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.

Health disparities among Burmese diaspora: an integrative review.

Tens of thousands of displaced Burmese ethnic minorities have endured various adversities for over six decades but are largely underserved. This study aimed to illuminate the health impacts of their misfortunes and unmet areas of concern. Using a holistic lens, we conducted an integrative review of 47 papers spanning the years 2004 to 2022 from diverse data sources. The results revealed widespread multimorbidity, triggered mainly by displacement. The diaspora's problematic health conditions were worse than their host country's general population. There was a strong indication that the diaspora's unfortunate health trajectory is determined early in life. Ongoing human rights violations and grossly inadequate health care interventions deepened pre-existing health conditions. Noteworthy emerging treatment initiatives, including integrative health care, were underutilized. The persisting health and intervention needs among the diaspora warrant advanced studies to facilitate much-needed resource mobilization and collaboration among stakeholders to promote health equity. Funding: There was no financial support for this manuscript.

A Qualitative Inquiry of Older Afghan Refugee Women's Individual and Sociocultural Factors of Health and Health Care Experiences in the United States.

INTRODUCTION: Approximately 132,000 Afghans have resettled in the United States since the 1980s and are now aging. As older adults, sociocultural factors influence health and health-related behaviors. This study aimed to explore older Afghan refugee women's perceptions of individual and sociocultural factors of health and health care experiences. METHODS: A focused ethnography methodology was conducted with 27 semi-structured interviews with older Afghan refugee women, family members, and community key informants in Southern California. Recorded interviews were transcribed and analyzed using inductive thematic analysis. RESULTS: Five themes were identified as key to health promotion in the post-migration setting: (a) health promotion through Islam, (b) the centrality of family, (c) ongoing stressors that impact health, (d) needing support in navigating health services, and (e) miscommunication leading to mistrust of health care providers. DISCUSSION: Health interventions should consider social and cultural contexts and faith-based and family-centered approaches when addressing older Afghan refugee women's long-term health and well-being.

Beyond Resettlement: Sociocultural Factors Influencing Breast and Colorectal Cancer Screening Among Afghan Refugee Women.

Immigrants and refugees have an increased risk for developing chronic health conditions, such as breast and colorectal cancer, the longer they reside in the USA. Moreover, refugees are less even likely to use preventive health services like mammography and colonoscopy screening when compared with US-born counterparts. Focused ethnography was employed to examine sociocultural factors that influenced cancer screening behaviors among aging Afghan refugee women. We conducted 19 semi-structured interviews with Afghan women 50 and older and their family member/caregivers. Interview transcripts were inductively coded using Atlas.ti, where focused codes were sorted and reduced into categories, and we extracted meaning around groups of categories. Findings of this study revealed factors like fear of cancer, pre-migration experiences, family involvement, provider recommendation, and provider gender concordance influenced women's cancer screening behaviors. This study also found that women who have had a recent mammogram or colonoscopy described empowerment factors that helped them withstand the stressful process of screening, through encouragement and reminders from providers, support from adult family members, and finding strength through duaas (prayers). As refugee women continue to age in the USA, clinicians should incorporate multi-level strategies, including family-centered and faith-based approaches to promote preventive screening behaviors in this population.

Acculturative stress, stigma, and mental health challenges: emic perspectives from Somali young adults in San Diego county's 'Little Mogadishu'.

OBJECTIVES: The purpose of this study was to explore the social factors that contribute to the mental health challenges that Somali young adults endure. DESIGN: In a two-phase qualitative approach carried-out in the San Diego area, in phase-I, we conducted exploratory interviews with key-informants including clinicians and local Somali leaders (n = 7) who are familiar with the challenges of young Somalis. This information was then augmented through a focus group discussion with Somali young adults (n = 4) to gain further contextual knowledge and for access to the larger community of young people for phase-II. In this second phase, we carried-out individual interviews with 21 Somali young adults. Interviews covered topics including the social factors influencing their mental health, typical strategies for coping with psychological distress, barriers to seeking professional mental health services, and suggestions for combating mental health problems affecting young Somalis. RESULTS: Participant narratives indicate that psychological distress (depression and posttraumatic stress disorder) are highly pervasive, and that shame, acculturative stress and ethnic discrimination as well as parents' dismissive reactions to their children's emotional problems perpetuate mental health problems. Coping strategies included support from friends, religious activities, and playing soccer. Suggestions for addressing their challenges centered on engagement from their own community to advocate for mental health. CONCLUSIONS: Implications of this study are discussed in the context of bridging intergenerational and acculturation divides to deliver culturally competent interventions that improve the mental health and well-being of Somali young adults and aid them in their adjustment to the U.S.

