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How indians view gender roles in families and society, indians accept women as political leaders, but many favor traditional gender roles in family life.

This study is part of Pew Research Center’s most comprehensive, in-depth exploration of India to date. For this report, we surveyed 29,999 Indian adults (including 22,975 Hindus, 3,336 Muslims, 1,782 Sikhs, 1,011 Christians, 719 Buddhists, 109 Jains and 67 respondents who belong to another religion or are religiously unaffiliated). Many findings from the survey in India were previously published in “ Religion in India: Tolerance and Segregation ,” which looked in detail at religious and national identity, religious beliefs and practices, and attitudes among religious communities. The survey also included several questions on gender roles in Indian society, but these questions were not analyzed in the previous report and are now being published for the first time. Interviews for this nationally representative survey were conducted face-to-face under the direction of RTI International from Nov. 17, 2019, to March 23, 2020.

To improve respondent comprehension of survey questions and to ensure all questions were culturally appropriate, the Center followed a multiphase questionnaire development process that included expert review, focus groups, cognitive interviews, a pretest and a regional pilot survey before the national survey. The questionnaire was developed in English and translated into 16 languages, independently verified by professional linguists with native proficiency in regional dialects.

Respondents were selected using a probability-based sample design that would allow for robust analysis of all major religious groups in India – Hindus, Muslims, Christians, Sikhs, Buddhists and Jains – as well as all major regional zones. Data was weighted to account for the different probabilities of selection among respondents, and to align with demographic benchmarks for the Indian adult population from the 2011 census. The survey is calculated to have covered 98% of Indians ages 18 and older and had an 86% national response rate.

For more information, see the Methodology   for this report. The questions used in this analysis can be found here .

More than half a century ago, India was one of the first countries in the world to elect a woman as prime minister , and the country currently has several highly influential women politicians, including Sonia Gandhi, the head of one of the major national parties . Today, most Indians say that “women and men make equally good political leaders,” and more than one-in-ten feel that women generally make better political leaders than men, according to a recent Pew Research Center survey of nearly 30,000 adults throughout India. Only a quarter of Indian adults take the position that men make better political leaders than women.

Yet, in domestic settings, Indians tend to say men should have more prominent roles than women. About nine-in-ten Indians agree with the notion that a wife must always obey her husband, including nearly two-thirds who completely  agree with this sentiment. Indian women are only slightly less likely than Indian men to say they completely agree that wives should always obey their husbands (61% vs. 67%), according to the survey, which was conducted between late 2019 and early 2020 (mostly before the COVID-19 pandemic ).

Many Indians express egalitarian views toward some gender roles in the home. For instance, 62% of adults say both men and women should be responsible for taking care of children. But traditional gender norms still hold sway among large segments of the population: Roughly a third of adults (34%) feel that child care should be handled primarily by women.

Similarly, a slim majority (54%) says that both men and women in families should be responsible for earning money, but many Indians (43%) see this as mainly the obligation of men. And Indian adults overwhelmingly say that when jobs are in short supply, men should have greater rights to employment than women, reflecting the continued prominence of men in the economic sphere. Eight-in-ten agree with this sentiment, including a majority (56%) who completely agree.

Indians value having both sons and daughters: Nearly all Indians say it is very important for a family to have at least one son (94%) and, separately, to have at least one daughter (90%). And most Indians say that both sons and daughters should have equal rights to inheritance from parents (64%) and have the responsibility to care for parents as they age (58%). But survey respondents are far more likely to say that sons, rather than daughters, should have greater rights and responsibilities in these areas. For example, while about four-in-ten Indian adults say that sons should have the primary responsibility to care for aging parents, just 2% say the same about daughters.

Related India research

This is one in a series of Pew Research Center reports on India based on a survey of 29,999 Indian adults conducted Nov. 17, 2019, to March 23, 2020, as well as demographic data from the Indian Census and other government sources. Other reports can be found here:

• Religion in India: Tolerance and Segregation
• Religious Composition of India
• India’s Sex Ratio at Birth Begins To Normalize

Moreover, most Indians (63%) see sons – not daughters – as being primarily responsible for parents’ last rites and burial rituals. Religious funeral practices for loved ones are widely seen as very important , and at least according to Hindu tradition , sons must perform last rites for a parent to ensure freedom for the soul in the afterlife. Recently, women – including actress Mandira Bedi and the daughters of India’s former Chief of Defense Staff – have publicly challenged these norms by lighting family members’ funeral pyres.

These norms are part of a wider phenomenon in Indian society where, for a variety of historical, social, religious and economic reasons, families tend to place higher value on sons rather than daughters – a custom broadly referred to as “son preference.” Adult sons traditionally live with their parents and provide financial support to the family. Meanwhile, when daughters marry, their families may pay a dowry, an illegal practice that still features in some marriages , and daughters often live with their husband’s parents and fulfill obligations toward their in-laws. In recent years, Indian society has paid increased attention to improving the status of daughters – the government’s Beti Bachao, Beti Padhao (“Save the girl child, Educate the girl child”) program, for example, seeks to prevent sex-selective practices during pregnancy and to ensure educational opportunities for girls by conducting public awareness media campaigns , among other policies.

Many Indians see sex-selective abortion as acceptable in at least some circumstances: Four-in-ten Indians say it is either “completely acceptable” or “somewhat acceptable” to “get a checkup using modern methods to balance the number of girls and boys in the family,” a euphemism to connote sex-selective abortion. 2  A similar share (42%) says balancing the number of girls and boys in a family via modern methods is completely  unacceptable , while roughly one-in-ten describe the practice as “somewhat” unacceptable.

On this question and all others included in this report, differences in opinion between men and women and across age groups are modest. In other words, Indian women typically are not much more likely than Indian men to express egalitarian views on son preference and gender roles (see “ In India, men a little more likely than women to have conservative views on gender ”), and the same is true of young Indian adults (ages 18 to 34) relative to their elders.

This is the second report based on a Pew Research Center survey conducted face-to-face nationally among 29,999 Indian adults. Many findings from the survey were previously published in “ Religion in India: Tolerance and Segregation ,” which looked in detail at religious and national identity, religious beliefs and practices, and attitudes among religious communities. The survey also included several questions on gender roles in Indian society, but these questions were not analyzed in the previous report and are now being published for the first time. (Another recent Pew Research Center report, “ Religious Composition of India ,” used Indian census data to examine how India’s religious makeup has changed since independence.)

Local interviewers administered the survey between Nov. 17, 2019, and March 23, 2020, in 17 languages. The survey covered all states and union territories of India, with the exceptions of Manipur and Sikkim – where the rapidly-developing COVID-19 situation prevented fieldwork from starting in the spring of 2020 – and the remote territories of the Andaman & Nicobar Islands and Lakshadweep; these areas are home to about a quarter of 1% of the Indian population. The union territory of Jammu and Kashmir was covered by the survey, though no fieldwork was conducted in the Kashmir region itself due to security concerns.

This study, funded by The Pew Charitable Trusts and the John Templeton Foundation, is part of a larger effort by Pew Research Center to understand religious change and its impact on societies around the world. The Center previously has conducted religion-focused surveys across sub-Saharan Africa ; the Middle East-North Africa region and many other countries with large Muslim populations ; Latin America ; Israel ; Central and Eastern Europe ; Western Europe ; and the United States .

The rest of this Overview covers perceptions of gender discrimination; how Indian attitudes on gender compare globally; the strong influence of education and religion in gender attitudes; the minimal differences in gender attitudes between Indian men and women, and among adults of different ages; and regional and state-level variation in how gender roles are viewed.

Indians perceive more discrimination against women than religious minorities, but most say women do not face ‘a lot of discrimination’

About one-in-six Indian women (16%) said that they had personally felt discriminated against because they are a woman in the last 12 months before the 2019-2020 survey – comparable to the shares of women who said they have recently felt discriminated against due to their religion (16%) or their caste (14%). Similar shares of Indian men said they had faced recent gender (14%), religious (17%) or caste (15%) discrimination.

But far more adults see violence against women as a major national issue. As described in a previous Pew Research Center report , three-quarters of Indians say violence against women is a “very big problem” – greater than the share who say communal violence is a very big problem (65%), and similar to the shares who say this about crime and corruption (76% each). Police cases registered as “crimes against women” nearly doubled between 2010 and 2019 , and rapes and murders of women have led to massive protests across India .

The survey asked respondents which of two options is more important to improve the safety of women in their community: teaching boys to respect all women or teaching girls to behave appropriately. Roughly half of Indians say teaching boys to respect women is more important, while about a quarter of Indians say teaching girls to behave appropriately is the better way to improve women’s safety. An additional quarter of Indian adults don’t take a clear position between those two options, instead voicing that some combination of the two approaches is necessary, that improved law and order through policing will improve the situation or that women are already safe. Women are slightly more likely than men to say that teaching boys to respect all women is the more important way to improve safety (53% vs. 48%).

How India’s gender attitudes compare globally

Pew Research Center has asked a couple of the questions on this survey in many countries around the world, allowing a glimpse of where Indians fit globally when it comes to public opinion on these issues.

Indians are less likely than people in North America (92% median ), Western Europe (90%) and Latin America (82%) to place high importance on women and men having the same rights. But they are more likely than those living in sub-Saharan Africa (48% median) and the Middle East-North Africa region (44%) to say this. Adults in Central and Eastern Europe (69% median) are roughly similar to Indians on this question.

Within South Asia, Indians are somewhat more likely than Pakistanis to say it is very important for men and women to have equal rights (72% vs. 64%).

Despite broadly aligning with global public opinion on equal rights for women, Indians tend to be more conservative than people in most other countries surveyed when it comes to gender dynamics in the home and in the economy.

For instance, across 61 countries surveyed from 2013 to 2019, a median of 17% completely agree with the statement “When jobs are scarce, men should have more rights to a job than women,” but roughly three times as many Indians say the same (55%). 4  In fact, only one surveyed country – Tunisia (64%) – has a higher share who completely agree with the notion that men should have greater rights to jobs in times of high unemployment.

On this measure, Indians are substantially more traditional than people from North America (4% median), Western Europe (7%), Central and Eastern Europe (14%) and Latin America (20%).

The 2019 Global Attitudes survey in 34 countries also asked a question about gender roles that was not on the 2019-2020 India survey: “Which kind of marriage is more satisfying, one where the husband provides for the family and the wife takes care of the house and children, or one where the husband and wife both have jobs and together take care of the house and children?”

Indians are among the most likely to say the husband should provide for the family while the wife focuses on the home: Four-in-ten Indians prefer this traditional family dynamic, compared with a global median of 23%.

Indians with a college degree are less likely to hold traditional views on gender roles

Indian adults with a college degree are less likely than those without a college education to support conservative gender norms. For example, about a quarter of college-educated Indians (24%) say women in a family should be primarily responsible for taking care of children, while roughly a third of Indians with less formal education (35%) say child care responsibility should rest with women.

However, even Indians who have completed college sometimes do overwhelmingly endorse traditional views on gender-related issues. For instance, large majorities among those with a college degree (80%) and those with less education (88%) agree with the notion that wives must always obey their husbands.

Muslims more likely than other Indians to say men should provide a family’s income

India’s main religious groups have widely divergent opinions about gender roles in the family. For example, while nearly three-quarters of Indian Muslims (74%) say that sons should have the primary responsibility for a parent’s burial rituals, just 29% of Sikhs say that sons alone should handle last rites. Across several aspects of family life, this pattern repeats: Muslims are the most likely, and Sikhs are the least likely, to support traditional gender roles.

Muslims are somewhat less likely than Sikhs to have a college education (5% vs. 9%), based on the 2011 census , and as noted previously, Indians without a college degree are more likely to hold conservative gender attitudes. But even when considering education, Muslims are far more likely than Sikhs to support traditional gender roles in the family. For instance, about a third of college-educated Muslims (32%) say women should be primarily responsible for taking care of children, while only about one-in-ten college-educated Sikhs (9%) share this view.

The overwhelming majority of India’s Sikh community lives in the state of Punjab (India’s only majority-Sikh state), and people in Punjab consistently express less preference for traditional gender roles within the home – a pattern that is not just driven by Sikhs in the state. Indeed, Punjabi Hindus are much less likely than Hindus nationally to express traditional views on some gender roles. For example, while 34% of Indian Hindus overall say women should be primarily responsible for taking care of children, just 13% of Punjabi Hindus say this – similar to the 14% of Indian Sikhs who take this position. (See “ Southern states not necessarily more egalitarian than Hindi Belt states in gender attitudes ” for more on state and regional differences across India.)

In India, men a little more likely than women to have conservative views on gender

Across a variety of measures, Indian men are more likely than women – but only slightly – to take a traditional view of gender roles. For instance, 82% of men say that when there are few jobs, men should have more rights to jobs, compared with 77% of women who share this perspective.

Similarly, older Indians (ages 35 and older) are marginally more likely than younger adults to hold traditional views on gender roles. While 45% of Indians ages 35 and older say that men in a family should be primarily responsible for earning money, 42% of those ages 18 to 34 agree.

Even when looking at attitudes only among Indian women, the differences between younger and older adults are minimal, with older women slightly more likely than younger women (ages 18 to 34) to hold conservative views on gender roles. For example, 37% of older Indian women (ages 35 and older) think women in a family should be primarily responsible for caring for children, while a third of younger Indian women take this position.

Sidebar: India’s changing gender norms

The general consistency across age groups could suggest that Indian attitudes on family gender roles may not be changing very much over time. But a long-running survey shows that attitudes and behaviors on gender roles appear to have become more egalitarian since the end of the 20th century, with perhaps the biggest changes in the early 2000s.

India’s National Family Health Survey (NFHS) has been conducted five times, with the first happening roughly three decades ago. Typically, women ages 15 to 49 and men ages 15 to 54 in selected households are eligible to be interviewed. 6 By comparison, all Indian adults (ages 18 and older) were eligible to be included in the Pew Research Center survey. Differences in sampling and question wording make it difficult to compare the two surveys directly. Still, NFHS surveys are useful in analyzing data over time.

Between the survey’s second (1998-99) and third (2005-06) rounds of data collection, several measures showed a move away from traditional attitudes. For example, while 31% of married women under age 50 who were earning money in 1998 and 1999 said that their husband was mainly deciding how to use the money the wife earned, that number halved (15%) by 2005 and 2006.

Southern states not necessarily more egalitarian than Hindi Belt states in gender attitudes

Women in India’s Southern states generally have better socioeconomic outcomes, on average, than those in other parts of the country, particularly when compared with states in the Northern Hindi Belt. For instance, Southern women tend to be more highly educated and to live longer . This North-South divide is commonly discussed in academic literature .

But Southern attitudes toward gender roles are not necessarily more egalitarian. While Indians in the South are less likely than those in the Hindi Belt to say, for example, that a wife must always obey her husband (75% vs. 94%), Southern adults are more likely to say that men in families should be responsible for making decisions about expenses (25% vs. 13%) and that women should be primarily responsible for taking care of children (44% vs. 30%).

The Hindi Belt also has large variations between states on gender roles. For example, Uttar Pradesh is often among the most conservative states, while the National Capital Territory of Delhi is consistently at the other end of spectrum. For complete state-level details on these questions, see Chapter 3 .

How regions of India are defined for this report

Previous reporting from this survey largely used membership in India’s six zonal councils to define regions. In this report, however, it makes more sense to analyze at the state level due to wide variations among states within the same zone.

