Afghan mental health and psychosocial well-being: thematic review of four decades of research and interventions.

BACKGROUND: Four decades of war, political upheaval, economic deprivation and forced displacement have profoundly affected both in-country and refugee Afghan populations. AIMS: We reviewed literature on mental health and psychosocial well-being, to assess the current evidence and describe mental healthcare systems, including government programmes and community-based interventions. METHOD: In 2022, we conducted a systematic search in Google Scholar, PTSDpubs, PubMed and PsycINFO, and a hand search of grey literature (N = 214 papers). We identified the main factors driving the epidemiology of mental health problems, culturally salient understandings of psychological distress, coping strategies and help-seeking behaviours, and interventions for mental health and psychosocial support. RESULTS: Mental health problems and psychological distress show higher risks for women, ethnic minorities, people with disabilities and youth. Issues of suicidality and drug use are emerging problems that are understudied. Afghans use specific vocabulary to convey psychological distress, drawing on culturally relevant concepts of body-mind relationships. Coping strategies are largely embedded in one's faith and family. Over the past two decades, concerted efforts were made to integrate mental health into the nation's healthcare system, train cadres of psychosocial counsellors, and develop community-based psychosocial initiatives with the help of non-governmental organisations. A small but growing body of research is emerging around psychological interventions adapted to Afghan contexts and culture. CONCLUSIONS: We make four recommendations to promote health equity and sustainable systems of care. Interventions must build cultural relevance, invest in community-based psychosocial support and evidence-based psychological interventions, maintain core mental health services at logical points of access and foster integrated systems of care.

Community-based reports of morbidity, mortality, and health-seeking behaviours in four Monrovia communities during the West African Ebola epidemic.

The goal of this study was to assess morbidity, mortality, and health-seeking behaviours during the 2014 Ebola outbreak in Monrovia, Liberia. This study examined commonly reported symptoms of illness, pre-clinical diagnostic practices, typical healthcare-seeking strategies, and health resources available to populations, in order to identify salient needs and gaps in healthcare that would inform local emergency response efforts. Semi-structured interviews were conducted with household members in four Monrovia neighbourhoods. Researchers used a multi-stage cluster approach to recruit participants. Within 555 households sampled, 505 individuals were reported sick (69%) or recently sick (38%) or deceased (7%). Common self-diagnoses included malaria, hypertension, influenza, typhoid, and Ebola. The most cited health-seeking strategy was to purchase medications from the private sector. Respondents also obtained healthcare from community members known to have medical experience. Findings suggest that non-formal healthcare systems played an important role in managing morbidity during the West African Ebola virus disease (EVD) outbreak. Lay community members engaged in complex assessments of health symptoms and sought biomedical care at rates perhaps higher than anticipated during the response. This study highlights how informal networks of healthcare providers can play an important role in preventing and curbing future emerging disease outbreaks.

The Opposite of Denial: Social Learning at the Onset of the Ebola Emergency in Liberia.

This study analyzes findings from a rapid-response community-based qualitative research initiative to study the content of Ebola-related communications and the transmission of Ebola-related behaviors and practices through mass media communications and social learning in Monrovia, Liberia during August-September 2014. Thirteen neighborhoods in the common Monrovia media market were studied to appraise the reach of health communications and outreach regarding Ebola prevention and response measures. A World Health Organization (WHO) research team collected data on social learning and Ebola knowledge, attitudes, and practices through focus group-based discussions and key informant interviews over a 14-day period to assess the spread of information during a period of rapidly escalating crisis. Findings show that during a 2-week period, Monrovia neighborhood residents demonstrated rapid changes in beliefs about the source of Ebola, modes of contagion, and infection prevention and control (IPC) practices, discarding incorrect information. Changes in practices tended to lag behind the acquisition of learning. Findings also show that many continued to support conspiracy theories even as correct information was acquired. The implications for community engagement are substantial: (1) Under conditions of accelerating mortality, communities rapidly assimilate health information and abandon incorrect information; (2) Behavior change is likely to lag behind changes in beliefs due to local physical, structural, sociocultural, and institutional constraints; (3) Reports of "resistance" in Monrovia during the Ebola response were overstated and based on a limited number of incidents, and failed to account for specific local conditions and constraints.

