Experienced Stigma Related to Common Mental Illness and Alcohol Use Disorder in Rural Uganda: A Qualitative Study

Abstract

Background:

Stigma remains a major barrier to mental health care in low- and middle-income countries (LMICs), yet little is known about how stigma operates for common mental illnesses (CMIs) and alcohol use disorder (AUD) in rural Uganda.

Methods:

We conducted 80 in-depth interviews (IDIs) with individuals and family members affected by CMIs (n=34) or AUD (n=46) in Buyende District, Uganda. Interviews were analyzed inductively using the framework method to identify cross-cutting themes.

Results:

Three interlocking themes emerged: Internal Dysphoria, Community Dynamics, and Family Burden. Internalized stigma manifested as denial, concealment, shame, and helplessness. AUD participants resisted moral judgment through denial, while those with CMIs internalized stigma through concealment. Communities perpetuated stigma via misinformation, moralization, indifference, and alienation—framing AUD as moral failure and CMIs as irrational or contagious. Families faced emotional exhaustion, economic strain, and religious or moral conflict. AUD households reported sharper public condemnation and financial collapse, while CMI households experienced chronic caregiving stress and hidden grief.

Conclusions:

Stigma toward people with CMIs and AUD in rural Uganda is pervasive, multilayered, and sustained by moral and structural factors. AUD is publicly moralized, while CMIs are concealed and pathologized. Stigma-reduction strategies should integrate psychoeducation, community and religious engagement, family-centered support, and economic empowerment to disrupt cycles of exclusion and improve care uptake.

Background

Mental and substance use disorders are among the leading contributors to the global burden of disease (1, 2). More than 80% of this burden occurs in low and middle-income countries (LMICs), where health systems remain under-resourced and treatment gaps are as high as 75-85% for common mental illnesses (3–5). In Uganda, mental health, including for substance use disorders, receives less than 1% of the national health budget (6), leaving large rural populations underserved and reliant on a patchwork of traditional and faith-based care providers (7, 8). In rural districts such as Buyende, help-seeking occurs within dense social networks where privacy is limited, and reputational harm can have tangible consequences for social standing, marriage prospects, and access to community-based economic and caregiving support (9, 10). Care pathways are often pluralistic, involving biomedical services alongside faith-based and traditional healers (8), and local explanatory models may draw on social, economic, moral, and spiritual interpretations alongside biomedical understandings (11).

Stigma is a critical barrier to closing these treatment gaps. Public stigma – negative stereotypes and prejudicial attitudes that public hold that can motivate discrimination and social exclusion – along with self-stigma, by which stigmatizing beliefs are internalized, have been shown to delay help-seeking, reduce adherence to care, foster social exclusion, and impose emotional and financial burdens on patients and families (12, 13). Structural stigma, expressed through chronic underfunding and poor quality service delivery and limited availability of specialized services, compounds these challenges (14, 15). Together, these forms of stigma lead to untreated and poorly treated illness, disability, and poverty (4).

Most prior studies of stigma in Uganda have focused on stigma towards people with psychotic disorders (16, 17). Far less is known about how stigma is experienced by people with common mental illnesses (CMIs), such as depression and anxiety, or by people with alcohol use disorder (AUD). Existing research from rural Eastern Uganda suggests that stigma may operate differently across disorders and social roles (18). However, it remains unclear how much evidence from psychosis-focused studies generalizes to rural communities where social visibility is high and care is commonly sought across biomedical, faith, and traditional sectors. In particular, few studies have compared CMIs and AUD side-by-side while incorporating both affected individuals’ and family members’ accounts of lived stigma and stigma management in daily life. Qualitative work shows that community understandings of CMIs and suicidality frequently emphasize interpersonal and economic stressors and the role of community support, highlighting how social relationships and reputation may shape experiences of illness and help-seeking (11). In contrast, AUD is frequently moralized and linked to concerns about irresponsibility, productivity, and harm to family functioning (19), and may also generate stigma toward family members by association (20). Taken together, these findings suggest that stigma may operate through distinct mechanisms across CMIs and AUD in rural Uganda highlighting the need for disorder-specific inquiry to identify actionable intervention targets.

