Peace,love,and justice: A participatory phenomenological study of psychosocial well-being in Afghanistan

Abstract

While there have been many studies that elucidate the extent of human suffering in Afghanistan, there has been no formal study of what it means to be psychologically and socially well. This article reports on a participatory phenomenological study conducted in Afghanistan designed to better understand psychosocial well-being. Collecting data from 440 Afghan participants in 56 focus group discussions, the research specifically elaborated and operationalized definitions of psychosocial well-being that were relevant to the Afghan context. This study adds critical value around definitions of what it means to be psychosocially well in Afghanistan and other conflict-affected countries.

Keywords

Afghanistan mental health participatory research psychosocial well-being

Introduction

For the last four decades, Afghans have experienced war, prolonged and chronic violence, severe drought, and accompanying economic insecurity (United Nations Development Programme [UNDP], 2016). These experiences have had a profound impact on the emotional and social lives of all Afghans (Babury and Hayward, 2013; Cameron et al., 2018; O’Leary et al., 2018; Wildt et al., 2017). To address these needs, Afghanistan’s governmental and non-governmental organizations have worked quickly to provide services to the population, increasing roles for social work and allied professions (Bragin and Akesson, 2018). Yet to date, there is little research that explores Afghan-specific descriptions and understandings of psychosocial well-being.

This article draws upon data from research with 440 Afghan participants in 56 focus group discussions (FGDs) interviewed across four of seven regions in Afghanistan. Using participatory, qualitative methods, this article presents domains of psychosocial well-being that might be referenced by practitioners, researchers, and policymakers seeking to find ways to work with Afghan populations to evaluate the effectiveness of programs that aim to enhance well-being. Including the concept of ‘feeling’ in the questions invited respondents to engage emotional experience in their operational definitions, ensuring that the psychological was integrated with the social in the results and contributing an added element to the literature.

Background

One of the hidden realities in Afghanistan is the consequence of more than 30 years of war. No one escapes its effects – the death of loved ones, personal injuries, destruction of homes and families, and shattered lives . . . Few escaped unscathed. Added to these are the normal challenges and traumas of ordinary life – illness, separation from families, end of relationships, and serious accidents. (Babury and Hayward, 2013: 1)

In December 2001, when the Afghan Interim Authority took over the country’s governance with the support of international forces, the preceding civil wars had destroyed nearly all infrastructure, closed public services, and created conditions of random violence and insecurity. Epidemiological studies indicated high prevalence rates of mental illness, including depression, anxiety, and post-traumatic stress disorder (Cardozo et al., 2004; Ventevogel et al., 2006). The new Afghan Interim Authority moved quickly to address these issues. The Ministry of Public Health (MoPH) set out to improve population health through the creation of a Basic Package of Health Services (BPHS), which included essential mental health services, and embarked on an ambitious program to train medical professionals, paraprofessional health workers, and mental health workers (Government of Islamic Republic in Afghanistan [GOIRA] and MoPH, 2009; Mental Health Department of the Ministry of Public Health, 2009; Ventevogel and Faiz, 2018).

However, in the ensuing years, conflict, drought, and resulting economic difficulties worsened. With these challenges came the myriad daily stressors that seeped into every aspect of life, inhibiting Afghanistan’s progress in all areas of development (Miller et al., 2008; Wildt et al., 2017). Eighty percent of Afghans visiting mental health clinics exhibited emotional distress not related to psychiatric illness, but rather the result of adversity-related stressors and traumatogenic events. These stressors overwhelmed protective factors, requiring urgent psychosocial support that recognized the response to these events as normal responses to terrible experiences, requiring attention beyond that which medication alone provides (Alemi et al., 2018; Eggerman and Panter-Brick, 2010; Panter-Brick and Eggerman, 2012). Recent studies have shown that Afghan families were well aware that these stressors affected childrearing and intimate partner violence; yet at the time, they were unable to take action (Cameron et al., 2018; Gibbs et al., 2018; Li et al., 2018; O’Leary et al., 2018).

In the face of unrelenting trauma, it is important to not pathologize ongoing traumatic experiences, but rather to recognize, listen, and acknowledge survivors’ realities (Mannell et al., 2018; Mehraby, 2002; Oriya, 2019). Increasing evidence supports the contention that people responding to ongoing trauma do not ‘get over it’; instead, they need help to integrate their experiences into a coherent narrative that helps them to make meaning and act in their own interests (Bragin, 2020; Panter-Brick and Eggerman, 2012; Ventevogel and Faiz, 2018).

As a response, the Dean of Academic Affairs of the Ministry of Higher Education (MoHE) called for the establishment of academic departments that could cultivate a national cadre of professionals qualified to address the psychosocial effects of these experiences (Babury and Hayward, 2013). The goal was to use higher education to fill positions in education, child protection, justice, community development, and women’s programs, as well as to work with university students themselves (Babury and Hayward, 2013). The Ministry of Labor and Social Affairs established National Skills Standards for Social Work at the Associate degree level in 2012. And, in collaboration with the United Nations Children’s Fund (UNICEF) and the MoHE, a Bachelor of Social Work (BSW) program was established in 2014 (Bragin et al., 2014b). The first counseling department was established in 2012 at Kabul University and the second at Herat University in 2016. The MoHE also called for the establishment of a Model Counseling Center to be established at the university level and for academic programs in professional counseling to accompany the existing academic programs in social work (Babury and Hayward, 2013). The Model Counseling Center opened in 2019.

The next task was to seek culturally relevant measures by which Afghan clinicians could evaluate the success of their work. If the goal of psychosocial counseling and clinical social work is to improve psychosocial well-being, the concept of psychosocial well-being has to be defined and operationalized in order to create a means of evaluating the success of that work (Hoffman et al., 2019). Studies of psychosocial conditions in Afghanistan have identified idioms of distress as well as risk and protective factors that create resilience in the context of mental illness (Ventevogel and Faiz, 2018). Yet only a limited literature exists that addresses the perceptions and understandings of psychosocial well-being – in other words, what it means to be well, psychologically and socially – within the Afghan context. That context includes continuous exposure to extreme violence, trauma, and their correlated everyday stressors exacerbated by unrelenting poverty and deprivation. It also includes history, culture, and values (Eggerman and Panter-Brick, 2010; Miller et al., 2008).

