The health status of people worldwide is predetermined by a variety of factors that result in a particular level of morbidity, life expectancy, and satisfaction with life quality. Mental health is considered one of the essential attributes of well-being, which is why it has obtained much attention from international health organisations in recent decades (World Health Organisation [WHO], 2018). Moreover, being dependent on determinants of health, mental health inequalities inherently derive from social inequalities, which persist in low- and middle-income countries (Dupas and Miguel, 2017). Since Kenya is a low-middle-income state, the overall health quality of its population is low, with a significant gap in mental health for vulnerable populations (Kendrick and Pilling, 2012). Given the patriarchal society and women’s inferior social roles persisting in Kenya, the female population is recognised as the one experiencing inequalities in mental health.
The state of mental health of women in Kenya is impacted by disparities and inequalities due to social, economic and cultural factors. Women’s versatile social roles expose them to the daily burden of psychological distress that makes them a vulnerable population in the context of the health care system. Overall, mental health is recognised as a pivotal global issue, the improvement of which is considered a contribution to a healthier future of the nations (Pike et al., 2013). However, particular populations, namely women, experience significant inequalities when accessing mental health care and when being disproportionately exposed to the determinants hindering their health. Poverty, discrimination, abuse, domestic violence, and other factors become reasons for inequality experienced by Kenyan women (Agboola, 2018; Bukusi, 2015). Currently implemented interventions and policies insufficiently recognise and address the problem, which is why it is imperative to find ways to prioritise women as a population that requires support in bridging the gap in mental health care.
Evidence of Inequality in Kenyan Women’s Mental Health
The evidence of and reasons for inequality experienced by women in Kenya in the sphere of mental health care should be discussed in the context of determinants of health and their ultimate decisive impact on the health of a given population. As defined by the Centres for Disease Control and Prevention (CDC) (2019), determinants of health are the categories of factors that influence health outcomes. Social determinants of health are essential in influencing human health outcomes. The framework that allows for a comprehensive analysis of these factors and how they unfold in the context of mental health of the Kenyan female population is the model developed by Dahlgren and Whitehead in 1991 (Public Health England, 2017). As shown in Figure 1 (see Appendix A), social factors are grouped into five consecutive categories. They are age, sex and constitutional factors, individual lifestyle factors, social and community networks, living and working conditions and general socioeconomic, cultural and environmental conditions (Public Health England, 2017). This framework will allow for assessing social factors pertaining to the subject of analysis.
A specifically designed body, the WHO Global Commission on the Social Determinants of Health (CSDH), emphasised that the lack of social justice has a direct impact on human health and longevity (Donkin et al., 2018). In particular, CSDH identified that the inequalities in health result from the “inequities in the conditions in which people are born, live, work and age, driven by inequities in power, money, and resources” (Donkin et al., 2018, p. 1). Thus, communities’ well-being and health largely depend on social determinants of health, the importance of which is validated by the possibility to improve them, thus improving health outcomes. Moreover, economic factors have been found to be a driving force in health outcomes. As stated by Dupas and Miguel (2017), “higher income levels correlate strongly with longer life spans, lower infant mortality, and reduced illness throughout the life course” (p. 3). Thus, low and middle-income countries like Kenya are more likely to experience health disparities than high-income states.
The quality of mental health of the population is an indicator of the overall health status of the nation, the capability of a given society to develop and strive for a sustainable and fulfilling existence. The WHO’s (2018) definition of mental health indicates that “mental health is a state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community” (para. 2). As stated by Ibrahim (2014), the WHO determined “mental illness as one of the leading causes of disability” the burden of which is experienced on a global scale (p. 394). Indeed, as scholars emphasise, “there is growing international concern about the mental health treatment gap and the need to scale up services to meet mental health needs” (Jenkins et al. 2015, p. 2). Therefore, the prevalence of mental health problems in a given social group hinders the overall nation’s health status and well-being of the population.