This report does, though, describe differences between two commonly discussed regions: the Hindi Belt and the South. While different definitions exist, a broad definition of the Hindi Belt includes the following 11 states and union territories, located in the Northern part of the country: Bihar, Chandigarh, Chhattisgarh, Delhi, Haryana, Himachal Pradesh, Jharkhand, Madhya Pradesh, Rajasthan, Uttar Pradesh and Uttarakhand.

The South includes the following six states and union territories: Andhra Pradesh, Karnataka, Kerala, Puducherry, Tamil Nadu and Telangana.

Sidebar: National Family Health Surveys also show big variation within regions

Even though the surveys include different questions and have different sample compositions, NFHS surveys broadly show similar patterns to the Center’s recent survey: Southern attitudes and behaviors often are comparable to, or even more traditional than, those in the Hindi Belt, and states within both regions are diverse in how traditional gender roles are considered.

• These statistics are referred to as sex ratio at birth (SRB). International convention is to present SRB as the number of boys per 100 girls. In the census of India and India’s National Family Health Survey, however, this ratio is often expressed as the number of girls per 1,000 boys. This report follows the international practice, so all ratios are presented as the number of boys per 100 girls. Around the world, SRB naturally tends to skew slightly male (roughly 105 boys for every 100 girls). The exact causes of the skew are debated, but some scientists posit that the explanation may lie, at least in part, in higher female mortality rates early in pregnancy. ↩
• This is the first major study in India to ask about opinions of sex-selective abortion. Because the practice is illegal, researchers designed the question in consultation with a subject-matter expert and subsequently tested it with respondents before including it in the full survey – all part of the extensive questionnaire design process for this project. Testing found this question to be understood by respondents without being offensive. ↩
• This figure (72%) comes from the 2019 Global Attitudes survey and is slightly lower than the share (80%) who said this in the 2019-2020 India survey on which most of this report is based. Context effects could account for this difference: The survey question comes much later in the Global Attitudes survey than in the India-specific survey; and the Global Attitudes survey question is the third in a battery asking respondents to rank how important things are, while the question stands on its own in the India-specific survey. No matter the cause for the slight difference, a solid majority of Indians support equal gender rights. ↩
• This figure (55%) comes from the 2019 Global Attitudes survey and is nearly identical to the figure (56%) from the 2019-2020 India survey on which most of this report is based. ↩
• These statistics are referred to as sex ratio at birth (SRB). International convention is to present SRB as the number of boys per 100 girls. In the census of India and India’s National Family Health Survey, however, this ratio is often expressed as the number of girls per 1,000 boys. This report follows the international practice, so all ratios are presented as the number of boys per 100 girls. Around the world, SRB naturally tends to skew slightly male (roughly 105 boys born for every 100 girls). The exact causes of the skew are debated, but some scientists posit that the explanation may lie, at least in part, in higher female mortality rates early in pregnancy. ↩
• The more recent rounds of this survey have included a men’s module alongside the longstanding women’s module, although the questions asked of men sometimes differ from those asked of women. This analysis of NFHS data only includes respondents ages 18 to 49 for both women and men. ↩
• As of publication, the NFHS round five dataset (fielded 2019-2021) has not been released for analysis. Initial fact sheets from the fifth round (released at the end of 2021) indicate that women’s involvement in household decisions has slightly increased since the fourth round, suggesting that Indians may be continuing toward more egalitarian attitudes. Some of the largest increases in women’s involvement in decision-making between the fourth and fifth rounds are in the Hindi Belt locations of Delhi, Bihar and Haryana. ↩
• This analysis is based on men ages 18 to 49. As of publication, the NFHS round five dataset (fielded 2019-2021) has not been released for analysis. ↩
• Initial fact sheets from the fifth round of the NFHS (released at the end of 2021) again indicate that there is within-region variation on women’s involvement in household decisions. ↩

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About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

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• Volume 13, Issue 8
• Gender-based discrimination and son preference in Punjabi-Canadian families: a community-based participatory qualitative research study
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• http://orcid.org/0000-0003-0840-9006 Susitha Wanigaratne 1 ,
• Alia Januwalla 2 ,
• Manvir Bhangu 3 ,
• Pamela Uppal 4 ,
• Amrita Kumar-Ratta 5 ,
• Amanpreet Brar 6 ,
• http://orcid.org/0000-0002-8928-7647 Cindy-Lee Dennis 7 , 8 , 9 ,
• Marcelo Urquia 10 , 11
• 1 Edwin S.H. Leong Centre for Healthy Children , SickKids Research Institute , Toronto , Ontario , Canada
• 2 Knowledge Translation Program , Unity Health , Toronto , Ontario , Canada
• 3 Laadlilyan Celebrating & Empowering Daughters , Brampton , Ontario , Canada
• 4 Catholic Family Services Peel Dufferin , Brampton , Ontario , Canada
• 5 Department of Geography & Planning , University of Toronto , Toronto , Ontario , Canada
• 6 Department of Medicine , University of Toronto , Toronto , Ontario , Canada
• 7 Lawrence S. Bloomburg Faculty of Nursing , University of Toronto , Toronto , Ontario , Canada
• 8 Li Ka Shing Knowledge Institute , St. Michael's Hospital , Toronto , Ontario , canada
• 9 Lunenfeid-Tanenbaum Research Institute , Sinai Health , Toronto , Ontario , Canada
• 10 Department of Community Health Sciences , College of Medicine Rady Faculty of Health Sciences University of Manitoba , Winnipeg , Manitoba , Canada
• 11 Dalla Lana School of Public Health , University of Toronto , Toronto , Ontaroi , Canada
• Correspondence to Dr Susitha Wanigaratne; susitha.wanigaratne{at}sickkids.ca

Objectives To conduct a qualitative study, guided by the principles of community-based participatory research, with the following objectives: (1) to provide a conceptual framework describing the drivers of son preference; (2) to understand experiences of son preference among Punjabi-Canadians and (3) with this understanding, identify and co-design an appropriate educational tool.

Design, setting, participants, methods Qualitative study consisting of four bilingual (Punjabi and English) focus group discussions with 11 mothers, 4 fathers and 17 grandmothers in Toronto and Brampton, Canada. Participants were queried about experiences and perspectives related to reproductive decision-making, gender equity and son preference, and for appropriate approaches to reducing inequities. Transcripts were simultaneously translated and written in English and thematic analysis was conducted. An infoposter was identified as a feasible educational tool and was co-designed by researchers and community partners.

Results Participants identified patrilocality (ie, married sons reside with parents, married daughters with in-laws) and patrilineality (ie, sons inherit assets, daughters’ husband receives a dowry) as structural precursors to proximal drivers (ie, old-age security) of son preference. Mothers’ and grandmothers’ value to their families depended strongly on having a son but did not guarantee security. Pressures (ie, internalised discrimination, reproductive coercion) to conceive a son were common after the birth of at least one daughter in the absence of sons. Participants did not know anyone who had a sex selective abortion in Canada; however, traditional sex selection methods (eg, herbal medicines) were mentioned. Our co-designed infoposter entitled ‘Truths About Son Preference’ addressed three misconceptions identified in discussions.

Conclusion This study may be useful to health and social care providers in providing structurally competent and culturally humble counselling and care, particularly after the birth of daughters in the absence of sons. Community engagement is necessary for future intervention development.

• health equity
• qualitative research
• public health

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-074276

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STRENGTHS AND LIMITATIONS OF THIS STUDY

We conducted a community-based participatory research project with community members engaged throughout the research process.

One-third of the participating parents had children <5 years old, limiting the representation of parents with recent experiences of navigating pregnancy and early parenthood.

Fathers were under-represented, and the extent of their engagement was limited.

In the interest of creating a safe space we did not audio-record focus group discussions thus some details may have inadvertently been left out of transcripts.

Our co-designed educational tool reflected the needs, values and languages spoken of community members.

Introduction

In recent years numerous studies conducted in high-income countries including Canada and the UK have quantified son-biased sex ratios among immigrants or their second generation descendants from some South and East Asian countries. 1–16 Almost all groups examined were found to have son-biased sex ratios, particularly after one or two previous daughters. For example in Ontario, Canada, between 1993 and 2012, 14 women who immigrated from India, had two previous daughters and a third child, were twice as likely to have a male than a female at the third birth with this ratio doubling if the third birth was preceded by one induced abortion. Among Indian-born mothers living in England and Wales, 5 between 1990 and 2005 the third and higher order male to female sex ratio was 113 (99% CI 109.5 to 116.6) described as the only biased ratio among mothers from several countries. While many studies revealed the magnitude of the phenomenon, the explanation for son-biased ratios was often absent or simplistic. More fulsome explanations for son preference have largely resided within the development, 17 economic 18 and sociological 19 20 literature with some of these explanations explored in an American qualitative study. 21 These nuanced, but largely decontextualised, explanations are not widely known by health researchers, healthcare and social service providers or policy and decision-makers, likely contributing to ineffective and discriminatory institutional responses 22 and proposed policies 23–25 including a recently defeated Act to amend the federal criminal code 26 27 in Canada. The recently defeated Act (Bill C-233) attempted to criminalise healthcare providers who provide an abortion based on the sex of the fetus; however, there is ample evidence that similar legislation in other jurisdictions was difficult to enforce, 27 led to worse outcomes for mothers and daughters, 28 and in the Canadian context could contribute to systemic discrimination in healthcare settings. This underscores the need to promote greater understanding of the roots of gender-based discrimination occurring in specific immigrant communities to better inform effective, culturally appropriate and equitable interventions.

Our study took place in Brampton and Etobicoke, Canada (part of the Greater Toronto Area (GTA)). We had three objectives. The first was to create a conceptual framework synthesising the drivers for son preference, drawing from literature across disciplines. The second, was to conduct a qualitative study exploring the experiences and perspectives of Punjabi-Canadians related to reproductive decision-making, gender inequity and son preference. We focus on Punjabi-Canadians because our previously published epidemiological studies 3 14 suggest a preference for sons in this community, and because our community partners mostly serve this large diasporic community. Our third objective was to describe community-identified ways to address son preference and, in keeping with the community-based participatory research (CBPR) imperative to integrate knowledge gained with action, we share our co-designed educational tool to encourage its wider dissemination and use.

Conceptual framework—the roots of son preference and factors reinforcing son preference in the immigration context

We created a conceptual framework ( figure 1 ) to understand the determinants of son preference in North Indian/Punjabi-Canadian communities which may also be relevant for similar communities residing in other immigrant-receiving countries. We share a version here that includes literature that was published after we developed our focus group guide.

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Conceptual framework—understanding the determinants of son preference in North Indian/Punjabi-Canadian communities.

Kinship (ie, family) structures and related cultural factors are cited as key drivers of son preference in East and South Asia in the development and economics literature. 17 18 These inter-related structures and factors are summarised in the inner circle of figure 1 —patrilocality, patrilineality, dowry, old age security, family dishonour for daughters, ceremonial roles for sons and family lineage. Das Gupta et al 17 notes that ‘patriarchy’ alone is not a sufficient explanation for son preference since societies around the world, including ‘Western’ ones, are patriarchal. Rather they suggest that flexibility in the logic of patrilocal and patrilineal kinship systems is key, with rigid adherence in Northern India, parts of China and South Korea and less rigid adherence in Southern India.

These factors are further supplemented by development and social work researchers who have identified factors exacerbating son preference in Punjabi-Canadian communities (outer circle of figure 1 ). These factors include immigration policies which intensify the vulnerability of immigrant women, 19 transnational marriage 19 and the necessity to maintain family honour (or ‘Izzat’) in the face of discrimination and racism from wider Canadian society. 20

Qualitative approach and research paradigm

In this phenomenological study we aimed to understand Punjabi-Canadian community members’ lived experiences of son preference and gender-based discrimination in relation to family planning and to identify common features of this experience. We subscribe to critical theory in that we understand son preference in the Punjabi-Canadian community to be shaped by intersecting social factors including gender, culture, ethnicity and immigration. This project was guided by the principles of CBPR. 29 We followed relevant reporting guidelines for qualitative research. 30

Patient and public involvement

Two community organisations serving the South Asian community, with close ties to the Punjabi community in the GTA, partnered on this study’s grant proposal; a third organisation partnered in the study’s early stages. Punjabi-Canadian community members employed by or volunteers with these organisations, and community members independent of these organisations, were recruited as study staff and were involved throughout the research process, dissemination of our research findings and development and dissemination of the co-designed educational tool (details are provided in the remainder of the methods section).

Research team and reflexivity

The primary author (SW) is a PhD trained social epidemiologist and was a postdoctoral fellow at the time the study was initiated. She is a second-generation Canadian with Sri Lankan origins. MU is a PhD trained social epidemiologist with a background in anthropology who led several Canadian epidemiological studies examining son preference. AJ (MPH) is a health promoter and knowledge translation specialist interested in sexual and reproductive health rights of structurally marginalised women and is a Muslim Kenyan-Canadian of Indian descent. MB (MA) is a researcher, founder and executive director of ‘Laadliyan Celebrating & Empowering Daughters’ (a community partner on this study) and at the time of the study was a youth worker. MB co-facilitated the discussion with mothers and facilitated one of the grandmother discussions. PU (MA) is a director of policy in the non-profit sector and at the time facilitated Ontario’s court mandated Partner Assault Counselling Programme. PU co-facilitated the discussion with mothers and grandmothers. AK-R is a social researcher and PhD candidate in Human Geography and facilitated the community member discussion identifying appropriate interventions. AB is a general surgery resident physician. MB, PU, AK-R and AB self-identify as Punjabi-Canadian. CLD is a PhD trained perinatal health researcher.

Focus group methods

Recruitment.

Participants were recruited in August and September 2017 through two community social service agencies with close ties to the Punjabi community in the GTA and by facilitators and research assistants who self-identified as Punjabi. The recruitment call, which described ‘a discussion on family life and the health of Indian immigrants’, was also disseminated by word-of-mouth through announcements at community events, internal listservs, e-newsletters and on social media (Twitter and Facebook). A volunteer at the second community agency recruited participants through word-of-mouth.

Interested participants contacted a bilingual (English/Punjabi) research associate by telephone or email (coauthor PU). The research associate described the study purpose as ‘exploring how families make decisions about having children and how these decisions may affect the health and well-being of families’. A screening survey was conducted over the phone to determine eligibility. Mothers and fathers were eligible if they were immigrants from India and had a daughter who was born in Canada. Grandmothers were eligible if they had a son with a daughter living in Canada. The study team aimed to recruit 10–12 participants from each of the three groups for each discussion. Participants had no prior relationship with the researchers.

Data collection

Four focus group discussions were conducted; three took place at a community partner’s office and the fourth at a local public library. For several reasons related to CBPR principles, focus group discussions were the preferred method since: (1) they offered a format for participants to collectively reflect on individual and common experiences and potentially motivate collective action; (2) early consultations with community partners indicated this method was preferred, contributing to shared decision-making and; (3) they shift the balance of power towards participants.

A semi-structured focus group guide ( online supplemental table 1 was developed by SW and AJ and refined with feedback from community partners and facilitators and adapted for each group.

Supplemental material

Focus group discussions.

Four 2-hour focus group discussions were held; one for mothers, one for fathers, 31 and two discussions for grandmothers. All participants were given a $C50 gift card (2023 - US$37 and £31). Bilingual (Punjabi/English) facilitators were community members of the same gender and of a similar age as the participants, with extensive experience working with the local Punjabi community and discussing sensitive issues.