At the time of this study in 2018, an intensive campaign of intimidation was underway by numerous fighting parties, including the Taliban, Daesh, and other local groups. Especially targeted were government employees, academics, teachers, health workers, social workers, members of the Hazara ethnic group, local nongovernmental organizations (NGOs), and community-based psychosocial support organizations, including those protecting women and children in the Islamic context. Violence included threatening visits to family, physical attacks on individuals, bombings, and targeted assaults. These were most widely reported in Kabul and Kandahar, but in fact were regular occurrences throughout Afghanistan. Under the current circumstances, neither social work nor counseling could bring an end to the traumatic circumstances of daily life, nor could they erase the psychic effects of past trauma triggered by present events. Therefore, this research aimed to determine whether it was possible to imagine and describe the necessary conditions for psychosocial well-being in such circumstances.

Defining ‘psychosocial’

The word ‘psychosocial’ has its origins in social work starting with Mary Richmond’s work on ‘social diagnosis’ in 1917. Richmond’s approach differentiated social work from other disciplines by understanding human behavior as inextricably in dialog with the social environment (Goldstein, 2013). Influenced by medical models, the health community uses the words ‘mental health’ and ‘mental disorders’ when referring to both serious and persistent mental illness, substance use, and neurological disorders as well as other forms of distress. Non-medical professionals tend to use the term ‘psychosocial distress’ when referring to adversity related to emotional suffering (Inter-Agency Standing Committee [IASC], 2007). For example, the word psychosocial has been defined by the humanitarian community as a combined term reflecting the

. . . dynamic relationship that exists between psychological and social processes, each continually influencing the other. The prefix ‘psycho-’ relates to the psychological aspect of the individual and incorporates individual thoughts, feelings, desires, beliefs, values, cognition and ways in which people perceive themselves and others. The suffix ‘social’ insinuates the relationships and outer environment of the individual, and contains the material world in addition to the social/cultural context in which people live. (UNICEF, 1997)

Combining the terms ‘psycho-’ and ‘social’ reflects their interconnectedness and inseparability with each aspect influencing the other.

Afghan perceptions of psychosocial distress

The literature discussing the Afghan experience and perception of psychosocial distress within a cultural lens gives careful attention to local idioms, understandings, and definitions of distress (Miller et al., 2006; Panter-Brick et al., 2008). An idiom of distress is ‘an adaptive response or an attempt to resolve a pathological situation in a culturally meaningful way’ (Nichter, 1982: 379). Such idioms can be described by somatic complaints, spirit possession, and other culture-specific ways of discussing experience (Kohrt and Hruschka, 2010). For instance, previous findings indicate three categories describing psychosocial distress in Afghanistan: (1) biological mental disorders; (2) distress caused by djinns, spirits who take over a person’s mind and body for either good or ill; and (3) distress as a result of adverse life experiences, including war, poverty, and violence (Miller et al., 2006; Panter-Brick, 2008). Specific words also exist that describe certain expressions of stress, anger, and grief as differentiated from mental illness (Eggerman and Panter-Brick, 2010; Rasmussen et al., 2014). These three categories have also been found in other diverse contexts (Ventevogel et al., 2013). For example, social stressors such as economic and political instability, sickness of a family member, family conflict, and inability to achieve one’s life goals have been reported as the most frequent and burdensome daily stressors among young people seeking psychosocial support in Afghanistan (Eggerman and Panter-Brick, 2010; Panter-Brick and Eggerman, 2012; Panter-Brick et al., 2008).

A note on the role of Islam in contemporary Afghan social work practice

Afghanistan is an Islamic Republic, like its neighbors Pakistan and Iran. Afghanistan’s 2004 Constitution guarantees freedom of religion, speech, and dissent. It accords full civil rights to women, as well as to religious, cultural, and national minorities, and does not differentiate between Islamic tendencies or sects. The suppression of Islam during the Soviet occupation of the 1980s and the subsequent imposition of a strict form of Sunni Islam in the years that followed left many Afghans hungry for free expression of religion in all of its complexities (Murphy, 2011).

Islam, like other religions, has a long tradition of concern for and discussion of social justice as a moral and ethical obligation. There is a significant and growing literature on children’s rights and protections in Islam and their relationship to child welfare systems in general (Hutchinson et al., 2015; O’Leary et al., 2019a). Less well known is the current literature on women in Islam – utilizing strong liberatory readings of the Qur’an – to exemplify the religion’s defense of women’s rights in an unjust and patriarchal world (Barlas, 2019; Hickcox, 2017). Like other religions, Islam also has a long history of complex discussions on how diverse views on human rights and social justice should be manifested and what form their expression should take (Bragin et al., 2018; Hutchinson et al., 2015; O’Leary et al., 2019a).

The concept of ‘Islamic structure’ (chowkat Islami) formed a frame for the discussion of well-being in this study. It was introduced by participants during the ‘qualitative concept clarification’ section of the study in which participants refined their thinking in order to formulate specific domains and indicators. In particular, participants added the concept of Islamic structure to modify the word ‘freedom’. When asked how to further define Islamic structure as a modifier, participants explained that Islam is a religion of freedom (Hickcox, 2017), and that Islamic structure ensures that one’s freedom does not impinge on that of others. Therefore, the interpretation of this concept is situational, determined by the conditions in which the believer lives in the context of each family’s understanding. This framing enabled participants with divergent emphases to agree among themselves on the essential meaning of each domain and to rank them accordingly. Their views on these issues – reflected in the findings section below – speak for themselves.

Methodology

The study was designed to learn how concepts of psychosocial well-being are understood and operationalized in contemporary Afghanistan. The two main research questions were as follows:

How do Afghans understand psychosocial well-being? What language do people use to express well-being as a feeling? How do they operationalize the language of well-being?

What are the conditions that study participants believe are necessary to achieve a feeling of well-being?