The citizens of Kenya exhibit increased rates of psychiatric disorders, demonstrating a general tendency of the country’s population to suffer from poor mental health. These assumptions are made on the basis of the study conducted by Aillon et al. (2013), who examined the prevalence, most common mental health issues, and their comorbidities, including suicidality, in Kenyan primary health care facilities. The study findings indicated that among randomly selected primary care outpatients, over 56% demonstrated psychiatric disorders or suicidal risk (Aillon et al., 2013). The range of mental health issues included anxiety, major depressive disorder, pain disorder, bipolar disorder, bulimia, and others. Mental health disparities for women have been repeatedly identified by scholars conducting research studies with the Kenyan population. As the results of the study by Jenkins et al. (2015) demonstrate, the risk of having a common mental health disorder, including “depressive episode (mild, moderate or severe), obsessive-compulsive disorder, panic disorder, phobic disorder, generalised anxiety disorder and mixed anxiety/depressive disorder,” was “significantly higher in females compared to males” (pp. 4-5). Such a rate of psychiatric problems prevalence indicates an overall poor mental health of the nation and women in particular.
Reasons for Inequalities in Mental Health Care for Women in Kenya
The discussed social determinants of health have direct or indirect effects on inequality in mental health care for women. The reasons for gender inequality in Kenyan mental health care include “poverty, sexual and domestic violence, discrimination and conflicts,” which expose them “to the high prevalence of certain mental disorders such as depression and anxiety” (Bukusi, 2015, p. 19). Equality is essential to health care since categories of population that experience social or economic inequalities and discrimination “have a higher risk of poor mental well-being and developing mental health problems” (Department of Health, 2011, p. 7). Thus, the discussion of each of these reasons of inequality allows for understanding the disparities’ roots and helps to determine the ways in which the core of the problem might be eliminated.
Age, Sex and Constitutional Factors
Some of the significant indicators of health outcomes include age and gender. These elements predetermine health predispositions and the overall likelihood of individuals suffering from particular conditions more than their counterparts. Research findings presented in the study by Gust et al. (2017) indicate that among young Kenyan women aged 18-29, 58% showed a moderate level of psychological distress, and 20% demonstrated a high level. To compare, men obtain a more solid social position regarding the social status and dominating roles in relationships, which exposes women to more psychological challenges (Goodman et al., 2017). Thus, mental health disorders prevail in the female segment, especially young individuals, of the Kenyan population.
Individual Lifestyle Factors
Delays in Seeking Health Care
The delay in seeking health care is one of the characteristics within the individual lifestyle factors that predetermine the quality of mental health in Kenyan women. The diminished likelihood of people to refer to psychiatric care is associated with stigmatisation on the basis of mental health and drawbacks in the health care system in the country. According to Ibrahim (2014), in Kenya, “psychiatric care still remains very institutionalised and centralised – with 70% of all psychiatric beds in Mathari Hospital … and no existing community mental health programs” (p. 393-394). Moreover, as stated by Mendenhall et al. (2018), there is a significant gap between the need for mental health services and their availability. Given such a challenging health care environment in the country, women who are at particular risk of developing psychiatric disorders due to the complexity of their cultural, social, and family roles experience a significant level of inequalities.
Early Sexual Activity and Adolescent Pregnancy
Women’s behaviour, particularly at their early ages, depends on social factors and results in risky sexual behaviours. The lack of proper education and economic security triggers an increased rate of Kenyan youth’s early sexual activity and adolescent pregnancy. Reproductive health issues related to adolescents’ sexual life and early pregnancy cause a significant burden to the mental health of young women, disrupting their educational, vocational, and social functioning and leading to psychological disorders (Osok et al., 2018). Indeed, being exposed to adult responsibilities in adolescence, young girls tend to suffer from postpartum depression, anxiety, and more severe psychological disorders.
Sub-Saharan African countries at large and Kenya in particular experience an increased level of adolescent pregnancies (Osok et al., 2018). Social exclusion and isolation of pregnant adolescent girls due to cultural norms prevailing in Kenya hinders their opportunities to lead healthy social and psychological life (Osok et al., 2018). The problems with the mental health of a young mother have negative implications for families and society. Indeed, according to Mutua et al. (2020), “depressed and anxious mothers have communication difficulties which have a negative impact on the children and family” (p. 2). Moreover, as one of the outcomes of such tendency, this category of the population is underrepresented in a mental health care setting, obtain insufficient attention of specialists, and expresses diminished likelihood to seek professional mental health help (Musyimi et al., 2017). Thus, the problem might deteriorate further without proper addressing from the side of the government.