To preserve participants’ anonymity and cultivate a safe space, focus group discussions were not audio-recorded; however, two note takers wrote and translated their detailed transcript notes into English ( online supplemental file 2 : Focus group notes). The study team met with the facilitator and note takers after each discussion to clarify any details and ensure a shared understanding of the findings. An employee of the community organisation was present during discussions to facilitate connection to counselling services if needed.

Focus group discussion analysis

SW and AJ used a mutually agreed on, predetermined coding framework to conduct independent thematic analyses 32 on each transcript to identify relevant quotes and passages. During this process, the two authors also identified emergent themes and subthemes with appropriate quotes or passages, discussed them for inclusion/exclusion in team meetings and updated the coding framework as necessary, until no new themes or subthemes could be identified. Finally, the authors met to discuss and review their complete analytical notes and developed a combined analytical document organised by theme in a tabular format. Within each theme, relevant summary statements and quotes from participants were included and a summary paragraph of each theme was written ( online supplemental file 3 : Transcript analyses). The analytical document was shared with facilitators (and coauthors) PU, MB and AKR to confirm that the findings resonated with community member’s perspectives.

Ethical considerations

Prior to beginning the discussions, all participants were given an English or Punjabi informed consent form. Focus group facilitators informed participants that counselling services could be made available to them on request.

Co-designing an educational intervention

A community advisory meeting (facilitated by AK-R) was convened and attended by our community partner’s leadership teams, social service providers (eg, settlement services) as well as community members. An overview of focus group participant’s perspectives on how to address gender-based discrimination was provided and the group was tasked with identifying a way for this project to contribute to community action.

Focus group participants

In total 11 mothers, 4 fathers and 17 grandmothers participated in focus group discussions (see table 1 for characteristics).

• View inline

Frequency of demographic characteristics of focus group participants

Focus group discussion themes

Seven predetermined themes and emergent subthemes were identified. Quote identification is signified by a number in the 100s for mothers, 200s for fathers and 300s for grandmothers. See online supplemental file 1 for additional thematic results and sixth and seventh themes (not included below).

The perceived value of men and sons versus women and daughters

Many participants described women and daughters being treated like they were less valuable compared with men and sons. Fathers, mothers and grandmothers described that girls were raised to ‘belong to another family’ since after marriage daughters are expected to leave their parent’s home and reside with and care for their in-laws.

…women don’t belong anywhere [on the family tree], they belong to in-laws…” (102)

In contrast, both mothers and grandmothers noted the importance placed on sons to preserve the family name and lineage.

Our people love the concept of saying he’s so and so’s son. (112)

Participants described that patrilocality both physically and symbolically prevented daughters from caring for their parents in their old age.

I can’t expect for my daughter to come and take care of me. (313)

Not only were daughters unable to care for their own parents, but one mother and two grandmothers explicitly stated that the role of daughters was that of household labour and servitude to her in-laws.

Patrilineality was described as a simultaneous mechanism by which sons embody financial and old age security while daughters endanger security.

Sometimes if you have only daughters, in the future your son-in-law can come in and compete for land or property. So, if there is a brother in the picture sometimes this can be avoided. (317)

Participants described that having a son ensured that the family’s wealth remained in the family and could be used to support parents as they age. Fathers mentioned that sons were considered bread winners and were an investment which would eventually benefit his parents. Grandmothers described that daughters may be a drain on resources because prospective in-laws often require a dowry for daughters.

A mother and several grandmothers also mentioned that sons receive special treatment in families because cultural celebrations and festivals revolve around boys.

It is about traditions – celebrations, weddings or “rakhri” [a celebration between brothers and sisters; brothers agree to protect sisters and sisters pray for the wellbeing of brothers]. It is how our culture is. The girl has her own place and the son has his own place. (305)

Participants 311 and 313 also indicated that traditionally only sons light the funeral pyre (as per Hindu tradition), ensuring the safe passage of parents into the afterlife.

Unrelated to funeral traditions but in contrast, fathers mentioned that daughters can bring shame to the family.

Finally, while mostly negative impressions of daughters were conveyed, one mother noted that daughters truly continue the generation (since they bear children) and one grandmother stated that: ‘Daughters take care of moms like no other’. (308)

Experiences of pressure to bear sons

Direct and indirect pressure to conceive and give birth to a son..

These experiences of pressure to have a son (n=13) often occurred soon after marriage and/or after the birth of one or more daughters, particularly in the absence of any sons.

…when it comes to your first daughter, no one says anything…but when it’s about the second daughter, it becomes a problem… (104) we don’t have to fear for the second time, if there is a son the first time. (312)

For many participants, the dominant sources of direct pressure were in-laws but an individual’s own parents also contributed. This was the case for grandmothers, but also for nine mothers and fathers. Two mothers noted that in-laws pressured them to check for the sex of the fetus while pregnant; one mother noted that her in-laws were angered when the ultrasound technician refused to disclose the sex of the baby. One grandmother (301) said she prayed for a son out of fear of her in-laws’ reaction.

Many parents received comments that insinuated a preference for males.

…it would be nice to have two boys … (to 106 by her mother-in-law) …you better give me a grandson… (to 301 by her mother-in-law)

Neighbours shared with one mother that ‘they would lose faith in God if they had a girl first’ (to 105).

One mother (112) described explicit coercion from her mother-in-law. She was pressured to consume certain foods, medications, traditional treatments and perform certain traditional rituals to have a son. Her mother-in-law also told her to have an abortion if she was having a girl. One grandmother (308) described that her mother-in-law made her perform various rituals such as consuming pearls or standing facing in a specific direction.

Participants also described indirect pressures. Fathers noted that the pressure from family members was exacerbated by multigeneration living circumstances. This led them to be more worried about making their parents happy rather than focusing on themselves.

A few mothers seemed to describe internalised pressure to have a boy.

I had a stroke of luck, a son first, then a daughter. (101)

Personal and family reactions to the birth of a girl—the importance of birth order and the sex of previous children

More concern and/or negative reactions occurred if the first child was a daughter. Mother 110 described personal disappointment when she had her only daughter. Negative reactions seemed to intensify at the birth of a second or additional daughter. Mother 112 experienced strong negative reactions from both her husband and her mother-in-law after the birth of her second and third daughter.

The oldest grandmother described the experience of her son having three daughters and no sons:

I was okay with the first was born. The 2 nd time, I was a bit sad. I still feel it. Oh my god, what happened at my son’s house!? There should have been a boy. By the third daughter I had accepted it. (316)

Feelings of relief were described at the birth of a son after first having a daughter.

I felt somewhere that I was secure that now I had a boy and a girl. (106)

In contrast to the experiences of mothers, three out of the four fathers (all with daughters) indicated that they were happy at the birth of their daughter and would not have felt differently if they had a son. However, fathers noted family members were unhappy.

The impact of son preference on family members well-being

The treatment of young mothers and grandmothers by their family members when first married, appeared strongly tied to having at least one son.

When I found out that it was a boy, my husband and mother-in-law changed completely. They became extremely careful [with me]. (101)

This was in stark contrast to mother 112 who was treated very poorly by both her husband and her mother-in-law for not having any boys.

My husband planned to send me to India. He used the excuse that he could not afford to keep me and our two girls with him. (112)

In contrast, one father stated that ‘growing up, I would be treated better than my sister’ (206). Another father (203) noted feeling ‘too much pressure’ from his own parents to have a son.

The reality of having sons

There were several mother and grandmother participants who expressed dissatisfaction and disappointment that the security promised with sons does not necessarily materialise.

Our society thinks that sons will take care of us in old age. (110) There are many sons who don't take care of their parents, even then moms still worship that son. (112) …why should we have expectations of our sons? In reality, we will all go to old age homes. (311)

Knowledge of methods for sex selection

Methods other than abortion..

These included spiritual practices, such as visiting gurus for specific prayers or amulets, usually during pregnancy. Some women mentioned consuming specific foods (eg, jaggery (a sweet)), herbal medicines or pills to have a son. Some women also mentioned consuming pearls, peacock feathers or a coconut with a flower inside, as well as taking a bath at night-time with a bucket of water in the middle of a neighbourhood intersection (in Canada). Others mentioned media advertisements in newspapers or television were common.

Awareness of and experiences with abortion

Of the 32 participants, only 2 described experiencing personal pressure to have an abortion. One father discussed his wife receiving pressure from her mother (203) while another mother described pressure from her mother-in-law and husband to have an abortion in India after having two daughters (112). Neither of these participants confirmed that an abortion had been done. Two grandmothers (301 and 311) recounted stories of women they suspected or knew had abortions. Several participants indicated that aborting girls was common in India. One grandmother believed people were not aborting girls in Canada, while another indicated that women in Canada were being sent back to India to get abortions. Many grandmothers did not know that abortion was legal in Canada.

Recommended methods/approaches to advance gender equity

Several participants indicated that the focus of any intervention should be on awareness and education about the existence of son preference in Canada. Participants indicated that communication between family members should be improved and that formal training or counselling to improve interpersonal communication would be helpful. Many participants highlighted the use of community-based newspapers, television or radio programmes to demonstrate, for example, effective communication between family members. Participants expressed a need for multilingual interventions where families, communities, schools, religious institutions and even governments could be involved in a social movement to advance gender equity and reduce daughter discrimination.

Educational infoposter development

The community advisory group decided that a multilingual educational infoposter would be developed. Given the suggestion to improve awareness and education, key misconceptions related to son-preference were identified from focus group transcripts by SW and AJ and formulated into straightforward statements which were supported by scientific evidence and accompanied by professionally designed graphics and layout. Researchers and community partner’s leadership teams decided on the infoposter’s final content and format. English, Punjabi and Hindi infoposters were made available to partner agencies and a small social media campaign was launched to disseminate it online. See figure 2 for English infoposter with additional details and online supplemental file 1, figures 1–3 for shareable versions of the English infoposter and the Hindi and Punjabi translations.

Truths about son preference—English language infoposter with additional details.

The participants in this CBPR study described experiences related to the root factors of son preference illustrated in the inner circle of figure 1 , specifically patrilocality and patrilineality leading to financial, old age security and care as well as social status motivators which were strong incentives for Punjabi mothers, fathers and grandmothers to want sons and grandsons over daughters and granddaughters. The experiences of mothers in our study were remarkably similar to those reported in the USA 21 confirming immense internal and external pressure to have sons. Fathers and grandmothers acknowledged son preference, many stated the motivations for the phenomenon and personally experienced pressures to have sons but none admitted to perpetrating reproductive coercion. Mothers and fathers had few formal conversations with their spouses related to family planning. No one stated knowing anyone who had an abortion done in Canada, but several participants alluded to women travelling back to India to get an abortion. Numerous traditional sex selection methods described by participants have not been reported elsewhere and suggests a long-standing investment in producing sons.

We also identified culturally appropriate and community-driven solutions to address and reduce son preference and gender inequity. Among numerous suggestions, participants mentioned interventions should focus on improving awareness and knowledge of son preference and wider social interventions which recognise the diverse contributions of women to society. We co-designed an educational infoposter using scientific findings to tackle misconceptions related to son preference uncovered in focus group discussions. To date, the infoposter has been viewed and discussed by ~350 grandmother–granddaughter pairs participating in an intergenerational relationship building workshop 33 and ~100 men participating in a court mandated partner assault response programme in the GTA (facilitated by coauthor PU). It has also been shared at over 27 community events across the GTA.

Study implications

The findings of this study have several implications for primary care physicians, obstetricians, midwives and social service providers who provide care to the Punjabi community in Canada and possibly in other countries. First, the conceptual framework along with the experiences of son preference shared by participants is critical information which can enhance delivery of culturally humble 34 and structurally competent 35 care and in turn cultivate shared medical decision-making. These approaches are vital to establish trust so that providers may have an opportunity to facilitate meaningful conversations around equitable reproductive decision-making and son preference. Second, given that participants described higher levels of pressure to have a son and had negative experiences after the birth of one or more daughters in the absence of sons, these are time points at which providers may consider counselling mothers in need of social, emotional and mental health support and ensuring such supports are available. Third, at these times it may also be beneficial for providers to encourage and facilitate communication between family members. Fourth, providers involved in preconception and antenatal care should also be aware that some women may be consuming herbal medicines or pills to have a son. The sale of these pills in Canada was confirmed by an English language newspaper in 2009. 36 While the content of these pills is unknown in the Canadian context, researchers from India have described drugs for the same purpose as ‘sex selective drugs’ (SSDs). Neogi et al 37 found these pills, consumed in the first trimester, contained hormones in quantities detrimental to embryonic growth. Additionally, the odds of congenital malformations or stillbirth was almost three times higher among women who took SSDs. 37 38 Given this, it is important that healthcare providers consider asking about consumption of these drugs and provide culturally safe counselling about their harms. Our infoposter may help guide such discussions. From a drug safety and regulation perspective, the scope and sale of SSDs in Canada needs to be further investigated.

In terms of interventions, countries such as India have attempted to reduce son preference and son-biased sex ratios through various policies (eg, granting women legal rights to ancestral land) 18 ; however, in addition to being minimally enforced, Das Gupta et al 17 argues that successful interventions must raise the value of girls to her parents relative to the value of boys. This approach may be particularly important in the Canadian context since there are fewer barriers to high-quality education and employment opportunities for women and so should not, theoretically, constrain a daughter’s ability to support her parents as they age. Active and visible recognition by community-members, religious and grassroots organisations, of daughters providing support may help shift the social position of women and girls within families.

Strengths and limitations

There were limitations to our study. The focus group format increased the chances of social desirability bias (eg, less likely to admit to reproductive coercion, more likely to express gender equitable attitudes). At the advice of our community partners and in the interest of creating a safe space, we did not audio-record focus group discussions which could have led to some details being left out of transcripts. One-third of participating parents had children <5 years, consequently we had limited representation from parents with more recent experiences of navigating pregnancy and early parenthood. Only four fathers participated in our study and the extent of their documented engagement was limited. Our study also had several strengths. The focus group format offered opportunities to reflect on common experiences and contribute to solidarity and collective action, an important goal of CBPR studies. To cultivate open dialogue and minimise some aspects of social desirability bias we conducted gender and age group specific focus group discussions. Focus group discussion notes and analyses were reviewed by note-takers and facilitators to ensure notes captured the discussion and appropriate interpretation of the data. To encourage participation of parents with young children we offered free high-quality childcare, conducted discussions on weekend afternoons and offered a cash honorarium. Our co-designed infoposter reflected the needs, values and languages spoken of community members; an approach which encourages adoption and sustained use. 39

Conclusions

Given the specific and evolving system of patriarchal structures experienced by the Punjabi-Canadian community (ie, originating from within the community, as described in this paper, and outside the community as described elsewhere), community-engagement is necessary to identify and develop interventions which effectively reduce gender-based discrimination while also mitigating harm to the community, and girls and women in particular. The conceptual framework and experiences described in this paper are useful for healthcare and social service providers serving the Punjabi community in Canada and in other immigrant receiving-countries to enhance cultural humility and structural competency, which may in turn facilitate shared and more equitable reproductive decision making at critical periods—that is, after the birth of one or more daughters, in the absence of sons. Our co-designed infoposter may assist in these discussions.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by St. Michael’s Hospital, Toronto, Canada (#17-132c). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors would like to thank Baldev Mutta, Anu Randhawa and Amandeep Kaur at Punjabi Community Health Services (PCHS), Kripa Sekhar at South Asian Women’s Centre (SAWC) and MB at Laadliyan Celebrating & Empowering Daughters for their support of this work. We thank the numerous staff and volunteers at PCHS and SAWC who helped to recruit focus group participants and those who conducted the focus group discussions—Teena Gidda, Amandeep Virk, Vanita Sabharwal, Pamela Uppal, Karen Pannu, Harinder Sahota, Prabhjot Gida, Harish Minocha and Prem Minocha. We also thank members of our community advisory panel (not already mentioned)—AK-R, Sumit Rai, Amanjit Kahlon, Gurpreet Singh, Palwinder Kahlon, Shanjot Singh, Jasmin Balla, Daljit Basra, Arwinder Kapour and Manjeet Sahota. We thank Meghan D’Mello for her graphic design work on the infoposters. We are especially grateful to the 11 mothers, 4 fathers and 17 grandmothers who generously shared their time, experiences and insights with the research team.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3

Contributors SW led all aspects of the study including study conception, study design, data acquisition and analysis, interpretation of the data and drafted and substantively revised the work. AJ was involved with study design, data acquisition and analysis, interpretation of the data, drafted and substantively revised the work. MB, PU and AK-R were involved with study design, data acquisition, interpretation of the data and substantively revised the work. CLD contributed to data acquisition and revised the work. AB and MU were involved with study conception and substantively revised the work. All authors approved the submitted version and agree to be personally accountable for their contributions and ensure that the questions related to the accuracy and integrity of any part of the work, even ones in which they were not personally involved in, are appropriately investigated, resolved and the resolution documented in the literature. SW accepts full responsibilty for the work and the conduct of the study, had access to the data and controlled the decision to publish.