Ethnic Differences Among Black Men in Prostate Cancer Knowledge and Screening: a Mixed-Methods Study.

Black men are disproportionately affected by prostate cancer (PCa) incidence and mortality. Limited research has been reported on the ethnic differences among Black men in regard to family history, knowledge, and screening habits. Thus, this study was conducted to understand and compare knowledge levels and family history of the three main Black subgroups (African Americans, Caribbean immigrants, and African immigrants) in the USA and to assess the influence of knowledge on past screening behavior and intentionality for screening in the future for PCa. A concurrent mixed-methods design was used with participants (N = 396) recruited from different parts of the country. The grounded theory method of analysis was used for qualitative data and a logistic regression was used to explain the relationship between screening intentionality and PCa knowledge and family history. Qualitative results indicated that subjective PCa knowledge between the three subgroups was relatively similar but differed based on whether a person knew a family member or friend who had been affected by the disease. Themes focused on risk, PCa education, screening, and impact on sexuality. Quantitatively, result revealed that there are ethnic differences in knowledge across the three subgroups. Additionally, regression results revealed that family history is a stronger predictor of screening behavior and intentionality than knowledge. This study was able to unveil a deeper understanding on the role of family history and knowledge on PCa among Black subgroups.

Prevalence and Social-Ecological Correlates of Intimate Partner Violence in a Conflict Zone-Evidence From the 2015 Afghanistan Demographic and Health Survey.

This study examined the prevalence and social-ecological correlates of male-to-female intimate partner violence (IPV) in Afghanistan. Using data from the 2015 Afghanistan Demographic and Health Survey, which included 20,793 currently married women, we found that the past-year prevalence of physical IPV was highest (46%), followed by emotional (34%) and sexual forms (6%). Results also showed that the risk of IPV in general was associated with an array of community and societal-, family and relationship-, and person-level factors. Our findings point to potential intervention targets for women in this conflict zone where IPV is a highly pervasive and complex societal challenge.

Factors Influencing Formal and Informal Resource Utilization for Mental Distress Among Korean Americans in Southern California.

Despite the high prevalence of mental distress in the Korean American (KA) community, KAs continue to have significantly lower rates of professional mental health utilization than the general U.S. population, making it increasingly critical to study factors related to such utilization. A total of 243 surveys were collected at Korean churches of various denominations in the greater Los Angeles area. This cross sectional study examined KAs' resource utilization using Andersen's Behavioral Model of Health Services Use as a multi-level theoretical framework. Level of education and employment status significantly predicted professional health service utilization. Informal resource utilization was significantly influenced by gender, attitudes toward professional mental health services, acculturation, and views of God and religion. Future studies should further explore which types of interventions or resources would be most effective for KAs to decrease their high levels of mental distress based on their unique intersections and cultural realities.

Prevalence and social determinants of tobacco use in Afghanistan.

