This review found gender disparities in mental health burden and access in Bangladesh. Women have higher rates of common disorders (Mental-Health-Survey-Report.Pdf, n.d.), but are half as likely to seek help as men (Azdi, 2023, Koly et al., 2022)), facing barriers due to stigma (Giasuddin et al., 2012). This aligns with previous research of worldwide that demonstrating women globally tend to have higher rates of common mental disorders like depression and anxiety, often related to factors like gender discrimination, violence, and poverty (Afifi, 2007; Prowse et al., 2021; Walton et al., 2021).Moreover, our findings show stigma surrounding mental illness persists, especially for women, preventing many from seeking help (Giasuddin et al., 2012). Evidence suggests from one study that female patients prefer same-sex providers when discussing sensitive issues like depression, trauma, or abuse (Fink et al., 2020). But the number of trained, culturally competent female mental health professionals is severely lacking in Bangladesh's healthcare system (Hossain et al., 2014). We delve further into the possible causes of women's increased exposure to mental health in light of this perilous circumstance, which was not explored specifically in other researches.
4.1. Vulnerability
Women in Bangladesh are twice as likely as men to experience common mental health issues in terms of depression and anxiety (Saiful Islam, 2020). We can see clear evidence from the National Mental Health Survey 2019 that men suffer from anxiety (4%) and women suffer (5.4%); in terms of depression, men suffer (5.4%); women suffer (7.9%); in terms of any mental health disorder, men suffer (15.7%); and women suffer (21.5%) (Mental-Health-Survey-Report.Pdf, n.d.). We can observe the reasons behind the vulnerability of women through a study (Koly et al., 2022) conducted in Bangladesh focused on the analysis of social media platform. It is seen that women cited as reasons for their mental health issues a lack of physical intimacy in their relationships, abnormal sexual fantasies, pornography addiction, and infidelity by their male partners. They also cited that their anxiety over children's health and education had a negative impact on their mental health. The unsupportive attitude of in-laws toward career choices or participation in household duties frequently disturbs women's marital harmony. A few women also addressed psychological symptoms because of social judgment. People in society are too concerned about their marriage, attire, career, pregnancy, etc. Some women said family members advised them not to discuss their emotional issues with outsiders out of fear of social judgment.
4.1.1 Violence
Violence is also another cause that affects women's mental health. Research says approximately 60% of Bangladeshi women who have ever been married have experienced sexual and physical intimate partner violence (Naved et al., 2009). Domestic violence, dowry-related acid attacks, rape, forced abortion, prostitution, and trafficking are prevalent forms of gender-based violence, with victims frequently suffering from severe psychological and psychosomatic symptoms (Sumon, 2013). During the 2020 COVID-19 period, the Daily Kaler Kantho reported, according to the Bangladesh Women's Council, that approximately 3,440 women and children were raped and tortured. Even during the government lockdown, approximately 11,025 women were victims of domestic violence, including 4,947 women who were subjected to psychological abuse and 3,550 women who were abused because of financial matters (Nabila Ashraf et al., 2021). Bangladeshi women experience a greater proportion of psychiatric disorders as a result of this severe abuse.
4.1.2 Perinatal mental health
A plethora of myths, stigmas, and social barriers, combined with husbands' lack of awareness of women's emotional needs during and after pregnancy and financial dependence on husbands, make women's perinatal lives agonizing. A study found that 14% of women with depression admitted to having suicidal thoughts during their current pregnancy (Gausia et al., 2009) and did not seek mental health care after suffering depression (Adams et al., 2013). Frequently, husbands believe that their only obligation is to provide financial support, and women fear violence not only from them but also from in-laws, thereby creating an abusive family environment for postpartum mothers (Edhborg et al., 2015). Many believed, including women, that mental illness during pregnancy was the result of possession by God or the devil, sin, black magic, or witchcraft, as well as pressure from the husband and in-laws for a son, based on the myth that female children are not valuable for a family or can’t take responsibility in the future. Women also think that the health of their infant is more important than their own (Insan et al., 2022). Furthermore, they think sharing and counseling mental health issues with family is pointless or difficult because of the resulting quarrels and judgment from others (Fahmida et al., 2009).
4.1.3 Abortion
A study by the Bangladesh Medical College looked at 240 women who had an unplanned abortion between July 2020 and December 2021. The majority of the 240 women, approximately 77.5%, reported depressive symptoms, and more than half, 58.75%, reported anxiety within one and a half years of spontaneous abortion (Depression, Anxiety Prevalent in Women with History of Abortion Living in Bangladesh’s Urban Slums, 2023a)
4.2. Affordability
4.2.1 Income Disparities
If we explore the present situation in Bangladesh indicates that nationwide, women’s wages are much lower than men’s wages for all kinds of labor where the low level of education and skill of female workers, longer working hours, etc. are the main factors contributing to this gender-differentiated income (Rahman, 2014). Further, the RMG sector that most Bangladeshi women work in is monotonous, high-paced, physically draining, and mentally exhausting (Apparel Workers’ Mental Health, n.d.).