This study addresses these gaps by exploring how individuals and their families in rural Buyende District experience and navigate stigma related to CMIs as contrasted with AUD. By centering their voices, we aim to generate insights that can inform culturally relevant strategies to reduce stigma, thereby reducing barriers in access to mental health care, support families, and foster community integration.

Methods

Study Site

This study was conducted in Buyende District, a rural district in the Busoga region of Uganda with a population of approximately 400,000 people (21). Buyende District was selected for this study because it is representative of many rural areas in Uganda with majority of its residents engaged in subsistence farming (22). Previous research in this region has shown complex patterns of healthcare-seeking, including use of biomedical, religious and traditional spiritual modalities of care (23, 24).

Study Design and Recruitment

This qualitative study employed in-depth interviews (IDIs) to explore mental illness stigma among individuals with CMIs or AUD and their family members. A total of 80 IDIs were conducted: 34 with people with anxiety and depressive disorders (17 individuals and 17 family members) and 46 with people with AUD (23 individuals and 23 family members). Data collection continued until content saturation was achieved, which we operationalized as no new themes emerging across five consecutive interviews.

The study was explained verbally to local leadership and community health workers in Bugoya and Kagulu sub-counties of Buyende District, who assisted in participant recruitment. Participants were also identified from the existing mental illness patient sample at Mpunde Health Center and through referrals by community health workers. Descriptions of CMIs and AUD were provided to local leadership and community health workers to aid case identification. Research assistants screened study participants with the Patient Health Questionnaire (PHQ-9) for depression (25); the Generalized Anxiety Disorder 7-item scale (GAD-7) for anxiety (26); and the Alcohol Use Disorders Identification Test (AUDIT) for alcohol use disorder (27). Positive screens were defined as follows: PHQ-9 with a score of 10 or higher (including a positive response to either question #1 or #2) (28), GAD-7 with a score of 10 or higher (29), and AUDIT with a score of 8 or higher (30). Those screening positive were evaluated with the relevant Mini-International Neuropsychiatric Interview (M.I.N.I.) module(s): Module A for PHQ-9 positives, Module N for GAD-7 positives, and Module I for AUDIT positives. Module administration was conducted by trained research assistants, with oversight from a clinician for diagnostic confirmation. Participants were included if they self-identified as having a mental illness and met M.I.N.I. criteria for one of the three disorders. Self-identification was ascertained by asking participants whether they recognized themselves as having problems with the relevant condition, using locally appropriate terminology developed in consultation with the Lusoga-speaking research assistant and community health workers. If participants met criteria for multiple conditions, they were assigned to the group reflecting their most debilitating condition, as determined by the study team clinician, who was a psychiatric clinical officer.

Inclusion and Exclusion Criteria

Participants were required to be 18 years or older and willing and able to provide informed consent. Individuals with mental illness needed to self-identify as affected and meet M.I.N.I. diagnostic criteria. Exclusion criteria included inability or unwillingness to provide consent, age under 18, and failure to meet both self-identification and diagnostic criteria for a mental illness. Each enrolled individual was asked whether they were willing to identify a family member who was aware of their condition and could be invited to participate; declining to identify a family member did not affect eligibility. In this sample, all participants agreed and identified a family member.

