An Exploratory Study of Gender Role Stress and Psychological Distress of Women in Kosovo.

INTRODUCTION: Although investigations of changing gender roles have been performed globally, most studies have been conducted in high-income countries, and studies from emerging and developing countries are lacking. This study aims to examine the factor structure of the feminine gender role stress scale among women (FGRS) and explore its relationship with psychological distress (PD).
METHODS: A cross-sectional study was carried out with 656 women from Kosovo using a convenience sampling technique during October 2017 and March 2018. The data were collected through face-to-face interviews and analyzed using the Statistical Package for the Social Sciences version 21 and Mplus 7.3. Confirmatory factor analysis (CFA) and path analysis were used to understand the goodness-of-fit of the FGRS scale in the Kosovo context and explore the relationship between the FGRS scale and PD when treated as latent variables. Multivariance analysis of variance (ANOVA) was used to understand the differences between groups of women based on employment and FGRS. Multinomial logistic regression was used to assess the prediction of different domains of FGRS for PD separately for each category while controlling for age.
RESULTS: After demonstrating that the five-factor model of the FGRS showed a good fit to the data in this sample of Kosovo women, analyses revealed that the FGRS domains (fear of victimization and behaving with assertiveness) were positively associated with psychological distress.
CONCLUSION: The findings validate the usefulness of the FGRS scale in a sample of Kosovar women. The intersectionality perspective was used to interpret the importance of multiple layers of vulnerabilities and their coexistence, including education, socioeconomic status, and their implications for health inequalities.

Introduction

Mental health concerns in the last decade have increased by approximately 13% according to the World Health Organization (WHO) , Report in 2018, and research evidence shows that common mental health disorders (anxiety and depression) are significantly shaped by social, economic, and environmental factors2. Unemployment, poverty, poor educational outcomes, and low socioeconomic status have been consistently associated with higher psychological distress, particularly in low- and middle-income countries.[3,4] Social and community influences and living and working conditions, including accommodation instability, social exclusion, and lack of access to services, have also been found to be related to health and well-being. Moreover, factors of gender, ethnicity, and minority status also cause individuals to have poor mental health due to cultural stigma, social inequality, and discrimination. Mental health conditions (anxiety, depression, and lower levels of well-being) are more common among women due to different experiences related to social, economic, and environmental factors. Feminist theorists of intersectionality provide a comprehensive framework for understanding compound ways that the social determinants of health shape women’s health across their lifetimes.[8,9] According to the intersectionality framework, human experiences cannot be understood when prioritizing single factors such as gender, age, sexuality, race, ethnicity, sexuality, and the mental health stigma.[10,11] Instead, all these factors are socially constructed, fluid, and shaped by the interaction of social processes and structures influenced by contextual factors. Gender-specific factors related to unequal access to resources, education, employment, decision making, gender-based violence, and child marriage practices also represent risk factors for women’s physical and mental health.[13,14] These risk factors interact with cultural norms and socioeconomic status, increasing the vulnerability to experiencing health risks such as depression, anxiety, and suicide.[15,16] Moreover, researchers acknowledge the importance of specific circumstances and other intervening variables in this association.[17,18,19] Specifically, evidence shows that populations that experience war, migration, and trauma are at a higher risk for developing mental health issues. This increased risk occurs due to traumatic experiences and the necessity for the alteration and reconstruction of roles to adapt to newly created circumstances and structural changes, including situations related to economic, cultural, and social changes. In these circumstances, the issue of gender roles and their changing nature becomes even more salient. It is essential to focus on reducing stigmatization and discrimination and supporting the social and emotional well-being of individuals and families.

Although the investigation of gender role stress is a global phenomenon, it has been mainly examined in high-income countries, and studies from emerging and developing countries are lacking. This study aims to analyze the association between experiences of gender role stress and its relatedness to mental health among women in Kosovo, a post-conflict society characterized by many structural and social changes that influence the everyday life of individuals in this society.

Gender Roles, Gender Role Stress, and Psychological Distress

Research evidence shows that gender roles have changed during the last decade, and women are expanding their roles and responsibilities from traditional ones to become more agentic.[22,23] These changes in gender roles contribute to the expansion of women’s role in being an economic provider for the family and the conversion of men’s role toward family responsibilities and child care. However, despite these changes, women continue to assume significant responsibilities in children’s primary care and manage family life despite having a full-time job.[25,26] According to a study from Pew Research Center, conducted in 2013, although most respondents (79%) indicated that women should not return to traditional gender roles, approximately 50% of respondents noted that children benefit more when their mothers are at home. Consequently, these attitudes worsen the childcare crisis, creating a double burden for women and simultaneously contributing to maintaining rigid gender roles that contribute to gender inequality. Many studies have shown that the primary role women take in childcare and other housework has a high impact on their work and life balance. A recent meta-analytic study shows that work–family conflict was more prevalent in countries with certain level of gender inequality and in those that had collectivist structure of functioning within society.