Funding This study was funded by the Women’s Xchange (Women’s College Hospital, Toronto, Canada) and was partially supported by a Canadian Institutes of Health Research grant (FDN-154280) (salary for SW). MU is supported by a Canada Research Chair in Applied Population Health (950-231324). The funders had no role in the design of the study, collection, analysis or interpretation of data or in writing the manuscript.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Toxic Masculinity and the Construction of Punjabi Women in Music Videos

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• Published: 02 August 2020
• Volume 38 , pages 200–209, ( 2021 )

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• Jaspreet Bal   ORCID: orcid.org/0000-0002-2872-0726 1  

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Toxic masculinity fosters the domination and devaluation of women, often resulting in overt violence. As Punjabi women within Punjab and in diaspora have moved into the digital space, so has the reproduction of their womanhood. This paper serves to look at one of the many complex overlapping and intersecting trends that contributes to these constructions; Punjabi music videos. The author looked at the top 20 most viewed Punjabi music videos on YouTube in 2017 and coded for the gender of the producers and singers, as well as coding for themes in the final product. Major themes included that women were powerless, were objects to be acquired, were in need of saving, and were unable to consent. As an alternative to these toxic representations, the author suggests that the political potential of the multitude can be used to imagine digital spaces as sites of resistance where women reclaim telling their stories.

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Appendix A: Full List of Videos Analyzed

Aulakh, M. [Speed Records]. (2016, Nov 17). Kadar. [Video]. YouTube. https://www.youtube.com/watch?v=_BgrJ4k5FtE .

Dharia, P. [White Hill Music]. (2017, Feb 20). Na ja. [Video]. YouTube. https://www.youtube.com/watch?v=Q-GOFPM01d0 .

Dhami, J. [Jaz Dhami]. (2012, Sept 5). High heels. [Video]. YouTube. https://www.youtube.com/watch?v=Tkgad9gngOQ .

Dosanjh, D. [Speed Records]. (2014, Nov 17). Patiala peg. [Video]. YouTube. https://www.youtube.com/watch?v=xB9-dsTC_0U .

Dosanjh, D. [Speed Records]. (2015, Dec 18). 5 taara. [Video]. YouTube. https://www.youtube.com/watch?v=MsTW5cyWKj4 .

Dosanjh, D. [Speed Records]. (2016, Dec 20). Laembadgini. [Video]. YouTube. https://youtube.com/watch?v=15Sjjl_24x0 .

Gill, J. [Speed Records]. (2014, Oct 14). Bapu zimidar. [Video]. YouTube. https://www.youtube.com/watch?v=jOYR3k1VhUQ .

Inder, N. [Times Music]. (2015, Sept 8). Wakhra swag [Video]. YouTube. https://www.youtube.com/watch?v=iMdH_G4N9nY .

Mann, S. [T-Series Apna Punjab]. (2016, Dec 17) 3 peg [Video]. YouTube. https://www.youtube.com/watch?v=hzTg4zPBtDU .

Mehndi, D. [Soni Music India VEVO]. (2014, March 21). Tunak tunak [Video]. YouTube. https://www.youtube.com/watch?v=vTIIMJ9tUc8 .

Pasreja, A. [Crown Records]. (2016, Feb 13). Khaab [Video]. YouTube. https://www.youtube.com/watch?v=lBuLUidR9r0 .

Randhawa, G. [T-Series]. (2015, April 2). Patola [Video]. YouTube. https://www.youtube.com/watch?v=btxXHe2E4CQ .

Randhawa, G. [T-Series]. (2016, Jun 24). Suit [Video]. YouTube. https://www.youtube.com/watch?v=uQ763VvqiEM .

Sandhu, H. [T-Series]. (2016, Apr 12). Hornn blow [Video]. YouTube. https://youtube.com/watch?v=IssysxAisfo .

Sandhu, H. [T-Series]. (2017, Jan5). Backbone [Video]. YouTube. https://www.youtube.com/watch?v=bqGtrvcR5ls .

Singh S. [T-Series]. (2015, OCT 10). All black [Video]. YouTube. https://www.youtube.com/watch?v=ReXw6TOnUOc .

Singh S. [T-Series]. (2016, Sept 9). Suicide [Video]. YouTube. https://youtube.com/watch?v=9p7TiGx7b-4 .

Sisodia, A. P. S. [Soni Music India]. (2017, Apr 1). Mercy [Video]. YouTube. https://youtube.com/watch?v=Jyst8oIHOAY .

Star, J. [J STAR Productions]. (2015, Feb 18). Na nan a na [Video]. YouTube. https://www.youtube.com/watch?v=lBuLUidR9r0 .

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Bal, J. Toxic Masculinity and the Construction of Punjabi Women in Music Videos. Gend. Issues 38 , 200–209 (2021). https://doi.org/10.1007/s12147-020-09264-1

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Gender Discrimination Essay

500 words gender discrimination essay.

Gender discrimination is when there are unfair rights between male and female. It differs because of their gender roles which ultimately leads to unequal treatment in life. Gender discrimination has been around for many centuries. However, as we are evolving, it is time to do away with such notions of gender roles. Thus, gender discrimination essay will take us through it in detail.

Causes of Gender Discrimination

There are many causes of gender discrimination. The first one has to be illiteracy . When people do not educate themselves, they continue to live in the old times. Thus, they follow the old-age sexist traditions and norms.

Education can bring about a change in this mindset because educated people will less likely partake in gender discrimination. Further, poverty is also another reason which is interlinked in a way.

It is the root cause in many places because the economic dependence remains on the male counterparts mostly. Thus, women suffer a lot from it because of the same reason. They never get out of this and stay financially dependent on men.

Furthermore, the patriarchal setup in our society plays a big role. In this setup, the male dominates almost every aspect of life. Thus, they consider themselves to be superior to others.

This way, a lot of violence and injustice is meted out against females. Thus, when there is a gender considering themselves to be superior, it becomes difficult for everyone to avail equal opportunities.

Impact of Gender Discrimination

Gender discrimination has a deep impact on society as a whole. It does not just impact a specific section of the society but every part of it. First of all, it impacts children as they fall prey to gender stereotypes from a young age.

Further, it impacts young people because it impacts their behaviour, study choices, ambitions, attitudes and more. Thus, many girls do not participate in many sports and women experience physical violence more than men.

Next up, we have gender discrimination affecting adults because there is a gender pay gap between the working class. Men earn more for doing the same work as women. In addition, older women have more risk of becoming homeless than men.

It also impacts the aboriginal women because they have it a lot worse. It is more likely to happen that they can die from family violence, 11 times more than men. Even for men, it is not beneficial as it sets difficult standards for men to follow.

It draws a line on men being emotional. Thus, they can never showcase their emotions truly without being judged. Similarly, men do not parental leave in many places. Ultimately, all this results in more suicide in men. Thus, it impacts everyone.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of Gender Discrimination Essay

Gender discrimination must be checked at every stage so that no person should be denied a chance to learn and grow. Thus, everyone, no matter male or female, must get a start in life in terms of educations and other opportunities. We must come together as a society to do this.

FAQ on Gender Discrimination Essay

Question 1: Who is affected by gender inequality?

Answer 1: Gender inequality affects everyone, which includes men as well. Stereotypes about how women and men, girls and boys should be, start from their childhood and follow us to adulthood. Thus, it does not affect just one but all.

Question 2: Give an example of gender discrimination.

Answer 2: There are many examples of gender discrimination. For instance, restriction on clothing. If a man wears shorts, no one will bat an eye. However, if a woman wears shorts, she will be seen in a bad light and be called names. Similar is the case for housework.

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CULTURAL PORTRAIT OF WOMEN IN A PUNJABI VILLAGE (PERCEPTION OF PEOPLE REGARDING GENDER ROLES AND LITERACY)

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Dr. Anwaar Mohyuddin

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This study “Cultural Barriers to Girls Education” shows local perception of parents regarding their daughters’ education. In spite of the fact that the people are aware of the importance of literacy, there is a gender gap. People are still reluctant to send their daughters to the schools. There are certain cultural barriers to girls’ education which helps to maintain the status quo. The pardah has been a major barrier for the girls’ education since a long time. The other barriers include division of labour, male decision makers, nonparticipation in economic activities, temporary family membership, and inheritance. Fathers belonging to different classes and age groups have their own reasons for not sending their daughters to school. The group of fathers aging more than 60 years was more concerned about pardah whereas the group between 20 to 40 years had economic reasons. Mothers have slightly different opinion about female education. They have their own reasons for not sending their daughters to school. The pattern of change among males and females was almost similar. In younger groups, both of them were more concerned for economic reasons. So with the passage of time the reasons have been shifted from pardah to economy which includes nonparticipation in economic activities, investment on temporary family member and the inheritance.This research was conducted in Villag Dasuha District Faisalabad. Qualitative anthropological techniques were used to collect empirical data.

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Female education plays an important role in the societal progress and improvement. The literacy rate among rural females is 29% in Pakistan. In the developing countries like Pakistan, the traditional attitude towards women education is painstaking a keyobstacle in girls' schooling. In this study an effort had been made to explore the effect of traditional attitude on the educational attainment of rural females in Pakistan. The present study was conducted in the rural areas of the district Hafizabad. A sample of size 700 female children was selected using multistage random sampling technique. The final completed school grade was considered as the response variable. The analysis reveals that the girls, who belonged to households where the minds of the heads of the households were entrenched in the local cultural values, had lower levels of educational attainment as compared to the girls of households where the heads of the households were liberal. The study realizes the need to encourage the male heads of the households for schooling of their daughters as a short-run policy. Efforts to neutralize an innovative attitude towards females in the third world nations are the need of the hour. International organizations and States of the developing world should manage to promulgate the importance of female education.

Dhruv Bhargava

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• Published: 22 December 2022

Perpetuation of gender discrimination in Pakistani society: results from a scoping review and qualitative study conducted in three provinces of Pakistan

• Tazeen Saeed Ali   ORCID: orcid.org/0000-0002-8896-8766 1 , 2 ,
• Shahnaz Shahid Ali 1 ,
• Sanober Nadeem 3 ,
• Zahid Memon 4 ,
• Sajid Soofi 4 ,
• Falak Madhani 3 ,
• Yasmin Karim 5 ,
• Shah Mohammad 4 &
• Zulfiqar Ahmed Bhutta 6 , 7  

BMC Women's Health volume  22 , Article number:  540 ( 2022 ) Cite this article

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Gender discrimination is any unequal treatment of a person based on their sex. Women and girls are most likely to experience the negative impact of gender discrimination. The aim of this study is to assess the factors that influence gender discrimination in Pakistan, and its impact on women’s life.

A mixed method approach was used in the study in which a systematic review was done in phase one to explore the themes on gender discrimination, and qualitative interviews were conducted in phase two to explore the perception of people regarding gender discrimination. The qualitative interviews (in-depth interviews and focus group discussions) were conducted from married men and women, adolescent boys and girls, Healthcare Professionals (HCPs), Lady Health Visitors (LHVs) and Community Midwives (CMWs). The qualitative interviews were analyzed both manually and electronically through QSR NVivo 10. The triangulation of data from the systematic review and qualitative interviews were done to explore the gender discrimination related issues in Pakistan.

The six major themes have emerged from the systematic review and qualitative interviews. It includes (1) Status of a woman in the society (2) Gender inequality in health (3) Gender inequality in education (4) Gender inequality in employment (5) Gender biased social norms and cultural practices and (6) Micro and macro level recommendations. In addition, a woman is often viewed as a sexual object and dependent being who lacks self identity unless being married. Furthermore, women are restricted to household and child rearing responsibilities and are often neglected and forced to suppress self-expression. Likewise, men are viewed as dominant figures in lives of women who usually makes all family decisions. They are considered as financial providers and source of protection. Moreover, women face gender discrimination in many aspects of life including education and access to health care.

Gender discrimination is deeply rooted in the Pakistani society. To prevent gender discrimination, the entire society, especially women should be educated and gendered sensitized to improve the status of women in Pakistan.

Peer Review reports

Gender discrimination refers to any situation where a person is treated differently because they are male or female, rather than based on their competency or proficiency [ 1 , 2 ]. Gender discrimination harms all of society and negatively impacts the economy, education, health and life expectancy [ 1 , 2 ]. Women and girls are most likely to experience the negative impacts of gender discrimination. It include inadequate educational opportunities, low status in society and lack of freedom to take decisions for self and family [ 1 , 3 ].

Likewise, gender discrimination is one of the human rights issues in Pakistan and is affecting huge proportion of women in the country [ 1 , 2 ]. In Pakistan, nearly 50% of the women lacks basic education [ 4 ]. In addition, women in Pakistan have lower health and nutritional status. Furthermore, most of the women are restricted in their homes with minimal or no rights to make choices, judgments, and decisions, that directly affect their living conditions and other familial aspects [ 2 ]. In contrast, men are considered dominant in the Pakistani society [ 5 ]. This subordination of women has negative influences on different stages of women’s life.

Study design

The mixed method study design was used. Systematic review was done in phase one and qualitative interviews; in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in phase two.

The objective of the systematic review

To map a broad topic, gender discrimination/inequality research in Pakistan including women undergoing any form of intimate partner violence.

Systematic review

The three authors (TSA, SSA and SN) independently performed an extensive literature search using two databases: PubMed and Google Scholar and reports from organizations such as WHO and the Aurat Foundation. Quantitative and Boolean operators were used to narrow down the search results. The following keywords and phrases were used: Intimate partner violence (IPV), domestic violence, violence against women, domestic abuse, spousal violence, and Pakistan. Articles from 2008 to 2021 were assessed. The selection criteria of the articles included: women undergoing any form of IPV (physical, psychological, and sexual); quantitative study design; English as the publication language; and articles in which Pakistan was the study setting. The shortlisted articles were cross-checked by two of the authors (TSA, and SN) for final selection. The quality of the selected articles was reviewed using a STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist, which ensured all articles followed a structured approach, including an introduction, methodology, results, and a discussion section. It was also determined that all selected articles are published in peer-reviewed journals and have been used nationally or internationally. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart was used for study selection (Fig.  1 ).

