In many under-served populations, women have considerable mental health needs. However, until recent years, the conception of women's mental health has been limited as have attempts to protect and promote it. When women's health issues have been addressed in these populations, activities have tended to focus on issues associated with reproduction - such as family planning and child-bearing - while women's mental health has been relatively neglected (WHO, 1993; WHO, 1995).
Women are integral to all aspects of society. However, the multiple roles that they fulfill in society render them at greater risk of experiencing mental problems than others in the community. Women bear the burden of responsibility associated with being wives, mothers and carers of others. Increasingly, women are becoming an essential part of the labour force and in one-quarter to one-third of households they are the prime source of income (WHO, 1995).
In addition to the many pressures placed on women, they must contend with significant gender discrimination and the associated factors of poverty, hunger, malnutrition and overwork. An extreme but common expression of gender inequality is sexual and domestic violence perpetrated against women. These forms of socio-cultural violence contribute to the high prevalence of mental problems experienced by women.
In investigating common mental, behavioural and social problems in the community we find that women are more likely than men to be adversely affected by specific mental disorders, the most common being: anxiety related disorders and depression; the effects of domestic violence; the effects of sexual violence; and escalating rates of substance use.
Prevalence rates of depression and anxiety disorders as well as psychological distress are higher for women than for men. These findings are consistent across a range of studies undertaken in different countries and settings (Desjarlais et al, 1995). In addition to the higher rates of depression and anxiety, women are much more likely to receive a diagnosis of obsessive compulsive disorder, somatization disorder and panic disorder (Russo, 1990). In contrast men are more likely to receive a diagnosis of antisocial personality disorder and alcohol abuse/dependency. The gender differences associated with mental disorders are brought out most clearly in the case of depression (Russo, 1990). Data from the World Bank study revealed that depressive disorders accounted for close to 30% of the disability from neuropsychiatric disorders amongst women in developing countries but only 12.6% of that among men. The disparity in rates between men and women tend to be even more pronounced in underserved populations (World Bank, 1993).
Explanations for the gender differences in mental disorders have been discussed in relation to different help-seeking behaviours of the sexes, biological differences, social causes and the different ways in which women and men acknowledge and deal with distress (Paykel, 1991). Blue et al, (1995) argue that while all these factors may contribute to higher rates of depression or psychological problems among women, social causes seem to be the most significant explanation. Women living in poor social and environmental circumstances with associated low education, low income and difficult family and marital relationships, are much more likely than other women to suffer from mental disorders. They conclude that the combined impact of gender and low socio-economic status are critical determinants of mental ill-health (Blue et al, 1995).
It is essential to recognise how the socio-cultural, economic, legal, infrastructural and environmental factors that affect women's mental health are configured in each country or community setting. A gender-based, social model of health needs to be adopted to investigate critical determinants of women's mental health with the overall objective of contributing to improved, more effective promotion of women's mental health. Risk factors for mental disorder as well as for good mental health need to be addressed and where possible, a clear distinction should be made between the opportunities that exist for individual action and individual behaviour change and those that are dependent on factors outside the control of the individual woman.
To help clarify the meaning women themselves ascribe to mental health and various forms of psychological distress, findings from qualitative research need to augment those from quantitative research. Descriptions of life situations, case studies and direct quotes from women themselves can vivify the contexts in which emotional distress, depression, anxiety and other psychological disorders occur. Such first hand accounts of the experiences of poverty, inequality and violence will assist in developing a more accurate understanding of the structural barriers women face in attempting to exercise control over the determinants of their mental health and in effecting behavioural change. Both are needed to better inform the promotion of women's mental health.
Women's views and the meanings they attach to their experiences have to be heeded by researchers, health care providers and policy makers. Without them, research and the evidence it gathers, service delivery and policy formation, will be hampered in responding to women's identified health priorities, problems and needs. Moreover, all three will be ignorant of the nature and magnitude of unmet needs and unaware of the factors influencing women's utilisation of health care.
The identification and modification of the social factors that influence women's mental health holds out the possibility of primary prevention of certain mental disorders.