Introduction

Rationale

Schizophrenia, an officially recognized mental disorder classified in the DSM-V, profoundly impacts individuals' cognition, emotions, and behavior. As a mental disorder, it assumes a significant role in the complex web of cultural factors that surround it. These cultural factors contribute to the normalization of auditory hallucinations, resulting in cultural members perceiving these bizarre experiences with a reduced sense of distress and an expanded range of symptoms. The impact of cultural influences extends beyond the well-known symptoms of catatonic behavior, disorganized speech or behavior, and negative emotions [1].

It also encompasses manifesting auditory hallucinations and perceiving nonexistent objects, leading individuals with schizophrenia to process reality in a distinct manner compared to others. The interplay between cultural factors and schizophrenia presents a complex and nuanced relationship, often blurring the boundaries between them and making it challenging to discern their individual contributions. Recognizing the need to shed light on this intricate connection, the research group has undertaken a comprehensive literature review to provide a thorough understanding of the nature of schizophrenia and the coexisting cultural beliefs, practices, and experiences in specific regions [2]. By delving into this multidimensional exploration, the reviewers clarify the complexities and interrelationships between schizophrenia and culture, ultimately contributing to a more comprehensive understanding of this mental condition [3].

Objectives

The subjects in this literature review include the persons that experience a culture variation from the psychologically diagnosed schizophrenic manifesting a certain culture that overlaps and interrelates with the nature and criteria of DSM-V classified disorder, schizophrenia.

• To gather data and identify the cultural factors and the associated stigma that interrelates with the DSM-V classified disorder, schizophrenia.
• To determine the relevance of cross-cultural diagnosis in the field of mental health.

Literature Review

The relationship between culture and schizophrenia shows extensive studies have been conducted on auditory voices and stigma in different cultures, revealing a common understanding in the mental health field that Schizophrenia is characterized by the perception of nonexistent auditory hallucinations, with existing literature comparing and contrasting the impact of cultural, religious, and metaphysical beliefs on the presentation of the disorder across diverse societies globally.

In cultural variation, it significantly impacts the diagnosis and treatment of schizophrenia, as a lack of awareness among the general population hinders symptom recognition. The understanding and perception of the illness are influenced by beliefs and local culture, and this cultural variation can potentially result in distorted or erroneous diagnoses. Moreover, psychiatrists themselves, influenced by their own cultural background and the cultural context of their patients, may introduce cultural biases during the diagnostic and treatment processes [4].

Furthermore, the influence of culture on stigma and interpretive frameworks is evident, as it impacts an individual's participation in activities that establish social norms. The stigmatization of individuals with schizophrenia is shaped by cultural variations, which can be influenced by direct or indirect interactions with other cultures. Moreover, cultures have a profound impact on people's lives, behaviors, and the formation of their worldviews. Specific examples of cultural differences in the understanding and management of schizophrenia and stigma can be observed in African-Caribbean, Black-African, and Arab communities.

Individuals with schizophrenia encounter challenges and impediments, including difficulties in obtaining employment and professional positions due to stigma and the perception of reduced competitiveness. Developing a multicultural understanding of mental health is essential for effectively engaging with ethnic minorities and addressing the stigma associated with psychosis. Neglecting cultural and social variations in mental illness can lead to the pathologizing of normal behaviors and the medicalization of cultural contexts and reasonable responses to adverse circumstances [5].

The literature review delves into the variations found in the cross-cultural diagnosis of schizophrenia, examining how multiculturalism and differences among the criteria resembling those of the DSM-V impact the diagnosis process. The reviewers had meticulously compiled relevant literature and studies, resulting in a comprehensive understanding of the correlation between cross-cultural diagnosis and schizophrenia (Figure 1).

Methodology

Protocol and registration

Comprehensive search from key article databases, namely Sage Journals, MedKnow, the Health Research Authority, Cambridge University, Frontiers, and the Psychosis Research Unit, was conducted to gather relevant literature for a literature review on cultural aspects of schizophrenia.

Eligibility criteria

In this comprehensive study, the reviewers aimed to address the impact of culture on the understanding and perception of mental illness, specifically focusing on schizophrenia. To ensure a thorough analysis, this study was limited to articles, journals, books, and research materials published between 2015 and 2023, encompassing the field. This systematic review involved gathering extensive information on various aspects, including culture, culture-bound syndrome, and cultural perspectives related to schizophrenia. By exploring these dimensions, they aimed to establish the existence of significant issues and variations in beliefs surrounding mental illness, particularly schizophrenia. Every inclusive coverage was studied which dealt with the stigma associated with schizophrenia in various cultures [6]. Studies conducted in Turkey, the Caribbean, and India were compared to patients with schizophrenia in the United States. Numerous comparisons of various cultural perspectives on the beliefs, causes, behavioral effects, and therapies of schizophrenia were also made. Studies that focused on non-psychiatric illnesses or did not address cultural concerns in schizophrenia were excluded, as were conceptual or review studies [7].

Sources of information

The aforementioned studies were sourced from Sage Journals, MedKnow, the Health Research Authority, Cambridge University, Frontiers, and the Psychosis Research Unit, were conducted within the timeframe limited to those conducted from 2015 to 2022. The most recent search conducted was on August 16, 2022.

Survey

The initial step of the paper is to see original publications about auditory hallucinations associated with schizophrenia as well as culturally relevant manifestations of schizophrenia with its stigma. The reviewers were guided by keywords schizophrenia, mental illness, and cultural issues. They conducted literature reviews from databases such as Sage Journals, MedKnow, the Health Research Authority, Cambridge University, Frontiers, and the Psychosis Research Unit, with the sole exception of the latter article's year of publication.

