INTRODUCTION

Gender roles refer to the roles expected from men and women in social and cultural terms (1). The development and socialization of gender roles begin in the family environment (2). Some of the most important aspects of human life are heavily regulated by the gender roles and gender development is vital in human life (3,4).

Gender roles are not only regarded as a difference but also indicate power inequality and imbalance mostly against women (5,6). Therefore, it has been reported that there is a relationship between mental health and gender roles (7). In another study which was conducted with a large sample of adults in Russia showed that traditional gender roles based on gender inequality are associated with depression and anxiety disorder (8). It has been reported that characteristics related to gender roles can also affect adolescent mental health. Gender inequalities were associated with a tendency to depression and conduct disorder (9,10).

The coronavirus disease-2019 (COVID-19) pandemic and quarantine have psychological effects on people (11-13). It is estimated that mental problems and the need for support increase in this period (14). In addition, face- to-face education was suspended in schools, out-of-home activities decreased, and the time spent at home increased (15-17). During the pandemic period, parents reported difficulties in balancing their responsibilities and providing motivation for learning due to practices such as distance education (18). In a study examining the effects of distance education on parenting activities during the pandemic period (17), it was reported that two out of five parents met the criteria for depression or anxiety disorder. In another study, depression and anxiety symptoms of parents with children in education were investigated in terms of variables such as marital relationship, perceived social support, and the school that child attended (19). During the pandemic, gendered power relations between spouses working from home were investigated and examined in a qualitative study. In that study, attention was drawn to the disadvantaged position of women (20). However, to the best of our knowledge, there is no study that examines the relationship between gender roles and depressive or anxiety symptoms in the COVID-19 pandemic period when parents’ domestic responsibilities increase.

Gender role-related responsibilities in the family are important for the development of gender role attitudes in individuals (2). Also, gender - type attitudes are associated with mental problems (8). In the COVID-19 pandemic period, when the domestic responsibilities of parents increase (18), it is possible that the unequal role distribution may affect the mental health of the parents and indirectly the mental health of the children. Therefore, the purposes of this study were determined:

i To study the effect of COVID-19 pandemic restrictions on depression/anxiety symptoms in the family,

ii To investigate the relationship between parental gender role attitudes and children’s depression/anxiety symptoms,

iii. To investigate the relationship between gender role attitudes and depression/anxiety symptoms in parents with school-aged children.

For these purposes, two study groups were formed on the basis of the severity of their experience with COVID-19 pandemic restrictions. Study groups were compared in terms of maternal gender role attitudes, paternal gender role attitudes, maternal depression/anxiety/stress symptoms, paternal depression/anxiety/stress symptoms, and depression/anxiety symptoms in children.

METHODS

This study is a cross-sectional comparative survey study. Only parents with school-aged children were included. To examine the impact of COVID-19 restrictions, two distinct groups of families were formed. Study groups were determined by participants’ responses to three questions. Families that suspended all social, economic or educational face-to-face activities are grouped as group 1. On the other hand, families that maintain their face-to-face activities with minimal restrictions are grouped as group 2.

Hence, families in group 1 are affected more by restrictions. Both parents mostly stayed home for the entire period and suspended almost all face- to-face social, economic and educational activities. This criteria has particular importance in our study, as having both parents affected by restrictions, the outcome could be more prominent. Therefore, if the parents had different restriction experiences, they were not included in the study.

Families in group 2 are significantly less affected by the restrictions compared with those in group 1. Both parents maintained face-to-face activities during COVID-19 pandemic restrictions. Couples in group 2 kept going out and continued their daily life because of their professions, and duties were considered less affected by restrictions.

Participants were recruited from Pediatric Outpatient Clinics in University of Health Sciences Türkiye, Başakşehir Çam and Sakura City Hospital between June 16 and July 16 2021. The target number is determined based on statistical significance and is explained in section 2.2.

All parents included in the study had at least one child between the ages of 6 and 18. Single parents were excluded. Due to the potential impacts on depression and anxiety symptoms, a history of chronic disease in oneself or a child, a history of loss of a loved one in the last six months, and being unemployed due to the pandemic were determined as exclusion criteria. Traumatic event history was also evaluated by the Life Events Checklist (LEC) as traumatic events are considered a risk factor for depression (21).

The minimum sample size (n) was found to be 21 patients and 21 controls (details can be found in the statistical analysis section). Group 1 consists of 21 couples, whereas group 2 consists of 22 couples.

The Declaration of Helsinki is used as the standard of medical ethics in the study design. University of Health Sciences Türkiye, Başakşehir Çam and Sakura City Hospital reviewed and approved all study materials (no: 2021.06.109, date: 02.07.2021). Informed consent was obtained from the parents who agreed to participate in the study.