According to Diekman et al., when men and women enter nontraditional roles, social perception infers a corresponding shift to personality characteristics to accommodate these new roles. In this regard, the perceived change of women in the labor force explains that typical women today are more agentic, suggesting that descriptive stereotypes about women might include more agency. However, prescriptive stereotypes still require women to avoid agency. Although the research evidence shows that the time allocated by men to housework and child-rearing practices has increased and women’s participation in the labor force has increased, many aspects of this conflict may arise due to work–life balance and satisfaction with family life. In many high-income countries, several mechanisms have been put place to support working parents. They are mainly oriented toward the empowerment of working mothers, policies of parental leaves, flexible schedules and workplaces, publicly funded daycare services, and raising expenditures for child care purposes. Researchers argue that high-quality care has positive effects on child cognitive development and, at the same time, provides an opportunity for sustainable economic growth.[34,35] On the other hand, in low- and middle-income countries, where childcare practices are lacking and not yet institutionalized, the burden of care is mainly placed on parents and extended family members, such as grandparents, uncles, and aunts.[36,37] Although extended family members provide an essential resource for helping with child-rearing, a lack of structure, skills, and resources might hinder children’s development.[37,8] Therefore, countries with fewer resources and shortages related to daycare and institutionalized leave are at greater risk and need attention.[38,39]

Goldscheider et al. argue that gender role transformation proceeds through two stages. The first phase is characterized by the increased number of women in the labor force, while gender roles remain the same and represent the double burden model of women in dual-earner families. In the second phase, the gender revolution starts with the increased engagement of males in childcare and family chores as part of the dual-earner/dual-career model. Studies in Europe show that the transition of gender roles from a male breadwinner model to a dual-earner/dual-career model is more advanced in Nordic countries. In contrast, a conventional model of gender roles remains in the Mediterranean and Central and Eastern Europe. The newly created conditions and meanings individuals associate with these particular roles might have significant implications concerning women’s well-being. Women who experience higher rates of this domestic and caregiving burden report poorer physical health and high rates of depression and anxiety.[41,42]

Consequently, psychological distress and mental health diagnoses are higher in women than in men. However, these conditions do not exist in isolation, but they interact with other factors, such as stress, environment, community, and social context. An emphasis has been devoted to social and wealth inequalities. The research shows that unpaid work at home, high hours of work, low social status, lack of support, and lack of access to rights, health, and education impact women’s health. Findings from a recent article using data from the United Nations World Bank and Global Burden of Diseases showed an association between gender inequality and gender disparities in mental health. Gender inequality was mainly related to a greater rate of depression for women. The double presence, which is mainly faced by women, implies fewer job opportunities and more significant physical and mental strain, which is reflected in the poorer mental health of women. Other factors, such as greater exposure to violence, social exclusion, and having lower profiles in the political and social sphere, may also explain their poor mental health.

Moreover, the living conditions of women and the demand placed on women under the dominant heteropatriarchal system pose a risk factor for their mental health, whether they comply with the system or fight it. Similarly, studies exploring the concept of gender role stress among women show that the experience of gender role stress is significantly associated with limited coping strategies and an increased risk of developing dysfunctional behavioral styles, anxiety, and eating disorders.[45-47] Other studies have shown that gender role stress is associated with body dissatisfaction, thinness, anxiety, and eating disorders.[48-51] On the other hand, social science researchers propose that men and women experience different amounts of stress in their daily lives due to different responses to strain based on gender norms. Specifically, Rosenfield et al. introduce the self-salience theory, which helps understand gender differences in mental health. The self-salience schemas refer to the relative importance of the self versus others in social relationships, and schemas that put others first are problematic for mental health. Through the socialization process, boys receive messages that elevate self over others, while girls develop schemas that put others first. As a result, women inhabit a role in which there is a conflict between tending to their own needs and desires and fulfilling this social expectation. This state of stress has significant consequences for well-being, making women experience higher psychological distress, anxiety, and depression. Another line of research has introduced the concept of gender role stress, which refers to stress resulting from a perceived failure to meet the demands of one’s adhered gender role. Notably, the theory of feminine gender role stress considers that the overstress imposed by social norms in attaining the feminine ideal constitutes a vulnerability factor for women, regardless of their endorsement. It is considered that the strain experienced due to the need for the fulfillment of socially constructed gender roles and the failure to do so might increase the likelihood of stress related to gender roles and fear of negative evaluation. Fear is related to failure to live up to specific expectations. For example, failure to live up to expectations related to emotional orientation (warmth, understanding, emotional awareness) and interpersonal orientation (sensitivity toward the needs of others) increases the vulnerability of women to anxiety or psychological distress[53,54] In addition, research shows that poor mental health is associated with inconsistencies between gender role attitudes and actual gender roles. Specifically, poorer mental health was observed among women who had egalitarian attitudes toward gender roles but experienced unequal division of housework and lower spousal support. In this regard, the post-conflict circumstances in Kosovo represent a compelling context for exploring new dynamics within gender roles, gender role stress, and its association with psychological distress.

Gender Role-related Stress in Post-conflict Societies

Research evidence shows that war and postwar conditions might have different impacts on women’s lives and mental health55. In her extensive research in southeastern Europe, Nikolic-Ristanovic argued that war and postwar conditions ultimately have a negative impact on women’s mental health. These conditions increase their vulnerability to different forms of violence and maltreatment due to the newly created circumstances of post-conflict societies. Correspondingly, she acknowledges that all of these postwar changes positively contribute to women’s self-organizing and their active participation in advocacy and reconciliation processes through the mediation of the social and economic factors that are in place in the newly created context. Similarly, research shows that women in Sri Lanka became firmly reestablished after the traumatic events that they experienced due to conflict and displacement. These experiences provided more freedom to challenge the patriarchy and traditional cultural norms through agency, courage, and bravery to continue lives and take responsibility for the good of their families and themselves. However, this is not ultimately accurate in all circumstances, given that research evidence shows that one of the significant challenges to women’s empowerment remains traditional gender roles, which continue to consider women as primarily responsible for domestic roles. These roles are sustained by family, media and society, and self-salience. Consequently, in their battle for work–life balance, women experience psychological distress and increased rates of stress. Therefore, it is crucial to understand what can be done to support overall mental health. As social and cultural norms prescribe gender roles, the dimensions of gender role stress across diverse groups merit examination. Most studies have been conducted in Western and developed countries (Western, educated, industrialized, rich, and democratic cultures). Masculine gender role stress and its association with intimate partner violence were assessed among males in Kosovo. This study aims to explore the suitability of the Albanian version of the FGRS scale for women in Kosovo and its association with psychological distress.

