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. Author manuscript; available in PMC: 2026 May 27.
Published in final edited form as: Drug Alcohol Depend. 2025 May 20;274:112718. doi: 10.1016/j.drugalcdep.2025.112718

Portrayals of alcohol use disorder treatment outcomes and their effects on stigma: Population-based, randomized survey experiment in rural Uganda

Yang Jae Lee a,*, Jordan Jurinsky b,*, Charles Baguma c, Scholastic Ashaba c, Bernard Kakuhikire c, Elizabeth Betty Namara c, Phionah Ahereza c, Viola Kyokunda c, Emily N Satinsky d,e, Alexander C Tsai c,e,f,g, Jessica M Perkins h,i,†
PMCID: PMC12896135  NIHMSID: NIHMS2104173  PMID: 40483789

Abstract

Introduction:

We assessed the extent to which portrayals of AUD treatment effectiveness influenced multiple domains of stigma.

Methods:

This cross-sectional, whole-population survey experiment was conducted with 1363 adults living in eight villages of southwestern Uganda in 2021–2022. Participants were randomly assigned to receive a vignette describing a typical man (control) or one of six vignette variants describing a man with untreated AUD, treated AUD, or other variations of treated or untreated AUD with differing outcomes. Outcomes: personal willingness to have the man marry into their family, belief that he is receiving divine punishment, and belief that he brings shame on his family. Participants also reported their perceptions about whether most people in their villages would hold those stigmatizing attitudes (i.e., perceived norms). We fitted multivariable Poisson regression models to estimate the effect of vignette assignment on personal beliefs and perceived norms.

Results:

Participants reported more stigmatizing personal beliefs across all AUD vignettes compared to control. Average marginal effects (AME) of assignment on the excess probability of stigmatizing personal beliefs ranged from 0.57 (95% Confidence Interval CI=0.43–0.71) to 0.74 (CI=0.58–0.90) for unwillingness to have the man marry into their family, 0.66 (CI=0.53–0.80) to 0.81 (CI=0.67–0.95) for believing the man brings shame upon his family, and 0.29 (CI=0.20–0.38) to 0.36 (CI=0.27–0.46) for believing the man is receiving divine punishment. AMEs of vignette assignment on perceived norms were similar.

Conclusion:

Stigma toward men with AUD in rural Uganda was high regardless of AUD treatment effectiveness. Culturally-tailored stigma reduction interventions are needed.

Keywords: recovery, perceived norms, East Africa, alcohol consumption, discrimination, stigma

1. Introduction

Alcohol use disorder (AUD) accounts for 5.3% of all deaths and 132.6 million disability-adjusted life years (DALYs) worldwide (World Health Organization 2018). Uganda, the site of this research study, has been reported to have one of the highest rates of per capita alcohol consumption globally (Kabwama et al. 2016). AUD is also one of the most highly stigmatized illnesses (Martin et al. 2000, Pescosolido et al. 2010, Schomerus et al. 2011, Yang et al. 2017, Kilian et al. 2021, Elliott et al. 2024, Lee et al. 2024b, Spata et al. 2024). Individuals with AUD are often viewed as personally responsible for their illness and elicit more social rejection compared to other disorders (Kelly et al. 2010, Kelly and Westerhoff 2010, Livingston et al. 2012, Kelly and Earnshaw 2021, Kilian et al. 2021). This stigma is widely recognized as a major barrier in treatment seeking across substance use disorders (Wallhed Finn et al. 2014, Probst et al. 2015, Crapanzano et al. 2019, Tsai et al. 2019, Cousin et al. 2022, Krendl and Perry 2022) with evidence that lower levels of social support lead to poor outcomes (Glass et al. 2013). This stigma coincides with a large treatment gap: compared to other psychiatric disorders, AUD has one of the largest gaps between number of individuals with the disorder and those in treatment (Kohn et al. 2004). Uganda, in particular, has few AUD treatment programs, and most are inaccessible in rural areas (Kuule et al. 2018).

One class of interventions to reduce stigma associated with mental and behavioral health conditions has focused on conveying messages about the extent to which these conditions are treatable (Reinke et al. 2004, Evans-Lacko et al. 2012, Evans-Lacko et al. 2013, Crapanzano et al. 2014, Knaak et al. 2014, Henderson et al. 2016, Gronholm et al. 2017, Nalwadda et al. 2018, Lee et al. 2022, Wallhed Finn et al. 2023, Lee et al. 2024a, Lee et al. 2024c), which may be particularly impactful in Uganda. Nalwadda et al found that 56% of adult Ugandan men who screened positive for AUD did not seek treatment because they did not view AUD as treatable, and many also endorsed stigmatizing beliefs related to AUD (Nalwadda et al. 2018). Studies conducted in the U.S. have demonstrated that presenting vignettes depicting successful mental illness treatment can diminish negative attitudes toward individuals with mental illnesses (Romer and Bock 2008, Lebowitz and Ahn 2012, McGinty et al. 2015). A study in rural Uganda using a similar design, however, did not appear to reduce mental illness stigma (Rasmussen et al. 2019).

