Gender Inequality in Mental Health: A Review from the South Asian Context

Gender equity refers to the fairness and justice in the allocation of benefits and responsibilities between women and men, while gender-based inequity may emanate from a psychosocial, epidemiological; or perhaps a global perspective. The concepts of gender equity are merely elusive; nevertheless, increasingly have been used inappropriately. Gender inequities in mental health, pervasive in South Asian societies, indicate biases in power, resources, entitlements, and the way organizations are arranged and programs are designed to adversely affect the lives of millions of women. Four major areas highlighted in this study are: Prevalence of gender inequality in mental health; role of gender in South Asia; unraveling gender and mental health paradox in South Asia; and effective strategies to minimize gender inequality. Eliminating gender inequalities requires not only acknowledging the necessity of basic medical services to women, but scrutinizing mental health through a gender lens and taking measures for expanding women’s accessibility, affordability and suitability to mental health facilities in South Asian countries.


Introduction
An evolving thrust toward attaining universal health coverage (UHC) in developing countries elevates three global concerns: Well-being of individuals (goal3); gender equality (goal 5); and lessening of inequality across international and national borders (goal 10). 1 In 2002, World Health Organization (WHO) conceded its first Gender Policy, promoting the gender issue as important agenda globally and emphasizing the importance of gender equality and the empowerment of women. 2 The concepts of gender equity are merely elusive; nevertheless, increasingly have been used inappropriately.Gender equality is often interpreted as concerning only the dissimilarities between women and men.Whilst gender equity refers to the fairness and justice in the allocation of benefits and responsibilities between women and men, gender-based inequity may emanate from a psychosocial, epidemiological; or perhaps a global perspective.Extended understanding of gender and health, shaped by political, economic and cultural affairs 3,4,5 , shines light on the notion of gender inequality.
Gender inequality in mental health, pervasive in South Asian societies, indicates biases in power, resources, entitlements, and the way organizations are arranged and programs are designed to adversely affect the lives of millions of women.The disparities in mental health services stem from large-scale cultural, social, economic, and political processes, producing differential health risks for women. 6Mental diseases are projected to account for 12% of disability-adjusted life-years lost worldwide; yet, approximately 90% of the countries have no mental health policy, nearly 40% have no mental health plan, more than 30% have a few mental health awareness and preventive programs. 7Although mental health issues are among the significant contributors to the global burden of diseases, gender inequalities in mental health surpass differences in the proportions of several disorders, especially in the phases of vulnerability, diagnosis, treatment and adjustment to mental disorder 8 among South Asian women.
The aim of this paper is to review gender inequalities in mental health in South Asian countries,unveiling the relationship of gender, mental disease burden and health services as a powerful determinant of gender differences, and raising some recommendations for stemming gender disparities.A search of PubMed, Medline and Web of Science (January 1989 to December 2016), and other search engines were carried out to retrieve potentially relevant studies on gender inequity and mental health and their relevant MESH terms.Databases were searched for Englishlanguage articles using key words including: 'mental health', 'gender', 'inequity', 'South Asia'.Four major areas highlighted in this study are:Prevalence of gender inequality in mental health; role of gender in South Asia; unraveling gender and mental health paradox in South Asia; and effective strategies to minimize gender inequality.

Prevalence of Gender Inequality in Mental Health
Gender inequalities in mental syndromes extend further than dissimilarities in the degrees of various mental disorders and encompass an array of facets that affect diagnosis, treatment and adjustment to mental disorder among women 8 .Conduct disorder is the communal psychiatric disorder in childhood years, entailing three times more prevalence among girls compared to boys. 9During adolescence, girls happen to have higher prevalence of depression, eating disorders,and suicide, who are likely to succumb to high risk behaviors than boys 10,11 .While mental diseases, especially depression and anxiety, are the most common comorbid illnesses, a major gender disparity exists in the proportion of comorbidity among women.Chronic strain and rumination are more common in women than in men, interceding gender difference in depressive episodes.Women, also, reported to worry more for lack of confidence issues 12 .Moreover, women are two to three times more likely to develop post-traumatic stress disorder (PTSD) than men 13 and are more prone to be diagnosed with either mental disorder alone or comorbidity compared to men. 14

The Role of Gender in South Asia
Gender, a common phenomenon, necessitates to be understood within a multifaceted and unambiguous local setting.By shifting the research lens on apprehending the diverse experiences of men and women, underlying elements of gender can be better understood and interconnecting social determinants can be scrutinized which have an impact on women's role in the South Asian society.South Asian women are deemed to have inferior status than men, especially, from social, cultural, and economic facets. 15Women, the inferior group, are left out from making major decisions, are restricted in their movement, and often fall a victim of violence from male relatives, and have inadequate access to health care resources and services. 16uth Asian communities have been skeptical about the equal privileges for women in health arena and have succumbed to stereotyping beliefs and attitudes toward appropriate gender specific roles in the society.The role of gender should not be swayed by superficial and unenlightened beliefs; however, it is a common practice in South Asian countries.The preconceived notions about masculinity and femininity shape the way how gender equality is posed in South Asia.Hence, gender inequalities have steered to a methodical devaluation and negligence in women's health.