Kosovo Context and the Current Study

Overall, the position of women in Kosovo, similar to that noted in other countries in the Western Balkans, has progressed; however, work is needed to ensure gender equality. Kosovo has adopted the required legislation for ensuring gender equality. However, this legislation has not been completely implemented, and the quality of services is rather problematic.[62,63]

A study on the gender profile in Kosovo that focused on various areas that should ensure gender equality showed that women are primarily underrepresented and discriminated against. In terms of women’s participation in education in Kosovo, when compared to men’s participation, there are noticeable improvements. In the latest gender profile, women and men have similar rates of participation in higher education. However, this improvement has not translated into the realm of employment; the unemployment rate is higher among women at 38% versus 25% for men. The major obstacle to women’s participation in the labor force has been their mainly sociocultural role as caregivers. As far as inheritance is concerned, findings from Cadastral Agency show that women own only 17% of all properties in Kosovo, showing that women experience several difficulties related to loans, protection, and property rights (p. 16). Despite the changes in terms of gender roles in postwar Kosovo, the public, political, and social spheres remain dominated by men, and postwar conditions have contributed to the reconstruction of re-traditionalization while empowering patriarchal power relations in public, political, and social spheres. Instead, women in Kosovo have shown social and political agency throughout nonviolent resistance in the prewar period and the postwar reconstruction and peacebuilding processes.[66,67] However, their roles and participation have been silenced and diminished (p.212). Women are underrepresented in municipal assemblies and parliament at the decision-making levels among police, prosecutors, and judges. In the aftermath of the war, research evidence shows that women had higher rates of post-traumatic stress symptoms, particularly those women who experienced a lack of social support. Instead, women have more sociocultural barriers to accessing healthcare services related to time, income, and decision making.

Specifically, women in Kosovo experience the double burden model through the expectations to fulfill traditional feminine gender roles within the family while simultaneously moving toward the conception of a new agentic role in society associated with independence and self-determination.

Primarily, the aim of this study is to assess the factorial validity of the dimensions that underlie the FGRS using confirmatory factor analysis (CFA), including reliability characteristics. Third, the study explores feminine gender role stress and its association with psychological distress among women in Kosovo by focusing on four specific groups: students, working women, nonworking women, and self-employed women.

Methodology

Study Design, Participants, and Sample Size Determination

A cross-sectional study was carried out with 656 women from Kosovo using a convenience sampling technique during October 2017 and March 2018. Student data for this analysis were obtained from a recent study conducted between October 2017 and March 2018 exploring gender role stress and its association with psychological distress among university students using convenience sampling. All of the participants fulfilled the following criteria: being older than 18 years and having been engaged in at least one intimate relationship that lasted at least one month. To better understand feminine gender role stress among diverse categories of women, the study was expanded to include working, self-employed, and nonworking women. Convenience sampling was also used to target the participants in the second part of the study. The sociodemographic characteristics of the study sample are presented in Table 1. The sample size for this study was determined via power analysis, which was performed using G*Power 3.1 and indicated that a sample size of N = 277 was needed to detect the minimum effect size of R = 0.25 at the given power of 0.8 and alpha at the 0.05 level. The study was part of a larger study and was approved by the Ethical Committee of the Department of Psychology, Faculty of Philosophy at the University of Pristina.

Table 1.

Sociodemographic characteristics of the sample.

	Female students (N = 510)	Other women (N = 146)
Age M (SD) (in years)	19 (2.95)	46 (3.12)
Area
Urban	74%	55%
Rural	26%	45%
Education
Primary education	67%	17.70%
Secondary	32%	49.60%
Bachelor studies		21%
Master studies		2.80%
Other
Civil status
Single	15%	1.80%
In a relationship	39%
Engaged	18%
Married	27%	95%
Widowed		2.30%
Employment status
Nonworking		38.20%
Working		37.60%
Self-employed		23.20%
Student	100%

SD: Standard deviation.

Instruments

Gender role stress was measured using the feminine gender role stress scale (FGRS). The FGRS scale consists of situations that might appear to be stressful to females: fear of unemotional relationships (ten items (e.g., not being able to meet family members’ emotional needs), alpha = 0.92), fear of physical unattractiveness (eight items (e.g., being perceived by others as overweight), alpha = 0.85), fear of victimization (six items (e.g., feeling that you are being followed), alpha = 0.86), fear of behaving assertively (six items (e.g., trying to be a good parent and excel at work), alpha = 0.82), and fear of not being nurturing (eight items (e.g., having someone else raise your child), alpha = 0.87). The participants responded to each item using a scale that ranged from 1 (not stressful) to 6 (extremely stressful).

