This study assessed how gender roles in Pakistan can impact anxiety levels and behavioural responses among men and women during the COVID-19 pandemic. Both men and women were found to be mildly anxious due to the COVID-19 pandemic. However, compared to men, more women perceived the disease to be fatal, and were more likely to engage in preventive behavior. These results highlight a greater need to develop gender-responsive policies in the fight to contain COVID-19.
Overall, fewer women than men responded to the questionnaire. This may be due to a prominent male dominated access to internet facilities in Pakistan. Indeed, several reports on internet penetration found that, at least three-fourths of internet and social users in the country are male (25). In Pakistan, cellular devices remain the most frequent means of accessing internet facilities, and there is a gender gap of 38%in mobile phone ownership (26).
There were also significant differences in respondents’ city of permanent residence. Three-fifths of all the female participants, and two-fifths of the males were from Karachi. This was expected, as the survey tool was disseminated over a Karachi-based university hospital’s Facebook page. The remaining respondents were from Punjab and Sindh. There are significant provincial disparities in access to internet facilities. Islamabad Capital Territory has the highest internet penetration, followed by Punjab and Sindh (27). The fewest respondents were from Balochistan, further reflecting the province’s poor internet accessibility. One-third of the male respondents were from smaller cities and towns throughout the country, compared to one-tenth of women. Differences in the nature of Pakistani men in smaller towns/cities may impact mobile phone ownership and social media usage, and explain why fewer women were from these towns and cities (28).
Although men and women considered themselves equally susceptible to a COVID-19 infection, women were more likely to perceive the disease to be fatal. This is a misperception, as gender-disaggregated data (until 24 June) on COVID-19 in Pakistan shows that three-quarters of diagnosed cases and deaths were among males, compared to a quarter among females (29). Gender-specific patterns of smoking are implicated as a significant contributor to disease severity among men (30). Indeed, this study also suggested that men were twice as likely as compared to women in reporting that either they might start smoking cigarettes and using recreational drugs or their usage might increase. These gender disparities in use of tobacco and narcotics are frequently seen in Pakistan (31–33). Furthermore, men are more likely to suffer from non-communicable diseases (34). Research suggests that excess mortality during the pandemic is higher than if these surplus deaths were caused by COVID-19 alone, particularly among cancer or heart disease patients and are attributable to delays in seeking or obtaining lifesaving care (35,36). Furthermore, women, particularly working mothers, tend to spend more time than men focused on medical issues related to their family’s healthcare, as well as their own (37). This could explain why women are more likely to believe that the disease symptoms are severe, with a low likelihood of survival.
Despite at being lower risk, women were more likely to conform to preventive measures. This included practicing social distancing measures, such as avoiding going to meat shops/market, going out, and going to work. One digital ethnographic study suggests that the majority of the population in Pakistan was in favor of continuing prayers in mosques while 1 in 4 men reported to have attended Friday prayers (38). Other studies also demonstrate men’s priorities during the pandemic. A comparison of COVID-19-related content shared on Twitter by men and women based in the U.S. found that women were more likely to tweet about family, social distancing and healthcare whereas men were more likely to tweet about sports cancellations and politics (39).
While this finding might imply that men are considerably less interested in social distancing practices, only one-fifth of the Pakistani women contribute to the labor force and wherein men constitute a majority of waged and salaried workers in cities and women contribute to over 70% of share of work in agriculture and informal sectors (40).These differences in employment could explain why men are less likely to conform to social distancing practices than women. In order to improve the labor forces’ capacity to work from home, initiatives should be taken to improve telecommunication facilities (including improving internet service provision).
Differences were also seen in practicing hygiene measures, such as disinfecting floors and tables at home (with phenyl products). School closure, lockdown and work-from-home orders have resulted in women carrying a double shift of home-schooling and working responsibilities. This increases the proportion of paid and unpaid labour in women’s work (41). Working mothers spend more hours engaged in household work and child care than their husbands (42). One study conducted in the United Kingdom during the lockdown estimates that, on average, mothers spend 11 more hours weekly on childcare than fathers. Single parents have less time to spend on childcare than partnered mothers, as they are single-handedly forced to bear the brunt of the shifts in the job market (43). This additional housework could result in women permanently exiting from the labor market. These developments are concerning, and emphasize the urgent need to develop labour policies which protect women in the workforce.
