Depression and anxiety symptoms among Afghan war widows and their associated factors: A cross-sectional analytical study

Abstract

Background:

The 4 decades of conflict have particularly exacerbated the mental health of Afghan war widows, a population that has not been extensively studied in this context.

Aim:

This study aims to fill the gap in the literature by providing robust data on the prevalence of depression and anxiety symptoms and identifying associated factors among Afghan war widows.

Methods:

A cross-sectional study was carried out in 2023, interviewing war widows from four community health centers in Kandahar, Afghanistan. We employed a validated Patient Health Questionnaire and Generalized Anxiety Disorder Scale. A multivariable binary logistic regression model was used to determine factors associated with depression and anxiety symptoms.

Results:

The prevalence of depression and anxiety symptoms was 57.9% (95% CI: 52.7%–62.8%) and 61.5% (95% CI: 56.4%–66.4%), respectively. There were significant differences in the prevalence of mental health symptoms across our population with different sociodemographic and health-related profiles (in particular, time since widowhood, household income, history of comorbidity, and level of social support).

Conclusion:

The stark prevalence of mental health issues among Afghan war widows underscores an overlooked humanitarian crisis. The findings call for immediate mental health interventions, tailored to the sociopolitical realities of Afghanistan.

INTRODUCTION

The death of a husband is often highly stressful for a woman and might have negative consequences on her health and wellbeing.[1,2] Globally, an estimated 258.5 million women face this situation.[3] In Afghanistan, it was estimated that there were more than 2 million widows in 2017.[3] Vulnerability to mental health problems is particularly high among widows who have experienced the premature death of their husbands due to armed conflict[4,5]; yet, the epidemiology of mental health disorders has been less described in such cases.

Widows represent a high-risk population for mental health disorders worldwide, particularly those who lost their spouses in conflicts.[4,6] The war widows face high levels of adversities, from challenges meeting basic needs to financial problems.[5,6] They are predisposed to significantly higher rates of poor mental and physical health outcomes, leading to reduced quality of life.[1,5,7] Therefore, war widows face a myriad of unique health challenges that require immediate attention, and this is especially true of mental health conditions, which are pressing public health concerns in Afghanistan.[8,9]

Afghanistan is characterized by nearly half-a-century-long conflict, high levels of poverty and unemployment, and political instability, all of which are associated with a higher risk for mental health problems.[10,11] The most common mental health disorders in conflict-affected situations are depression, anxiety, and posttraumatic stress disorder (PTSD) with prevalence rates much higher than in areas without a recent history of conflict.[8,12] The growing burden of mental health conditions is linked to substantial repercussions, including a decreased quality of life and greater use of health services.[1,2]

Most research on mental health symptoms has been conducted in widows following spousal loss due to causes other than armed conflict.[1,2,7] To our knowledge, the mental health of war widows has been less documented. Thus, we aimed to assess the prevalence of depression and anxiety symptoms and their associated factors among Afghan war widows in Kandahar, Afghanistan.

MATERIALS AND METHODS

Study setting and design

Between January and June 2023, we conducted a multicenter cross-sectional study in Kandahar, Afghanistan, that focused on the mental health symptoms of war widows whose husbands were killed in armed conflict between 2017 and 2022. Each participant attended one of four (Nazu Ana, Shams-Ul-Haq, Panjwai District, and Maiwand District) randomly selected community health centers (CHCs) in Kandahar province. These centers provide primary and secondary health services free of charge to the population in its catchment area.

Study population

Our target population consisted of all women residing in Kandahar province whose husbands have been killed due to armed conflict in the past 5 years and have not remarried. Women who were unwilling to participate in the study were excluded.

Sample size and sampling procedure

We determined our sample size by using a single population proportion formula [n = Z²P (1 − P)/(d)²]. In the study area, there are no previous studies on the prevalence rates of depression and anxiety in war widows. Therefore, we assumed a 50% prevalence rate. Considering a 95% confidence level, a 5% margin of error, and a 10% nonresponse rate, at least 422 samples were required for the analysis. The response rate was 90.5%. The final analysis includes a total of 382 war widows. We used a sample random method to select four CHCs, and we employed a non-probability sampling method to select potential participants from the population residing within the catchment area of these selected CHCs.

