Exploring barriers to access to care following the 2021 socio-political changes in Afghanistan: a qualitative study

BACKGROUND

Following the change of government in August 2021, the social and economic landscape of Afghanistan deteriorated into an economic and humanitarian crisis. Afghans continue to struggle to access basic healthcare services, making Universal Health Coverage (UHC) in the country a major challenge. The aim of this study was to perform a qualitative investigation into the main access to care challenges in Afghanistan and whether these challenges have been influenced by the recent socio-political developments, by examining the perspectives of health professionals and hospital directors working in the country.

METHODS

Health professionals working in facilities run by an international non-government organisation, which has maintained continuous operations since 1999 and has become a key health reference point for the population, alongside the public health system, and hospital directors working in government hospitals were recruited to participate in an in-depth qualitative study using semi-structured interviews.

RESULTS

A total of 43 participants from ten provinces were interviewed in this study. Four issues were identified as critical barriers to achieving UHC in Afghanistan: (1) the lack of quality human resources; (2) the suboptimal management of chronic diseases and trauma; (3) the inaccessibility of necessary health services due to financial hardship; (4) the unequal accessibility of care for different demographic groups.

CONCLUSIONS

Health professionals and hospital directors shed light on weaknesses in the Afghan health system highlighting chronic issues and issues that have deteriorated as a result of the 2021 socio-political changes. In order to improve access to care, future healthcare system reforms should consider the perspectives of Afghan professionals working in the country, who are in close contact with Afghan patients and communities.

Access to care in Afghanistan after august 2021: a cross-sectional study exploring Afghans' perspectives in 10 provinces

BACKGROUND

The Taliban takeover in August 2021 ended a decades-long conflict in Afghanistan. Yet, along with improved security, there have been collateral changes, such as the exacerbation of the economic crisis and brain drain. Although these changes have altered the lives of Afghans in many ways, it is unclear whether they have affected access to care. This study aimed to analyse Afghans' access to care and how this access has changed after August 2021.

METHODS

The study relied on the collaboration with the non-governmental organisation EMERGENCY, running a network of three hospitals and 41 First Aid Posts in 10 Afghan provinces. A 67-item questionnaire about access to care changes after August 2021 was developed and disseminated at EMERGENCY facilities. Ordinal logistic regression was used to evaluate whether access to care changes were associated with participants' characteristics.

RESULTS

In total, 1807 valid responses were returned. Most respondents (54.34%) reported improved security when visiting healthcare facilities, while the ability to reach facilities has remained stable for the majority of them (50.28%). Care is less affordable for the majority of respondents (45.82%). Female respondents, those who are unmarried and not engaged, and patients in the Panjshir province were less likely to perceive improvements in access to care.

CONCLUSIONS

Findings outline which dimensions of access to care need resource allocation. The inability to pay for care is the most relevant barrier to access care after August 2021 and must therefore be prioritised. Women and people from the Panjshir province may require ad hoc interventions to improve their access to care.

The underlying mechanisms by which Post-Traumatic Growth is associated with cardiovascular health in male UK military personnel: The ADVANCE cohort study

Post-Traumatic Growth (PTG) is associated with good cardiovascular health, but the mechanisms of this are poorly understood. This cross-sectional analysis assessed whether factors of PTG (Appreciation of Life (AOL), New Possibilities (NP), Personal Strength (PS), Relating to Others (RTO) and Spiritual Change (SC)) are associated with cardiovascular health in a cohort of 1006 male UK military personnel (median age 34). The findings suggest AOL, PS and RTO are associated with better cardiovascular health through cardiometabolic effects (lower levels of triglycerides, and total cholesterol) and haemodynamic functioning (lower diastolic blood pressure), but not inflammation. However, NP and SC were associated with poorer cardiovascular health through cardiometabolic effects (lower levels of high-density lipoproteins and higher levels of total cholesterol) and AOL had a non-linear association with low-density lipoproteins. These findings suggest that the relationship between PTG and cardiovascular functioning is complex and in need of further scrutiny.

Progress in Access and Oral Polio Vaccine Coverage Among Children Aged <5 Years in Polio Campaigns After the Political Change in Afghanistan

BACKGROUND

Warfare has long impeded vaccination programs in polio-endemic Afghanistan. We aimed to describe progress in access to children under 5, oral polio vaccine (OPV) coverage among children under 5 in nationwide polio campaigns, and polio surveillance performance indicators after the Islamic Republic of Afghanistan collapsed to Taliban forces in August 2021.

METHODS

Trends in the number of wild poliovirus type 1 (WPV1) and circulating vaccine-derived poliovirus type 2 (cVDPV2) cases and surveillance indicators from 2015 to 2023, and trends in the OPV coverage in the November 2020-June 2022 polio campaigns, were described.

RESULTS

From 2015 to mid-July 2020, 74 of 126 (58.7%) WPV1 cases were reported from inaccessible areas. In November 2020, 34.1% of target children under 5 were inaccessible; in November 2021 (the first postchange polio campaign), all were accessible. From November 2020, under-5 OPV coverage of 69.9% rose steadily to 99.9% in the May 2022 campaign. The number of cVDPV cases fell from 308 (2020) to zero (2022). June 2022's house-to-house OPV coverage was 34.2% higher than non-house-to-house modalities. Nonpolio acute flaccid paralysis and stool adequacy rates rose from 18.5/100 000 and 92.6% in 2020 to 24.3/100 000 and 94.4% in 2022, respectively.

CONCLUSIONS

Children's inaccessibility no longer vitiates polio eradication; polio surveillance systems are less likely to miss any poliovirus circulation.

Patterns and determinants of healthcare utilization and medication use before and during the COVID-19 crisis in Afghanistan, Bangladesh, and India

BACKGROUND

COVID-19 rapidly spread through South Asian countries and overwhelmed the health systems that were unprepared for such an outbreak. Evidence from high-income countries showed that COVID-19 impacted healthcare utilization, including medication use, but empirical evidence is lacking in South Asia. This study aimed to investigate the effect of COVID-19 on healthcare utilization and medication use in South Asia.

METHOD

The current study used longitudinal data from the 'Premise Health Service Disruption Survey' 2020 and 2021. The countries of interest were limited to Afghanistan, Bangladesh, and India. In these surveys, data related to healthcare utilization and medication use were collected for three-time points; 'Pre-COVID phase', 'Initial phase of COVID-19 outbreak', and 'One year of COVID-19 outbreak'. Generalized estimating equation (GEE) along with McNemar's test, Kruskal-Wallis test and χ2 test were applied in this study following the conceptualization of Andersen's healthcare utilization model.

RESULT

The use of healthcare and medication was unevenly impacted by the COVID-19 epidemic in Afghanistan, Bangladesh, and India. Immediately after the COVID-19 outbreak, respondents in Bangladesh reported around four times higher incomplete healthcare utilization compared to pre-COVID phase. In contrast, respondents in Afghanistan reported lower incomplete utilization of healthcare in a similar context. In the post COVID-19 outbreak, non-adherence to medication use was significantly higher in Afghanistan (OR:1.7; 95%CI:1.6,1.9) and India (OR:1.3; 95%CI:1.1,1.7) compared to pre-COVID phase. Respondents of all three countries who sought assistance to manage non-communicable diseases (NCDs) had higher odds (Afghanistan: OR:1.5; 95%CI:1.3,1.8; Bangladesh: OR: 3.7; 95%CI:1.9,7.3; India: OR: 2.3; 95% CI: 1.4,3.6) of non-adherence to medication use after the COVID-19 outbreak compared to pre-COVID phase.

CONCLUSION

The present study documented important evidence of the influence of COVID-19 epidemic on healthcare utilization and medication use in three countries of South Asia. Lessons learned from this study can feed into policy responses to the crisis and preparedness for future pandemics.

Psychological Problems in the Context of Political Violence in Afghan Children

PURPOSE OF REVIEW

This review provides an overview of recent literature examining psychological problems in the context of political violence among Afghan children.

RECENT FINDINGS

Using recent literature (2018-2023) we identified: 1) heightened levels of psychological problems experienced by children in Afghanistan; 2) the factors associated with these psychological problems, including loss of family and community members, poverty, continuous risk of injury and death, gender, substance use, war, daily stressors, and poor access to education; 3) psychological problems have potentially worsened since the 2021 political changes; 4) conflict and poverty have resulted in violence against children being a serious issue; 5) emerging psychological interventions have been adapted to Afghan contexts; and 6) there is a desperate need for psychological assistance and further research in the region. All children in Afghanistan have experienced conflict and political violence. While children are not responsible for this conflict, it has impacted their mental health. Further research is needed to examine the development and evaluation of interventions.