Another class of interventions to reduce stigma has been motivated by social science theories about drivers of stigma in the region. In resource-limited settings, informal networks of mutual aid may carry outsize importance in the setting of limited or absent formal social protection schemes (Thomas 2006, Ware et al. 2009, Tuller et al. 2010, Tsai et al. 2013). Qualitative studies conducted in Uganda have shown that a primary driver of the stigma of alcohol use disorder is its association with social difficulties, including unemployment, economic incapacity, and lack of contribution to the financial viability of one’s family (Weiser et al. 2024). Interventions to reduce the stigma of HIV, for example, have directly addressed this driver of stigma, with strong evidence of efficacy (Kakuhikire et al. 2016, Tsai et al. 2017a, Onono et al. 2023, Weiser et al. 2024).

To explore the treatable-illness hypothesis for AUD stigma, we embedded a survey experiment into a randomized population cohort study in southwestern Uganda. Adapting the vignettes employed in the General Social Survey and by previous scholars (McGinty et al. 2015), our aim was to test whether presenting AUD as a treatable condition could reduce either personal stigmatizing attitudes toward men with AUD or perceived norms about stigmatizing attitudes toward men with AUD. We hypothesized that portrayals of successful treatment would reduce stigma; that emphasizing the negative economic and social impacts of AUD (independent of treatment) would worsen stigma; and that portrayals of recurrence after successful treatment would worsen stigma.

2. Methods

2.1. Study Context and Population

This study took place in the eight villages of Nyakabare Parish, a rural administrative subunit situated in Rwampara District in the southwestern region of Uganda. The study site reflects typical rural communities in the area, characterized by a lack of local public infrastructure; economic activity primarily centered around farming, animal husbandry, and small-scale trading; and prevalent food and water insecurity (Tsai et al. 2016, Perkins et al. 2018b). The experimental procedures were integrated into an ongoing population-based social network cohort study (Takada et al. 2019). The study encompassed the whole population of adults aged 18 years and above (including emancipated minors aged 16–17 years) who reported permanent residence within the approximately 11-square-kilometer area of the parish, and who could provide informed consent. Exclusions comprised individuals unable to communicate effectively with the research team due to factors such as deafness, mutism, or aphasia; those exhibiting behavioral signs indicative of psychosis, neurological damage, or acute intoxication; and individuals with cognitive impairments hindering informed consent. The preceding survey wave, conducted in 2018–21, formed the census of potential study participants who were randomized for the present survey experiment, conducted in 2021–22.

2.2. Study Procedures

Eligible individuals were approached for participation, typically at their residence or workplace, by a research assistant proficient in the local language (Runyankore). Participants were invited to partake in a study framed generally as an exploration of the social lives and health of parish residents, with no stated emphasis on mental illness or alcohol use. For individuals expressing interest, detailed study information was provided, and written informed consent was obtained. Participants unable to sign their name (e.g., due to literacy reasons) could signify consent with a thumbprint. Research assistants received rigorous training on administering surveys involving sensitive information, including instructions to pause the survey if another person was within earshot.

The Mass General Brigham Human Research Office/Institutional Review Board, Vanderbilt University Human Research Protections Program/Institutional Review Board, and the Research Ethics Committee at the Mbarara University of Science and Technology granted ethical approval to conduct this study. Additionally, clearance for the study was secured from the Uganda National Council of Science and Technology and the Research Secretariat in the Office of the President of the Republic of Uganda.

2.3. Experimental Design

Participants were randomly assigned to one of 7 distinct vignettes depicting a young man (Supplemental Table 1). Participants were evenly distributed across these 7 treatment arms in a parallel group design using a centrally determined computerized random number generator. To maintain balance across sex and village strata, 16 separate randomization schedules were generated for subsets based on sex and village of residence. Additional details are reported in the Consolidated Standards of Reporting Trials (CONSORT) checklist (Supplemental Text 1). Research assistants and participants were unaware of treatment assignment. (Research assistants could not practically be blinded because they had to administer the survey, so it is possible that they could have perceived differences in the surveys they administered.)

The control vignette presented the basic life story of a typical Ugandan man from the area who has never consumed alcohol or drugs, without further elaboration. The remaining six vignettes followed the same structure but described a typical Ugandan man experiencing AUD in the following situations: 1) untreated AUD; 2) untreated AUD with negative economic impacts for the family; 3) AUD with successful treatment; 4) AUD with initially successful treatment followed by recurrence; 5) AUD with negative economic impacts for the family that is successfully treated; and 6) AUD with negative economic impacts for the family and initially successful treatment followed by recurrence. All vignettes, except the control, included details of the man’s alcohol use and its social consequences, such as public intoxication, verbal altercations, and observable impairment in community settings (Supplemental Table 1).

