Photo ©: Flickr / Beverly McArthur Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa This policy brief presents an update on the state of unhappiness and depression in the Middle East and North Africa (MENA) region during the COVID-19 pandemic June 2023 using findings from a large-scale phone survey in 10 MENA countries, conducted by the World Values Survey (WVS) Association. The survey interviewed 12,366 respondents, distributed almost equally across Algeria, Palestine, Iran, Iraq, Jordan, Lebanon, Morocco, Saudi Arabia, Tunisia, and Egypt. Middle East Key Findings and North 1) A concerning 90 percent of individuals in MENA reported a rise in anxiety or depression within their communities Africa Gender 2) Gender-based differences in community reporting of increased community- level anxiety or depression are not notable in seven out of the 10 countries Innovation Lab 3) Contrary to community-level reporting, at the individual level, women’s well- being was disproportionately affected during COVID-19, with a higher likelihood The Middle East and North Africa than men of feeling very sad and depressed about their life situation Gender Innovation Lab (MNAGIL) 4) There is significant country heterogeneity when it comes to reporting individual carries out impact evaluations and experiences of sadness and depression, with a general tendency to underreport inferential research to produce 5) Social relationships matter for the well-being of both women and men, with a rigorous evidence on what works in slightly stronger association among women closing gaps in assets, economic 6) Higher education decreased the likelihood of experiencing sadness and opportunities, and agency between depression, while unemployment increased this likelihood, with more effects women and men, and how closing on men compared to women these gaps can help achieve other 7) Poor physical health and increased concerns related to COVID-19, both in terms development outcomes. Ultimately, of health and economic aspects, are negatively associated with well-being MNAGIL promotes the adoption of policies and interventions that are shown to close gender gaps and Context improve the well-being of women The World Happiness Report, which assesses happiness based on various factors and men in the Middle East and such as GDP per capita, social support, healthy life expectancy, freedom, generosity, North Africa. and corruption, highlights significant variations in happiness levels across MENA countries. The region exhibits a wide gap in happiness, with some countries ranked among the top performers, others in the average range, and a few at the bottom. Saudi Arabia, for instance, ranks 30th out of 137 countries according to the three-year average data from 2020 to 2022. However, there are three MENA countries, namely Lebanon (136th), Jordan (123rd), and Egypt (121st), that are among the 20 least happy countries globally. The majority of MENA countries fall into the middle bracket, including Algeria (81st), Iraq (98th), Palestine (99th), Morocco (100th), Iran (101st), and Tunisia (110th).1 1 Helliwell, John F, Richard Layard, Jeffrey Sachs. 2023. The Happiness Agenda: The Next 10 Years. In World Happiness Report 2023 (11th ed., Chapter 1). Sustainable Development Solutions Network. #2 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa There is evidence that the COVID-19 pandemic had a negative impact on happiness levels worldwide (Alzueta et al., 2020; O'Connor et al., 2020). The measures implemented to control the spread of the virus, including lockdowns, social distancing, and economic disruptions, led to various hardships for individuals. The pandemic also triggered feelings of uncertainty, anxiety, and stress. Job losses and financial difficulties further exacerbated the situation for many people. Specific channels have disproportionately affected the well-being of women, such as the increased burden of caregiving responsibilities and domestic workload. Due to a lack of sex-disaggregated data, especially in the MENA region, few studies were able to address the variations in experiences and reporting patterns of sadness and depression by gender, as well as the gender-based drivers and implications in the context of the COVID-19 pandemic. What did we do?23 What did we find? We use a novel survey collected in collaboration with the First: Community-level reporting World Values Survey (WVS) amidst the COVID-19 pandemic Based on community-level reporting, the COVID-19 in 2021 to analyze the gender differences in experiencing pandemic had a profound impact on anxiety and depression and reporting severe sadness and depression by women in MENA communities, affecting high-income countries and men. World Values Surveys are cross-sectional