Psychological Malaise, psycho-social factors and health services: women's health. (The Malaise of Gender).

The author, a psychologist with a Master's in Public Administration, teaches at the Instituto de Investigacion y Formacion en Administracion Publica (Public Administration Research and Training Institute) at the Universidad Nacional de Cordoba. She is also head of Public Health and Epidemiology Research in the Mental Health Department of the Ministry of Health in Cordoba, Argentina.

Worry not about her whispers, her cries and her pains. Nature has made her for our use and able to withstand all: the children, the suffering, the blows and the sorrows of men. Do not accuse us of being heartless. In all societies that claim to be civilized, men have written laws that control the destiny of women, under this bloody epigraph: "Vae victis! Pity the conquered!"

--Honore de Balzac

Introduction

Epidemiological research shows that women present psychological symptoms more frequently than men, particularly with regard to the most common symptoms of anxiety and depression. (1) In addition, women are more frequent users of health services and take more prescription drugs than men. Other studies confirm the relationship between women's mental health problems and lower levels of education, low income and unemployment. The fact that women are over-represented in each of these categories attests to the indirect role played by gender (Paez, 1986).

The following article shares results obtained from different studies involving local women from the city of Cordoba, Argentina, applying a gender perspective to female psychological complaints associated with psychosocial factors and analyzing institutional relationships between women and the health services. Our analysis will utilize a perspective based in psycho-social epidemiology and incorporate concepts such as social support, stressful events and coping mechanisms.

After contrasting the psychological conditions of women and men in Cordoba, I will present some relevant conclusions from studies carried out with housewives, whose vulnerability is fundamentally linked to gender and working conditions. Next, I will summarize some aspects of behavior associated with health and illness in women users of public health services, especially behavior related to reproductive health. Finally, an examination of the debate on health sector reform will highlight the need to include women's perspective in policy design to assure more equitable reforms.

By approaching these issues from a variety of perspectives, I hope to construct a empirical, interpretive and critical vision of women's health and mental health problems.

Women's Psychological Malaise 

Psychological malaise can be understood as the individual's own perception of thoughts, feelings and behaviors that can indicate a mental health problem: the perceived level of stress and the level of discouragement. Psychological malaise "has as its reference point well-being, happiness and ideal personal development or positive standards of behavior." (2) Thus, psychological malaise is a broader concept than mental illness, which only includes syndromes or specific sets of symptoms. According to this definition, then, mental health is not just the absence of mental illness. Burin et al. have defined "women's psychological malaise" as a product of the contradictions and tensions that exist between gender expectations and women's life experiences, the result of the interaction of specific elements in women's lives. (3)

Since 1993, a number of epidemiological studies on psychological malaise have been conducted in the city of Cordoba, Argentina. For these studies, an instrument called the Epidemiological Questionnaire of Mental Symptomatology (CESIM) (4) was developed and locally validated. The CESIM was applied to two representative samples of the general population in 1993 and 1998. It has also been applied in different local groups considered vulnerable (housewives, the unemployed, teachers and students, among others).

The data collected in 1993 and 1998 allowed us to obtain a "snapshot" of perceived levels of stress and the changes they provoked. Between these two surveys, the state of Cordoba experienced a brutal financial crisis, and these two studies offer objective indicators of the impact of the crisis on the psyches of the citizens of Cordoba, including the increase in dissatisfaction and discontent. (5)

The studies (6) on psychological illness carried out on the general population of Cordoba confirm the hypothesis that women manifest more symptoms of mental distress than men. In the 1993 study, 14.4% of the general population presented symptoms of serious psychological illness or disorders. Of them, 75% were women.

In the epidemiological study of 1998, the symptoms were distributed as follows: (7)

                     WOMEN 1998   MEN 1998

Few Symptoms            9.1%       12.3%
Some Symptoms          45.2%       54.2%
Many Symptoms          29.9%       20.1%
Very Many Symptoms     15.7%       13.4%

As seen in the table above, 45.6% of the women surveyed fall into the "many" or "very many" categories while only 33.5% of the men fall into these categories. In other words, approximately half of the women present a set of symptoms that correspond to psychological malaise.

The following table compares the averages obtained from the CESIM for both sexes, compared to the overall average:

          GENERAL POPULATION   WOMEN   MEN

Average          21.8          22.56   21

The values above are higher for women than for men, implying that Cordoban women experience greater psychological malaise than their male counterparts.

