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Women, poverty and common mental disorders in four restructuring societies
Social Science & Medicine 49 (1999) 1461±1471
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Women, poverty and common mental disorders in four restructuring societies Vikram Patel a, b,*, Ricardo Araya c, Mauricio de Lima d, Ana Ludermir e, Charles Todd f Sangath Centre, 841/1 Alto Porvorim, Goa 403521, India b Institute of Psychiatry, London, UK c University of Santiago, Santiago, Chile d Universidade Federal de Pelotas, Pelotas, RS-Brazil e Secretaria Estadual de Saude de Pernambuco, Brazil f University of Zimbabwe Medical School, Harare, Zimbabwe a
Abstract Background: Poverty and female gender have been found to be associated with depression and anxiety in developed countries. The rationale behind this paper was to bring together ®ve epidemiological data sets from four low to middle income countries to examine whether key economic and development indicators such as income and poor education, and female gender, were associated with common mental disorders. Method: The paper is based on ®ve datasets: three based on primary care attenders in Goa, India; Harare, Zimbabwe and Santiago, Chile; and two based on community samples in Pelotas, Brazil and Olinda, Brazil. All ®ve studies estimated prevalence of common mental disorders along with variables to measure economic deprivation and education. Findings: In all ®ve studies, female gender, low education and poverty were strongly associated with common mental disorders. When income was divided into tertiles, with the lowest tertile as a reference value, there was a signi®cant trend for reduced morbidity for the lower two tertiles. Discussion: These ®ndings have considerable implications since the rapid economic changes in all four societies have been associated with rising income disparity and economic inequality. Examples of population based prevention strategies based on increasing the proportion of those who complete schooling and on high-risk strategies such as providing loan facilities to the impoverished are potential outcomes of these ®ndings. Development agencies who focus on women as a priority group have failed to recognize their unique vulnerability to common mental disorders and need to reorient their priorities accordingly. 1999 Published by Elsevier Science Ltd. All rights reserved.
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Keywords: Mental health; Women; Poverty; Cross-cultural; India; Zimbabwe; Chile; Brazil
Introduction * Corresponding author. Fax: +91-832-415-244. E-mail address: [email protected] (V. Patel) 0277-9536/99/$ - see front matter PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 2 0 8 - 7
Common mental disorders (CMD) was a term coined by Goldberg and Huxley (1992, pp. 7±8) to
# 1999 Published by Elsevier Science Ltd. All rights reserved.
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471
1462 Table 1 Methodology of studiesa Setting Investigator Population Design Sample Sampling Case criteria
Olinda AL community survey 621 random SRQ
Pelotas ML community survey 1277 multistage random SRQ
Harare VP,CT PHC case-control 199 cases,197 controls systematic SSQ
Goa VP PHC survey 303 random CISR
Santiago RA PHC survey 4200 systematic GHQ/CISR
a
GHQ=General Health Questionnaire (Goldberg, 1978); SRQ=Self Reporting Questionnaire (Harding et al., 1980); SSQ=Shona Symptom Questionnaire (Patel et al., 1997a); CISR=Revised Clinical Interview Schedule (Lewis et al., 1992).
describe ``disorders which are commonly encountered in community settings, and whose occurrence signals a breakdown in normal functioning''. CMD, also referred to as non-psychotic mental disorders or neurotic disorders, manifest with a mixture of somatic, anxiety and depressive symptoms. CMD are the third most frequent causes of morbidity in adults (prevalence rates) worldwide (World Health Organization, 1995). They are an important cause of disability and pose a signi®cant public health problem (Ormel et al., 1994). The recent WHO report ``Investing in Health Research and Development'' predicts that depression will be the single most important cause of disability by the year 2020 in the developing world (World Health Organization, 1995). The warning of a mounting crisis of unmet needs for the countless millions with such disorders have been building up over the past 20 years. Evidence of a high prevalence of CMD has been generated from a range of settings in low and middle income countries such as rural Lesotho, primary health clinics in Santiago and the urban general practices of India (Shamasundar et al., 1986; Holli®eld et al., 1990; Araya et al., 1994). These studies reveal prevalence ®gures of CMD exceeding 30% in community samples and approaching 50% in primary care samples. The WHO Multinational study of the prevalence, nature and determinants of CMD in general medical care settings was conducted in 14 countries (Ustun et al., 1995b). The startling ®nding of this study was that, despite the use of standardized methods in all centres, there were enormous variations in most variables. Indeed, the only similarities across centres were the general observations of the ubiquity of CMD, the comorbidity of anxiety and depression, and the association of CMD and disability even after adjustment for physical disease severity. On the other hand, speci®c variables showed substantial variations; thus the prevalence rates of CMD ranged from 7 to 52% of primary care attenders; physician recognition of CMD varied from 5% to nearly 60% and the association of key variables such as gender, physical ill-health and education with CMD were in opposite directions in dierent centres. These ®ndings demonstrate the need for
locally relevant studies with locally validated methodologies whose aim is to identify local needs and inform local health services (Patel and Winston, 1994). Female gender, social, economic and interpersonal factors remain the most consistently demonstrated risk factors for CMD in industrialised societies. There is growing evidence of an association between socioeconomic deprivation as represented by unemployment (Warr, 1987; Bartley, 1994; Gunnell et al., 1995), low income (Eaton and Ritter, 1988; Power et al., 1991) and lower social class (Brown and Harris, 1978; Meltzer et al., 1995), with suicide rates (Platt and Kreitman, 1990) and psychological disorder. There is consistent evidence of an association between economic deprivation as measured by social class, income and employment, in developed countries and CMD (e.g. Bartley, 1994). A recent household survey from the United Kingdom demonstrated a strong association between CMD and low household income and not saving from income (Weich et al., 1997). Similarly, many studies from these settings have demonstrated a greater risk for women to suer CMD (Jenkins, 1985). Most epidemiological studies of CMD in low-income countries have concentrated on prevalence rate estimations, rarely examining the role of risk factors. The aim of this paper is to bring together data collected by the authors in ®ve separate studies conducted in four low and middle income countries in dierent stages of economic development to examine two hypotheses: ®rst, that female gender is associated with CMD and, second, that poverty is associated with CMD. The rationale for these hypotheses was that these risk factors had been demonstrated in some studies from industrialised societies. If similar associations were demonstrated in low and middle income countries, the implications would be of great importance since they would re¯ect not only the universal nature of these risk factors, but also have a bearing on the impact of the dramatic economic changes in these countries on the increased morbidity of CMD. These studies were conducted by the authors in their own countries, using methodologies that were sensitive and valid for the local setting. Thus, this paper is not based on a multi-
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471 national study in the traditional sense of having its emphasis on uniformity. Instead, this is a model of what the authors propose as locally sensitive research whose ®ndings can be collated to examine themes arising out of diverse cultural settings.
Method The overall methodology of the 5 studies is summarised in Table 1. Brief information on key aspects of the methodology are described below. Details for each study can be obtained from the original publication describing the studies as referenced.
Harare, Zimbabwe (Patel et al., 1997b) Harare is the administrative and ®nancial capital of Zimbabwe. The study was set in primary care in two high-density suburbs of the city. The high-density suburbs are the poorer, more crowded areas of Harare; they were, during the colonial era, assigned for the African population of the city. The study design was a case-control investigation of the risk factors of CMD. The primary care sites were 2 Primary Health Clinics (PHC), 4 GP surgeries and 14 Traditional Medical Practitioners (TMP) in these suburbs. Recruitment was by systematic sampling at GP and PHC while all eligible TMP attenders were recruited. The measure of CMD was the Shona Symptom Questionnaire, an indigenously developed instrument for the measurement and detection of CMD in primary care attenders with an established validity and reliability (Patel et al., 1997a). 199 cases and 197 non-cases of CMD were recruited from the 3 care provider sites.