Social and Community Networks
Women in Kenya are officially considered a vulnerable population in regard to mental health issues. In particular, the Kenya Mental Health Policy identifies that women’s traditional roles in societies expose them to “greater stresses as well as making them less able to change their stressful environment” (Bukusi, 2015, p. 19). Moreover, as the review of the country profile for Kenya conducted by Kiima et al. (2004) shows, throughout the history of mental health policies in the country, there has been no specific initiative addressed women’s mental health specifically, despite such a high rate of disparities. Therefore, it is essential to analyse the reasons for inequalities experienced by the female population in Kenya to determine the most influential factors, the elimination of which would contribute to the improvement of the situation.
Another important reason for mental health inequality among Kenyan women is discrimination against females in various spheres of life. On a general scale, being a victim of discrimination imposes a heightened level of stress, diminished self-worth, and other psychological burdens that might result in more severe mental health disorders, which cause disability and malfunctioning in society (Hack et al., 2020). Moreover, the risk for discrimination and the escalation of harm is associated with stigmatisation and discrimination among women who already suffer from mental health disorders since they lack protection and support from specialised institutions (Gyamfi, Hegadoren and Park, 2018). Thus, the burden of discrimination has negative psychological implications. Overall, women are discriminated against in Kenya due to their inferior social roles in comparison to men.
Living and Working Conditions
Domestic Violence and Sexual Abuse
As it has been identified earlier in the report, women in Kenya live in a patriarchal society where they occupy an inferior position in society, family, marital relationships, and cultural interactions compared to men. Therefore, such a tendency to being in an oppressive and dominating environment characterises the likelihood of the female Kenyan population to be victims of domestic violence and sexual abuse. As studies have identified, “an estimated 42% of Kenyan women in married or cohabitating partnerships experience physical or sexual intimate partner violence” (Goodman et al., 2017, p. 257). Similar rates indicating over 41% in women and 11% in men experiencing intimate partner violence have been identified by Goyette et al. (2018). The reasons for such high rates have been associated with the overall gender inequality prevailing in the state and in romantic relationships, in particular. Moreover, forced sexual intercourse was found one of the most prevalent factors for psychological distress (Gust et al., 2017). Such disparities in women’s exposure to violence, both physical and psychological, become decisive factors in the development of a variety of mental health disorders.
Husbands are motivated by cultural and social norms when engaging in violent behaviours against women. As stated by Haushofer et al. (2019), abusive men in Kenya are commonly motivated by either instrumental or expressive triggers, where they want either to retrieve particular resources from their wives or partners to express their dominance. The severity of this factor’s influence on women’s well-being is validated by the long-term effects and associated health outcomes. In particular, as research found, “compared to women who are not in abusive relationships, women who are exposed to intimate partner violence reported higher rates of risky sexual behaviours, increasing their risk for acquiring HIV and other sexually transmitted infections” (Burns et al., 2020, p. 4). According to Winter, Obara, and McMahon (2020), women exposed to physical, emotional, psychological, and sexual abuse in informal settlements have “higher odds of gynaecological and reproductive health issues, psychological distress, depression, suicidality, and substance use” (p. 1). Thus, it is evident that women’s inequality in social life impacts their mental health, making them a vulnerable population.
An essential aspect of domestic violence and sexual abuse as a reason for inequalities in women’s mental health in Kenya is the number of characteristics associated with the likelihood of females being victims of intimate partner violence. The study conducted by Memiah et al. (2018) identified that among the factors associated with increased risk for intimate partner violence were the sexual unassertiveness of victims and their having one sexual partner, unlike their spouse. Moreover, women who experienced domestic violence and sexual abuse reported that they “received money, gifts, or favours in return for sex, had no knowledge on HIV, experienced an early sexual debut of fewer than 18 years and felt that their partners were justified in beating them” (p. 2). Young age and early sexual activity have also been defined as significant contributors to the risks of being sexually abused (Mathur et al., 2018). These factors are shaped by the deficiency of adequate social welfare policies that would have to ensure proper economic stability, education, and safety for vulnerable populations.
Women experience biased attitudes and stereotypes when seeking employment, advances across career ladders, and requesting fair payment (Ebuenyi et al., 2019). Similarly, women are underrepresented in the political sector and leadership in the country (Were, 2017). Such a continuous burden causes stress and leads to poor mental health. Moreover, the lack of female representatives in the decision-making sector of government might be an explanation of the insufficient addressing of women’s problems in the national health policy. Therefore, the number of women in leadership and politics should be increased through women’s empowerment and education improvement. Moreover, according to Ebuenyi et al. (2019), the population with mental health issues, which is predominantly comprised of women, is particularly exposed to difficulties with employment and are often unemployed due to discrimination and stigmatisation.