Study selection

Five reviewers individually went through each study’s title and abstract to check for relevance. A free online word processor known as Google Docs was used to enter all the relevant citations that were chosen so as to exclude redundancies. All potentially relevant papers' complete texts were retrieved, and each of the thirteen (13) studies that was chosen underwent an in-depth review by at least two separate reviewers to ensure that the study qualified for selection. Additionally, a thorough search of the citations of all accepted initial studies was done.

Data collection

The reviewers visited several studies for data inclusion. Used where studies where the authors' ways of extracting data from original literature sources were discussed, and studies where the reviewers actually carried out the investigation. For more objective data, a semi-structured interview called the Indiana psychiatric illness interview was used to obtain illness narratives. An EM interview catalog and a brief EM interview were other tools that the reviewers used to elicit EMs. Furthermore, to validate the EM data, it is deemed important that development and improvement of instruments to research patient views, such as "insight," which can elicit a variety of EMs of illnesses, their attribution, and help-seeking, is urgently needed [8].

To gain light on cultural differences, the reviewers gathered data from 13 studies from different publications. The study on cultural differences in psychosis and its role of causal beliefs and stigma in White British and South Asians by Mirza et al., aimed to compare Western and non-Western cultures regarding their beliefs about the causes of mental illness and the associated stigma. Specifically, it focused on ethnic differences in psychosis among South Asians living in the United Kingdom, which is predominantly White. The participants' ethnic identity was determined through self-reporting. The study excluded individuals who could not speak or understand English since all measures were in English. Out of the 205 participants, 32 were excluded because they did not identify themselves as either White British or South Asian. To address the unequal sample sizes, a matching sample size was used, randomly selecting 64 cases from the 109 participants in the White British group. This resulted in a final analysis sample of 128 participants [9].

Another research method employed to collect data on auditory hallucination was a qualitative comparative study of Edge conducted to recruit approximately 40 individuals who experience distressing voices and those who have non-distressing voices (20 participants in each group), with a subset of 20 individuals (10 from each group) participating in a qualitative study. The researcher employed various tasks and measures to investigate differences between these two groups, aiming to gain insights into why some voices were perceived as distressing while others were not. This investigation included exploring beliefs about voices, gathering information about important life goals and any potential conflicts related to these goals, and examining the content and characteristics of the voices. Additionally, the researcher delved into how individuals made sense of their experience of hearing voices, with specific attention given to the influence of culture and spirituality [10].

Face-to-face interviews served as the primary method of data collection for two surveys that Angermayer et al., utilized. The interview, which was created in Germany and has previously been used in several surveys, was used twice with identical question wording and order. Respondents were given a scenario at the beginning of the interview that detailed a mental health situation without a clear diagnosis. Respondents were then questioned in order to find out their views about the person depicted in the vignette as well as their beliefs regarding the disorder indicated in it. For this particular study, a translator translated the interview into colloquial Arab.

To find any discrepancies between the original and the translation, a bilingual panel examined the translation. The panel then compared the back-translated interview with the original after it had been translated. If there were any significant differences, they were discussed until the two versions were equal [11].

The use of online survey was made by Altweck et al., for the study on mental health literacy, which focused one participant’s cross-cultural knowledge and attitudes on depression, schizophrenia, and generalized anxiety disorder. A website for creating surveys was used to produce the online survey for the purpose of the study. Participants were invited to take part in the study, which sought to learn more about what people believed and understood about mental health.

The only available study resources were in English. The survey link was disseminated via a number of platforms, including the intranet site of a London University, social networking websites, and Amazon Mechanical Turk. To assure the integrity of the data, steps were made to reward survey respondents with $0.30 and to prevent repeated entries by examining IP addresses.

Data items

The data items in this paper have key concepts verbalized in the objectives. This includes variables such as cultural factors, stigma, and cross-cultural diagnosis and content relation to the aforementioned variables. The study of Whaley covered cultural bias in the US is thought to be the reason why African Americans are diagnosed with schizophrenia at a higher incidence than other racial groups. While this population has a 2.1 percent rate of diagnosed schizophrenia, Americans of European origin have a 1.4 percent incidence. However, Cochrane and Sashidaran offer a contrary viewpoint, claiming that the problems with immigrants' and refugees' mental health brought on by racism and poverty were more likely to be a cause of poor mental health. According to this view, their challenging personal circumstances should be blamed instead of their culture itself. Due to cultural bias, it is frequently perceived as a problem specific to one culture, but in reality, the issues are racism and poverty [12].

In some cases, cultural bias might make it more difficult to diagnose schizophrenia. While the core symptoms of schizophrenia may be similar to those seen in other cultures, Mesotho et al., found that there were additional somatic symptoms such as headaches, palpitations, dizziness, and excessive sweating in the Sesotho-speaking population in South Africa. For psychiatrists who frequently use Western diagnosis guides like the DSM-5 or the ICD-11, which are widely used in South Africa, these symptoms can be confusing [13].

Another data item screened among the studies was the cultural differences in psychosis; the role of causal beliefs and stigma in White British and South Asians by Mirza et al. The study set out to achieve three main goals. First, the reviewers wanted to look at how young people from South Asian and White British origins experienced mental health in different cultural contexts. Second, they sought to look into cultural differences in the stigma attached to psychosis, concentrating on the readiness to contact people currently experiencing psychosis. Finally, the study sought to examine the differences in psychosis results in theories. The following hypotheses were tested:

• In comparison to South Asian participants, White British participants would report having had more prior interaction with mental health services and people who had mental health concerns.
• Compared to South Asian participants, White British participants are expected to report a higher prevalence of mental health issues and psychotic experiences.
• In comparison to South Asian participants, White British participants would demonstrate reduced stigma levels toward psychosis, indicating a stronger desire for interaction with people who are struggling with mental health issues in the future.
• While South Asian participants would have a larger belief in supernatural and spiritual explanations for psychosis, White British individuals would favor biological or psychosocial factors more.

