Discussion

This study assessed how gender roles in Pakistan can affect anxiety levels and behavioural responses among men and women during the COVID-19 pandemic. Both men and women were found to be anxious because of the COVID-19 pandemic. However, compared with men, more women perceived the disease to be fatal, and women were more likely to engage in preventive behaviour. 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 because of the male-dominated access to internet facilities in Pakistan. 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. Indeed, several reports on internet penetration found that at least three-fourths of internet and social media users in the country are male.^{Reference Kemp24}

There were also significant differences in respondents’ cities of permanent residence. Three-fifths of all of the female participants and two-fifths of the male participants were from Karachi. This was expected, as the survey tool was disseminated over a Karachi-based university hospital's Facebook page. There are significant provincial disparities in access to internet facilities. The fewest respondents were from Balochistan, further reflecting the province's poor internet accessibility. More male (a third) respondents were from smaller cities and towns throughout the country, compared with a tenth of female respondents. These differences can be attributable to fewer women having mobile phone ownership and social media usage in smaller towns/cities.^{Reference Kemp24}

Although men and women considered themselves equally susceptible to a COVID-19 infection, women were more likely to perceive the disease to be fatal and worry about their own and their family's healthcare. Apart from their professional role, women serve as primary caregivers within their family.^{Reference Roy, Tripathy, Kar, Sharma, Verma and Kaushal25} Women's greater sensitivity toward familial roles and responsibilities was also reflected in a European study, which noted that pregnant women had heightened stress levels regarding the health status of their older relatives, children and unborn babies during COVID-19.^{Reference Corbett, Milne, Hehir, Lindow and O'Connell26} Similarly, a comparison of COVID-19-related content shared on Twitter by men and women based in the USA 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.^{Reference Thelwall and Thelwall27}

Men's casual attitude can be explained by gender-disaggregated data (until 24 June 2020) on COVID-19 in Pakistan, which shows that three-quarters of diagnosed cases and deaths were among men compared with a quarter among women.²⁸ Gender-specific patterns of smoking are implicated as a significant contributor to disease severity among men.^{Reference Cai29} It was also noted that men in our study had a higher likelihood to start smoking cigarettes and using recreational drugs during the pandemic, compared with women. It is therefore not surprising that excess mortality during the pandemic was higher among men complemented by comorbid non-communicable diseases and a delay in seeking lifesaving care.^{Reference Lai, Pasea, Banerjee, Hall, Denaxas and Chang30,31}

Unequal share of household responsibilities and women staying home because of school closure, lockdown and work-from-home orders may have resulted in women being more stressed. Housework is largely undocumented and unpaid.^{Reference McLaren, Wong, Nguyen and Mahamadachchi32} Working mothers spend more hours engaged in household work and child care than their husbands. One study conducted in the UK during the lockdown estimates that, on average, mothers spend 11 hours more per week on child care than fathers. Single mothers have less time to spend on child care than partnered mothers, as they are single-handedly forced to bear the brunt of the shifts in the job market.^{Reference Zhou, Hertog, Kolpashnikova and Kan33} This additional housework could result in women permanently exiting from the labour market and add to their anxieties. These developments are concerning and emphasise the urgent need to develop labour policies that protect women in the workforce.

Despite being at lower risk of exposure to the disease and subsequently succumbing to it, women in this study were more likely to practice hygiene measures and social distancing, such as avoiding going to meat shops/markets, going out and going to work. The Gallup survey conducted during various waves of the pandemic (April 2020 to August 2021) shows that Pakistani women are more likely to stay at home as a preventive measure.^{Reference Gallup Pakistan34} One digital ethnographic study in Pakistan suggests that one in four men reported having attended Friday (congregational) prayers during the early phase of the pandemic in 2020.^{Reference Ghadyani, Hussain, Odeh and Wood35} Although this finding might imply that men are considerably less interested in social distancing practices, men constitute a majority of waged and salaried workers in cities, and only a fifth of Pakistani women are part of the labour force.³⁶ These differences in employment could explain why men are less likely to conform to social distancing practices than women.

