagining a lot", "low 

self-esteem", "anxiety" were used by participants that believed that psychological factors cause 

schizophrenia. For alcohol use disorder, participants that believed social factors caused the 

disorder used expressions such as "life issues", and "too much pressure on self" to describe the 

causes of alcohol use disorder. 

 

Table 11 

 

Knowledge and beliefs about treatment of mental disorders 

Treatment of mental 

disorders 

Examples of responses 

Encourage professional 

help-seeking 

Go see a psychologist, talk and seek social work, counselling, 

attend counselling sessions and get professional mental help, by 

going to a doctor or talk out her problems from outside, mental 

health professional, to the rehab centre, Lifeline, needs to talk to 

someone and get rehab, She can go for therapy 

Listen to/talk to/support By having someone that she can talk to openly about how she's 

feeling, meet people and talk to them, talking to friends and 

family, talking to others who can relate,  

Refer to family By going to people around at home, talk to family,  

Traditional seeing a traditional healer, go to sangoma, go initiation school 

so that she can be a traditional doctor,  



42 
 

 

Religious By being prayed and offered a counselling 

Other Lock her up, she must believe in herself, needs to look for 

something to relieve the effect she wants from alcohol, separate 

from the wrong group of friends,  

The results in Table 11 show the different categories of beliefs about treating mental 

disorders as expressed by the participants. Similar responses were combined to form the 

following categories: (1) encourage professional help-seeking (e.g. see a psychologist, go for 

therapy/rehabilitation), (2) listen to/talk to/support (e.g. meet people and talk to them, having 

someone to talk to openly about feelings), (3) refer to family (e.g. talk to family, be around 

people at home), (4) traditional (e.g. seeing a traditional healer, go to sangoma), (5) religious 

(e.g. being prayed for), and (6) other (lock up, separate from wrong group of friends). 

 

Table 12 

 

Percentage of participants related to knowledge and belief of treatment of mental disorders 

Disorder, N (%) 

Category of 

Treatment 

Depression Schizophrenia Alcohol use 

disorder 

Total 

Encourage 

professional 

help-seeking 

53 (66.3) 50 (62.5) 51 (63.7) 154 (64.2) 

Listen to/talk 

to/support 

16 (20.0) 13 (16.3) 9 (11.1) 38 (15.8) 

Refer to family 0 (0.0) 3 (3.8) 2 (2.5) 5 (2.1) 

Traditional 0 (0.0) 12 (15.0) 0 (0.0) 12 (5.0) 

Religious 0 (0.0) 0 (0.0) 1 (1.3) 1 (0.4) 

Other 10 (12.5) 2 (2.5) 17 (21.3) 29 (12.1) 



43 
 

 

Note indicated 1 (1.3) 0 (0.0) 0 (0.0) 1 (0.4) 

Total 80 80 80 240 (100) 

X2 (12) = 44.49, p < .001 

 

The results in Table 12 showed the differences in participants' responses regarding the 

belief in the treatment of mental disorders across the three disorders assessed. It was observed 

that the majority (n = 154, 64.2%) of the participants believed that people with mental disorders 

should seek professional help to treat the disorder. Of the participants that believed that 

treatment for mental disorders could be achieved by listening or talking to other people, many 

were in the sample for the depression (n = 16, 20%) and schizophrenia (n =13, 16.3%) 

vignettes, while many of those who believed that mental disorders could be treated by different 

'other' means were in the sample for depression (n = 10, 12.5%) and alcohol use disorder (n = 

17, 21.3%) vignettes. Interestingly, participants that believed that traditional methods should 

treat mental disorders were in the sample for the schizophrenia (n = 12, 15%) vignette, and 

religious treatment was suggested for alcohol use disorder (n = 1, 1.3%) alone. 

  

The results of the chi-square analysis showed significant differences in the participants' 

belief of treatment of mental disorders across the three disorders assessed X 2 (12) = 44.49, p < 

.001. For instance, most of the sample was in favour of encouraging professional help-seeking 

for the three mental disorders. In contrast, only those in the vignette of schizophrenia 

encouraged traditional help-seeking.  

 

Table 13 

 

Examples used to describe the knowledge and belief of treatment of mental disorders 

Category of 

Treatment 

Depression Schizophrenia Alcohol use 

disorder 

Encourage 

professional help-

seeking 

By seeing a doctor 

go to the clinic, 

getting professional 

help, rehab, go for a 

Go see a 

psychologist, attend 

counselling 

sessions, and get 

To the rehab centre, 

rehab, rehab, and 

life coaching, visit a 

psychologist,  



44 
 

 

psychological 

evaluation, a 

psychologist to 

counsel her,  

professional mental 

help, by going to a 

doctor or talk out 

her problems from 

outside 

Listen to/talk 

to/support 

Opening up to 

someone she trusts 

because she is being 

bothered, talking to 

people,  

by having someone 

that she can talk to 

openly about how 

she's feeling, talk to 

someone, talking to 

friends and family 

She needs to talk 

about what is 

bothering her,  

Refer to family  By going to people 

around at home, 

talk to family 

Talk to her family,  

Traditional  seeing a traditional 

healer, go to 

sangoma, cultural 

ritual,  

 

Religious   By being prayed 

and offered a 

counselling 

Other She should get 

some sleep, maybe 

she needs to take a 

vacation, needs a 

break,  

Lock her up, she 

must believe in 

herself 

She needs a new 

way of wanting to 

relieve her stress, 

take a break, cut 

down her going out 

Table 13 presents the different examples used by the study participants to describe their 

belief in the treatment of mental disorders across the three disorders assessed. Participants that 

believed that depression can be treated by receiving help from professionals used words such 

as "seeing a doctor or go to the clinic", go for psychological evaluation" to express their 



45 
 

 

knowledge and belief about how depression could be treated. For schizophrenia, those that 

believed that listening or talking to someone could be a treatment used expressions such as 

"talking to friends and family", while examples of expression used by participants that believed 

in religious methods for treating alcohol use disorder include "being prayed for and offered 

counselling". 

 

5.3.Objective three 

To investigate the relationship between aetiological and treatment beliefs 

Table 14 

 

Relationship between aetiological and treatment beliefs for mental disorders 

 Medical  Psychological  Social  Traditional Religious Total 

Encourage 

professional 

help-seeking 

8 (72.7) 99 (67.8) 47 (61.8) 0 (0.0) 0 (0.0) 154 (64.2) 

Listen to/talk 

to/support 

0 (0.0) 23 (15.8) 14 (18.4) 0 (0.0) 1 (100) 38 (15.8) 

Refer to family 0 (0.0) 2 (1.4) 3 (3.9) 0 (0.0) 0 (0.0) 5 (2.1) 

Traditional 0 (0.0) 3 (2.1) 3 (3.9) 6 (100) 0 (0.0) 12 (5.0) 

Religious  0 (0.0) 1 (0.7) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.4) 

Other 3 (27.3) 17 (11.6) 9 (11.8) 0 (0