Goa, India (Patel et al., 1998) Goa is the smallest state of India. 40% of its population is urbanized. Its main economy is based on mining, agriculture, ®shery and tourism. Patients were recruited from 2 Primary Health Clinics, one in a rural and one in an periurban district of Goa. The study design was a cross-sectional survey. PHC attenders were recruited by random sampling of consecutive attenders (n = 302). The measure of CMD was the Konkani version of the Revised Clinical Interview Schedule (CISR) (Lewis et al., 1992), a structured interview for the measurement and diagnoses of CMD in primary care and community settings.
Olinda, Brazil (Ludermir, 1998) Olinda is part of the Recife Metropolitan Area in the state of Pernambuco in north-east Brazil. Leisure, tourism, commercial sales and services represent the
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main economic activities. More than a third of the population live in shanty towns. Subjects were recruited from a community survey in Olinda, which is a high-density urban population area. A sample of 621 adults were recruited by random sampling of all enumerated households. The measure of CMD was the Portuguese version of the 20 item Self-Reporting Questionnaire (SRQ) which is one of the most widely used screening measures for identi®cation of CMD in developing countries (Harding et al., 1980).
Pelotas, Brazil (Lima et al., 1996) Pelotas is a city located in the extreme south of Brazil, near the Uruguayan border. It is the commercial and services centre of an active agricultural, subtropical area. The local economy is based on agriculture (mainly rice, soybeans and cattle) and on the food industry, this being one of the most developed areas of Brazil. Although most of the urban population is middle class, there are a few shanty towns located near to the central urban area. The study setting was 30 randomly selected census tracts (out of 259 tracts comprising approximately 300 households each) in the central urban area. Using multi-stage sampling, a total of 1277 adults from 600 households were recruited. The measure of CMD was, as with the Olinda study, the Portuguese version of the SRQ.
Santiago, Chile (Araya, 1994; Araya et al., 1994) Santiago is the administrative and commercial capital of Chile. Chile has been undergoing dramatic socioeconomic changes in the past 5 years as a result of a sustained economic growth. The study setting was Primary Health Clinics in high-density suburbs (i.e. poorer areas) of Santiago. The study design was a cross-sectional survey of adult attenders in 24 PHC. A sample of 4200 subjects was recruited by systematic sampling. The measures of CMD were the Spanish versions of the 12 item General Health Questionnaire (Goldberg, 1978) and the Revised Clinical Interview Schedule in a two-stage case identi®cation method.
Indicators of poverty Emphasis was placed on using indicators that had been found to be sensitive and valid for the local setting. In four studies, income was considered the most reliable indicator of economic status. However, the type of income measured varied. Thus, in the Brazilian and Chilean studies, household income data were collected because investigators were con®dent of eliciting accurate data from the index respondent and, in the case of the Brazilian studies, the community setting of the studies. Thus, in both studies, interviews took
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Table 2 Sociodemographic characteristics and prevalence of CMD of study populationsa Setting Female % Age (mean years) Education: % not completed secondary school Prevalence of CMD (%) a
Goa 69 44.6 (S.D. 14.3) 78 46
Olinda 57 36.1 (S.D. 16.0) 56 35
Pelotas 55.5 41.4 (S.D. 18) 58 23
Santiago 69.5 37.5 (S.D. 14.5) 58 52
Harare data is not applicable for this table due to the case-control design.
place at home. In Harare, household data was considered unreliable because of the variable de®nitions of a household in the high-density suburbs. Thus, households could consist of unrelated persons living in the same home (who would not share information on their income), persons who had informal occupations and undisclosed incomes, partners/spouses who had families and children in other homes as well and so on. Thus, personal income of the index patient was used as the indicator of poverty. Other indicators of poverty in Harare were indebtedness, hunger in the previous month due to lack of money to buy food, and having cash savings. In Goa, however, income, was considered unreliable since the majority of PHC attenders were women who were often not directly involved in income generation; thus, their responses to a question on income may not re¯ect the real economic situation of the household. Many households involved more than one earning member and accurate estimates of household income were not possible on the basis of interviewing the index patient. Finally, much income in India is `undeclared' and there is discomfort in sharing sensitive information on income with researchers. Instead, economic indicators were discussed amongst the research team and two indicators were chosen: whether the subject was in debt and whether the subject had been unable to buy food due to lack of money in the previous month. The same two `proxy' indicators were also used in the Harare study.
tinuous in some studies and categorical in others. Ttests were used for comparisons of continuous data. All signi®cance tests are two-tailed.
Results Sociodemographic data and prevalence of CMD These are summarised in Table 2.
Association of socio-demographic variables with CMD Tables 3 and 4 show that there is a consistent association between CMD and female gender, older age and lower education. While there is a trend for those who were previously married (i.e. widowed, separated/ divorced) and those who were unemployed, this was not consistent after adjustment for age and sex.
Association of economic indicators with CMD For the four studies where income data was elicited, the samples were categorized on the basis of income tertiles (Tables 5 and 6). Using the lowest income tertile as a reference value, there were signi®cant trends for lower morbidity as income levels were higher. In the two studies in which proxy variables were used to measure poverty, strong associations were found between morbidity and economic problems.
Analysis First, each investigator examined the associations of gender, age and educational status with CMD. Next, each investigator identi®ed indicators of economic deprivation from their study data and analysed their association with CMD. Income data were grouped into tertiles and the odds ratios for CMD were computed using the highest tertile as the reference value. Statistical strength of associations was examined using odds ratios (adjusted for age and sex) and Chi-square test for trends. Data collection was not standardised since the studies were conducted at dierent times; thus, some data such as years of education were con-
Discussion The aim of this paper was to collate data from 5 data-sets elicited in 4 countries which are currently in the midst of radical economic reforms, to examine the associations between female gender and economic indicators with common mental disorders. In contrast to the stress laid on uniformity in multi-national study designs, all 5 studies collated in this paper were conducted independently. All the authors of the studies described in this paper were resident in the areas of their study and this paper is a post-hoc analysis of
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471
1465
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their datasets. Thus, there is no standardisation of the criteria of psychiatric caseness or for the choice of measure of economic deprivation. While this may be argued to be a limitation of this paper, the authors are of the view that in this diversity of methodologies lies the strength and unique nature of the collation of data presented in this paper. Thus, each study employed variables, instruments and case criteria which were sensitive and valid for the local culture; yet, the data yielded, though not identical, were comparable and, as this paper shows, can be used to derive themes and associations across the study settings. Thus, this paper is evidence that in order to achieve cross-cultural comparability in multinational studies of mental illness, it is not necessary to use the same instruments or measures in all settings. What is crucial is that the method used is valid for the local setting. Another potential limitation is the lack of data on individual sub-categories of CMD such as depression, anxiety and so on. Although a categorical classi®cation of CMD has been devised for use in primary health care (Ustun et al., 1995a), there is substantial evidence that in community and primary care settings, a dimensional approach to morbidity is more valid. This discrepancy is accounted for by the fact that classi®cations have tended to re¯ect the results of psychiatric assessments at tertiary care level. In most primary care patients, symptoms of anxiety and depression co-exist to such an extent that their categorisation in either group is dicult. For example, the WHO multinational study of CMD found that for all speci®c psychiatric disorders (excluding alcohol dependence), comorbidity rates (with other psychiatric disorders) exceeded 50% (Ustun et al., 1995b). This suggests that one of the basic criteria of a successful classi®cation, i.e. the mutual exclusiveness of dierent categories, was not achieved. Indeed, Goldberg and Huxley (1992) state that ``it is becoming clear that the idea that CMD should be thought of as discrete disease entities with distinct causes, course and treatment is probably untenable''. This problem of validity is arguably even greater in cultures dierent from those which dominate the ICD10 classi®cation; for example, there is evidence that sub-categories of CMD lack conceptual validity in many African settings and that even their categorisation as a psychiatric disorder may be partly to blame for the low recognition rates in primary care (Patel, 1996). The data presented in this paper provide compelling evidence of an association between CMD and female gender, older age, low education and economic deprivation. While it may be possible that these associations were not representative of the community in the studies in primary health care settings, the associations were also demonstrated in both of the community based studies.