Psychological distress was measured using the Kessler et al. scale, a ten-item questionnaire for evaluating overall distress based on anxiety and depressive symptoms in the past 30 days. A sample item is provided as follows: During the last 30 days, how often did you feel tired for no good reason, feel nervous, and feel hopeless? The participants were asked to respond from the range of choices from 1 (none of the time) to 5 (all of the time). The reliability coefficient was 0.92.

Procedure

The questionnaires were translated and back-translated for better adaptation to the Albanian language. The FGRS and psychological distress scale were combined and presented as one questionnaire, and completion of the questionnaire took approximately 20 min. The administration of the questionnaire among the students and women was conducted via convenience sampling techniques. All of the participants were informed that participation in the survey was voluntary and that they could stop at any moment. We obtained written informed consent before participation in the study. Participants were also provided with a list of counseling services.

Data Analysis

Descriptive statistical analysis was used to provide the sociodemographic characteristics of the sample. Confirmatory factor analysis was used to assess the goodness-of-fit of the factor structure of the feminine gender role stress scale in a sample of Kosovan Albanian females using Mplus version 7.3. Multivariance analysis of variance (ANOVA) was used to understand the differences between groups of women based on employment and FGRS. Multinomial logistic regression was used to assess the prediction of different domains of feminine gender role stress for psychological distress separately for each category while controlling for age. Finally, we conducted a path analysis to assess the relationship between FGRS and psychological distress when treated as latent variables.

Results

Primary Analysis

The primary analysis of the factor structure of the feminine gender role stress scale in a sample of Kosovan Albanian females was conducted using Mplus 71 version 7.3. Prior to conducting the primary analysis, the data were screened. Of the 675 women who participated in the study, 19 were removed (16 due to missing values and three outliers). Thus, the final sample included 656 women.

Factorial Validity

The intercorrelations between the feminine gender role stress subscales are presented in Table 2. All correlations of the subscale were positive and varied from 0.466–0.694.

Table 2.

Intercorrelation between feminine gender role stress subscales.

Subscales	1	2	3	4	5
Fear of unemotional relationships	1	0.597 **	0.639 **	0.466 **	0.694 **
Fear of physical unattractiveness		1	0.596 **	0.483 **	0.565 **
Fear of victimization			1	0.534 **	0.647 **
Fear of behaving assertively				1	0.632 **
Fear of not being nurturing					1

p < 0.01.

As mentioned above, to evaluate the model fit, the chi-square c2 test, goodness-of-fit index (GFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA) were examined. The chi-square c2 test assesses the difference between the hypothesized model and the identified model, where smaller values and non-significant chi-square results indicate a better fit. Considering that c2 is sensitive to the sample size, a value of c2/df was reported, and values less than 3 were considered to indicate an acceptable fit.[73,74] As an alternative to the chi-square test, the GFI was created to calculate the variance accounted for by the estimated population covariance, and the cutoff criterion for the GFI was 0.95. The CFI evaluates improvements from a less restrictive model to a more restrictive model, and values greater than 0.95 indicate a good fit. The RMSEA indicates how well the model with unknown but optimally chosen parameter estimates provides the population covariance matrices, and values ranging between 0.01 and 0.05 indicate that the model exhibits good fit. The fit indices of the feminine role stress scale were first examined for the three following models: the first model, which was the original model as proposed by Gillespie and Eisler; the second model by Tang and Lau; and a single-factor model. Following Hu and Bentler’s recommendation for inspecting standardized root mean square residuals (SRMR) cutoff values close to 0.08 and RMSEA cutoff values of 0.06 based on the two-index presentation strategy, the five-factor model (original model) met the criteria for model fit (RMSEA = 0.05 and SRMR = 0.06), whereas the two other models were rejected. Furthermore, no overlap between the values and the 90% RMSEA confidence intervals (CIs) were noted for the five-factor and three-factor models compared with the one-factor model (see Table 3), which supports the multidimensional approach of the measurement of the masculine gender role stress scale. Moreover, in terms of the comparative fit index (CFI), no model met the criterion of model fit (i.e., CFI > 0.95); however, the five-factor model showed higher rates of CFI.

Table 3.

Fit indices for factor models.

Feminine Gender role Stress	Chi-square/df	RMSEA	90% CI	CFI	TLI	SRMR
Five-factor model a	2.5	0.05	0.04–0.05	0.88	0.87	0.09
Three-factor model b	4.3	0.07	0.06–0.07	0.86	0.86	0.07
One-factor model	4.5	0.07	0.07–0.08	0.72	0.71	0.07

RMSEA: Root mean square error of approximation; CI: Confidence interval; CFI: Comparative fit index; SRMR: Standardized root mean square residuals.

Five-factor model: physical inadequacy, emotional inexpressiveness, subordination to women, intellectual inferiority, and performance failure.

Three-factor model: inadequacy, unassertiveness, and victimization.

Reliability

The internal consistency coefficients for all feminine gender role stress subscales are presented in Table 4, which shows the homogeneity index and the range of the item-remainder correlations for each gender role stress subscale. Regarding the feminine gender role stress subscales, the Cronbach’s alphas for all the subscales were satisfactory and ranged from 0.87 to 0.92. Moreover, the mean interim correlations and the range of the item-remainder correlations were within acceptable limits for all gender role stress subscales.

Table 4.

Internal consistency (Cronbach’s alpha), homogeneity (mean interim correlation), and range of item-remainder correlations of feminine gender role stress subscales.