BACKGROUND: Limited evidence exists on the prevalence and social determinants of tobacco use in Afghanistan-a fragile post-war context where the tobacco epidemic is on the rise. This study aimed to estimate the prevalence and social determinants of tobacco use in Afghan men and women. METHODS: Data from the 2015 Afghanistan Demographic and Health Survey of 10 760 men and 29 461 women were used to generate weighted prevalence estimates for smoking, smokeless tobacco (SLT) products including chew and snuff tobacco, 'any tobacco use' and 'dual tobacco use'. We also modelled associations with tobacco outcomes using binary logistic regressions. RESULTS: We found that for men, smoking cigarettes was the most prevalent form of tobacco use (21.9% [95% confidence interval {CI} 21.2-22.7]). Prevalence rates were far lower for women, with cigarette/pipe smoking at 3.4% (95% CI 3.2-3.7). For both sexes, tobacco use was inversely associated with education and positively associated with agricultural and skilled and unskilled manual labour occupations. Wealth increased the odds of smoking for men but decreased the odds for women. Media exposure had little influence on tobacco use among women; however, the effects were more varied for men. CONCLUSIONS: Our results demonstrate social inequalities in tobacco use among Afghan men and women, which calls for stronger tobacco control measures and continued monitoring of this growing epidemic.

African Immigrant Health: Prostate Cancer Attitudes, Perceptions, and Barriers.

Prostate cancer (PCa) is the second leading cause of cancer-related death among Black men who present with higher incidence, mortality, and survival compared to other racial groups. African immigrant men, however, are underrepresented in PCa research and thus this research sought to address that gap. This study applied a social determinants of health framework to understand the knowledge, perceptions, and behavioral tendencies regarding PCa in African immigrants. African immigrant men and women residing in different parts of the country (California, Texas, Colorado, Oklahoma, and Florida) from various faith-based organizations, African community groups, and social groups were recruited to participate in key informant interviews (n = 10) and two focus groups (n = 23). Four themes were identified in this study: (a) PCa knowledge and attitudes-while knowledge is very limited, perceptions about prostate health are very strong; (b) culture and gender identity strongly influence African health beliefs; (c) preservation of manhood; and (d) psychosocial stressors (e.g., financial, racial, immigration, lack of community, and negative perceptions of invasiveness of screening) are factors that play a major role in the overall health of African immigrant men. The results of this qualitative study unveiled perceptions, attitudes, beliefs, and knowledge of PCa among African immigrants that should inform the planning, development, and implementation of preventive programs to promote men's health and PCa awareness.

Preventive Cancer Screening Among Resettled Refugee Women from Muslim-Majority Countries: A Systematic Review.

As refugee populations continue to age in the United States, there is a need to prioritize screening for chronic illnesses, including cancer, and to characterize how social and cultural contexts influence beliefs about cancer and screening behaviors. This study examines screening rates and socio-cultural factors influencing screening among resettled refugee women from Muslim-majority countries of origin. A systematic and integrative review approach was used to examine articles published from 1980 to 2019, using PubMed, CINAHL, and PsycINFO. A total of 20 articles met the inclusion criteria. Cancer screening rates among refugee women are lower when compared to US-born counterparts. Social and cultural factors include religious beliefs about cancer, stigma, modesty and gender roles within the family context. The findings of this review, suggest that resettled refugee women underutilize preventive services, specifically mammography, Pap test and colonoscopy screening, and whose perceptions and behaviors about cancer and screening are influenced by social and cultural factors.

Association between HIV knowledge and stigmatizing attitudes towards people living with HIV in Afghanistan: findings from the 2015 Afghanistan Demographic and Health Survey.

BACKGROUND: Afghanistan has witnessed a dramatic increase in HIV infections. Public health officials have responded with campaigns to educate the public about HIV prevention and transmission. We examine the association between HIV prevention and transmission knowledge and stigma towards people living with HIV (PLHIV) in Afghanistan. METHODS: We conducted a secondary analysis of cross-sectional data (n=11 930) from the 2015 Afghanistan Demographic and Health Survey. Hierarchical linear regression analysis was used to examine the effects of accurate HIV knowledge related to safer sex and local misconceptions about the virus's transmission (e.g. mosquitos and witchcraft) on two stigma outcomes, namely, stigma towards public others with HIV (teachers and food vendors) and stigma towards close family members with HIV. RESULTS: Stigmatizing attitudes were highly prevalent and HIV knowledge varied widely. Multivariate analyses show that correct knowledge related to local misconceptions about HIV prevention and transmission is significantly associated with lower stigma towards public others (ΔR2adjusted=0.07); however, knowledge had little and contradictory influence in the model predicting stigma towards close family members with HIV (ΔR2adjusted=0.005). CONCLUSIONS: These findings suggest that it would be worthwhile designing interventions that dispel local misconceptions about HIV. This may be helpful in reducing stigma towards PLHIV in public positions but not towards family members, which calls for alternative strategies for reducing HIV-related stigma.

