Access to Care for Mental Health Problems in Afghanistan: A National Challenge

Document Type : Original Article

Authors

1 Department of Psychiatry, McGill University, Montreal, QC, Canada

2 Conseil Santé, Clichy, France

3 Laboratoire de Psychopathologie et Processus de Santé (LPPS), Université de Paris, Boulogne-Billancourt, France

4 Department of Psychiatry & Clinical Psychology, St. George Hospital University Medical, Beirut, Lebanon

5 Faculty of Medicine, University of Balamand Medical Center, University of Balamand, Beirut, Lebanon

6 Institute for Development, Research, Advocacy & Applied Care (IDRAAC), Beirut, Lebanon

7 Mailman School of Public Health, Columbia University, New York City, NY, USA

8 Governance Institute of Afghanistan (GI-A), Kabul, Afghanistan

9 Department of Mental Health & Substance Abuse, Primary Health Care Directorate, Ministry of Public Health, Kabul, Afghanistan

Abstract

Background 
This paper describes the access to care for mental health problems in Afghanistan, according to the nature of the mental health problems and the service provider. Following the Andersen model, it evaluates the respective roles in access to care of “predisposing,” “needs,” “enabling” factors, and other “environmental” factors such as exposure to traumatic events and level of danger of the place of residence. 

 
Methods 
Trans-sectional probability survey in general population by multistage sampling in 16 provinces, nationally representative: N = 4445 (15 years or older), participation rate of 81%. Face to face interviews using standardized measures of mental health (CIDI, Composite International Diagnostic Interview). Different logistic regression models are presented. 
 

Results 
The 12-month rate of mental health help-seeking was 6.56% with substantial regional variation (2.35% to 12.65%). Providers were mainly from the health sector; the non- health sector (religious and healers) was also prevalent. Most consultations were held in private clinics (non-governmental organisation, NGO). The severity of mental health disorders as well as the perceived impairment due to mental health were independently very important: odds ratio (OR) = 6.04 for severe disorder, OR = 3.79 for perceived impairment. Living in a dangerous area decreased access to care: for high level of danger and for very high level: OR = 0.22. Gender, education and ethnicity were not associated with mental health help-seeking after controlling for exposure to trauma. 

 
Conclusion 
Access to care for mental health problems depended mainly on the needs as defined as disorder severity level and impairment, and on environmental factors such as exposure to traumatic events. The system seems equitable; however, this is counterbalanced by a very challenging environment. This survey is a testimony to the hardship experienced by the Afghan population and by health professionals, and to the efforts to deliver organized mental healthcare in a challenging situation. This research may inform and support policy-makers and NGOs in other countries undergoing similar challenges.

