Abstract
Identifying the critical modifiable risk factors for anxiety and depression is crucial for reducing the increasing burden of mental illness among reproductive-aged women 15–49 years in Nepal. We investigated Population Attributable Fractions (PAFs) of generalized anxiety disorder and major depressive disorder attributable to potentially modifiable risk factors among reproductive-age women. This cross-sectional study analysed the data from the Nepal Demographic Health Survey in 2022. Multilevel logistic regression analyses determined odds ratio (ORs) for risk factors associated with depression and anxiety. PAFs adjusted for communality were calculated using adjusted ORs and prevalence estimates for each risk factor. This study included a weighted sample of 7,410 women, with a mean age of 30 (± 10) years. Highest PAFs of depression were associated with women who experienced emotional abuse (PAF: 18.2%; 95%CI: 15.4–20.2), physical violence (PAF: 12.1%; 95%CI: 5.1–16.7), and sexual abuse (PAF: 9.0%; 95%CI: 5.9–11.5), functional difficulty (PAF: 6.9%; 95%CI: 2.8–10.1) and food insecurity (PAF: 6.6%; 95%CI: 4.4–8.4). These five potentially modifiable risk factors accounted for 52.8% (95%CI: 33.7–67.0) of depression cases. Highest PAFs for anxiety were associated with women who experienced emotional abuse (PAF: 10.8%; 95%CI: 8.7–12.7), functional impairment (PAF: 7.8%; 95%CI: 5.7–9.6), physical violence (PAF: 7.8%; 95%CI: 4.4–10.6), sexual abuse (PAF: 5.6%; 95%CI: 3.9–7.3), and food insecurity (PAF: 3.7%; 95%CI: 2.4–4.9). These five potentially modifiable risk factors accounted for 35.7% (95%CI: 25.2–45.1) of anxiety cases. The results of this study highlight the necessity of targeted strategies at the community and household levels to address violence against women. Couple-based approaches involving men are particularly relevant to break the cycle of intergenerational violence and fostering environments conducive for better mental health.
Similar content being viewed by others
Data availability
The datasets supporting the conclusions of this article are available in the DHS repository, (https:/dhsprogram.com/data/available-datasets.cfm). The DHS provides open access to survey data files for legitimate academic research purposes. To initiate the download process, registration is mandatory. Researchers are required to provide their contact information, research title, and a brief description of the proposed analysis. Approval for dataset access is typically confirmed via email. It is important to note that these datasets are third-party resources and not under the ownership or collection of the authors, who possess no special access privileges.
Abbreviations
- CI:
-
Confidence Interval
- GAD:
-
Generalised Anxiety Disorder
- MHM:
-
Mental Health Module
- NDHS:
-
Nepal Demographic and Health Survey
- OR:
-
Odds Ratio
- PAF:
-
Population Attributable Fraction
- PCA:
-
Principal Component Analysis
- PHQ:
-
Patient Health Questionnaire
References
GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry 9, 137–150. https://doi.org/10.1016/S2215-0366(21)00395-3 (2022).
World Health Organization. World mental health report: transforming mental health for all. Geneva. https://www.who.int/publications/i/item/9789240049338 (2022).
Walker, E. R., McGee, R. E. & Druss, B. G. Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry 72, 334–341. https://doi.org/10.1001/jamapsychiatry.2014.2502 (2015).
Chesney, E., Goodwin, G. M. & Fazel, S. Risks of all-cause and suicide mortality in mental disorders: A meta-review. World Psychiatry 13, 153–160. https://doi.org/10.1002/wps.20128 (2014).
Arias, D., Saxena, S. & Verguet, S. Quantifying the global burden of mental disorders and their economic value. EClinicalMedicine 54, 101675. https://doi.org/10.1016/j.eclinm.2022.101675 (2022).
Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Global Burden of Disease (GBD) Study 2019, (2020). http://vizhub.healthdata.org/gbd-compare
Kirkbride, J. B. et al. The social determinants of mental health and disorder: Evidence, prevention and recommendations. World Psychiatry 23, 58–90. https://doi.org/10.1002/wps.21160 (2024).