These vignettes were adapted from two studies (McGinty et al. 2015, Rasmussen et al. 2019), which we reviewed to create draft vignettes comparable in length and similar in narrative arc but in which the narrative was driven by AUD rather than by mental illness or substance use disorder. We then sought input from a group of 9 Ugandan key informants who were asked to review the draft vignettes and suggest revisions to make the vignettes more consistent with their personal perceptions and/or experiences. The vignettes were also reviewed by a qualified Ugandan psychiatrist with expertise treating people with a broad range of mental and substance use disorders. While diagnosis and treatment of psychiatric disorders in Uganda is based on the Diagnostic and Statistical Manual of Mental Disorders, which is taught universally in undergraduate and graduate medical education, the specific manifestations of psychiatric disorders may differ from culture to culture. For example, the narrative of psychotic experiences related to witchcraft is likely to follow a different trajectory in the beliefs and observations of people from the southern United States compared with people from southwestern Uganda (Gaines 1995, Lundberg et al. 2004, Abbo et al. 2008).

Vignettes and associated survey questions were initially composed in English, translated into Runyankore, and then back-translated to English to verify the translated text’s fidelity to the original text. This process involved extensive consultation and pilot testing with key informants and mental health professionals local to the area who had expertise in socio-behavioral and psychiatric research. Vignettes and associated interview survey questions were programmed into laptop computers utilizing the Computer Assisted Survey Information Collection (CASIC) Builder software program for field administration. The experimental procedures were registered with ClinicalTrials.gov (NCT04832321), with the protocol record entered in April 2021.

2.4. Measures

Participants were read one of the 7 vignettes. They were then administered three questions related to their personal stigmatizing attitudes: whether they would allow the man depicted in the vignette to marry into their families, whether they believed the man is suffering from divine punishment, and whether they believed the man brings shame to his family. These questions were designed to elicit three stigma constructs: desires for social distance (Link et al. 1987, Link et al. 2004, Boysen et al. 2019), non-neurobiological attribution of etiology (Pescosolido et al. 2010), and courtesy stigma (Goffman 1963, Angermeyer et al. 2003, Corrigan and Miller 2004). Courtesy stigma is the negative impact that results from being associated with someone who marked by a stigma (Goffman 1963). Each question had 5 possible response options: “Yes,” “No,” “It depends on knowing more details,” “Do not know,” and “Refuse to respond.”

Mirroring the three questions about personal stigmatizing attitudes, participants were also queried about perceived norms regarding these stigmatizing attitudes. Following previously published work about perceived norms related to different health behaviors and health risk behaviors (Perkins et al. 1999, Tsai et al. 2017b, Perkins et al. 2018a, Carey et al. 2020, Perkins et al. 2022a, Perkins et al. 2022b, Larimer et al. 2023), we asked participants to estimate the proportion of people in their village who would allow the man to marry into their families, who would agree that the man is suffering from divine punishment, and who would agree that the man brings shame to his family. The stem component (“your village”) was specified so all participants would have a similar, unambiguous reference group when describing their perceptions about the norms within their villages (Shibutani 1955). These questions assessed the same stigma constructs but focused on perceived norms instead of personal beliefs. Response options for the perceived norm variables included “All or almost all,” “More than half,” “Fewer than half,” “Very few, or no one,” “Don’t know,” or “Refuse to respond.”

2.5. Analysis

For the three outcome variables corresponding to personal stigmatizing attitudes about AUD, responses were coded such that 0 signified an unambiguously non-stigmatizing response and 1 signified a stigmatizing response (i.e., refusal to allow the man to marry into their families, agreement that the man is suffering from divine punishment, and agreement that the man brings shame to his family). The response option of “It depends” was not considered an unambiguously non-stigmatizing response and was therefore coded as a stigmatizing response. Response options of “Don’t know” and “Refuse to respond” were considered missing data. As described in more detail below, only a minority of study participants selected these responses across all outcomes: "depends" (1–9%), "donť know" (0–1%), "refuses" (0–1%).

For the three outcome variables corresponding to perceived norms around AUD stigma, response options were recoded such that 0 denoted perceiving most (more than 50%) people to hold a non-stigmatizing belief and 1 denoted perceiving most (more than 50%) people to hold a stigmatizing belief. The perceived norm outcome variables were dichotomized to simplify the interpretation and enhance the robustness of our analysis due to the limited variation across the four original categories. Merging the top two and bottom two categories allowed for clearer insights and more stable estimates. Again, the response options of “don’t know” (0–2%) and “refuse to respond” (0%) were considered missing data.