Methodological approach

This is a participatory phenomenological study of the subjective views of psychosocial well-being among people who work with conflict-affected people in four regions of Afghanistan. The research used two methodological approaches – stepwise ethnographic exploration (SEE) (Nagpal and Sell, 1985; Sell and Nagpal, 1992) and the participatory ranking method (Stark et al., 2009) – which were selected following their successful adaptation in similar contexts (Bragin et al., 2014a; Kühhas et al., 2018). The findings of both of these studies yielded specific indicators that were then used for monitoring and evaluation purposes, including both quantitative and qualitative inquiries (Bragin et al., 2019).

Ethical review

Ethical reviews of the study were conducted sequentially by the Office of Internal Review of Ethics (OIRE) of FHI-360 (the fiscal sponsor of the university partnership) and CUNY-UI (City University of New York – University Integrated Institutional Review Board), as well as the Ethical Review Committees of Kabul University and the MoHE of Afghanistan. Informed consent and all documentation were secured in accordance with published international guidelines for ethical conduct of research during armed conflict (Mazurana et al., 2013).

Study locations and study team composition

All research took place in cities located in four of the country’s seven regions: Kabul, Herat, Kandahar, and Mazar-i-Sharif. Security concerns prohibited research in the northeastern, eastern, and northwestern regions. The research team was comprised of faculty members from Kabul University and Herat University as part of a partnership with the Silberman School of Social Work at Hunter College, CUNY. The Principal Investigators (PIs) from Kabul University and Herat University were both fluent in Dari and English, with native Pashto speakers on each team. A specific interpretation team, led by the Herat PI, was assembled to coordinate language during each step of the research. The study team included members of a number of different ethnolinguistic groups and members of Shi’a and Sunni Islamic traditions.

Recruitment and sampling

To advise on curriculum development, the universities developed Technical Advisory Committees (TACs), comprised of representatives of governmental, non-governmental, and private organizations who were currently employing counselors or social workers or that planned to hire program graduates.¹ The research team asked the TAC members to identify experienced Afghan clinicians, professors, or persons currently engaged with the care of people with adversity-related distress in schools, community clinics, and justice, ‘de-addiction’, women’s rights, and child protection programs. Care was taken to include a sample that had a range of educational levels, from basic literacy to advanced degrees. A recruitment letter in the local language at an appropriate level of reading comprehension was shared with potential participants to invite them to participate in the research.

A total of 440 persons participated in the study, including 187 women and 253 men seen in 56 FGDs in four Afghan provinces (see Table 1). The makeup of the 56 focus groups aimed to ensure participants’ maximum participation. The researchers separated the focus groups by gender, organization, and – when applicable – university department. Women and men were interviewed separately due to the gendered nature of the Afghan experience, as well as concerns regarding safety among women participants (GoIRA and UNICEF, 2018; Van Mierlo, 2012). Some focus groups had members with greater formal education, while others had members with greater practical experience. Research team members (and co-authors of this study) who were gathering data during the FGDs were often familiar to the participants due to their long history as experienced community practitioners working with communities. The research team wanted to be sure that all members of each group were comfortable in one another’s presence and whenever possible known to one another.

Table 1.

Total numbers of participants by gender and region.

	Kabul	Herat	Mazar-i-Sharif	Kandahar	Total
Men	92	46	46	69	253
Women	53	60	38	36	187
Total	145	106	84	105	440

An assumption of the sampling strategy was that, as professionals, the participants would have different understandings of well-being than those of the general population. The participants all work with Afghans who experience the effects of ongoing trauma resulting from a history of exposure to war-related violence and everyday stressors such as interpersonal and family violence, substance use, and loss of loved ones. Because of their professional responsibilities with a range of populations, they hear individuals’ stories and are informed about their aspirations. Therefore, the participants’ perceptions of well-being were viewed not just through their own experiences, but through the experiences of the diverse people with whom they work.

Study procedures

Aligned with SEE (Nagpal and Sell, 1985; Sell and Nagpal, 1992), the methodological approach involved five steps.

Step 1: Concept identification

In order to study the nature and meaning of a concept in a cultural context, it is necessary to identify and build consensus regarding that concept among the research team members. The study began with a workshop consisting of study team members and members of the TAC considered to be knowledgeable about psychosocial issues. The workshop asked questions about how the team understood psychosocial well-being, the language used to describe psychosocial well-being, and how they defined psychosocial well-being in their programs. Answers to these questions were recorded and used to inform Step 2 of the research.

Step 2: Concept clarification

Using the language and concepts uncovered through the concept identification workshop, the first round of FGDs was conducted. The FGDs included discussion about the concepts and free-listing activities to establish which questions were most useful. In this and subsequent steps, whenever there was a preponderance of one point of view, research team members stopped to ask participants for specific contravening ideas. Research team members paraphrased the ideas of each participant in the group and ensured that participants’ contributions were accurately represented to others in the group and to the research process as a whole.

Step 3: Consensus on concepts

Consensus on concepts was developed through group meetings among research team members immediately upon conclusion of each FGD. The research team checked methods, compared translation notes, and gathered needed information from the day’s discussions for recording, which was immediately completed by the international PI and approved by the research team members present. The typed notes from the FGDs were coded by a research assistant, who used Microsoft Word to organize and count the number of FGDs in which the codes occurred. The results of the analysis were combined, synthesized, and discussed in a series of research team conferences.

Step 4: Qualitative concept validation

The international PI conducted an in-person workshop with the research team to present the coded findings, elicit comments and revisions, and discuss questions requiring further clarification from the study participants. This workshop resulted in a preliminary list of domains and indicators.

The preliminary domains and indicators were presented in a second round of FGDs. These FGDs consisted of 50 percent of the original participants and 50 percent new participants. The purpose of mixing original and new participants was to see whether the domains and indicators ‘held up’ with those who had not originally identified them. The research team used the participatory ranking method (Stark et al., 2009) to add additional rigor to the qualitative concept validation step. The participatory ranking method ensured that each research participant would actively comment on each domain.