4.2.2 Unemployment and poverty
It is seen that there is a significant employment gap between the sexes in Bangladesh where employment-to-population ratio for men is 79.71%, and for women it is 42.67%; this gap is nearly double. In urban areas, however, this gap is threefold (Bangladesh Quarterly Labour Force Survey 2022, 2023). Hence, a large number of females are unemployed; moreover, rural women are more dependent on natural resources for their subsistence and income, also bear the disproportionate burden of unpaid care work and are more likely to live in poverty than men, which makes them more vulnerable (Climate Change and Mental Health Risks in Bangladesh, 2021). Furthermore, it is a major factor motivating female migrant workers to leave rural areas than men due to the loss of livelihoods, food insecurity, and lack of adaptation options in their villages. However, their children remain in their village with their grandparents due to the working conditions of their mothers and the lack of available child care. Due to the double burden of work and separation from their children and family support, the women reported feelings of anxiety, restlessness, and suicidal ideation (Alam et al., 2021).
4.3. Mental health literacy and stigma
A study has shown that women report more stigma related mental health than men in Bangladesh (Faruk & Rosenbaum, 2023). Women with mental health conditions, in particular, do not know when and where to obtain mental healthcare which proved the vulnerability of women (Raising Awareness for Women’s Mental Health via Facebook, n.d.).
A summarized view of the differences in common mental health problems and inequities in access, highlighting the key points, is presented in the table-3.
Table-3 Summary of Included Studies
Study
|
Study Design
|
Sample
|
Key Results
|
Firoz et al., 2006
|
Epidemiological study
|
Respondents aged 18 and above (n=13080)
|
Higher prevalence of psychiatric disorders among females in rural and urban areas of Bangladesh compared to males.
|
Islam, 2015
|
Review
|
Papers included (n=24)
|
Elevated prevalence of psychiatric disorders observed among females in Bangladesh, irrespective of social status, compared to males.
|
Karim et al., 2006
|
Cross-sectional study
|
Adult respondents (n=327)
|
In Bangladesh, women are more likely than men to suffer from mental illnesses in all social classes.
|
Ahmed et al. 2022
|
Online survey
|
Bangladeshi adults during COVID-19 (n=500)
|
Women reported higher rates of anxiety/depression symptoms than men
|
Anjum et al. 2019
|
Cross-sectional pilot study
|
High school students in Bangladesh (n=311)
|
Higher rates of depressive symptoms among female students
|
Khan et al., 2020
|
Cross-sectional study
|
Students from secondary schools (n=755)
|
Adolescent girls in semi-urban schools in Bangladesh demonstrated higher prevalence of depressive symptoms compared to boys.
|
Baxter et al., 2014
|
Systematic Review
|
Prevalence studies for anxiety disorders (n=91) and studies for MDD (n=16)
|
Global data indicate a 1.7-fold higher depression prevalence among women compared to men. The prevalence rate of depression among women is 5.5%, and among men it is 3.2%.
|
Hasan et al., 2021
|
Review
|
Not applicable
|
Depression prevalence is higher among women globally and in Bangladesh compared to men.
|
Baxter et al., 2013
|
Systematic Review
|
Prevalence studies of anxiety disorders published between 1980 and 2009 (n=87)
|
Global data indicate a higher than double anxiety prevalence among women compared to men. The prevalence rate of anxiety among women is 7%, and among men it is 3%.
|
McLean et al., 2011
|
Epidemiological study
|
A large sample of adults (N = 20,013)
|
Global data showing higher anxiety prevalence among women compared to men.
|
Muzaffar et al., 2022
|
Cross-sectional study
|
Current students of two universities in Bangladesh (n=605)
|
Anxiety prevalence in Bangladesh indicates gender disparities in mental health, with marginal elevation among women compared to global trends.
|
(Men and Women, n.d.)
|
Report
|
Not applicable
|
Overall mental disorders are higher among women (20%) compared to men (12.5%)
|
National Mental Health Survey 2019 (*Mental-Health-Survey-Report.pdf*, n.d.)
|
Cross-sectional survey
|
Nationally representative sample of adults in Bangladesh (n=7270)
|
Higher rates of common mental disorders among women vs men. The prevalence of depression is higher among women (8%) compared to men (5.4%), and the prevalence of anxiety is higher among women (5.4%) compared to men (4%). Overall mental disorders are higher among women (21.5%) compared to men (15.7%).