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471
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Table 4 Association of gender, age and education with common mental disorders: continuous variables (the ®gures quoted are for CMD subjects versus those without CMD) Age (mean, S.D.; t-test, p ) Harare Goa Olinda Pelotas Santiago
34.5 46.8 39.5 44.1 38.7
(12.8) (12.3) (16.4) (18.8) (14.1)
versus versus versus versus versus
31.8 42.6 34.2 40.4 36.2
(11.5), (15.5), (15.5), (17.6), (14.8),
Years of education (mean, S.D.; t-test, p )
t = 2.2, p = 0.02 t = 2.5; p = 0.01 t = 4; <0.0001 t= 2.9 ; p = 0.004 t = 5.4; <0.0001
7.8 (3.5) versus 9 (3.3), t = 3.4, p < 0.001 categorical (see above) categorical (see above) 5.1 (3.8) versus 7.3 (4.5), t = 8.4; <0.0001 categorical (see above)
Table 5 Association of indicators of poverty with common mental disorders: association between income (categorized in tertiles) and CMDa Harare Olinda Pelotas Santiago (income: personal) (income: household per capita) (income: household per capita) (income: household total) Tertile1 1 Tertile2 0.59 (0.3, 1.1) Tertile3 0.46 (0.2, 0.9) Chi square test for trend 5.6, p = 0.05
1 0.66 (0.4, 1.1) 0.47 (0.3, 0.8) 11.4, p = 0.003
1 0.75 (0.5, 1) 0.54 (0.4, 0.8) 15.8, p < 0.001
1 0.7 (0.6, 0.9) 0.5 (0.4, 0.7) 60.2, p < 0.001
a All odds ratios adjusted for age and sex with 95% con®dence intervals. Tertile 1 is the lowest income tertile and is the reference value.
The association of female gender with CMD The ®ndings of the studies in this paper corroborate the ®ndings of several earlier community-based and studies of treatment seekers which demonstrate that women are disproportionately aected by mental health problems (e.g. Orley and Wing, 1979; Desjarlais et al., 1995; Pearson, 1995). Women's mental health cannot be considered in isolation from social, political and economic issues. When women's position in society is examined, it is clear that there are sucient causes in current social arrangements to account for the surfeit of depression and anxiety experienced by women. The multiple roles played by women such as child-bearing and child-rearing, running the family home, caring for sick relatives and, in an increasing
Table 6 Association of indicators of poverty with common mental disorders: associations of proxy indicators of poverty with CMDa
Debt Hunger
Goa
Harare
2.8 (1.7, 4.6) 3.2 (1.9, 5.2)
1.1 (0.7, 1.7) 2.1 (1.3, 3.2)
a All odds ratios adjusted for age and sex with 95% con®dence intervals.
proportion of families, earning income are likely to lead to considerable stress. Diculties for women are encountered in a number of dierent areas such as their social position, aspirations and domestic problems. The reproductive roles of women, such as their expected role of bearing children, the consequences of infertility and the failure to produce a male child and postnatal depression, are examples of mechanisms which make women vulnerable to CMD. Cox studied women attending an antenatal clinic at a health centre in Uganda and found that 30% had psychiatric morbidity in the antenatal period, and among those followed up into puerperium, 10% suffered from postnatal depression (Cox, 1979, 1983). A community study from Zimbabwe showed that 18% of mothers in the eighth month of pregnancy had a signi®cant emotional disorder; 16% had postnatal depression (Nhiwatiwa et al., 1998). A study of mothers living in a squatter settlement in Brazil reported that 36% had emotional problems (Reichenheim and Harpham, 1991). Violence against women is emerging as a pervasive global issue and contributes signi®cantly to preventable morbidity and mortality for women across diverse cultures. Violence has serious psychological and emotional consequences including depression, anxiety, Post Traumatic Stress Disorder (PTSD), dissociation disorders, somatization, sexual dysfunction and self-harm behaviour (Fischbach and Herbert, 1997).
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471 Physical health problems and women's roles as carers can also place considerable burdens on their mental health. For example, in Harare, women had to cope with a high level of death and morbidity related to HIV disease. A recent survey showed that 30% of pregnant women attending antenatal PHC in Harare were HIV-positive (Mbizvo et al., 1996); thus, women have to cope not only with illness in their male partners and children but with their own failing health as well. It is also possible that biological factors may play some role in explaining the female risk for CMD. Gender dynamics and power relations which lead to an unequal status for women in a variety of situations are likely to make their lives more stressful. Indeed, ``it is not surprising that the health of so many women is compromised from time to time. Rather, what is more surprising is that stress related health problems do not aect more women'' (WHO, 1993). In addition to being more likely to suer CMD, the precarious status of women in their husband's family comes to the fore when they suer mental illness (Shiva, 1992; Raghavan et al., 1995). Because of the dierent expectations and evaluations of men's and women's behaviour, mental illness in women attracts a greater amount of shame and dishonour and has a greater impact on family life due to the womans role in running the domestic activities of the household (Skultans, 1991; Malik, 1993). In view of the enormous social, physical and economic stresses facing women, the association of female gender with CMD is, arguably, not surprising. Its implications for health research and development activity are, however, immense. The bulk of health research and development in low-income countries currently focuses on `maternal and child health' or the health of young women. Paradoxically, the approach taken by funding and development agencies is to focus almost entirely on reproductive health, as if this area of health was somehow discrete and separate from psychological health. Indeed, the remarkable paucity of data on postnatal depression and the relationship between reproductive symptoms and infertility with psychosocial health is a marker of the myopic view of health research in low and middle income countries. Thus, it is essential to conduct research on women's health that encompasses the holistic nature of health, viz., incorporating psychological, reproductive and social viewpoints. Examples of potential research themes are: the ethnographic description of the experience of CMD by women and their interpretation of the symptoms and causes; examination of the social and cognitive matrix which underlies the strong association between female gender and CMD; the association of CMD with violence against women, childbearing, infertility, childbirth and reproductive symptoms; the impact of CMD on the daily lives of women and the nature of disability that it imposes; the management of CMD using
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locally available personnel and resources and the development of locally sensitive intervention strategies.