Dhungana, R. R. et al. The burden of mental disorders in Nepal between 1990 and 2019: Findings from the Global Burden of Disease Study 2019. Camb. Prisms Glob. Ment. Health. 10, e61. https://doi.org/10.1017/gmh.2023.55 (2023).
Nepal Health Research Council. Report of National Mental Health Survey 2020 https://nhrc.gov.np/wp-content/uploads/2022/10/National-Mental-Health-Survey-Report2020.pdf (2021).
Sapkota, B. D., Simkhada, P., Newton, D. & Parker, S. Domestic violence against women in Nepal: A systematic review of risk factors. Trauma Violence Abuse 25, 2703–2720. https://doi.org/10.1177/15248380231222230 (2024).
Suanrueang, P. & Peltzer, K. Depression and generalized anxiety and associated factors among adult women and men in Nepal: Results of a national cross-sectional survey in 2022. J. Hum. Behav. Soc. Environ. 35, 513–535. https://doi.org/10.1080/10911359.2024.2316127 (2024).
Oram, S., Khalifeh, H. & Howard, L. M. Violence against women and mental health. Lancet Psychiatry 4, 159–170. https://doi.org/10.1016/S2215-0366(16)30261-9 (2017).
Lemon, C. A. et al. Priorities for research promoting mental health in the south and east of Asia. Lancet Reg. Health Southeast Asia 23, 100287. https://doi.org/10.1016/j.lansea.2023.100287 (2024).
Pengpid, S., Peltzer, K. & Hasan, M. T. Undiagnosed depressive and anxiety disorders in a nationally representative sample of Bangladeshi and Nepali women: Prevalence and associated factors. Int. J. Ment. Health Syst. 19, 22. https://doi.org/10.1186/s13033-025-00677-7 (2025).
Papola, D., Barbui, C. & Patel, V. Leave no one behind: Rethinking policy and practice at the national level to prevent mental disorders. Ment. Health Prev. 33, 200317. https://doi.org/10.1016/j.mhp.2023.200317 (2024).
Patel, V. et al. The Lancet Commission on global mental health and sustainable development. Lancet 392, 1553–1598. https://doi.org/10.1016/S0140-6736(18)31612-X (2018).
Lund, C. et al. Social determinants of mental disorders and the Sustainable Development Goals: A systematic review of reviews. Lancet Psychiatry 5, 357–369. https://doi.org/10.1016/S2215-0366(18)30060-9 (2018).
Pandey, A. R. et al. Prevalence, determinants and care-seeking behaviour for anxiety and depression in Nepalese population: A secondary analysis of data from Nepal Demographic and Health Survey 2022. BMJ Open 14, e078582. https://doi.org/10.1136/bmjopen-2023-078582 (2024).
Risal, A., Manandhar, K., Linde, M., Steiner, T. J. & Holen, A. Anxiety and depression in Nepal: Prevalence, comorbidity and associations. BMC Psychiatry 16, 102. https://doi.org/10.1186/s12888-016-0810-0 (2016).
Shawon, M. S. R., Hossain, F. B., Hasan, M. & Rahman, M. R. Gender differences in the prevalence of anxiety and depression and care seeking for mental health problems in Nepal: Analysis of nationally representative survey data. Camb. Prisms Glob. Ment. Health 11, e46. https://doi.org/10.1017/gmh.2024.37 (2024).
Ministry of Health and Population (Nepal), New Era and ICF. Nepal Demographic and Health Survey 2022. Nepal. https://dhsprogram.com/pubs/pdf/FR379/FR379.pdf (2023).
Polack, S. et al. Disability inclusion in the Brazilian health system: Results of a health system assessment. Glob. Health Action 18, 2550793. https://doi.org/10.1080/16549716.2025.2550793 (2025).