as well, despite their lower levels of financial stress. On surveys that assess individual attitudes and values, such average, a concerning 90 percent of respondents in 10 MENA as cultural values; attitudes and beliefs towards gender, countries reported that more people were becoming very family, and religion; attitudes and experience of poverty; anxious or depressed in their communities since the onset of education, health, and security; social tolerance and the COVID-19 pandemic in March 2020. The highest reported trust; and attitudes towards multilateral institutions. In effects are observed in Tunisia (97 percent of respondents), addition to the standard WVS modules, this round includes followed by Iraq (95 percent), Iran (95 percent), Palestine (95 questions related to COVID-19, such as perceptions of percent), Jordan (91 percent), Lebanon (90 percent), Morocco COVID-19 effects on the respondent, their family, and in the (89 percent), Egypt (88 percent), and Algeria (84 percent). This community. The survey covers 10 countries in the MENA rise in anxiety and depression could be attributed to various region: Algeria, Palestine, Iran, Iraq, Jordan, Lebanon, factors, including but not limited to health concerns, social Morocco, Saudi Arabia, Tunisia, and Egypt. A total of isolation, economic consequences of COVID-19, and rapid 12,366 adult respondents (aged 18+) were interviewed changes and uncertainty. High-income countries like Saudi via phone between March and June 2021.2 The survey is Arabia also experienced a rise in anxiety and depression representative at the national level.3 during the pandemic. Despite having relatively less financial stress, these countries still faced ample pandemic-induced Importantly, given the individual focus of WVS, this survey challenges, such as health risks, disruptions to daily life, offers a rare perspective on individual experiences of and uncertainty about the future. Approximately 72 percent sadness and depression within households and allows of respondents in Saudi Arabia reported an increase in for differentiation between individuals' observations at the anxiety and depression within their communities. It is worth community level (which may also partly reflect their own mentioning, however, that Saudi Arabia had the lowest experiences) and their personal experiences. Moreover, the share of respondents reporting an increase in anxiety and survey offers valuable insights into the implications for the depression compared to the rest of the MENA countries. well-being of family members spending much more time together, as well as lifestyle changes since the beginning of the pandemic, including the redistribution of time Based on community-level reporting, the allocated to various activities. This wealth of information provides a unique opportunity to delve deeper into the COVID-19 pandemic had a profound impact on factors that have affected the well-being of both men and anxiety and depression in MENA communities, women in MENA. affecting high-income countries as well, despite their lower levels of financial stress. 2 There are slight differences in the interview timeframe. For example, in Lebanon, the survey was concluded in a week (April 2-8), while it took two months to finish the survey in Iran (April 14-June 19). All 10 country surveys started in a similar timeframe, between March 28 and April 17. 3 Stratified random sampling was used to minimize selection bias. However, it is worth noting that the response rate varies across coun- tries, from a low of 8 percent in Iran to a high of 79 percent in Lebanon and Morocco. #3 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa In general, gender-based differences in community than their male counterparts. This variation highlights reporting of increased anxiety or depression in the MENA the need for further investigation into the individual-level region are not prominent. However, notable exceptions experiences of anxiety and depression within households. are observed in Algeria, Egypt, and Saudi Arabia, where The WVS provides valuable information in this regard, as a larger proportion of female respondents reported a it differentiates between individuals’ observations at the rise in anxiety or depression within their communities community level (which may also partly reflect their own compared to male respondents since the beginning experiences) and their personal experiences. of the COVID-19 pandemic in March 2020. (Figure 1). In Algeria, 88 percent of female respondents reported increased anxiety or depression at the community level In general, gender-based differences in compared to 81 percent of male respondents. In both community reporting of increased anxiety Egypt and Saudi Arabia, female