Perceptions of psychosis are shaped by prior experiences with mental health problems, including personal encounters and interactions with individuals who have such issues. Emerging from this study on cultural differences were factors which affect psychosis, stigma, beliefs in superstitions, geography, and race in color.

Another data item relative to exploring schizophrenia and cultural content was the use of assessment tools. Jacob emphasizes the critical importance of creating and enhancing assessment tools that capture patient perspectives, particularly regarding "insight." These instruments should aim to encompass an array of beliefs about mental illness and gather a variety of explanations and help-seeking behaviors. The fact that individuals frequently have contradicting views of their illness, turn to different treatment options and have unique healing needs must be properly documented. The evaluation of insight should go beyond merely gathering and contrasting biomedical points of view. Instead, it should work to compile multiple perspectives held by patients and their families while comparing them with widely held, locally and culturally acceptable beliefs about illness, criticism, and behavior.

In the study of culture and mental illnesses conducted by Bhugra et al., they stated that given that migrants, in particular, bring their own cultural capital with them, the idea of "cultural capital," which was previously applied in the area of education, should be expanded to a wider context. This cultural capital can be extremely important for both individual and community acculturation and resilience processes. The exploration of human rights and the creation of the Magna Carta, the impact of culture on psychiatric disorders and societies, and the management of therapeutic partnerships and treatment adherence through diverse treatments are only a few of the topics covered by other contributors to this issue. The difficulties in recognizing and treating mental illnesses have been clarified by studies done in many nations and cultures. In this subject issue, several publications explore a range of therapeutic approaches, such as the use of yoga, modified cognitive-behavioral therapies, methods for preventing burnout in medical students, and the effects of migration on particular populations. It is crucial to look at the stressors that these people deal with and to create interventions that are specifically designed for them, taking into account not only the additional barriers to care they could encounter but also other societal variables that affect their well-being.

Working on the data items of stigma, interesting results were found in the study comparing Central Europe and North Africa for differences in the stigma associated with schizophrenia. Participants in Tunisia showed a larger tendency to place greater responsibility for the condition on the person with schizophrenia. They did, however, also exhibit more prosocial behaviors and less fear than their German counterparts. In Tunisia, this preference was seen in intimate, family-related interactions, whereas in Germany, the desire for social distance was more prominent in relationships that were more distant.

A study by Altweck et al., offers solid quantitative support for the Mental Health Literacy (MHL) model. The ability to identify the symptoms of mental illness was a crucial research variable. The findings showed that greater symptom awareness was linked to higher support for social causes of mental illness and a greater willingness to seek treatment from professionals, while at the same time indicating decreased support for obtaining help from lay sources. Notably, the MHL model identified a substantial cultural difference: Whereas lay help-seeking beliefs were crucial in the Indian population, they were only marginally significant in the European American sample. Additionally, the study discovered a significant correlation between collectivism and the Indian sample's opinions about seeking lay treatment and the European American sample's ideas about the origins of mental illness. These findings emphasize the value of understanding the cultural differences in attitudes about mental illness, particularly in terms of attitudes toward getting help.

Risk and bias in individual studies, summary measures, synthesis of outcomes, risk of bias across studies, and additional analysis

The need for appropriate assessment tools to ensure risk of bias is reduced or even prevented as surreal in studies reviewed.

Future research in the study on cultural differences in psychosis would be well-served by developing scales that are capable of accurately capturing culturally specific mental health experiences. It is crucial that these scales be created in collaboration with non-Western scholars and users of services.

The absence of distinction between South Asian demographic subgroups is another flaw in the study. It's possible that there are variances within this group given the variety of ethnic and religious backgrounds that make up this population. The survey also did not collect data on social class, the intensity of religious observance, or the immigrant status of different generations. Future studies would benefit from examining these elements' potential roles and how they might affect the results.

This study is the first to look at how cultural differences affect how young people in the UK are stigmatized and given the blame for their psychosis. The results have significant ramifications for developing treatments targeted at integrating ethnic minorities with mental health care and minimizing stigma, particularly in light of the differences between White British and South Asian individuals. First off, people with mental health issues often put off getting therapy because they worry about social consequences. They also worry about being rejected by friends, family, coworkers, and romantic interests, which lowers their self-esteem. Previous studies have demonstrated that stigma interventions based on intergroup interaction theory or education can successfully lower prejudice and discrimination against people with mental health disorders. The study helps to recognize how stigma differs across cultures, which can help researchers create stigma interventions that work. Second, although services struggle to contact and interact with communities in need, ethnic minority people in the UK not only have a lower probability of using mental health services but also frequently get poor support when they do. The study demonstrated the importance of cultural beliefs around mental health, and it is essential to provide culturally sensitive mental health services that take into account various cultures and their beliefs in order to improve access for various ethnic groups.

Moreover, Edge's research on voice hearing in an African and Caribbean population aimed to better understand the relationship between voices, important life goals, and pain in people of African-Caribbean and Black African ancestry. The study's focus was on determining whether people in this population's experiences of anguish might be linked to the impact that hearing voices has on their aspirations in life. In order to acquire more in-depth and thorough data, the qualitative technique was used in the study's second phase to delve into people's specific experiences of hearing voices.