Association of hormone receptors and human epidermal growth factor receptor-2/neu expressions with clinicopathologic factors of breast carcinoma: a cross-sectional study in a tertiary care hospital, Kabul, Afghanistan

BACKGROUND

Breast cancer (BC) is one of the major causes of death worldwide. It is the most common cause of death before the age of 70 years. The incidence and mortality of BC are rapidly increasing, posing great challenges to the health system and economy of every nation.

METHODOLOGY

A cross-sectional analytical study was conducted at the Department of Pathology and Clinical Laboratory of the French Medical Institute for Mothers and Children (FMIC) to demonstrate the association of human epidermal growth factor receptor 2 (Her2/Neu) and estrogen receptor (ER)/ progesterone receptor (PR) with clinical as well as pathological parameters among women with BC. A consecutive nonprobability sampling method was used for this study over a span of one and a half years.

RESULTS

One hundred twenty participants diagnosed with breast cancer were included in the study. The mean age at diagnosis was 44.58 ± 11.16 years. Out of the total patients, 68 (56.7%) were above 40 years old, 108 (90%) were married, 94 (78.3%) were multiparous, and 88 (73.3%) had a history of breastfeeding. 33.3% of cases were within the age range of menopause (40-50 years). The positive expression rates of ER, PR, and Her2/neu were found to be 48.8%, 44.6%, and 44.6%, respectively, and Her2/neu overexpression was found to be higher among ER/PR-negative cases.

CONCLUSION

In our study, we demonstrated that among Afghan women, grade II invasive ductal carcinoma, not otherwise specified, was the most common type of BC and frequently affected women above the age of 40. We also revealed that the percentage of negative ER (50.4%), negative PR (54.4%), and concordant ER/PR-negative cases were high compared to other possibilities. Additionally, the study revealed that expression of Her2/neu was in contrast with the expression of ER and PR receptors. The findings of our study still support the importance of performing immunohistochemical stains for hormonal receptor classification in terms of better clinical outcomes and prognosis.

Patients' Satisfaction With Physiotherapy Services of Red Cross Physical Rehabilitation Services and Related Factors: A Case Study of Afghanistan

Patient satisfaction is essential to the patient-centered approach in health services delivery, but little is known about satisfaction with physiotherapy services in Afghanistan. This study evaluated patients' satisfaction with physiotherapy services and related factors in this country. This study was conducted on 420 recipients of a physiotherapy center in Afghanistan. A questionnaire was used to collect data that measured satisfaction in 4 dimensions: treatment process, logistics, organizational factors, and overall. The scale of the questionnaire was 5-point Likert. The highest possible score was 100. Statistics methods included Spearman's correlation coefficient, Mann-Whitney and Kruskal-Wallis tests for univariate analysis, and Linear Regression for multivariate analysis. The average overall satisfaction score was 84.82 ± 13.24. Among the demographic variables, the relationship between education level and overall satisfaction score was significant. The findings of the linear regression model showed that the 3 dimensions of satisfaction, including the treatment process, logistics, and organizational factors, had statistically significant relationships with overall satisfaction. The level of satisfaction was high in all dimensions. To maximize satisfaction, reducing waiting time and better communication with patients, as components of logistics and organizational factors, are suggested. Patients also need to receive feedback from physiotherapists that are an essential components of the treatment process dimension.

Modelling the amount of inputs needed for methamphetamine manufacture in Afghanistan

BACKGROUND AND AIMS

The use and manufacture of methamphetamine has increased in Afghanistan in recent years. Recent research and reports have pointed to the ephedra plant, which grows wildly, as a key source of ephedrine used in the manufacture of methamphetamine. This paper aimed to estimate the relative efficiencies and scale of inputs required to manufacture methamphetamine in Afghanistan.

METHODS

Monte Carlo simulations model of the amount of ephedra or cold medications needed to render a pure kilogram of methamphetamine in Afghanistan, accounting for uncertainty in ranges of key parameters informed from the literature and elsewhere. Final estimates were extrapolated to recent seizure totals.

RESULTS

For dried ephedra, the median estimate is 196.8 kg (25th-75th percentiles 119.3-346.6 kg) needed to produce 1 kg of methamphetamine compared with 27.9 kg (25th-75th percentiles 21.9-36.8 kg) for cold medications. Nearly 2.7 t of methamphetamine were seized in Afghanistan in 2021. Assuming a purity range of 50%-90%, some 266-478 t of dried ephedra or 38-68 t of cold medication would need to have been processed.

CONCLUSION

Simulated estimates show that considerable amounts of either ephedra or cold medication are needed to produce 1 kg of methamphetamine in Afghanistan. This raises questions about the plausibility of ephedra as the dominant source of Afghanistan's methamphetamine.

Prevalence and correlates of diabetes and impaired fasting glucose among adults in Afghanistan: Insights from a national survey

Objectives

Afghanistan is experiencing an escalating burden of noncommunicable diseases, with diabetes and impaired fasting glucose being of particular concern. To explore the prevalence of diabetes and impaired fasting glucose and associated factors among adult Afghans.

Methods

This cross-sectional study used secondary data from a nationally representative survey, conducted in 2018 in Afghanistan. A blood sample was collected from the fingertip and tested through a strip to measure blood glucose. The complex sampling design and sampling weights were accounted for in all analyses to produce representative estimates of the target population in Afghanistan.

Results

Of 3890 Afghan adults aged 18-69 years who participated in this survey, 11.07% and 10.32% had diabetes and impaired fasting glucose, respectively. For overweight individuals with abdominal obesity, the risk for diabetes became significantly elevated, with an adjusted relative risk ratio of 2.12 (95% CI: 1.10-4.09). However, the most pronounced effect was observed among individuals classified as having obesity with abdominal obesity with an adjusted relative risk ratio of 2.54 (95% CI: 1.37-4.70). Moreover, high cholesterol level was significantly associated with both impaired fasting glucose (ARRR: 2.52, 95% CI: 1.55-4.12) and diabetes (ARRR: 4.12, 95% CI: 2.59-6.56), whereas high blood pressure was significantly associated with only diabetes (ARRR: 1.82, 95% CI: 1.16-2.86).

Conclusions

This investigation provides critical insight into the prevalence of diabetes and IFG among Afghan adults aged 18-69 years. Relative to the global average, the higher prevalence observed calls for specifically designed interventions targeting individuals with cardiometabolic risk factors, such as elevated body mass index, abdominal obesity, hypertension, and hypercholesterolemia.

Post-marketing surveillance of intussusception after Rotarix administration in Afghanistan, 2018-2022

BACKGROUND

In January 2018, Afghanistan introduced the monovalent oral rotavirus vaccine (Rotarix) nationwide, administered as a 2-dose series at six and ten weeks of age. We describe characteristics of intussusception cases and assess potential intussusception risk associated with Rotarix vaccination in Afghan infants.

METHODS

Multi-center prospective active hospital-based surveillance for intussusception was conducted from May 2018 to March 2022 in four sentinel sites in Afghanistan. We applied the Brighton Level 1 criteria for intussusception and verified vaccination status by reviewing vaccine cards. We used the self-controlled case series (SCCS) methodology to compare intussusception incidence in the 1 to 21 days after each dose of Rotarix vaccination against non-risk periods.

RESULTS

A total of 468 intussusception cases were identified in infants under 12 months, with 264 cases aged between 28 and 245 days having confirmed vaccination status contributing to the SCCS analysis. Most case-patients (98 %) required surgery for treatment, and over half (59 %) of those who underwent surgery required intestinal resection. Nineteen (7 %) case-patients died. Eighty-six percent of case-patients received the first dose of Rotarix, and 69 % received the second dose before intussusception symptom onset. There was no increased risk of intussusception in the 1-7 days (relative incidence: 0.9, 95 % CI: 0.1, 7.5), 8-21 days (1.3, 95 % CI: 0.4, 4.2), or 1-21 days (1.1, 95 % CI: 0.4, 3.4) following receipt of the first dose or in the 1-7 days (0.2, 95 % CI: 0.3, 1.8), 8-21 days (0.7, 95 % CI: 0.3, 1.5), or 1-21 days (0.6, 95 % CI: 0.3, 1.2) following the second dose.

CONCLUSION

Rotarix vaccination was not associated with an increased intussusception risk, supporting its continued use in Afghanistan's immunization program. However, there was a high level of death and resection due to intussusception among Afghan infants.

Foot-and-mouth disease virus dynamics in border areas of Pakistan with Afghanistan

BACKGROUND

Foot and mouth disease (FMD) is a highly contagious disease that impacts cloven-hoofed animals globally. The illegal trade of livestock between the border regions of Pakistan and Afghanistan can contribute to the spread of this disease. This study focuses on investigating the outbreaks of FMD that occurred in this area from June 2020 to May 2021.

