Exercise Adherence in Afghan Women With Depression

Depression is one of the most common mental health disorders worldwide and is a leading cause of disability. Women are affected more frequently than men and often experience substantial impairment in emotional well-being, family life, social participation, and daily functioning. In Afghanistan, women may face additional challenges that increase their risk of depression, including prolonged exposure to conflict, financial hardship, caregiving responsibilities, social restrictions, current political restrictions, and limited access to mental health services. In addition, current restrictions imposed by the de facto authorities prohibit women from accessing public parks and gyms, substantially limiting opportunities for outdoor and facility-based physical activity. As a result, many women have few opportunities to engage in regular exercise despite its recognised benefits for both physical and mental health.

Regular physical activity has been shown to improve depressive symptoms and overall well-being. Proposed mechanisms include improvements in neurotransmitter function, reduction of stress-related physiological responses, enhancement of neuroplasticity, and positive psychological effects such as improved self-efficacy, mood, and quality of life. Exercise is therefore widely recommended as an adjunct to standard treatment for mild and moderate depression.

Although the benefits of exercise are well established, maintaining regular participation remains a major challenge. Many people begin exercising but discontinue after a short period because of motivational, environmental, cultural, or practical barriers. For Afghan women, these barriers may be particularly important. Opportunities to participate in organised exercise programmes are limited, and access to women-only fitness facilities is restricted. Cultural expectations, household responsibilities, concerns about privacy and modesty, transportation difficulties, and limited safe outdoor environments may further reduce participation in physical activity.

Home-based exercise programmes may provide a practical alternative by allowing women to exercise in a familiar and culturally acceptable environment without requiring specialised facilities or equipment. However, simply advising people to exercise may not be sufficient to encourage sustained participation. Programmes that provide clear instructions, culturally appropriate educational materials, and structured support may help improve adherence by increasing confidence, reducing uncertainty, and making exercise easier to incorporate into everyday life.

Despite growing international evidence supporting exercise as part of depression management, little research has examined culturally adapted home-based exercise interventions among Afghan women. Furthermore, limited evidence exists regarding exercise adherence in this population. Understanding whether a culturally appropriate programme improves adherence is important because the effectiveness of exercise depends largely on participants' ability and willingness to continue exercising over time.

This pilot randomised controlled trial has been designed to evaluate the feasibility and preliminary effectiveness of a structured culturally adapted home-based exercise programme for Afghan women with mild to moderate depression receiving outpatient psychiatric care. The study will compare this structured approach with routine exercise advice delivered as part of usual clinical care. The primary focus is to determine whether providing a culturally tailored exercise programme improves adherence to physical activity over an eight-week period.

In addition to evaluating exercise adherence, the study will explore whether greater participation in physical activity is associated with improvements in depressive symptoms, functional status, participant satisfaction, and the overall acceptability of the intervention. Information regarding adverse events occurring during participation will also be collected to better understand the safety of implementing a home-based exercise programme in this population.

The intervention has been developed to reflect the cultural and practical circumstances of Afghan women. The programme consists of illustrated guidance for home-based exercises that can be performed without specialised equipment and can be adapted to individual physical ability and available time. This flexible approach is intended to improve long-term engagement while respecting individual differences in daily responsibilities, physical fitness, and health status.

The study also seeks to generate preliminary data that may support the planning of future larger-scale clinical trials. As no previous randomised studies have specifically investigated culturally adapted home-based exercise adherence among Afghan women with depression, information from this pilot study will help estimate adherence rates, assess study feasibility, identify implementation challenges, and inform sample size calculations for future definitive research.

If the structured home-based exercise programme demonstrates improved adherence and favourable clinical outcomes, it could provide a practical, low-cost, and culturally appropriate strategy for integrating physical activity into routine mental health care for women with depression in Afghanistan. Because the intervention requires minimal resources and can be delivered without specialised exercise facilities, it may also be suitable for implementation in other low-resource or culturally similar settings where access to supervised exercise programmes is limited.

The findings of this study are expected to contribute to the limited evidence on behavioural interventions for depression in Afghanistan and may support the development of culturally appropriate, non-pharmacological approaches that complement existing psychiatric care. The results may also help healthcare providers and policymakers better understand how structured home-based physical activity programmes can be incorporated into comprehensive depression management within resource-constrained healthcare systems.