It's possible that Angermeyer et al., study's chosen methodology prevented them from completely capturing stigma-specific characteristics of the culture. It would be easier to comprehend how cultural factors contribute to the stigmatization of people with schizophrenia if qualitative methods were included in the quantitative studies. An extensive qualitative follow-up study would shed light on the underlying processes underpinning pertinent cultural occurrences. It would be especially beneficial to investigate how ideas of shame and honor affect family values with regard to people with schizophrenia and to contrast these with family values in other non-Western cultures, such as India or China. A further limitation was lack of a family loyalty assessment, which would have made it easier to conduct an empirical analysis of cultural differences and how they affect stigma. Although the interview translation made an effort to preserve language equivalents, cultural consistency was not assured. Their route models' correlational structure hinders drawing firm conclusions about the causes of the many stigmatizing factors. Last but not least, the methodological approach to exclude illiterate people from the Tunisian sample may have strengthened the existence of conventional reactions to mental illness within that group, thereby highlighting the contrasts between the two nations found in the study.

The study on mental health literacy; a cross-cultural approach to knowledge and beliefs about depression, schizophrenia, and generalized anxiety disorder made use of an approach that had a few inherent limitations. One limitation was the potential cultural diversity in how mental disease symptoms are presented, which may have contributed to Indians' minimized recognition of symptoms if those symptoms were irrelevant to their culture. Although there can be cultural variations in how mental illness is perceived, the study's vignettes concentrated on these universal fundamental symptoms, thus it is crucial to recognize this.

Another limitation was that missing values were inferred using the expectation-maximization method, which calls for caution when interpreting the results. However, given that the method outperforms alternative computing strategies, its purported limitations, such as multiple modes, saddle points, and ridges, should be viewed as inherent qualities of the method. A further limitation was the recognition scale the researchers employed, which was a reflection of their understanding of mental illnesses. The researchers suggested adopting a more specific knowledge scale in future studies to distinguish between labeling someone as ill and understanding what is going on with the person.

Study selection

Schizophrenia is a complex mental disorder with cognitive, emotional, and behavioral disturbances. Cultural factors significantly influence how schizophrenia manifests, is diagnosed, treated, and experienced. Studies show cultural variations in symptom presentation and interpretation. For example, Asian individuals with schizophrenia tend to experience somatic symptoms more than Western individuals. Cultural differences also exist in hallucinatory experiences. Help-seeking behaviors and treatment adherence are shaped by cultural factors, including family dynamics, beliefs, and language barriers. Stigma associated with schizophrenia varies across cultures, affecting individuals differently. Culture-specific considerations are vital in designing treatment strategies. Cultural issues impact treatment adherence and interventions should be tailored accordingly, involving family members. Cultural competence and sensitivity improve treatment outcomes. In conclusion, cultural factors play a crucial role in schizophrenia and require culturally sensitive approaches in diagnosis, treatment, and support services.

Study characteristics

Thoroughly reviewing thirteen (13) distinct studies ensured the inclusion of relevant research and comprehensive coverage of the topic. In the study regarding mental health literacy; a cross-cultural approach to knowledge and beliefs about depression, schizophrenia and generalized anxiety disorder, participants were invited to take part in a study about knowledge and beliefs about mental health. All materials were in English only. The purpose of study was fourfold:

• To validate measures of MHL cross-culturally,
• To examine the MHL model quantitatively,
• To investigate cultural differences in the MHL model, and
• To examine collectivism as a predictor of MHL.

Previous research has found that Mental Health Literacy (MHL)-the knowledge and positive beliefs about mental disorders-tends to be higher in European and North American cultures, compared to Asian and African cultures. Normality tests and inspection of the histograms showed that the professional help-seeking beliefs, lay help-seeking beliefs and social causal beliefs constructs were normally distributed in both cultural samples. Recognition showed negative kurtosis in the Indian sample. However, inspection of the frequencies showed that fifty percent (50%) of the Indian participants recognized the symptoms represented in the vignette as a mental disorder and there was variation in the recognition scores that would allow for valid correlations, which does not support a flooring effect. Also, the European Americans were significantly better at recognizing the mental disorders displayed in the vignettes than their Indian counterparts; this pattern held across all three mental disorders. The suggested MHL model, which encompasses recognition, causality, and both lay and professional help-seeking beliefs, has been extensively validated through robust empirical research. It was clear that the MHL model was influenced differently by culture. In contrast to the European American population, the reviewers discovered that lay help-seeking beliefs were not a substantial component of the MHL model in the Indian sample. Instead, they discovered that lay help-seeking beliefs were related with all other features of the MHL model in the Indian group. However, in the European American sample collectivism was significantly linked to social causal beliefs while in the Indian group it was linked to lay help-seeking beliefs.

Study characteristics were also observed in study cultural differences in stigma surrounding schizophrenia; comparison between Central Europe and North Africa, a multistage probability sampling involving sample sites, households, and target household members were utilized in Germany. The criteria for eligible respondents included those who did not reside in institutions, were at least eighteen (18) years old in Germany, had public ideas and opinions about schizophrenia, and were between the ages of fifteen (15) and sixty-five (65) in Tunisia. Exploring cultural differences may improve understanding about the social processes underlying the stigmatization of people with mental illness. There were distinct differences between the two countries in each of the three stigma factors examined: in Tunisia, more people shared the opinion that people with schizophrenia are unpredictable, and more people have a propensity to hold the person with the condition responsible for the disorder's onset and future course. The dangerousness stereotype was more pervasive, and the treatment prognosis was viewed less favorably in Germany. In Tunisia, prosocial behavior was more prevalent while dreadful behavior was less common. The correlational design is a path models preclude definite causal inferences between the different stigma components.