The association of age, low income and education with CMD The ®ve studies show clear associations between low education, low income and older age with CMD. These studies are consistent with ®ndings in other low and middle income countries (e.g. Bahar et al., 1992; Desjarlais et al., 1995; Kishore et al., 1996; Mumford et al., 1997). In public health terms, the most powerful implication of these ®ndings is that low education is a potentially preventable risk factor. It is perhaps important to recognize that the key factor may not be whether 100% of children are in primary school, but rather the proportion of children who fail to complete the minimum years needed to obtain a secondary school certi®cate (10±12 years in most countries). This is a far more signi®cant landmark in society, for without it the number of years of schooling is irrelevant to prospective higher educational institutions or employers. Thus, even though there are impressive gains in increasing school enrollment, there may need to be further emphasis on reducing school drop-out rates; in India and Zimbabwe, for example, less than half the children who are in primary school go on to complete their 10 years of secondary education. In Brazil, only one in seven children completes elementary school. One of the reasons for this high dropout rate is the need to earn money very early in life (Iacoponi et al., 1991). Education re¯ects socioeconomic circumstances of the family at early life (Rutter and Madge, 1976) and is an important cause of perpetuating inequalities in Brazil (Urani, 1995), given its role in sorting individuals into occupations. Education permits greater choices in life decisions and in¯uences aspirations, selfimage (Brown et al., 1986) and opportunities to acquire knowledge, which may motivate attitudes and behaviour toward lifestyle and health status (BMA, 1987). Older age is consistently associated with CMD; this has implications for all 4 societies studied where average life spans are gradually increasing even as birth rates are falling, thus increasing the proportion of the elderly. It is essential for health services to respond to the needs of the older subjects, and for social services to recognise that as rural societies change, the fabric of support for the elderly is also changing. Increasing numbers of elderly persons are living out their twilight years in loneliness as their family structures change. In a similar way, elderly people in many low and middle income countries do not have enough ®nancial support from the government and suer considerable economic diculties. Research on the needs of older women is even rarer in many countries, as if the health of
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women is less relevant once their reproductive years are completed. Low income groups are more vulnerable to suer CMD, irrespective of the overall state of development of the society they live in. Thus, it would appear that it is relative poverty, i.e. low income, which is a risk factor for CMD. This ®nding is consistent with those from developed countries (Weich and Lewis, 1998). This ®nding would predict that even if developing countries reduce the proportion of those who live in absolute poverty, if income inequality grows, the impact on reducing the burden of mental illness may not be as remarkable. If this was the case, then the potential implications for the prevalence of CMD are ominous, since across all four nations included in this paper, there are radical economic structural changes being implemented. Despite raising average income, these changes are also widening socioeconomic inequality, characterized by marked inequalities in the distribution of income and access to education and another basic needs. For example, in Brazil the proportion of the GNP by the poorest 50% of the population dropped from 17.4 to 12.6% from 1960 to 1989, the equivalent ®gures for the richest 10% rose from 39.6 to 51.3% (Pereira, 1988). In Zimbabwe, a 1995 poverty assessment survey found that 45% of households were living below the food poverty line and 61% below the total consumption line (Government of Zimbabwe, 1996). Thus, economic inequality is being enhanced which, in turn, may lead to higher levels of CMD amongst low income groups. In Harare and Goa, local communities had implicated indebtedness as being a consistent source of stress and worry. This was especially so because the poorest who needed loans to cover short-term ®nancial shortfalls were not considered credit-worthy by banks and, in desperation, relied on loan-sharks. The latter charged exorbitant interest rates and it was not uncommon for the children of a family to spend their lives toiling to repay the interest of relatively small loans taken out by their parents. We tested the hypothesis that being in debt was associated with CMD and found this to be the case in both settings. It is clear that here lies another potential preventive strategy in that local banks could step in and review their process of assessing credit-worthiness for persons who belong to the poorest sectors of society. Radical community banks and loan facilities such as those run by 1 The Hindu newspaper of January 1, 1998, reported that the Indian Government had set up a panel to investigate why farmers in Andhra Pradesh tend to commit suicide following the crop failure. The article mentioned that the farmers had to take loans from local money lenders to help their families through the ®nancial crises.
Fig. 1. A model to explain the relationship between poverty and common mental disorders.
SEWA in various parts of India could be involved in setting up such loan facilities in areas where they do not exist. Further evidence of this relationship is fuelled by a recent spate of suicides by farmers in the Indian state of Andhra Pradesh where the seasonal crop failed and farmers were deeply in debt to local money-lenders1. A potential research theme would be evaluating CMD and suicidal behaviour in populations who have access to such facilities and comparing them to populations with similar economic and social circumstances but without loan facility access. What is unclear is the direction of the association between poverty, low education and psychological disorder. As with any cross-sectional study design, the ®ndings of the ®ve studies collated in this paper cannot be used to provide a de®nite indication of causal direction. However, as Wilkinson (1996, pp. 81±82) points out, there are strong arguments against `reverse causality' when considering the relationship between illhealth and income distribution. He states that ``if the arrow of causality pointed in that direction, we would be obliged to say that health is one of the most important determinants of income distribution. Not only
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471 does this run counter to economic theory, but it ¯ies in the face of commonsense notions of the in¯uence on income distribution of employment and unemployment, pro®ts, tax and bene®ts'' Psychologists have conceptualized poverty as a situation with a number of attendant conditions which individually or collectively in¯uence the development of the individual, rendering him or her less capable of overcoming poverty by personal eort (Sinha, 1997). Fig. 1 presents a model which provides a basis for explaining the association and mediating factors between poverty and psychological disorder. It is clear that this is not a unidimensional one-way relationship but is an interactive and complexly dynamic one. Thus, for example, while poor nutrition may be a stressor which triggers depression in a woman already facing other deprivation related problems, depression in turn robs the woman of the necessary coping skills and energy to overcome her problems. Further, the potential stresses imposed by absolute poverty may be considerably dierent from those of relative poverty. It is suggested that the psychological impact of relative poverty is the result of both the indirect (e.g. increased exposure to behavioural risk factors due to psychosocial stress) and direct (e.g. physiological eects of chronic mental and emotional stress) eects of psychosocial circumstances associated with social position. The mechanism involved is one of `cognitive comparison' whereby people are made aware of the vast dierences in socioeconomic status that prevail, and the knowledge of how the richer ``other half live'' aects psychosocial well-being and thus, overall health status (Wilkinson, 1997).
Conclusions The key ®ndings of this paper are that female gender, low income and other measures of poverty, older age and low education are associated with CMD in all ®ve studies from 4 low to middle income countries. The analyses reported in this paper were conducted post-hoc and, in this sense, the ®ndings of this paper may be considered as preliminary, needing replication through prospective studies with the stated aims of examining these associations and controlling for all possible confounders, such as employment status, social class, family size, etc. However, the pervasiveness of the key associations across the study settings, despite the use of varying methodologies and the consistency of this association with developed country studies, lead us to suggest that, even if there are unmeasured confounders, the associations are valid. The vulnerability of women needs to be more widely acknowleged by those who fund and work in the area of women's health so that psychosocial factors are properly evaluated and included in their research and
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service agendas. If the associations of income inequality are replicated, this would be of serious concern to all four study countries where the formula for economic development is leading to a reduction in public health expenditure, a rising inequality between the rich and poor, increased migration to urban areas with its attendant rise in urban squalor and rapid culture change as the great urban centres take on an international cosmopolitan ¯avour. Research which is sensitive to regional factors, such as the ®ve studies reported in this paper, is needed to inform local health planners and policy makers on the potential mental health needs of the community as these economic changes profoundly alter the fabric of their societies.
Acknowledgements The study in Harare was funded by the International Development Research Centre (Canada); in Goa by the Wellcome Trust (UK); in Olinda by FACEPE and CNPq (Brazil); in Santiago by Fondo Nacional de Ciencia y TecnologõÂ a (FONDECYT, Chile) and in Pelotas by CAPES (Ministry of Health, Brazil). All authors are indebted to the numerous individuals and researchers who participated in each of the studies and are acknowledged in detail in the main publications referenced for each study.