PRISMA Diagram to select the final articles

The selected articles were approved by one of the authors (TSA), who is an expert in the field of IPV. Articles were excluded: (i) If the study was not conducted in Pakistan; (ii) Studied spousal violence against men and (iii) Domestic violence involving in-laws or other family members. Furthermore, from the selected articles, the data were extracted by 3 authors (TSA, SSA, SN) by carefully studying the methodology and results. The methodology was entered into an extraction template in which location was summarized including the study design and sample size in the articles. The results covered: (i) The title, (ii) Authors, (iii) Publication year, (iv) Objectives of the research, (v) Population and Setting, (vi) Research design, (vii) Data collection methods, (ix) Results, (x) Perpetuating factors (xi) Recommendations and (xii) prevalence of Intimate Partners Violence (IPV) faced by women, which was further categorized into: (a) Psychological/emotional violence, (b) Physical violence, (c) Sexual violence, (d) Both combined and (e) Violence of any other type.

Qualitative data collection

Participants selection.

Purposeful sampling was done to recruit the participants for qualitative data collection. Participants included groups of married men and women aged between 18 to 49 years, groups of unmarried adolescent boys and girls aged between 14 to 21 years, and groups of healthcare professionals (HCPs), comprising of doctors, nurses, Lady Health Visitors (LHVs), Lady Health Workers (LHWs) and Community Midwives (CMWs). Ethics approval was obtained from the Aga Khan University, Ethics Review Committee.

Study sites

The selected study sites included two districts from Chitral (Upper and Lower Chitral), six districts from Gilgit (Gilgit, Ghizer, Hunza, Nagar, Astore, and Skardu), and two districts from Sindh (Matiari and Qambar Shadadkot). The following are the details of the data collection (Refer Table  1 ).

Data collection

Data were collected by conducting (IDIs) and (FGDs). The IDI and FGD interview guides were developed specifically for the study and reviewed based on the literature. IDIs were conducted with the healthcare industry administrators, Heads of the Departments (HODs), and HCPs of private and government health settings, including gynaecologists, LHWs, LHVs, and CMWs. The IDI interview guides comprised of the questions related to knowledge, sources of information, and attitudes regarding gender-based discrimination (how each gender is perceived in society and how physical and social differences in the roles of males and females affect an individual or society). The IDIs were conducted in Urdu and local language. The interviews were audio-recorded. Each IDIs lasted for 45–60 minutes.

Likewise, the FGDs were conducted using different interview guides, which were designed to assess the perception of adolescent girls and boys, married men and women and health care workers regarding gender discrimination in the society (perceptions of masculinity and femininity, and gender role expectations of a society). The FGDs were conducted in Urdu and local language. The interviews were audio-recorded. Each FGDs lasted for 60–120 minutes.

Data analysis

All interviews were audio recorded and transcribed in English. Training was provided to the data collectors, and they were supervised by the authors throughout the process to ensure transcriptions are written accurately and correctly, representing the actual data collected during interviews. Thematic analysis was carried out in four different steps. Firstly, manual analysis was done by the research team where transcriptions were thoroughly read, and codes were identified. These codes were combined according to their contextual similarity which followed the derivation of categories, based on which, themes were developed. Secondly, similar manual analysis was conducted by an expert data analyst. Thirdly, analysis was conducted using QSR NVivo 10. In the final step, all three analyses were combined and verified by the research team followed by the compilation of results.

Data integrity

To maintain the credibility or truthfulness of the data, the following strategies were used: (1) Prolonged engagement: Various distinct questions were asked related to the topic and participants were encouraged to share their statements with examples, (2) Triangulation: Data was analyzed by the author, expert data analyst and through QSR NVivo10, (3) Persistent observation: The authors read and reread the data, analyzed them recoded and relabeled codes and categories and revised the concepts accordingly, and (4) Transferability: The ability to generalize or transfer the findings to other context or settings, was ensured by explaining in detail the research context and its conclusions [ 6 ].

Ethical considerations

Ethical approval was obtained from the ethics review committee (ERC), Aga Khan University. The ERC number is 2020-3606-11,489. To ensure voluntary participation of the study participants both verbal and written consent were obtained. For those who were younger than 18 years of age were given written assent, and their parent, or guardian’ verbally consented due to literacy issues. In addition to anonymity of the study participants were maintained by assigning codes to the study participants. To avoid loss of data, interview recordings were saved on a hard drive and in the email account of the author. The data on hard copies such as note pads used during IDIs and informed consents were kept in lock and key. All the data present in hard copy was scanned and saved in the hard drive with password protection. To ensure confidentiality, only the authors had access to hard and soft data of the study.

The studies selected were scrutinized to form a data extraction template with all the relevant data such as author, publication year, study title, purpose, design, setting, sampling, main results, perpetuating factors, and recommendations (Refer Table  2 , provided in the attachment). Most of the 20 studies included in the review were conducted in Pakistan however the most frequent study design was cross-sectional ( n  = 9) followed by narrative research based on desk reviews ( n  = 8), one was a case study, and two were cross-country comparison by using secondary data. Four studies were conducted in Province Punjab, three studies were conducted in KPK, and one in both KPK and Punjab. Only one study was conducted in Sindh province. The remaining used whole Pakistan in systematic review. The maximum sample size in a cross-sectional study was ( n  = 506). Six major themes have emerged from the review which included (1) Status of Women in Society (2) Gender Inequality in Health (3) Gender Inequality in Education (4) Gender Inequality in Employment (5) Gender Biased Social Norms and Cultural Practices (6) Micro and Macro Level Recommendations.

Status of a woman in the society

The Pakistani women often face gender inequality [ 13 ]. Women are seen as a sexual object who are not allowed to take decision for self or their family. However, the male is seen as a symbol of power. Due to male ownership and the patriarchal structure of the Pakistani society women are submissive to men, their rights are ignored, and their identity is lost. Out of twenty, nine studies reported that a female can not take an independent decision, someone else decides on her behalf, mainly father before marriage then-husband and son [ 1 , 3 , 4 , 6 , 7 , 8 , 13 ]. The three studies report that women are not allowed to participate in elections or have very limited participation in politics. Furthermore, women often face inequalities and discrimination in access to health, education, and employment that have negative impact in their lives [ 1 , 2 ]. In addition, media often portrays women in the stereotyped role whose only responsibility is to look after the family and household chores [ 2 ]. Likewise, women have less access and control over financial and physical assets [ 13 ]. Similarly, in most of the low economic and tribal families’ women face verbal and physical abuse [ 8 ].

Gender inequality in health

Gender disparity in health is obvious in Pakistan. Women suffer from neglect of health and nutrition. They don’t have reproductive health rights, appropriate prenatal and postnatal care, and decision-making power for birth spacing those results in maternal mortality and morbidity [ 13 ]. Women can not take decision for her and her children’s health; she doesn’t have access to quality education and health services [ 13 , 15 ]. Furthermore, many papers report son preference [ 1 , 3 ]. Gender-based violence is also very common in Pakistan that leads to harmful consequences on the health and wellbeing of women [ 9 ].

Gender inequality in education

Low investment in girls’ education has been reported in almost all the papers reviewed. The major reason for low investment is low returns from girls, as boys are perceived to be potential head of the house and future bread winner [ 6 , 10 , 11 , 12 , 13 , 15 ]. One of the case study reports, people believe, Muslim women should be brought up in a way that they can fulfill the role of a good daughter, wife, and a mother; and education can have a “bad influence” to develop these characteristics in women [ 12 ]. If girls are educated, they become less obedient and evil and don’t take interest in household chores that is the primary responsibility of her [ 12 ]. Moreover, religious leaders have strong authority in rural areas. They often misuse Islamic teaching and educate parents that through education, women become independent and cannot become a good mother, daughter, and a wife. These teachings mostly hinder girl’s education. Other barriers in girls’ education are access to the facility and women’s safety. Five studies reported that most of the schools are on long distances and have co-education system that is perceived as un-Islamic. Parents are reluctant to send their daughters for education as they feel unsafe and threatened [ 1 , 4 , 12 , 13 , 15 ]. Poverty is another root cause of gender disparity in education, as parents cannot afford the education of their children and when there is a choice, preference is given to boys due to their perceived productive role in future. As a result, more dropouts and lower attainment of education by girls particularly living in rural areas [ 6 , 7 , 8 , 9 , 11 , 13 ].

Gender inequality in employment

Economic disparity due to gender inequality is an alarming issue in Pakistan. The low status of women in society, home care responsibilities, gender stereotyping, and social-cultural humiliated practices against women are the main hurdles in women’s growth and employment opportunities. Low education of females, restriction on mobility, lack of required skillsets, sex-segregated occupational choices are also big obstacles in the attainment of economic opportunities. Most of the women are out of employment, however those who are in economic stream are facing several challenges [ 7 ]. They face discrimination in all layers of the economy. Men are mostly on the leadership positions, fewer females are involved in decision making, wages are low for females if compared with males, workplace harassment and unfavourable work environment is common that hinders long stay in job [ 1 , 7 , 8 ]. Moreover, a study reported that in a patriarchal society very limited number of females are in business field and entrepreneurship. The main hurdles are capital unavailability, lack of role models, gender discrimination in business, cultural and local customs, and lack of training and education [ 8 ].

Gender biased social norms and cultural practices

The gender discrimination is deeply rooted in the Pakistani society. The gender disparity in Pakistan is evident at household level. It includes Distribution of food, education, health care, early and forced marriages, denial of inheritance right, mobility restriction, abuse, and violence [ 1 , 2 , 4 , 6 , 7 , 11 ]. Furthermore, birth of a boy child is celebrated, and the girl is seen as a burden. Likewise, household chores are duty of a female, and she cannot demand or expect any reward for it. On the other hand, male work has socio-economic value [ 2 , 7 , 15 ]. Furthermore, the female has limited decision making power and most of the decisions are done by male figures in a family or a leader of the tribe or community who is always a male. This patriarchal system is sustained and practiced under the name of Islamic teaching [ 2 , 12 , 13 ]. The prevalence of gender-based violence is also high, in form of verbal abuse, physical abuse, sexual assault, rape and forced sex, etc., In addition, it is usually considered a private matter and legal actions are not taken against it [ 8 ] . Moreover, Karo Kari or honor killing of a female is observed in Pakistan. It is justified as killing in the name of honor . Similarly, women face other forms of gender-based violence that include: (i) bride price (The family of the groom pay their future in-laws at the start of their marriage), (ii) Watta Satta (simultaneous marriage of a brother-sister pair from two households.), (iii) Vani (girls, often minors, are given in marriage or servitude to an aggrieved family as compensation to end disputes, often murder) and (iv) marriage with Quran (the male members of the families marry off their girl child to Holy Quran in order to take control of the property that legally belongs to the girl and would get transferred to her after marriage) [ 1 , 4 , 9 , 14 , 15 ]. Furthermore, the women are restricted to choose political career [ 13 ].

Micro and macro level recommendations

The women should have equal status and participation in all aspects of life that include, health, nutrition, education, employment, and politics [ 1 , 4 , 7 , 9 , 11 ]. Women empowerment should be reinforced at policy level [ 1 , 7 ]. For this, constitution of Pakistan should give equal rights to all citizens. Women should be educated about their rights [ 1 , 2 , 4 , 6 , 13 , 14 , 15 ]. To improve status of women, utmost intervention is an investment in girls education. If women is not educated she cannot fight for her rights. Gender parity can only be achieved if women is educated and allowed to participate in decision-making process of law and policies [ 4 , 5 , 6 , 9 , 11 , 14 ]. Similarly, access to health care services is women’s right. Quality education, adequate nutrition, antenatal and post-natal care services, skilled birth attendants, and access and awareness about contraceptives is important to improve women’s health and reduce maternal mortality.

Similarly, women should be given equal opportunities to take part in national development and economic activities of the country to reduce poverty. This is possible through fair employment opportunities, support in women’s own business, equitable policies at workplace and uniform wages and salaries. Besides these, female employees must be informed about their rights and privileges at workplace and employment [ 1 , 7 , 8 , 11 ]. Policy actions should be taken to increase the level of women’s participation in economic growth and entrepreneurship opportunities. There should be active actions to identify bottlenecks of gender parity and unlock growth potential of social institutions [ 5 ]. Another barrier for women empowerment is threatened and unsafe environment to thrive. There should be policies and legislation to protect women from harm, violence, and honor killing that ensure their health, safety, and wellbeing [ 4 , 12 ]. Educational institutions and mass media are two powerful sources that can bring change in society. Government must initiate mass media awareness campaign on gender discrimination at household level, educational institutes, and employment sectors to break discriminatory norms of patriarchal society and to reduce the monopoly of males in marketplace. Parent’s education on gender-equitable practices is also important to bring change at the microlevel. It includes gender-equitable child-rearing practices at home including boys mentoring because they think discrimination against females is a very normal practice and part of a culture [ 3 ]. There is insufficient data on women’s participation and gender parity in health, education, and employment. Thus, there is a strong need to identify effective interventions and relevant stakeholders to reduce the gender discrimination in Pakistan [ 5 ] .

Findings from primary data collection

The following are the major themes emerged from the primary data collection (Refer Table  3 ).

Theme 1: perception of women regarding gender discrimination in society

Woman as a sexual object.

Female participants highlighted that they are seen as “sexual objects” and “a mean of physical attraction” which prevents them from comfortably leaving their homes. One female participant explained this further as,

“We are asked to stay inside the house because men and boys would look at our body and may have bad intentions about us” (Adolescent girl, FGD).

Male participants echoed this narrative as they agreed that women are judged by their physical appearance, such as the shape of their bodies. A male participant stated,

“ Woman is a symbol of beauty and she's seen by the society as the symbol of sex for a man" (Male HCP, IDI).

A male participant reported,

“Women should cover themselves and stay inside the house” (married man, FGD).

One female participant verbalized,

“ We have breasts, and therefore, we are asked to dress properly". (adolescent girls, FGD).

Another stated,

“ Girls are supposed to dress properly and avoid eye contact with boys while walking on the road” (adolescent girls, FGD).

Women as dependent beings

One of the major study findings suggests the idea that women must be “helped” at all times, as they are naturally dependent upon other persons to protect them. One participant stated,

“If a woman is alone, she is afraid of the man's actions ” (adolescent girl, FGD).

Some female participants, however, agreed with this statement to some extent because they felt that men help women to fit into society. Oftentimes, judgment is passed for women without an accompanying male. Participants verbalized that wife cannot survive without husband and similarly daughter cannot live without her father. One participant mentioned,

“We are only allowed to go out when we have our father or brothers to accompany us” (Adolescent girl, FGD).

Other participants agreed with the sentiment differently. Since it is implied that men easily get attracted to women, having a male figure with female will protect her from naturally prying eyes. However, if she cannot be accompanied by a male, she must protect herself by covering fully and maintain distance with males.

Women’s autonomy

Female participants, especially young adolescent girls, shared how restrictions have affected their livelihoods. Participants expressed how easy it is for males to gain permission and leave the house, while females often have series of obstacles in front of them. A young girl stated,

“ There are lot of constraints when we see women in our culture. They must take care of everything at home, yet they must get everybody's permission to go five minutes away. Whereas a boy can go out of town and that too, without anyone’s permission. Looking at this, I wish I were a boy. I'd go wherever I want, and I could do whatever I want” (adolescent girl, FGD).

