Mental health is slowly gaining global significance as a key health issue ( Keyes, 2007; World Health Organization, 2004). This has not, however, resulted in a significant decrease in the stigma attached to psychosis, especially in low-income countries ( Kemp et al., 2019). Neither has there been an in-depth exploration of sustainable, cost-effective and replicable community engagement strategies that address mental health myths and stigma as a major barrier to early health-seeking behaviours. In low income and resource-constrained countries such as Zimbabwe, cultural and spiritual beliefs are at the centre of most mental health explanatory models ( Refugee Review Tribunal AUSTRALIA, 2009). This perpetuates an environment in which public conversations about mental health are the equivalent of a cultural taboo ( Patel et al., 1995; Wintersteen et al., 1995). Mental health interventions should therefore be accompanied by creative ways of engaging communities with health research ( Walker, 2009). As public engagement is increasingly becoming an indispensable tool in promoting global health ( Adhikari et al., 2019), it is helping to ensure that interventions are not only suited to the local setting but equally important, communities are given a voice in directing their health initiatives ( Nisker et al., 2006).

Zimbabwean culture has always valued drama and its sub-components of music and dance as a crucial element in community socialization and fostering unity. Drawing from the experiences of health researchers from the African Mental Health Research Initiative (AMARI) and the University of Zimbabwe who have successfully engaged the public in creative ways, Z Factor, a drama competition modelled on the popular television music competition franchise (X Factor), combined music, dance and poetry as a socially acceptable medium of community socialization in Zimbabwe. This medium, which has never been adequately harnessed in mental health programmes, was adapted as a creative tool for public engagement with psychosis in rural Zimbabwe. The implementing organization, the Zimbabwe Early Intervention in Psychosis (ZimEIP) project, which has been working in rural Zimbabwe since 2016, sought to introduce a community arts and culture competition (Z Factor) as a creative way of opening up conversations, sparking public debate and tackling stigma attached to psychosis in rural Zimbabwe. Key outcomes for Z Factor include gaining a more in-depth appreciation of community perceptions towards psychosis treatment by health researchers, as well as increasing community awareness about psychosis.

As noted by the World Health Organization, there is a shortage of skilled mental health service providers in Zimbabwe, with 13 clinical social workers, six psychologists, 18 psychiatrists and 917 psychiatric nurses ( WHO, 2020). As such, Z Factor efforts were also directed towards mental service provider collaboration to promote early detection and treatment-seeking behaviours. This is especially important as current work by the ZimEIP project in rural Zimbabwe has identified a deeply embedded traditional belief system influencing how, when and where to seek mental health care. Refugee Review Tribunal Australia (2009); Patel et al. (1995) and Winston & Patel (1995) argue that these deeply embedded traditional beliefs attributing the causes of psychosis to evil spirits and witchcraft attacks is a recurrent theme across most of sub-Saharan Africa. Consequently, this has led to the stigmatization of psychosis, which in turn fuels poor health-seeking behaviours in African communities. It was, therefore, hoped that the psychosis themed drama competition would help to combat stigma by offering alternative explanations of psychosis as well as allowing the implementing organization (ZimEIP) and its mental health research collaborators to learn more about the community belief systems, with the hopes of identifying suggestions for further exploration in which the two mental health care pathways (traditional and biomedical) may collaborate towards a more robust and context responsive psychosis treatment model in Zimbabwe.

The Z Factor project aimed to pilot the use of drama as a public engagement tool to open up community conversations about psychosis in Zimbabwe. This would be achieved through engaging young adults and their support networks across a variety of socioeconomic groups through their participation in a local drama competition to:

1. Reduce psychosis stigma and discrimination in rural Zimbabwe.

2. Describe the community’s perspective about psychosis treatment pathways and outcomes in rural Zimbabwe.

3. Develop collaborative care between the traditional/faith-based and medical models of psychosis treatment.

4. Develop a context-specific and community acceptable mental health public engagement model for low resource settings.

The drama competition, therefore, served a dual role as follows:

a) As a vehicle for opening up community conversations using the psychosis themed drama.

b) As a medium for psychosis treatment information exchange between service providers (traditional/ faith-based, biomedical practitioners) and service users (the local community, persons with psychosis and their support networks).

Goromonzi Rural District is approximately 40km from Zimbabwe’s capital city, Harare. According to Goromonzi Rural District Council (2020) and ZimStat (2012), the Goromonzi District of Zimbabwe is made up of 25 wards with a population of 224 987. Communal areas make up 53.17% of the district, 42.36% are commercial farming areas, and the remainder are semi-urban settlements ( ZimStat, 2012). The ZimEIP program has been working in two of the 25 wards of Goromonzi and these have a combined population of 22,647. ZimEIP has been working in two of the major district referral clinics, one of which houses the only psychiatric nurse in the district. The Z Factor project was therefore implemented in the two wards of Goromonzi where the implementing organization already had a presence since 2016 with an established mental health stakeholder network. As Goromonzi Rural District Council (2020) note that the population density of the district is approximately nine people per square kilometre, each ward can be made up of as many as 30 villages.