Per Diems in Polio Eradication: Perspectives From Community Health Workers and Officials.

Nearly all global health initiatives give per diems to community health workers (CHWs) in poor countries for short-term work on disease-specific programs. We interviewed CHWs, supervisors, and high-level officials (n = 95) in 6 study sites across sub-Saharan Africa and South Asia in early 2012 about the per diems given to them by the Global Polio Eradication Initiative. These per diems for CHWs ranged from $1.50 to $2.40 per day. International officials defended per diems for CHWs with an array of arguments, primarily that they were necessary to defray the expenses that workers incurred during campaigns. But high-level ministry of health officials in many countries were concerned that even small per diems were unsustainable. By contrast, CHWs saw per diems as a wage; the very small size of this wage led many to describe per diems as unjust. Per diem polio work existed in the larger context of limited and mostly exploitative options for female labor. Taking the perspectives of CHWs seriously would shift the international conversation about per diems toward questions of labor rights and justice in global health pay structures.

The Global Context of Vaccine Refusal: Insights from a Systematic Comparative Ethnography of the Global Polio Eradication Initiative.

Many of medical anthropology's most pressing research questions require an understanding how infections, money, and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a $9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This article describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior.

The Global Context of Vaccine Refusal: Insights from a Systematic Comparative Ethnography of the Global Polio Eradication Initiative.

Many of medical anthropology's most pressing research questions require an understanding how infections, money and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a $9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This paper describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior. This article is protected by copyright. All rights reserved.

Community-centered responses to Ebola in urban Liberia: the view from below.

BACKGROUND: The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia. METHODOLOGY/PRINCIPAL FINDINGS: This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia--one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support. CONCLUSIONS/SIGNIFICANCE: Local communities' strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.

The impact of polio eradication on routine immunization and primary health care: a mixed-methods study.

BACKGROUND: After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC). METHODS: Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review. RESULTS: Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year. CONCLUSIONS: Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

The validity and clinical utility of post-traumatic stress disorder in Afghanistan.

This study examined the validity and utility of PTSD among 320 adults in Afghanistan. Findings support the validity of PTSD in this cultural context: PTSD symptoms were highly prevalent, shared common variance, and correlated as expected with exposure to traumatic stress. However, only limited support was found for the clinical utility of PTSD. Other types of psychiatric symptomatology, including depression and a culturally specific measure of general distress, correlated more highly with traumatic stress than did PTSD; and PTSD accounted for limited variance in functioning beyond that explained by depression and general distress. Implications for research and intervention are considered.

Daily stressors, war experiences, and mental health in Afghanistan.

Working in Afghanistan's capital city of Kabul, the authors assessed the relative contribution of daily stressors and war-related experiences of violence and loss to levels of depression, PTSD, impaired functioning, and a culturally specific measure of general psychological distress. For women, daily stressors were a better predictor than war experiences of all mental health outcomes except for PTSD; for men, daily stressors were a better predictor of depression and functional impairment, while war experiences and daily stressors were similarly predictive of general distress. For men, daily stressors moderated the relationship between war experiences and PTSD, which was significant only under conditions of low daily stress. The study's implications for research and intervention in conflict and post-conflict settings are considered.

The Afghan symptom checklist: a culturally grounded approach to mental health assessment in a conflict zone.

This article describes a methodology for developing culturally grounded assessment measures in conflict and postconflict situations. A mixed-method design was used in Kabul, Afghanistan, to identify local indicators of distress and develop the 22-item Afghan Symptom Checklist (ASCL). The ASCL contains several indigenous items and items familiar to Western mental health professionals. The ASCL was pilot tested and subsequently administered to 324 adults in 8 districts of Kabul. It demonstrated excellent reliability (alpha=.93) and good construct validity, correlating strongly with a measure of exposure to war-related violence and loss (r=.70). Results of the survey indicate moderate levels of distress among Afghan men and markedly higher levels of distress and impaired functioning among women (and widows in particular).