Males as an identity for females

Women are often identified through a prominent male figure in their life and are not considered to have individual personalities and identities. A female participant mentioned that,

“Woman is someone having a low status in society. People know her through their husband or father name” (married women, FGD).

Child’s upbringing responsibility

Culturally, it is expected from the female members of the family, often mothers, to rear children and take care of their upbringing. Male members, mainly fathers, are expected to look after finances. Thus, mothers usually take a greater portion of responsibility for child’s upbringing and blame in case of misconduct. A married woman explained that,

"If a girl does something, the mother is blamed for that. Even in our house, my mother-in-law talks to my mother if I argue or refuse for anything. This is the culture in my maiden home as well" (Married Woman, FGD).

Unrecognized contribution of women

Many female participants verbalized their concern for disregard they receive from their families despite contributing significantly. Women who perform major roles in maintaining the family and household chores are not recognized for their efforts. By doing cleaning, cooking and other duties, they keep family healthy and help keep costs low. One participant mentioned,

“If women don’t clean the house, it is extremely dirty. If women do not rear children, no one else would do it. We do so much for the family” (married woman, FGD).

Gender differences in daily activities

Both men and women struggle with self-expression as certain expectations from both genders hold people back from expressing their views and opinions. Men, for example, as indicated by participants, are expected to remain firm in challenging situations and not show emotions. Even for hobbies, participants shared that, parks and recreational activities are geared towards young boys and men, while girls and women are given more quiet and indoor activities. A female participant verbalized that,

“ Boys have a separate area where they play cricket and football daily but for girls like us, only indoor activities are arranged” (adolescent girl, FGD).

In places where males and females freely mix or live closely in one area, people often find themselves taking extra precautions in their actions, as to not be seen disgraceful by the community. One female participant reported,

“ Two communities are residing in our area. Events for females, such as sports day, are very rarely arranged. Even then we cannot fully enjoy because if we'll shout to cheer up other players, we would be scolded as our community is very cautious for portraying a soft image of females of our community ” (adolescent girl, FGD).

Another participant stated that,

“ After prayers, we cannot spend time with friends as people would point that girl and say that she always stays late after prayers to gossip when she is supposed to go home ” (adolescent girl, FGD).

Deprivation of women’s rights

A woman’s liberty has always struggled to be accepted and males are always favoured. Thus, women are given lower status. Participants highlighted that, in general, men are seen as superior to women. One participant stated,

“ Men are the masters of women…” (FGD married women).

On the other side, male suppress female liberty and women are unaware of their rights leaving them vulnerable to deprivation. A female participant explained,

“Women do not dominate society that's why people take away their rights from them” (married woman, FGD).

Female participants also shared that they see men as strong and dominant personalities, making them better decision makers regarding health care acquisition, family income, availing opportunities and producing offspring. One female participant verbalized,

“If there's one egg on the table and two children to be fed, it is considered that males should get it as it is believed that males need more nutrition than us” (HCP, IDI).

Another reported that,

“There is a lack of equal accessibility of health care facilities and lack of employment equality for women” (HCP, IDI).

Theme 2: perception of men regarding gender discrimination in society

Male dominance.

Inferiority and superiority are common phenomenon in Pakistan’s largely patriarchal society. This allows men to be seen as dominant, decision-maker of family and the sole bread winner. Women, however, are caught in a culture of subordination to men with little power over family and individual affairs. A female participant said,

“If we look at our society, men are dominant. They can do anything while a woman cannot, as she is afraid of the man's reactions [gussa] and aggression” (adolescent girl, FGD).

While another reported,

"In our society, husband makes his wife feel his superiority over her and would make her realize that it is him, who has all the authority and power” (married woman, FGD).

Preference for male child

There is often an extreme desire for birth of sons over daughters, which adds to the culture of gender discrimination in Pakistan. Male children are important to the family as they often serve their parents financially, once they are able. This is one of the main reasons that parents are more inclined towards birth of a male child rather than female. Consequently, education is prioritized for male children. Female participants expressed that their desire for a male child is to appease their husband’s family and reduce the pressure on her to fit in the house. According to a female participant,

“When my son was born, I was satisfied as now nobody would pressurize me. I noticed a huge difference in the behavior of my in-laws after I gave birth to my son. I felt I have an existence in their family” (married woman, FGD).

Participants highlighted that, women who have brothers are often more protected. According to a young participant,

“Brothers give us the confidence to move within the society because people think before saying anything about us” (adolescent girl, FGD).

Lack of communication among husband and wife

Married couples often lack communication and rarely discuss important matters with each other. Men often choose not to share issues with their wives as they believe they are not rational enough to understand the situation. A male participant stated,

“ Women are so sensitive to share anything. They can only reproduce and cook food inside the home” (married man, FGD).

Men are protectors

Many female participants considered men as a source of protection, as they manage finances and ensure safety of family members. They feel confident in man’s ability to contribute to their livelihoods. One participant mentioned,

“We go out when we have our father or brothers to accompany us” (Adolescent girl, FGD).

Another highlighted,

“Men are our protectors. We can only survive in the society because of them” (Married woman, FGD).

Theme 3: factors influencing gender discrimination

The role of family head.

A tight-knit family situation, difference of opinions, cultural values and generation gap can highly affect one’s view on gender. Participants highlighted the role of elders in the family who often favor their sons and male family members. Married women expressed that daughter in-laws often struggle to raise their voice or express their concerns in such family situation. One participant mentioned,

“We don’t take decisions on when to have the child or what method needs to be used for family planning. Our mothers-in-law decide and we must obey” (married woman, FGD).

The family system that often includes three generations living closely, allows traditional norms to carry forward, as opposed to a typical nuclear family. This includes attire, conduct, and relationships. One participant mentioned,

“I live with my mother-in-law. I must cover my head whenever I had to leave the house”. (Married woman, FGD).

Media influence

Media plays an important role in disseminating gender awareness. For example, advertisements of cooking oils and spices usually show young girls helping their mothers in kitchen, while men and boys are observed enjoying something else or not present. These short advertisements are impactful in perpetuating gender conduct solely for societal acceptance. One participant verbalized,

“Every household has a radio, on which different advertisements are going on. People get messages through media” (married man, FGD).

The study reveals that women are seen as sexual objects and therefore confined to their homes. Women are often judged on their physical appearance that hinders their autonomy in various aspects of life. Many women face difficulties in leaving their homes alone and require protection from men [ 3 ]. Men are, therefore, labeled as protectors while women are regarded as dependent beings who need man’s identity. The role of men inside the house is identified as authoritative, while women need approval from male because they are considered incapable of making appropriate decisions. Women are caretaker of their families and have primary responsibility of husband, children, and in-laws. However, these contributions are mostly unnoticed. These gender power differentials are so strong in households, that many women do not know their rights. Women comply with societal and cultural values that force them to become lesser beings in the society. Girls in society grow up and eventually adopt the traditional role of women [ 8 ]. Increased education and awareness level among communities can improve status of women in the Pakistani society [ 3 ].

Moreover, males have dominant role in the society [ 1 ]. Likewise, there is discrepancy in power structures between male and female in the family system that often leads to lack of communication especially between married couples as husbands do not share concerns with their wives nor ask for their advice, considering women incapable to understand anything [ 5 ].

Furthermore, a common phenomenon observed in the Pakistani society, is the strong desire for a male child, while the birth of a female child is mourned [ 5 ]. Girls are seen as a liability, while the birth of a male child is celebrated as it is believed that males will be the breadwinner of the family in the future [ 5 ]. Thus, preference for a male child leads to illegal termination of pregnancies with female fetuses in many situations [ 9 ]. In addition, some of the studies suggest that the preference for a son is significantly high in low socioeconomic areas if compared with the middle and upper ones. Men are seen as economic and social security providers of the household. Therefore, men are tagged as manhood in the society as it is considered that hierarchal familial structures are produced from them, and all powers are attributed to men. This increases the disparity of roles between men and women leading to gender discrimination [ 5 ]. Our study also reveals that media has important influence towards gender discrimination. It is commonly observed in the Pakistani TV advertisements, that household chores are mostly performed by women while men have professional roles in the society [ 6 ].

Thus, lack of female autonomy and empowerment are recognized as the major reasons of discrimination of women in our society. They do not have the means to participate in society, neither they are allowed to speak against traditions. Therefore, interventions are required to increase female autonomy and decision-making capacity. The other significant contributor to gender discrimination is male dominance, which must be brought down to empower women. To reduce this, communication is key between spouses, family members and community members. Gender discrimination has greater influence at different levels of Pakistani society. Certain schools and television advertisements portrays stereotypes, such as allowing boys to be active outdoors and forcing girls to remain indoors. Therefore, media channels and other public systems such as healthcare facilities and schooling systems must promote gender equity and equality. In terms of Sexual and Reproductive health (SRH), the health care facilities should play an important role in providing knowledge and effective treatment to both males and females. The SRH related services are often compromised for people due to lack of resources, staff, and attention. Schools and communities should play an important role in creating SRH related awareness among youth and adults that include puberty, pregnancy, and motherhood. SRH should also be made part of curriculum in educational institutes.

The use of group interviews allowed rapport development with communities. With multiple people present sharing similar views, many were inclined to give purposeful answers and recommendations regarding gender roles in communities. Based on previous literature searches, this study, to the best of our knowledge, has not been published in Pakistan at the community level. No other study explores the views of Pakistanis on gender discrimination with inclusion of multiple community groups and across multiple districts. In limitations, due to the topic’s sensitive topic, may have held back participants from answering fully and truthfully. Thus, considerable time was taken to develop trust and rapport. Therefore, it is possible that some study subjects might not have answered to the best of their ability. Furthermore, challenges were faced due to the COVID-19 pandemic and extreme weather conditions in some areas, as some participants could not reach the venue. Also, the lockdowns following the pandemic made it very difficult to gather 10–12 people at one place for the FGDs. Interviews could not be done virtually as the information was very sensitive.

Gender roles in Pakistani society are extremely complex and are transferred from generation to generation with minimal changes since ages. This study reveals some of the factors due to which women in Pakistan face gender discrimination. The cultural and societal values place women in a nurturing role in the Pakistani society. Through reinforcement of these roles by different family members, as well as by the dominant men in the society, women face adverse challenges to seek empowerment that will help them defy such repressive roles assigned to them. Gender discrimination is evident in public institutions such as healthcare facilities and schooling systems. Thus, administrative reorganization and improved awareness in the healthcare facilities, and appropriate education in schools for boys and girls will help decrease gender discrimination in the Pakistani societies.

Availability of data and materials

On request, the data will be available by hiding the IDs.

Though we have already provided the transcripts, yet there is a need of further information then kindly contact the corresponding author. Dr. Tazeen Saeed Ali: [email protected] .

Abbreviations

Aga Khan Foundation

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Reporting of Observational studies in Epidemiology

Intimate Partner Violence

Healthcare Professionals

Lady Health Visitors

Lady Health Workers

Community Midwives

In-Depth Interviews

Focus Group Discussions

Heads of the Departments

Sexual and Reproductive health

United Nations Population Fund

Ethics Review Committee

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Acknowledgments

The authors would like to thank the research specialist, coordinator, and research associates for data collection, and the study participants for their time and valuable data. We would also like to appreciate and thank Mr. Adil Ali Saeed for helping us with the literature for the systematic review of the paper, and Ms. Amirah Nazir and Daman Dhunna for the overall cleaning of document. We are thankful to UNFPA and AKF for providing advisory and monitoring support. We would like to acknowledgment UNFPA Pakistan that through them the funding was received from Global Affairs Canada.

Global Affairs Canada (GAC). Project No: P006434; Arrangement #: 7414620.

Role of the funder: This is to declare that there was no role of the funding agency for planning and implementation of this study.

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Tazeen Saeed Ali

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All authors have read and approved the manuscript. Their contribution is as follows: TSA contributed to proposal development, interview guide development, ERC approval, data supervision, data validation, systematic review, data analysis, manuscript development, and overall supervision. SSA assisted in proposal development, data collection supervision, data validation, systematic review, data analysis, and reviewed manuscript. SN, contributed in -literature Review, analysis of literature review and write up of findings. ZM reviewed interview guides, assisted in ERC approval, filed preparation for data collection, assisted in data validation and enhancing the approval processing, reviewed data analysis, and the final manuscript. SSA, contributed to proposal development, assisted in ERC approval, overall supervision, filed preparation for data collection and training of data collectors, assisted in data validation and enhancing the approval process and review of final manuscript. FM contributed to the interview guide development, facilitated field data collection, and contributed to the validation and analysis processes. Reviewed the final manuscript before submission. YK contributed to the interview guide development, facilitated field data collection, and contributed to the validation and analysis processes. Reviewed the final manuscript before submission. SM, contributed to proposal development, field preparation for data collection, validation, and review of the final manuscript. ZB, contributed to proposal development, brought the funding, assisted in ERC approval, overall supervision, data validation and enhancing the approval process and reviewed the final manuscript. He provided overall mentorship.

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Ali, T.S., Ali, S.S., Nadeem, S. et al. Perpetuation of gender discrimination in Pakistani society: results from a scoping review and qualitative study conducted in three provinces of Pakistan. BMC Women's Health 22 , 540 (2022). https://doi.org/10.1186/s12905-022-02011-6

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Perpetuation of gender discrimination in Pakistani society: results from a scoping review and qualitative study conducted in three provinces of Pakistan

Tazeen saeed ali.

1 School of Nursing and Midwifery, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan

2 Department of Community Health Sciences, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan

Shahnaz Shahid Ali

Sanober nadeem.

3 Aga Khan Health Services, Karachi, Pakistan

Zahid Memon

4 Center of Excellence Women & Child Health, Aga Khan University, Karachi, Pakistan

Sajid Soofi

Falak madhani, yasmin karim.

5 Aga Khan Rural Service Pakistan, Gilgit, Pakistan

Shah Mohammad

Zulfiqar ahmed bhutta.

6 Institute for Global Health, Karachi, Pakistan

7 Department of Paediatrics & Child Health, Aga Khan University, Karachi, Pakistan

Associated Data

On request, the data will be available by hiding the IDs.

Though we have already provided the transcripts, yet there is a need of further information then kindly contact the corresponding author. Dr. Tazeen Saeed Ali: [email protected].

Gender discrimination is any unequal treatment of a person based on their sex. Women and girls are most likely to experience the negative impact of gender discrimination. The aim of this study is to assess the factors that influence gender discrimination in Pakistan, and its impact on women’s life.

A mixed method approach was used in the study in which a systematic review was done in phase one to explore the themes on gender discrimination, and qualitative interviews were conducted in phase two to explore the perception of people regarding gender discrimination. The qualitative interviews (in-depth interviews and focus group discussions) were conducted from married men and women, adolescent boys and girls, Healthcare Professionals (HCPs), Lady Health Visitors (LHVs) and Community Midwives (CMWs). The qualitative interviews were analyzed both manually and electronically through QSR NVivo 10. The triangulation of data from the systematic review and qualitative interviews were done to explore the gender discrimination related issues in Pakistan.

