A Randomized Controlled Trial Comparing Exercise Adherence Between a Structured Culturally Adapted Home-Based Exercise Program and Routine Exercise Advice Among 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.