Discussions with participants led to rich explanations of the final concepts. However, participants in all of the groups in all of the settings insisted that the ranking was not a realistic exercise, because psychosocial well-being was an integrated concept in which each single domain interacted with others to develop a holistic view.

Step 5: Final data analysis

Preliminary data analysis was done concurrently with fieldwork using a reflexive and iterative process, including the same procedure described in Step 3. Notes were reviewed and manually coded to discern emerging issues, unique quotations, and crosscutting experiences across regions. Decisions on interpretation were made in conferences with the international PI, the Herat and Kabul PIs, the research assistant, and members of the translation team.

Results and discussion

As discussed earlier in this article, psychosocial well-being is a concept imported for use by the international community.² The literal translation of salamat ravani ejtemay in Dari has come to be used to refer to ‘mental health treatment’. But there are also important subtleties within the language. For example, the study revealed that the word ravani specifically refers to ‘psychosis’ in Dari, thereby complicating participants’ understandings of ‘mental health treatment’ to include emotional distress as a response to traumatic events. However, there is a word that means to feel psychologically and socially well, or rather, to have ‘peace of mind’ (aramesh or aram), which was often used by participants in the FGDs. Another word that was used with great frequency was rahat, which means ‘to be comfortable and relaxed, with a free state of mind’. These terms – aramesh, aram, and rahat – were used interchangeably by both men and women to identify indicators of psychosocial well-being. The terms were frequently associated with a state in which one was not plagued by constant worry. A more temporary state would be khob (‘good’) or khosh (‘happy’).

Due to the gendered nature of Afghan experience the findings below have been separated between women and men. The domains of well-being for women are presented in Table 2 and the domains of well-being for men are presented in Table 3.

Table 2.

Domains and indicators of well-being for women.

Domain	Indicators
Peace, security, justice	• To have continuous peace in society • To have no armed conflict or war • To have equal rights as women • To be free of all discrimination (e.g. ethnic, gender, religious, class) • To have a society based on universal respect for civil law and justice ○ To have a society free from corruption
Love/support in the family	• To have a supportive and loving relationship with all family members • To have equal love for daughters and sons • To have trust and approval from family members • To have a mutually respectful and loving marriage • To have a husband who is also feeling well and happy • To solve one’s problems through peaceful means, discussion • To know that children are happy and well • To be honest with one another within the family • For all family members to live together in mutual respect and harmony ○ When family members disagree, to find solutions by peaceful means, through discussion
Freedom	• To have freedom within Islamic structure (chowkat Islami; چوکات اسلامی) • To be accepted by others • To live without constant fear of accusations and criticisms on the street, in the workplace, and in the home ○ To have freedom of movement ○ To move freely at home, work, or in the streets without harassment, judgment, or threat of violence • To speak and write what one thinks and believes • To be respected for one’s religious beliefs and expressions
Physical health	• To be physically healthy
Economic security/access to resources	• To be economically secure • To have access to the necessities of life ○ To have the resources to ensure that these necessities are continuously available ○ To have access to job opportunities ○ To have knowledge and education • To be free to contribute to the economic well-being of the family without having the morality of one’s efforts questioned
Participation in cultural/religious practices	• To participate in cultural traditions/festivals that bring people together, such as weddings, holidays, etc. • To be able to fully participate in religious festivals, sharing the responsibility of cooking, cleaning, and providing for others • To help others in need, known as the hashar system (حشر) or zakat (زکات) • To have a religious faith and a personal relationship with God • To practice formal, ritual, daily prayer (namaz; نماز) • To have one’s individual expression of religion and culture respected, in one’s practice and in one’s dress
Friendship/support outside the family	• To spend time with friends in mutual support (gardak; گردک یا دور هم بودن) • To make others feel good by supporting them • To have respectful, honest, and trustworthy friendships • To receive praise for one’s work in the workplace or in any setting • To be able to make important contributions at work or in society and be respected for having made them
Self-efficacy/self-esteem	• To be able to adapt, change, or survive any difficulty • To achieve one’s goals and responsibilities • To have confidence in one’s abilities • To be effective in one’s actions at home or at work
Leisure activities, or time to enjoy living	• To follow personal interests (e.g. arts, study, make-up, shopping) • To participate in women’s group activities (e.g. sports, reading groups, music or dancing within cultural traditions) • To enjoy humor and laughter • To be able to travel • To go to the park, walk in green areas, and have picnics

Table 3.

Domains and indicators of well-being for men.

Domain	Indicators
Peace, security, justice	• To have ongoing peace, security, and safety • To have law and order in the society with no corruption • To have societal acceptance of people’s differences • To have respect for everyone’s human values, civil and human rights • To have unity in the country
Economic security/ability to provide for family	• To be economically secure ○ To have a steady job with job security or to have access to necessary resources • To have all basic needs fulfilled for self and family • To be able to support one’s family
Strong family relations support	• To have unity within the family • To have mutual respect and kindness within the family • To have a strong marriage
Independent power and authority	• To have power and authority • To be independent • To have freedom of thought, expression, and spirituality • To be free to access and ask for civil and human rights
Friendship/solidarity outside family	• To spend time with friends and colleagues • To have trustworthy and honorable friends ○ To share our thoughts and experiences with one another ○ To participate in night-time gatherings of same-sex friends, shab nesheni (شب نشینی) • To be respected and appreciated in the workplace and community (e.g. to be socially connected) • To participate in community governance including shura • (شورا) or jirga (جرگه)
Religious observance	• To engage in religious observance (e.g. to participate in religious practice such as prayer, attending mosque, attending funerals, making Hajj) • To help one another through hashar (حشر) and zakat (زکات) • To have religious faith, such as trust in God, a personal relationship with God, or personal spiritual expression
Successful fulfillment of obligations	• To set and reach one’s goals • To have the ability to solve problems and overcome hardships • To do one’s best • To provide support to one’s tribe and/or community
Leisure activities	• To participate in active and outdoor leisure activities (e.g. to play sports, to go to parks and other green areas, and to have picnics) • To participate in social leisure activities (e.g. to play games, to go to parties, to play with children, to cook with family) • To participate in creative/artistic leisure activities (e.g. to read, write, and recite poetry and stories; to watch cinema)
Participation in cultural practices	• To participate in cultural practices • To honor and promote Afghan culture within communities and other countries • To revise cultural practices that bring challenges
Personal capabilities and attributes	• To be honest, respectful, and accepting • To be patient • To be realistic and thankful for what one has in life • To be hopeful and optimistic • To have self-awareness and self-confidence • To be physically healthy

Domains of well-being for women

Table 2 details the domains of psychosocial well-being operationalized by the women participants. The following section will discuss these domains and indicators.

