Coping strategies for dealing with gender norms that negatively impact women’s mental health. An evaluation of a group intervention

Introduction. Somatic symptoms with no organic cause are more prevalent among women than among men, with mental health problems generated by gender and social norms mainly being presented by females, to which the health system tends to provide an exclusively medicalised response. It is possible to implement group interventions that address the consequences of divergent socialisation hinging on gender as regards mental health, with these efforts having a positive impact on perceptions of well-being. The aim of this paper is to assess the impact of socio-educational groups on the participants, using a qualitative methodology. Methodology. We Resumen

Introduction.Somatic symptoms with no organic cause are more prevalent among women than among men, with mental health problems generated by gender and social norms mainly being presented by females, to which the health system tends to provide an exclusively medicalised response.It is possible to implement group interventions that address the consequences of divergent socialisation hinging on gender as regards mental health, with these efforts having a positive impact on perceptions of well-being.The aim of this paper is to assess the impact of socio-educational groups on the participants, using a qualitative methodology.Methodology.We

Resumen
Introducción.Los síntomas somáticos sin causa orgánica están más presentes en las mujeres que en los hombres.El género y las normas sociales están relacionados con los problemas de salud mental que presentan las mujeres.El sistema sanitario tiende a dar una respuesta exclusivamente medicalizada.Es posible llevar a cabo intervenciones grupales que aborden las consecuencias de la socialización diferencial de género en la salud mental, con un impacto positivo en el bienestar percibido.El objetivo de este trabajo es evaluar el impacto de los grupos socioeducativos en las participantes utilizando metodología cualitativa.Metodología.Realizamos diez entrevistas conducted ten semi-structured interviews with participants in the socio-educational groups.Sample selection was intentional, selecting ten participants on the basis of the following variables: age, level of education, marital status, employment status, income level, and the size of the municipality in which they resided.This theoretical sampling technique allowed us to guarantee the heterogeneity of the participants and their discourse.To analyse the information, we applied a phenomenological and critical approach, and conducted a process of thematic analysis.Results.Well-being is the main theme that emerges from the analysis of the information, grouping together different sub-themes and properties.In the female participants discourse we noted that socio-educational groups helped them approach their lives differently, allowing them to feel better on the personal and relational levels.The coping mechanisms observed included problem-focused (questioning, gender awareness, acting on the problem, self-determination, social relations and integration into the labour market) and emotion-focused strategies (relativisation, acceptance and living in the present, relaxation techniques and emotional expression).Discussion.This study contributes to an understanding of how socio-educational groups offered a good strategy to improve participants' mental health and perceived wellbeing by applying group work with a gender perspective.They provided a forum in which the participants became gender-aware, leading them to reconsider themselves and their lives, find new explanations for their experiences, and realise their ability to develop their creativity in the face of guilt and fear, allowing them to pursue new life projects.Conclusions.The results are consistent with the literature, which indicates the existence of gender norms adversely affecting participants' mental health problems.These problems could be reduced through work undertaken in socio-educational groups that enables them to develop new coping strategies.The implications for social policies include evaluating the potential of incorporating this type of strategy into the portfolio of public health services, as well as assessing the relevance of creating and carrying out socio-educational groups with men.With a view to the future, it would be valuable to establish qualitative measures over time to observe any changes in the participants' discourse and experiences.Keywords: women; gender; mental health; qualitative analysis; group work semiestructuradas a las participantes en los grupos socioeducativos.La selección de la muestra fue intencional, seleccionando a diez participantes en función de las siguientes variables: edad, nivel de estudios, estado civil, situación laboral, nivel de renta y tamaño del municipio de residencia.Esta técnica de muestreo teórico nos permite garantizar la heterogeneidad de participantes y discursos.Para analizar la información, aplicamos un enfoque fenomenológico y crítico, y realizamos un proceso de análisis temático.Resultados.El bienestar emerge como tema principal del análisis de la información, agrupando diferentes subtemas y propiedades.En el discurso de las participantes observamos que los grupos socioeducativos les ayudaron a enfocar sus vidas de forma diferente, permitiéndoles sentirse mejor a nivel personal y relacional.Los mecanismos de afrontamiento observados incluían estrategias centradas en los problemas -cuestionamiento, conciencia de género, actuación sobre el problema, autodeterminación, relaciones sociales e integración en el mercado laboral-y estrategias centradas en las emociones -relativización, aceptación y vivencia del presente, técnicas de relajación y expresión emocional-.Discusión.Este estudio contribuye a comprender cómo los grupos socioeducativos son una buena estrategia para mejorar la salud mental y el bienestar percibido de las participantes, aplicando el trabajo grupal con perspectiva de género.Proporcionaron un espacio donde las participantes tomaron conciencia de género, llevándolas a reconsiderarse a sí mismas y a sus vidas, encontrando nuevas explicaciones para sus experiencias, y la posibilidad de desarrollar su creatividad frente a la culpa y el miedo, permitiéndoles desarrollar nuevos proyectos vitales.Conclusiones.Los resultados son coherentes con la literatura que indica la existencia de mandatos de género relacionados con los problemas de salud mental de las mujeres.Estos problemas podrían reducirse mediante el trabajo realizado en grupos socioeducativos que les permite desarrollar nuevas estrategias de afrontamiento.Las implicaciones para las políticas sociales pasan por evaluar el potencial de incorporar este tipo de estrategias en la cartera de servicios de salud pública, así como valorar la pertinencia de realizar grupos socioeducativos con hombres.De cara al futuro, sería interesante recoger información cualitativa a lo largo del tiempo para observar posibles cambios en los discursos y experiencias de las participantes.