	M	SD	Cronbach’s alpha	Mean interim correlation	Range of item-remainder correlations
FGRS			0.9	0.36	0.59 to 0.72
Fear of unemotional relationships	32.31	14.22	0.92	0.519	0.29 to 0.66
Fear of physical unattractiveness	22.93	9.86	0.84	0.39	0.33 to 0.59
Fear of victimization	21.05	8.76	0.86	0.52	0.27 to 0.63
Fear of behaving assertively	18.76	9.31	0.80	0.42	0.39 to 0.66
Fear of not being nurturing	29.69	10.78	0.87	0.44	0.35 to 0.61

SD: Standard deviation; FGRS: Feminine gender role stress scale.

Feminine Gender Role Stress among Various Groups of Women

Multivariate analysis of variance (MANOVA) was used to test for the differences between groups of women. The results showed differences (F(15, 1789.244) = 4.090, p < 0.01; Wilk’s Λ = .91, partial η2 = .03) (Table 5). Differences were present in two of the five FGRS factors: fear of physical unattractiveness (F(3, 652) = 5.098; p < .002; partial η2 = .02) and fear of behaving assertively (F(3, 656)) = 6.284; p < .001; partial η2 = .02). A post hoc Tukey test showed that the group of self-employed women differed significantly in two FGRS factors compared to the other groups. No significant differences were noticed for the other factors.

Table 5.

Feminine gender role stress (FGRS): MANOVA among women.

Source	Dependent variable	Type III sum of squares	Df	Mean square	F	Sig.	Partial Eta squared
Factors of FGRS	Fear of unemotional relationship	1322.99	3	440.997	2.401	0.067	0.011
	Fear of physical unattractiveness	1402.031	3	467.344	5.098	0.002	0.023
	Fear of victimization	465.947	3	155.316	2.138	0.094	0.01
	Fear of behaving assertively	946.483	3	315.494	6.284	0.01	0.028
	Fear of not being nurturing	386.366	3	128.789	1.196	0.311	0.005

FGRS: Feminine gender role stress scale.

Notes. *p < .05, **p < .01.

Psychological Distress

To obtain a better overview, we categorized the scores obtained on the psychological distress scale following Kessler et al.’s criteria, where scores less than 20 were also considered and categorized as belonging to the well category. Participants who scored between 20 and 24 were categorized as mildly distressed, participants who scored between 25 and 29 were categorized as moderately distressed, and participants who scored greater than 30 were categorized as severely distressed. Overall, 47% of the women showed lower scores of psychological distress, approximately 13% showed mild symptoms of distress, approximately 14% showed a moderate level of distress, and approximately 22% showed severe symptomatology. Furthermore, we analyzed the psychological distress differences between various categories of women in terms of psychological distress (see Table 6). As shown in the table, approximately 35% of self-employed women reported experiencing severe distress compared to only 25% of female students and 7.70% of working and 10.70% of nonworking women. In contrast, most of the other categories of women, such as students, working and nonworking women, reported a significantly higher percentage of feeling well (approximately 50%) compared to only 21% of self-employed women.

Table 6.

Percentage of psychological distress by categories.

	Well	Mildly distressed	Moderately distressed	Severely distressed
Student women	50.4%	13%	11.20%	25.40%
Self-employed	20.90%	11.60%	32.60%	34.90%
Working women	59%	12.80%	20.50%	7.70%
Nonworking women	47.40%	15.80%	26.30%	10.50%

Furthermore, the findings from this study reveal a positive but rather weak-to-moderate correlation between psychological distress and the feminine gender role stress scale, which ranged from 0.07 to 0.35, and were all significant at p < .0.01 (see Table 7).

Table 7.

Spearmen rank correlation between feminine gender role stress subscales and psychological distress.

	Psychological distress
Fear of unemotional relationships	0.244**
Fear of physical unattractiveness	0.242**
Fear of victimization	0.247**
Fear of behaving assertively	0.263**
Fear of not being nurturing	0.230**
Feminine gender role stress (total scale)	0.407**

Furthermore, a multinomial logistic analysis was conducted to assess the prediction of different feminine gender role stress domains for psychological distress separately for each category while controlling for age. Those who scored well on the psychological distress scale served as a reference category for all categories (Table 8). For students, the findings show that fear of not being nurturant was significantly associated with mild psychological distress [odds ratio, OR = 1.042, p < 0.05, confidence intervals, CI = 1.00–1.08]. Similarly, fear of victimization was positively associated with moderate psychological distress [OR = 1.04, p < 0.05, CI = 0.99–1.09] and severe psychological distress [OR = 1.03, p < 0.05, CI = 0.97–1.03] compared to those who felt well. For self-employed women, fear of behaving assertively was positively associated with moderate psychological distress [OR = 1.32, p < 0.05, CI = 1.00–1.87] and negatively associated with fear of not being nurturant [OR = 0.402, p < 0.05, CI = 0.166–0.971]. In contrast, the participants who experienced severe symptoms of distress compared to those who felt well showed a significant negative association with the fear of behaving assertively [OR = 0.786, p < 0.05, CI = 0.61–0.99]. In addition, for nonworking women, severe psychological distress was positively associated with fear of victimization [OR = 1.396 p < 0.05, CI = 1.03–1.88].

Table 8.

FGRS domains as predictors of psychological distress; multinomial logistic regression, by categories.