Main outcomes

The main outcomes of this study were the assessment of depression and anxiety symptoms in war widows. For this purpose, we employed the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7).

The PHQ-9 is a 4-point scale ranging from 0 (not at all) to 3 (almost every day) that measures the presence and severity of depressive symptoms in the past 2 weeks and assesses the prevalence of probable depression.[13] The total depression score was interpreted as normal (1–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20-27). A score of ≥10 was used to denote a comorbid depression.[13] The Pashto version of the PHQ-9 has been used previously in Afghanistan and has good psychometric properties.[14,15]

We employed the GAD-7 scale to assess anxiety symptoms over the past 2 weeks. Scores range from 0 to 21, with higher scores indicating severe anxiety.[16] The total anxiety score was considered normal (0–4), mild (5–9), moderate (10–14), and severe (15–21). A score of ≥10 was used to denote comorbid anxiety.[16] Cronbach’s α for the Pashto version of GAD-7 in the current study was 0.91.

Study variables

We selected the study variables based on relevant literature about factors involved in both widowhood and the risk of depression or anxiety.

We considered the following sociodemographic variables: age, residence, highest educational level, occupational status, source of household income, availability of financial support, household size (<5 or ≥5 persons per household), and time since widowhood.

The following health and other related variables were also included: any substance use (yes or no), presence of chronic medical conditions, and the level of social support (low, intermediate, or high).

Additionally, we employed the 3-item Oslo Social Support Scale (OSSS-3) to assess the level of social support.[17] The sum of scores in OSSS-3 ranges from 3 to 14, with low scores representing a lower level of social support. The level of social support was categorized as follows: low social support: 3–8, intermediate social support: 9–11, and high social support: 12–14.[17] The Cronbach’s α of the OSSS-3 in the current study was 0.82.

Data collection

The study questionnaire consisted of questions covering several aspects of widows’ sociodemographic information, health-related factors, and mental health status. The interview team consisted of eight female doctors with an MD degree in medicine and had at least 2 years of clinical experience. They received 1-day training on interviewing war widows, completing questionnaires, and dealing with ethical concerns that might arise during the study. Considering the cultural nuances and the sensitive nature of the topic, interviewers were trained to approach questions with utmost empathy and respect, always prioritizing the comfort of the participants. Participants were recruited at the reception centers of the selected CHCs and interviewed in a private room. Each interview took approximately 15–20 minutes to complete.

Statistical analysis

We employed descriptive statistics, such as frequency and percentage, to describe the sociodemographic characteristics and health-related factors of our participants. Multivariable logistic regression was used to assess the relationship between independent variables and depression or anxiety symptoms. We set the significance level at a P value of < 0.05.

RESULTS

Among 382 war widows included in this study, 128 (33.5%) were aged 15–30 years, 271 (70.9%) were urban residents, and 261 (68.3%) had no formal education. Moreover, the majority (89.3%, 341) of them were homemakers, and 231 (60.5%) lived in households with five or more than five members. Private business (41.9%), livestock (20.9%), and agriculture (19.4%) were the main sources of household income in the study area [Table 1].

Table 1.

Sociodemographic and other related characteristics of the study participants (n=382)