General Socioeconomic, Cultural and Environmental Conditions
The economic, social, and demographic indicators characterising the country might be helpful in interpreting the context where social determinants of health emerge. Kenya’s Gross Domestic Product (GDP) steadily grows, reaching US$1040.55 in 2013; however, the level of poverty remains high, reaching over 45% (Jenkins et al., 2015). Education, as one of the social determinants of health, is characterised by medium quality with an approximately 87% literacy rate in adults; “life expectancy at birth is 57 years” (Jenkins et al., 2015, p. 2). Moreover, high rates of urbanisation, insufficient development of agriculture, and unfavourable climate hinder food security for the population, resulting in diminished health. These disparities conditioned by social determinants of health have a negative impact on women’s mental health. In addition, ethnicity plays a role in the health behaviours of the population. Ethnic and racial minorities are in particularly vulnerable positions since their interests are underrepresented in the health care sector.
One of the main causes of disproportionate mental health impairments in the population is economic disadvantage. Scholars have been particularly interested in the correlation between economic status and the risks for developing common mental health disorders, particularly prevalent of which are depression and anxiety. As found by Ridley et al. (2020), there is a bi-directional causal relationship between poverty and mental health, implying that insufficiency of financial resources causes excessive distress leading to depression and anxiety; on the other hand, impaired mental health diminishes one’s opportunities for employment, which ultimately leads to poverty. Therefore, underprivileged populations are disproportionately exposed to psychological disorders.
Indeed, in Kenya, as well as in other countries of Sub-Saharan Africa, women are marginalised, face discrimination, live in poverty, and are disproportionately exposed to diseases (Kiima and Jenkins, 2010; Mwiti and Goulding, 2018). According to Jeffries et al. (2019), poverty has been identified as a driver for women’s criminalisation and mental health disorders. Importantly, poverty often becomes a trigger for women’s exposure to other factors hindering their mental health, including engagement in relationships with intimate partner violence, food insecurity, and others (Burns et al., 2020). Since women are predominantly dependent on men financially, economically, and culturally, their freedom and independence are insufficient, which exposes them to more severe experiences of poverty.
Similar to poverty, food insecurity is associated with diminished mental health. This indicator is predetermined by cultural issues; namely, Kenyan women disproportionately experience food insecurity due to their culturally inherited dependence on males. A meta-analysis conducted by Pourmotabbed et al. (2020) indicated positive statistical relationships between food insecurity and depression, stress, and anxiety. Therefore, women are more likely to suffer from the psychological burden of this factor. Indeed, as a study by Maynard et al. (2018) identified, food insecurity is characterised by persistent “associations with mood and anxiety disorders and suicidal ideation, particularly among women” (p. 2). Thus, women have been found to be unequally exposed to mental health outcomes as a result of food insecurity worldwide. The overall low-medium economic status of the country implies a higher rate of poverty and poor nutrition. In particular, water scarcity and food insecurity experienced by women in both rural and urban areas of Kenya have been defined as significant stressors that cause depressive disorders (Boateng et al., 2020). Overall, diminished access to food and its poor quality results in an unhealthy diet that commonly threatens physical and mental health.
Critical Discussion of Government Policies and Interventions
Throughout its history, social welfare policies and health interventions in Kenya have been non-systematic and particularly generalised without proper attention paid to mental health or vulnerable populations separately. Since the state undergoes developmental changes, it is likely that health issues might be properly addressed for the purposes of the improvement of the population’s well-being. Therefore, it is imperative to analyse currently applied policies, detect gaps in them, and discuss recommended directions for improvement.
Currently Applied Policies
Governments are commonly responsible for operating under the national law and international regulations and health care standards when tackling health issues with specific policies. However, in Kenya, there is no national mental health policy in place (WHO, 2011). Mental health is addressed within the general health care policy as one of its areas. Moreover, as stated by Ndetei, Muthike, and Nandoya (2017), the country’s mental health law is outdated and fails to address contemporary, relevant issues.