respondents are 10 ppts or depression in the MENA region are not more likely to report increased anxiety or depression prominent. Figure 1 Share of individuals reporting that more people are becoming very anxious or depressed in their community since the beginning of COVID-19 100 90 80 70 60 50 40 30 20 Male 10 0 Female Algeria Egypt Iran Iraq Jordan Lebanon Morocco Palestine Saudi Arabia Tunisia Note: 95% Confidence Interval Source: Author’s calculations using data from the World Values Survey, World Bank, 2021. Second: Individual experiences Unlike reporting community effects, there is significant the open expression of negative emotions, fear of potential country heterogeneity in MENA when it comes to reporting consequences for disclosing mental health struggles, and individual experiences of sadness and depression, with a a lack of awareness or understanding of one’s own feelings general tendency to underreport (Figure 2 versus Figure 1). of sadness and depression. Take Iran, for example, where The percentage of respondents reporting frequent feelings of a relatively low percentage of 62 percent of respondents severe sadness and depression about their life situation in reported personally experiencing severe sadness and the 10 months leading up to the survey varies significantly depression (Figure 2), in contrast to the average of 95 percent across the region, ranging from a high of 89 percent in Iran of respondents reporting increased anxiety and depression in and 85 percent in Tunisia to a low of 62 percent in Iran and their communities (Figure 1). 50 percent in Saudi Arabia. In parallel, when comparing reported personal experiences with reported observations at the community level, a notable disparity emerges, with the Unlike reporting community effects, there former being significantly lower. This suggests a hesitancy among individuals to openly report or disclose their feelings is significant country heterogeneity in of sadness and depression, which may be driven by MENA when it comes to reporting individual various factors, including the stigma surrounding mental experiences of sadness and depression, health issues, cultural and societal norms discouraging with a general tendency to underreport #4 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa Figure 2 Share of individuals feeling very sad and depressed about their life situation sometimes or often in the 10 months preceding the survey 100 90 80 70 60 50 40 30 20 Male 10 0 Female Algeria Egypt Iran Iraq Jordan Lebanon Morocco Palestine Saudi Arabia Tunisia Note: 95% Confidence Interval Source: Author’s calculations using data from the World Values Survey, World Bank, 2021. In contrast to community-level reporting, at the individual gathered insightful data on personal experiences regarding level, the COVID-19 pandemic unevenly impacted women’s the situation where family members living in the same well-being in MENA: women were more likely than men to household had been spending much more time together feel very sad and depressed about their life situation. Except since the outbreak of COVID-19. One particularly relevant for Iraq, larger shares of female respondents (than of male question asked respondents about the frequency with respondents) reported feeling very sad and depressed about which they felt that the unity of their family was getting their life situation sometimes or often in the 10 months stronger. Additionally, two other questions inquired about the preceding the survey (Figure 2). The most notable gender frequency of verbal and physical arguments between family differences are observed in Egypt, Jordan, and Saudi Arabia. members. On average, in the 10 countries, a higher frequency In Egypt, about 86 percent of female respondents expressed of verbal and physical arguments between family members experiencing severe sadness and depression about their is associated with an increased risk of experiencing severe life situation compared to 70 percent of male respondents. sadness and depression (Figure 3, Panels B and C). Notably, Similarly, in Jordan and Saudi Arabia, women were 10 and 13 even verbal arguments appear to have an impact on the ppts more likely, respectively, than their male counterparts to prevalence of severe sadness and depression (Panel B). This report severe sadness and depression. The pandemic had could indicate that verbal arguments serve as an indicator of likely exacerbated existing gender inequalities, leading to a underlying physical arguments that some respondents may disproportionate impact on women's well-being in a number be hesitant to report. Alternatively, it is possible that even of ways, such as increased caregiving responsibilities, verbal arguments can have a negative effect on