INTRODUCTION
For years now, many Primary Health Care (PHC) consultations have involved patients presenting with somatic symptoms of no identifiable organic cause (SSNIOC), or psychosocial problems with non-specific symptoms (Bacigulpe et al., 2020;World Health Organization [WHO], 2015).Recent data indicate that anxiety and depression are the most frequent health problems identified in women (Bacigulpe et al., 2020).A total of 9.1% of the women surveyed reported suffering from chronic anxiety, compared to 4.3% of men.In relation to depression, 9.2% of women suffer from it, compared to 4% of men (Ministerio de Sanidad, Consumo y Bienestar Social, 2018).In both cases, the figures were higher for women than for men, supporting one of the most well established findings in psychiatric epidemiology: common mental health problems affect women (14.1%) more than men (7.2%) (Bacigulpe et al., 2020;Ministerio de Sanidad, Consumo y Bienestar Social, 2018;WHO, 2002).The work of Bones et al. (2010) points out that the prevalence of mental health problems is higher among women (24.6%) than among men (14.7%).Furthermore, a higher prevalence of mental health problems has been observed among those on sick leave (43.3% of men and 47% of women) and unemployed people (27.9% of men and 30.2% of women), conditions that disproportionately affect women (Comisión Europea, 2017).
The prevalence of SSNIOCs is clearly higher among women (Casado & Botello, 2018;Kroenke & Spitzer, 1998), with these being defined as «of poorly known aetiology, difficult and overlapping diagnosis, which are chronic, and for which no medical treatment has proven to be effective» (Velasco et al., 2006, p. 318).
The gender literature points to gender norms and social norms as two factors that provoke more illnesses among women (Borges & Waitzkin, 1995;Cislaghi & Heise, 2020;Vinagre-González et al., 2020).The ailments that many women present in the health system, and which can manifest as SSNIOC, sometimes correspond to gender-linked mental health problems, which have come to be known as the other mental health (Rodríguez, 1990): «suffering that cannot be deciphered and expressed in words, which manifests as suffering in the mind or body, presenting somatic and mood symptoms without any demonstrable organic cause» (Velasco et al., 2007, p. 112).
Complaints and mental health problems reported by women tend to receive medicalised responses, leading to «pathologising» situations of daily life (Bacigulpe et al., 2020;Markez et al., 2004;Matud et al., 2017;Secades et al., 2003).The consumption of prescribed psychotropic drugs is 1.75 times https://doi.org/10.14198/ALTERN.24318 Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention higher among women than men (Ministerio de Sanidad, Consumo y Bienestar Social, 2018).
A purely biomedical approach to these demands is inadequate, since its theory of health does not include those aspects of human functioning that probably determine symptomatology.Consequently, physicians tend to consider emotional reactions as pathological.They respond by medicalising them and fail to seek the root causes underlying the symptoms.Women are perceived to be «the problem» because they seem weak, dependent, emotionally uncontrollable and in need of help to face their afflictions (Burin et al., 1990;Casado & Botello, 2018;Velasco et al., 2006).Contributing to this situation are, among others, the working conditions of medical professionals (e.g., a lack of time to give patients proper explanations), perceived pressure at work, and the development of a punitive model, where the level of uncertainty that clinicians can handle is not considered, and penalised (Coll-Benejam et al., 2018;Molina et al., 2003).
There are alternative theories classified by Velasco et al. (2006) in the contextual and subjectivity arena (biopsychosocial, psychoanalytical), as well as the feminist arena (biomedical-socialist-biopsychosocial-ecosocial-psychoanalytical).These theories broaden our capacity to understand the problem by including contextual, gender and subjective factors associated with the health/illness problem, and producing models with greater potential for comprehensive care (Velasco et al., 2006).For its part, the WHO has highlighted the importance of psychosocial and environmental factors that condition individual and community mental health, and has defined the protective and risk factors that need to be addressed through a mental health promotion strategy (Organización Mundial de la Salud, 2013, 20221 ; WHO, 2005WHO, , 2013)).Some of these factors are the burdens of a traditional role (dependence, isolation and a lack of social networks, caregiving responsibilities, and conflicts with partners), and transgressing those roles, gender syncretism, and a lack of public policies aimed at tackling these situations (Borges & Waitzkin, 1995;Vinagre-González et al., 2020).
In response to clinical evidence regarding the health of women presenting with SSNIOC, in 2011 the Andalusian Public Health System (APHS) designed socio-educational groups (Grupos Socioeducativos en Atención Primaria [Primary Care Socio-educational Groups]) (GRUSE) (Table 1) applied to PHC.The strategy was designed following a health resource approach with a gender perspective to promote women' s mental health.It is based on the salutogenic model (Antonovsky, 1987).This model is viable for Health Promotion research and practice by focusing on problem solving and finding solutions (Antonovsky, 1996).In addition, it identifies General Resilience Resources that help people move in the direction of positive health.Finally, it incorporates a global and pervasive sense in individuals, groups, populations or systems, that serves as the overall mechanism or capacity for this process: the sense of coherence (SOC) (comprehensibility, manageability and meaningfulness of life events) (Lindstrom & Eriksson, 2006).The aim of socio-educational groups, included in the strategy and led by social work professionals, is to strengthen and develop the participants' personal abilities, promote gender awareness, and identify community resources.Working on health resources implies addressing those factors that have positive effects on health (Morgan et al., 2010).The goal of these GRUSE groups is to promote emotional well-being and facilitate healthier coping in daily life.To this end, they work by stimulating personal resources and encouraging the use of community resources.
Working on care management, facilitating the establishment of networks, and promoting community participation through socio-educational groups contributes to improving women' s self-esteem, autonomy, decision-making capacity and self-care (Burton et al., 2010;Hathaway et al., 2008;McGrady et al., 2009;Moreno-Peral et al., 2020;Velasco, 2009).In addition, sharing experiences and gender awareness in small groups is essential for women, because they learn from each other, move out of their private spheres, "politicise" their daily experiences and identify themselves in terms of gender (Casado, 2018;Velasco et al., 2007;Velasco, 2009).Studies on the effectiveness of group interventions focused on health issues produce better results when they address issues experienced by the participants (Burton et al., 2010;McGrady et al., 2009).Since its inception, social work has valued group work as a methodology for intervention (Andrews, 2001;Schwartz, 1986).Konopka (1968) offers one of the classic definitions of group social work, referring to «a method of social work that helps individuals, through intentional team experiences, to improve their social functioning and to cope more effectively with their personal, group or community problems» (p.50).For its part, qualitative methodology is considered appropriate for capturing how gender norms affect people' s lives and how they change over time (Cislaghi & Heise, 2020).https://doi.org/10.14198/ALTERN.24318 Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention Thus, taking into account all of the above, the objective of this paper is to assess the impact of GRUSE on the participants, using a qualitative methodology.