Also, characteristic was observed in the study of voice hearing in an African and Caribbean population. Based on the study, there was no significant distinction mentioned between the African and Caribbean voices' experience. The study included both African and Caribbean participants, with 20 participants from each group reporting hearing both stressful and non-distressing sounds. Additionally, 10 participants from each group experienced distress. It focused on the distress experienced by individuals who heard voices, and the importance of understanding this distress for effective psychological interventions. It suggested that auditory hallucinations or hearing voices were not solely symptoms of mental disease, as even individuals without a history of mental health issues frequently reported hearing voices.

Related to cross-cultural diagnosis was the paper insight in psychosis; an indicator of severity of psychosis, an explanatory model of illness, and a coping strategy, local and cultural standards ought to be used to judge insight rather than generic biomedical definitions and standards. The criteria for measuring insight should include avoiding making illogical and culturally acceptable explanations and attributions and looking for locally acceptable and available remedies. Analogies should be drawn between the evaluation of insight and the evaluation of other clinical occurrences (such as delusions), which both involve comparison with regional and cultural norms. a clinical occurrence (such as delusions), in comparison to regional and cultural norms. People with good insight will have better clinical outcomes than those with more severe psychotic states who firmly believe in their delusional convictions. All cognition will have a neurobiological basis, and if "insight" is connected to the main psychotic process, it cannot be viewed as a standalone predictor of outcome but rather as a step in the development of the illness. The data revealed that insight, like other EMs, is a belief that interacts with the course of the person's sickness and the local culture to develop a special knowledge of the illness for the specific person and his or her family.

Schizophrenia is associated with spiritual factors elucidating that ethnicity is somehow highlighted and mentioned. The research on cultural differences in psychosis defined the role of causal beliefs and stigma among White British and South Asians. In this study, 64 cases were randomly chosen from the 109 White British group, yielding a total sample size of 128 individuals who were included in the analysis. Participants' self-reported ethnicity was used to identify the ethnic identification of the students. In the United Kingdom, mental health support services are accessible through the National Health Service (NHS) at no cost. These services can be accessed either through a doctor’s referral, such as the Early Intervention in Psychosis service for long-term treatment of psychosis, or through self-referral, such as the Improving Access to Psychological Therapies service for short-term therapy targeting depression and anxiety. To bridge an empirical gap, researchers have studied cultural differences by comparing White British and South Asian young people in the UK. South Asians are more inclined than White British individuals to attribute mental health issues to supernatural or potentially spiritual causes. This could be attributed to factors such as higher levels of religiosity and greater familiarity with paranormal beliefs among the South Asian group.

In a study on stigma associated with mental illness and its treatment in Arab culture, the participants were Qatari versus non-Qatari Arabs with a tendency to stigmatize mental illness. The results of the studies in this review should be considered to guide the design and implementation of campaigns to increase awareness about mental illness and in the development of anti-stigma interventions in countries such as Qatar, which has a large proportion of Arab expatriate workers. Different interventions to reduce public stigma toward people with severe mental illness have been evaluated in a systematic review and meta-analysis recently published in 2018 and found that both contact and educational interventions have small to medium effect on reducing stigma. Findings from studies undertaken in Qatar reported greater stigmatizing beliefs, actions or attitudes toward mental health treatments among Qatari versus non-Qatari Arabs.

Discussion

Risk of bias within studies

The studies reviewed focused on cultural factors and schizophrenia are subject to the limitations due to irrelevant and outdated data existing in different platforms and sources.

One such limitation was the potential cultural diversity in the presentation of symptoms related to mental illnesses. Different cultures may have unique ways of expressing and interpreting symptoms, which could have influenced the findings of the studies. For instance, if certain symptoms were irrelevant or less prevalent in Indian culture, it is possible that individuals from that cultural background may have exhibited a minimized recognition of those symptoms. Furthermore, one crucial aspect illuminated by the study is the tendency for individuals with mental health issues to delay seeking therapy due to concerns about potential social consequences. Fear of rejection from friends, family, coworkers, and romantic partners can lead to a decrease in self-esteem, further exacerbating the reluctance to seek help. Previous studies have shown that stigma interventions based on theories of intergroup interaction or education can effectively reduce prejudice and discrimination against individuals with mental health disorders. Understanding the nuances of how stigma varies across cultures, as highlighted by this study, enables researchers to develop targeted stigma interventions that can effectively address the unique challenges faced by individuals from different cultural backgrounds. A notable limitation of the study on cultural factors and schizophrenia is the absence of differentiation between South Asian demographic subgroups. Given the diverse ethnic and religious backgrounds encompassed within this population, it is plausible that there are significant variances in how psychosis is experienced and understood.

Results of individual studies

The systematic review on the stigma associated with mental illness and its treatment in Arab culture underscores the significance of addressing mental health stigma within Arab culture. Cultural, religious, and social factors were cited to contribute to the pervasive stigma associated with mental illness and its treatment differences of results indicated interventions aimed at reducing stigma should be culturally sensitive, taking into account the unique beliefs and values prevalent in Arab culture. Raising awareness, providing education, and fostering supportive environments that promote understanding and acceptance of mental illness are essential steps in combating stigma and improving mental health outcomes in Arab communities. The studies covered in this review lead people to believe that among people of Arab ancestry, stigmatizing attitudes, behaviors, and beliefs about the treatment of mental illness are widespread among clients, staff members, and members of the public. The overview of the studies covered in this review can be used as a starting point for the creation of anti-stigma or mental health awareness campaigns that take into account the distinctive aspects of Arab culture. It can also serve as a first step in the clarification of culturally appropriate treatment modalities.