Data Collection

Two trained research assistants—one Ugandan, fluent in English and Lusoga (the local language), and one American—conducted all IDIs. These assistants were bachelor or master-level students, trained in qualitative methods, research ethics, and administration of screening tools. Interviews were conducted at participant-chosen locations, typically homes or community settings, between July 2024 and August 2024. The research team’s composition, including a mix of Ugandan and American researchers with urban and educated backgrounds, likely introduced power dynamics that could have influenced participant responses. Participants, primarily rural residents with limited formal education, might have perceived the interviewers (Ugandan or American) as outsiders or authority figures, potentially leading to social desirability bias or reluctance to share sensitive experiences of stigma. To mitigate this possibility, the Ugandan research assistant led the interview to foster cultural connection, and community health workers, familiar to participants, were present during initial introductions to build trust. Interviews were conducted in Lusoga or English based on participant preference to ensure comfort and accurate expression.

Each potential study participant was approached by the research assistants and a community health worker, who explained the study and sought verbal consent to assess eligibility. For eligible participants, written informed consent was obtained using a form translated into Lusoga by native speakers and back-translated to English to verify fidelity to the original. Participants who could not read or write provided a fingerprint, witnessed by an impartial third party. A separate consent form was used for audio recording to ensure participants explicitly understood the recording procedures. Audio recording was required for participation to support accurate transcription and analysis; all participants consented. Interviews lasted 20 to 60 minutes, were audio-recorded, and later transcribed into Lusoga and translated into English. Interviews that were in English were transcribed directly into English. Recordings were stored on a password-protected, encrypted device. Consistent with local custom, study participants received a transportation reimbursement. Because eligibility required a positive screen on instruments assessing recent symptoms and confirmation via M.I.N.I. diagnostic criteria, enrolled CMI and AUD participants that had active symptoms at the time of enrollment. Those participants were therefore referred for treatment at Mpunde Health Center following the interview. Inquiry focused on participants’ experiences of mental illness stigma, including perceived causes, social impacts, and coping strategies, using semi-structured guides with probing questions to elicit detailed responses.

Analysis

Data were analyzed using the framework method to inductively identify recurring themes (31). Audio-recorded interviews were transcribed verbatim into English, with each transcript reviewed by two independent transcribers to ensure accuracy; discrepancies were resolved through consensus and with reference to recordings. Two or three study team members, including at least one Ugandan and one non-Ugandan researcher, familiarized themselves with the initial three to five transcripts per participant group (individuals and family members) and independently applied descriptive codes to passages reflecting key concepts, such as concealment or social rejection. When cultural or linguistic ambiguities arose, the team consulted original interviewers to ensure accurate interpretation.

The study team met to compare initial codes, reaching consensus on a standardized codebook to apply to all subsequent transcripts, which were coded by groups of two or three team members. Codes were grouped into categories, forming an analytical framework that was iteratively refined as new codes emerged. This framework was converted into themes and subthemes, organized into a matrix to facilitate comparison across participant groups, ensuring systematic representation of stigma-related narratives. To ensure analytical rigor, we employed independent coding by multiple team members with consensus-based reconciliation, audit trail documenting coding decisions and framework revisions, and regular debriefing sessions in which team members discussed emerging interpretations and challenged assumptions. Reflexivity was operationalized through ongoing discussion of how the researchers’ positionalities, including the team’s mix of Ugandan and American, clinical and non-clinical backgrounds, may have shaped data interpretation. The inclusion of at least one Ugandan team member in each coding pair helped surface cultural nuances that might otherwise have been overlooked.

Ethical Considerations

All research procedures were approved by the institutional review boards (IRBs) of Yale University in the U.S. (2000034605) and The AIDS Support Organization in Uganda (TASO-2023-222). Consistent with national guidelines, we obtained clearance to conduct the study from the Uganda National Council for Science and Technology (SS1860ES). This study was conducted in accordance with the principles of Declaration of Helsinki.

Results

The qualitative interviews revealed three interlocking themes: Internal Dysphoria, Community Dynamics, and Family Burden. Each theme included several subthemes that further clarify how stigma shapes their lives, which we illustrated using participants’ voices alongside analytic interpretation to show both convergence and divergence across conditions. Basic demographic information on gender and average age can be found in Table 1.

Table 1.