We then fitted a series of Poisson regression models specifying each personal belief and perceived norm as the dependent variable and the vignette treatment assignment as the primary exposure of interest. Cluster-correlated robust estimates of variance were used, which allow for incidence rate ratio estimates derived from a Poisson regression model fitted to binary dependent variable data to be interpreted as risk ratios (Zou 2004, Yelland et al. 2011). Marginal effect estimates of treatment assignment and other covariates were used to show effects in absolute probability differences in the outcomes (Norton et al. 2019). To ensure accurate confidence intervals that adjusted for the stratified randomization scheme, we modified treatment estimates for sex and village by including them as covariates in the Poisson models described above. Additional covariates (e.g., age, education, marital status) were not included in the adjusted models to maintain parsimony and to focus on variables most relevant to the study design and primary hypotheses. Stata statistical software was used for data cleaning (version 16, StataCorp LLC, College Station, Tex.). R was used for all data analysis (version 4.4.0, R Foundation for Statistical Computing, Vienna, Austria).

3. Results

Of 1553 participants in the 2018–21 census who were randomized, 1363 participants were re-interviewed in 2021–2022, 32 (2.1%) were incorrectly randomized and excluded, 39 (2.5%) moved out of the parish, 15 (0.97%) died, 28 (1.8%) became ineligible for other reasons (e.g., impaired cognitive or auditory functioning), and 76 (4.9%) were lost to follow up (e.g., refused, could not be found). Participants included 606 (44%) men and 757 (56%) women, of whom 784 (58%) had completed primary school and 912 (67%) were married or cohabiting (Table 1). Participant characteristics stratified by treatment assignment are displayed in Supplemental Table 2.

Table 1.

Participant Demographics (N = 1363)

Variable N (%)
Sex
 Male 606 (44%)
 Female 757 (56%)
Education
 None (no education) 176 (13%)
 Some primary school (P1-P6) 403 (30%)
 Completed primary school (P7) 297 (22%)
 Completed education beyond primary school (S1-S6, vocational training, university) 487 (36%)
Married
 No 451 (33%)
 Yes 912 (67%)
Age Category
 16–25 yrs 159 (12%)
 26–35 yrs 313 (23%)
 36–45 yrs 312 (23%)
 46–55 yrs 270 (20%)
 56+ yrs 293 (22%)
Village
 1 183 (13%)
 2 201 (15%)
 3 187 (14%)
 4 181 (13%)
 5 101 (7%)
 6 196 (14%)
 7 112 (8%)
 8 202 (15%)
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Participants who were assigned to treatment vignettes reported more personal stigmatizing attitudes compared to participants who were assigned to the control vignette regardless of whether the man was described in the treatment vignettes as untreated, treated, or treated with recurrence, and with or without economic. Specifically, participants receiving the treatment vignettes were more likely to refuse to allow the man to marry into their family (79%-96% vs. 22% for control; all p<0.001), more likely to believe that he was receiving divine punishment (35%-42% vs. 5.5% for control; all p<0.001), and more likely to believe he brings shame to his family (77%-92% vs. 10% for control; all p<0.001) (Table 2). Similarly, participants receiving the treatment vignettes were also more likely to perceive that most other village residents had these stigmatizing attitudes (Table 3).

Table 2:

Stigmatizing personal beliefs, by treatment assignment

N** Unwilling for family member to marry Is receiving divine punishment Brings shame on family
Control* 183 41 (22%) 10 (5.5%) 19 (10%)
AUD* 198 175 (88%) 78 (40%) 169 (85%)
AUD Tx* 199 166 (84%) 75 (38%) 179 (90%)
AUD Ec* 188 180 (96%) 74 (40%) 173 (92%)
AUD Ec Tx* 194 154 (79%) 66 (35%) 149 (77%)
AUD Tx R* 200 185 (92%) 83 (42%) 180 (90%)
AUD Ec Tx R* 201 181 (91%) 78 (39%) 183 (91%)
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*

Abbreviations: AUD, vignette depicting alcohol use disorder; AUD Tx, vignette depicting alcohol use disorder that is successfully treated; AUD E, vignette depicting alcohol use disorder with adverse economic impacts; AUD Ec Tx, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated; AUD Tx R, vignette depicting alcohol use disorder that is successfully treated, followed by subsequent recurrence; AUD Ec Tx R, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated, followed by subsequent recurrence.

**

Percentages shown are calculated relative to the N assigned to the treatment arm specified in the row header.