The six major themes have emerged from the systematic review and qualitative interviews. It includes (1) Status of a woman in the society (2) Gender inequality in health (3) Gender inequality in education (4) Gender inequality in employment (5) Gender biased social norms and cultural practices and (6) Micro and macro level recommendations. In addition, a woman is often viewed as a sexual object and dependent being who lacks self identity unless being married. Furthermore, women are restricted to household and child rearing responsibilities and are often neglected and forced to suppress self-expression. Likewise, men are viewed as dominant figures in lives of women who usually makes all family decisions. They are considered as financial providers and source of protection. Moreover, women face gender discrimination in many aspects of life including education and access to health care.

Gender discrimination is deeply rooted in the Pakistani society. To prevent gender discrimination, the entire society, especially women should be educated and gendered sensitized to improve the status of women in Pakistan.

Gender discrimination refers to any situation where a person is treated differently because they are male or female, rather than based on their competency or proficiency [ 1 , 2 ]. Gender discrimination harms all of society and negatively impacts the economy, education, health and life expectancy [ 1 , 2 ]. Women and girls are most likely to experience the negative impacts of gender discrimination. It include inadequate educational opportunities, low status in society and lack of freedom to take decisions for self and family [ 1 , 3 ].

Likewise, gender discrimination is one of the human rights issues in Pakistan and is affecting huge proportion of women in the country [ 1 , 2 ]. In Pakistan, nearly 50% of the women lacks basic education [ 4 ]. In addition, women in Pakistan have lower health and nutritional status. Furthermore, most of the women are restricted in their homes with minimal or no rights to make choices, judgments, and decisions, that directly affect their living conditions and other familial aspects [ 2 ]. In contrast, men are considered dominant in the Pakistani society [ 5 ]. This subordination of women has negative influences on different stages of women’s life.

Study design

The mixed method study design was used. Systematic review was done in phase one and qualitative interviews; in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in phase two.

The objective of the systematic review

To map a broad topic, gender discrimination/inequality research in Pakistan including women undergoing any form of intimate partner violence.

Systematic review

The three authors (TSA, SSA and SN) independently performed an extensive literature search using two databases: PubMed and Google Scholar and reports from organizations such as WHO and the Aurat Foundation. Quantitative and Boolean operators were used to narrow down the search results. The following keywords and phrases were used: Intimate partner violence (IPV), domestic violence, violence against women, domestic abuse, spousal violence, and Pakistan. Articles from 2008 to 2021 were assessed. The selection criteria of the articles included: women undergoing any form of IPV (physical, psychological, and sexual); quantitative study design; English as the publication language; and articles in which Pakistan was the study setting. The shortlisted articles were cross-checked by two of the authors (TSA, and SN) for final selection. The quality of the selected articles was reviewed using a STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist, which ensured all articles followed a structured approach, including an introduction, methodology, results, and a discussion section. It was also determined that all selected articles are published in peer-reviewed journals and have been used nationally or internationally. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart was used for study selection (Fig.  1 ).

PRISMA Diagram to select the final articles

The selected articles were approved by one of the authors (TSA), who is an expert in the field of IPV. Articles were excluded: (i) If the study was not conducted in Pakistan; (ii) Studied spousal violence against men and (iii) Domestic violence involving in-laws or other family members. Furthermore, from the selected articles, the data were extracted by 3 authors (TSA, SSA, SN) by carefully studying the methodology and results. The methodology was entered into an extraction template in which location was summarized including the study design and sample size in the articles. The results covered: (i) The title, (ii) Authors, (iii) Publication year, (iv) Objectives of the research, (v) Population and Setting, (vi) Research design, (vii) Data collection methods, (ix) Results, (x) Perpetuating factors (xi) Recommendations and (xii) prevalence of Intimate Partners Violence (IPV) faced by women, which was further categorized into: (a) Psychological/emotional violence, (b) Physical violence, (c) Sexual violence, (d) Both combined and (e) Violence of any other type.

Qualitative data collection

Participants selection.

Purposeful sampling was done to recruit the participants for qualitative data collection. Participants included groups of married men and women aged between 18 to 49 years, groups of unmarried adolescent boys and girls aged between 14 to 21 years, and groups of healthcare professionals (HCPs), comprising of doctors, nurses, Lady Health Visitors (LHVs), Lady Health Workers (LHWs) and Community Midwives (CMWs). Ethics approval was obtained from the Aga Khan University, Ethics Review Committee.

Study sites

The selected study sites included two districts from Chitral (Upper and Lower Chitral), six districts from Gilgit (Gilgit, Ghizer, Hunza, Nagar, Astore, and Skardu), and two districts from Sindh (Matiari and Qambar Shadadkot). The following are the details of the data collection (Refer Table  1 ).

Details of Qualitative assessments of community members and Health care professionals

Data collection

Data were collected by conducting (IDIs) and (FGDs). The IDI and FGD interview guides were developed specifically for the study and reviewed based on the literature. IDIs were conducted with the healthcare industry administrators, Heads of the Departments (HODs), and HCPs of private and government health settings, including gynaecologists, LHWs, LHVs, and CMWs. The IDI interview guides comprised of the questions related to knowledge, sources of information, and attitudes regarding gender-based discrimination (how each gender is perceived in society and how physical and social differences in the roles of males and females affect an individual or society). The IDIs were conducted in Urdu and local language. The interviews were audio-recorded. Each IDIs lasted for 45–60 minutes.

Likewise, the FGDs were conducted using different interview guides, which were designed to assess the perception of adolescent girls and boys, married men and women and health care workers regarding gender discrimination in the society (perceptions of masculinity and femininity, and gender role expectations of a society). The FGDs were conducted in Urdu and local language. The interviews were audio-recorded. Each FGDs lasted for 60–120 minutes.

Data analysis

All interviews were audio recorded and transcribed in English. Training was provided to the data collectors, and they were supervised by the authors throughout the process to ensure transcriptions are written accurately and correctly, representing the actual data collected during interviews. Thematic analysis was carried out in four different steps. Firstly, manual analysis was done by the research team where transcriptions were thoroughly read, and codes were identified. These codes were combined according to their contextual similarity which followed the derivation of categories, based on which, themes were developed. Secondly, similar manual analysis was conducted by an expert data analyst. Thirdly, analysis was conducted using QSR NVivo 10. In the final step, all three analyses were combined and verified by the research team followed by the compilation of results.

Data integrity

To maintain the credibility or truthfulness of the data, the following strategies were used: (1) Prolonged engagement: Various distinct questions were asked related to the topic and participants were encouraged to share their statements with examples, (2) Triangulation: Data was analyzed by the author, expert data analyst and through QSR NVivo10, (3) Persistent observation: The authors read and reread the data, analyzed them recoded and relabeled codes and categories and revised the concepts accordingly, and (4) Transferability: The ability to generalize or transfer the findings to other context or settings, was ensured by explaining in detail the research context and its conclusions [ 6 ].

Ethical considerations

Ethical approval was obtained from the ethics review committee (ERC), Aga Khan University. The ERC number is 2020-3606-11,489. To ensure voluntary participation of the study participants both verbal and written consent were obtained. For those who were younger than 18 years of age were given written assent, and their parent, or guardian’ verbally consented due to literacy issues. In addition to anonymity of the study participants were maintained by assigning codes to the study participants. To avoid loss of data, interview recordings were saved on a hard drive and in the email account of the author. The data on hard copies such as note pads used during IDIs and informed consents were kept in lock and key. All the data present in hard copy was scanned and saved in the hard drive with password protection. To ensure confidentiality, only the authors had access to hard and soft data of the study.

The studies selected were scrutinized to form a data extraction template with all the relevant data such as author, publication year, study title, purpose, design, setting, sampling, main results, perpetuating factors, and recommendations (Refer Table  2 , provided in the attachment). Most of the 20 studies included in the review were conducted in Pakistan however the most frequent study design was cross-sectional ( n  = 9) followed by narrative research based on desk reviews ( n  = 8), one was a case study, and two were cross-country comparison by using secondary data. Four studies were conducted in Province Punjab, three studies were conducted in KPK, and one in both KPK and Punjab. Only one study was conducted in Sindh province. The remaining used whole Pakistan in systematic review. The maximum sample size in a cross-sectional study was ( n  = 506). Six major themes have emerged from the review which included (1) Status of Women in Society (2) Gender Inequality in Health (3) Gender Inequality in Education (4) Gender Inequality in Employment (5) Gender Biased Social Norms and Cultural Practices (6) Micro and Macro Level Recommendations.

Status of a woman in the society

The Pakistani women often face gender inequality [ 13 ]. Women are seen as a sexual object who are not allowed to take decision for self or their family. However, the male is seen as a symbol of power. Due to male ownership and the patriarchal structure of the Pakistani society women are submissive to men, their rights are ignored, and their identity is lost. Out of twenty, nine studies reported that a female can not take an independent decision, someone else decides on her behalf, mainly father before marriage then-husband and son [ 1 , 3 , 4 , 6 – 8 , 13 ]. The three studies report that women are not allowed to participate in elections or have very limited participation in politics. Furthermore, women often face inequalities and discrimination in access to health, education, and employment that have negative impact in their lives [ 1 , 2 ]. In addition, media often portrays women in the stereotyped role whose only responsibility is to look after the family and household chores [ 2 ]. Likewise, women have less access and control over financial and physical assets [ 13 ]. Similarly, in most of the low economic and tribal families’ women face verbal and physical abuse [ 8 ].

Gender inequality in health

Gender disparity in health is obvious in Pakistan. Women suffer from neglect of health and nutrition. They don’t have reproductive health rights, appropriate prenatal and postnatal care, and decision-making power for birth spacing those results in maternal mortality and morbidity [ 13 ]. Women can not take decision for her and her children’s health; she doesn’t have access to quality education and health services [ 13 , 15 ]. Furthermore, many papers report son preference [ 1 , 3 ]. Gender-based violence is also very common in Pakistan that leads to harmful consequences on the health and wellbeing of women [ 9 ].

Gender inequality in education

Low investment in girls’ education has been reported in almost all the papers reviewed. The major reason for low investment is low returns from girls, as boys are perceived to be potential head of the house and future bread winner [ 6 , 10 – 13 , 15 ]. One of the case study reports, people believe, Muslim women should be brought up in a way that they can fulfill the role of a good daughter, wife, and a mother; and education can have a “bad influence” to develop these characteristics in women [ 12 ]. If girls are educated, they become less obedient and evil and don’t take interest in household chores that is the primary responsibility of her [ 12 ]. Moreover, religious leaders have strong authority in rural areas. They often misuse Islamic teaching and educate parents that through education, women become independent and cannot become a good mother, daughter, and a wife. These teachings mostly hinder girl’s education. Other barriers in girls’ education are access to the facility and women’s safety. Five studies reported that most of the schools are on long distances and have co-education system that is perceived as un-Islamic. Parents are reluctant to send their daughters for education as they feel unsafe and threatened [ 1 , 4 , 12 , 13 , 15 ]. Poverty is another root cause of gender disparity in education, as parents cannot afford the education of their children and when there is a choice, preference is given to boys due to their perceived productive role in future. As a result, more dropouts and lower attainment of education by girls particularly living in rural areas [ 6 – 9 , 11 , 13 ].

Gender inequality in employment

Economic disparity due to gender inequality is an alarming issue in Pakistan. The low status of women in society, home care responsibilities, gender stereotyping, and social-cultural humiliated practices against women are the main hurdles in women’s growth and employment opportunities. Low education of females, restriction on mobility, lack of required skillsets, sex-segregated occupational choices are also big obstacles in the attainment of economic opportunities. Most of the women are out of employment, however those who are in economic stream are facing several challenges [ 7 ]. They face discrimination in all layers of the economy. Men are mostly on the leadership positions, fewer females are involved in decision making, wages are low for females if compared with males, workplace harassment and unfavourable work environment is common that hinders long stay in job [ 1 , 7 , 8 ]. Moreover, a study reported that in a patriarchal society very limited number of females are in business field and entrepreneurship. The main hurdles are capital unavailability, lack of role models, gender discrimination in business, cultural and local customs, and lack of training and education [ 8 ].

Gender biased social norms and cultural practices

The gender discrimination is deeply rooted in the Pakistani society. The gender disparity in Pakistan is evident at household level. It includes Distribution of food, education, health care, early and forced marriages, denial of inheritance right, mobility restriction, abuse, and violence [ 1 , 2 , 4 , 6 , 7 , 11 ]. Furthermore, birth of a boy child is celebrated, and the girl is seen as a burden. Likewise, household chores are duty of a female, and she cannot demand or expect any reward for it. On the other hand, male work has socio-economic value [ 2 , 7 , 15 ]. Furthermore, the female has limited decision making power and most of the decisions are done by male figures in a family or a leader of the tribe or community who is always a male. This patriarchal system is sustained and practiced under the name of Islamic teaching [ 2 , 12 , 13 ]. The prevalence of gender-based violence is also high, in form of verbal abuse, physical abuse, sexual assault, rape and forced sex, etc., In addition, it is usually considered a private matter and legal actions are not taken against it [ 8 ] . Moreover, Karo Kari or honor killing of a female is observed in Pakistan. It is justified as killing in the name of honor . Similarly, women face other forms of gender-based violence that include: (i) bride price (The family of the groom pay their future in-laws at the start of their marriage), (ii) Watta Satta (simultaneous marriage of a brother-sister pair from two households.), (iii) Vani (girls, often minors, are given in marriage or servitude to an aggrieved family as compensation to end disputes, often murder) and (iv) marriage with Quran (the male members of the families marry off their girl child to Holy Quran in order to take control of the property that legally belongs to the girl and would get transferred to her after marriage) [ 1 , 4 , 9 , 14 , 15 ]. Furthermore, the women are restricted to choose political career [ 13 ].

Micro and macro level recommendations

The women should have equal status and participation in all aspects of life that include, health, nutrition, education, employment, and politics [ 1 , 4 , 7 , 9 , 11 ]. Women empowerment should be reinforced at policy level [ 1 , 7 ]. For this, constitution of Pakistan should give equal rights to all citizens. Women should be educated about their rights [ 1 , 2 , 4 , 6 , 13 – 15 ]. To improve status of women, utmost intervention is an investment in girls education. If women is not educated she cannot fight for her rights. Gender parity can only be achieved if women is educated and allowed to participate in decision-making process of law and policies [ 4 – 6 , 9 , 11 , 14 ]. Similarly, access to health care services is women’s right. Quality education, adequate nutrition, antenatal and post-natal care services, skilled birth attendants, and access and awareness about contraceptives is important to improve women’s health and reduce maternal mortality.

Similarly, women should be given equal opportunities to take part in national development and economic activities of the country to reduce poverty. This is possible through fair employment opportunities, support in women’s own business, equitable policies at workplace and uniform wages and salaries. Besides these, female employees must be informed about their rights and privileges at workplace and employment [ 1 , 7 , 8 , 11 ]. Policy actions should be taken to increase the level of women’s participation in economic growth and entrepreneurship opportunities. There should be active actions to identify bottlenecks of gender parity and unlock growth potential of social institutions [ 5 ]. Another barrier for women empowerment is threatened and unsafe environment to thrive. There should be policies and legislation to protect women from harm, violence, and honor killing that ensure their health, safety, and wellbeing [ 4 , 12 ]. Educational institutions and mass media are two powerful sources that can bring change in society. Government must initiate mass media awareness campaign on gender discrimination at household level, educational institutes, and employment sectors to break discriminatory norms of patriarchal society and to reduce the monopoly of males in marketplace. Parent’s education on gender-equitable practices is also important to bring change at the microlevel. It includes gender-equitable child-rearing practices at home including boys mentoring because they think discrimination against females is a very normal practice and part of a culture [ 3 ]. There is insufficient data on women’s participation and gender parity in health, education, and employment. Thus, there is a strong need to identify effective interventions and relevant stakeholders to reduce the gender discrimination in Pakistan [ 5 ] .