Demographics of Participants

Participant Group	N	Average Age	Female, n (%)	Male, n (%)
AUD	23	45.6	5 (21.7%)	18 (78.3%)
AUD Family	23	35.6	17 (73.9%)	6 (26.1%)
CMI	17	44.0	9 (52.9%)	8 (47.1%)
CMI Family	17	37.6	12 (70.6%)	5 (29.4%)

Theme 1: Internal Dysphoria

Stigma first manifested as psychological pain at the level of the individual, shaping how participants viewed themselves and responded to their condition. We identified three interrelated experiences—minimization/denial or concealment, shame, and helplessness—that together reinforced their social isolation.

Denial vs. Concealment

For many participants, stigma first appeared as a personal struggle to resist or hide their condition. AUD participants often denied the severity of their drinking, framing it as moderate or manageable:

“No, I don’t drink too much, and it’s not like I take alcohol the whole day.” – 40 year old woman with AUD

Because minimization can also reflect limited insight or social desirability, we interpreted minimization as stigma-related only when participants explicitly linked it to fear of judgment, labeling, or reputational harm, or described active efforts to avoid being seen. For example, one participant described withdrawing from close relatives due to embarrassment and fear of being perceived negatively:

“I will fear and feel embarrassed sitting near them. I don’t want them to see me like this.” – 44 year old man with AUD

Accordingly, minimization sometimes appeared to function as a stigma-management strategy, even as it could also coexist with limited recognition of alcohol-related harm. In several cases, participants both minimized their drinking while at the same time describing conflict or harm resulting from their drinking, suggesting limited recognition of the problem. In contrast, CMI participants described quiet concealment rather than outright denial, seeking to avoid gossip or public exposure:

“Even if people see me, I can’t show it on the surface. Whatever is happening, I keep it on the inside.” - 32 year old woman with CMI

Other participants made this interpretive link explicit, describing concealment as a way to avoid becoming “talked about” in the community:

“I don’t want to be talked about. I don’t want them to know what is happening to me.” – 80 year old woman with CMI

Such self-isolation may have preserved their dignity but also concealed their illness, potentially reducing opportunities to reach out to others for support.

Shame

Shame was nearly universal. For people with AUD and their families, shame was often tied to public disruption and perceived loss of respect or status in the community:

“I feel bad because I don’t want people to know about what’s happening in my home.” – 45 year old woman, family member of person with AUD

CMI participants, similarly, framed their shame around fear of gossip and judgment:

“When I feel bad, I just sleep it off. I don’t tell anyone.” - 28-year-old man with CMI

Helplessness

AUD participants described alcohol as their only reliable mechanism for coping with stressors:

“Apart from alcohol, I don’t think there’s anything else that makes me happy” - 45 year old man with AUD

CMI participants highlighted helplessness in the face of poverty and caregiving demands:

“My thoughts are a lot about poverty.. I am worried about what will happen” – 32 year old man with CMI

Both CMI and AUD were associated with helplessness, but people with CMI commented about how structural hardship compounds stigma, reinforcing a sense of inevitability about their suffering. Internal struggles were marked by parallel feelings of denial, shame, and helplessness across groups, but AUD narratives emphasized resisting community judgment, while CMI narratives emphasized hiding suffering.

Across conditions, people experiencing illness most often emphasized embarrassment, rumination, and concealment, whereas family members more often framed these internal struggles in terms of household reputation and difficulty of addressing the problem openly.

Theme 2: Community Dynamics

Beyond the individual, stigma was sustained by the broader social environment. Community dynamics reflected misinformation, moralization, indifference, enabling, alienation, and abuse. Together, these forces reinforced exclusion and shaped how families and individuals navigated daily life.