Table 3:

Perception that most others hold stigmatizing personal beliefs, by treatment assignment

N** Most others unwilling for family member to marry Most others believe receiving divine punishment Most others believe brings shame on family
Control* 183 41 (23%) 14 (7.8%) 17 (9.3%)
AUD* 198 180 (92%) 68 (35%) 156 (79%)
AUD Tx* 199 170 (86%) 54 (28%) 158 (79%)
AUD Ec* 188 171 (93%) 77 (42%) 156 (83%)
AUD Ec Tx* 194 160 (84%) 58 (31%) 138 (72%)
AUD Tx R* 200 180 (92%) 65 (33%) 161 (80%)
AUD Ec Tx R* 201 180 (92%) 72 (37%) 167 (84%)
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*

Abbreviations: AUD, vignette depicting alcohol use disorder; AUD Tx, vignette depicting alcohol use disorder that is successfully treated; AUD E, vignette depicting alcohol use disorder with adverse economic impacts; AUD Ec Tx, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated; AUD Tx R, vignette depicting alcohol use disorder that is successfully treated, followed by subsequent recurrence; AUD Ec Tx R, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated, followed by subsequent recurrence

**

Percentages shown are calculated relative to the N assigned to the treatment arm specified in the row header.

The Poisson regression models adjusted for stratification variables yielded consistent findings: all variants of AUD increased stigmatizing responses compared to control. The average marginal effects indicated that participants randomly assigned to an AUD vignette had between a 0.57 (95% Confidence Interval [CI] = 0.43–0.71) to 0.74 (CI=0.58–0.90) increased probability (relative to a probability of 0.22 in the control group) of being personally unwilling to allow the man to marry into their families, between a 0.29 (CI=0.20–0.38) to 0.36 (CI=0.27–0.46) increased probability (relative to a probability of 0.06 in the control group) of personally believing that the man is receiving divine punishment, and between a 0.66 (CI = 0.53–0.80) to 0.81 (CI = 0.67–0.95) increased probability (relative to a probability of 0.10 in the control group) of personally believing that the man brings shame to his family (Table 4). The Poisson regression models for perceived norms yielded a similar pattern of estimates (Table 5). The exponentiated regression coefficients (incidence rate ratios) corresponding to the average marginal effects are shown in Supplemental Tables 3 & 4.

Table 4:

Stigmatizing personal beliefs, average marginal effects (AME) of treatment assignment based on modified Poisson regression

Unwilling for family member to marry
(n=1359)		 Brings shame on family (n=1363) Is receiving divine punishment
(n=1346)
AME 95% CI P-value AME 95% CI P-value AME 95% CI P-value
AUD* 0.66 (0.51, 0.81) <0.0001 0.75 (0.61, 0.89) <0.0001 0.35 (0.25, 0.44) <0.0001
AUD Ec* 0.74 (0.58, 0.90) <0.0001 0.81 (0.67, 0.96) <0.0001 0.34 (0.25, 0.44) <0.0001
AUD Ec Tx* 0.57 (0.43, 0.71) <0.0001 0.66 (0.53, 0.80) <0.0001 0.29 (0.20, 0.38) <0.0001
AUD Ec Tx R* 0.69 (0.54, 0.84) <0.0001 0.81 (0.67, 0.95) <0.0001 0.34 (0.24, 0.43) <0.0001
AUD Tx* 0.61 (0.47, 0.76) <0.0001 0.80 (0.66, 0.94) <0.0001 0.33 (0.24, 0.42) <0.0001
AUD Tx R* 0.70 (0.55, 0.85) <0.0001 0.80 (0.66, 0.94) <0.0001 0.36 (0.27, 0.46) <0.0001
Female −0.0021 (−0.10, 0.09) 0.97 0.022 (−0.072, 0.12) 0.65 0.10 (0.036, 0.16) 0.0020
Village 2 −0.0033 (−0.19, 0.18) 0.97 0.014 (−0.16, 0.19) 0.88 −0.040 (−0.16, 0.075) 0.49
Village 3 −0.061 (−0.24, 0.12) 0.51 −0.013 (−0.19, 0.16) 0.89 0.027 (−0.10, 0.15) 0.67
Village 4 −0.052 (−0.23, 0.13) 0.57 0.0019 (−0.18, 0.18) 0.98 −0.020 (−0.14, 0.10) 0.74
Village 5 −0.038 (−0.26, 0.18) 0.73 0.027 (−0.19, 0.24) 0.80 −0.010 (−0.15, 0.13) 0.89
Village 6 −0.0079 (−0.19, 0.17) 0.93 0.059 (−0.12, 0.24) 0.52 −0.0072 (−0.13, 0.11) 0.91
Village 7 −0.025 (−0.24, 0.19) 0.81 0.087 (−0.12, 0.30) 0.42 −0.074 (−0.20, 0.056) 0.27
Village 8 −0.0078 (−0.19, 0.17) 0.93 0.066 (−0.11, 0.24) 0.46 0.055 (−0.067, 0.18) 0.38
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*

Abbreviations: AUD, vignette depicting alcohol use disorder; AUD Tx, vignette depicting alcohol use disorder that is successfully treated; AUD E, vignette depicting alcohol use disorder with adverse economic impacts; AUD Ec Tx, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated; AUD Tx R, vignette depicting alcohol use disorder that is successfully treated, followed by subsequent recurrence; AUD Ec Tx R, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated, followed by subsequent recurrence.