Instruments

The sociodemographic data form was created by integrating the measurement tool developed by Kalaycıoğlu et al. (22). A socioeconomic status index (SES) is calculated as quantitative data. Higher scores mean higher socioeconomic level (22). Also, there were questions on the child’s gender, parent’s age, the number of children and education level.

The Gender Role Attitudes scale (GRAS) was developed by García-Cueto et al. (23). The scale was adapted to the Turkish population by Bakioğlu and Türküm (24). Higher scores mean egalitarian attitudes toward gender. Lower scores signified a gender-type attitude in this study. Depression Anxiety and Stress scale-21 (DASS-21) was developed by (Henry and Crawford, 2005) (25). It is widely used to assess depression, anxiety, and stress. DASS-21 was adapted to the Turkish population in community and clinical samples by Sarıçam (26) and found to be reliable. It is a self-report scale consisting of 21 questions on depression, anxiety, and stress subscales. In this study, clinical threshold levels are accepted as 9 for depression subscale, 7 for anxiety subscale, and 14 for stress subscale (27).

Revised Child Anxiety and Depression scale-Parent Version (RCADS-P) assesses parent reports of children’s depression and anxiety symptoms and was renovated in 2000 by Chorpita et al. (28). The Turkish validity study was carried out by Gormez et al. (29). In this study, mothers were asked to complete the RCADS-P for their school-age children evaluated in the pediatric outpatient clinic.

The LEC was used to screen potentially traumatic events in the subject’s lifetime (30). LEC is a 17-item self-report measure. For each question, subjects select one of the following answers: “happened to me”, “witnessed it”, “learned about it” and “part of my job”. A past traumatic experiences score was calculated for each subject based on their answers, with a possible range of 0 to 68 points.

Statistical Analysis

Statistical analyses were conducted using SPSS 21.0 software (IBM Corp., Armonk, NY, USA; licensed to Istanbul University). The sample size was estimated using Epi Info 2000 Statcalc software (Centers for Disease Control, Atlanta, GA) with a predicted exposure of 10% and 50% for controls (group 2) and patients (group 1), respectively (31-33). Accordingly, the minimum sample size (n) based on the statistical power 0.80 was found to be 21 patients and 21 controls. The normal distribution of continuous variables was assessed using the skewness-kurtosis and the Kolmogorov-Smirnov test or Shapiro-Wilk test. The logarithmic transformation was used for nonnormal data. Pearson’s chi-square test or Fisher’s Exact test was used to compare categorical data. The Student t-test was performed on the continuous data with normally distributed. Spearman’s rank correlation test was used to compare nonnormally distributed continuous variables. Finally, linear regression analysis was performed. A p-value of <0.05 was considered significant.

RESULTS

Descriptive Data of Study Groups

Demographic Variables

In this sample, 9 (42.9%) of the children in group 1 and 11 (50,0%) of the children in group 2 were female. Mean education level by years was 13.4 (±4.6) in group 1 and significantly lower than that in group 2 (16.2±4.0, p=0.04). Mean parent ages were 40.2 (±4.3) in group 1 and 41.2 (±6.6) in group 2. The number of school-aged children that parents have were 1.6 (±0.6) in group 1 and 1.59 (±0.6) in group 2. The mean ages of children were 10.0 (±3.1) in group 1 and 10.9 (±4.1) in group 2. The child’s gender, parent and child’s mean ages and number of school-aged children that parents have were similar in the study groups (p=0.63; p=0.56; p=0.43; p=0.89). Mean SES is 70 (±20.8) in group 1 and 73.2 (±14.0) in group 2. There was no significant difference between SES of groups (Table 1).

Psychiatric Parameters

Fifteen (71.4%) mothers in group 1 and 12 (54.5%) mothers in group 2 had depressive symptoms higher than the clinical threshold. Seventeen (81.0%) mothers in group 1 and 20 (90,9%) mothers in group 2 had stress symptoms higher than the clinical threshold. Twenty one (100.0%) mothers in group 1 and 22 (100.0%) mothers in group 2 had anxiety symptoms higher than the clinical threshold. Nine (42.9%) fathers in group 1 and 8 (36.4%) fathers in Group 2 had depression symptoms higher than the clinical threshold. 12 (57.1%) fathers in group 1 and 11 (50.0%) fathers in group 2 had stress symptoms higher than the clinical threshold. Nine (42.9%) fathers in group 1 and 4 (18.2%) fathers in group 2 had depression symptoms higher than the clinical threshold. Differences between groups 1 and 2 were not statistically significant in terms of maternal depression (p=0.25), stress (p=0.34), anxiety and paternal depression (p=0.66), stress (p=0.63), and anxiety at the clinical level (p=0.07) (Table 1).