METHODS

RESULTS: A total of 233 epithelial tissue samples were collected, and 77% were found positive for FMDV through an antigen-detection by ELISA and molecular conformation through RT-PCR. The study found three serotypes of FMDV dominating in the border area of Pakistan with Afghanistan: O, A, and Asia-1. The outbreak activity was peaked between August/September followed by July/October 2020. Phylogenetic analysis conducted using the VP1 region sequence showed that serotype O isolates belonged to the Middle East-South Asia (ME-SA) topotype, PanAsia-2 lineage, and ANT-10 sub-lineage, while serotype Asia-1 isolates belonged to a novel lineage BD-18.The highest prevalence of serotype O of FMDV was found in cattle and buffalo of 1-2 year age group, while the highest outbreak ratio of serotype O was recorded in goats of 0-1 year age group and sheep of > 2 year age group. The serotype O was more prevalent in male than female sheep. The type A was more prevalent in females of sheep and goats than their corresponding males. The serotype Asia-1 was more prevalent in females of cattle and sheep than their corresponding males. The outbreak epidemiology of FMD varied significantly between various regions, months of study, animal species, age groups, and gender.

CONCLUSIONS

The study found that FMD outbreaks in the border area of Pakistan and Afghanistan were diverse and complicated, and that different types of FMDV were circulating. The study recommended effective actions to stop FMD transmission in this area.

Barriers to healthcare utilization among married women in Afghanistan: the role of asset ownership and women's autonomy

Women face multiple socio-economic, cultural, contextual, and perceived barriers in health service utilization. Moreover, poor autonomy and financial constraints act as crucial factors to their healthcare accessibility. Therefore, the objective of the present study is to study the association between health care utilization barriers and women empowerment, including asset ownership among currently married women in Afghanistan. Data of 28,661 currently married women from Afghanistan demographic health survey (2015) was used to carry out this study. Barriers to access healthcare were computed based on problems related to permission, money, distance, and companionship, whereas women empowerment and asset ownership were computed as potential covariates along with other socio-economic risk factors. Bivariate and logistic analysis was carried out to study the association and odds of explanatory variables. Our results confirm the significant and strong association between the barriers to access healthcare and various explanatory variables. Women having any decision-making autonomy are less likely to face any odds [(AOR = 0.56, p < 0.001), CI: 0.51-0.61] among the currently married women than those who don't have any decision-making authority. Similarly, women who justify their beating for some specific reasons face the greater difficulty of accessing health care [(AOR = 1.76, p < 0.001), CI: 1.61-1.93]. In terms of asset ownership, women having any asset ownership (land or household) are less likely to face any barriers in health services utilization given the lower odds [(AOR = 0.91, p < 0.001), CI: 0.90-0.98]. Accessing maternal health is a crucial policy challenge in Afghanistan. A substantial proportion of women face barriers related to approval, money, distance, and companionship while accessing the health services utilization in Afghanistan. Similarly, women empowerment and asset ownership are significantly associated with health service accessibility. This paper therefore suggests for some policy interventions to strengthen the healthcare needs of women and ensure healthcare accessibility by scaling down these potential barriers like poor autonomy, asset ownership and domestic violence.

The validity of the environmental Kuznets curve in the presence of long-run civil wars: A case of Afghanistan

The war in Afghanistan left significantly negative consequences in all spheres of its society, leading the country to the highest levels of poverty, hunger, and environmental damage. This study explores the long-run impact of civil wars on environmental degradation in Afghanistan using the conceptual framework of the Environmental Kuznets Curve and models augmented with pollutants, civil wars, comprehensive financial development index, and macroeconomic predictors on a set of data from the first quarter of 2002 to the first quarter of 2020. However, while the results confirm long-run relationships amid indicators by the autoregressive distributed lags bound test, the results of the vector error-correcting model to Granger causality reveal bidirectional causality links between CO2 emissions, per capita real GDP, civil wars, the financial development index, energy consumption, trade openness, and the inflation rate in the long-run, while the findings extend to confirm multidimensionality and interdependencies among predictors in the short-run. Moreover, the results indicate dual findings. First, it confirms that civil wars, the financial development index, per capita real gross domestic product, population growth, and the inflation rate significantly increase CO2 emissions, while the squared per capita real gross domestic product, energy consumption, and trade openness reduce CO2 emissions both in the short and long runs. Second, the results confirm an inverted U-shaped relationship, supporting the validity of the Environmental Kuznets Curve hypothesis in Afghanistan. Based on the findings, appropriate policy measures are recommended.

Prevalence of major non-communicable diseases and their associated risk factors in Afghanistan: a systematic review and meta-analysis

Background

Non-communicable diseases (NCDs) are the leading cause of mortality worldwide, and increasingly so in low- and middle-income countries. Afghanistan is dealing with a double burden of diseases, yet there has been no evidence synthesis on the prevalence of major NCDs and their risk factors.

Objective

This study aims to provide a comprehensive synthesis of the existing data on the prevalence of major NCDs and the common related risk factors in Afghanistan.

Method

We systematically reviewed scientific articles from 2000 to 2022 that reported the prevalence of diabetes, chronic respiratory diseases (CRDs), cardiovascular diseases (CVDs) or cancer, and their risk factors in Afghanistan. Four online databases (PubMed, Web of Science, Cochrane and Google Scholar) and two local journals in Afghanistan (not indexed online) were systematically searched and screened. Two reviewers independently screened and appraised the quality of the articles. Data extraction and synthesis were performed using tabulated sheets.

Results

Among 51 eligible articles, 10 (19.6%) focused on cancer, 10 (19.6%) on diabetes, 4 (7.8%) on CVDs, 4 (7.8%) on CRDs and 23 (45.1%) on risk factors as the primary outcome. Few articles addressed major NCD prevalence; no evidence of CVDs, cancer was 0.15%, asthma ranged between 0.3% and 17.3%, and diabetes was 12%. Pooled prevalence of hypertension and overweight were 31% and 35%, respectively. Central obesity was twice as prevalent in females (76% versus 40%). Similarly, gender differences were observed in smoking and snuff use with prevalence rates of 14% and 25% among males and 2% and 3% among females, respectively. A total of 14% of the population engaged in vigorous activity. Pooled prevalence for physical inactivity, general obesity, fruit and vegetable consumption, dyslipidaemia and alcohol consumption couldn't be calculated due to the heterogeneity of articles.

Conclusion

Only little evidence is available on the prevalence of major NCDs in Afghanistan; however, the NCD risk factors are prevalent across the country. The quality of the available data, especially those of the local resources, is poor; therefore, further research should generate reliable evidence in order to inform policymakers on prioritizing interventions for controlling and managing NCDs.

Burden of Disease Due to Air Pollution in Afghanistan-Results from the Global Burden of Disease Study 2019

INTRODUCTION

Air pollution is a significant risk factor for a range of diseases and leads to substantial disease burden and deaths worldwide. This study aimed to investigate the burden of disease in Afghanistan attributed to air pollution in 2019.

METHODS

Data from the Global Burden of Disease (GBD) Study 2019 were used to investigate disability-adjusted life-years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), and deaths attributed to air pollution in Afghanistan.

RESULTS

In 2019, air pollution in Afghanistan was associated with significant health impacts, and contributed to 37,033 deaths (14.72% of total deaths), 1,849,170 DALYs (10.80% of total DALYs), 76,858 YLDs (2.07% of total YLDs), and 1,772,311 YLLs (13.23% of total YLLs). The analysis further revealed that lower respiratory infections, neonatal disorders, ischemic heart disease, stroke, chronic obstructive pulmonary disease, lung cancer, and diabetes mellitus were the leading causes of mortality and disease burden associated with air pollution in Afghanistan from 1990 to 2019. Comparative assessments between 1990 and 2019 underscored air pollution as a consistent prominent risk factor that ranked closely with other risk factors, like malnutrition, high blood pressure, and dietary risks, in contributing to deaths, DALYs, YLDs, and YLLs. In a comparative country analysis for the year 2019, Afghanistan emerged as having a substantial burden of disease due to air pollution, closely mirroring other high-burden nations like China, India, Pakistan, and Bangladesh.

DISCUSSION

Air pollution is one of the major health risk factors that significantly contribute to the burden of disease in Afghanistan, which emphasizes the urgent need for targeted interventions to address this substantial public health threat.

Women's experience of childbirth care in health facilities: a qualitative assessment of respectful maternity care in Afghanistan

BACKGROUND

Respectful maternity care (RMC) remains a key challenge in Afghanistan, despite progress on improving maternal and newborn health during 2001-2021. A qualitative study was conducted in 2018 to provide evidence on the situation of RMC in health facilities in Afghanistan. The results are useful to inform strategies to provide RMC in Afghanistan in spite of the humanitarian crisis due to Taliban's takeover in 2021.

METHODS

Focus group discussions were conducted with women (4 groups, 43 women) who had used health facilities for giving birth and with providers (4 groups, 21 providers) who worked in these health facilities. Twenty key informant interviews were conducted with health managers and health policy makers. Motivators for, deterrents from using, awareness about and experiences of maternity care in health facilities were explored.