Design
We designed a quasi-experimental study using a mixed methodology to evaluate the impact of the GRUSE strategy on participants' mental health.For quantitative evaluation, participants completed standardised questionnaires to assess their sociodemographic situations, community assets, time use, quality of life, assertiveness and emotional regulation, symptoms of anxiety and depression, self-esteem, and coping with adversity.They were administered to the experimental and comparison groups at four different moments in time.
To carry out qualitative evaluation, we conducted semi-structured interviews with the participants, and focus groups with the professionals (social work, medicine and nursing) linked to GRUSE (Iáñez-Domínguez et al., 2019).The results of the qualitative analysis are presented here.
For a better understanding of the work presented, the design of the GRUSE strategy is briefly described (see Table 1).The design and implementation of the strategy takes into account the principles of the International Association for Social Work with Groups' (IASWG) Standards for the Practice of Social Work with Groups for group development2 .This can be seen in the 2011 (Mateo et al., 2011) edition of the GRUSE guide: values and knowledge relevant to the practice of group work, the necessary knowledge and the main tasks and skills that the social worker should have in each phase of the group work practice, identifying the aspirations and needs of the group' s members, knowing the structure of the group and its impact on its functioning, knowing the actions to be carried out in each phase of the group, and the ethical considerations for the practice of social work with groups.