Women were more likely to report that they avoid going to hospitals. Furthermore, they were also more likely to perceive that doctors were a reliable source of information. It may be too soon to estimate the impact of COVID-19 on maternal and child health services, but one study estimates that a modest decline of 10% in coverage of pregnancy-related and newborn health care in lower-middle income countries could result in an additional, 1.7 million women who give birth, and 2.6million newborns who need urgent medical care (44). Studies conducted during the 2013–2016 Ebola outbreak in Western Africa show how sexual and reproductive health was adversely impacted by strains on health care systems, which often resulted in interruptions of care, and redirected resources (45–49). Similar reduction in access can be seen during the current pandemic. Clinics operated by Marie Stopes International, which is the largest private provider of family planning services in India, had to halt operations due to the country-wide lockdowns (50). Similarly, Marie Stopes International reports that its activities have been reduced by up to 40% in Pakistan due to the pandemic (51). Furthermore, some studies noted how diversion of staff and funding from maternal, neonatal and child health programmes to the front-line of the COVID-19 response has also decreased the quality of services available to women (52–54)
A larger number of men than women considered radio to be a reliable source of information. Pakistan has a considerable audience of radio programming. One study found that radio has the largest listeners in Sindh (60%), followed by Balochistan (53%), KPK (52%) and Punjab (19%), particularly in rural areas and small towns (55). Therefore, this gendered difference in trusting radio could be explained by the significantly larger proportion of men who came from smaller cities and towns. Furthermore, men in this study were more likely to trust friends and family than women. Pakistanis are considered to be a collectivistic society, with an emphasis on men engaging in commitments to the members of their ‘group’, friends and family (56). Similarly, men were more likely to trust social media sources than women. The lockdown enforced due to COVID pandemic has resulted in online activity substituting social activity between families, and may be considered as representative of a given person’s public interactions (38,39). While one study found that the public was often skeptical of official figures on COVID-19, but most polling suggests that Pakistanis in general are confident in the government’s management of the crisis (4,5). This is in contrast with Syria, where experiences of war, and propaganda campaigns by the state and its opponents, meant that Syrians were very distrustful of official news sources (38). Facebook users were much more likely to share official news sources. Therefore, radio content, as well as shareable social media content might be an appropriate avenue to provide targeted health information to men and improve their risk perceptions and subsequent indulgence in precautionary measures
In this study, women depicted higher levels of anxiety and depression in comparison with men, which suggests that they hold a greater psychiatric burden of the COVID-19 pandemic. One study conducted in India found that 33% of the respondents had experienced either depression or anxiety as a result of COVID-19 (57). Another study in China established that 54% of respondents suffered some psychological impact from the outbreak (58). In both studies, women were found to have suffered a greater psychological impact due to the pandemic as compared to men. Similarly, our findings corroborate with data from Turkey, where women had significantly higher scores of depression and anxiety (14). Research conducted in China also reports that women may be three times more anxious than their male counterparts because of COVID-19 (11,54,58). These results align with previous studies which show that women have a higher vulnerability for developing anxiety disorders (59)
There are many possible sources of this concern. Apart from their professional role, women serve as primary caregivers within their family (57). Women’s greater sensitivity towards familial roles and responsibilities was also reflected in a research which noted that pregnant women had heightened stress levels regarding the health status of their older relatives, their children and then their unborn baby during COVID-19 (60). One study found that family income stability and social support networks were protective factors against anxiety (61). Given the difficulties in forming stable social support networks during pandemic-induced lockdowns, as well as women’s lower likelihood of seeking medical care, this psychological support could be provided via telemedicine or other online platforms which can connect them to qualified psychiatrists. The timely and effective provision of such psychological support is also imperative for literate women that are already suffering from mental illness and feel that their symptoms have aggravated due to the ongoing pandemic.