Impact of Heart Disease Risk Factors, Respiratory Illness, Mastery, and Quality of Life on the Health Status of Individuals Living Near a Major Railyard in Southern California.

The potential health risks for communities that surround railyards have largely been understudied. Mastery and quality of life (QoL) have been associated with self-reported health status in the general population, but few studies have explored this variable among highly vulnerable low-income groups exposed to harmful air pollutants. This study investigates the relationship between self-reported health status and correlates of Heart Disease Risk Factors (HDRF) and Respiratory Illness (RI) with mastery and QoL acting as potential protective buffers. This cross-sectional study of 684 residents residing near a Southern California railyard attempts to address this limitation. Results from three separate hierarchal linear regressions showed that those who reported being diagnosed with at least one type of HDRF and/or RI reported lower perceived health status. For those that lived further from the railyard, mastery and QoL predicted modest increases in perceived health status. Results suggest that mastery and QoL may be helpful as tools in developing interventions but should not solely be used to assess risk and health outcomes as perceived health status may not measure actual health status.

Discrimination and distress among Afghan refugees in northern California: The moderating role of pre- and post-migration factors.

This study investigates the effect of perceived discrimination on the mental health of Afghan refugees, and secondly, tests the distress moderating effects of pre-migration traumatic experiences and post-resettlement adjustment factors. In a cross-sectional design, 259 Afghans completed surveys assessing perceived discrimination and a number of other factors using scales developed through inductive techniques. Multivariable analyses consisted of a series of hierarchical regressions testing the effect of perceived discrimination on distress, followed by a sequential analysis of moderator variables. Perceived discrimination was significantly associated with higher distress, and this relationship was stronger among those with a strong intra-ethnic identity and high pre-resettlement traumatic experiences. The expected buffering effects of civic engagement, ethnic orientation (e.g. integration), and social support were not significant. Discrimination is a significant source of stress for Afghan refugees, which may exacerbate stresses associated with other pre- and post-migration stressors. Future research is needed to tailor interventions that can help mitigate the stress associated with discrimination among this highly vulnerable group.

Risk and protective factors associated with the mental health of young adults in Kabul, Afghanistan.

BACKGROUND: We examined the mental health status and severity of psychological distress symptoms among young adults residing in Kabul, Afghanistan and determined how such outcomes might be influenced by an array of risk and protective factors. METHODS: A cross-sectional study design was adopted using convenience, snowball, and street-intercept recruitment techniques. Surveys were completed by 232 young adults between 18 and 35 years of age in September 2015. We used both etic (mental health component of the SF-8) and emic (Afghan Symptom Checklist) measures of mental health and psychological distress, respectively, and regressed these outcome measures against socio-demographic, physical health, and psychological variables (resilience, hope-optimism) using ordinary least squares (OLS) regression methods. RESULTS: We found that poor mental health is common in this sample, affecting 75% of participants; and, that distress symptoms (depressive, anxiety, and somatoform symptoms) occur often. Regression models were consistent in showing higher education as a risk-factor for both outcomes, whereas, age, ethnicity, and income significantly contributed only to the ASCL model as risk-factors. However, both outcomes were strongly influenced by protective factors such as good physical health status and higher perceived hope-optimism. CONCLUSIONS: Our study provides further evidence of how current economic conditions in Kabul contribute to poor mental health and symptom severity, but also show how positive physical health and perceived hope-optimism can be protective. This study provides support for developing culturally-competent policies and interventions that build on protective factors.

Effect of Perceived Discrimination on Depressive Symptoms in 1st- and 2nd-Generation Afghan-Americans.