Table 5:

Perception that most others hold stigmatizing personal beliefs, average marginal effects (AME) of treatment assignment based on modified Poisson regression

Most others unwilling for family member to marry (n=1341) Most others believe brings shame on family (n=1361) Most others believe receiving divine punishment (n=1333)
AME 95% CI P-value AME 95% CI P-value AME 95% CI P-value
AUD* 0.69 (0.54, 0.84) <0.0001 0.69 (0.56, 0.83) <0.0001 0.28 (0.18, 0.37) <0.0001
AUD Ec* 0.70 (0.55, 0.86) <0.0001 0.74 (0.60, 0.87) <0.0001 0.34 (0.24, 0.45) <0.0001
AUD Ec Tx* 0.62 (0.47, 0.76) <0.0001 0.62 (0.49, 0.75) <0.0001 0.23 (0.14, 0.32) <0.0001
AUD Ec Tx R* 0.69 (0.54, 0.85) <0.0001 0.74 (0.61, 0.87) <0.0001 0.29 (0.20, 0.38) <0.0001
AUD Tx* 0.64 (0.49, 0.79) <0.0001 0.70 (0.57, 0.83) <0.0001 0.20 (0.11, 0.28) <0.0001
AUD Tx R* 0.69 (0.54, 0.85) <0.0001 0.71 (0.58, 0.84) <0.0001 0.25 (0.16, 0.34) <0.0001
Female 0.010 (−0.087, 0.11) 0.85 −0.0030 (−0.09, 0.086) 0.95 0.041 (−0.018, 0.10) 0.18
Village 2 0.018 (−0.17, 0.20) 0.85 −0.0017 (−0.17, 0.16) 0.98 −7e-04 (−0.11, 0.10) 0.99
Village 3 −0.048 (−0.23, 0.13) 0.61 −0.020 (−0.19, 0.15) 0.81 0.078 (−0.037, 0.19) 0.18
Village 4 −0.050 (−0.23, 0.13) 0.59 0.056 (−0.12, 0.23) 0.52 0.035 (−0.076, 0.15) 0.53
Village 5 −0.010 (−0.23, 0.21) 0.93 −0.014 (−0.21, 0.19) 0.89 0.074 (−0.065, 0.21) 0.30
Village 6 0.016 (−0.17, 0.20) 0.86 0.042 (−0.13, 0.21) 0.62 0.036 (−0.073, 0.14) 0.52
Village 7 0.022 (−0.19, 0.24) 0.84 0.12 (−0.080, 0.32) 0.24 0.040 (−0.090, 0.17) 0.54
Village 8 −0.012 (−0.19, 0.17) 0.90 0.054 (−0.11, 0.22) 0.52 0.055 (−0.054, 0.16) 0.33
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*

Abbreviations: AUD, vignette depicting alcohol use disorder; AUD Tx, vignette depicting alcohol use disorder that is successfully treated; AUD E, vignette depicting alcohol use disorder with adverse economic impacts; AUD Ec Tx, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated; AUD Tx R, vignette depicting alcohol use disorder that is successfully treated, followed by subsequent recurrence; AUD Ec Tx R, vignette depicting alcohol use disorder with adverse economic impacts that is successfully treated, followed by subsequent recurrence.

While study participants who received all AUD vignettes—regardless of successful treatment, adverse economic impact, or recurrence—showed significantly higher stigma compared to those who received the control vignette, we also examined differences between various AUD vignette types to directly test our hypotheses about treatment effectiveness and economic impact. In general, study participants presented with vignettes about AUD with negative economic impacts had higher levels of stigma compared to study participants presented with vignettes about AUD (and no information about economic impacts). Successful treatment reduced stigma, while initial treatment success followed by recurrence worsened stigma (relative to successful treatment with no information about recurrence). Also in general, the positive effects of successful treatment, and the negative effects of recurrence and adverse economic impacts, were larger for the outcomes “unwillingness for a family member to marry” and “brings shame upon family” compared with the outcome “is receiving divine punishment.” However, because the effect of AUD stigma itself (across all treatment conditions regardless of modifier, compared with control) was so large, the magnitudes of the differences attributable to treatment effectiveness and economic impact were relatively small in comparison.