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www.elsevier.com/locate/socscimed
Women, poverty and common mental disorders in four restructuring societies Vikram Patel a, b,*, Ricardo Araya c, Mauricio de Lima d, Ana Ludermir e, Charles Todd f Sangath Centre, 841/1 Alto Porvorim, Goa 403521, India b Institute of Psychiatry, London, UK c University of Santiago, Santiago, Chile d Universidade Federal de Pelotas, Pelotas, RS-Brazil e Secretaria Estadual de Saude de Pernambuco, Brazil f University of Zimbabwe Medical School, Harare, Zimbabwe a
Abstract Background: Poverty and female gender have been found to be associated with depression and anxiety in developed countries. The rationale behind this paper was to bring together ®ve epidemiological data sets from four low to middle income countries to examine whether key economic and development indicators such as income and poor education, and female gender, were associated with common mental disorders. Method: The paper is based on ®ve datasets: three based on primary care attenders in Goa, India; Harare, Zimbabwe and Santiago, Chile; and two based on community samples in Pelotas, Brazil and Olinda, Brazil. All ®ve studies estimated prevalence of common mental disorders along with variables to measure economic deprivation and education. Findings: In all ®ve studies, female gender, low education and poverty were strongly associated with common mental disorders. When income was divided into tertiles, with the lowest tertile as a reference value, there was a signi®cant trend for reduced morbidity for the lower two tertiles. Discussion: These ®ndings have considerable implications since the rapid economic changes in all four societies have been associated with rising income disparity and economic inequality. Examples of population based prevention strategies based on increasing the proportion of those who complete schooling and on high-risk strategies such as providing loan facilities to the impoverished are potential outcomes of these ®ndings. Development agencies who focus on women as a priority group have failed to recognize their unique vulnerability to common mental disorders and need to reorient their priorities accordingly. 1999 Published by Elsevier Science Ltd. All rights reserved.
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Keywords: Mental health; Women; Poverty; Cross-cultural; India; Zimbabwe; Chile; Brazil
Introduction * Corresponding author. Fax: +91-832-415-244. E-mail address: [email protected] (V. Patel) 0277-9536/99/$ - see front matter PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 2 0 8 - 7
Common mental disorders (CMD) was a term coined by Goldberg and Huxley (1992, pp. 7±8) to
# 1999 Published by Elsevier Science Ltd. All rights reserved.
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471
1462 Table 1 Methodology of studiesa Setting Investigator Population Design Sample Sampling Case criteria
Olinda AL community survey 621 random SRQ
Pelotas ML community survey 1277 multistage random SRQ
Harare VP,CT PHC case-control 199 cases,197 controls systematic SSQ
Goa VP PHC survey 303 random CISR
Santiago RA PHC survey 4200 systematic GHQ/CISR
a
GHQ=General Health Questionnaire (Goldberg, 1978); SRQ=Self Reporting Questionnaire (Harding et al., 1980); SSQ=Shona Symptom Questionnaire (Patel et al., 1997a); CISR=Revised Clinical Interview Schedule (Lewis et al., 1992).
describe ``disorders which are commonly encountered in community settings, and whose occurrence signals a breakdown in normal functioning''. CMD, also referred to as non-psychotic mental disorders or neurotic disorders, manifest with a mixture of somatic, anxiety and depressive symptoms. CMD are the third most frequent causes of morbidity in adults (prevalence rates) worldwide (World Health Organization, 1995). They are an important cause of disability and pose a signi®cant public health problem (Ormel et al., 1994). The recent WHO report ``Investing in Health Research and Development'' predicts that depression will be the single most important cause of disability by the year 2020 in the developing world (World Health Organization, 1995). The warning of a mounting crisis of unmet needs for the countless millions with such disorders have been building up over the past 20 years. Evidence of a high prevalence of CMD has been generated from a range of settings in low and middle income countries such as rural Lesotho, primary health clinics in Santiago and the urban general practices of India (Shamasundar et al., 1986; Holli®eld et al., 1990; Araya et al., 1994). These studies reveal prevalence ®gures of CMD exceeding 30% in community samples and approaching 50% in primary care samples. The WHO Multinational study of the prevalence, nature and determinants of CMD in general medical care settings was conducted in 14 countries (Ustun et al., 1995b). The startling ®nding of this study was that, despite the use of standardized methods in all centres, there were enormous variations in most variables. Indeed, the only similarities across centres were the general observations of the ubiquity of CMD, the comorbidity of anxiety and depression, and the association of CMD and disability even after adjustment for physical disease severity. On the other hand, speci®c variables showed substantial variations; thus the prevalence rates of CMD ranged from 7 to 52% of primary care attenders; physician recognition of CMD varied from 5% to nearly 60% and the association of key variables such as gender, physical ill-health and education with CMD were in opposite directions in dierent centres. These ®ndings demonstrate the need for
locally relevant studies with locally validated methodologies whose aim is to identify local needs and inform local health services (Patel and Winston, 1994). Female gender, social, economic and interpersonal factors remain the most consistently demonstrated risk factors for CMD in industrialised societies. There is growing evidence of an association between socioeconomic deprivation as represented by unemployment (Warr, 1987; Bartley, 1994; Gunnell et al., 1995), low income (Eaton and Ritter, 1988; Power et al., 1991) and lower social class (Brown and Harris, 1978; Meltzer et al., 1995), with suicide rates (Platt and Kreitman, 1990) and psychological disorder. There is consistent evidence of an association between economic deprivation as measured by social class, income and employment, in developed countries and CMD (e.g. Bartley, 1994). A recent household survey from the United Kingdom demonstrated a strong association between CMD and low household income and not saving from income (Weich et al., 1997). Similarly, many studies from these settings have demonstrated a greater risk for women to suer CMD (Jenkins, 1985). Most epidemiological studies of CMD in low-income countries have concentrated on prevalence rate estimations, rarely examining the role of risk factors. The aim of this paper is to bring together data collected by the authors in ®ve separate studies conducted in four low and middle income countries in dierent stages of economic development to examine two hypotheses: ®rst, that female gender is associated with CMD and, second, that poverty is associated with CMD. The rationale for these hypotheses was that these risk factors had been demonstrated in some studies from industrialised societies. If similar associations were demonstrated in low and middle income countries, the implications would be of great importance since they would re¯ect not only the universal nature of these risk factors, but also have a bearing on the impact of the dramatic economic changes in these countries on the increased morbidity of CMD. These studies were conducted by the authors in their own countries, using methodologies that were sensitive and valid for the local setting. Thus, this paper is not based on a multi-
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471 national study in the traditional sense of having its emphasis on uniformity. Instead, this is a model of what the authors propose as locally sensitive research whose ®ndings can be collated to examine themes arising out of diverse cultural settings.
Method The overall methodology of the 5 studies is summarised in Table 1. Brief information on key aspects of the methodology are described below. Details for each study can be obtained from the original publication describing the studies as referenced.
Harare, Zimbabwe (Patel et al., 1997b) Harare is the administrative and ®nancial capital of Zimbabwe. The study was set in primary care in two high-density suburbs of the city. The high-density suburbs are the poorer, more crowded areas of Harare; they were, during the colonial era, assigned for the African population of the city. The study design was a case-control investigation of the risk factors of CMD. The primary care sites were 2 Primary Health Clinics (PHC), 4 GP surgeries and 14 Traditional Medical Practitioners (TMP) in these suburbs. Recruitment was by systematic sampling at GP and PHC while all eligible TMP attenders were recruited. The measure of CMD was the Shona Symptom Questionnaire, an indigenously developed instrument for the measurement and detection of CMD in primary care attenders with an established validity and reliability (Patel et al., 1997a). 199 cases and 197 non-cases of CMD were recruited from the 3 care provider sites.