individuals' economic hardships, and a surge in domestic violence and well-being. Interestingly, our analysis also reveals that gender-based violence. regardless of the frequency of physical arguments, whether they occur often or sometimes, they similarly contribute to an increased risk of severe sadness and depression (Panel In contrast to community-level reporting, at the C). It is worth considering the possibility of underreporting, individual level, the COVID-19 pandemic unevenly where “often” may be reported as “sometimes.” In parallel, the contradictory relationship between strengthened family impacted women’s well-being in MENA: women unity and well-being is counter-intuitive (Panel A), which were more likely than men to feel very sad and warrants further investigation. depressed about their life situation. Social relationships matter for the well-being Social relationships matter for the well-being of both women of both women and men in MENA, with and men in MENA, with a slightly stronger association observed among women compared to men. The WVS a slightly stronger association observed among women compared to men #5 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa Exploring the variation by gender, Figure 3 provides evidence significantly better well-being compared to their male of a slightly stronger association between social relationships counterparts. This pattern holds for both verbal and physical and well-being among women compared to men, particularly arguments (Panels B and C). However, when physical when the status of social relationships is measured by the arguments occur, the frequency of these arguments similarly frequency of verbal arguments (Panel B). Interestingly, in the affects the well-being of both men and women (Panel C). absence of any arguments, female respondents experience Figure 3 (Mean) Prevalence of sadness and depression in the 10 months preceding the survey by family relationships’ status Panel A Panel B Panel C By strengthened family unity By verbal arguments By physical arguments between family members between family members 100 100 100 80 80 80 60 60 60 40 40 40 Never 20 20 20 Sometimes 0 0 0 Often Male Female Male Female Male Female Source: Author’s calculations using data from the World Values Survey, World Bank, 2021. Higher levels of educational attainment decreased the have slightly better well-being compared to both unemployed likelihood of experiencing severe sadness and depression women and women who are out of the labor force (Figure 4, in MENA in the aftermath of the COVID-19 pandemic, Panel B). These findings are consistent with the empirical whereas unemployment increased this likelihood, with evidence of the strong negative association between more pronounced effects detected among men compared to unemployment and subjective well-being.5 women. There is empirical evidence that higher educational attainment is generally associated with better mental health outcomes, including lower levels of sadness and depression.4 Higher levels of educational attainment This may be attributed to several factors, such as increased decreased the likelihood of experiencing knowledge and skills, better job prospects and economic stability, access to resources and opportunities, and severe sadness and depression in MENA in improved social support networks. In the 10 MENA countries, the aftermath of the COVID-19 pandemic, educational attainment seems to be a stronger determinant whereas unemployment increased this of the prevalence of sadness and depression among men compared to women, on average (Figure 4, Panel A). Similarly, likelihood, with more pronounced effects unemployed men exhibit lower well-being compared to detected among men compared to women. unemployed women. In parallel, employed women seem to 4 Dolan, Paul, Tessa Peasgood, and Mathew White. 2008. “Do We Really Know What Makes Us Happy? A Review of the Economic Litera- ture on the Factors Associated with Subjective Well-Being.” Journal of Economic Psychology 29 (1): 94–122. https://doi.org/10.1016/j.joep.2007.09.001 5 Dolan, Paul, Tessa Peasgood, and Mathew White. 