Peace, security, justice (solh, amniyat, adalat; صلح، امنیت، عدالت)

The women participants described this domain as the necessary precondition for peace of mind. This included a condition of persistent societal peace as differentiated from temporary lulls in fighting for short cease-fires. The women considered peace in relation to rights and lawfulness, respect for Afghanistan’s diverse populations (including the poor), and an end to corruption. All participants agreed to the importance of women’s rights. However, according to the more religiously conservative women in the groups, women’s rights are an essential part of Islam, and therefore their abrogation promotes violence. More is said about this under the next domain related to freedom.

Freedom (azadi; آزادی)

The domain of freedom was endorsed strongly by the women participants. However, some women participants suggested the need for a caveat within the Islamic context: no one wanted anarchy or a freedom that did not respect the Afghan culture and the rights of others. Participants agreed that ‘Islamic structure’, or chowkat Islami (چوکات اسلامی), is something that is understood on a personal level, not something that is juridical. This is the area where women (especially in Kabul and in Kandahar) talked about being subject to constant scrutiny and criticism, whether by family members, co-workers, or strangers in the street, regarding any aspect of their behavior, dress, or way of observing their faith.

At the time this research was conducted, these small but constant criticisms had grown to be dangerous, with women participants reporting that strangers were coming to women’s homes and workplaces to denounce women. In some cases, these events were followed by threats by members of armed groups. A particular issue was the fact that, depending on their faith, women might choose different means of ‘covering’ or praying, and they wanted their choices to be respected. While ‘writing and speaking freely’ may seem like an elite concern, there is a strong and still vibrant cultural tradition of poetry memorization and recitation among poor and illiterate women as well as written poetry among Afghan women (Dupree, 1992).

Love/support in the family (eshq/hemayat dar famil; عشق/ حمایت در فامیل )

The women participants did not challenge the Afghan norm of living their lives in an extended family structure in Afghanistan. They assumed that they would live with their parents and extended family until they themselves were married. After marriage, they assumed that they would live in the home of their husband’s extended family. With so many years of armed conflict taking its toll on Afghan society, family life can reflect fears and insecurities engendered by violence (Eggerman and Panter-Brick, 2010; Panter-Brick and Eggerman, 2012). Therefore, the women participants carefully discussed the requirements for a supportive and loving family life as integral to well-being.

The women participants also discussed the difficulties of family life related to, for example, living with the husband’s family and missing one’s parents, family members, and the norms one grew up with. So, family harmony, mutual respect, and peaceful problem solving all contributed to well-being. Mutual love and respect with one’s husband were also described as a key element of well-being. One woman participant said, ‘When you lose your husband’s love, you lose all happiness’. Yet participants were hopeful that with honesty and trust, love could be regained. Along with that was the children’s happiness and that both girl and boy children received equal love.

Physical health (sehat-e-jesmi; صحت جسمی)

Women participants noted that the ‘gift’ of good health was necessary to psychosocial well-being. But unlike other countries where this study was done (Bragin et al., 2014a; Kühhas et al., 2018), the issue of adequate or effective health care did not come up in the research process.

Economic security/access to resources (amniyat-e-eqtesadi, dast rasi be manabe; امنیت اقتصادی/دسترسی به منابع)

Women participants described feeling best when they were able to find ways to contribute to society with their labor. They acknowledged that this contribution need not be through a formal workplace or job, although those are important, because they provide stability that entrepreneurial ventures do not. Women also described the importance of women’s cooperatives or groups where they can be paid for work or to do economic activities together. Women paraprofessionals talked about the economic benefit of their work with the Ministry of Health as well as with NGOs that use their professional skills to reach other women in need.

Leisure activities (faliyat-haye-oghat faraghat; فعالیت های اوقات فراغت )

The participants included leisure activities as a domain because unlike the other domains, women agreed that it could provide momentary times of happiness, known as khosh hastam (خوش هستم), even in the most difficult times.

Indicators with multiple meanings for women

Some indicators developed by the women participants were the subject of passionate controversy and eventually resulted in agreement to keep the opposing indicators. These disagreements are discussed below.

Participation in cultural and religious practices (sherkat dar marasem-e-fargangi va mazhabi; شرکت در مراسم فرهنگی و مذهبی)

There were four areas of disagreement within this domain. The first was sharing of household responsibilities during religious holidays, especially Ramazan. For women participants whose faith was deeply important, the logistical roles (i.e. cooking, cleaning, and serving) women fulfill during religious holidays prevented them from participating in the holiday’s spiritual aspects. They felt strongly that the domestic duties of the religious holiday should be shared equally among men and women to reduce these issues. However, other women felt that their domestic service during holiday times was in itself a special blessing, and therefore looked forward to it.

The question of namaz (نماز), or ‘formal prayer’, was also contested. Many women found this practice a source of deep satisfaction and peace of mind. However, a substantial minority of women participants expressed their desire to have their own choice of religious expression respected by others, which was experienced as a source of peace of mind. Therefore, both indicators were agreed to by the participants and added to the final list.

Visits to selected shrines for prayer and meditation is an accepted part of Shi’a Islamic practice. Women often use this as a way to travel, to get time alone, and to gain mental clarity. However, Sunni Islam does not recognize any shrine except the Kaaba. Visit to the Kaaba, called the Hajj, is an Islamic pilgrimage to Mecca, Saudi Arabia. It is required of each Muslim at least once during his or her lifetime. In the end, the word for ‘shrines’ was removed and subsumed under visits to green places as part of leisure activities so that the findings did not fuel religious controversies.