Goa, India (Patel et al., 1998) Goa is the smallest state of India. 40% of its population is urbanized. Its main economy is based on mining, agriculture, ®shery and tourism. Patients were recruited from 2 Primary Health Clinics, one in a rural and one in an periurban district of Goa. The study design was a cross-sectional survey. PHC attenders were recruited by random sampling of consecutive attenders (n = 302). The measure of CMD was the Konkani version of the Revised Clinical Interview Schedule (CISR) (Lewis et al., 1992), a structured interview for the measurement and diagnoses of CMD in primary care and community settings.
Olinda, Brazil (Ludermir, 1998) Olinda is part of the Recife Metropolitan Area in the state of Pernambuco in north-east Brazil. Leisure, tourism, commercial sales and services represent the
1463
main economic activities. More than a third of the population live in shanty towns. Subjects were recruited from a community survey in Olinda, which is a high-density urban population area. A sample of 621 adults were recruited by random sampling of all enumerated households. The measure of CMD was the Portuguese version of the 20 item Self-Reporting Questionnaire (SRQ) which is one of the most widely used screening measures for identi®cation of CMD in developing countries (Harding et al., 1980).
Pelotas, Brazil (Lima et al., 1996) Pelotas is a city located in the extreme south of Brazil, near the Uruguayan border. It is the commercial and services centre of an active agricultural, subtropical area. The local economy is based on agriculture (mainly rice, soybeans and cattle) and on the food industry, this being one of the most developed areas of Brazil. Although most of the urban population is middle class, there are a few shanty towns located near to the central urban area. The study setting was 30 randomly selected census tracts (out of 259 tracts comprising approximately 300 households each) in the central urban area. Using multi-stage sampling, a total of 1277 adults from 600 households were recruited. The measure of CMD was, as with the Olinda study, the Portuguese version of the SRQ.
Santiago, Chile (Araya, 1994; Araya et al., 1994) Santiago is the administrative and commercial capital of Chile. Chile has been undergoing dramatic socioeconomic changes in the past 5 years as a result of a sustained economic growth. The study setting was Primary Health Clinics in high-density suburbs (i.e. poorer areas) of Santiago. The study design was a cross-sectional survey of adult attenders in 24 PHC. A sample of 4200 subjects was recruited by systematic sampling. The measures of CMD were the Spanish versions of the 12 item General Health Questionnaire (Goldberg, 1978) and the Revised Clinical Interview Schedule in a two-stage case identi®cation method.
Indicators of poverty Emphasis was placed on using indicators that had been found to be sensitive and valid for the local setting. In four studies, income was considered the most reliable indicator of economic status. However, the type of income measured varied. Thus, in the Brazilian and Chilean studies, household income data were collected because investigators were con®dent of eliciting accurate data from the index respondent and, in the case of the Brazilian studies, the community setting of the studies. Thus, in both studies, interviews took
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V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471
Table 2 Sociodemographic characteristics and prevalence of CMD of study populationsa Setting Female % Age (mean years) Education: % not completed secondary school Prevalence of CMD (%) a
Goa 69 44.6 (S.D. 14.3) 78 46
Olinda 57 36.1 (S.D. 16.0) 56 35
Pelotas 55.5 41.4 (S.D. 18) 58 23
Santiago 69.5 37.5 (S.D. 14.5) 58 52
Harare data is not applicable for this table due to the case-control design.
place at home. In Harare, household data was considered unreliable because of the variable de®nitions of a household in the high-density suburbs. Thus, households could consist of unrelated persons living in the same home (who would not share information on their income), persons who had informal occupations and undisclosed incomes, partners/spouses who had families and children in other homes as well and so on. Thus, personal income of the index patient was used as the indicator of poverty. Other indicators of poverty in Harare were indebtedness, hunger in the previous month due to lack of money to buy food, and having cash savings. In Goa, however, income, was considered unreliable since the majority of PHC attenders were women who were often not directly involved in income generation; thus, their responses to a question on income may not re¯ect the real economic situation of the household. Many households involved more than one earning member and accurate estimates of household income were not possible on the basis of interviewing the index patient. Finally, much income in India is `undeclared' and there is discomfort in sharing sensitive information on income with researchers. Instead, economic indicators were discussed amongst the research team and two indicators were chosen: whether the subject was in debt and whether the subject had been unable to buy food due to lack of money in the previous month. The same two `proxy' indicators were also used in the Harare study.
tinuous in some studies and categorical in others. Ttests were used for comparisons of continuous data. All signi®cance tests are two-tailed.
Results Sociodemographic data and prevalence of CMD These are summarised in Table 2.
Association of socio-demographic variables with CMD Tables 3 and 4 show that there is a consistent association between CMD and female gender, older age and lower education. While there is a trend for those who were previously married (i.e. widowed, separated/ divorced) and those who were unemployed, this was not consistent after adjustment for age and sex.
Association of economic indicators with CMD For the four studies where income data was elicited, the samples were categorized on the basis of income tertiles (Tables 5 and 6). Using the lowest income tertile as a reference value, there were signi®cant trends for lower morbidity as income levels were higher. In the two studies in which proxy variables were used to measure poverty, strong associations were found between morbidity and economic problems.
Analysis First, each investigator examined the associations of gender, age and educational status with CMD. Next, each investigator identi®ed indicators of economic deprivation from their study data and analysed their association with CMD. Income data were grouped into tertiles and the odds ratios for CMD were computed using the highest tertile as the reference value. Statistical strength of associations was examined using odds ratios (adjusted for age and sex) and Chi-square test for trends. Data collection was not standardised since the studies were conducted at dierent times; thus, some data such as years of education were con-
Discussion The aim of this paper was to collate data from 5 data-sets elicited in 4 countries which are currently in the midst of radical economic reforms, to examine the associations between female gender and economic indicators with common mental disorders. In contrast to the stress laid on uniformity in multi-national study designs, all 5 studies collated in this paper were conducted independently. All the authors of the studies described in this paper were resident in the areas of their study and this paper is a post-hoc analysis of
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471
1465
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their datasets. Thus, there is no standardisation of the criteria of psychiatric caseness or for the choice of measure of economic deprivation. While this may be argued to be a limitation of this paper, the authors are of the view that in this diversity of methodologies lies the strength and unique nature of the collation of data presented in this paper. Thus, each study employed variables, instruments and case criteria which were sensitive and valid for the local culture; yet, the data yielded, though not identical, were comparable and, as this paper shows, can be used to derive themes and associations across the study settings. Thus, this paper is evidence that in order to achieve cross-cultural comparability in multinational studies of mental illness, it is not necessary to use the same instruments or measures in all settings. What is crucial is that the method used is valid for the local setting. Another potential limitation is the lack of data on individual sub-categories of CMD such as depression, anxiety and so on. Although a categorical classi®cation of CMD has been devised for use in primary health care (Ustun et al., 1995a), there is substantial evidence that in community and primary care settings, a dimensional approach to morbidity is more valid. This discrepancy is accounted for by the fact that classi®cations have tended to re¯ect the results of psychiatric assessments at tertiary care level. In most primary care patients, symptoms of anxiety and depression co-exist to such an extent that their categorisation in either group is dicult. For example, the WHO multinational study of CMD found that for all speci®c psychiatric disorders (excluding alcohol dependence), comorbidity rates (with other psychiatric disorders) exceeded 50% (Ustun et al., 1995b). This suggests that one of the basic criteria of a successful classi®cation, i.e. the mutual exclusiveness of dierent categories, was not achieved. Indeed, Goldberg and Huxley (1992) state that ``it is becoming clear that the idea that CMD should be thought of as discrete disease entities with distinct causes, course and treatment is probably untenable''. This problem of validity is arguably even greater in cultures dierent from those which dominate the ICD10 classi®cation; for example, there is evidence that sub-categories of CMD lack conceptual validity in many African settings and that even their categorisation as a psychiatric disorder may be partly to blame for the low recognition rates in primary care (Patel, 1996). The data presented in this paper provide compelling evidence of an association between CMD and female gender, older age, low education and economic deprivation. While it may be possible that these associations were not representative of the community in the studies in primary health care settings, the associations were also demonstrated in both of the community based studies.