2008. “Do We Really Know What Makes Us Happy? A Review of the Economic Litera- ture on the Factors Associated with Subjective Well-Being.” Journal of Economic Psychology 29 (1): 94–122. https://doi.org/10.1016/j.joep.2007.09.001 #6 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa Figure 4 (Mean) Prevalence of sadness and depression in the 10 months preceding the survey by socio-economic status Panel A Panel B By educational attainment By labor force status 80 80 60 60 40 40 Less than secondary Out of the force 20 20 Less than college Unemployed 0 BA and above 0 Employed Male Female Male Female Source: Author’s calculations using data from the World Values Survey, World Bank, 2021. Poor physical health and increased concerns related to are associated with a higher likelihood of experiencing COVID-19, both in terms of health and economic aspects, extreme sadness and depression. Economic concerns, are negatively associated with well-being in the MENA however, seem to have a more significant effect on well- region. Individuals who had a higher self-perceived being compared to health concerns among both women physical health were less likely to experience feelings of and men (Figure 5, Panels B and C). extreme sadness and depression about their life situation, whether it was sometimes or often, in the 10 months preceding the survey (Figure 5, Panel A). This association Poor physical health and increased is stronger among male respondents compared to female concerns related to COVID-19, both respondents. Poor physical health can contribute to a decline in overall well-being by imposing limitations on in terms of health and economic daily activities and causing pain, discomfort, and reduced aspects, are negatively associated energy levels. Moreover, it can also have an impact on an with well-being in the MENA region. individual’s social interactions, relationships, and overall quality of life, thereby further worsening their well-being. Additionally, in the context of COVID-19, worry about contracting COVID-19 could increase feelings of sadness and depression. The uncertainty and fear associated with the virus could take a toll on mental well-being, causing heightened levels of sadness and depression. Similarly, concerns about the economic consequences of the pandemic, such as job losses, financial instability, and reduced opportunities, could contribute to feelings of sadness and depression. The WVS includes specific questions that address not only the health concerns associated with COVID-19 but also the economic concerns related to the pandemic. This allows for a comprehensive understanding of the impact of COVID-19 on well-being, taking into account both the health and economic dimensions. When comparing the impact of health-related concerns and economic-related concerns Photo ©: Flickr / Pedro Orihuela on well-being, our analysis reveals that both factors #7 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa Figure 5 (Mean) Prevalence of sadness and depression in the 10 months preceding the survey by COVID-19 health- and economic-related concerns Panel A Panel B Panel C By physical health By worry from By economic anxiety contracting COVID-19 triggered by COVID-19 Bad/fair 80 80 80 Good 60 60 60 V. good/ excellent 40 40 40 Afraid 20 20 20 Not sure 0 0 0 Not afraid Male Female Male Female Male Female Source: Author’s calculations using data from the World Values Survey, World Bank, 2021. The increased burden of caregiving responsibilities and particularly in terms of the redistribution of time typically domestic workload are two channels through which allocated to various activities. Interestingly, on average, in all COVID-19 could have particularly affected the well-being 10 countries, approximately half of the female respondents of women. These factors could reduce the amount of reported spending more time taking care of children leisure time available to women, which is an important compared to 38 percent of male respondents. Additionally, determinant of happiness and well-being. The WVS about 59 percent of female respondents reported spending includes questions that provide insights into the extent more time on housework compared to 42 percent of male of lifestyle changes since the beginning of the pandemic, respondents. These notable gender differences in the allocation of childcare responsibilities and housework during the pandemic have led to disparities in leisure time between The increased burden of caregiving men and women. About 27 percent of female respondents responsibilities and domestic workload are two reported spending less time on their hobbies compared to 22 percent of male respondents. However, it is important to note channels through which COVID-19 could have that the time reallocations during the pandemic, regardless particularly affected the well-being of women. of gender differences, had similar implications for the well- being of both men and women (Figure 6). Figure 6 (Mean) Prevalence of sadness and depression in the 10 months preceding the survey by time redistribution due to COVID-19 Panel A Panel B Panel C By time spent on By time spent on By time spent on childcare responsibilities housework hobbies 80 80 80 60 60 60 40 40 40 Decreased 20 20 20 The same 0 0 0 Increased Male Female Male Female Male Female Source: Author’s calculations using data from the World Values Survey, World