Misinformation and Moralization

Communities often misattributed symptoms to moral or spiritual failure. We use moralization to refer to interpretations that frame the condition as a personal failing or wrongdoing (e.g., irresponsibility, lack of self-control) experienced through blame, loss of respect, and social sanction. CMI participants reported being seen as irrational:

“Those who don’t know what happened would say they don’t know what is wrong with my head. That I don’t know how to think or reason.” – 32 year old woman with CMI

Such misconceptions cast mental illness as a defect of character, justifying exclusion. For AUD, moralization frequently framed drinking as a choice or vice rather than illness:

“(Why is she an alcoholic?) Nothing. There is nothing wrong. She just likes drinking.” – 45 year old man, family member of person with AUD

Misinformation about CMIs and moralization of AUD converged to the same social judgment, but the content differed: people with CMIs felt they were portrayed as impaired or dangerous, while people with AUDs felt they were perceived as engaged in willful misconduct.

Indifference

People with CMIs and their family members felt that their communities sometimes offered superficial sympathy that did not translate into meaningful action. AUD participants described being deliberately overlooked:

“The neighbors… out of a hundred, you find ten who will greet you and ninety pretend they have not seen you.” – 45 year old man with AUD

Such everyday avoidance left people with AUD without practical support. Among CMI participants, communities sometimes offered limited support:

“They (Family and Community) just collected money, whatever they had 100 or 200 shillings maybe they gave me and told me to start with that as I look after the kids.” – 38 year old woman with CMI

Participants and family members described indifference not only as limited material support, but as being kept at a distance – watched from afar, avoided in day-to-day interaction, and left without concrete assistance. One family member described this distance explicitly:

“They just look at him from afar… They didn’t do anything for him.” – 31 year old woman, family member of person with CMI

They felt that these gestures acknowledged their need but did not offer sustained engagement. Both experienced this stigma as indifference. In other accounts, this lack of sustained engagement was interpreted as others “giving up,” reinforcing feelings of abandonment:

“I failed to quit (alcohol), and they also gave up on me.” – 65 year old man with AUD

Together, these excerpts show how participants interpreted avoidance, distant observation, and one-off contributions as evidence of non-engagement rather than the absence of resources.

Alienation and Abuse

Alienation represented the most severe community response. AUD participants described rejection and even violence:

“One day, I took alcohol, and fought people, and they beat me up badly… I think I did some improper things, so that’s why they beat me.” – 32 year old man with AUD

The stigma was not contained solely to the person with AUD. Family members also recounted harsh judgment from the community for helping a family member with AUD:

“Most of them treat me badly and see me badly because I am helping someone who drinks alcohol. Some people wanted to steal land from her because they thought no one would be there to help her.” – 32 year old woman, family member of a person with AUD

Several accounts also suggested a gendered dimension to AUD stigma, in which women who drank were described as attracting heightened hostility. For example, one family member described community mistreatment of a woman with AUD:

“To those who don’t know her, they beat her up. They mistreat her.” – 32 year old woman, family member of a person with AUD

These accounts show how social ties fracture under stigma towards AUD, producing moralistic criticism and risk of harm. Families of people with CMI reported less outward criticism and more silent community and kinship ostracism related to contagion fears:

“All the family members have deserted us ever since our son became sick. They don’t even want us to visit them because they say this sickness will get them also.” – 40 year old woman, family member of a person with CMI

Community responses ranged from gossip and moral judgment to overt rejection. AUD was more often framed as willful misconduct, sometimes leading to punishment especially in women, whereas CMI was seen as pitiable or dangerous, prompting avoidance. These dynamics deepened isolation for both groups and strained their relationships with neighbors and extended family.

Theme 3: Family Burden

Finally, stigma was perceived as placing heavy burdens on households, affecting emotional well-being, economic stability, and spiritual life. Families frequently reported emotional strain, financial hardship, and moral or religious conflicts that reshaped relationships and coping strategies.

