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


METHODS
We 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.


RESULTS
We 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.


CONCLUSIONS
Our 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.
Brown School of Social Work, Washington University in St Louis, 1 Brookings Drive, St Louis, MO 63130 USA.
Jean-Francois
0000-0002-9187-0946
JF
Trani
Brown School of Social Work, Washington University in St Louis, 1 Brookings Drive, St Louis, MO 63130 USA.
Ellis
E
Ballard
Program in Occupational Therapy, School of Medicine, Washington University in St Louis, St Louis, USA.
Parul
P
Bakhshi
Brown School of Social Work, Washington University in St Louis, 1 Brookings Drive, St Louis, MO 63130 USA.
Peter
P
Hovmand
Afghanistan; Causal loop diagram; Community based system dynamics; Complex problems; Development intervention; Mental health