Finally, the question of cultural dress was a point of disagreement. Many women participants from all parts of the country agreed that wearing prescribed local cultural dress, including the burqa (an outer garment worn by women that covers the body and face), gave them peace of mind. Some felt pride in wearing the hijab (a head covering worn by women) as a visible sign of their faith. Other women felt that they were never free of harassment regardless of what they wore, noting activists who have been murdered while wearing a burqa. These participants felt that, like men, each woman must be free to define what is appropriately modest dress and that her choice should be respected.

Self-efficacy/self-esteem (khod kar amadi/ezzat –e- nafs; خودکارآمدی / عزت نفس)

The indicator ‘to be able to adapt, change or survive any difficulty’ is often considered a hallmark of Afghan resilience (Eggerman and Panter-Brick, 2010). During the first round of FGDs (Step 2), women participants gave many examples of women who had adapted to the most terrible circumstances in Afghanistan. However, during qualitative concept validation (Step 4), almost all women participants questioned whether this contributed to peace of mind or simply reflected a kind of despair disguised as peace. For some, the most important factor was finding a way to fight, no matter how subtle. And the participants shared numerous examples, such as some women being hospitalized for mental illness when they try to express themselves or resist.

Domains of well-being for men

Table 3 lists the domains of psychosocial well-being operationalized by the men participants. The following section will discuss the men’s domains.

Peace, security, justice (solh, amniyat, adalat; صلح، امنیت، عدالت)

Like the women participants, the men participants agreed that peace, security, and justice were of utmost importance to achieving well-being. A unified nation coupled with law and order, respect for human values, and the rights of all peoples, combined with a lawful society without corruption, were reported as factors that were necessary to ensure a lasting peace.

Economic security/ability to provide for family (amniyat-e-eqtesadi/tavanae baraye tamin-e-famil; امنیت اقتصادی/ توانایی برای تأمین فامیل)

The men participants were very clear that economic security and an ability to provide for the family was their responsibility as men. To feel psychosocial well-being, they described needing to have their basic needs met and being able to support their families. The men indicated that the armed conflict in Afghanistan had destroyed the economy and therefore the best way to provide for their families would be through holding a secure job or being able to access resources.

Strong family relations/support (rawabet/hemayat mohkam family; روابط /حمایت محکم فامیلی)

Similar to findings uncovered from the women’s data, family relations within the large extended family could be a source of tension and distress for men. For psychosocial well-being, men require unity within the family, mutual respect and kindness, as well as a strong marriage.

Independent power and authority (esteqlal qudrat va ekhtiar; استقلال قدرت و اختیار)

Regardless of region, religious belief, or ethnicity, the men participants longed for independence in their personal and political lives. This included freedom of thought, expression, and spirituality, including in what they read and wrote. They wanted free access to information, travel, and choice of work along with the right to ask for or demand their civil and human rights. They all stated that this should belong to all Afghans, independent of ethnicity or class, although it was unclear whether that included women.

Friendship/solidarity outside of the family (doosti/hambastegi kharej az famil; دوستی/ همبستگی خارج از فامیل)

According to the men participants, they spend consistently more time outside the family than women do. Time spent with their friends was an important source of psychosocial well-being, and, for these men, sharing thoughts and experiences with other men was akin to or better than therapy. Like the women participants, appreciation in the workplace and community were highly valued by the men. However, this domain also included obligations, which brought satisfaction including participating in traditional systems of governance and ‘social connections’ which guarantee inclusion in information sharing that could be vital to security.

Religious observance (payravi az din; پیروی ازدین)

The men who participated in this study found it crucial to separate religious observance from cultural practices. They all agreed that going to mosque, praying with others, and making Hajj were great sources of well-being. Like the women, they also valued participating in charitable giving and shared work. They were careful to explain that faith was a personal matter in Islam and each person’s spiritual practice might differ. But no matter how it is experienced, they insisted that personal faith could be a source of well-being that should be supported.

Successful fulfillment of obligations (movafaqiyat dar anjame vazayef; موفقیت در انجام وظایف)

The men participants agreed that once they incurred any obligation in their home or work life, they were mandated to fulfill it in order to feel well. When circumstances prevented that fulfillment, they could still feel well only if they could claim, to themselves and to God, that they had made all possible efforts to do so. These include those obligations incurred to tribe or community, which depended on social location (class) as well as ethnicity.

Leisure activities (fa’aliyat-haye-oghat faraghat; فعالیت های اوقات فراغت)

Like the women, men described the importance of having moments to enjoy life. Sports, active outdoor activities, and time spent in green spaces were all highlighted by the men participants. Activities with family members such as playing with their children, cooking with family members, and going to parties were also among their everyday pleasures. Poetry is an Afghan art form that many enjoy. Reading, writing, storytelling, viewing films, and participating in individually chosen art forms were described as leisure activities that brought pleasure and reduced stress. Afghan poetry slams – popular in the cities, especially Herat, Mazar, and Kandahar – were mentioned by the men participants with real joy.

Indicators with multiple meanings for men

Like the women participants, the research also revealed areas of complexity that emerged during qualitative concept validation (Step 4) through a number of indicators within the domains. They were organized in two areas.

Participation in cultural practices (sherkat dar marasem-e-farhangi; شرکت در مراسم فرهنگی)

In the free-listing activity, the men participants spoke with pleasure about Afghan traditions such as living in the extended family. They were equally universally positive about wedding ceremonies and all of the traditional practices that accompanied these events. In regard to mate selection, all men participants were insistent that men should be able to choose their own mate rather than having one selected by family members.

However, during the qualitative concept validation process (Step 4), a number of issues emerged. Many men described their extended families as stressful and did not want to include this as a cultural tradition that leads to well-being. Like the women participants, the men confined the discussion to how to improve or lessen the negative impact of such living conditions. Similarly, they dreaded the expense incurred by weddings and other such celebrations that could lead to debt and other economic difficulties. Therefore, in Step 4, the men participants added an indicator that was almost universally endorsed, which was to have the ability to review and revise the cultural practices that they found challenging.