Feminine gender role stress domains student	Mild distress versus well			Moderate distress versus well			Severe distress versus well
	OR	(SE)	95% CI	OR	(SE)	95% CI	OR	(SE)	95% CI
Fear of unemotional relationships	1.045 **	1.017	1.073	1.029	0.997	1.061	1.015	0.991	1.039
Fear of physical unattractiveness	1.003	0.97	1.037	1.005	0.966	1.046	1.003	0.972	1.034
Fear of victimization	1.003	0.962	1.045	1.045 *	0.996	1.096	1.039 *	1.001	1.078
Fear of behaving assertively	1.011	0.964	1.061	1.006	0.951	1.064	1.035	0.991	1.08
Fear of not being nurturing	1.042 *	1.003	1.083	0.992	0.95	1.035	1.014	0.981	1.048
Age	1.18	0.957	1.454	1.132	0.887	1.446	1.226 *	1.019	1.476
Chi-square	91.202 (18) ***
Nagelkerke R square	0.178
Self-employed	Mild distress versus well			Moderate distress versus well			Severe distress versus well
	OR	(SE)	95% CI	OR	(SE)	95% CI	OR	(SE)	95% CI
Fear of unemotional relationships	1.327	0.942	1.869	1.084	0.919	1.278	1.059	0.897	1.25
Fear of physical unattractiveness	0.911	0.704	1.179	1.008	0.863	1.179	1.088	0.935	1.267
Fear of victimization	0.838	0.586	1.199	0.873	0.701	1.088	0.786 *	0.618	0.999
Fear of behaving assertively	1.37 *	1.003	1.87	1.002	0.808	1.243	1.105	0.901	1.355
Fear of not being nurturing	0.402 *	0.166	0.971	0.872	0.657	1.157	1.036	0.793	1.353
Age	1.168	0.755	1.808	1.129	0.902	1.412	0.981	0.785	1.224
Chi-square	25.653(!8) *
Nagelkerke R square	0.477
Working women	Mild distress versus well			Moderate distress versus well			Severe distress versus well
	OR	(SE)	95% CI	OR	(SE)	95% CI	OR	(SE)	95% CI
Fear of unemotional relationships	1.097	0.965	1.247	1.065	0.914	1.242	0.952	0.764	1.186
Fear of physical unattractiveness	0.912	0.793	1.049	1.043	0.904	1.202	1.015	0.802	1.284
Fear of victimization	1.07	0.88	1.301	0.823	0.637	1.063	1.12	0.836	1.5
Fear of behaving assertively	0.952	0.766	1.184	0.922	0.737	1.154	1.129	0.856	1.489
Fear of not being nurturing	0.928	0.767	1.122	1.151	0.92	1.44	0.909	0.7	1.181
Age	0.837	0.685	1.022	0.694	0.516	0.934	0.7	0.509	0.963
Chi-square	27.641 (18) *
Nagelkerke R square	0.536
Nonworking women	Mild distress versus well			Moderate distress versus well			Severe distress versus well
	OR	(SE)	95% CI	OR	(SE)	95% CI	OR	(SE)	95% CI
Fear of unemotional relationships	0.934	0.857	1.018	0.926	0.849	1.011	0.924	0.811	1.052
Fear of physical unattractiveness	1.078	0.958	1.213	1.12	0.99	1.267	1.076	0.908	1.275
Fear of victimization	1.012	0.878	1.165	1.077	0.94	1.234	1.396 **	1.035	1.883
Fear of behaving assertively	0.971	0.85	1.109	0.963	0.843	1.1	0.829	0.676	1.016
Fear of not being nurturing	1.06	0.961	1.169	1.008	0.899	1.131	1.083	0.854	1.374
Age	0.963	0.827	1.121	1.02	0.878	1.184	0.936	0.737	1.19
Chi-square	27.305(18) *
Nagelkerke R square	0.394

OR: Odds ratio; SE: Standard error; CI: Confidence interval.

*p < 0.05, ** p<0.01, ***p<0.001.

Finally, a path analysis was conducted to assess the relationship between feminine gender role stress and psychological distress, where both variables were treated as latent variables (see Figure 1). The fit indices for the initial model showed an acceptable fit (c2 (82, 656) = 260.278, p < 0.01; RMSEA = 0.05, CFI = 0.95, TLI = 0.94, SRMR = 0.07). The findings from the model showed that all the items of psychological distress significantly affected the latent variable of psychological distress, with coefficients that ranged from (ß = 0.455, p < 0.01) for the item “Have you felt tired?” to (ß = 0.839 p < 0.01) for the item “Have you felt that everything was an effort?”. Similarly, all domains of feminine gender role stress significantly affected the latent variable of psychological distress, specifically, the fear of being unemotional in relationships (ß = 0.283 p < 0.01), fear of physical unattractiveness (ß = 0.621 p < 0.01), fear of victimization (ß = 0.712 p < 0.01), fear of behaving assertively (ß = 0.681 p < 0.01), and fear of not being sufficiently nurturing (ß = 0.791 p < 0.01). Finally, the latent construct of feminine gender role stress showed a positive direct path to latent psychological distress (ß = 0.212 p < 0.01), which indicates an association between the two constructs.

Figure 1.

Path model between latent variables feminine gender roles stress (MGRS) and psychological distress.

Discussion

The primary aim of this study was to explore the factorial validity and internal consistency of the FGRS scale among women in Kosovo. The findings from this study validate the usefulness of the FGRS scale in a sample of Kosovar women and confirm the factorial validity, internal consistency, and homogeneity. Regarding factor validity concerns, the confirmatory factor analysis clearly shows a better fit with the five-factor model compared with the three-factor model and the one-factor model. It is important to note that these findings are consistent with previous studies on the FGRS and demonstrate the multidimensionality of the FGRS, which shows that women across diverse cultural and ethnic groups experience stress when they fail to live up to socially constructed feminine gender roles.