Unraveling Gender and Mental Health Paradox in South Asia
Women, the unprivileged component of the society, seldom seek out help and appropriate mental health care services in South Asia.The burden of mental disease and the eminence of mental health care for South Asian women have not been acknowledged and well documented.Although general illnesses have an equal prevalence in both men and women worldwide, women in South Asia suffer excessively from non-communicable diseases, 17,18,19 especially, from mental disorders.
Studies in different districts of India revealed that women had significantly higher prevalence proportions for psychiatric disorders than men. 20ender inequality, manifested through matrimony, work place discrimination, and poor psychological health, has stemmed rural Indian women from seeking health advice and health care services for their mental disorders. 21A research conducted in Nepal revealed that women had higher mental disorder compared to men, reaching a sex ratio of 2.8:1 in the health post, and 1.1:1 in the regional clinic. 22A study in Bangladesh unveiled that sex ratio for mental diseases was 2:1 and the sex proportion for suicide was 3:1, 23 while a recent Bangladeshi study reported that people with drug addiction and psychological disorders were associated with an increased number of relapse. 24Another significant research showed that top five common reasons linking with depressive episodes among women in Pakistan 25 were: matrimonial disputes (25.5%); job dissatisfaction (14%); financial dependency (10%); disputes with in-laws (13%); and stress of responsibilities both at home and at work (9%).
Since the 1990s, growing emphasis has been placed on health promotion in Bangladesh; nevertheless, a large number of people in rural areas have little access 26 to mental healthcare services compared to their urban counterparts.South Asian women suffer from ill health, especially, mental diseases as they grow old. 19Additionally, women who are ignorant, unemployed, and/or widowed, are more likely to be vulnerable 27 toward mental diseases and services.
Absence of a multi-disciplinary health approach not only ceases women's autonomy, but sabotages women's right to mental health services in South Asia.Health ministries in South Asian countries, moreover, are lagging behind in championing approaches based on social determinants of health which can demonstrate effectiveness through good practice and support from other ministries in creating policies that promote gender equity in mental health.Lack of support mechanisms contributes to a poor quality of life for the South Asian women; hence, gender equity needs to be at the heart of urban governance and planning in South Asian countries.

Effective Strategies to Minimize Gender Inequality
Eliminating gender inequalities requires not only acknowledging the necessity of basic medical services to women, but 6 scrutinizing mental health through a gender lens and taking measures for expanding women's accessibility, affordability and suitability to mental health facilities in South Asian countries.
Firstly, ministries of health in South Asian countries should assimilate gender-specific pointers in the prevailing national health systems, and explore mechanisms to monitor gender sensitivity in the health planning system.Gender equity in mental health, needs to be prioritized as national concern 28 for government and international entities, assuring its comprehensible reflection in national policies and comprising social-emotional advancement of women in South Asia.
Secondly, there is a requirement for addressing the reasons and consequences of mental health illiteracy and accompanying stigma within the South Asian society.Furthermore, educating the importance of mental health and raising awareness of mental disorders among women, perhaps can improve literacy and management of mental health hazards, thus promoting gender equity in mental health in South Asian community.The media, hence, can play a vital role to increase community awareness of women and reduce the stigma of mental problems in South Asian countries.
Finally, it is essential to reinforce South Asian women's accessibility and affordability over health resources, which can protect mental health through identifying gender-specific obstacles in utilizing mental health amenities.The prevalent abuse of women's health privileges, including reproductive rights, adds to the rising encumbrance of disability triggered by poor mental condition. 29,30Ensuring gender equity in mental health will reduce the unwarranted clinical disparities between male and female and will ensure mental health coverage for everyone, regardless of the social, cultural and political backdrop of different South Asian countries.

Conclusion
Effective strategies for risk factors' reduction in relation to mental health cannot be genderneutral, while the risks themselves are genderspecific, and women's status and life opportunities remain low in South Asia.Literature unveil that prevalence of mental diseases among women and existing disparities in mental health services in South Asia and are not acknowledged as a national health concern in South Asian countries.Intertwined within socioeconomic delusions and discrepancies, women miss out on essential mental health care in comparison to men in South Asia.Evidence also pinpoints that the burden of mental diseases will increasingly cause greater morbidity in the next decades; nevertheless, research on effective strategies to minimize gender inequality in mental health in South Asian countries is still in infancy.Governments need to implement a multifaceted approach to build gender equity with mental health prevention programs in South Asian countries.This approach will require inter agency mechanisms to provide a comprehensive package that extends to all women, regardless of their ability to pay, thus facilitating effective translation of evidence into policy.