Participants
We interviewed ten women who manifested mental health problems and attended PHC facilities (Table 2).To select the sample, we applied intentional sampling to guarantee the heterogeneity of the participants and their discourse.Respondents were selected from the experimental group, made up of 114 women, from the aforementioned study (see Table 1) (Iáñez-Domínguez et al., 2019) considering: age, level of education, marital status, employment status, income level and the size of the municipality in which they resided.Six of the eight provinces of (Andalusia, Spain) and different geographical areas (rural, urban) were represented in the sample.The age of the women ranged from 32 to 58, with an average age of 48.4.60% of the women had primary-level education and were separated or divorced.80% had children, 50% worked at home without pay, and 2% worked without a contract.

Data collection instrument
We conducted semi-structured interviews (Smith, 1995) following a script that included 4 groups of questions: the perceived impact of GRUSE on their lives and environments; how they evaluated these changes; satisfaction with their participation; and strengths and ways to improve the GRUSE.https://doi.org/10.14198/ALTERN.24318 Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention

Procedure
The social workers who had worked with the participants contacted them.After agreeing to be interviewed, a meeting was arranged by telephone.During the interview, the participants signed the informed consent form and were assured of the confidentiality of the information.The study was approved by the Ethics Committee at the Hospital Universitario Juan Ramón Jiménez (Huelva, Andalusia, Spain).Therefore, this article uses pseudonyms.Three members of the research team with experience in the technique conducted the interviews, which took place at the PHC centre of each participant, and each encounter lasted approximately 90 minutes.The interviews took place from June to November 2017 in the provinces of Cadiz, Seville, Malaga and Jaen (Andalusia).The information was audio-recorded and transcribed.

Data Analysis
The core data analysis encompassed specific narratives and themes, as well as the search for their possible meanings (Creswell, 2012;Mertens, 2005).We conducted a thematic analysis (TA), an empirical approach that allows us to methodologically control the analysis of the texts.We also adopted an experiential orientation, focusing on what the participants think, feel and do.This is based on the idea that language reflects reality (Braun & Clarke, 2006).
In this study, the analysis carried out was fundamentally interpretative.The TA encompassed six phases: familiarisation with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report (Braun & Clarke, 2006).
Atlas.ti 8.0 software was used to support the analysis.The interviews took place in Spanish, and the researchers subsequently translated the most significant sections of the interviews when drafting this article.
The analysis was a recursive process.Subsequently, we drew constant comparisons between codes, themes and their relationships.In a cyclical manner, we checked the information obtained against the initial information to confirm its definition.The study codes distinguish between coping strategies that focus on the problem vs. ones that focus on emotions.
The study followed the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Tong et al., 2007).To ensure validity and reliability, we applied different triangulation processes (Lincoln & Guba, 1985): the triangulation of methodology and methods, as shown in the quantitative results presented in the paper (Palacios-Gálvez et al., 2021); the triangulation of data, as shown in the results of the focus groups conducted with the professionals Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention working with the GRUSE participants (Iáñez-Domínguez et al., 2021); and triangulation with experts, facilitated by the fact that two members of the research team analysed the information.COREQ advises researchers to recognise their identity, for example, their occupation, gender, and experience to reduce bias and improve the credibility of the findings.The analysis was performed by a female social psychologist and a male social worker and anthropologist, both university teaching staff in Andalusia (Spain).The social psychologist was a middle-aged Spaniard with training in gender and feminism.The anthropologist was a middle-aged Spaniard social worker active in the defence of Human Rights, particularly in vulnerable contexts and/or groups.They worked in a coordinated manner, though independently, comparing all their analyses and reaching agreements on the categories extracted, as well as on their interpretations.

