Viviane Kovess-Masfety - Department of Psychiatry, McGill University, Montreal, QC, Canada
Elie Karam - Department of Psychiatry & Clinical Psychology, St. George Hospital University Medical, Beirut, Lebanon
Katherine Keyes - Mailman School of Public Health, Columbia University, New York City, NY, USA
Ajmal Sabawoon - Governance Institute of Afghanistan (GI-A), Kabul, Afghanistan
Bashir Ahmad Sarwari - Department of Mental Health & Substance Abuse, Primary Health Care Directorate, Ministry of Public Health, Kabul, Afghanistan

Background  This paper describes the access to care for mental health problems in Afghanistan, according to the nature of the mental health problems and the service provider. Following the Andersen model, it evaluates the respective roles in access to care of “predisposing,” “needs,” “enabling” factors, and other “environmental” factors such as exposure to traumatic events and level of danger of the place of residence.   Methods  Trans-sectional probability survey in general population by multistage sampling in ۱۶ provinces, nationally representative: N = ۴۴۴۵ (۱۵ years or older), participation rate of ۸۱%. Face to face interviews using standardized measures of mental health (CIDI, Composite International Diagnostic Interview). Different logistic regression models are presented.   Results  The ۱۲-month rate of mental health help-seeking was ۶.۵۶% with substantial regional variation (۲.۳۵% to ۱۲.۶۵%). Providers were mainly from the health sector; the non- health sector (religious and healers) was also prevalent. Most consultations were held in private clinics (non-governmental organisation, NGO). The severity of mental health disorders as well as the perceived impairment due to mental health were independently very important: odds ratio (OR) = ۶.۰۴ for severe disorder, OR = ۳.۷۹ for perceived impairment. Living in a dangerous area decreased access to care: for high level of danger and for very high level: OR = ۰.۲۲. Gender, education and ethnicity were not associated with mental health help-seeking after controlling for exposure to trauma.  Conclusion  Access to care for mental health problems depended mainly on the needs as defined as disorder severity level and impairment, and on environmental factors such as exposure to traumatic events. The system seems equitable; however, this is counterbalanced by a very challenging environment. This survey is a testimony to the hardship experienced by the Afghan population and by health professionals, and to the efforts to deliver organized mental healthcare in a challenging situation. This research may inform and support policy-makers and NGOs in other countries undergoing similar challenges.

Public Policy, Service Research, Epidemiology, Mental Health, Psychiatry, Afghanistan