Self-Perception of Mental Illness, Use of Mental Health Services and of Prescription Drugs

Different studies have reported that although women have more emotional problems than men, they also tend to recognize these ills as psychological problems. In addition, they are more inclined to seek psychotherapy and to take prescription drugs than men with similar degrees of illness. The following information confirms that local is consistent with the trends shown in the studies listed in the bibliography:

                      WOMEN    MEN

Self-Perception
of Mental Illness     27.4%   15.1%

Use of Mental
Health Services       20.8%   11.2%

Use of Prescription
Drugs                 15.3%   10.9%

As the table illustrates, women are the predominant users of mental health services. Another study found that women use state mental health services more than men, by a ration of 7 to 3.

Psychosomatic Illnesses

The studies on the relationship between gender and psychosomatic illness are contradictory. Some noted no differences between the sexes while others associated psychosomatic illness with men. In the most recent Cordoba survey, we observe that gastritis and headaches are more frequent in women.

               WOMEN    MEN

Ulcers          7.8%    7.6%
Asthma          6.7%    6.1%
Allergies        24%   23.4%
Headaches      45.2%   25.1%
Gastritis        31%   27.4%
Hypertension   22.9%   23.9%
Trembling      12.3%    7.6%
Sweatiness     16.2%   13.2%

One possible explanation is that women are more frequently diagnosed with psychosomatic illness because they are more inclined than men to recognize that they are unwell and to seek treatment.

Stressful Events

Stressful events--defined as events that are perceived as threatening one's physical or psychological well-being--are associated with the appearance of psychological symptoms. (8) According to the studies reviewed, inter-personal incidents are the stressful events most commonly related to illness. Women and lower-income populations are subjected to stressful situations more often.

The stressful events were reorganized into three subgroups: social, personal and family events. These subgroups were then divided into three categories: few, some and many stressful events. Women are more frequently represented in the category "many"; however, when the averages for each group are calculated, we find that men show higher values in the "many" category of all three areas--social, personal and family events.

STRESSFUL EVENTS               MEN               WOMEN

                         YES    SOMETIMES   YES    SOMETIMES

Economic Difficulties    22.3     11.2      32.5     13.7

Unemployment             39.1      3.9      52.3      5.6

Problematic Family
Relationships             4.5      8.9       9.6      5.6

Health Problems          34.6      9.5      39.1     10.7

Alcoholism                2.2        -       5.1      0.5

Homelessness             10.6      1.1      16.2      0.5

Drugs                     2.8      0.6       3.0        -

Death of a Family
Member                   30.7      1.1      34.0      1.0

Worry about the Future   58.1     10.1      60.9     10.7

Excess Work
or Job Dissatisfaction   22.3     10.1      19.3      7.1

Problems with Partner     3.4     13.4       6.1      7.6

Domestic Violence           -      1.7       2.5      2.0

                              MEN                    WOMEN

                      FEW    SOME    MANY     FEW    SOME    MANY

Social     %          41.3    34.6      24    29.9    37.1      38
Events     N            74      62      43      59      73      65
           AVERAGE   14.93   21.14   31.23   16.89   21.84   28.49

Personal   %          37.4    59.2     3.4      32    62.4     5.6
Events     N            67     106       6      63     123      11
           AVERAGE    17.4   21.99   42.66   18.84   23.37   34.72

Family     %          42.5    33.5      24    37.1      32      31
Events     N            76      60      43      73      63      61
           AVERAGE   16.25   19.96   30.83   17.90   21.60   29.11

Coping Mechanisms

Coping mechanisms are cognitive and behavioral responses to stress developed by an individual to deal with the specific external and/or internal demands that are judged to be beyond her/his capacity or resources.

As seen in the table on page 20, for the most part there was little difference between how men and women coping with stressful events. Women predominate in only three items (Get depressed, Take pills and Keep busy ...).

The issue of "Coping Mechanisms" was further divided into three sub-categories: avoidance, substance abuse (taking prescription medication, illegal drugs or alcohol), and emotional outbursts (see table, p.20). In the categories of avoidance and emotional outbursts, more women place themselves in category of "many." This agrees with the theory that women have learned ineffective tactics and methods for coping with stress. The most effective coping mechanisms are those that involve facing the problem directly and with a degree of emotional control, believing that one will be able to resolve it. Nevertheless, when one compares the averages of the category "many" in both groups, men surpass women.

In summary, Cordoban women display more symptoms than Cordoban men. They are more often aware of their psychological problems, seek medical attention more often and take more prescription drugs. In addition, they experience stressful events and employ ineffective coping techniques more frequently. However, when we compare the average values of men who suffer from "many" stressful events with those of the same group of women, there is a greater incidence of stressful events and stronger association between a high frequency of ineffective coping mechanisms and symptomatology among men.