|
(NIMH » Mental Illness, n.d.
|
Report
|
Not applicable
|
Mental illness prevalence is higher among women in the United States.
|
Giasuddin et al. 2012
|
Qualitative study
|
New patients at the Psychiatry outpatient department of a tertiary hospital (n=50)
|
Women half as likely as men to seek mental health treatment
|
WHO Special Initiative for Mental Health, n.d.
|
Report
|
Not applicable
|
Global initiatives for mental health may inform policies and interventions in Bangladesh.
|
Nuri et al. 2019
|
Cross-sectional study
|
Secondary data was collected from various hospital records
|
Gender disparity in inpatient mental healthcare utilization
|
Nimh-Fact-Sheet-5-11-19.Pdf, n.d.
|
Report
|
Not applicable
|
Only a small percentage of mentally affected women in Bangladesh seek treatment.
|
Akhter et al. 2017
|
Qualitative study
|
Female garment workers(n=20) and supervisors (n=14) in Dhaka
|
Long work hours and inadequate workplace healthcare limit women factory workers' access to services
|
Hosman et al., 2004
|
Summary report
|
Not applicable
|
A significant portion of the Bangladeshi population suffers from various mental disorders, highlighting the need for mental healthcare services.
|
Choudhury et al., 2006
|
Epidemiological study
|
Not applicable
|
Limited availability of specialized mental health care facilities in Bangladesh.
|
(Mental Health Continues to Remain Ignored, n.d.).
|
Report
|
Not applicable
|
Systemic issues, including limited resources and service inequities, hinder mental healthcare in Bangladesh.
|
Hossain et al., 2014
|
Systematic review
|
Papers included (n=32)
|
Barriers to accessing mental healthcare exist for working women in Bangladesh.
|
Mohatt et al., 2021
|
Systematic review
|
Papers included (n=34)
|
Rural women in Bangladesh face mental health stigma and cultural barriers to seeking services.
|
4.4. Policy & recommendations
The Government of Bangladesh has enacted a new law known as the Mental Health Act, 2018 has superseded the 1912 law known as the Lunacy Act, to protect people from these types of agonizing situations and provide protections for all citizens. Nonetheless, the policies have not yet been implemented (Mental Health Continues to Remain Ignored, n.d.). Changes in policy have not been reflected in the allocation of resources for mental health prevention and treatment. Subsequently, the legislation does not include any provisions on inequity or women's mental health.
Overall, the findings highlight the need for multi-level interventions to promote mental health equity and access for women in Bangladesh. First and foremost, systemic changes are needed to challenge restrictive gender norms and discrimination against women (Tedstone Doherty & Kartalova-O’Doherty, 2010). Prior research has shown that mental health outcomes may be improved by reducing income inequality (Bechtel et al., 2012). To ensure financial stability, microfinance programs, which provide low-resource individuals with small loans to launch or expand a business, have been found to improve women's mental health and financial standing (Collier et al., 2020). Secondly, integrating mental health services into existing primary care and recruiting more female providers can also help improve the availability and acceptability of treatment for women. Further, mass media can enhance public awareness of mental health by improving understanding and changing health-related behaviors, which will definitely reduce shame and stigma by focusing on gender and cultural settings. Examples include Meena, an animated television series in Bangladesh that increased educational inclusion for girls in hard-to-reach rural areas and lowered discrimination (Hasan & Thornicroft, 2018). As well, digital mental health interventions (DMHIs), a web- and mobile-application-based approach, have to be used to support patients and clinicians remotely, increasing access to mental health care and addressing inequities in rural communities (Graham et al., 2021). This strategy has not yet been applied to the prevention of mental disorders. Reducing gender disparities and inequities in mental health access should be an urgent public health priority for improving population mental health in Bangladesh.
4.5. Limitations
Limitations could arise due to the lack of real-time, firsthand data. Relying on existing literature and published reports might overlook recent developments or emerging trends in the field. Additionally, the absence of direct interaction with participants and the inability to clarify or probe for deeper insights could restrict the depth and nuance of the findings presented in the review. Furthermore, the absence of data prevented this paper from contrasting rural and urban scenarios, which would have enhanced its quality. In order to elucidate the broader context of Bangladesh, this may constitute the substantial evidence that requires additional scrutiny. Gender based differences in other mental health diseases, such as bipolar disorder and schizophrenia, have been identified through further research. Due to lack of data it was not possible to explore. Additionally, disparities among ethnic and minority groups may exist; additional research is required to investigate this.