This community and public engagement project had a three-pronged approach. It sought to promote mental health conversations in rural communities by providing a fun and interactive platform for community discussions. These were designed to demystify psychosis by providing accurate treatment information from different mental health service providers, as well as explore a collaborative model for biomedical, traditional and faith-based service providers to work together towards reducing psychosis treatment delays. A five-staged psychosis themed drama competition (see Figure 1) was therefore implemented in the Goromonzi District of Zimbabwe where ZimEIP has been implementing its Early Intervention in Psychosis project since October 2016.

The competitions endeavoured to open up community conversations about psychosis in rural communities where mental health stigma is fuelled by cultural and religious explanatory models of mental health causes. Z Factor adopted a co-production model where both the research participants and mental health researchers work together in formulating and delivering the engagement project. A community participatory method was therefore adopted in planning, implementing and evaluation throughout the project’s life cycle as a way of encouraging participation and ownership. As visual methods have been noted to be a useful public engagement tool in HIV and other illnesses, the project also explored the use of drama as a creative and fun way of opening up psychosis conversations.

Zimbabwe has a dual judicial and administrative system composed of the colonially inherited British system as well as the traditional system, which is more pronounced in rural districts ( Bennett, 1981). As Kurebwa (2018) observes, in Zimbabwe, both the central government departments and traditional chiefdom serve as community gatekeepers dictating the provision of social services in their areas. It was, therefore, crucial to get these gatekeepers’ buy-in as well as permission to implement the Z Factor project. Permission was therefore sought from the Ministry of Health and Child Care, Ministry of Local Government, Ministry of Home Affairs and the Ministry of Youth, the area chiefs, their headmen and village heads, the ward councillors and District Member of Parliament for Goromonzi among other relevant authorities in the area. These gatekeepers were visited individually as well as invited to a gatekeepers’ stakeholders meeting at the District Administrator’s office introducing the Z Factor project as well as getting their feedback on the proposed project implementation plan.

The village health workers in the rural sites chosen had prior training in early detection of Psychosis and appropriate patient referral system under the ZimEIP project. Efforts were made towards engaging and recruiting the two wards’ village health workers and village heads to be responsible for onsite planning and mobilizing participants. Feedback from these onsite planners and participant mobilisers were to be incorporated in further developing the project implementation plan. Feedback from the first stakeholders’ meeting with government ministerial heads was also intended to further refine the project implementation plan. This monitoring and evaluation strategy was intended to be a continuous process throughout the project life cycle where both project implementors and the participants would actively take part in co-planning and co-implementation. Selected and willing village health workers acting as community mobilizers were tasked with promoting the drama competition through village meetings and any other community forums with permission from local gatekeepers. Stakeholder consultation meetings with village heads and other traditional as well as church leaders were intended to assist village health workers to gain the necessary permission and support needed to mobilize communities. The drama competitions and discussion workshops were, therefore, to be advertised at village level meetings, church gatherings and other community gatherings. The competitions were also to be publicised in local schools, both primary and secondary as well as local health facilities. The disseminated information was to include contact details for community mobilisers available to provide more details on the proposed competitions, as well as the activities calendar and location.

The project’s aim was engaging young adults and their support networks across a variety of socioeconomic groups in Goromonzi Rural District of Zimbabwe through their participation in a local drama competition (Z Factor). The competitions, therefore, focused on psychosis with subcategories of the initial presentation/detection, seeking help/pathway to care, and the road to recovery/treatment (see Table 1). Each drama group had to be composed of an adolescent/young adult and a representative of their support network i.e., family members, friends, neighbours and teachers. The drama and drama group composition was therefore intended to act as a reflection of society. Further, each drama group had a 10-minute slot with a limit on the number of groups per event (see Table 1) as more time was to be allocated to follow up discussions soon after the drama exhibitions.

The work of the implementation organization (ZimEIP) in the Goromonzi communities has revealed that family elders’ i.e. parents, uncles, aunties and grandparents are key stakeholders in deciding the pathway to care for the ill family member, as well as being better positioned to influence early health-seeking behaviours. Therefore, to be in sync with the cultural norms in Zimbabwean communities that highly venerate community elders, with assistance from the ZimEIP Team, local clinic personnel and drama experts, community elders were appointed as part of the judging panel as a way of ensuring their active involvement in the public engagement as well as encouraging community ownership of the activities.

The competitions were open to auditions whereby an adolescent or young adult and their potential support networks were invited to take part and compete within and between wards and villages. Community members and stakeholders in attendance voted for who should proceed to the next level based on the accuracy to which their dramatizations mirrored community psychosis perceptions and social norms. Break-out groups were to run parallel to the competitions as a platform for in-depth discussion between community members, mental health service stakeholders and ZimEIP personnel as an aid to the drama voting system. These competitions were conceived as an incentive for the general public to attend, as drama can be dually entertaining and informative. Discussion workshops were to follow through as a platform for further community engagement exploring themes brought out from the drama. The drama competition was designed to act as a common factor that brings together the whole community, from churches to African traditionalists, school students and families to enjoy themselves and open up the conversation about psychosis. Interested drama groups were not given any scripts to use but a theme/topic to dramatize what is happening in their communities and this would be judged by a trained panellist of community elders chosen during the first community meeting. These dramatizations that reflect what is happening in the community would act as conversation starters, paving the way for a more interactive discussion where service providers would also share accurate cultural and biopsychosocial information of mental health treatment and recovery within the Zimbabwean context.