COPING MECHANISM              MEN               WOMEN

                        YES    SOMETIMES   YES    SOMETIMES

Do not rest until
a solution is found     49.7     17.3      50.3     22.8

Seek help
from others             36.3     24.0      35.5     24.9

Seek distractions       50.3     14.5      47.2     11.7

Get depressed           26.3     22.9      38.6     24.9

Resign one's self
to the problem          28.5     10.6      28.4     10.7

Get upset               12.3     24.6      13.7     23.9

Go out to distract
oneself                 39.7     16.8      41.1     15.2

Take pills               8.4      3.9      11.2      4.1

Drink more
than usual               2.8      5.6       2.0      1.5

Keep busy so as
not to think about it   15.6     11.7      31.0     15.7

Hurt members
of their families        4.5      8.9       6.1      8.1

Do not seek
solutions               23.5      7.8      24.9      6.1

COPING MECHANISM              MEN                     WOMEN

                      FEW     SOME    MANY    FEW     SOME    MANY

Avoidance   %          27.4    36.3    36.3    25.4    31.0    43.7
            N          49.0    65.0    65.0    50.0    61.0    86.0
            AVERAGE   16.87    20.4   24.70   19.22   24.75   22.94

Addiction   %          88.8    10.6     0.6    87.3    12.2     0.5
            N         159.0    19.0     1.0   172.0    24.0     1.0
            AVERAGE   19.04   35.52    56.0   21.43   30.66    22.0

Emotional   %          36.9    42.5    20.7    29.4    44.7    25.9
bursts      N          66.0    76.0    37.0    58.0    88.0    51.0
            AVERAGE   13.22   20.30   36.29   15.41   22.50   30.78

Women's Work: Malaise Among Housewives (9)

Various studies confirm that women who do not work outside the home manifest higher levels of tension and malaise than women in the labor market. In the case of housewives, this could be due to the fact that their role is unstructured and invisible. In addition, domestic work is filled with boring, repetitive tasks requiring few skills and providing little prestige. Working in the home also isolates women from other adults. The housewife syndrome is characterized by digestive problems, gastrointestinal disruptions, respiratory difficulties and shortness of breath, heart palpitations and hypertension, migraines, mood swings, irritability and so on. This phenomenon occurs when the repetition of certain actions creates frustration, generates hostility and mechanizes behavior, turning women into robots. The symptoms arise in order to break the domestic routine (Ferreyra, 1992).

The CESIM was also applied in our research with housewives in Cordoba. The average for this group was 24 compared to an average for the general population in the 1993 study of 19 and in 1998, 22.56). The variables associated with illness among homemakers are described below:

* Women who had finished primary school obtained an average of 30.06 while those who had completed postsecondary education averaged 24.98.

* Their partners' attitude towards housework plays a significant role in women's mental state. Women who responded that their partners consider their work unimportant present more symptoms. As her work at home is relatively invisible and unstructured, a homemaker does not have an objective standard against which to measure her efforts, to determine if her work is weld done. It is easy to see, then, why her partner's opinion is of vital importance. In addition, this unpaid work creates psychological and economic dependence and undermines women's self-esteem.

* In contrast, their maternal role is one of the few sources of gratification for housewives. Nevertheless, in this study we observed that greater identification with this role produced greater symptomatology: adherence to the maternal ideal prevents women from acknowledging the ambivalence they feel in this role (in response to excess work, children's needs and other demands). Some idealize the maternal role to overcome this ambivalence.

* The likelihood of symptoms of mental distress increases when a woman experiences conflict between the role of homemaker and the demands of working outside of the home. Other contributing factors are tension with her partner and the woman's perception that her work in the home is not valued.

* As a general conclusion, we concur with Burin that it is necessary to analyze women's understanding of the meanings they assign to the supposed risk factors. Isolated, key episodes, or intrinsic factors (for example, the number of children under five years old) do not produce increased symptomatology; rather, the key is how homemakers react to these factors and the meanings they ascribe to them.

Women as Users of Health Services (10)

Although women are in great need of mental health care, a number of gender-related factors--such as women's neglect of their bodies and unwanted/unplanned pregnancy--as well as the shortcomings in health services in responding to women's needs produces what has come to be called "the law of inverse care," that is, the probability of good quality and timely health care is inversely proportional to a woman's need for said care. In other words, those who most need care have the least access to it. For example, women living in rural areas have the most health problems; yet, they have the least access to health care and the lowest level of coverage.