RESULTS

Women gave birth in facilities for availability of maternity care and skilled providers, while various verbal and physical forms of mistreatment were identified as deterrents from facility use by women, providers and key informants. Low awareness, lack of resources and excessive workload were identified among the reasons for violation of RMC.

CONCLUSION

Violation of RMC is unacceptable. Awareness of women and providers about the rights of women to respectful maternity care, training of providers on the subject, monitoring of care to prevent mistreatment, and conditioning any future technical and financial assistance to commitments to RMC is recommended.

Treatment outcomes for maculopathy secondary to retinal vein occlusion in Afghanistan

OBJECTIVES

The objective of this study was to investigate the efficacy of intravitreal antivascular endothelial growth factor (VEGF) therapy in the treatment of macular edema secondary to retinal vein occlusion (RVO) in Afghanistan.

METHODS

A retrospective analysis was conducted of all RVO cases that underwent intravitreal ant-VEGF injection at the two leading hospitals in Kabul. The main outcome measures were visual acuity and central retinal thickness as determined by optical coherence tomography. Information was also collected on the distance traveled by each patient and the frequency of injections.

RESULTS

One hundred and twenty-five eyes of 121 patients (86 males) with RVO were identified as having undergone treatment, with a mean age of 53.1 years (range 20-80). The only agent used was bevacizumab. The mean central retinal thickness reduced from 624.2 ± 24.9 μm at the baseline to 257.8 ± 5.7 μm following treatment (P < 0.001). There was a small increase in visual acuity from 1.33 LogMAR at the baseline to 1.13 LogMAR following the most recent injection (P = 0.03, paired t-test). The mean distance traveled by patients was 173.9 km (range 2-447 km).

CONCLUSION

Despite the challenges of health-care provision in Afghanistan, this review shows that the use of intravitreal bevacizumab has provided an effective treatment for macular edema after RVO.

Prevalence, risk factors, and comorbidities of psychotic experiences in Afghanistan: a highly stressful environment

OBJECTIVES

To estimate the prevalence and demographic, psychiatric, and trauma-focused correlates of psychotic experiences (PEs) in the Afghan general population.

METHODS

Data were drawn from a cross-sectional household survey implemented in eight regions of Afghanistan (N = 4445). The CIDI structured instrument was administered to adults to assess psychiatric disorders and psychotic experiences; life events and PTSD were assessed using validated instruments. Weighted multivariate models integrated socio-demographics, regions, traumas as determinants of PE.

RESULTS

PEs were frequently reported in the Afghan population: 27.50% of the population reported a lifetime PE. PEs were more common among specific ethnic groups, and were associated with lower income in adjusted regression models. PEs were associated with mental health problems including major depressive disorders (OR = 3.43), PTSD (OR = 5.08), generalized anxiety (OR = 4.2); lifetime suicidal attempts (OR 6.04), lifetime suicidal thoughts (OR = 3.42), addiction (OR = 2.18); and psychological distress and impairment due to mental health (OR = 2.95 and 2.46, respectively).

CONCLUSION

Psychotic experiences in the Afghan general population confirm general population findings in other countries, that psychotic experiences are common and associated with economic and social marginalization, and part of a continuum of mental health problems experienced in populations. Efforts to reduce and treat psychotic experiences within a broad array of psychiatric conditions are needed.

Exploring the diversity of CFTR gene mutations in cystic fibrosis individuals of South Asia

OBJECTIVE

Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the CFTR gene. This study aimed to identify the spectrum of CFTR variants reported in individuals with CF from South Asia (ISA).

DATA SOURCES AND STUDY SELECTION

We conducted a PubMed search for CFTR variants reported in ISA. Full text of original articles and case reports was read to compile data on reported variants. To gather additional data, we independently cross-referenced each variant with the CFTR Mutation Database and ClinVar.

RESULTS

Our investigation identified a total of 92 CFTR variants reported across 30 articles. The most frequently tested, and reported variant was ΔF508 with a global frequency of 69.74%. Notably, we found 14 pathogenic CFTR mutations shared among ISA, originating from more than one South Asian country: ΔF508, 1525-1 G > A, G542X, S549N, R117H, S549R, R709X, V456A, Y569D, L1077P, 1161delC, 1898 + 1 G > T, G551D, and 2184insA.

CONCLUSION

In summary, the higher prevalence of consanguinity and the limited availability of CF diagnostic resources in South Asia considerably contribute to the prevalence of genetic disorders like CF. The spectrum of CFTR mutations exhibits noticeable variations within South Asian and other populations. The inclusion of current study-enlisted CFTR gene variants is highly recommended for CF disease genetic testing in South Asia which may aid in achieving a precise diagnosis, enhancing disease management, and discovering drugs for currently untreatable genetic variants. It is also imperative to conduct a comprehensive study in this region, especially in previously unexplored countries such as Nepal, Bhutan, Maldives, and Bangladesh.

The individual- and community-level women's empowerment and utilization of maternity care services in Afghanistan: a multilevel cross-validation study

BACKGROUND

This study aimed to explore the relationship between women's empowerment and utilization of maternity care for married Afghan women aged 15-49 y in Afghanistan, assessing the convergence validity of the Survey-based Women's Empowerment Index in Afghanistan (SWEI-A).

METHODS

The study used data from the 2015 Afghanistan Demographic Health Survey to examine the association of different domains of women's empowerment with the utilization of maternity care using multilevel Poisson regression at both individual and community levels.

RESULTS

The utilization of maternity services was considerably higher among women with high scores compared with those with low scores in almost all domains of the SWEI-A, except for property owning, in which women with high scores appeared to have lower rates of utilization of such services compared with those with low scores. At the community level, those communities with high participation of women in the labor force were less likely to have adequate antenatal care (ANC), institutional delivery and postnatal care (PNC). Individual-level literacy was associated with higher utilization of ANC, institutional delivery and PNC, contrary to community-level literacy.

CONCLUSIONS

Except for property owning, the high score in almost all other domains was associated with higher utilization of maternity care, which indicates an acceptable level of convergence validity for the developed index (i.e. the SWEI-A) in measuring women's empowerment among married Afghan women aged 15-49 y.

Contents of antenatal care services in Afghanistan: findings from the national health survey 2018

BACKGROUND

Maternal and newborn mortality is a public health concern in low- and middle-income countries (LMICs), including Afghanistan, where the evolving socio-political circumstances have added new complexities to healthcare service delivery. Birth outcomes for both pregnant women and their newborns are improved if women receive benefits of quality antenatal care (ANC).

OBJECTIVES

This study aimed to assess the contents of ANC services and identify predictors of utilization of services by pregnant women during ANC visits to health facilities in Afghanistan.

METHODS

In this cross-sectional study, we used data from the Afghanistan Health Survey 2018 (AHS2018). We included a total of 6,627 ever-married women, aged 14-49 years, who had given birth in the past 2 years or were pregnant at the time of survey and had consulted a health worker for ANC services in a health facility. The outcome was defined as 1-4 services and 5-8 services that a pregnant woman received during an ANC visit. The services were (i) taking a pregnant woman's blood pressure, (ii) weighing her, (iii) testing her blood, (iv) testing her urine, (v) providing advice on nutrition, (vi) advising about complicated pregnancy, (vii) advising about the availability of health services, and (viii) giving her at least one dose of Tetanus Toxoid (TT) vaccine. The binary outcome (1-4 services versus 5-8 services) was used in a multivariable logistic regression model.

RESULTS

Of all 6,627 women, 31.4% (2,083) received 5-8 services during ANC visits. Only 1.3% (86) received all 8 services, with 98.7% (6,541) receiving between 1 and 7 services, and 71.6% (4,745) women had their blood pressure measured during ANC visits. The likelihood (adOR = Adjusted Odds Ratio) of receiving 5-8 services was higher in women who could read and write (adOR = 1.33: 1.15-1.54), in women whose husbands could read and write (adOR = 1.14: 1.00-1.28), in primipara women (adOR = 1.42: 1.02-1.98), in women who knew one danger sign (adOR = 5.38: 4.50-6.45), those who knew 2 danger signs (adOR = 8.51: 7.12-10.19) and those who knew ≥ 3 danger signs (adOR = 13.19: 10.67-16.29) of complicated pregnancy, and in women who had almost daily access to TV (adOR = 1.16: 1.01-1.33). However, the likelihood of receiving 5-8 services was lower in women who used private clinics (adOR = 0.64: 0.55-0.74) and who received services from nurses (adOR = 0.27 (0.08-0.88).

CONCLUSION

Our findings have the potential to influence the design and implementation of ANC services of health interventions to improve the delivery of services to pregnant women during ANC visits.