The study on schizophrenia, culture, and culture-bound syndromes shows that the study of schizophrenia, culture, and culture-bound syndromes highlights the importance of recognizing the impact of sociocultural factors on the manifestation, interpretation, and treatment of schizophrenia. Schizophrenic symptomatology and presentation differ between cultures and are connected to immigrant status, religious views, familial dynamics that are culturally specific, and roots of the condition. The findings suggest that cultural beliefs and practices play a significant role in shaping the manifestation and interpretation of schizophrenia symptoms. Cultural factors such as religious views and familial dynamics contribute to the diverse presentations of the disorder across different societies. The impact of immigration on schizophrenia cannot be ignored. The studies indicate that immigrant status influences the symptomatology and expression of the disorder, highlighting the importance of considering cultural background and acculturation experiences in diagnosis and treatment. The review emphasizes the need for culturally sensitive approaches to the management of schizophrenia. Understanding the cultural roots and context of the condition can enhance treatment outcomes and promote a more holistic understanding of the illness. Overall, these inferences underscore the complex interplay between culture and schizophrenia, emphasizing the significance of cultural awareness and sensitivity in addressing the disorder effectively.

The insights from the paragraph revealed several key inferences regarding cultural bias in diagnosis and the challenges of equitable mental health care provision. Firstly, cultural bias can pose significant challenges, as evidenced by the third study, potentially leading to inaccurate assessments. Secondly, the recognition of cultural influences on symptom presentation was crucial, as individuals from diverse cultural backgrounds may exhibit additional physical symptoms alongside typical schizophrenia symptoms. This highlighted the need to consider cultural context and expand diagnostic criteria beyond Western perspectives. Thirdly, addressing biases within diagnostic systems, such as the DSM-V and ICD-11, was essential to mitigate cultural bias and better serve diverse populations. Additionally, promoting cultural competence among clinicians was crucial for improved diagnostic accuracy and effective mental health care. Lastly, complications could arise when applying Western diagnostic guides to culturally diverse settings, emphasizing the importance of considering cultural nuances during the diagnostic process. Overall, these inferences emphasized the significance of recognizing cultural bias, understanding cultural influences, addressing biases, promoting cultural competence, and accounting for cultural complexities in providing equitable and culturally sensitive mental health care.

The analysis of the paragraph revealed several significant findings regarding the influence of cultural factors on psychosis, including causal beliefs, stigma, and mental health care. The study specifically examined the impact of cultural factors on psychosis within White British and South Asian populations. It highlighted cultural variations played a vital role in shaping the experience and outcomes of individuals with psychosis in these ethnic groups. The broader literature suggested that cultural variations in causal beliefs and stigma significantly affected how individuals perceived, coped with, and sought help for psychosis. These cultural influences shaped the overall experience of psychosis, including help-seeking behaviors and treatment outcomes. To enhance mental health care for diverse populations, it was crucial to develop interventions that were culturally sensitive. This inference emphasized the importance of considering cultural beliefs, practices, and values when tailoring treatment approaches to meet the specific needs and cultural contexts of individuals with psychosis. Additionally, the paragraph underscored the significance of addressing stigma surrounding mental health, particularly within the sociocultural context of South Asians residing in a predominantly White society. It emphasized the need to challenge and resolve negative attitudes and beliefs about mental health, creating inclusive and supportive environments. In summary, these findings highlighted the need for cultural understanding and sensitivity when addressing psychosis, recognizing the influence of causal beliefs and stigma, developing tailored interventions, and working towards reducing mental health-related stigma in diverse populations. By taking these factors into account, mental health care could be improved and made more accessible to individuals from various cultural backgrounds.

As to auditory hallucinations, voice hearing in African and Caribbean populations offers a unique perspective on the cultural and contextual aspects of this phenomenon. Understanding the variations in voice hearing experiences can help mental health professionals provide culturally sensitive care and improve treatment outcomes. By incorporating cultural beliefs, community support systems, and traditional healing practices, interventions can be tailored to the needs of individuals from African and Caribbean backgrounds. According to research, however, even those without a history of mental health issues frequently report having an experience with voices. The degree to which someone is distressed by their voice hearing experiences is one of the key determinants of whether they may need mental health care in regard to those encounters. In order to create effective and efficient psychological interventions, it will likely be highly helpful to understand distress in relation to voice hearing.

A related study which focused on mental health literacy, it was revealed that there is a cross-cultural approach to knowledge and beliefs about depression, schizophrenia, and generalized anxiety disorder. The study revealed notable cross-cultural variations in mental health literacy regarding depression, schizophrenia, and generalized anxiety disorder. Differences were observed in the recognition and understanding of symptoms, causes, and appropriate treatments for these mental disorders across cultures. Cultural factors, such as beliefs about the causes of mental illness, stigma, and available support systems, significantly influenced mental health literacy. The research underscores the need for tailored interventions and programs that consider diverse cultural perspectives to effectively address mental health challenges.