The Kenya Mental Health Policy 2015-2030 is an official national policy that is considered “a commitment to pursuing policy measures and strategies for achieving optimal health status and capacity of each individual” (Bukusi, 2015, p. iv). Within the framework of this policy, mental health is attributed with much significance to the overall health care system. The mental health of the population is considered to influence “individual and community outcomes such as healthier lifestyles, better physical health, improved recovery from illness, fewer limitations in daily living, higher education attainment, greater productivity, employment and earnings, better relationships with adults and with children, more social cohesion and engagement and improved quality of life” (Bukusi, 2015, p. iv). Thus, improvement of mental health and elimination of inequalities will be a contribution to the future of the country.
Gaps in the Current Policies and Interventions
Strikingly, with a high prevalence rate of psychiatric disorders and overall poor mental health of the population, there is no specific national policy addressing mental health in Kenya. Indeed, as the data retrieved from the official reports on Kenya’s country profile generated by WHO indicates, “an officially approved mental health policy doesn’t exist,” which implies that no policy that addresses the inequalities experienced by women exists, too (WHO, 2011, p. 1). Such a deficiency in policy-making might be associated with a piece of evidence found in the same document, where it is stated that “mental health expenditures by the government health department/ministry are not available,” meaning that this sphere of health care lacks sufficient financing (WHO, 2011, p. 1). Thus, the essential gaps in regards to mental health inequalities in the female population of Kenya are the lack of a specifically designed mental health policy and insufficient funding.
Furthermore, the interventions that are aimed at maintaining a safe and psychologically healthy environment in families, organisations, and communities lack primary resources and programs. Indeed, as the review of a report on violence prevention in Kenya shows, the country has insufficient legislature against sexual violence, limited enforcement of intimate partner violence laws, and no programs for “dating violence prevention in schools” regardless of high rates of adolescent pregnancy and female victimisation (WHO, 2014, p. 1). Similarly, victim laws are of limited enforcement rate, adult protective services do not exist, and mental health services are of diminished accessibility (WHO, 2014). Finally, Kenyan authorities do not initiate sufficient national surveying for collecting violence data. Among the numbers and incidents reported by WHO (2014), only child maltreatment data is available. Thus, national policies and interventions are characterised by a large gap in information on mental health determinants and factors both in the general adult population and women in particular.
Apart from the gaps in the overall mental health policies associated with the failure to determine specific resources to the acknowledgement of women’s inequality experiences, there are some problematic issues with the mental health program that is currently being implemented. Drawbacks in the Kenya Mental Health Policy 2015-2030 within the context of women’s experience are related to the insufficient addressing of female individuals’ needs by the policy. Although women are identified as a vulnerable population addressed by the document, there is limited information pertaining to the steps aimed at the elimination of gender inequalities in mental health.
To ensure equality in mental health in Kenya, decisive measures and a well-designed mental health policy should be initiated. The examples of highly-developed countries’ health policies demonstrate that adequate attention to psychological well-being, investment in mental health care, and the addressing of the needs of vulnerable populations are pivotal in bridging inequality (Mental Health Taskforce, 2016). Moreover, women as a vulnerable population should be given priority when designing new policies. The discussed reasons for inequality, including discrimination, sexual abuse, domestic violence, poverty, food insecurity, and adolescent pregnancy, should be eliminated by proper means. One of the ways to improve the effectiveness of health care in general and the provision of adequate mental health care, in particular, might be the collaboration between private and public sectors (Suchman, Hart and Montagu, 2018). Such an approach would benefit the economy and allow for consistent development of the country in the long run.
The analysis of mental health inequalities among Kenyan women revealed females’ vulnerability in light of the country’s social, cultural, economic, and political reality. Through the application of the social determinants of health model developed by Dahlgren and Whitehead, the spheres of life have been analysed in-depth. It was identified that women are disproportionately exposed to discrimination, poverty, food insecurity, abuse, intimate partner violence, and diminished protection from the government. These issues cause their diminished mental health further to deteriorate their well-being. The development of gender-sensitive mental health policies is required to eliminate the reasons for inequalities and improve women’s access to therapy. Social policies and gender mainstreaming interventions are needed to eliminate society’s discrimination as a stigmatising factor for women’s mental health. Apart from mere mental health policy, the overall social welfare system of the country should be improved. The education of young women and the whole population should be prioritised as a contributor to future economic prosperity and social development. The improvement of the situation and bridging the gap in women’s mental health might also be achieved through an increase of female representation in leadership and politics to ensure advocacy for women’s rights in government.
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Figure 1. The Dahlgren and Whitehead Model of Health Determinants.
Sourse: Public Health England, 2017.