Keywords


  1. WHO. Mental Disorders Fact Sheet. Geneva: WHO; 2016.
  2. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575-1586. doi:10.1016/s0140-6736(13)61611-6
  3. Semrau M, Evans-Lacko S, Koschorke M, Ashenafi L, Thornicroft G. Stigma and discrimination related to mental illness in low- and middle-income countries. Epidemiol Psychiatr Sci. 2015;24(5):382-394. doi:10.1017/s2045796015000359
  4. Newbrander W, Waldman R, Shepherd-Banigan M. Rebuilding and strengthening health systems and providing basic health services in fragile states. Disasters. 2011;35(4):639-660. doi:10.1111/j.1467-7717.2010.01235.x
  5. Ventevogel P, Nassery R, Azimi S, Faiz H. Psychiatry in Afghanistan. Int Psychiatry. 2006;3(2):36-38.
  6. WHO. Mental Health ATLAS. https://www.who.int/mental_health/evidence/atlas/profiles-2017/AFG.pdf?ua=1. Published 2017. Accessed 2020.
  7. Ventevogel P, van de Put W, Faiz H, van Mierlo B, Siddiqi M, Komproe IH. Improving access to mental health care and psychosocial support within a fragile context: a case study from Afghanistan. PLoS Med. 2012;9(5):e1001225. doi:10.1371/journal.pmed.1001225
  8. Ministry of Public Health (MoPH). The Essential Package of Hospital Services for Afghanistan. Kabul: MoPH; 2005.
  9. Ministry of Public Health, General Directorate of Preventive Medicines Mental Health &DDR Department. National Mental Health Strategy 2009-2014. Kabul, Afghanistan; 2009.
  10. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.
  11. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen's behavioral model of health services use: a systematic review of studies from 1998-2011. Psychosoc Med. 2012;9:Doc11. doi:10.3205/psm000089
  12. Tolera H, Gebre-Egziabher T, Kloos H. Using Andersen's behavioral model of health care utilization in a decentralized program to examine the use of antenatal care in rural western Ethiopia. PLoS One. 2020;15(1):e0228282. doi:10.1371/journal.pone.0228282
  13. Amowitz LL, Heisler M, Iacopino V. A population-based assessment of women's mental health and attitudes toward women's human rights in Afghanistan. J Womens Health (Larchmt). 2003;12(6):577-587. doi:10.1089/154099903768248285
  14. Ware JE, Kosinski M, Dewey JE, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Quality Metric Inc; 2000.
  15. Mehraban D, Naderi G, Salehi M. Development of SF-36 questionnaire in the measurement of quality of life in patients on renal replacement therapy in Iran. Saudi J Kidney Dis Transpl. 2003;14(1):15-17.
  16. Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. The Life Events Checklist for DSM-5 (LEC-5). USA: The National Center for PTSD; 2013.
  17. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5). The National Center for PTSD; 2013.
  18. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059
  19. Malekzai AS, Niazi JM, Paige SR, et al. Modification of CAPS-1 for diagnosis of PTSD in Afghan refugees. J Trauma Stress. 1996;9(4):891-898. doi:10.1007/bf02104111
  20. Karam EG, Friedman MJ, Hill ED, et al. Cumulative traumas and risk thresholds: 12-month PTSD in the World Mental Health (WMH) surveys. Depress Anxiety. 2014;31(2):130-142. doi:10.1002/da.22169
  21. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183-1194. doi:10.1046/j.1360-0443.2002.00185.x
  22. Patten SB. Performance of the composite international diagnostic interview short form for major depression in community and clinical samples. Chronic Dis Can. 1997;18(3):109-112.
  23. Khazaie H, Najafi F, Hamzeh B, et al. Cluster analysis of psychiatric profile, its correlates, and using mental health services among the young people aged 15-34: findings from the first phase of Iranian youth cohort in Ravansar. Soc Psychiatry Psychiatr Epidemiol. 2018;53(12):1339-1348. doi:10.1007/s00127-018-1580-4
  24. Kessler RC, Haro JM, Heeringa SG, Pennell BE, Ustün TB. The World Health Organization world mental health survey initiative. Epidemiol Psichiatr Soc. 2006;15(3):161-166. doi:10.1017/s1121189x00004395
  25. Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet. 2007;370(9590):841-850. doi:10.1016/s0140-6736(07)61414-7
  26. Karam EG, Mneimneh ZN, Karam AN, et al. Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey. Lancet. 2006;367(9515):1000-1006. doi:10.1016/s0140-6736(06)68427-4
  27. Karam EG, Karam GE, Farhat C, et al. Determinants of treatment of mental disorders in Lebanon: barriers to treatment and changing patterns of service use. Epidemiol Psychiatr Sci. 2019;28(6):655-661. doi:10.1017/s2045796018000422
  28. Kovess-Masfety V, Keyes K, Karam E, Sabawoon A, Sarwari BA. A National survey on mental health in Afghanistan: A highly traumatized population. BMC Psychiatry. 2021; In Press.

Articles in Press, Corrected Proof
Available Online from 24 May 2021
  • Receive Date: 14 September 2020
  • Revise Date: 13 April 2021
  • Accept Date: 18 April 2021