Findings from primary data collection

The following are the major themes emerged from the primary data collection (Refer Table  3 ).

Major themes emerged from the primary data collection

Theme 1: perception of women regarding gender discrimination in society

Woman as a sexual object.

Female participants highlighted that they are seen as “sexual objects” and “a mean of physical attraction” which prevents them from comfortably leaving their homes. One female participant explained this further as,

“We are asked to stay inside the house because men and boys would look at our body and may have bad intentions about us” (Adolescent girl, FGD).

Male participants echoed this narrative as they agreed that women are judged by their physical appearance, such as the shape of their bodies. A male participant stated,

“ Woman is a symbol of beauty and she's seen by the society as the symbol of sex for a man" (Male HCP, IDI).

A male participant reported,

“Women should cover themselves and stay inside the house” (married man, FGD).

One female participant verbalized,

“ We have breasts, and therefore, we are asked to dress properly". (adolescent girls, FGD).

Another stated,

“ Girls are supposed to dress properly and avoid eye contact with boys while walking on the road” (adolescent girls, FGD).

Women as dependent beings

One of the major study findings suggests the idea that women must be “helped” at all times, as they are naturally dependent upon other persons to protect them. One participant stated,

“If a woman is alone, she is afraid of the man's actions ” (adolescent girl, FGD).

Some female participants, however, agreed with this statement to some extent because they felt that men help women to fit into society. Oftentimes, judgment is passed for women without an accompanying male. Participants verbalized that wife cannot survive without husband and similarly daughter cannot live without her father. One participant mentioned,

“We are only allowed to go out when we have our father or brothers to accompany us” (Adolescent girl, FGD).

Other participants agreed with the sentiment differently. Since it is implied that men easily get attracted to women, having a male figure with female will protect her from naturally prying eyes. However, if she cannot be accompanied by a male, she must protect herself by covering fully and maintain distance with males.

Women’s autonomy

Female participants, especially young adolescent girls, shared how restrictions have affected their livelihoods. Participants expressed how easy it is for males to gain permission and leave the house, while females often have series of obstacles in front of them. A young girl stated,

“ There are lot of constraints when we see women in our culture. They must take care of everything at home, yet they must get everybody's permission to go five minutes away. Whereas a boy can go out of town and that too, without anyone’s permission. Looking at this, I wish I were a boy. I'd go wherever I want, and I could do whatever I want” (adolescent girl, FGD).

Males as an identity for females

Women are often identified through a prominent male figure in their life and are not considered to have individual personalities and identities. A female participant mentioned that,

“Woman is someone having a low status in society. People know her through their husband or father name” (married women, FGD).

Child’s upbringing responsibility

Culturally, it is expected from the female members of the family, often mothers, to rear children and take care of their upbringing. Male members, mainly fathers, are expected to look after finances. Thus, mothers usually take a greater portion of responsibility for child’s upbringing and blame in case of misconduct. A married woman explained that,

"If a girl does something, the mother is blamed for that. Even in our house, my mother-in-law talks to my mother if I argue or refuse for anything. This is the culture in my maiden home as well" (Married Woman, FGD).

Unrecognized contribution of women

Many female participants verbalized their concern for disregard they receive from their families despite contributing significantly. Women who perform major roles in maintaining the family and household chores are not recognized for their efforts. By doing cleaning, cooking and other duties, they keep family healthy and help keep costs low. One participant mentioned,

“If women don’t clean the house, it is extremely dirty. If women do not rear children, no one else would do it. We do so much for the family” (married woman, FGD).

Gender differences in daily activities

Both men and women struggle with self-expression as certain expectations from both genders hold people back from expressing their views and opinions. Men, for example, as indicated by participants, are expected to remain firm in challenging situations and not show emotions. Even for hobbies, participants shared that, parks and recreational activities are geared towards young boys and men, while girls and women are given more quiet and indoor activities. A female participant verbalized that,

“ Boys have a separate area where they play cricket and football daily but for girls like us, only indoor activities are arranged” (adolescent girl, FGD).

In places where males and females freely mix or live closely in one area, people often find themselves taking extra precautions in their actions, as to not be seen disgraceful by the community. One female participant reported,

“ Two communities are residing in our area. Events for females, such as sports day, are very rarely arranged. Even then we cannot fully enjoy because if we'll shout to cheer up other players, we would be scolded as our community is very cautious for portraying a soft image of females of our community ” (adolescent girl, FGD).

Another participant stated that,

“ After prayers, we cannot spend time with friends as people would point that girl and say that she always stays late after prayers to gossip when she is supposed to go home ” (adolescent girl, FGD).

Deprivation of women’s rights

A woman’s liberty has always struggled to be accepted and males are always favoured. Thus, women are given lower status. Participants highlighted that, in general, men are seen as superior to women. One participant stated,

“ Men are the masters of women…” (FGD married women).

On the other side, male suppress female liberty and women are unaware of their rights leaving them vulnerable to deprivation. A female participant explained,

“Women do not dominate society that's why people take away their rights from them” (married woman, FGD).

Female participants also shared that they see men as strong and dominant personalities, making them better decision makers regarding health care acquisition, family income, availing opportunities and producing offspring. One female participant verbalized,

“If there's one egg on the table and two children to be fed, it is considered that males should get it as it is believed that males need more nutrition than us” (HCP, IDI).

Another reported that,

“There is a lack of equal accessibility of health care facilities and lack of employment equality for women” (HCP, IDI).

Theme 2: perception of men regarding gender discrimination in society

Male dominance.

Inferiority and superiority are common phenomenon in Pakistan’s largely patriarchal society. This allows men to be seen as dominant, decision-maker of family and the sole bread winner. Women, however, are caught in a culture of subordination to men with little power over family and individual affairs. A female participant said,

“If we look at our society, men are dominant. They can do anything while a woman cannot, as she is afraid of the man's reactions [gussa] and aggression” (adolescent girl, FGD).

While another reported,

"In our society, husband makes his wife feel his superiority over her and would make her realize that it is him, who has all the authority and power” (married woman, FGD).

Preference for male child

There is often an extreme desire for birth of sons over daughters, which adds to the culture of gender discrimination in Pakistan. Male children are important to the family as they often serve their parents financially, once they are able. This is one of the main reasons that parents are more inclined towards birth of a male child rather than female. Consequently, education is prioritized for male children. Female participants expressed that their desire for a male child is to appease their husband’s family and reduce the pressure on her to fit in the house. According to a female participant,

“When my son was born, I was satisfied as now nobody would pressurize me. I noticed a huge difference in the behavior of my in-laws after I gave birth to my son. I felt I have an existence in their family” (married woman, FGD).

Participants highlighted that, women who have brothers are often more protected. According to a young participant,

“Brothers give us the confidence to move within the society because people think before saying anything about us” (adolescent girl, FGD).

Lack of communication among husband and wife

Married couples often lack communication and rarely discuss important matters with each other. Men often choose not to share issues with their wives as they believe they are not rational enough to understand the situation. A male participant stated,

“ Women are so sensitive to share anything. They can only reproduce and cook food inside the home” (married man, FGD).

Men are protectors

Many female participants considered men as a source of protection, as they manage finances and ensure safety of family members. They feel confident in man’s ability to contribute to their livelihoods. One participant mentioned,

“We go out when we have our father or brothers to accompany us” (Adolescent girl, FGD).

Another highlighted,

“Men are our protectors. We can only survive in the society because of them” (Married woman, FGD).

Theme 3: factors influencing gender discrimination

The role of family head.

A tight-knit family situation, difference of opinions, cultural values and generation gap can highly affect one’s view on gender. Participants highlighted the role of elders in the family who often favor their sons and male family members. Married women expressed that daughter in-laws often struggle to raise their voice or express their concerns in such family situation. One participant mentioned,

“We don’t take decisions on when to have the child or what method needs to be used for family planning. Our mothers-in-law decide and we must obey” (married woman, FGD).

The family system that often includes three generations living closely, allows traditional norms to carry forward, as opposed to a typical nuclear family. This includes attire, conduct, and relationships. One participant mentioned,

“I live with my mother-in-law. I must cover my head whenever I had to leave the house”. (Married woman, FGD).

Media influence

Media plays an important role in disseminating gender awareness. For example, advertisements of cooking oils and spices usually show young girls helping their mothers in kitchen, while men and boys are observed enjoying something else or not present. These short advertisements are impactful in perpetuating gender conduct solely for societal acceptance. One participant verbalized,

“Every household has a radio, on which different advertisements are going on. People get messages through media” (married man, FGD).

The study reveals that women are seen as sexual objects and therefore confined to their homes. Women are often judged on their physical appearance that hinders their autonomy in various aspects of life. Many women face difficulties in leaving their homes alone and require protection from men [ 3 ]. Men are, therefore, labeled as protectors while women are regarded as dependent beings who need man’s identity. The role of men inside the house is identified as authoritative, while women need approval from male because they are considered incapable of making appropriate decisions. Women are caretaker of their families and have primary responsibility of husband, children, and in-laws. However, these contributions are mostly unnoticed. These gender power differentials are so strong in households, that many women do not know their rights. Women comply with societal and cultural values that force them to become lesser beings in the society. Girls in society grow up and eventually adopt the traditional role of women [ 8 ]. Increased education and awareness level among communities can improve status of women in the Pakistani society [ 3 ].

Moreover, males have dominant role in the society [ 1 ]. Likewise, there is discrepancy in power structures between male and female in the family system that often leads to lack of communication especially between married couples as husbands do not share concerns with their wives nor ask for their advice, considering women incapable to understand anything [ 5 ].

Furthermore, a common phenomenon observed in the Pakistani society, is the strong desire for a male child, while the birth of a female child is mourned [ 5 ]. Girls are seen as a liability, while the birth of a male child is celebrated as it is believed that males will be the breadwinner of the family in the future [ 5 ]. Thus, preference for a male child leads to illegal termination of pregnancies with female fetuses in many situations [ 9 ]. In addition, some of the studies suggest that the preference for a son is significantly high in low socioeconomic areas if compared with the middle and upper ones. Men are seen as economic and social security providers of the household. Therefore, men are tagged as manhood in the society as it is considered that hierarchal familial structures are produced from them, and all powers are attributed to men. This increases the disparity of roles between men and women leading to gender discrimination [ 5 ]. Our study also reveals that media has important influence towards gender discrimination. It is commonly observed in the Pakistani TV advertisements, that household chores are mostly performed by women while men have professional roles in the society [ 6 ].

Thus, lack of female autonomy and empowerment are recognized as the major reasons of discrimination of women in our society. They do not have the means to participate in society, neither they are allowed to speak against traditions. Therefore, interventions are required to increase female autonomy and decision-making capacity. The other significant contributor to gender discrimination is male dominance, which must be brought down to empower women. To reduce this, communication is key between spouses, family members and community members. Gender discrimination has greater influence at different levels of Pakistani society. Certain schools and television advertisements portrays stereotypes, such as allowing boys to be active outdoors and forcing girls to remain indoors. Therefore, media channels and other public systems such as healthcare facilities and schooling systems must promote gender equity and equality. In terms of Sexual and Reproductive health (SRH), the health care facilities should play an important role in providing knowledge and effective treatment to both males and females. The SRH related services are often compromised for people due to lack of resources, staff, and attention. Schools and communities should play an important role in creating SRH related awareness among youth and adults that include puberty, pregnancy, and motherhood. SRH should also be made part of curriculum in educational institutes.

The use of group interviews allowed rapport development with communities. With multiple people present sharing similar views, many were inclined to give purposeful answers and recommendations regarding gender roles in communities. Based on previous literature searches, this study, to the best of our knowledge, has not been published in Pakistan at the community level. No other study explores the views of Pakistanis on gender discrimination with inclusion of multiple community groups and across multiple districts. In limitations, due to the topic’s sensitive topic, may have held back participants from answering fully and truthfully. Thus, considerable time was taken to develop trust and rapport. Therefore, it is possible that some study subjects might not have answered to the best of their ability. Furthermore, challenges were faced due to the COVID-19 pandemic and extreme weather conditions in some areas, as some participants could not reach the venue. Also, the lockdowns following the pandemic made it very difficult to gather 10–12 people at one place for the FGDs. Interviews could not be done virtually as the information was very sensitive.

Gender roles in Pakistani society are extremely complex and are transferred from generation to generation with minimal changes since ages. This study reveals some of the factors due to which women in Pakistan face gender discrimination. The cultural and societal values place women in a nurturing role in the Pakistani society. Through reinforcement of these roles by different family members, as well as by the dominant men in the society, women face adverse challenges to seek empowerment that will help them defy such repressive roles assigned to them. Gender discrimination is evident in public institutions such as healthcare facilities and schooling systems. Thus, administrative reorganization and improved awareness in the healthcare facilities, and appropriate education in schools for boys and girls will help decrease gender discrimination in the Pakistani societies.

Acknowledgments

The authors would like to thank the research specialist, coordinator, and research associates for data collection, and the study participants for their time and valuable data. We would also like to appreciate and thank Mr. Adil Ali Saeed for helping us with the literature for the systematic review of the paper, and Ms. Amirah Nazir and Daman Dhunna for the overall cleaning of document. We are thankful to UNFPA and AKF for providing advisory and monitoring support. We would like to acknowledgment UNFPA Pakistan that through them the funding was received from Global Affairs Canada.

Abbreviations

Authors’ contributions.

All authors have read and approved the manuscript. Their contribution is as follows: TSA contributed to proposal development, interview guide development, ERC approval, data supervision, data validation, systematic review, data analysis, manuscript development, and overall supervision. SSA assisted in proposal development, data collection supervision, data validation, systematic review, data analysis, and reviewed manuscript. SN, contributed in -literature Review, analysis of literature review and write up of findings. ZM reviewed interview guides, assisted in ERC approval, filed preparation for data collection, assisted in data validation and enhancing the approval processing, reviewed data analysis, and the final manuscript. SSA, contributed to proposal development, assisted in ERC approval, overall supervision, filed preparation for data collection and training of data collectors, assisted in data validation and enhancing the approval process and review of final manuscript. FM contributed to the interview guide development, facilitated field data collection, and contributed to the validation and analysis processes. Reviewed the final manuscript before submission. YK contributed to the interview guide development, facilitated field data collection, and contributed to the validation and analysis processes. Reviewed the final manuscript before submission. SM, contributed to proposal development, field preparation for data collection, validation, and review of the final manuscript. ZB, contributed to proposal development, brought the funding, assisted in ERC approval, overall supervision, data validation and enhancing the approval process and reviewed the final manuscript. He provided overall mentorship.

Global Affairs Canada (GAC). Project No: P006434; Arrangement #: 7414620.

Role of the funder: This is to declare that there was no role of the funding agency for planning and implementation of this study.

Availability of data and materials

Declarations.

The ERC approval was taken from the Aga Khan University Ethics Review Committee for primary data collection. The ERC number is 2020-3606-11489. The written informed consent was taken from all the participants. For those who were younger than 18 years of age were given written assent, and their parent, or guardian verbally consented.

We declare that this is original research and all the authors have contributed to the proposal writing, funding management, data collection, analysis, and manuscript development.

Authors declare that they have no conflict of interest.

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