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471
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Table 4 Association of gender, age and education with common mental disorders: continuous variables (the ®gures quoted are for CMD subjects versus those without CMD) Age (mean, S.D.; t-test, p ) Harare Goa Olinda Pelotas Santiago
34.5 46.8 39.5 44.1 38.7
(12.8) (12.3) (16.4) (18.8) (14.1)
versus versus versus versus versus
31.8 42.6 34.2 40.4 36.2
(11.5), (15.5), (15.5), (17.6), (14.8),
Years of education (mean, S.D.; t-test, p )
t = 2.2, p = 0.02 t = 2.5; p = 0.01 t = 4; <0.0001 t= 2.9 ; p = 0.004 t = 5.4; <0.0001
7.8 (3.5) versus 9 (3.3), t = 3.4, p < 0.001 categorical (see above) categorical (see above) 5.1 (3.8) versus 7.3 (4.5), t = 8.4; <0.0001 categorical (see above)
Table 5 Association of indicators of poverty with common mental disorders: association between income (categorized in tertiles) and CMDa Harare Olinda Pelotas Santiago (income: personal) (income: household per capita) (income: household per capita) (income: household total) Tertile1 1 Tertile2 0.59 (0.3, 1.1) Tertile3 0.46 (0.2, 0.9) Chi square test for trend 5.6, p = 0.05
1 0.66 (0.4, 1.1) 0.47 (0.3, 0.8) 11.4, p = 0.003
1 0.75 (0.5, 1) 0.54 (0.4, 0.8) 15.8, p < 0.001
1 0.7 (0.6, 0.9) 0.5 (0.4, 0.7) 60.2, p < 0.001
a All odds ratios adjusted for age and sex with 95% con®dence intervals. Tertile 1 is the lowest income tertile and is the reference value.
The association of female gender with CMD The ®ndings of the studies in this paper corroborate the ®ndings of several earlier community-based and studies of treatment seekers which demonstrate that women are disproportionately aected by mental health problems (e.g. Orley and Wing, 1979; Desjarlais et al., 1995; Pearson, 1995). Women's mental health cannot be considered in isolation from social, political and economic issues. When women's position in society is examined, it is clear that there are sucient causes in current social arrangements to account for the surfeit of depression and anxiety experienced by women. The multiple roles played by women such as child-bearing and child-rearing, running the family home, caring for sick relatives and, in an increasing
Table 6 Association of indicators of poverty with common mental disorders: associations of proxy indicators of poverty with CMDa
Debt Hunger
Goa
Harare
2.8 (1.7, 4.6) 3.2 (1.9, 5.2)
1.1 (0.7, 1.7) 2.1 (1.3, 3.2)
a All odds ratios adjusted for age and sex with 95% con®dence intervals.
proportion of families, earning income are likely to lead to considerable stress. Diculties for women are encountered in a number of dierent areas such as their social position, aspirations and domestic problems. The reproductive roles of women, such as their expected role of bearing children, the consequences of infertility and the failure to produce a male child and postnatal depression, are examples of mechanisms which make women vulnerable to CMD. Cox studied women attending an antenatal clinic at a health centre in Uganda and found that 30% had psychiatric morbidity in the antenatal period, and among those followed up into puerperium, 10% suffered from postnatal depression (Cox, 1979, 1983). A community study from Zimbabwe showed that 18% of mothers in the eighth month of pregnancy had a signi®cant emotional disorder; 16% had postnatal depression (Nhiwatiwa et al., 1998). A study of mothers living in a squatter settlement in Brazil reported that 36% had emotional problems (Reichenheim and Harpham, 1991). Violence against women is emerging as a pervasive global issue and contributes signi®cantly to preventable morbidity and mortality for women across diverse cultures. Violence has serious psychological and emotional consequences including depression, anxiety, Post Traumatic Stress Disorder (PTSD), dissociation disorders, somatization, sexual dysfunction and self-harm behaviour (Fischbach and Herbert, 1997).
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471 Physical health problems and women's roles as carers can also place considerable burdens on their mental health. For example, in Harare, women had to cope with a high level of death and morbidity related to HIV disease. A recent survey showed that 30% of pregnant women attending antenatal PHC in Harare were HIV-positive (Mbizvo et al., 1996); thus, women have to cope not only with illness in their male partners and children but with their own failing health as well. It is also possible that biological factors may play some role in explaining the female risk for CMD. Gender dynamics and power relations which lead to an unequal status for women in a variety of situations are likely to make their lives more stressful. Indeed, ``it is not surprising that the health of so many women is compromised from time to time. Rather, what is more surprising is that stress related health problems do not aect more women'' (WHO, 1993). In addition to being more likely to suer CMD, the precarious status of women in their husband's family comes to the fore when they suer mental illness (Shiva, 1992; Raghavan et al., 1995). Because of the dierent expectations and evaluations of men's and women's behaviour, mental illness in women attracts a greater amount of shame and dishonour and has a greater impact on family life due to the womans role in running the domestic activities of the household (Skultans, 1991; Malik, 1993). In view of the enormous social, physical and economic stresses facing women, the association of female gender with CMD is, arguably, not surprising. Its implications for health research and development activity are, however, immense. The bulk of health research and development in low-income countries currently focuses on `maternal and child health' or the health of young women. Paradoxically, the approach taken by funding and development agencies is to focus almost entirely on reproductive health, as if this area of health was somehow discrete and separate from psychological health. Indeed, the remarkable paucity of data on postnatal depression and the relationship between reproductive symptoms and infertility with psychosocial health is a marker of the myopic view of health research in low and middle income countries. Thus, it is essential to conduct research on women's health that encompasses the holistic nature of health, viz., incorporating psychological, reproductive and social viewpoints. Examples of potential research themes are: the ethnographic description of the experience of CMD by women and their interpretation of the symptoms and causes; examination of the social and cognitive matrix which underlies the strong association between female gender and CMD; the association of CMD with violence against women, childbearing, infertility, childbirth and reproductive symptoms; the impact of CMD on the daily lives of women and the nature of disability that it imposes; the management of CMD using
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locally available personnel and resources and the development of locally sensitive intervention strategies.