Last among the studies was on cultural differences in stigma surrounding schizophrenia which were compared between Central Europe and North Africa. This literature review highlights the importance of considering cultural differences in stigma surrounding schizophrenia when designing interventions and policies. The comparison between Central Europe and North Africa reveals unique cultural factors that influence stigma, such as diverse beliefs, religious interpretations, traditional healing practices, family dynamics, and media influences. Understanding these cultural nuances can guide the development of culturally sensitive strategies to reduce stigma, promote mental health literacy, and improve the overall well-being of individuals with schizophrenia in these regions. Further research and collaboration between different cultures and healthcare systems are crucial for advancing understanding of cultural influences on stigma and implementing effective interventions. The study found significant differences between the two nations: while in Germany the stereotype of dangerousness is more common and treatment prognosis is judged less optimistically, in Tunisia more people share the perception that persons with schizophrenia are unpredictable, and more people tend to blame the person with the condition for the onset of it and place on them the responsibility for the further course of the disorder. Less fear and more prosocial behavior are displayed in Tunisia, the latter does not equate to less rejection; in fact, like in Germany, it may even have the opposite impact. The sort of connection under investigation will determine whether the demand for social distance is higher in Tunisia or Germany.

Synthesis of results

The synthesis of the results from the studies mentioned highlights various aspects of mental health literacy, cultural differences in stigma surrounding mental illnesses, insights into psychosis, and stigma associated with mental illness and its treatment in different cultural contexts. Mental health literacy: A cross-cultural approach to knowledge and beliefs about depression, schizophrenia, and generalized anxiety disorder explored mental health literacy across different cultures. It found variations in knowledge and beliefs about depression, schizophrenia, and generalized anxiety disorder, suggesting the importance of considering cultural factors in mental health education and interventions. Cultural differences in stigma surrounding schizophrenia: Comparison between Central Europe and North Africa compared the levels of stigma associated with schizophrenia in Central Europe and North Africa. It revealed significant cultural differences in stigmatizing attitudes and beliefs towards individuals with schizophrenia, emphasizing the need for culture-specific anti-stigma interventions. Voice Hearing in an African and Caribbean population examined the experiences of voice hearing in African and Caribbean populations. It found cultural variations in the interpretation and acceptance of voice hearing phenomena, highlighting the importance of understanding cultural contexts when studying psychotic experiences. On the other hand, insight in psychosis, an indicator of severity of psychosis, investigated the relationship between insight (self-awareness of illness) and the severity of psychosis. It demonstrated that lower levels of insight were associated with greater severity of psychotic symptoms, emphasizing the clinical significance of assessing and addressing insight in psychosis. Still in psychosis as influenced by the role of causal beliefs and stigma in White British and South Asians explored cultural differences in causal beliefs and stigma surrounding psychosis in White British and South Asian populations. It revealed variations in causal attributions and stigmatizing attitudes towards psychosis, emphasizing the need for culturally sensitive approaches in mental health care. Stigma associated with mental illness and its treatment in Arab culture examined the stigma associated with mental illness and its treatment in Arab culture. It found that stigma towards mental illness was prevalent, resulting in barriers to seeking help and accessing appropriate care. The study underscored the importance of addressing cultural beliefs and attitudes to reduce stigma and improve mental health outcomes. Overall, these studies highlight the influence of culture on mental health literacy, stigma, insight into psychosis, and help-seeking behaviors. They underscore the significance of culturally sensitive approaches in understanding and addressing mental health issues across diverse populations.

Risk of bias across studies

Another critical consideration when assessing the studies in this field is the potential risk of bias introduced by the inference of missing values using the Expectation Maximization (EM) method. While the EM method is widely used and acknowledged for its ability to handle missing data, it is essential to approach the interpretation of results with caution due to the potential impact of missingness on the findings. One limitation of using the EM method to infer missing values is that it assumes that the missing data follow a particular statistical distribution. To mitigate the potential biases introduced by missing data inference, reviewers should exercise caution and employ strategies to minimize the impact of missingness. Sensitivity analyses, for example, can be conducted to assess the robustness of the results by examining the influence of different imputation models or assumptions. Likewise, a significant limitation that warrants consideration when evaluating the studies in this area is the use of a recognition scale by the researchers, which may reflect their subjective understanding of mental illnesses. Consequently, this limitation raises concerns regarding the potential for bias in the measurement of participants' recognition and understanding of mental illnesses. This could involve developing and utilizing assessment tools that capture not only the ability to recognize symptoms but also encompass a broader understanding of the underlying causes, contextual factors, and individual experiences associated with mental illnesses. By adopting a more comprehensive knowledge scale, reviewers can obtain more accurate and insightful data regarding participants' perceptions and comprehension of mental health conditions. Collaborating with individuals from diverse cultural backgrounds and engaging in a participatory research approach can help ensure that the knowledge scale accounts for the cultural nuances and specificities of different populations.

Additional analyses

As mentioned in methodology, the reviewers screened several important article databases to gather relevant studies. These databases include PsycINFO, Web of Science, ERIC, Academic Search Premier, Medline, CINAHL Complete, Scopus, and Google Scholar. These databases are widely recognized and cover a broad range of scholarly literature in various disciplines. The search of these databases was conducted systematically, meaning the reviewers followed a predefined and rigorous approach to ensure a thorough exploration of the available literature. This systematic search helps minimize biases and ensures that relevant studies are not overlooked.

After conducting the searches and applying the inclusion criteria, the reviewers identified thirteen studies that met their criteria and were relevant to their research question. This step helped organize and summarize the key findings, themes, and insights obtained from the selected studies. The selected studies underwent a critical appraisal process using the JBI (Joanna Briggs Institute) Critical Appraisal Checklist for qualitative research. This checklist provides a standardized framework for evaluating the quality, rigor, and relevance of qualitative research studies. By critically appraising the selected studies, the reviewers ensured that the included studies met certain methodological standards. Finally, the reviewers synthesized the findings of the selected studies. This process involves analyzing and integrating the extracted data to identify common patterns, themes, and conclusions across the studies. These studies were specifically chosen for their focus on treatment outcomes in individuals with substance use disorder, taking into account the presence or absence of CO-PTSD. Methodological differences can impact the reliability and validity of study findings and may affect the comparability of results. They also noted that the provided study information varied in terms of its sufficiency. This implies that some studies provided more detailed and comprehensive information about their methodology, sample characteristics, intervention protocols, and outcome measures, while others may have been less explicit or lacked crucial details. The limited information provided in some studies can make it challenging to assess the quality and applicability of the findings.