4. Discussion

In this randomized, population-based survey experiment conducted in a rural region of southwestern Uganda, we found evidence of pervasive stigma attached to AUD. Large majorities of participants reported an unwillingness to have someone with AUD marry into their families and reported a belief that people with AUD bring shame to their families; nearly half reported a belief that people with AUD are receiving divine punishment. The randomized design enables a causal interpretation of our estimates. Participants who were randomly assigned to be read a vignette depicting a man with AUD were more likely to report stigmatizing attitudes toward AUD compared with participants who received the control vignette. There was negligible amelioration of the stigmatizing attitudes toward AUD (relative to the overall stigmatizing effect of being assigned to a vignette depicting AUD) when the vignette depicted successful treatment. There was also a negligible exacerbation of the stigmatizing attitudes toward AUD when the vignette depicted initial treatment followed by recurrence, or when the vignette depicted AUD associated with adverse economic impacts on the man’s family. Overall, any additional information contained in the vignette variants had neither a significantly larger nor a significantly smaller effect on the overall stigmatizing attitudes attached to AUD; the estimated marginal effects were very large both in absolute terms and relative to the probabilities in the control group.

Although casual alcohol use is widely accepted in Uganda (Abbo et al. 2016, Ssebunnya et al. 2020), our findings are consistent with literature worldwide demonstrating that AUD is one of the most stigmatized medical conditions (Keyes et al. 2010, Pescosolido et al. 2010, Schomerus et al. 2011, Yang et al. 2017, Nalwadda et al. 2018, Kilian et al. 2021). Compared with data collected in the same population using vignettes about schizophrenia, bipolar disorder, and major depression, a greater proportion of participants in the present study believed that people with AUD brought shame onto their families. However, the proportion of participants reporting that they were unwilling to allow the person to marry into their families and reporting the belief that the person is receiving divine punishment were similar across the two studies (i.e., for AUD and for schizophrenia, bipolar disorder, and major depression) (Rasmussen et al. 2019). Other studies from high-income countries have suggested that AUD is more highly stigmatized than other mental disorders (Schomerus et al. 2011, Schomerus et al. 2013, Barry et al. 2014).

Our primary finding—that portrayals of successful treatment had minimal effect on moderating stigmatizing attitudes toward AUD—did not support our prespecified hypothesis and does not align with similar studies conducted in the United States. These other studies found that portrayals of effective treatment reduced stigmatizing attitudes for different mental illnesses, including substance use disorders (Romer and Bock 2008, Lebowitz and Ahn 2012, McGinty et al. 2015). There are notable cultural and societal differences between Uganda and the United States that could potentially explain the difference in these findings. First, belief in neurobiological etiologies of mental illness is more widespread in the United States (Pescosolido et al. 2010). Although such neurobiological attributions have not been shown to improve mental illness stigma (Pescosolido et al. 2010, Lebowitz and Ahn 2012), Lebowitz and Ahn’s study on the impact of etiology in stigmatizing attitudes and treatment descriptions may clarify the observed inconsistency (Lebowitz and Ahn 2012). Their experiment showed that describing mental illness as having neurobiological origins (rather than psychosocial origins) decreased stigma, but only when an effective treatment was also described. When mental illness was attributed to non-neurobiological causes, providing information about effective treatments had little impact on stigmatizing attitudes. (Lebowitz and Ahn 2012). Second, while access to evidence-based treatment for AUD is suboptimal in the United States (Kelly et al. 2017, Abraham and Yarbrough 2021, Degenhardt et al. 2021, Edmonds et al. 2021), availability is nonetheless much more limited in Uganda. Only 10 registered drug treatment centers are available in Uganda (Namara 2020). The portrayals of successful treatment in the vignettes may not have been sufficient to overcome participants’ experiences or observations of AUD and AUD treatment in their communities, as well as general societal perceptions about the challenges of overcoming addiction. This hypothesis aligns with findings from Uganda, where alcohol use is deeply embedded in cultural practices and spiritual beliefs, making it challenging to change perceptions about AUD and treatment engagement (Rudenstrand and Bäärnhielm 2024).

It should be noted that the treatment depicted in our vignettes emphasized hospital stay, symptom management, and counseling rather than medication-based interventions. This choice reflected the typical treatment approaches available in the Ugandan context but may have influenced participant perceptions. Hospital-based interventions temporarily remove individuals from their communities and family responsibilities, potentially reinforcing perceptions of social disruption. In this cultural context, where family and community obligations are highly valued, the portrayal of treatment requiring hospitalization might not have effectively countered stigmatizing attitudes. Future research should explore whether depicting different treatment modalities, particularly those requiring less separation from family and community, might have greater potential to reduce stigma.