Variables	Frequency (%)
Age (in completed years)
15-30	128 (33.5)
31-45	120 (31.4)
>45	134 (35.1)
Residence
Urban	271 (70.9)
Rural	111 (29.1)
Educational Status
No formal education	261 (68.3)
Religious education	107 (28.1)
Primary education	7(1.8)
Higher studies	7(1.8)
Employment status
Public employed	12 (3.1)
Private employed	19 (5.0)
Self-employed	10 (2.6)
Homemakers	341 (89.3)
Household members
<5	151 (39.5)
≥5	231 (60.5)
Source of household income
Agriculture	74 (19.4)
Livestock	80 (20.9)
Private employment	160 (41.9)
Monthly salary	5 (1.3)
Donations	63 (16.5)
Time since widowhood (in years)
1-2	223 (58.4)
>2	159 (41.6)
Comorbidity
Yes	109 (28.5)
No	273 (71.5)
Substance use
Yes	90 (23.6)
No	292 (76.4)
Level of social support
Low	319 (83.5)
Intermediate	53 (13.9)
High	10 (2.6)
Any financial aid received from the government or NGOs
Yes	89 (23.3)
No	293 (76.7)
Depression symptoms
None/minimal depression	65 (17.0)
Mild depression	96 (25.1)
Moderate depression	89 (23.3)
Moderately severe depression	101 (26.4)
Severe depression	31 (8.2)
Anxiety symptoms
None/minimal anxiety	55 (14.4)
Mild anxiety	92 (24.1)
Moderate anxiety	168 (44.0)
Severe anxiety	67 (17.5)

NGOs, nongovernmental organizations

In terms of time since widowhood, more than half of the women (58.4%) lost their husbands in the past 2 years. Additionally, 128 (28.5%) of them had comorbidity and 90 (23.6%) were engaged in substance use. When assessing their social support, most of the participants had low social support (83.5%), and 53 (13.9%) had intermediate social support [Table 1].

The prevalence of depression and anxiety symptoms was 57.9% (95% CI: 52.7%–62.8%) and 61.5% (95% CI: 56.4%–66.4%), respectively [Table 1].

The multivariable logistic regression revealed that death of the husband within the past 2 years (AOR 7.57, 95% CI 4.03–14.1), irregular household income (AOR 3.31, 95% CI 2.03–5.39), comorbidity (AOR 1.27, 95% CI 1.13–2.56), and low social support (AOR 4.77, 95% CI 2.30–9.91) were factors significantly associated with depression symptoms [Table 2], whereas the death of the husband within the past 2 years (AOR 6.03, 95% CI 3.36–10.7), irregular household income (AOR 2.69, 95% CI 1.66–4.35), and low social support (AOR 3.74, 95% CI 1.90–7.36) were factors significantly associated with anxiety symptoms [Table 3].

Table 2.

Factors associated with depression symptoms; crude and adjusted odds ratio with 95% CI

Covariates	Categories	COR (95% CI)	P	AOR (95% CI)	P
Household income	Regular	Ref	<0.001	Ref	<0.001
	Irregular	3.41 (2.22-5.22)		3.31 (2.03-5.39)
Comorbidity	Yes	1.37 (1.22-2.16)	0.002	1.27 (1.13-2.56)	0.04
	No	Ref		Ref
Time since	1-2 years	9.70 (5.41-17.4)	<0.001	7.57 (4.03-14.1)	<0.001
widowhood	>2 years	Ref		Ref
Level of social	High	Ref	<0.001	Ref	<0.001
support	Low	7.20 (3.75-13.8)		4.77 (2.30-9.91)

COR, Crude Odds Ratio; AOR, Adjusted Odds Ratio; CI, Confidence Interval

Table 3.

Factors associated with anxiety symptoms; crude and adjusted odds ratio with 95% CI

Covariates	Categories	COR (95% CI)	P	AOR (95% CI)	P
Can read and write	Yes	Ref	0.005	Ref	0.235
	No	1.87 (1.20-2.90)		1.36 (0.81-2.28)
Household income	Regular	Ref	<0.001	Ref	<0.001
	Irregular	3.06 (1.99-4.69)		2.69 (1.66-4.35)
Time since widowhood	1-2 years	8.10 (4.69-13.9)	<0.001	6.03 (3.36-10.7)	<0.001
	>2 years	Ref		Ref
Level of social support	High	Ref	<0.001	Ref	<0.001
	Low	5.84 (3.19-10.7)		3.74 (1.90-7.36)

COR, Crude Odds Ratio; AOR, Adjusted Odds Ratio; CI, Confidence Interval

DISCUSSION

We found that Afghan war widows had staggering rates of depression (57.9%) and anxiety (61.5%) symptoms. We also found considerable disparities across the sample. Specifically, there were significant differences in the prevalence of mental health symptoms across our population with different sociodemographic and health-related profiles (in particular, time since widowhood, household income, history of comorbidity, and level of social support).