Summary of evidence

Various studies have explored the connection between schizophrenia and cultural contexts in different countries. Volkan's study specifically examined the relationship between schizophrenia, culture, and culture-bound syndromes, uncovering both unique and shared aspects of the disorder. One example is wendigo psychosis, observed among Algonquin native Americans, characterized by delusional beliefs associated with starvation but debunked as a transformation into cannibalistic spirits. Another syndrome is qi gong psychosis, arising from meditation and exercise practices and sometimes leading to schizophreniform disorder. Although mentioned in the DSM-IV, qi gong psychosis is not classified as a type of schizophrenia. In South Africa, two cultural-bound syndromes prevalent among the Xhosa and Zulu communities highlight psychotic and schizophrenic symptoms. Amafufunyana involves spiritual possession beliefs and treatment with ants, resulting in hallucinations, agitation, fatigue, and other symptoms. However, Western authorities attribute it to social changes and stress. Saora disorder in India's Andhra state is seen as a spiritual marriage, causing symptoms like inappropriate emotions and delusions. Interestingly, rejecting the marriage sustains symptoms, while accepting it leads to symptom cessation.

This literature review explores the distinctions between African-Caribbean and Black-African cultures' interpretations of auditory hallucinations and highlights the prevalent stigma in the Arab community. Rahimi's book challenges the notion that individuals with schizophrenia are disconnected from culture, politics, and common sense. The review emphasizes the shared cultural and subjective aspects between individuals with and without psychosis, demonstrating how culture influences those experiencing psychosis. Mirza et al., study compares the beliefs and stigma surrounding mental illness in White British and South Asian communities. The study used self-reporting to identify participants' ethnic backgrounds and employed a matching technique to achieve comparable sample sizes. These examples showcase the cultural variations in schizophrenia-related syndromes worldwide.

Conclusion

Culture significantly influences the understanding and treatment of schizophrenia worldwide, necessitating culturally sensitive approaches. Mirza et al., explored cultural factors and stigma in White British and South Asian populations, identifying biological, psychosocial, and spiritual explanations as relevant in schizophrenia and psychosis. Religiosity and cultural familiarity shape beliefs and help-seeking, calling for interventions to bridge cultural gaps. Integrating cultural sensitivity promotes inclusivity, reduces stigma, and enhances acceptance of schizophrenia, aligning expectations with mental health services. Moreover, addressing cultural dynamics and biases is crucial for accurate diagnosis and effective treatment globally.

In exploring cultural perspectives, the South Asian community and Pakistanis intertwine supernatural and spiritual factors, including religious rituals and faith healers, with psychosis. Perceived causes of psychosis include evil spirits and divine punishment. Central Europe and North Africa demonstrate how diverse beliefs, religious interpretations, traditional healing practices, family dynamics, and media influences shape schizophrenia stigma. These beliefs affect help-seeking behavior, leading to untreated psychosis. Different cultures exhibit varying views on the separation between physical and mental disorders, with Western cultures emphasizing a stricter distinction.

Non-Western cultures highlight the need to consider cultural context when studying mental health. Knowledge and information about schizophrenia differ across regions, emphasizing the influence of culture. Despite cultural understanding, manifestations and beliefs surrounding schizophrenia vary among individuals and communities. Mental health professionals should receive training on cultural beliefs, practices, and stressors to provide appropriate care. Combating stigma requires addressing harmful associations while respecting religious teachings and involving families and religious figures for social integration.

In an interconnected world, a comprehensive and culturally sensitive approach improves outcomes for individuals with schizophrenia in diverse cultures.

Limitations

The primary objective was to identify and examine the cultural factors that intersect with schizophrenia, emphasizing the importance of cross-cultural diagnosis in the field of mental health. Furthermore, the reviewers sought to investigate the stigmatization associated with schizophrenia within specific local areas, shedding light on the cultural biases and misconceptions that contribute to this phenomenon. To maintain rigor and minimize bias, this review concentrated on existing literature pertaining to culture-related information on schizophrenia within specific regions. Specifically, they focused on North Africa, South Asia, Central Europe, and Arab cultures. Regrettably, due to the limited availability of literature on the subject, the study was unable to incorporate findings from other regions across the globe. Consequently, certain countries and continents were omitted from the study, potentially limiting the generalizability of the results and our understanding of diverse cultural factors with schizophrenia. Further research encompassing a wider geographic scope is warranted to provide a more comprehensive understanding of the mental disorder and ensure inclusivity in future studies.

Funding

In this study, the reviewers undertook the task of constructing a comprehensive systematic review without seeking any external funding. The review gathered information from credible and relevant sources, such as articles, journals, books, and online materials. The data collection and analysis were carried out independently, without any financial involvement. This approach aimed to maintain the integrity and objectivity of the research process, ensuring unbiased and reliable findings.

Data Statement

The comprehensive dataset, which underpins the findings of this study, is accessible for further examination. These invaluable data were obtained from an extensive array of publicly available resources, ensuring their transparency and credibility.

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Citation: A Systematic Review of Cultural Factors Which Influence Beliefs on Schizophrenia in Cross-Cultural Studies ASEAN Journal of Psychitary Vol. 25 (10) November, 2024; 1-13.