Our findings about how depictions of AUD’s negative economic impacts can worsen stigmatizing attitudes, while modest, deserve further comment. This finding aligns with cultural values in rural Uganda, where economic contribution to family welfare is closely tied to social status and moral evaluation (Sundararajan et al. 2015). This finding is also consistent with qualitative findings from Uganda identifying the negative economic impacts of AUD as being a primary driver of stigmatizing attitudes toward AUD (Ssebunnya et al. 2009, Ssebunnya et al. 2020, Rudenstrand and Bäärnhielm 2024). Community members may be particularly sensitive to AUD's economic disruption, given its potential social impacts that extend beyond personal health. The modest effect size, however, suggests that negative perceptions of AUD are already so entrenched that additional information about its economic harms only marginally increases already high levels of stigma.

The study has several important limitations. First, participants were exposed to brief hypothetical scenarios that lacked detailed context. Effective mental illness destigmatization interventions have emphasized recovery and resilience (Livingston et al. 2012, Clay et al. 2020, Lee et al. 2022). Vignettes with more empathetic components may have had a greater effect on priming study participants to respond to the surveys with less stigmatizing responses. Second, the vignettes all depicted a man of average socioeconomic status in the local context. We made this decision to control for residual heterogeneity. However, the stigma of mental illness has been shown to interact with other identities, such as gender and socioeconomic status (Wirth and Bodenhausen 2009, Kennedy-Hendricks et al. 2016, Lee et al. 2024b). Thus, we are unable to determine whether portrayals of other identities (e.g., a wealthy woman) could have affected participant responses. Third, given the experimental design (and consequent need to measure outcomes using survey items specific to the vignettes), we did not administer standardized scales to measure different aspects of stigma in more detail. Although existing scales could be adapted for the Ugandan setting (e.g., the AUD adaptation of the Perceived Devaluation-Discrimination Scale (Link 1987, Keyes et al. 2010)), they would not fit the context of our experimental design. Fourth, we elected to measure outcomes using survey items with binary response options rather than Likert-type scales (which are often administered with stigma scales in this literature (Link 1987, Keyes et al. 2010)). Doing so likely resulted in a loss of efficiency and reduced our ability to detect statistically significant effects (Cohen 1983, Selvin 1987). However, given the statistical (and substantive) significance of our findings, we are untroubled by the attenuated statistical power. Finally, the findings may not be generalizable to other regions of Africa. That said, the sample is a whole-population sample, and the study site has many similarities to other parts of East Africa.

5. Conclusion

Our findings on AUD stigma have important implications for public health in Uganda and similar settings in Africa. The finding that portrayals of successful treatment did little to ameliorate stigmatizing attitudes suggests that media stories and educational campaigns (e.g., through print, broadcast, Internet) may need to incorporate a diverse set of anti-stigma elements beyond focused information about treatability and treatment availability. While these particular elements are important, our findings suggest they may not be sufficient to reduce the stigmatizing attitudes attached to AUD (and, potentially, to other mental disorders) in this context. Other anti-stigma elements might include information about etiology, contact with people in recovery, support for people to seek treatment, and emphasis on the rights of people with AUD and other mental disorders (Walsh and Foster 2020). The stigma of AUD, and of mental disorders more generally, is a major impediment to treatment and sustained recovery (Wallhed Finn et al. 2014, Probst et al. 2015, Crapanzano et al. 2019, Tsai et al. 2019, Cousin et al. 2022, Krendl and Perry 2022, Finn et al. 2023). More evidence-based interventions need to be tested and adapted to reduce stigmatizing attitudes and improve the lives of people with AUD throughout Africa.

Supplementary Material

Supplemental Tables

Acknowledgements

We thank the HopeNet cohort study participants, without whom this research would not be possible. We also thank members of the HopeNet study team for research assistance; in addition to the named study authors, HopeNet team members who contributed to data collection and/or study administration during all or any part of the study were as follows: Dickson Beinomugisha, Patrick Gumisiriza, Mercy Juliet, Justus Kananura, Allen Kiconco, Michael Matte, and Patrick Lukwago Muleke. We also thank Roger Hofmann of West Portal Software Corporation (San Francisco, CA, USA), for developing and customizing the Computer Assisted Survey Information Collection Builder software program used to collect the survey data.

Funding support:

This study was funded by Friends of a Healthy Uganda and U.S. National Institutes of Health (NIH) R01MH125667. The authors also acknowledge salary support from NIH K24DA061696 (ACT), NIH K01MH115811 (JMP), and NIH R01AA031936 (JMP).

Footnotes

Clinical trial registration: ClinicalTrials.gov (NCT04832321)

Conflict of Interest: ACT and ENS report receiving financial honoraria from Elsevier for their work as Co-Editor in Chief (ACT) and Editorial Assistant (ENS) of the Elsevier-owned journal SSM – Mental Health. The other authors report no conflicts of interest.

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