Women's practices in relation to health and illness do not occur in a vacuum, but rather are actively influenced by different health institutions. The stories we hear describe not only the women themselves but also their relationships with different health services. To resolve health problems in their families, women develop a series of strategies that include seeking help from municipal health centers, provincial and teaching hospitals, and social services. Women do not attempt to resolve all of their problems with one provider but access different services according to their specific needs, their ability to pay for transportation, and their relationship with specific health professionals.

To this range of resources, we must add the knowledge that they acquire by seeking health care for their children. This is most evident among experienced mothers with limited means. Patience and the constant search for facilities, people and resources are fundamental strategies; but it is also possible to identify "secondary adjustments" made by these women, such as seeking out people whom they already know, making contact with key staff members or bringing a gift for the care provider. Thus, a mother's ability to benefit from health services is related to her familiarity with the services available, their rules and the availability of useful information. In short, she must adapt to and integrate herself into the system.

In general, relationships between women and public health services are characterized by a lack of adequate information, lack of knowledge of patients' rights and the absence of clear rules regarding access to services.

Furthermore, women's needs go beyond mere medical care and include specific psycho-social and cultural factors that should be taken into account when programs are designed. Health programs for women must incorporate the women's own ideas about sexuality, their bodies and similar topics. The merely technical solution must be complemented by a more comprehensive perspective. Treatment of women's health problems must attempt to break the framework of abstractions in which the homogenous category of "women" is used to address a heterogeneous reality. The ways in which women carry on their lives vary according to their backgrounds, their age groups and their stages of life, all of which play a part in determining the type of demands they will make of health institutions.

Health Sector Reforms Remedying the Inequities in Access (11)

One of the main concerns that drove health sector reforms in the 1990s in developed and developing countries alike was the need to strike a balance between equity and efficiency. As with other governmental reform, discussion of health sector reform takes place within the framework of an intense theoretical-ideological debate on the nature of health and illness, who should pay for health care and how it should be financed, and the role of the State. Other issues include defining adequate levels of access and coverage and determining the role that should be played by regulations, competition and free choice.

This debate has two theoretical poles. On the one hand, some argue that the use of health services should not be a question of individual choice or depend upon a family's economic situation (the egalitarian position). On the opposite end of the spectrum is the view that people should be able to consume the health services that they want and can afford (the extreme liberal position). For obvious reasons, there is not a great deal of support for such an extreme position. Some argue for a less extreme alternative, the right to a basic level of health services (the moderate liberal position) (Cetrangolo and Devoto 1998).

These philosophical perspectives can be placed within the framework of a wider discussion on the role of the State in all areas of social policy. In effect, this debate is nothing less than the confrontation between opposing belief systems on health/illness/care, whose final result will be a fundamental change in the paradigm of the State's involvement in the field of health.

All of these health sector reform processes are clearly influenced by the values, ideas and proposals arising from neoliberalism. Having ideologically dominated the processes of economic reform in Latin America, neoliberalism now aims to demarcate the boundaries of techno-political decision-making in social sector reform processes (mainly in the areas of health and education), in what are referred to as second-generation reforms.

Women's concerns must be presented within the discussion of this second wave of reforms, including different proposals: targeting, decentralization and privatization. In addition, it has been difficult to achieve consensus in the area of equity, though the need to introduce some selective criteria is now clear.

In terms of targeting, there is support for "selective universality" or "positive selectivity," which respectively imply universal access to essential goods and services or the selective identification of special needs according to circumstances. A more detailed analysis, based on empirical evidence, of the psycho-social factors that affect health and illness could help to identify in which areas health services must be adjusted to fit women's needs: "a homogenous offer of services for heterogeneous situations can only serve to perpetuate historical inequities."

The reforms also postulate the inclusion of a diverse group of actors. While the State should maintain a strong presence in defining policies, setting standards and implementing regulation, and financing health services--functions that as a matter of principle cannot be delegated--nevertheless, it may be possible to widen the discussion on the provision of health services to include different actors who could share these tasks with the State.

Another reform being promoted is that of popularization. (12) Popularization proposes strengthening, organizing and broadening the role of the public--as opposed to the governmental or the for-profit sector--in the administration of health services. This area is composed of nonprofit organizations that fulfill needs which are not met by the market or the State. While this new type of involvement presents some interesting possibilities, it also implies risks for women. Within this context, women are usually brought together and organized to participate as volunteers, which adds community work to their other responsibilities (remunerated and domestic work).