The average gender role stress score for the sample of Kosovo women was higher than the scores obtained in a Dutch sample and a Polish sample. The large differences between the FGRS scores among women in Kosovo compared to these two other social groups may be related to the heteronormative conceptualization of gender roles and social expectation of fulfilling this role regardless of whether they endorse traditional gender roles norms. The Kosovo context can be described as a conventional society, where gender roles are strictly defined, and adherence to these roles is highly expected; any deviation is associated with social rejection. Furthermore, the changing nature of gender roles within societies was associated with women’s increased level of education or increased participation in employment. However, these changes were not accompanied by a reduction in women’s role in domestic chores and childcare responsibilities or with the multiple engagements of men in these duties and roles. In this regard, Kosovo is still in the first phase of gender transformation, where the double burden of dual-earner women remains and research scholars consider that the redefinition of men’s role within the family is crucial for empowering the role of women as economic providers.[22,40] Researchers argue that the transformation of male gender roles toward more communal roles would benefit women, children, men, and society. Specifically, research shows that women who experience lack of support related to everyday chores are less satisfied and tend to be depressed. In contrast, women who experience support from their partners in pursuing their agentic career goals report higher satisfaction with these experiences. In this regard, countries such as Kosovo, with low resources related to institutionalized leave and childcare services, show vulnerabilities in individual mental and physical health, family functioning, child development, work–life balance/satisfaction, and economic growth. A recent study on early childcare services in Kosovo shows positive coefficients in terms of the overall employment of women and their inclusion in the labor market, suggesting higher participation in childcare services among those in the private sector than those in the public sector. However, many women remain unemployed and unsupported to participate in labor due to strictly defined gender norms. As Mustafa argued, public childcare services prioritize single earners compared to dual earners, consequently leading to a model that reinforces and maintains gender norms. In Kosovo, parental leave is paid, exclusively mother oriented, except for three days of leave for the father at birth. Recently, the government of Kosovo has extended paid maternity leave to unemployed women. The benefits provided for unemployed women are an essential change in terms of support provided; however, and Mustafa argues, it is too soon to see how these changes will be reflected in terms of employment rates for women. Research evidence shows that it is essential to embrace the “dual-earner–dual-career” model due to positive outcomes in many aspects. Primarily, this model will improve women’s employment outcomes and achievements and, at the same time, will degender the childcare responsibilities and contribute to changes in gender norms. In addition, research evidence shows that promoting men’s involvement in communal roles is highly beneficial to men, children, women, and society. Social connectedness and care for others and their children are associated with higher overall well-being, emotional growth, better mental health, and higher marital satisfaction.

In terms of gender role stress, the FGRS scores were designed to elicit moderate to high (> 60) responses for the sex only within their specified gender role test. The expected result was consistently moderate/high scoring across all FGRS factors. When analyzing the differences in terms of the FGRS domains, statistically significant differences were observed only for the failure to live up to the standard of beauty and failure to behave with non-assertiveness, where self-employed individuals reported higher scores than their counterparts. The theme binds physical unattractiveness as a failure to achieve a culturally defined and desired feminine standard of physical attractiveness that will result in social rejection. Research shows that the body ideal has become a standard by which all women are measured, and any deviation from the ideal is judged. Supposedly, gender role socialization shapes women to care more about health and holds women responsible for their size and shape. On the other hand, there is constant pressure from different levels of society to perform in different and various roles, such as being a mother, working, volunteering, and at the same time looking good and being an athlete. Chrisler entitled this the pressure of “doing it all” and to become perfectionist superwomen, consequently leading to negative outcomes in terms of well-being.

In contrast, the fear of behaving assertively is based on the assumption that women generally have social/cultural fear around confrontation, as it runs counter to the imagined feminine gender role. Research evidence shows that negotiation behaviors are primarily shaped by the pressure to behave congruently through social roles and norms.[85,86] Consequently, assertive behaviors are prescribed for those in high status and prohibited for those in low status. Assertiveness is considered more congruent with the male role than the female gender role. Therefore, women who show assertiveness are penalized and judged.[87,88] Instead, research evidence shows that despite the increase in gender equality and increased accommodation of agentic roles among women, these changes in perception are not necessarily reflected in the content of stereotypes.

Furthermore, results show that FGRS is positively associated with psychological distress, and similar findings have been noted in many other studies of women.[45,52,78] These findings demonstrate that the socialization process might share more similarities than differences in the reinforcement and maintenance of feminine gender roles, which are mainly related to communal self-concept. Moreover, if we analyze the domains of feminine gender role stress and its association with psychological distress, women in Kosovo show mild to moderate associations across this relationship. The fear of victimization significantly predicted moderate and severe levels of psychological distress among students. In contrast, the fear of behaving assertively predicted mild and severe levels of psychological distress for self-employed women. When we analyze the content of the items of these domains, it is observed that most of the domains contain items in which women are exposed to potential harm or violence. Research evidence shows that “doing gender” is a highly prescriptive process, and violation of gender role norms is considered a violation and increases the likelihood of discrimination and victimization.[90,91,92]

Moreover, the conflict between heteronormative expectations and individual violations of this expectation is associated with elevated levels of stress. This finding is not surprising in the Kosovo context when considering that the tendency to blame the victim is relatively common when explaining the phenomenon of violence in intimate relationships, rape, and sexual assault.[60,61] As scholars argue, blaming the victim refers to the tendency to hold victims of adverse events responsible for the outcomes. Research evidence shows that the socialization of gender norms makes women prone to experience victimization and communicate victim blaming as a norm.[95,96] Moreover, victim blaming, stigmatization, and lack of trust are highly present, and they impact the reporting of violence. In addition, research evidence shows that women learn to fear crime and victimization due to messages from family, friends, and media regarding their vulnerability. Consequently, through social interaction and media consumption, women learn to consider the risk of victimization as an inherent part of their definition. To avoid these experiences, they use protective strategies such as not going out at night alone. All women who do not conform to these strategies experience blame and mistrust when experiencing victimization.

