Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan

Abstract

BackgroundAfghanistan lacks suitable specialized mental healthcare services despite high prevalence of severe mental health disorders which are aggravated by the conflict and numerous daily stressors. Recent studies have shown that Afghans with mental illness are not only deprived of care but are vulnerable in many other ways. Innovative participatory approaches to the design of mental healthcare policies and programs are needed in such challenging context.MethodsWe employed community based system dynamics to examine interactions between multiple factors and actors to examine the problem of persistently low service utilization for people with mental illness. Group model building sessions, designed based on a series of scripts and led by three facilitators, took place with NGO staff members in Mazar-I-Sharif in July 2014 and in Kabul in February 2015.ResultsWe identified major feedback loops that constitute a hypothesis of how system components interact to generate a persistently low rate of service utilization by people with mental illness. In particular, we found that the interaction of the combined burdens of poverty and cost of treatment interact with cultural and social stigmatizing beliefs, in the context of limited clinical or other treatment support, to perpetuate low access to care for people with mental disorders. These findings indicate that the introduction of mental healthcare services alone will not be sufficient to meaningfully improve the condition of individuals with mental illness if community stigma and poverty are not addressed concurrently.ConclusionsOur model highlights important factors that prevent persons with mental illness from accessing services. Our study demonstrates that group model building methods using community based system dynamics can provide an effective tool to elicit a common vision on a complex problem and identify shared potential strategies for intervention in a development and global health context. Its strength and originality is the leadership role played by the actors embedded within the system in describing the complex problem and suggesting interventions.

Prevalence of tuberculosis among mentally ill patients in conflict-stricken Afghanistan: A cross-sectional study

“…In Afghanistan rates of mental illness are high because of decades of conflict, stress, and poverty, post-traumatic stress disorders, and illicit drug abuse (Cardozo et al, 2005;Trani et al, 2016;Cardozo et al, 2004;Miller et al, 2008). Considering the high prevalence of mental disorders and TB in Afghanistan, we designed this study to identify the prevalence of TB among mentally ill patients.…”

Understanding electricity legitimacy dynamics in an urban informal settlement in South Africa: A Community Based System Dynamics approach

“…Community Based System Dynamics has been applied to a variety of issues including alcohol abuse amongst college students in the United States (Apostolopoulos et al, 2018); mental health service uptake in a conflict setting in Afghanistan (Trani et al, 2016); sustained adoption of clean cooking systems in impoverished communities in India (Kumar et al, 2016); and knowledge change amongst smallholder farmers in Zambia (Hager et al, 2015); whilst variants of the method is used in natural resources management, such as water and forestry planning (Rosenthal et al, 2017).…”

“…Community-based Participatory Research (CBPR) is also recognised for its collaborative approach to effectively engage with communities by including community members as full participants (Frerichs et al, 2016;BeLue et al, 2012). While Minkler (2010) Dynamics focuses on outcomes that address the needs of the community and is 'particularly valuable for messy and neglected problems' (Trani et al, 2016;Rosenthal et al, 2017). Enkanini informal settlement is fast changing and dynamic: it's population nearly doubling from 4 500 (in 2011) to 8 000 people (in 2015), while the type of households have drastically changed from mostly single adult households (53% of the population in 2011) to mainly households with two or more people (76% in 2015).…”

Assessing the efficacy of group model building workshops in an applied setting through purposive text analysis

“…Recently, there has been an increased focus on the use of GMB approaches for engaging local stakeholders at a community level in more informal and applied settings (Hovmand, 2014a;Amadei, 2015;Neely, 2019). Examples include modeling complex watershed management (RESLIM, 2015), understanding the delivery of mental health services in conflict areas (Trani et al, 2016), assessing drivers of solar energy adoption (Walters et al, 2018), and developing innovative policies for reducing urban homelessness (Fowler et al, 2017). While these works have greatly expanded the scope and potential use of GMB beyond its traditional realm, there remains limited documentation of GMB within these contexts.…”