Emotional Strain

Families described profound emotional tolls. Family of people with AUD expressed fatigue and pity from the community:

“They just feel sorry for us and pray for us to get well soon.” – 43 year old woman, family member of a person with AUD

This pity, while compassionate, often left families feeling helpless rather than empowered to act. Other family members of those with AUD spoke of frustration and resignation:

“Sometimes we keep quiet about it because if you talk, he will fight you.” – 46 year old man, family member of a person with AUD

This highlights the tension between protecting harmony and addressing the behavior. Family members of people with CMI voiced quiet resignation and grief:

“I don’t do anything; I just feel bad and console him.” – 24 year old woman, family member of a person with CMI

Such passive coping and hidden sadness reflect limited resources and few avenues for emotional relief. Emotional strain affected nearly every household. For AUD, this strain was complicated by fear of conflict or violence, while for CMIs it manifested as sadness and worry that quietly permeated family life.

Financial Strain

Economic strain was a recurrent theme. Families of people with AUD reported loss of income and assets:

“We lack money, food. It’s hard to pay our children’s school fees and their basic needs since he lost all his businesses.” – 40 year old woman, family member of a person with AUD

For households with a person with CMI, the financial burden came from the loss of productive labor:

“Because she is sick, I don’t have time to go to the garden. I stay at home to watch her.” – 24 year old woman, family member of a person with CMI

This reveals how caregiving disrupts livelihood activities and perpetuates poverty. Financial hardship was both a cause and consequence of mental illness stigma. AUD narratives emphasized money lost through alcohol consumption and business collapse, whereas CMI narratives emphasized the opportunity costs of caregiving.

Religious and Moral Conflicts

Adding complexity were religious and moral conflicts often described by participants, where mental illness clashed with deeply held beliefs, creating tension within families. Stigma framed AUD or CMI as moral failings or divine will, heightening these conflicts. A family member from a Muslim household stated:

“We are Muslim family, so drinking is an abomination.” – 20 year old man, family member of a person with AUD

This moral framing created guilt for families with AUD and sometimes motivated punitive responses. Christian participants echoed similar sentiments, noting that drinking conflicted with church teachings and community expectations:

“The pastor talked to us and said drinking is a sin. People now look at our family differently.” – 33 year old woman, family member of a person with AUD

Such comments reveal how Christian, like Muslim moral codes also reinforced stigma, contributing to critical social judgment. In some CMI cases, faith served as a coping resource rather than a source of condemnation:

“Yes, we counsel him. Sheikhs also counsel him at mosques.” – 24 year old woman, family member of a person with AUD

Religious and moral narratives shaped whether families experienced stigma as condemnation or consolation. AUD families were more likely to face moral blame from both Islamic and Christian frameworks, while CMI families sometimes found spiritual support that reframed illness as part of divine will.

Family burden operated on emotional, economic, and moral levels. AUD households faced sharper moral condemnation and direct financial collapse, while CMI households faced ongoing emotional worry, opportunity costs, and caregiving strain. These burdens amplified stigma and shaped the daily lives of participants.

Discussion

Our qualitative study conducted in a rural Ugandan community found that stigma toward people with AUD and CMIs is multifaceted and operates at three interlocking levels: internal struggles, community dynamics, and family burden. At the individual level, participants with AUD frequently denied or minimized their drinking, resisting labels, while those with CMIs tended to conceal symptoms and withdraw from social contact to avoid gossip. Shame permeated both groups, though AUD participants often described a more public erosion of social standing, whereas CMI participants internalized distress and silence. Feelings of helplessness were common across conditions, with alcohol described as the only reliable coping mechanism among AUD participants and poverty and caregiving demands dominating the concerns of those with CMIs.

At the community level, stigma was reinforced through misinformation, moralization, superficial sympathy, enabling, and alienation. People with CMIs were frequently viewed as contagious or irrational, justifying avoidance and gossip, while people with AUD were viewed as having moral failings, sometimes resulting in physical punishment or abandonment. Interestingly, communities simultaneously condemned and enabled drinking behavior, with some peers providing alcohol despite its known harms. Families carried significant emotional, financial, and moral burdens. AUD households reported sharper moral condemnation, business loss, and domestic conflict, whereas CMI households endured persistent worry, caregiving strain, and foregone work. Religious frameworks—both Muslim and Christian—were prominent, often framing drinking as sinful but occasionally providing consolation and counsel for families affected by CMIs.