While it is well established that Afghan refugees are disproportionately affected by mental health problems, limited evidence exists concerning the psychosocial needs of their children who are transitioning to adulthood in the United States; that is, of 1st- and 2nd-generation Afghan-Americans. The purpose of this study was to examine the effect of perceived discrimination on depressive symptoms in this population, and to determine whether discrimination is buffered by ethnic identity and social support. A convenience sample of 133 1st- and 2nd-generation Afghan-Americans participated in this study by completing a brief survey. We used OLS regression methods to control for covariates, and to sequentially test study hypotheses. The results show that perceived discrimination was significantly associated with high levels of depression. Furthermore, the effect of discrimination on depression was not buffered by ethnic identity or social support. We found that perceived discrimination was a significant source of stress and a risk-factor for negative mental health outcomes among 1st- and 2nd-generation Afghan-Americans. Future research should examine additional pre-dispositional and protective factors for discriminatory experiences and associated health outcomes.

Determinants of Health Care Services Utilization among First Generation Afghan Migrants in Istanbul.

There is insufficient empirical evidence on the correlates of health care utilization of irregular migrants currently living in Turkey. The aim of this study was to identify individual level determinants associated with health service and medication use. One hundred and fifty-five Afghans completed surveys assessing service utilization including encounters with primary care physicians and outpatient specialists in addition to the use of prescription and nonprescription medicines. Multivariate logistic regression analyses were employed to examine associations between service use and a range of predisposing, enabling, and perceived need factors. Health services utilization was lowest for outpatient specialists (20%) and highest for nonprescription medications (37%). Female gender and higher income predicted encounters with primary care physicians. Income, and other enabling factors such as family presence in Turkey predicted encounters with outpatient specialists. Perceived illness-related need factors had little to no influence on use of services; however, asylum difficulties increased the likelihood for encounters with primary care physicians, outpatient services, and the use of prescription medications. This study suggests that health services use among Afghan migrants in Turkey is low considering the extent of their perceived illness-related needs, which may be further exacerbated by the precarious conditions in which they live.

Afghan Refugee Explanatory Models of Depression: Exploring Core Cultural Beliefs and Gender Variations.

Relatively little empirical attention has been paid to understanding how refugees conceptualize depression and how this concept varies between genders. The purpose of this study was to explore beliefs about depression among Afghans residing in San Diego County, California, using cultural consensus analysis. Using the prescribed mixed-method approach, we employed results from in-depth interviews to develop a culturally meaningful questionnaire about depression. Consensus analysis of responses to questionnaire items from 93 Afghans (50 men, 43 women) indicates shared beliefs that associates depression causality with mild traumatic experiences and post-resettlement stressors, symptomatology to include culturally salient idioms of distress, and treatment selections ranging from lay techniques to professional care. Divergence between genders occurred most in the symptoms subdomain, with women associating depression with more somatic items. This study contributes to understanding the etiology of and cultural responses to depression among this population, which is critical to improving culturally sensitive intervention for Afghan refugees.

Gendered Sources of Distress and Resilience among Afghan Refugees in Northern California: A Cross-Sectional Study.

Recent studies have emphasized the influence of resettlement factors on the mental health of refugees resettling in developed countries. However, little research has addressed gender differences in the nature and influence of resettlement stressors and sources of resilience. We address this gap in knowledge by investigating how gender moderates and mediates the influence of several sources of distress and resilience among 259 Afghan refugees residing in Northern California (USA). Gender moderated the effects of four factors on levels of distress. Intimate and extended family ties have little correlation with men's distress levels, but are strongly associated with lower distress for women. English ability is positively associated with lower distress for women, but not men. In terms of gender ideology, traditionally oriented women and egalitarian men have lower levels of distress. And experiencing greater dissonant acculturation increases distress for men, but not women. The influence of gender interaction terms is substantial and patterns may reflect difficulty adapting to a different gender order. Future studies of similar populations should investigate gender differences in sources of distress and resilience, and efforts to assist new arrivals might inform them of changes in gender roles they may experience, and facilitate opportunities to renegotiate gender roles.