Infectious diseases in Afghanistan: Strategies for health system improvement

Background and Aim

Afghanistan is grappling with a severe health crisis marked by a high prevalence of infectious diseases, particularly tuberculosis, malaria, HIV, and the added strain of the COVID-19 pandemic. The nation's healthcare system, already fragile, faces formidable challenges. Socioeconomic constraints, including limited resources and financial barriers, hinder healthcare accessibility, leading to delayed or inadequate care. Environmental factors, such as poor sanitation and crowded living conditions, exacerbate the transmission of diseases, especially waterborne illnesses. Governance issues, encompassing transparency, corruption, and political instability, disrupt healthcare efficiency and resource allocation. Addressing these multifaceted issues is vital to enhance Afghanistan's healthcare system and overall well-being. The withdrawal of international support has exacerbated these challenges. The primary research goal is to deeply understand Afghanistan's health system, focusing on the major disease burdens: Tuberculosis, Malaria, AIDS, COVID-19, Measles, Hepatitis, and Cholera. The study aims to assess the feasibility and effectiveness of current approaches, presenting a comprehensive view of challenges and opportunities within the Afghan healthcare system. The research concludes by highlighting policy implications, practical implementation, and offering recommendations for future endeavors.

Methodology

This paper provides a thorough analysis of the literature concerning infectious diseases in Afghanistan and the enhancement of the healthcare system in the nation. A systematic exploration of the literature was conducted through PubMed and Google Scholar databases. The search terms used encompassed "Tuberculosis" OR "TB," "Malaria," "acquired immunodeficiency syndrome" OR "AIDS," "Human immunodeficiency virus" OR "HIV," "COVID-19," "Measles," "Hepatitis virus," "Cholera," "Health system improvement," and "Afghanistan." Additionally, external sources like UNICEF, CDC, and WHO were referenced.

Results

In conclusion, while improving access to vital medicines and vaccines is crucial for enhancing health outcomes in Afghanistan, significant challenges must be addressed to ensure the effectiveness and sustainability of such strategies. The Afghan health system's fragile governance, corruption, logistical complexities, and failure to address broader social and economic factors pose significant risks and obstacles to the implementation of proposed health strategies. Therefore, the strategies discussed in this analysis align with key Sustainable Development Goals, particularly SDG 3, and their successful implementation will have implications not only for the health and well-being of Afghanistan but also for global health.

Conclusion

Hence, by adopting a comprehensive approach with complementary interventions as discussed, we can address issues in the Afghan health system and reduce transmissible diseases' burden, thereby building a better world for all.

"I did not expect the doctor to treat a ghost": a systematic review of published reports regarding chronic postamputation pain in British First World War veterans

Limb trauma remains the most prevalent survivable major combat injury. In the First World War, more than 700,000 British soldiers received limb wounds and more than 41,000 underwent an amputation, creating one of the largest amputee cohorts in history. Postamputation pain affects up to 85% of military amputees, suggesting that up to 33,000 British First World War veterans potentially reported postamputation pain. This qualitative systematic review explores the professional medical conversation around clinical management of chronic postamputation pain in this patient cohort, its development over the 20th century, and how this information was disseminated among medical professionals. We searched The Lancet and British Medical Journal archives (1914-1985) for reports referring to postamputation pain, its prevalence, mechanisms, descriptors, or clinical management. Participants were First World War veterans with a limb amputation, excluding civilians and veterans of all other conflicts. The search identified 9809 potentially relevant texts, of which 101 met the inclusion criteria. Reports emerged as early as 1914 and the discussion continued over the next 4 decades. Unexpected findings included early advocacy of multidisciplinary pain management, concerns over addiction, and the effect of chronic pain on mental health emerging decades earlier than previously thought. Chronic postamputation pain is still a significant issue for military rehabilitation. Similarities between injury patterns in the First World War and recent Iraq and Afghanistan conflicts mean that these historical aspects remain relevant to today's military personnel, clinicians, researchers, and policymakers.

Factors associated with Afghan household food security pre- and post-Taliban regime

To determine multifaceted determinants of household vulnerability to food insecurity in Afghanistan before and after the Taliban takeover, we randomly selected 555 households from 13 provinces, conducted in-person surveys, and applied the Household Food Insecurity Assess Scale (HFIAS) and Structural Equation Modeling (SEM). We collected data from January to April 2022. We observed an increase in both prevalence and severity of food insecurity among Afghan households after the Taliban takeover. Approximately, 98% and 70% of interviewed households were food insecure after and before the Taliban takeover, respectively. Similarly, households were more likely to be severely food insecure (81%) than before (40%). Our results showed that policy and political conditions contributed substantially to the food insecurity of Afghan households after the Taliban takeover. We recommend that the Taliban forces facilitate the presence of humanitarian organizations and NGOs to improve low-income households' food security, especially for women and children. We also recommend that international organizations enhance their attempts to negotiate with the Taliban to ensure freedom for women.

Improving the health status of Afghan mothers living in the Islamic Republic of Iran

Background

The healthcare system of the Islamic Republic of Iran provides special maternal health care services for mothers, regardless of their nationality.

Aim

This study, supported by the United Nations Population Fund, was conducted to review available data associated with health indicators of Afghan mothers living in Islamic Republic of Iran.

Methods

This descriptive study used data from the electronic registration system of the Maternal Health Office of the Ministry of Health and Medical Education on characteristics, morbidity and mortality among Afghan mothers in the Islamic Republic of Iran from 2017 to 2019. The data were analysed using SPSS version 23.0. Based on the results, we propose interventions to improve health services for vulnerable Afghan mothers.

Results

There were 168 488 deliveries over the 3 years of the study (2017-2019). Deliveries by Afghan women increased from 3.4% in 2017 to 5.2% in 2019, and more than 70% of these Afghan women were vulnerable. Ten percent of deliveries among Afghan mothers were performed by traditional birth attendants. The rate of caesarean section among Afghan mothers was 30%. Maternal mortality ratio among the Afghan mothers was 43 per 100 000 for the 3 years.

Conclusion

Afghan mothers in the Islamic Republic of Iran use primary health care services provided for mothers in the country. However, healthcare delivery to these mothers is inadequate, although considered better than the care provided to Afghan mothers living in Afghanistan. We recommend targeted interventions to improve the health status of Afghan women living in the Islamic Republic of Iran.

Predictors of Mothers' Care Seeking Behavior for Common Childhood Illnesses: Findings From the Afghanistan Health Survey 2015

BACKGROUND

Mothers' care seeking behavior for childhood illness is a key factor of utilizing healthcare for children. We examined predictors of mothers' care seeking for common childhood illnesses.

METHODS

This was a cross-sectional study, using data from the Afghanistan Health Survey (AHS) 2015. Data were used from women who sought healthcare for their unwell children. The women were asked whether their children were sick with fever, cough, faster breathing, or diarrhea in the past 2 weeks. The outcome variable was defined as whether the mother sought healthcare for her unwell child from a public clinic, a private clinic, or from a pharmacy store. The Andersen's healthcare seeking behavior model was used and multinomial regression analysis applied.

RESULTS

There were 4979 women, aged 15-49 years, whose under-5 children were sick in the past 2 weeks. Thirty-nine percent of women sought healthcare for their children from a health provider. Mother's age, child's age, child's sex, socioeconomic status, mothers' perceived severity of childhood illness, and number of under-5 children were predictors of mothers' care seeking behavior. The likelihood of healthcare seeking was lower for older children (Adjusted odds ratio [OR] [95% CI]: 0.51 [0.37-0.70] from public clinics; 0.33 [0.23-0.47] from private clinics; 0.36 [0.22-0.61] from pharmacy stores), and for girls (Adjusted OR [95% CI]: 0.74 [0.59-0.93] from private clinics). The likelihood of healthcare seeking was greater for children whose mothers knew symptoms of childhood illness (Adjusted OR [95% CI]: 2.97 [1.44-6.16] from public clinics; 7.20 [3.04-17.04] from pharmacy stores). The likelihood of healthcare seeking for children was greater in older mothers (Adjusted OR [95% CI]: 1.54 [1.11-2.12]). It was less likely for the mothers who have more children to seek healthcare for their children (Adjusted OR [95% CI]: 0.53 [0.43-0.65] from public clinics; 0.61 [0.48- 0.79] from private clinics; 0.51 [0.37-0.69] from pharmacy stores).

CONCLUSION

Health policy-makers may opt to use our findings, particularly mothers' knowledge (perceived severity) of symptoms of childhood illness to develop interventions to enhance timely assessment and effective treatment of common preventable childhood illnesses.

Conducting Health Research in the Current Afghan Society: Challenges, Opportunities, and Recommendations

Research makes a significant contribution to academic excellence and holds the potential to facilitate societal development. Despite the increasing importance of health research in developing new therapies and galvanizing notable progress in public health, the landscape of health research in Afghanistan remains profoundly deficient. This article reveals that health research in Afghanistan requires significant growth to meet the standards set on regional and global grounds.

