Developing and Testing a Cross-Cultural Measure of Gender Norms and Mental Health in Adolescence

Shoshanna Fine, PhD, MPH and her team are leading a critical international study to better understand how gender norms shape mental health in adolescents across diverse cultural contexts. Funded by the National Institute of Mental Health (NIMH), the project is being conducted by the Johns Hopkins Global Early Adolescent Study (GEAS) in collaboration with several global partners: the University of Santiago, Chile (USACH), the Kinshasa School of Public Health (KSPH) in the Democratic Republic of the Congo (DRC), and Universitas Gadjah Mada (UGM) in Indonesia. Initiated in 2023, this ongoing project aims to develop, refine, and validate a new cross-cultural measure of gender normative perceptions regarding adolescent mental health. 

The Research Problem 

This ambitious project emerged from findings from UNICEF’s State of the World’s Children 2021 report, which explored the mental health challenges faced by children, adolescents, and their caregivers worldwide. Through a collaboration with the GEAS and global partners, UNICEF initiated a series of focus group discussions (FGDs) with adolescents across 13 countries, including Chile, DRC, and Indonesia. A key takeaway from these discussions was adolescents’ recognition of the profound role that gender norms play in influencing their mental health. This aligns with a growing body of research, which suggests that gender norms can significantly impact both the development and expression of mental health challenges among adolescents.  

Building on these insights, Dr. Fine and her team identified a critical gap in the field: there was no validated tool to assess adolescents’ perceptions of gender norms regarding mental health that could be used across diverse cultural contexts. The goal of this project is to fill that gap. By developing a measure that captures adolescents’ views on gender norms and their connection to mental health, the project hopes to better understand and address the persistent gender inequalities in mental health that emerge during adolescence— a critical period of development. The ultimate aim is to use the measure to guide the development, implementation, and evaluation of gender-transformative interventions that can improve mental health outcomes for vulnerable adolescents across the globe. 

Progress and Emergent Themes

The project’s methodology is a sequential mixed-methods approach with three phases of research. The first phase involved conducting FGDs with adolescents in Chile, DRC, and Indonesia to explore gendered perceptions of mental health. These discussions provided deep insights into how gender norms shape the way boys and girls express psychological distress and cope with mental health challenges, as well as the social consequences for deviating from these norms.

Preliminary results from the FGDs revealed striking similarities in the perceptions of adolescents across these diverse contexts in how gender norms influence mental health. One of the key themes identified was the differential acceptability of emotional expression for boys versus girls. Across all three countries, adolescents agreed that boys are discouraged from voicing their vulnerability or distress when compared to girls. As one Indonesian girl described:

“[Boys] are not very emotional like girls… but it’s more difficult for them because they are not allowed, like among themselves, to cry much… one has to practically pull the words out of them, like with a corkscrew.”

However, an interesting double-standard emerged for girls: while they are often "allowed" to express and seek help for difficult emotions, they also face the risk of being labeled as “attention-seeking” or “overdramatic” if they do so. Further, girls reported that opening up about their emotions exposed them to gossip, often making it safer for them to suppress their feelings. One Chilean girl summed it up:

“We tend to shut ourselves off... we don’t allow ourselves to feel bad... It’s like trusting someone with a secret or a feeling, only for everyone to find out later. So, you keep what you feel to yourself... you just get used to feeling bad but pretending to be okay.”” 

Next Steps 

The team is now focused on the second phase of research: developing the novel measure. During this phase, they are first synthesizing qualitative findings in order to develop items which reflect gender norms regulating various dimensions of adolescent mental health. They will then be refining the measure by holding participatory workshops with diverse stakeholders from across the GEAS global network. The measure will also undergo cognitive testing with adolescents in each study country. The final phase will involve piloting the newly developed measure with 900 adolescents—300 from each of the three countries— to evaluate its validity and reliability. 

By creating this cross-cultural tool, Dr. Fine and her team hope to provide vital insights into the role gender norms play in adolescent mental health and guide the development of interventions that can transform gendered mental health experiences. The implications of this work have the potential to improve mental health outcomes for adolescents worldwide, making it a truly global and impactful initiative.