These findings build on prior work from rural Uganda showing that communities commonly attribute mental illness to spiritual or moral causes, and that stigma is expressed through avoidance, gossip, and other sanctions, shaping care-seeking pathways (11, 32). Our results extend this work by showing how these processes play out differently for CMIs vs. AUD. For alcohol use, our data are consistent with Ugandan studies documenting that drinking is widely socially accepted until it becomes disruptive or harmful, at which point condemnation and social sanctions rise—helping explain the highly moralized stigma our participants with AUD described (33). This pattern also mirrors population-level evidence that alcohol dependence is more stigmatized (with greater blame and desired social distance) than other mental disorders (18, 34). In contrast, for CMIs, stigma often takes the form of concealment and non-disclosure to avoid labeling and gossip, echoing qualitative evidence that people with depression deliberately keep symptoms private, even though secrecy can deepen isolation (35). Finally, while family narratives in our data primarily emphasized caregiving burden, some family members described affiliate stigma (or courtesy stigma) and being judged because of their association with the affected person, underscoring the need for supports that address both the individual and the household (36).

This study has several strengths. We used validated screening instruments followed by M.I.N.I. confirmation to ensure accurate classification and triangulated perspectives from individuals and family members. However, limitations include the single district setting, which may limit generalizability, and possible social desirability bias. Power dynamics between interviewers and participants could also have shaped responses – for example, participants may have underreported alcohol use or sensitive experiences to avoid judgment, or given answers they thought were desirable to educated interviewers from both Uganda and the United States. We also did not consistently record participants’ recruitment source, comorbid conditions, or (for family members) exact relationship to the affected individual, which limited our ability to stratify themes by these characteristics. Additionally, translation from Lusoga to English may have led to subtle loss of meaning. We grouped depression and anxiety together under CMIs, which reflects overlapping stigma experiences but precludes disorder-specific conclusions. We made this decision a priori because (1) depression and anxiety are highly comorbid (37); (2) the study was designed to compare CMIs vs. AUD rather than to distinguish depression versus anxiety; and (3) in this setting, participants often described overlapping distress and stigma processes that were not consistently differentiated by disorder label.

Our findings carry several implications for research and practice. Stigma-reduction interventions for AUD should focus on reframing alcohol problems as treatable health conditions rather than moral failings and should engage religious and community leaders to shift prevailing narratives. Economic support programs could buffer the household financial collapse commonly associated with AUD, while also potentially addressing the stigma associated with loss of labor productivity with CMIs, potentially similar to how anti-stigma interventions for people with HIV have been framed (38–40). For CMIs, interventions may emphasize psychoeducation to dispel contagion myths, normalize open discussion of psychological distress, and provide families with coping tools to reduce caregiver burden. For both groups, community education campaigns and family-centered programs offering psychosocial support and conflict mediation could mitigate stigma and improve engagement with care. Importantly, our results suggest that the drivers of stigma differ by condition, implying that interventions should be matched to mechanisms: for AUD, moralization and blame point to moral reframing alongside household economic buffering; for CMIs, misconceptions about danger/contagion and reputational concerns point to psychoeducation, normalization of distress, and strategies that reduce concealment and isolation.

In conclusion, stigma toward people with AUD and CMIs in rural Uganda is layered and reinforcing, silencing individuals, excluding them from community life, and straining households. While mechanisms overlap, AUD is more publicly moralized and sanctioned, whereas CMIs are hidden and pathologized. Addressing these patterns requires integrated, multilevel approaches that combine psychoeducation, moral reframing, family and community support, and economic empowerment to break the cycle of stigma and enhance treatment uptake.

Data Statement

Data is available upon reasonable request to corresponding author.