Comparison of DASS, RCADS-P, and LEC Scores Between Groups

The mean mother DASS anxiety score was 13.1±2.5 and mean father DASS anxiety score was 4.3±4.5 in group 1 and both of which were significantly higher than group 2 (Mother DASS: 11.7±3.9; p=0.09, Father DASS: 1.59±2.1, p=0.04). While mean mother GRAS scores were significantly lower in group 1 (47.5±18.4) compared to group 2 (56.0±11.3, p=0.03), mean father GRAS scores did not show significant difference between the groups (group 1: 64.9±19.4, group 2: 57.5±9.5, p=0.18). Mother LEC, mother DASS depression, mother DASS stress, father LEC, father depression, father stress, and RCADS-P scores were similar for both groups (p=0.50, p=0.24, p=0.94, p=0.95, p=0.18, p=0.38, p=0.14, p=0.27) (Table 2).

Correlational Relations Between GRAS, DASS, and RCADS-P Within Groups

In group 1, mother’s GRAS scores were negatively and moderately correlated with mother’s DASS depression scores (r=-0.598, p=0.004) and were also negatively and highly correlated with RCADS-P scores (r=-0.69, p=0.005). There was also a positive and moderate correlation between RCADS-P scores and father’s GRAS scores (r=0.48, p<0.001).

In group 2, while there was no association between mother’s GRAS scores, DASS and RCADS-P scores; father’s GRAS scores were positively and moderately correlated with father’s DASS depression scores (r=0.56, p=0.006). Also, father’s GRAS scores were positively and highly correlated with father’s DASS stress and anxiety scores (r=0.62, p=0.002; r=0.61, p=0.002) (Table 3).

Predictors of DASS and RCADS-P Scores

Predictors of parameters that were defined as the scores significantly correlated with GRAS scores were investigated by stepwise regression analysis (Table 4).

First, father’s DASS depression subscale scores were positive [β: 0.55, 95% confidence interval (CI): 0.20-0.54, p=0.001] and mother’s GRAS scores were negative (β: -0.8, 95% CI: -0.92- -0.03, p= 0.034) predictors of mother’s DASS depression subscale scores. Mother’s DASS total scores (β: 0.34, 95% CI: 0.31-1.34, p=0.002) and father’s GRAS scores were positive (β: 0.62, 95% CI: 1.43-3.15, p=0.001) and mother’s GRAS scores were negative (β: -0.35, 95% CI: -1.31-0.28, p=0.003) predictors of the father’s DASS total scores. Mother’s DASS total scores were positive (β: 0.49, 95% CI: 0.60-1.74, p=0.001) and mother’s GRAS scores (β: -0.43, 95% CI: -1.53- -0.45, p=0.001) were negative predictors of the RCADS-P scores (Table 4).

DISCUSSION

In this study, it was found that in group 1 both mothers and fathers had higher anxiety levels than in group 2. Gender-type attitudes of mothers are positively and moderately associated with maternal anxiety and are also positively and highly associated with child depression/anxiety symptoms. On the other hand, egalitarian attitudes of fathers in group 2 were positively associated with depression, stress, and anxiety symptoms in fathers. In regression analysis, maternal gender-type attitudes were found to be a predictor of maternal anxiety and depression/anxiety symptoms in children. Moreover, paternal egalitarian attitudes are found to be a predictor of paternal depression, stress, and anxiety symptoms.

Differences Related to COVID-19 Restrictions

Similar to our results, it was previously reported that parents with children younger than 18 years had very high rates of depression and anxiety disorders during the COVID-19 pandemic (34). In our sample, it is observed that parental anxiety levels in group 1 are higher than those in group 2. Social isolation and changes in daily routines may affect anxiety management (14) and cause parents to report higher anxiety. However, it can also be challenging to continue going out and working in pandemic conditions. As a matter of fact, parental depression and stress levels in group 2 do not show differences compared with those in group 1.

Gender-typed Attitudes and Depression/Anxiety/Stress Symptoms in Mothers

Although symptom levels are similar in the groups, associated factors might be different. In our study, gender role attitudes are examined among these factors. In group 1, maternal gender-type attitudes were associated with maternal anxiety and depression/anxiety symptoms in children. This relationship may have been found in group 1 as gender-type attitudes impose more domestic labor on women (35). Recently, gender inequality and mental health problems were investigated in a large sample in Russia, and traditional gender role attitudes were found to be associated with depressive symptoms in adults (8). Parallel to that study, in group 1, gender-type attitudes and depressive symptoms are associated in mothers. Additionally, gender-type attitudes were found to be predictors of mother depression. Consistent with interpersonal theory (36), spouse depression is also observed as a predictor of mother depression.