Singh, C. D. et al. Trauma-informed and relational approaches to service provision: Building community-based project capacity to respond to interpersonal violence through a national initiative. BMC Public Health 20, 1833. https://doi.org/10.1186/s12889-020-09960-3 (2020).
Lumley, T. survey: Analysis of complex survey samples. https://cran.r-project.org/web//packages/survey/survey.pdf (2024).
Brooks, M. et al. Generalized linear mixed models using template model builder. R package ‘glmmTMB’, version 1 (2022).
Khosravi, A., Nazemipour, M., Shinozaki, T. & Mansournia, M. A. Population attributable fraction in textbooks: Time to revise. Glob. Epidemiol. 3, 100062. https://doi.org/10.1016/j.gloepi.2021.100062 (2021).
Lee, M. et al. Variation in population attributable fraction of dementia associated with potentially modifiable risk factors by race and ethnicity in the US. JAMA Netw. Open 5, e2219672. https://doi.org/10.1001/jamanetworkopen.2022.19672 (2022).
R Core Team. R: A Language and Environment for Statistical Computing, < (2023). https://www.R-project.org/
Marphatia, A. A. et al. Maternal mental health and economic autonomy in lowland rural Nepal: Do parents-in-law provide constraint or support? Evol. Med. Public. Health. 11, 229–243. https://doi.org/10.1093/emph/eoad020 (2023).
Dragioti, E. et al. Global population attributable fraction of potentially modifiable risk factors for mental disorders: A meta-umbrella systematic review. Mol. Psychiatry 27, 3510–3519. https://doi.org/10.1038/s41380-022-01586-8 (2022).
Li, M., D’Arcy, C. & Meng, X. Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: Systematic review, meta-analysis, and proportional attributable fractions. Psychol. Med. 46, 717–730. https://doi.org/10.1017/S0033291715002743 (2016).
Thapa, S., Bhattarai, S. & Aro, A. R. “Menstrual blood is bad and should be cleaned”: A qualitative case study on traditional menstrual practices and contextual factors in the rural communities of far-western Nepal. SAGE Open Med. 7, 2050312119850400. https://doi.org/10.1177/2050312119850400 (2019).
Wessells, M. G. & Kostelny, K. The psychosocial impacts of intimate partner violence against women in LMIC contexts: Toward a holistic approach. Int J Environ Res Public Health 19, 14488. https://doi.org/10.3390/ijerph192114488 (2022).
Ramsoomar, L. et al. Pooled analysis of the association between mental health and violence against women: Evidence from five settings in the Global South. BMJ Open 13, e063730. https://doi.org/10.1136/bmjopen-2022-063730 (2023).
Suri, S. & Ray, S. Understanding the Link Between Food Insecurity and Negative Mental Health Outcomes. https://www.orfonline.org/research/understanding-the-link-between-food-insecurity-and-negative-mental-health-outcomes (2025).
Piperata, B. A., Schmeer, K. K., Rodrigues, A. H. & Salazar Torres, V. M. Food insecurity and maternal mental health in Leon, Nicaragua: Potential limitations on the moderating role of social support. Soc Sci Med 171, 9–17. https://doi.org/10.1016/j.socscimed.2016.10.029 (2016).
Jones, A. D. Food insecurity and mental health status: A global analysis of 149 countries. Am J Prev Med 53, 264–273. https://doi.org/10.1016/j.amepre.2017.04.008 (2017).
Koenig, J., McLean, K. J. & Bishop, L. Psychological distress and mental health diagnoses in adults by disability and functional difficulty status: Findings from the 2021 national health interview survey. Disabil. Health J. 17, 101641. https://doi.org/10.1016/j.dhjo.2024.101641 (2024).
Deierlein, A. L., Park, C., Patel, N., Gagnier, R. & Thorpe, M. Mental health outcomes across the reproductive life course among women with disabilities: A systematic review. Arch Womens Ment Health 28, 647–664. https://doi.org/10.1007/s00737-024-01506-5 (2025).
