"I think there is a certain worm that disturbs the head": Community perspectives and care pathways for psychosis in Malawi.

Psychosis remains a significant global health challenge, with people in low- and middle-income countries (LMICs) like Malawi disproportionately impacted. Yet, little is known about community perspectives, treatment-seeking practices, and acceptable pathways for psychosis management. This study explored diverse community perspectives of psychosis to inform the development of a community-based psychosis detection and management system. This exploratory qualitative study was conducted in Malawi's Salima and Chiradzulu districts between October and December 2023. Seventy-six participants, including traditional healers, religious leaders, caregivers, and PWLE, were purposively sampled for 16 in-depth interviews (IDIs) and six focus group discussions (FGDs). Data were collected using semi-structured interviews, transcribed, and thematically analysed. The majority across all participants largely attributed psychosis to witchcraft, smoking cannabis, and alcohol use. Traditional healers and religious leaders were commonly the first points of care, and preferred over biomedical services. Participants recommended active community involvement, engagement of health surveillance assistants (HSAs), stronger partnerships between community leaders and health workers, and resource availability for an ideal community-based psychosis detection and management system. Cultural norms and practices strongly influence psychosis care pathways in Malawi, in the context of severe economic challenges which shape the provision of healthcare. Future interventions should prioritise culturally sensitive community outreach programs to improve psychosis management.