Gender and Mental Health in Gilgit-Baltistan, Pakistan

Gender difference in mental health is one of the most important areas in psychology [1]. It is a common observation that women report a higher level of psychiatric morbidity but most studies have failed to incorporate other contributing factors especially social roles which tend to influence mental health [2]. After controlling for the social and domestic factors, women reported a slightly higher psychiatric morbidity [2]. Hence, the gender difference in psychiatric morbidity may depend on the context [2]. Some researchers found gender difference in some components of mental health such as psychological distress and positive relationships but not in other components such as psychological well-being, positive affect, negative affect, self-acceptance etc [3]. Other studies reported gender differences in various components of psychological distress, such as depression and anxiety [4]. The life time prevalence of depression was 21.3% for women and 12.7% for men [5]. Similarly, females scored significantly higher than males on anxiety and depression sub-scales of Minnesota Multiphasic Personality Inventory (MMPI) [6] and women reported higher levels of psychological distress as compared to men [7]. In contrast, other studies have found no gender difference in Mexican Americans, Australians, and in older Chinese [8-10]. In contrast to psychological stress, psychological well-being is people’s evaluation of their life. In some dimensions of psychological well-being such as positive relations, personal growth, purpose in life and in global psychological well-being, women have scored significantly higher than men [11]. Some studies reported higher positive affect, life satisfaction [4], and psychological well-being in women as compared to men [12]. Other empirical evidences yielded contradictory findings [13-15]. We are unaware of any studies that have examined the prevalence of psychological stress and well-being and gender differences in the population from Gilgit-Baltistan region of Pakistan. Therefore, the major objective of this research was to study the psychological stress and well-being and gender differences in mental health in GB, Pakistan.

This study enrolled 408 patients (214 females) from the outpatient departments of the district headquarter hospitals of GB. These patients presented for the treatment of different physical symptoms from March 2013 to December 2013. We included patients between 16 and 80 years of age. Patients with severe morbidity, intellectual deficits and other disabilities that would make the participants unable to answer questions were excluded. The study protocol and informed consent was approved by the medical superintendents of all the seven districts of GB, Pakistan as there were no institutional review/ethical boards. After getting verbal consent, structured interviews were conducted individually using a translated version of the Mental Health Inventory by Viet and Ware [16]. The inventory consists of 38 items and was designed to measure participants’ mental health. The cumulative score indicates participants’ global mental health. Score has two major domains; psychological distress domain consists of three sub-scales; anxiety, depression, and loss of behavioral/emotional control and psychological well-being domain consists of general positive affect, emotional ties, and life satisfaction. All participants were interviewed by their respective genders. Descriptive (frequencies, mean, and standard deviation) and inferential statistics (two sample t-test) were applied to analyze the data by using SPSS (SPSS 20.0).

Of the 408 participants, majority (64.7%) were married with a mean (standard deviation) age of 28.4 (11.3) years. Highest education level attained was post-graduation for 5.8%, graduation 14%, higher secondary 18.2%, and secondary 38.7%. The regional distribution of patients was as follows: 17.9% from Gilgit, 15.2% from Skardu, 13.3% from Hunza-Nagar, 14.2% from Ghizer, 13.7% from Ghanche, 12.7% from Astor, and 13% from Diamer district (Table 1). Additionally, there was a statistically significant negative correlation (r = -.31, <.001) between psychological distress and psychological well-being. Male participants’ scores on mental health index were higher than female participants indicating a higher level of mental health in men (mean difference 10, P<0.001). On the other hand, female participants had higher scores on psycho-logical distress than men indicating higher level of psychological distress. Insignificant gender difference was observed in psychological well-being suggesting that both genders have an equal level of psychological well-being in GB, Pakistan (Table 2).

 In the present study, we have found gender differences in mental health where women reported significantly lower level of mental health and higher psychological distress as compared to men. Our findings are consistent with previous studies reported by Vishwakarma in India, a region not culturally very different from Pakistani culture [17]. Garai reported consistent gender differences in many areas of mental health such as anxiety, depression, stress, satisfaction, happiness, intimacy in interpersonal relations, and frequency of mental disorders [18]. When discussing the risk factors for poor mental health of Indian women, Basu identified violence, childhood neglect, family breakdown, financial insecurity along with family history of psychiatric disorders [19]. In the cultural background of South Asia, women face gender-based discrimination at every phase of their lives as a result women are more likely to be surrounded by stress and this stress leads to the psychiatric illness [20]. In Pakistan, women are living in a world which is constructed by strict cultural, family and tribal customs that force them to live in submission and fear [21]. In Western countries, women experience higher psychological distress, such as depression and anxiety, as compared to men [22]. We have found similar findings in GB, Pakistan where women reported more psychological distress as compared to men in terms of depression, anxiety, and loss of behavioral/emotional control. Some researchers found that women experience more stressors as compared to men because of their social role based on gender differential exposure [23], as a result they are more vulnerable to psychological distress. For example, in the United States, Almeida and Kessler found that the gender difference in psychological distress diminished when participants’ daily stressors were statistically controlled [24]. The majority of married women in Pakistan showed mental stress due to the behavior of their husbands and around 56% of them reported to be physically abused [21]. Domestic abuse against women, their psychological and economic dependence on men throughout their lives are more common in patriarchal social system of Pakistan but their frequency and intensity vary across different groups and communities [25].

We found insignificant gender differences in psychological well-being in GB, Pakistan. These findings are consistent with previous empirical evidences. In the Western society, much less is known about gender differences in psychological well-being [15] and there were also insignificant gender differences in life satisfaction [26]. According to Stone, Schwartz, Broderick and Deaton, age is a very important factor to determine an individual’s psychological well-being [27]. They found that both affective and evaluative well-being were lower in respondents in their 40s and 50s as compared to younger people. Older adults scored lower on life satisfaction as compared to middle-life adults and young adults but they scored higher on positive relations as compared to their younger counterparts [28]. Other researchers have identified marital status, marital transition, and marital quality as factors associated with psychological well-being. Hence, married people with high marital quality are more satisfied with their lives as compared to unmarried people [29]. In addition to age and marital status, income [30], education level [31], race/ethnicity [32] and perceived social support from family and friends [33] are also related to people’s psychological well-being. In summary, the existing literature revealed that gender is not the only contributing factor but other demographic and contextual variables are also important to influence people’s psychological well-being. In addition to its importance for GB, the present study has some limitations. The study was conducted only on one segment of population through convenient sampling technique by enrolling patients who presented to hospitals for treatment, thus, limiting the generalizability of the study findings.

We conclude that female participants have reportedly higher level of psychological distress as compared to male participants but there was no significant gender difference in psychological well-being in GB, Pakistan. Future studies should explore the role of other potential factors that may lead women to higher level of psychological distress in GB.

 The authors are very grateful to all the people who took part in this research. We extend our gratitude to the Director of Health in Gilgit and Baltistan regions, and district medical superintendents of all the seven districts who gave generous and sustained assistance in the process of data collection.

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