Perceptions of psychosis and pathways to care in rural Zimbabwe: A mixed-methods study from the Z Factor community and public engagement project.

Background Psychosis is among the most stigmatised, poorly understood mental health conditions in low- and middle-income countries. In rural Africa, pathways to care are shaped by interactions between stigma, family decision-making, cultural explanatory models, and structural barriers, yet limited research has examined how community perceptions of psychosis are formed and enacted within social contexts. Methods This convergent mixed-methods study was nested within Z Factor, a community drama-based public engagement project implemented in rural Zimbabwe. Quantitative data were collected through a cross-sectional survey (N = 60) using an adapted Community Attitudes to Mental Illness scale. Qualitative data comprised transcripts and video recordings from seven community-authored drama performances. Data sources were analysed and integrated to examine convergence, complementarity, and divergence in community perceptions of psychosis and pathways to care. Results Survey responses showed heterogeneous and contradictory attitudes. Most respondents rejected exclusion, with 80% disagreeing that people with mental illness deserve to be locked away, yet expressed ambivalence about autonomy, risk, employment, and care pathways. 58% agreed that people with mental illness should be treated like minors, 59% disagreed that they could work like any other person, and 77% agreed that community reintegration supports recovery. Drama narratives contextualised these patterns through seven themes: crisis-based perceptions of psychosis, carer burden and delayed help-seeking, elder-led family decision-making, accessibility and familiarity in pathway choice, trust and reassurance, expectations of rapid recovery, and medication as limited, inaccessible, or insufficient. Conclusions Community perceptions reflected the interplay among stigma, caregiving responsibilities, treatment expectations, structural constraints, and cultural explanatory frameworks rather than a single belief system. Help-seeking was shaped by accessibility, familiarity, trust, and coexistence of biomedical, traditional, and faith-based care systems. Participatory arts-based approaches can generate contextually grounded insights into psychosis stigma and pathways to care, stressing the need for collaborative, family-centred, and culturally responsive mental health engagement approaches.