Women were more likely to report that they avoid going to hospitals during the pandemic as a measure of social distancing. 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 new-born healthcare in low-and middle-income countries could result in an additional 1.7 million pregnant women and 2.6 million new-borns in need of urgent medical care.^{Reference Riley, Sully, Ahmed and Biddlecom37} Research conducted during the 2013–2016 Ebola outbreak in Western Africa shows how sexual and reproductive health was adversely affected by strains on healthcare systems, which often resulted in interruptions of care and redirected resources.^{Reference Menéndez, Lucas, Munguambe and Langer38} A 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 Pakistan, reports that its activities have been reduced by up to 40% in Pakistan, as a result of the pandemic.^{Reference Hussain39} Furthermore, some studies noted how the 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.^{Reference de Paz, Muller, Munoz Boudet and Gaddis40,Reference Wenham, Smith and Morgan41}

Although women refrained from accessing health facilities during the pandemic, as a measure of social distancing, they still considered doctors as the most reliable source of information on COVID-19. This is consistent with findings from the Gallup survey in Pakistan.^{Reference Gallup Pakistan34} Hence, social media awareness campaigns and telemedicine engaging doctors can target women who tend to be more socially isolated than men during the pandemic. A study in Karachi has also commented on the need to develop psychosocial support, including essential assistance through online support groups, awareness through television or social media, and telemedicine for women.^{Reference Asim, Ghani, Ahmed, Asim and Qureshi42}

In this study, women showed higher levels of anxiety and depression compared with men, which suggests that they hold a greater psychiatric burden of the COVID-19 pandemic. One study conducted in China established that 54% of respondents suffered some psychological effect from the outbreak.^{Reference Wang, Di, Ye and Wei43} This Chinese study found that women have suffered a greater psychological effect as a result of the pandemic compared with men, and may be three times more anxious than their male counterparts. Similarly, our findings corroborate with data from Turkey, where women had significantly higher scores of depression and anxiety.^{Reference Özdin and Bayrak Özdin44} Surely this indicates that women have a higher vulnerability for developing anxiety disorders.

This is a novel study accounting for differences in perceptions of men and women, with regards to risk perceptions, anxiety levels and behavioural responses to COVID -19. However, the study had some limitations. The survey could only be accessed by the literate population in Pakistan with access to internet, so the generalisability of results needs to be viewed with caution. Moreover, in this study, most of the respondents were aged <35 years, which may not accurately represent the views of the older population who are at greater risk of contracting COVID-19. Nevertheless, as the majority of the population in Pakistan is <30 years of age, the responses are likely to represent the perceptions of the literate general population in Pakistan. Additionally, the perceptions are related to the early phase of the pandemic, and the trajectory of COVID-19-related beliefs over time is yet to be determined. However, the anxieties around COVID-19 still prevail. Indeed, the latest Gallup survey (2021) in Pakistan shows that approximately half of Pakistanis in urban areas are worried if people around them do not wear masks in public.^{Reference Gallup Pakistan34} Moreover, a large survey assessing anxiety and depression symptoms in the USA found that women were equally anxious at the start of the pandemic as they were in August 2021.⁴⁵ Hence, the recommendations of our study to develop gender-responsive psychosocial support strategies for women, and provide additional support in their employment and child care, are needed more than ever, as we continue to battle with the pandemic.

In summary, this study assessed the gender differences in risk perceptions (susceptibility and severity of the disease), preventive behaviour (social distancing, enhanced hygiene measures) and anxiety levels during the early phase of COVID-19. The results highlight the need for gender-responsive policies in mitigating the health and economic impact of the COVID-19 pandemic. The global economy has ground to a stop, and respondents face severe economic uncertainty. Differences in type of work based on gender may result in men being unable to maintain social distancing. Furthermore, it results in women being burdened with increasing housework, which can affect their ability to engage in professional work and add to their stresses. This indicates the urgent need to develop labour laws to protect the workforce, particularly women. Furthermore, the results indicate potential avenues of disseminating gender-specific health communication. Involving doctors in healthcare communication targeting women, focusing on their need to avoid skipping hospital appointments, might prove effective. Research is required to assess strategies of reducing the frequency of in-person maternal, neonatal and child health appointments, and the potential of telemedicine for all women to remain in contact with the health system. As men are more likely to trust what they read on social media, especially if it is shared by friends or family, social media campaigns and radio programming may be effective in disseminating information, and the latter could be an effective tool to diverse audiences.^{Reference Abrams and Greenhawt46} This health communication should include messages about men's higher risk of dying owing to COVID-19, a lack of non-communicable disease management and smoking cessation. Most importantly, based on the discussion, policy measures must be taken to ensure the continued provision of quality healthcare to women.

Differences in type of work based on gender may result in men being unable to maintain social distancing. Furthermore, it results in women being burdened with increasing housework, which can affect their ability to engage in professional work.