Personal capacities (tavanaee-haye-shakhsi; توانایی های شخصی)

The men participants listed characteristics of men whom they admired and stated that such men are happier in life and have greater peace of mind. Physical health, a separate domain identified by the women, was seen by men as an individual attribute, and therefore included as an indicator under the domain of personal capacities. In fact, this domain of personal capacities or capabilities was unique to the men participants. They wondered about and discussed the ‘capacity for emotional expression’ raised in the first round of data collection (Step 2). Did it bring peace of mind, as some of the younger men believed, or did it lead to further distress?

Education was also questioned as an important personal capacity contributing to well-being, with one man stating, ‘There is a saying that those who are educated suffer more. Perhaps education does not bring aram or rahat, but only troubles’. These critical discussions of personal capacities underscored the need for further research in this area.

Conclusion

This study adds critical value to a limited but growing literature around descriptions and definitions of what it means to be psychosocially ‘well’ in conflict-affected countries and in Afghanistan in particular. It is among the first to ask Afghan adults how they define psychosocial well-being. In this study, a participatory phenomenological methodology supported findings that were sensitive to the cultural context.

Study limitations

By their very nature, qualitative studies such as this are limited by the statistically small number of participants, purposive sampling, and the specificity of responses. Therefore, the results of qualitative studies are not typically generalizable beyond the specific place where the study is conducted. This study collected data from a large sample of Afghans that was geographically representative of four of Afghanistan’s seven regions. Sampling in this study resulted in 440 participants (187 women and 253 men) who worked as teachers, health workers, volunteers, counselors, and others involved in human service provision across the country. It also included members of the Faculty of Islamic Law at both Kabul and Herat University, as these faculties train pastoral counselors and provide specialized courses in Islamic law to students in social work and psychology. Security concerns prevented the research team from traveling to the other three regions, which could have added to the geographical representativeness of the sample. Furthermore, the sample had a disproportionate number of men participants (n = 253, 57%) compared to women participants (n = 187, 43%), which was due to the increasing restrictions on women’s movement in Afghanistan at the time of the study.

The study was limited to adults 18 years of age and older, excluding children and adolescents. However, children and adolescents are a group in need of tailored assistance due to high levels of violence against children, resulting from the poverty and stressors affecting families (Cameron et al., 2018; O’Leary et al., 2018). Therefore, a separate study to determine indicators of psychosocial well-being among Afghan children and adolescents using a methodology vetted and approved by UNICEF Afghanistan is being planned for the future.

Translation posed another limitation in this study. Every effort was taken to ensure fidelity and consistency of translation through daily team meetings, discussions, concept clarification, and back-translation. However, inherent in all cross-cultural studies is the potential for mistakes with the translation of words or phrases. Particularly, no glossary of psychological terms was validated in Afghanistan at the time of the data collection, thus leading to inconsistences in translation. Therefore, the team used its expertise to compensate for this. Efforts included using a call-and-response method of translation and clarification during concept clarification (Step 2) and qualitative concept validation (Step 4). The Afghan team also approved all interpretations made by the English-speaking analysis team on a line-by-line basis. The glossary of Dari terms used in the study can be found in Table 4.

Table 4.

Glossary of Dari terms for well-being used in this study.

English	Transliteration	Dari
Psychosocial well-being	Salamat Ravani Ejtemay	.سلامت روانی اجتماعی
Life is according to my life desire	Zendazi mutabeq ba male man ast	.زندگی مطابق به میل من است
I am well (fine)	Man khob astam	.من خوب هستم
I am feeling free of worries	Man ehsase rahati mikonam	.من احساس راحتی می کنم
I am feeling peaceful in my mind. I feel peaceful within	Ehsase aramesh mikonam	.احساس آرامش می کنم
Everything is excellent	Hama chiz aali ast	.همه چیز عالی است
Everything is according to my wishes	Hama chiz var vefqe morad ast	.همه چیز بر وفق مراد است
I am completely at peace	Rahate rahat astam	.راحت راحت هستم
I am fortunate	Khoshbakht astam	.خوشبخت هستم
I am feeling well	Sare hal astam	.سر حال هستم
I am happy	Khosh hastam	.خوش هستم
I have ‘peace of mind’	Fekre man aram ast	.فکرم آرام است
A better life	Zendegi Behtar	زندگی بهتر
Lively	Sar Zenda	سرزنده
I found myself free	Khod ra azad yaftam	خود را آزاد یافتم
A community council	Shura	شورا
A tribal council (Pashto)	Jirga	جرگه
Tawiz is an amulet or locket usually containing verses from the Quran or other Islamic prayers and symbols	Tawiz	تعویذ
Community work to help a person in need – a religious obligation	Hashar	حشر
Monetary charitable obligation, paid as a proportion of income (one of the five pillars of Islam)	Zakat	زکات
Full prayer ritual	Namaz	نماز
Prayer mat	Jaynamaz	جای نماز
Soiree, night-time gathering with same-sex friends	Shab neshini	شب نشینی
Islamic structure	Chowkat Islami	چوکات اسلامی

Implications for social work practice and research

There is a dearth of literature on indicators of psychosocial well-being in the Afghan context. This research addressed a practical need: to rapidly identify such indicators informed by the Afghan context in order to ensure that psychosocial programs are effective in the face of the ongoing suffering experienced by the Afghan people. The results of this study will ultimately help professional Afghan social workers and psychological counselors to understand psychosocial well-being in their clients and to tailor their work accordingly.

The study methodology also has the capacity to improve social work practice in Afghanistan. People who are affected by armed conflict often experience a lack of self-efficacy due to the adverse conditions that control their lives. Imposition of outside ideas of success can increase this helplessness (Hinestroza and Ioakimidis, 2011; IASC, 2007). Participatory monitoring and evaluation of programs designed for the benefit of communities may increase a sense of control in times of contexts of extreme adversity (Wessells, 2009). The methodology is replicable and can be used with community groups following violent attacks or with school communities where parents and teachers are seeking to reduce violence against children. Using this methodology, programs can be designed, monitored, and evaluated to meet the needs of the participants, and therefore can be measured by participants and practitioners for success (Sewpaul and Henrickson, 2019).