Gender-typed Attitudes and Depression/Anxiety/Stress Symptoms in Fathers

It has been claimed that most traditional gender roles create disadvantages for women (5,6). In our study, while gender-type attitudes were associated with mother’s depression, egalitarian attitudes were significantly associated with fathers’ depression, stress and anxiety. It has been reported in the literature that men who internalize traditional gender roles seek less psychological help and have limited emotional expression (37). Therefore, it can be suggested that in our sample, fathers who internalized egalitarian attitudes could recognize and express their symptoms more, while fathers with more gender-type attitudes may have masked the symptoms. However, the relationships between egalitarian attitudes and fathers’ depression, stress, and anxiety symptoms were observed only in group 2. Therefore, it can be concluded that fathers have difficulties in domestic responsibilities while working with the COVID-19 pandemic conditions outside their homes.

Parental Gender Role Attitudes and Depression/Anxiety Symptoms in Children

Maternal gender-type attitudes were related to children’s depression and anxiety symptoms. Although the relationship between gender role attitudes and psychological symptoms in adolescents has been reported in the literature (10), no study investigating parental attitudes and child symptoms has been found. The positive association between maternal gender-type attitudes and child depression/anxiety symptoms can be explained by the fact that children with maternal depression are at risk for psychopathology. Our findings showing that gender-typed mothers have more depressive symptoms and that maternal depression and maternal gender-typed attitudes predict child depression/anxiety symptoms are consistent with this data. Gender role attitudes are reported to be transmitted from generation to generation; therefore, it is possible that children with gender-type mothers have more gender-type attitudes. However, as a limitation, children’s gender role attitudes are not examined in this study, so we cannon make any comments about children’s gender role attitudes. Based on the literature and these findings, it can be suggested that maternal gender-type attitudes are related with depression and anxiety symptoms in both children and mothers. On the other hand, fathers’ egalitarian attitudes were positively associated with children’s depression/anxiety symptoms in group 1. Before the pandemic, it was pointed out that paternal adaptive strategies are associated with children’s emotional symptoms in a well-educated sample (38). After the pandemic, it was found that parental dynamics and children’s well-being were negatively affected by COVID-19 pandemic restrictions (39). In parallel, in our study, differences between study groups were obtained in this term. Risks and protective factors such as individual characteristics, family relations, and family characteristics (39). Because of our study, it can be considered that gender-type attitudes may be one of these risk factors. A trancendecent perspective claimed that domestic labor must not be allocated by sex (40). More egalitarian fathers may have had more difficulty balancing their domestic responsibilities in the event of confinement due to restrictions. In addition, family dynamics may have been more affected.

The significance and contribution of this study can be summarized in four major points. First, this is the first study that investigates the relationship between gender role attitudes, mental health, and COVID-19 restrictions. Also, the relationship between parents’ gender role attitudes and the child’s mental symptoms has not been investigated before. Second, although psychiatric disorders have multifactorial etiologies, moderate/high correlation results are obtained through the study’s exclusion criteria. Third, parents are included in the study as couples and a multidimensional evaluation is made. Fourth, by comparing families who were fully restricted with those who were partially restricted, it is shown that psychiatric symptoms associated with gender-type attitudes may differ according to living conditions. There are also some limitations to our study. The first limitation is that the gender role attitudes of children were not evaluated. Second, depression/anxiety symptoms in children were evaluated only from mothers. Lastly, participants were recruited from the pediatric outpatient clinic. Therefore, the generalization of the results is limited.

CONCLUSION

This study investigated the relationship between COVID-19 restrictions and gender role-associated psychiatric symptoms for the first time. Our findings showed that the restrictions of the COVID-19 pandemic impact mental symptoms related to gender role attitudes. The association between parental gender role attitudes and the child’s psychological symptoms was also investigated for the first time in this study. Our results emphasize the importance of attitudes toward gender equality in terms of women’s mental health. On the other hand, the relationship between gender role attitudes and men’s mental health is controversial, and further investigation in this area is needed.

Acknowledgments

The authors would like to thank Dr. Muhammed Said Boybay and Saadet Boybay for providing language help, proof reading of the article, and data entry.

ETHICS

Ethics Committee Approval: University of Health Sciences Türkiye, Başakşehir Çam and Sakura City Hospital reviewed and approved all study materials (no: 2021.06.109, date: 02.07.2021).

Informed Consent: Informed consent was obtained from the parents who agreed to participate in the study.

Authorship Contributions

Surgical and Medical Practices: Z.K., N.C.K., S.T., B.D., Concept: N.C.K., S.T., Design: Z.K., N.C.K., S.T., B.D., Data Collection or Processing: Z.K., N.C.K., S.T., B.D., Analysis or Interpretation: Z.K., N.C.K., S.T., Literature Search: Z.K., N.C.K., S.T., Writing: Z.K., N.C.K., S.T., B.D.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declare that this study received no financial support.