Another factor that predicted psychological distress was the fear of behaving assertively. When we analyze the items of these domains, it can be seen that all the items describe communication skills that require assertiveness. As shown, many of these items are related to the working conditions in which decisiveness and certainty are considered to be crucial. One can assume that these situations could be considered threatening for women in Kosovo because these items confront feminine ideals, such as empathy, compassion, caring, and dedication. In this regard, the fear of behaving assertively in the Kosovo context may be strongly associated with the fear of backlash, which is an adverse reaction toward women who behave in ways that violate gender norms. In this regard, a recent meta-analysis on gender stereotypes shows that despite the shift of women into male-dominated occupations, many of these occupations are not agentically demanding. Moreover, women’s competence in these male-dominated jobs is frequently perceived as lower in comparison with men. Instead, the perception of domestic and communion roles as non-obligatory increased their salience and consequently is considered a mechanism of differentiation among men and women.

Implications

Finally, this study has significant psychoeducational and clinical implications. In terms of psychoeducational efforts, the findings reveal the importance of the intersectionality concept in health research as a way of gaining an in-depth and broader understanding of inequalities in health . Notably, the intersectionality perspective considers the importance of focusing on multiple layers of vulnerabilities and their coexistence, including education, socioeconomic status, race, gender orientation, disability, and their implication for health inequalities. For the Kosovo context, the intersectionality approach is crucial to understanding women’s experiences, considering their low labor force participation, high unemployment rate, lack of property, high rate of experiences of gender-based violence, and implications for mental and physical health. Furthermore, findings from this study highlight the importance of gender transformation and the necessity of men to adopt communal roles to support women in pursuing more agentic roles and becoming role models for future generations. As mentioned previously, embracing the “dual-earner–dual-career” model would help create a ground for these changes. Notably, the ability to take parental leave as an individual right of both parents, including workplace flexibility in terms of workload, schedule, and location, will increase productivity and reduce the negative impact of work on families.

Furthermore, research evidence shows that exposure to counter-stereotypical role models might shift people’s implicit association.[102,103] On the other hand, educational efforts, including classroom activities that increase girls’ interest in science-related fields and encourage boys’ involvement with communal roles and activities, could represent a catalyst of change concerning gender inequality.

Clinical implications are related to the FGRS scale as a tool for treating specifically vulnerable aspects of the importance of self-salience theory and gender roles, which have not been otherwise explored. The association with psychological distress mainly helps the therapist and the client frame psychological distress as an expression of environmental circumstances rather than an intrapsychic condition. Furthermore, the intersectionality perspective helps understand the impact of gendered qualities, social locations, and coexistence.

Limitations and future research

The first limitation of the study is the sampling procedure. The participants were recruited through convenience sampling; thus, the results are not representative of the general population. Second, the study was cross-sectional, and changes in the participants’ health over time cannot be assessed in relation to feminine gender role stress. Third, our findings are limited by mono-method and self-reporting biases. Future studies should focus on diverse data collection methods, including focus group discussions, interviews, or vignettes, providing a broader and more nuanced understanding of how gender roles evolve. Additional research is needed on how stress experiences contribute to socially constructed feminine gender roles and overall health by focusing on multiple factors situated at different levels of social ecology, including family, community, and social–cultural values. In addition, future studies should also explore other factors, including domestic violence experiences, socialization of violence, and conflict due to work and life balance. These aspects of inquiry would provide a more thorough understanding of gender role stress and its association with psychological distress.

Conclusion

The findings from this study validate the usefulness of the FGRS scale in a sample of Kosovar women, where women report higher scores on the FGRS than in other countries. In particular, fear of victimization and fear of behaving with assertiveness were associated with psychological distress. The study results were interpreted using the intersectionality perspective, highlighting the importance of multiple layers of vulnerabilities and their coexistence, including education, socioeconomic status, and implications for health inequalities. In addition, the findings from this study show that mental health issues should not be treated only at the individual level of social ecologies since risk and protective factors operate at different levels, including family, community, culture, and values. Therefore, improving women’s health and well-being primarily requires using evidence to change policies that integrate women’s lifelong needs into health policies and intersectional actions. This aspect implies an increase in research on the role of gender in mental health and uses this knowledge to reduce the mental issues related to men and women. In addition, it is crucial to address the social determinants of health, particularly social and cultural aspects that increase women’s vulnerability to specific mental health issues. Finally, it is essential to promote a strength-based perspective, which helps identify resources and assets that promote resilience and well-being.

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Supplemental material, sj-docx-1-whe-10.1177_17455057221097823 for An Exploratory Study of Gender Role Stress and Psychological Distress of Women in Kosovo by Kaltrina Kelmendi and Liridona Jemini-Gashi in Women’s Health