An EMS Response to Refugees Arriving at an International Airport: A Report From the Field

Following Afghanistan's fall in August 2021, many refugees were settled in the United States as part of Operation Allies Welcome. They were flown from Kabul to the Middle East and Europe before continuing to the U.S. By late September Philadelphia was the sole destination. From there refugees were transported to Safe Haven military bases around the country. Philadelphia International Airport became the site of a months-long operation involving city, state, federal, and private agencies engaged in processing, medical screening, and COVID-testing of arriving refugees. The Philadelphia Fire Department played an integral role. Minor medical conditions were treated onsite. Higher acuity patients were transported to nearby hospitals. The goal was to maintain flow of refugees to their next destination while addressing acute medical issues. Between August 28, 2021, and March 1, 2022, the airport processed 29,713 refugees. Philadelphia's experience may serve as a guide for planning future such refugee operations.

Hydrogeochemical and isotopic evolution of groundwater in shallow and deep aquifers of the Kabul Plain, Afghanistan

Groundwater from shallow and deep aquifers are widely used for drinking, agricultural and industrial use in Kabul, the capital of Afghanistan. However, unplanned urbanization and rapid population growth has led to the installation of numerous unlicensed wells to meet the public demand. This has caused to extraction of huge amounts of groundwater from the subsurface and further deterioration of groundwater quality. Therefore, understanding the hydrogeochemical characteristics of groundwater in shallow aquifers and deep aquifers is imperative for sustainable management of the groundwater resource in Kabul Plain. Thus, in this study, we used a multi-parameter approach, involving hydrochemical and environmental isotopes to understand the geochemical evolution of entire groundwater system of the Kabul Plain including river and dam water. The results of this study show that shallow and deep aquifers are dominantly of Mg-(Ca)-HCO3 and Na-Cl water type, respectively. We observed that (1) water-rock interaction is the major contributing factor to the chemical compositions of groundwater in the Kabul Plain; (2) groundwater in deep aquifer is mainly influenced by silicate weathering, and dissolution of evaporitic and carbonate minerals and reverse cation exchange; (3) dissolution of carbonates and silicate weathering plays a pivotal role in the groundwater chemistry of shallow aquifer; (4) the stable isotopes of groundwater display that the shallow aquifer is principally recharged by river water and local precipitation; (5) the tritium analysis exhibited that groundwater of shallow aquifer was primarily recharged recently, whereas groundwater of deep aquifer is the mixture of pre 1953 with post 1953 groundwater. This study revealed that there are hydraulic interactions between the two aquifers and the deep aquifer is recharged through shallow aquifer. The findings of this study would be useful for Afghanistan's water authorities to develop an effective strategy for sustainable water resources management in the Kabul Basin.

Acute myeloid leukaemia in Afghanistan: Understanding an unfamiliar landscape

The paper by Noor et al. in this issue provides important and interesting data on the incidence and outcomes of patients with acute myeloid leukaemia in Afghanistan. The age of patients is much lower than we are used to seeing in the West, reflecting in part the particular demographics of the country; these data provide an important first step to identifying areas for improvement. Commentary on: Noor et al. Demographic and clinical characteristics of acute myeloid leukaemia diagnosed and treated at tertiary level in Afghanistan. Br J Haematol 2023;203:404-410.

"I hope to all the world they don't forget women of Afghanistan": An interrupted survey among doctors in Afghanistan

OBJECTIVE

To assess current access to essential sexual and reproductive health (SRHR) services in Afghanistan and how access has changed with the transition of power.

METHODS

This is a cross-sectional study based on data from an anonymous survey among doctors in Afghanistan in May 2022, analyzed using descriptive statistics. The survey recorded subjective estimates of access to SRHR services, barriers to access, extent of maternal mortality or near miss due to preventable factors, and the effect of the regime change on access.

RESULTS

The data collection was interrupted after 60 responses. A majority of providers responded that their population went hungry often or always. According to our criteria for "access", that 75% or more of the population was estimated to have it, no respondents (0%) assessed that access existed for services for gender-based violence. The corresponding proportion responding that access existed was 3.4% for services after rape, 12.6% for legal abortion, 13.3% for antenatal care, and 20% for labor care. According to 41.7% of respondents, untreated postpartum hemorrhage accounted for a large or very large proportion of preventable maternal mortality or near miss. Almost half of respondents (47.4%) reported the same for lack of skilled providers, 66.2% reported it for the concept "too many pregnancies", and 55% reported it for malnutrition and poor health. According to 43.3% of respondents, the regime change had reduced access to labor care to a large extent, 33.9% of respondents said this in relation to access to contraceptives, and 43.1% for overall access for internally displaced persons.

CONCLUSION

Interim data suggest that women in some settings in Afghanistan have no access to SRHR services, that preventable factors account for a large portion of maternal deaths or near miss, and that access has deteriorated since the transition of power.

Antibiotic Resistance among Patients with Urinary Tract Infections in Kandahar, Afghanistan

Background

Antimicrobial resistance is a global public health threat. Highest burden of resistance is reported from low- and middle-income countries.

Objectives

To investigate and report the current scenario of increased antibiotic resistance of uropathogens among symptomatic urinary tract infection patients in Kandahar, Afghanistan.

Methods

From January 2018 to December 2021, this retrospective study was carried out at two main hospitals in Kandahar City, Afghanistan. Here, culture and sensitivity profiles of uropathogens were studied among symptomatic Bacteriuria in the presence of genitourinary symptoms (i.e., dysuria, suprapubic pain or tenderness, frequency, or urgency) (UTI) patients.

Results

Among urine samples of 1589 patients, 1047 (65.9%) were culture positive and included in this study. Most of these patients (626/1047 [59.8%]) were females, with majority (818 [78.1%]) having age between 19 and 39 years. Gram-negative bacteria were the most prevalent (840/1047 [80.2%]), with E. coli (653/1047 [62.4%]) as the most common isolated uropathogen. Overall gram-negative bacteria had higher resistance against commonly used antibiotics of cotrimoxazole (62.8%), ciprofloxacin (56.0%), levofloxacin (47.5%), cefixime (44.5%), fosfomycin (41.5%), and even ceftriaxone (48.3%).

Conclusions

Kandahar province has higher resistance rates against commonly used empirical antibiotics like norfloxacin, ciprofloxacin, levofloxacin, and cefixime. Nitrofurantoin should be used as the first-line antibiotic in treating UTI patients. Public health authorities should make strict regulations and policies to reduce irrational use, inappropriate prescription, and over-the-counter availability of antibiotics in Kandahar.

Demographic and clinical characteristics of acute myeloid leukaemia diagnosed and treated at the tertiary level in Afghanistan

A retrospective case series design was conducted to elucidate the demographic features of acute myeloid leukaemia in Afghanistan. This study was conducted at Jamhuriat Hospital and French Medical Institute for Mothers and Children, Kabul, Afghanistan. A total of 203 patients with AML diagnosed and managed at Jamhuriat Hospital from 1 March 2018 to 31 March 2020, were included in the current study. The median age at diagnosis was 27 years. Housewives represented the largest subset of patients from an occupational point of view constituting 37.44% of the total sample population and 81.72% of the female population, followed by 20.69% patients who were students of which 14.77% were male and 5.91% were female, and 17.24% were farmers, which constituted 31.81% of the male population. Similarly, 69.95% of individuals presented with infection, 57.14% presented with bone tenderness, 46.3% presented with bleeding tendencies, 55.66% had hepatomegaly and/or splenomegaly, and 27.58% of patients had lymphadenopathy. Considering the chemotherapeutic regime, 64.53% of the individuals received standard 7 + 3 (cytarabine + daunorubicin) induction regimen, 10.68% of those received 5 + 2 re-induction chemotherapy (cytarabine + daunorubicin). 10.84% who were diagnosed with acute promyelocytic leukaemia received all-trans-retinoic acid + arsenic trioxide, while 5.42% of patients defaulted chemotherapy. High prevalence was noted in young individuals. Similarly, a high proportion of patients were constituted by housewives.

The association of the quality of life with Afghan households' food insecurity before and after the recent political change in Afghanistan: a comparative analysis

The overreaching objective of the current study is to investigate the association of quality of life with Afghan households' food insecurity. The data was collected immediately after the Taliban took control of a large part of Afghanistan. About a total of 555 households' heads participated in a face-to-face interview, using the HFIAS and WHOQOL-100 questionnaires along with some questions related to their socioeconomic characteristics at two different times, before and after the Taliban's takeover. The comparative analysis showed that 98% of Afghan households were food insecure after the Taliban takeover, while 70% of them faced food insecurity before the Taliban's takeover. The quality of life in the Taliban era is worse than before the Taliban. All dimensions of quality of life have decreased, and this decrease was more pronounced for the psychological, environmental, and physical domains. It is recommended that international organizations, NGOs, and local agents focus on these dimensions of the quality of life to improve food security.