The study also has implications for further curriculum development for social work and related disciplines, especially in the area of micro-level counseling practice. Qualitative concept validation is often considered a difficult aspect of methodology. In this study, we provided additional consent for this purpose, resolving some controversies in the process, and also included a large number of new participants to ensure a robust discussion of the operationalization of the original results. As curricula are developed going forward, revisiting the original data and allowing new thinking to emerge could be advanced to allow changes in curriculum. This will be especially true of traumatogenic conditions and the participants’ ability to manage them, as well as the programs’ ability to work within the ongoing constraints that are a key feature of Afghan life (Babury and Hayward, 2013; Missmahl, 2018).

The participants’ description of the requirements for well-being require simultaneous interventions at the micro, mezzo, and macro levels. The integrated nature of the biological, psychological, social, and spiritual spheres highlighted in this study’s findings continues to resonate among colleagues in Afghanistan. In turn, this has influenced the types of activities held in the Model Counseling Center at Kabul University (which opened in 2019 following the completion of this study) where individual, family, and group interventions are practiced, including experimental theater groups, poetry slams, and art-based projects. In addition, Kabul University’s Social Work and Counseling departments have used the Model Counseling Center to create a space for the university community to dialog to find commonality among difference and work for change.

Like other countries around the world, in Afghanistan the role of social work has sometimes been misunderstood as primarily connecting people to economic assistance and other public services. This study points to a key role for social work to provide clinical services in combination with economic and social assistance. The BSW programs at Herat and Kabul universities provide coursework in individual, family, and group support for people suffering from the traumatic effects of war and violence, as well as for participatory community organizing and policy development (Bragin et al., 2014b). This study has clarified and operationalized the usefulness of social work in providing emotional support to people who require intervention to assist them in their healing and to strengthen the capacity of the population to transform their circumstances in the face of a lifetime of war and violence.

Looking beyond Afghan borders

The study findings reveal a complex and liberatory understanding of Islam’s structure and meaning in everyday life that advances human rights and diversity in the Afghan context, particularly in regard to children and women’s rights. In this way, this study contributes to growing body of literature that offers an understanding of Islamic structure as part of a transformational and complex social practice (Barlas, 2019; Hutchinson et al., 2015; O’Leary et al., 2019a).

The study adds to the already rich and growing traditions of social work research in Muslim-majority countries, including the long-standing history of publication, from Pakistan and Iran where social work has been continuously taught at the university level since the 1950s (Nadkarni, 2011) to studies from emerging faculties in Indonesia (O’Leary et al., 2019b; Sukmana and Abidin, 2020), Central Asia (Murphy, 2011), and the Middle East (Ibrahim et al., 2020). Emerging social work faculties often partner with colleagues from more established research institutions, as in this study, including those from diverse cultural traditions. The authors wish to highlight the importance of accompaniment, when researchers coming from situations of greater safety and security physically partner with colleagues facing conditions of armed conflict to conduct research together. This may be particularly valuable in phenomenological studies, where part of the task is thinking together in situations where shared trauma can pose challenges to the free flow of ideas among local participants and researchers (Lavalette and Ioakimidis, 2011). Ultimately, this contributes to more robust understandings of intercountry collaborations during armed conflict.

Increasingly, social work has endeavored to ensure that its psychosocial role in communities experiencing armed conflict and postcolonial transition includes a trauma-informed approach to needs and resource assessment (Schiff et al., 2019). Literature on social work and shared trauma has contributed to social work in these situations, framing the context for locally based inquiry (Tosone et al., 2012). What can be lost in such situations is the inclusion of strengths-based elements, in which social work engages communities to imagine the future that they are struggling to build and measuring progress toward effective healing (Lavalette and Ioakimidis, 2011). Therefore, the authors hope that the methodology used in this study may be replicated by social workers in diverse contexts to explore whether they too might find critical information to utilize in building curricula and measurable, locally based, restorative practices in contexts of immense suffering.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this project came from the United States Agency for International Development’s (USAID) University Support and Workforce Development Program (USWDP), administered by FHI-360.

ORCID iDs

Martha Bragin

Bree Akesson

Bezhan Ayubi

Spozhmay Oriya

Rohina Zaffari

Basir Ahmad Azizi

Notes

Author biographies

Martha Bragin is an associate professor at the Silberman School of Social Work, Hunter College, City University of New York.

Bree Akesson is an associate professor at Wilfrid Laurier University’s Faculty of Social Work.

Mariam Ahmady is an associate professor and the chairperson of the Counselling Department at Kabul University.

Sediqa Akbari is an assistant professor in the Counselling Department at Kabul University.

Bezhan Ayubi is an assistant professor in the Counselling Department at Kabul University.

Raihana Faqiri is an associate professor and assistant dean in the Counselling Department at Kabul University.

Zekrullah Faiq is an assistant professor in the Counselling Department, Kabul University.

Spozhmay Oriya is an assistant professor in Counseling Department at Kabul University.

Rohina Zaffari is an assistant professor in the Social Work Department at Kabul University.

Mohammad Hadi Rasooli is a psychiatrist and technical consultant for mental health in private practice in Herat, Afghanistan. He was employed by Hunter College, City University of New York as Senior On-site Technical Advisor for this project.

Basir Ahmad Azizi is an assistant professor in the Department of Counseling at Herat University.

Fareshteh Barakzai is an assistant professor in the Counseling Department at Herat University.

Yasamin Haidary is an assistant professor in the Psychology Department at Herat University.

Sediqa Jawadi is a professional interpreter employed by Hunter College, City University of New York for this project.

Hannah Wolfson was employed as a research assistant by Hunter College, City University of New York for this project.

Sayed Jafar Ahmadi is an associate professor of Psychology at Shaheed Rabbanni Education University. He was employed by Hunter College, City University of New York as the Kabul-based On-site Technical Advisor for this project.

Basir Ahmad Karimi is dean of the Faculty of Education at Herat University.

Sataruddin Sediqi is dean of the Faculty of Psychology and Educational Science at Kabul University.

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