This focus on stressors for women in Third World countries does not make it a problem exclusive to the developing nations. Any assumption of such a dichotomy is artificial and merely serves to reiterate colonial views of the Third World nations. What is significant is that world over, poverty, lower levels of education, and gender inequalities affect the mental health of the population. Because the challenges of poverty and educational attainment are greater in developing nations, gender inequities become more pronounced and warrant closer consideration there. Leyla Gulcur (17) draws attention to the fact that the existing human rights treaties and consensus documents address the right to mental health only in very general terms. They do not address the specific ways in which cultural, social, and economic conditions interact with gender inequalities to produce gender differentials in mental health. Marginalization, powerlessness, poverty, overwork, stress, and the increasing incidence of domestic violence have been linked to mental disorders (18). Research has consistently shown that poverty, economic dependence, lower educational levels, lack of decisionmaking power, and high levels of domestic and child care responsibilities are negatively correlated with mental health (19).

A review of evidence shows that in the developed world, around 28% of all women report at least one episode of physical abuse, whereas in developing countries, studies indicate a prevalence ranging from 18% to 67% (20). While this is concerning, we have to exercise caution in drawing inferences regarding these disparities because the methods employed by studies to collect information might have been very different. The aforementioned review of evidence (20) also looked closely at six studies that examined the issue of violence against pregnant women in developing countries by reviewing six different studies undertaken in India, China, Pakistan, and Ethiopia. It concluded that the prevalence of violence against pregnant women in developing countries ranges from 4% to 29%. The main risk factors identified were low socioeconomic status, low education in both partners, and unplanned pregnancy.

A statistical profile of women in Bangladesh shows that life expectancy is lower for women than for men. The average age at marriage is around 18 years
for women, while it is 25 years for men. The maternal mortality rate was 600 per 100,000 live births. Literacy rates for men and women in 1991 were 45.5% and 24.2%, respectively. Women generally work more hours in a day than men, largely doing unpaid family work. They are largely employed in the agricultural and related industrial sectors and the garment industry. Spousal abuse in Bangladeshi homes was related to issues of dowry, finances, custody of children, and suspected adultery (21).

In explaining the source of their psychosocial health problems, like “thinking too much,” “worrying too much,” tiredness, insomnia, and multiple somatic complaints, participants of a study conducted in Ghana, West Africa, identified a number of primary contributing factors: gender division of labor, heavy workloads, the “compulsory” nature of their work, financial insecurity, and the considerable financial responsibility they assumed for their children (9). It is significant that reproductive health problems did not figure prominently among the problems outlined by the women. The authors of the study underscore two important facts. One is that the psychosocial symptoms described do not find place in the discussions of the burden of disease in the developing world. This is because the women themselves are not involved in health-care decisions relevant to them. The second fact is that women in developing countries have too long been defined as childbearers, and their role as workers and the stresses related to the nature and proportion of work have been neglected. Studies of women in developing countries have shown that a higher risk for depression is partly accounted for by negative attitudes toward women, lack of acknowledgment of their work, fewer opportunities for them in education and employment, and a greater risk of domestic violence (22). However Gulcar (17) suggests that disparities between developed and developing nations are not acute. She draws in on the findings of WHO’s Global Burden of Disease and states that, for women of reproductive age, of the 10 leading causes of disease burden, depression has currently become the major leading cause in both developing and industrialized regions.

A country’s social and political climate also determines the stresses and the discrimination to which women are subjected. Gender apartheid was practiced in Afghanistan from 1996, during the Taliban regime. Gender apartheid refers to the gender-based segregation policies that severely restricted women’s ability to function in society. Women were not allowed to work outside the home, except to a limited capacity in health care. Education was denied to them. Their mobility was severely restricted; they could travel only when accompanied by a male relative. This resulted in very restricted access to health and other essential services (23). It is little wonder that a survey by the Physicians for Human Rights showed a marked decrease in mental health of Afghanistani women under Taliban rule. Almost all Afghanistani women studied (97%) were diagnosed with depression, and 42% were diagnosed with post-traumatic stress disorder. This can well be attributed to the then ongoing war as well as the deteriorating conditions for women in Afghanistan (24). Worldwide, it is estimated that 80% of the 50 million people affected by war are women and children (25). In a large-scale survey (26) of the Sri Lankan Tamil community in Toronto, members of which had experienced a decades-long war and ethnic conflict in their home country, it was found that one third of the respondents reported traumatic events such as witnessing combat or experiencing physical assault or rape. Rates were higher for women (36.8%) than for men (30.7%).

Collectivistic or primarily non-Western cultures require a high level of relatedness and moderate levels of autonomy to maintain mental health (27). Many developing nations have collectivistic cultures, which have greater connectedness than Western cultures and extensive social networks. Hence in social contexts where there is a moderate level of autonomy, a woman’s degree of social and emotional connectedness, by virtue of her gender role as a caregiver, mother, and nurturer might actually enhance her mental well-being. In a study comparing the prevalence of alexithymia in rural India among women with functional somatic symptoms and those without, women without functional somatic symptoms showed coping such as talking to family members and seeking help and emotional support (28). However when the cultural context in developing countries or within communities stresses the caregiving and the homemaker roles while devaluing the contributions of women and disempowering them, then this is a ready formula for mental health problems.

Murthy (29) states that mental health programs in developing countries should be implemented in ways that strengthen the positive aspects of rural life, which generally symbolize a collectivistic culture. The availability of community support for patients, increased cohesion in patients’ families, and simple ways of life that more easily accommodate a patient’s rehabilitation and community reintegration are the strong points of a rural culture. Developing countries may present avenues for prevention of mental disorders because their traditional lifestyles often emphasize the importance of social supports in crisis (30). Research has shown better prognoses for people with psychiatric disabilities in developing nations than in Western countries. The emphasis on interdependence, the externalized locus of control, and family involvement are significant factors in caring for people with psychiatric disabilities (31). However, further research is needed to assess whether this cultural advantage is retained for women in particular when there is a shift from women as caregivers to women as care recipients when facing a mental health challenge.