Trust in higher guidance and suicidality in Afghan students under the Taliban regime{fr}(Confianza en la orientación superior y suicidalidad en estudiantes afganos bajo el régimen Talibán)

Background/Objective

After years of war, political instability and natural catastrophes high rates of PTSD and depression have been found in the Afghan population. On this background, it was investigated whether religious beliefs (trust in higher guidance; TIHG) moderated the association between PTSD symptoms and/or depression and suicidal ideation.

Method

A total of 279 Afghan university students (61.6% women; aged 18 to 30 years) took part in this cross-sectional study between July and November 2022. Self-report measures of PTSD, depression, suicidal ideation, trust in higher guidance were used.

Results

Severe PTSD symptoms were reported by 58.4%, clinically relevant depression symptoms were reported by 55.2% and current suicidal ideation was reported by 44.4% of the sample. TIHG moderated the impact of PTSD symptoms, on suicidal ideation. TIHG and depression were unrelated.

Conclusion

PTSD symptoms, depression and suicidal ideation show an alarmingly high prevalence in this specific sample of Afghan students. TIHG seems to be a resilience factor of special importance.

COVID-19 research in South Asia: a bibliometric analysis of the 100 most-cited articles

Background

With the surge in the number of infected individuals during the COVID-19 pandemic, there was also a surge observed in the number of publications discussing its epidemiology, characteristics, path-o-phys-i-ol-o-gy, diagnosis, prevention and treatment. This bibliometric analysis focuses on the papers published on COVID-19 in South Asia.

Methods

We searched articles in the Scopus database from December 2019 to October, 2022. After manual screening, a list of the 100 most-cited articles was obtained, which was analyzed for various factors, including the type of article, citation count, author's affiliation, country of origin, funding bodies, etc.

Results

The majority of the top 100 articles (n=79) in South Asia were published during 2020. India was affiliated with the highest number of articles (n=68), followed by Bangladesh (n=18) and Pakistan (n=12). However, 7 articles were authored by a researcher in Bangladesh. Female authors were under represented (32.38%), with no female author in lists of authors with 4 or more articles. The average number of citations for each of the top 100 most-cited articles was 180.8. Original articles constituted the major portion of the publications (82%), followed by letters (11%) and reviews (4%). Half of the publications belonged to the field of medicine (n=49), while others were contributed by science, psychology, social sciences, and biochemistry and allied sciences (n=8). Vaccine trials were under-represented. Jahangirnagar University, Bangladesh was affiliated with the maximum number of articles. Most articles were published in Science of The Total Environment (n=8) while Indian Council of Medical Research (n=4) was the top funding body.

Conclusion

These findings highlight that South Asia has a great potential to conduct research addressing its challenging health problems. But lack of funds hinders conducting trials of new medications and vaccines. Thus, there is need for allocation of sufficient funds for research and clinical trials by governments and the private sector to enhance the research productivity of this region.

A GIS-based approach to identifying communities underserved by primary health care services-An Afghanistan case study

Afghanistan has been in an active state of conflict and war for twenty continuous years. Social services like health and education have been badly affected, facing issues such as service disruption, brain drain, and generalized instability. Health indices that provide proxy indicators for general population wellness, such as maternal health, child mortality, and immunization coverage, show that the health services available to the Afghan population are sub-optimal. Investment in social service and interventions has increased. The World Bank and the United Nations through its agencies (The World Health Organization (WHO) and United Nations' Children's Fund (UNICEF) are providing social support through targeted and strategic programs. However, the topographic and environmental realities of Afghanistan, with its broad mountain coverage, propensity toward natural disasters, and latent conflict, has made data and information gathering arduous. Since data is essential for measurement and management, the WHO Health Emergencies (WHE) information management unit at WHO Afghanistan has delivered an innovative form of data analysis, specialized and targeted at providing improved information on communities that are not adequately covered by health services. Deploying a geographical information system (GIS) approach, the WHE team has collated primary and secondary data from a combination of datasets to produce a far-reaching piece of analysis. The analysis of underserved communities in hard to reach, remote locations, provides a live, evidence-based information product. This provides a working tool that is essential to primary health programming and intervention in Afghanistan. The estimates show that approximately 9.5 million individuals in 22,181 villages across 34 provinces are underserved by primary health services. This paper is presented to explain the underpinning methodology.

High sedentary behavior and low physical activity among adults in Afghanistan: results from a national cross-sectional survey

Objective

The study aimed to evaluate the prevalence and correlates of sedentary behavior and combination of sedentary behavior and low physical activity among adults in Afghanistan in 2018.

Methods

This was a national representative cross-sectional study. The study utilized the data from Afghanistan STEPS survey 2018, where 3,956 adults (ages between 18 and 69 years) were interviewed at community-dwelling level. Using the Global Physical Activity Questionnaire, we have calculated the sedentary behavior and physical inactivity. Logistic regression was applied to investigate factors associated high sedentary behavior and low physical activity.

Results

Approximately half of the participants (49.8%) exhibited high levels of sedentary behavior, 40.3% low physical activity and 23.5% had both high sedentary behavior and low physical activity. Adjusted logistic regression analysis revealed that individuals who were employed (AOR: 0.34, 95% CI: 0.13-0.88) or self-employed (AOR: 0.60, 95% CI: 0.38-0.94) had significantly lower odds of both high SB and low physical activity than those whose work status was unpaid. Furthermore, older age (AOR: 1.75, 95% CI: 1.35-2.28), urban residence (AOR: 3.17, 95% CI: 1.72-6.05), having 4 or 5 adult household members (AOR: 1.77, 95% CI: 1.21-2.58) and being underweight (AOR: 1.78, 95% CI: 1.02-3.12) were found to be associated with high sedentary behavior. Moreover, factors such as female sex, having 4 or 5 or 6 or more adult household members, urban residence, overweight, and diabetes were positively associated, and male sex (AOR: 0.24, 95% CI: 0.12-0.51), being employed (AOR: 0.34, 95% CI: 0.13-0.88) or self-employed (AOR: 0.60, 95% CI: 0.38-0.94) were negatively associated with the occurrence of combination of high sedentary behavior and low physical activity.

Conclusion

Half of the participants had high sedentary behavior, and one in four had both high sedentary behavior and low physical activity together. These findings emphasize the importance of targeted interventions aimed at reducing sedentary behavior and promoting physical activity, particularly among vulnerable populations such as females, individuals from lower socioeconomic background, urban residents, and those with chronic conditions. Addressing these factors can contribute to improving public health outcomes and reducing negative health impacts of sedentary behavior in Afghanistan.

Validation of the Farsi version of the Suicide Ideation and Behavior Scale

Objective

Suicide ideation and suicide attempts are prevalent in Farsi speaking populations. The present study aimed at validating the Farsi version of the Suicide Ideation and Behavior Scale (SIBS).

Methods

Reliability and validity of the Farsi version of the SIBS were established in a highly burdened Afghan student sample (N = 279). Internal consistency, convergent and discriminant validity were investigated, and confirmatory factor analysis was conducted.

Results

The Farsi version of the SIBS was shown to have a unidimensional structure with excellent internal consistency, as well as good convergent and divergent validity.

Discussion

The results suggest that the SIBS is a brief, reliable, and valid measure of current suicidal ideation and behavior that can be used in Farsi speaking populations.

Overview and understanding of mental health and psychosocial support in Afghanistan

More than four decades of war in Afghanistan has been both a main driver for poor mental health, and a barrier to the development of crucial mental health services. A study conducted by BMC Psychiatry in 2021, across eight regions in Afghanistan, found staggering levels of depressive and anxiety disorders among the general population. Almost one-half of those interviewed (47.12%) reported having high levels of distress in the last month, and almost 40% (39.44%) reported experiencing impairment to their lives due to poor mental health. Yet, despite the common experiences of much of the population, mental health is a hugely stigmatized topic of discussion in Afghanistan, due to a myriad of cultural, religious, socioeconomic and environmental factors. And now, under the de-facto Taliban government, mental health has been deprioritized in the face of a crumbling economy and acute levels of poverty, all but forgotten. This paper sought to review the impact and change to mental health services under the de-facto government, and to provide the reader with greater awareness into the current situation in Afghanistan and equip them with insight into how to respond to the mental health needs of Afghans.

Cancer prevalence, incidence, and mortality rates in Afghanistan in 2020: A review study

BACKGROUND

Afghanistan is in an epidemiological transition, as cancer is the second leading cause of mortality due to non-communicable diseases. This study is the first to provide a comprehensive perspective on the overall cancer situation in Afghanistan by discussing the top five most common cancers, their incidence variations, risk factors, and preventive measures. The limited number of cancer studies conducted in Afghanistan highlights the importance of the present review.