The project aimed to benefit the Chinyika and Rusike communities; it did not have any exclusion criteria as it sought to engage the community as a whole. Beneficiaries can, however, be classified into the following groups: individuals/community members, mental health service providers and organizations/policymakers within these communities. Further, as communities begin opening up about mental health conversations and the biases they may have towards persons with a mental health condition, it is hoped that such discussions may perhaps pave the way towards addressing and/or eradicating mental health stigma and discrimination, which are argued by Dharitri et al. (2015) to be one of the causes of poor health-seeking behaviours in communities.

The project’s monitoring and evaluation plan was informed by AMARI’s community and public engagement resources, as well as the University of Zimbabwe’s Research Support Centre. The logical framework approach was chosen to guide the planning, implementation and evaluation of the project as it is a widely used model for coming up with “indicators against which the project progress and achievements can be assessed” ( Barreto Dillon, 2020). Logical framework matrixes are argued by USAID (2011) to foster adherence to overall project aim yet are flexible enough to anticipate potential risks and threats, as well as incorporating learning to improve effectiveness from one project implementation stage to the next. Anticipated threats included poor attendance due to mental health stigma as well as geographical accessibility of project activity sites. Incentives such as refreshments and, where appropriate, transport fare reimbursement had to be budgeted for each engagement activity from dramas to discussion workshops. Transport reimbursements were to be given on a means-tested basis as well as mobilizing available transportation from community well-wishers. The logical framework approach was therefore adopted as a useful tool to track various project indicators to measure progress and allow for change management from one project phase to the next.

Due to the mental health stigma in the community of implementation, the project anticipated an overall turnout of 400 participants. This was based on data from mental health programmes carried out by other organizations and attendance statistics which were available at the District Administrator’s as well as local clinics’ databases.

Like in many sub-Saharan countries, rural communities in Zimbabwe have shown a general lack of accurate information regarding psychosis and its treatment, compounded by the traditional and religious explanatory models ( Refugee Review Tribunal AUSTRALIA, 2009). These models largely attribute the causes of psychosis to witchcraft and evil spirits, which in turn fuels stigmatization in communities ( Winston & Patel, 1995). As a result, not only are there delays in seeking treatment by communities, there is often dual consultation, diagnosis and treatment as people often seek treatment from traditional/faith as well as biomedical services, and this has often fuelled hostilities between these seemingly incompatible service providers. Mike Bestor et al. (2016) therefore argues that creative public engagement that promotes a “two- way communication that is interactive and continuous intending to share decision- making power and responsibility for those decisions” should inform strategies and programmes that seek to develop communities. Such “two-way communication” in public engagement is therefore needed to understand societal beliefs and offer mutually acceptable and culturally sensitive alternative evidence-based explanations for psychosis that promote early health-seeking behaviours. This also provides the potential to share accurate bio-psychosocial treatment information and encourage communities to reduce the delay in their health-seeking behaviours, with hopes to pave way for the two pathways to care (traditional/faith-based and the biomedical model) to collaborate in diagnosis and treatment management of mental illness in rural Zimbabwe.

Collins et al. (2012) argue that the link between mental health and poor health-seeking behaviours can be broken through promoting early intervention services. This is achieved through combating mental health stigma noted to be at the core of poor health-seeking among mental health service users ( Collins et al., 2012). The knowledge gaps about psychosis stigmatization and the need to encourage timely health-seeking have necessitated the need for creative methods of public engagement ( Weetra et al., 2019). We, therefore, aimed to provide a platform that attracts public attention ( Coyle et al., 2017), opening up conversations and sparking public debate about psychosis in ways in which communities feel comfortable expressing their true beliefs and experiences regarding psychosis. It was hoped that this public engagement would see both the implementing organization Zimbabwe Early Intervention in Psychosis (ZimEIP) and the Goromonzi community learning from each other to pave the way for collaboration towards promoting community mental health in communities with deeply entrenched traditional and religious beliefs. The engagement was to ride on the commitment pledged by the chieftain and other traditional and faith leaders in Goromonzi towards the promotion of community mental health.

Project outcomes and outputs will be shared with project participant groups in the form of lay summaries and, where requested, drama group participants will be provided with DVDs of their dramas and exhibitions. Manuscripts of the community and public engagement study design, methods and/or evaluation outcomes, as well as any other significant project outcomes/outputs, will be submitted to appropriate open access journals for wider dissemination.

Initial project activities began in November 2017 and data collection ended in July 2018. Currently (20/11/2020), project data analysis is underway.

The views expressed in this publication are those of the author(s) and not necessarily those of the Wellcome Trust.