Wallace, S., Mactaggart, I., Banks, L. M., Polack, S. & Kuper, H. Association of anxiety and depression with physical and sensory functional difficulties in adults in five population-based surveys in low and middle-income countries. PLoS One 15, e0231563. https://doi.org/10.1371/journal.pone.0231563 (2020).
Freeman, M. Investing for population mental health in low and middle income countries-where and why?. Int. J. Ment. Health Syst. 16, 38. https://doi.org/10.1186/s13033-022-00547-6 (2022).
Rai, Y., Gurung, D. & Gautam, K. Insight and challenges: Mental health services in Nepal. BJPsych Int. 18, E5. https://doi.org/10.1192/bji.2020.58 (2021).
Oswald, T. K. et al. Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: A systematic review of reviews. Psychol. Med. 54, 1475–1499. https://doi.org/10.1017/S0033291724000333 (2024).
Doustmohammadian, A. et al. Community-based participatory interventions to improve food security: A systematic review. Front. Nutr. 9, 1028394. https://doi.org/10.3389/fnut.2022.1028394 (2022).
Shawon, M. S. R. et al. Role of women empowerment on mental health problems and care-seeking behavior among married women in Nepal: Secondary analysis of nationally representative data. Arch. Womens Ment. Health 27, 527–536. https://doi.org/10.1007/s00737-024-01433-5 (2024).
Mathias, K. et al. Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa. PLoS Glob. Public Health 4, e0002575. https://doi.org/10.1371/journal.pgph.0002575 (2024).
Gartland, D., Giallo, R., Woolhouse, H., Mensah, F. & Brown, S. J. Intergenerational impacts of family violence - Mothers and children in a large prospective pregnancy cohort study. EClinicalMedicine 15, 51–61. https://doi.org/10.1016/j.eclinm.2019.08.008 (2019).
Meyer, S., Reeves, E. & Fitz-Gibbon, K. The intergenerational transmission of family violence: Mothers’ perceptions of children’s experiences and use of violence in the home. Child Fam. Soc. Work 26, 476–484. https://doi.org/10.1111/cfs.12830 (2021).
Hughes, K. et al. The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet. Public. Health. 2, e356–e366. https://doi.org/10.1016/S2468-2667(17)30118-4 (2017).
Eide, G. E. Attributable fractions for partitioning risk and evaluating disease prevention: A practical guide. Clin. Respir. J. 2(Suppl 1), 92–103. https://doi.org/10.1111/j.1752-699X.2008.00091.x (2008).
Acknowledgements
The authors are grateful to Measure Demographic Health Survey, ICF International, Rockville, MD, USA, for providing the data for analysis.
Author information
Authors and Affiliations
Contributions
SG: Conceptualization, Methodology, Investigation, Software, Formal analysis, Writing - Original Draft; NR: Writing- Reviewing and Editing; RK: Writing- Reviewing and Editing; AGR: Investigation, Writing- Reviewing and Editing; KYA: Methodology, Software, Validation, Formal analysis, Writing- Reviewing and Editing; PA: Investigation, Writing- Reviewing and Editing; MMH: Writing- Reviewing and Editing; AEA: Writing- Reviewing and Editing; FHA: Writing- Reviewing and Editing; SM: Writing- Reviewing and Editing; ST: Conceptualization, Methodology, Validation, Formal analysis, Writing- Reviewing and Editing, Supervision.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Ethics approval
The NDHS received ethical approval from the Ethical Review Board of Nepal Health Research Council (Reference number: 678, Date: Sep 30, 2021) and the institutional review board of ICF International (Reference number: 180657.0.001.NP.DHS.01, Date: April 28, 2022). All procedures were conducted in accordance with relevant ethical guidelines and regulations, including the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants prior to the interviews.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
About this article
Cite this article
Giri, S., Ross, N., Kornhaber, R. et al. Population-attributable burden of modifiable risk factors for depression and anxiety among reproductive-age women in Nepal. Sci Rep (2026). https://doi.org/10.1038/s41598-026-43908-8
Received:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41598-026-43908-8