Bank, 2021. #8 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa Insights for policy Women’s happiness and well-being were disproportionately 1. By raising awareness about the importance affected in the context of the COVID-19 pandemic, of mental health and challenging the stigma emphasizing a higher burden on women in terms of the surrounding it, it is possible to address economic and social impacts of unhappiness. Economically, the severe underreporting of sadness and unhappiness can undermine women’s careers and economic depression in the MENA region. Additionally, well-being. Unhappy women may experience reduced job offering training programs for healthcare satisfaction, lower motivation, and decreased productivity professionals, social workers, and community in the workplace, which can impede their career progression leaders can improve their knowledge and and financial stability. On the social front, unhappiness can skills in recognizing and addressing mental hinder women’s ability to effectively engage in parenting and health issues. Equipping them with the family life, as well as diminish their sense of empowerment necessary resources, including robust referral and agency in various aspects of life. networks, can further strengthen their ability to support individuals experiencing such issues effectively. Women’s happiness and well-being were disproportionately affected in the context of the COVID-19 pandemic, 2. Strengthening educational attainment for both emphasizing a higher burden on women men and women can have a positive impact in terms of the economic and social on their well-being and happiness. Education plays a crucial role in various aspects of impacts of unhappiness. individuals’ lives, including their personal development, social interactions, economic opportunities, and most importantly, their resilience during shocks. 3. Prioritizing unemployment support can create a safety net that supports individuals during times of economic hardship, leading to improved well-being and happiness. By providing robust and accessible unemployment support, such as financial assistance, job training programs, and career counseling, individuals who have lost their jobs can receive the necessary support to navigate through challenging times. Photo ©: Shutterstock / Marie Selissky Policymakers should calibrate and prioritize responses 4. There is an unmet need to regularly monitor such as promoting mental health and well-being, enhancing and evaluate the impact of any ongoing social support networks, improving access to health efforts on happiness and well-being, with care, investing in education and lifelong learning, and a special focus on women. This process strengthening social and economic policies. Our results allows for ensuring that efforts are tailored suggest a few policy implications: to address the specific needs and challenges faced by women in the MENA region. Policymakers should calibrate and prioritize responses #9 Navigating the Shadows: Unhappiness and Depression in the Middle East and North Africa Acknowledgments This brief is a product of MNAGIL. It was prepared by Nazmul Chaudhury, Amira El-Shal, and Daniel Halim. We gratefully acknowledge funding from the Umbrella Facility for Gender Equality (UFGE) to carry out this work. UFGE has received generous contributions from Australia, Bill & Melinda Gates Foundation, Canada, Denmark, Finland, Germany, Iceland, Latvia, Netherlands, Norway, Spain, Sweden, Switzerland, United Kingdom, and the United States. For more information Nazmul Chaudhury nchaudhury@worldbank.org References Alzueta, Elisabet, Paul Perrin, Fiona C. Baker, Sendy Caffarra, Daniela Ramos‐Usuga, Dilara Yuksel, and Juan Carlos Arango‐Lasprilla. 2020. “How the COVID‐19 Pandemic Has Changed Our Lives: A Study of Psychological Correlates across 59 Countries.” Journal of Clinical Psychology 77 (3). https://doi.org/10.1002/jclp.23082. Dolan, Paul, Tessa Peasgood, and Mathew White. 2008. “Do We Really Know What Makes Us Happy? A Review of the Economic Literature on the Factors Associated with Subjective Well-Being.” Journal of Economic Psychology 29 (1): 94–122. https://doi.org/10.1016/j.joep.2007.09.001 Helliwell, John F, Richard Layard, Jeffrey Sachs. 2023. The Happiness Agenda: The Next 10 Years. In World Happiness Report 2023 (11th ed., Chapter 1). Sustainable Development Solutions Network. O’Connor, Rory C, Karen Wetherall, Seonaid Cleare, Heather McClelland, Ambrose J Melson, Claire L Niedzwiedz, Ronan E O’Carroll, et al. 2020. “Mental Health and Wellbeing during the COVID-19 Pandemic: Longitudinal Analyses of Adults in the UK COVID-19 Mental Health & Wellbeing Study.” The British Journal of Psychiatry 218 (6): 1–17. https://doi.org/10.1192/bjp.2020.212.