In addition, the traditional guiding principle of the doctor-patient relationship has been that doctors are the perfect agents of their patients' health. This idea is now being questioned and alternatives proposed, such as: 1) the implementation of a system of general practitioners in which physicians handle their patient's primary care and make referrals to specialists; and 2) the promotion of nongovernmental public organizations that concern themselves with obtaining services for their clients. This role could be performed by the women's organizations referred to above.

The majority of researchers in the health sector have confirmed the dissatisfaction of users with the services which currently exist. Part of this dissatisfaction arises from the fact that public health services have failed to take social context into account. Although they pay lip service to psychological and social aspects of health care, the services do not incorporate these crucial elements into their operations. As a result, health care services continue to generate great dissatisfaction.

Women's ideas of health and illness, as well as their methods of dealing with them, are conditioned by their perceptions of and the meanings they assigned to health/ illness and how those interpretations are shared within their particular social environment. This perspective also affects the ways in which they interact with the health system, their decisions to seek care, the consumption of prescription drugs and other behavior. In this respect, health sector reform provides an opportunity to discuss and identify the institutional changes needed to create health services that meet women's real health needs.

Notes

(1.) Different studies indicate that women are more likely to suffer from depression and anxiety while other psycho-pathologies, such as personality disorders or addictions, are more common among men. These differences have been attributed to the different ways in which women and men express psychological suffering. Women manifest their psychological state through anxiety and depression, while men are socially encouraged to mitigate their suffering through their behavior or through substance abuse.

(2.) Dario Paez, Salud mental y factores psicosociales. (Spain: Editorial Fundamentos) 1986.

(3.) Mabel Burin, et al., "El malestar de las mujeres, la tranquilidad recetada." (Buenos Aires: Editorial Paidos) 1990.

(4.) The Epidemiological Questionnaire of Mental Symptomatology (CESIM) is a scale of symptoms presented in two versions: extensive (78 items) and short (54 items) (Grasso, Burijovich, et al., 1993). The short version was used for this study. CESIM was designed for epidemiological purposes. It does not make individual diagnoses but rather establishes a probability of mental disorder and provides a universal measure of psychological illness. CESIM was designed in Cordoba in response to the local need for a valid instrument that could provide an epidemiological profile of mental health.

(5.) Although it is beyond the subject of this paper, symptoms of mental health problems increased markedly in the population of Cordoba between 1993 and 1998.

(6.) Jacinta Burijovich, Marcelo Sandomirsky, Natalia Falcone, et al., "Estudio epidemiologico de sintomatologia mental" (Direccion General de Salud Mental, Ministerio de Salud de la Provincia de Cordoba) 1993; Jacinta Burijovich, Cecilia Berra and Adriana D'Lucca, "Segundo Estudio epidemiologico de sintomatologia mental. De los cordobeses y sus malestares" (Sub-Direccion General de Salud Mental, Ministerio de Salud y Seguridad Social de la Provincia de Cordoba) 1998.

(7.) In both the 1993 and the 1998 studies, gender was an important variable. However, in the 1998 study unemployment was more clearly associated with psychological illness.

(8.) Key events or stressful events: In daily life, there are important occasions or events that we perceive as positive or negative. These events are called life events. "They are objective experiences that disrupt or threaten to disrupt a person's normal actions, causing a significant adjustment in her/ his behavior" (Thoits, 1985).

(9.) This section presents the main results of the study "Insatisfaccion laboral y malestar psicologico en mujeres docenres y amas de casa" headed by Livio Grasso, with the participation of research assistants Jacinta Burijovich, Natalia Falcone and Francisco Ferreyra.

(10.) This section refers specifically to grassroots women and their relationship with public government services, based on information collected through workshops with grassroots women on Motherhood and Health, as part of the 1997 Socio-cultural Communication Diagnostic Evaluation in Cordoba undertaken by IIFAP-UNC and coordinated by Jacinta Burijovich and Ivan Ase.

(11.) Some of these ideas were presented in greater detail in Ivan Ase and Jacinta Burijovich's article "Las reformas del Sector salud en Cordoba. El naufragio de un `piloto de tormentas'," in the Revista Administracion Publica y Sociedad (Cordoba: IIFAP, Universidad Nacional de Cordoba) 1999.

(12.) Luiz Carlos Bresser Pereira and Nuria Cunnill Grau, "Lo publico no estatal en la Reforma del Estado" (Argentina: CLAD PAIDOS) 1998.