The prevalence of depression and anxiety symptoms was higher than the prevalence observed in other groups in Afghanistan.[18,19,20] A previous study in Nepal documented prevalence estimates of depression (53%) and anxiety (44.4%) among war widows, suggesting that the prevalence estimates of depression and anxiety symptoms were lower than those of the present study.[4] Another study of post-traumatic stress and depression among Tamil widows in Sri Lanka affected by war and disasters found an estimated prevalence of depression of 38%.[21] The variations in the prevalence of depression and anxiety symptoms across studies may relate to sociocultural differences, environmental differences, differences in mental healthcare services, differences in instruments used to assess these symptoms (different scales), or other factors warranting further investigation.

We observed that the time since the husband’s death was significantly associated with depression and anxiety symptoms. Newly bereaved people may be particularly vulnerable to emotional distress because of the intensity of their feelings and the challenges of adjusting to unexpected changes in their social and family responsibilities.[2,5,7] Other literature studies have also documented high prevalences of mental health symptoms in the first year of bereavement.[2,6,7] Hence, early intervention, access to mental health services, and social support in such widows are of paramount importance.

In the present study, irregular household income was another contributor to anxiety and depression symptoms. Existing studies have suggested a strong association between mental health symptoms and low socioeconomic status in Afghanistan.[8,9,19] Given the current financial and economic instability in Afghanistan, it is likely that vulnerable populations are disproportionately affected by such financial constraints, leading to heightened risks regarding mental health disorders.[9,10,18] Thus, considering socioeconomic factors like income and employment is crucial when addressing the mental health of Afghan war widows.

The current study found a significant association between comorbidity and depression symptoms. The healthcare system in areas impacted by long-term conflict may not be adequately equipped to address these comorbidities, making access to quality care a significant challenge.[8] Several studies have revealed that comorbid medical conditions account for a substantial part of the psychosocial burden in bereaved individuals.[1,2,5,7] Therefore, war widows with pre-existing medical conditions warrant adequate medical care in addition to mental health treatment to improve overall wellbeing.

Consistent with relevant literature, war widows who demonstrated higher rates of depression and anxiety symptoms were more likely to report lower levels of social support.[6,7] In a systematic review, Scott et al.[22] found that social support had a buffer effect against mental health problems following violent and/or sudden bereavement.[22] Depending on the household dynamics and individual relationships, a widow might experience increased support or further isolation, influencing her overall mental and emotional wellbeing.[23] Future research might benefit from exploring these household combinations and their impact on the perceived social support among war widows in Afghanistan.

Limitations

We acknowledge the limitations of this study as follows: First, the cross-sectional nature of our study precludes causal relationships. Second, we employed the nonprobability sampling method, therefore limiting the generalizability of our results. Third, the research articles that could provide a benchmarking context to our findings were very scarce. Finally, our data epitomize one province, therefore making any generalization calls for caution.

CONCLUSION

In conclusion, war widows in our cohort had high levels of depression and anxiety symptoms years after their husband’s death in the armed conflict. Recognizing the intricate interplay of sociocultural dynamics, especially in the Afghan context, bio-psycho-social interventions should be developed to reduce the risk of mental health problems among war widows in Afghanistan.

Authors’ contributions

Conceptualization and design: NAD, MHS, and MJ. Analysis: MHS. Writing- original draft: MHS and MJ. Writing- review and editing: MHS and MJ. All authors have read and approved the final manuscript.

Ethical approval

This study was approved by the Research and Ethics Committee, Faculty of Medicine, Kandahar University. We obtained informed consent either in written form or in oral form (if the participant was unable to read). This study followed established ethical guidelines for medical research involving human subjects and the Helsinki Declaration of 1975, as revised in 2008.

Data availability

The primary data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.