The association of age, low income and education with CMD The ®ve studies show clear associations between low education, low income and older age with CMD. These studies are consistent with ®ndings in other low and middle income countries (e.g. Bahar et al., 1992; Desjarlais et al., 1995; Kishore et al., 1996; Mumford et al., 1997). In public health terms, the most powerful implication of these ®ndings is that low education is a potentially preventable risk factor. It is perhaps important to recognize that the key factor may not be whether 100% of children are in primary school, but rather the proportion of children who fail to complete the minimum years needed to obtain a secondary school certi®cate (10±12 years in most countries). This is a far more signi®cant landmark in society, for without it the number of years of schooling is irrelevant to prospective higher educational institutions or employers. Thus, even though there are impressive gains in increasing school enrollment, there may need to be further emphasis on reducing school drop-out rates; in India and Zimbabwe, for example, less than half the children who are in primary school go on to complete their 10 years of secondary education. In Brazil, only one in seven children completes elementary school. One of the reasons for this high dropout rate is the need to earn money very early in life (Iacoponi et al., 1991). Education re¯ects socioeconomic circumstances of the family at early life (Rutter and Madge, 1976) and is an important cause of perpetuating inequalities in Brazil (Urani, 1995), given its role in sorting individuals into occupations. Education permits greater choices in life decisions and in¯uences aspirations, selfimage (Brown et al., 1986) and opportunities to acquire knowledge, which may motivate attitudes and behaviour toward lifestyle and health status (BMA, 1987). Older age is consistently associated with CMD; this has implications for all 4 societies studied where average life spans are gradually increasing even as birth rates are falling, thus increasing the proportion of the elderly. It is essential for health services to respond to the needs of the older subjects, and for social services to recognise that as rural societies change, the fabric of support for the elderly is also changing. Increasing numbers of elderly persons are living out their twilight years in loneliness as their family structures change. In a similar way, elderly people in many low and middle income countries do not have enough ®nancial support from the government and suer considerable economic diculties. Research on the needs of older women is even rarer in many countries, as if the health of
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women is less relevant once their reproductive years are completed. Low income groups are more vulnerable to suer CMD, irrespective of the overall state of development of the society they live in. Thus, it would appear that it is relative poverty, i.e. low income, which is a risk factor for CMD. This ®nding is consistent with those from developed countries (Weich and Lewis, 1998). This ®nding would predict that even if developing countries reduce the proportion of those who live in absolute poverty, if income inequality grows, the impact on reducing the burden of mental illness may not be as remarkable. If this was the case, then the potential implications for the prevalence of CMD are ominous, since across all four nations included in this paper, there are radical economic structural changes being implemented. Despite raising average income, these changes are also widening socioeconomic inequality, characterized by marked inequalities in the distribution of income and access to education and another basic needs. For example, in Brazil the proportion of the GNP by the poorest 50% of the population dropped from 17.4 to 12.6% from 1960 to 1989, the equivalent ®gures for the richest 10% rose from 39.6 to 51.3% (Pereira, 1988). In Zimbabwe, a 1995 poverty assessment survey found that 45% of households were living below the food poverty line and 61% below the total consumption line (Government of Zimbabwe, 1996). Thus, economic inequality is being enhanced which, in turn, may lead to higher levels of CMD amongst low income groups. In Harare and Goa, local communities had implicated indebtedness as being a consistent source of stress and worry. This was especially so because the poorest who needed loans to cover short-term ®nancial shortfalls were not considered credit-worthy by banks and, in desperation, relied on loan-sharks. The latter charged exorbitant interest rates and it was not uncommon for the children of a family to spend their lives toiling to repay the interest of relatively small loans taken out by their parents. We tested the hypothesis that being in debt was associated with CMD and found this to be the case in both settings. It is clear that here lies another potential preventive strategy in that local banks could step in and review their process of assessing credit-worthiness for persons who belong to the poorest sectors of society. Radical community banks and loan facilities such as those run by 1 The Hindu newspaper of January 1, 1998, reported that the Indian Government had set up a panel to investigate why farmers in Andhra Pradesh tend to commit suicide following the crop failure. The article mentioned that the farmers had to take loans from local money lenders to help their families through the ®nancial crises.
Fig. 1. A model to explain the relationship between poverty and common mental disorders.
SEWA in various parts of India could be involved in setting up such loan facilities in areas where they do not exist. Further evidence of this relationship is fuelled by a recent spate of suicides by farmers in the Indian state of Andhra Pradesh where the seasonal crop failed and farmers were deeply in debt to local money-lenders1. A potential research theme would be evaluating CMD and suicidal behaviour in populations who have access to such facilities and comparing them to populations with similar economic and social circumstances but without loan facility access. What is unclear is the direction of the association between poverty, low education and psychological disorder. As with any cross-sectional study design, the ®ndings of the ®ve studies collated in this paper cannot be used to provide a de®nite indication of causal direction. However, as Wilkinson (1996, pp. 81±82) points out, there are strong arguments against `reverse causality' when considering the relationship between illhealth and income distribution. He states that ``if the arrow of causality pointed in that direction, we would be obliged to say that health is one of the most important determinants of income distribution. Not only
V. Patel et al. / Social Science & Medicine 49 (1999) 1461±1471 does this run counter to economic theory, but it ¯ies in the face of commonsense notions of the in¯uence on income distribution of employment and unemployment, pro®ts, tax and bene®ts'' Psychologists have conceptualized poverty as a situation with a number of attendant conditions which individually or collectively in¯uence the development of the individual, rendering him or her less capable of overcoming poverty by personal eort (Sinha, 1997). Fig. 1 presents a model which provides a basis for explaining the association and mediating factors between poverty and psychological disorder. It is clear that this is not a unidimensional one-way relationship but is an interactive and complexly dynamic one. Thus, for example, while poor nutrition may be a stressor which triggers depression in a woman already facing other deprivation related problems, depression in turn robs the woman of the necessary coping skills and energy to overcome her problems. Further, the potential stresses imposed by absolute poverty may be considerably dierent from those of relative poverty. It is suggested that the psychological impact of relative poverty is the result of both the indirect (e.g. increased exposure to behavioural risk factors due to psychosocial stress) and direct (e.g. physiological eects of chronic mental and emotional stress) eects of psychosocial circumstances associated with social position. The mechanism involved is one of `cognitive comparison' whereby people are made aware of the vast dierences in socioeconomic status that prevail, and the knowledge of how the richer ``other half live'' aects psychosocial well-being and thus, overall health status (Wilkinson, 1997).
Conclusions The key ®ndings of this paper are that female gender, low income and other measures of poverty, older age and low education are associated with CMD in all ®ve studies from 4 low to middle income countries. The analyses reported in this paper were conducted post-hoc and, in this sense, the ®ndings of this paper may be considered as preliminary, needing replication through prospective studies with the stated aims of examining these associations and controlling for all possible confounders, such as employment status, social class, family size, etc. However, the pervasiveness of the key associations across the study settings, despite the use of varying methodologies and the consistency of this association with developed country studies, lead us to suggest that, even if there are unmeasured confounders, the associations are valid. The vulnerability of women needs to be more widely acknowleged by those who fund and work in the area of women's health so that psychosocial factors are properly evaluated and included in their research and
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service agendas. If the associations of income inequality are replicated, this would be of serious concern to all four study countries where the formula for economic development is leading to a reduction in public health expenditure, a rising inequality between the rich and poor, increased migration to urban areas with its attendant rise in urban squalor and rapid culture change as the great urban centres take on an international cosmopolitan ¯avour. Research which is sensitive to regional factors, such as the ®ve studies reported in this paper, is needed to inform local health planners and policy makers on the potential mental health needs of the community as these economic changes profoundly alter the fabric of their societies.
Acknowledgements The study in Harare was funded by the International Development Research Centre (Canada); in Goa by the Wellcome Trust (UK); in Olinda by FACEPE and CNPq (Brazil); in Santiago by Fondo Nacional de Ciencia y TecnologõÂ a (FONDECYT, Chile) and in Pelotas by CAPES (Ministry of Health, Brazil). All authors are indebted to the numerous individuals and researchers who participated in each of the studies and are acknowledged in detail in the main publications referenced for each study.
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