RECENT FINDINGS

This article provides an overview of cancer burden in Afghanistan in 2020. It utilizes IARC-generated GLOBOCAN 2020 data for one, three, and five-year prevalence rates, the estimated number of new cancer cases, and mortality rates by age group in Afghanistan. According to GLOBOCAN, the top five common cancers in both sexes in Afghanistan were breast (n = 3173, 14.3%), stomach (n = 2913, 7.8%), lung (n = 1470, 6.6%), cervix uteri (n = 1200, 5.4%), and colorectum (n = 1084, 4.9%).

CONCLUSION

This study provides a brief overview of the general cancer situation in Afghanistan, and a more in-depth analysis of the five common cancers identified. Effective therapies, awareness, and prevention initiatives targeting lifestyle, immunization, early diagnosis, and environmental risk factors are essential for addressing the impact of population growth and aging on cancer incidence in Afghanistan. Further research and extensive studies are needed to better understand cancer burden in the country.

Trend analysis of noncommunicable diseases and their risk factors in Afghanistan

Background

Afghanistan is suffering from 40-year chronic conflicts, displacement, and demolition of its infrastructure. Afghanistan mortality survey 2010 shows nearly 46% of all deaths in the country were attributed to noncommunicable diseases (NCDs). In this study, we aimed to understand the differences in mortality and premature death due to NCDs by sex and the trend for the next 8 years.

Methods

We applied trend analysis using the secondary data from the Institute for Health Metrics and Evaluation, Global Burden of Diseases 2019. The information on NCD mortality, NCD deaths attributed to its risk factors, NCD percent of total years lived with disability (YLDs) attribution to each risk factor extracted from this database from 2008 to 2019. We investigated the trend from 2008 to 2019 for the mentioned factors and then forecast their trends until 2030.

Results

Our study shows that Afghanistan has had an increasing death number due to NCDs from 2008 to 2019 (50% for both sexes) and this will reach nearly 54% by 2030. Currently, half of NCDs deaths are premature in Afghanistan. The mortality rate and prevalence of risk factors are higher among women. More than 70% of YLDs will be due to NCDs in Afghanistan till 2030. Five risk factors including high systolic blood pressure (28.3%), high body mass index (23.4%), high blood glucose (20.6%), high low-density lipoprotein cholesterol (16.3%), and smoking (12.3%) will have the highest contribution to NCDs death in 2030, respectively.

Conclusions

In general, our study indicates that without any specific intervention to address NCDs in Afghanistan, not only the Sustainable Development Goal target for NCDs will not be met, but an increase in almost all risk factors prevalence, as well as NCD mortality, will be seen in Afghanistan.

Developing Culturally Appropriate Content for a Child-Rearing App to Support Young Children's Socioemotional and Cognitive Development in Afghanistan: Co-Design Study

BACKGROUND

Optimal child-rearing practices can help mitigate the consequences of detrimental social determinants of health in early childhood. Given the ubiquity of personal digital technologies worldwide, the direct delivery of evidence-based information about early childhood development holds great promise. However, to make the content of these novel systems effective, it is crucial to incorporate place-based cultural beliefs, traditions, circumstances, and value systems of end users.

OBJECTIVE

This paper describes the iterative approach used to develop the Thrive by Five child-rearing app in collaboration with Afghan parents, caregivers (eg, grandparents, aunts, and nannies), and subject matter experts (SMEs). We outline how co-design methodologies informed the development and cultural contextualization of content to meet the specific needs of Afghan parents and the content was tested and refined in collaboration with key Afghan stakeholders.

METHODS

The preliminary content was developed based on a comprehensive literature review of the historical and sociocultural contexts in Afghanistan, including factors that influence child-rearing practices and early childhood development. After an initial review and refinement based on feedback from SMEs, this content was populated into a beta app for testing. Overall, 8 co-design workshops were conducted in July and August 2021 and February 2022 with 39 Afghan parents and caregivers and 6 SMEs to collect their feedback on the app and its content. The workshops were audio recorded and transcribed; detailed field notes were taken by 2 scribes. A theoretical thematic analysis using semantic codes was conducted to inform the refinement of existing content and development of new content to fulfill the needs identified by participants.

RESULTS

The following 4 primary themes were identified: child-rearing in the Afghan sociocultural context, safety concerns, emotion and behavior management, and physical health and nutrition. Overall, participants agreed that the app had the potential to deliver valuable information to Afghan parents; however, owing to the volatility in the country, participants recommended including more activities that could be safely done indoors, as mothers and children are required to spend most of their time at home. Additionally, restrictions on public engagement in music required the removal of activities referencing singing that might be performed outside the home. Further, activities to help parents reduce their children's screen time, promote empathy, manage emotions, regulate behavior, and improve physical health and nutrition were requested.

CONCLUSIONS

Direct engagement with Afghan parents, caregivers, and SMEs through co-design workshops enabled the development and refinement of evidence-based, localized, and contextually relevant child-rearing activities promoting healthy social, emotional, and cognitive development during the first 5 years of children's lives. Importantly, the content was adapted for the ongoing conflict in Afghanistan with the aim of empowering Afghan parents and caregivers to support their children's developmental potential despite the security concerns and situational stressors.

Afghan medical students' perceptions, and experiences of their medical education and their professional intentions: a cross-sectional study

BACKGROUND

Numerous challenges have crippled the Afghan healthcare system on individual, organizational, and societal levels. The Afghans have acknowledged that an evidence-based perspective is paramount to enhancing medical training capacities across the country, which may, in turn, best ensure appointing highly competent authorities to address health system problems on such multiple levels.

OBJECTIVES

This study assessed current Afghan senior medical students' perceptions, and experiences of their medical education and their future professional intentions.

METHODS

We conducted this cross-sectional study at seven public and private Afghan medical institutes from March to April 2022. We invited 665 senior medical students through an anonymous survey using the Google survey online forms via social-media platforms, such as WhatsApp Messenger. Descriptive statistics were employed for the data analyses.

RESULTS

The mean age (± SD) of the students was 23.7 (± 2.2) years and males constituted 79.9% (510) of the study sample. About 22.6% of them rated their medical training as excellent, and nearly a third of them (37%) said that it is good. Nearly half (48.7%) of the students would prefer to stay in Afghanistan. The leading motives for moving overseas were to obtain more advanced and quality education (69.9%), and a decent personal life (43.9%). Nearly two-thirds (67.4%) of them asserted that current political and armed conflicts in Afghanistan may have influenced their professional choices.

CONCLUSION

This study epitomizes that the quality of medical education in Afghanistan has room for growth and development to meet the standards set on regional and global grounds.

Effectiveness of a telehealth patient education intervention for breast cancer awareness and screening uptake among Afghan refugee women: a cross-sectional survey and feasibility study

Background

Refugee populations have low levels of cancer awareness, low cancer screening rates, and a high rate of advanced or metastatic cancer at diagnosis. Educational interventions to improve cancer awareness and screening have been successful in other nationality refugee populations but have never been implemented in Afghan refugee populations. We aimed to estimate the level of breast cancer awareness among Afghan refugee women and test the feasibility of a telehealth breast cancer educational intervention to increase breast cancer awareness in this population.

Methods

A cross-sectional survey of Afghan refugee women residing in Istanbul, Türkiye who had no personal history of breast cancer and who presented to outpatient primary clinics for care between August 1, 2022, and February 10, 2023 was performed. Participant awareness of breast cancer (BC) was assessed using the validated BC awareness tool, Breast Cancer Awareness Measure (BCAM), during a telehealth encounter. After this baseline assessment, a BC educational intervention was administered to each participant during the telehealth encounter. Six months after the initial assessment and education, a follow-up BCAM was administered via telehealth in order to determine the effectiveness of the education intervention.

Findings

One hundred participants were accrued to the study. Median age was 49 years (range: 40-64). All participants had no formal education, were married, and were not employed. Prior to the educational intervention, BC awareness was low; none of the participants were able to identify some common signs/symptoms and risk factors for BC. Prior to the educational intervention, zero participants had ever had a mammogram or seen a physician for a breast-related concern. Six months after the educational intervention, up to 99 percent of participants (99 of 100 participants) were able to correctly identify common signs or symptoms and risk factors for BC. Six months after the educational intervention, all one hundred participants had accepted the offer of a screening mammogram.

Interpretation

A telehealth BC education intervention meaningfully increased BC awareness in Afghan refugee women. This increase in BC awareness was associated with a strong increase in completion of BC screening. Further implementation of educational interventions is warranted in order to increase participant awareness and improve screening rates.

Funding

Dana Farber Cancer Institute Jay Harris Junior Faculty Research Grant.