RESULTS
Well-being is the main theme emanating from the analysis of the information, grouping together the sub-themes and properties.Below are narratives that show how GRUSE helped participants deploy new coping strategies that repositioned them with respect to themselves, other people and life (Table 3).Gender awareness.This involves participants' recognising the impact of gender socialisation on their lives.Narratives pointed to the importance of sharing life' s difficulties with peers, a tool that helped in acquiring this awareness and achieving gender identification; recognising the differences between theory and practice; and identifying the fear of the unknown.Gender syncretism is also present in the narratives: they knew they could act differently, as a «modern woman», but their daily routine was still governed by the norms of the «traditional woman».
A lot of things are imposed by society, and we are taught those things as we grow up and, then, when things are explained to you, you realise that no, not at all, things don't have to be that way because they've been instilled in you, somehow… Things that you impose on yourself, for example, you're young, «when are you going to get married?»Once you're married «when are you going to have children?», that they impose things that maybe you… But, then you start analysing yourself and, why.There' s a lot of prejudice… «well, that' s true, you're right».(Participant 2, Cádiz, age 51) Being a bit braver, we are often scared, and fears stop you from taking a step forward, right?So, trying, it' s not easy, because it isn't easy, because you're built a certain way and you've been acting the same way for many years, and now all of a sudden you know the theory, but in practice it' s more complicated.
(Participant 3, Málaga, age 42) Acting on the problem.This refers to the experience of moving from rumination to action, leaving emotional problems behind.It makes it possible to take responsibility for life circumstances and to make one' s own decisions.
I get nowhere by turning things over in my head, and they teach you that here too, it serves no purpose.What has to happen will happen, try not to worry without doing anything, and that' s part of the issues that are also addressed here in the groups.(Participant 3, Málaga, age 42) Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention Self-determination.This is identified when they experience having a voice and the possibility of choice in life by acting according to their own judgement, not to please others.They presented themselves as causal agents of their own lives.Steps towards self-determination occurred when fear and guilt became secondary, and they started to meet their own needs.mental and physical health by ending her relationship.Interviewees perceive the influence of marriage on health to be fluid and shifting (Reed, 2004).
Being alone together, and without a television, I raise a lot of subjects with him, since I talk a lot.I have lots of conversations, and it' s like he empties himself, a lot of issues come out related to emotions, that he couldn't talk about before and that we talk about now.Insertion in the labour market.This alludes to the implications of working outside the home: economic independence, to choose whether or not to remain with their partners, and mental activity.This situation gave them a power that they had lacked.Leisure.The participants talked about their involvement in different leisure activities, either individually and/or in groups.
the day to day, cleaning, going out, I do activities, I go to the gym, I go for walks, I go to the theatre with my friends, more or less… (Participant 7, Alcalá de Guadaira, age 56) I'm not a member of Caritas, but I help out, I do participate and, in fact, last year we set up a sewing workshop, because I suggested it.I said «look, why don't we do that instead» because here we organise a charity raffle every holiday, and we do a lot of handicrafts and sewing… and then I said «Hey, why don't we do that?Why don't we take our machines from home and, instead of doing our sewing at home individually, it would be good to get together».And yes, last year I participated, we spent 8 or 9 months and yes… before I did that, we would all be doing it individually in our homes.(Participant 1, Sabiote, age 52) https://doi.org/10.14198/ALTERN.24318 Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention

Coping strategies focused on the emotion
Analysis identified four properties of the subjects' coping strategies focused on emotion: relativising problems, accepting and living in the present, relaxation techniques, and emotional expression.
Relativising problems.This occurs when experiences are diversified, and a broader reality is taken as a reference point, transcending the domestic and daily environment, allowing them to start to feel a certain detachment from gender norms.
After being in this, everything found its own place.Accepting and living the present.This refers to the acceptance of their limitations in terms of solving problems and to a new approach, learning to live in the moment, which positively impacts their health.
I'm living life a bit more intensely… you have to live life in the here and now.I was living in the moment, but thinking about what was going to happen… and that' s very bad for the mind.(Participant 6, Dos Hermanas, age 41) I accept things more… there are things that I cannot change myself.I'm not going to be able to change them.So, in situations when you used to get angry, well, you try to accept things… you realise that… you have to have a limit, and if the other person realises that, then good, and, if they don't, then that' s their process.(Participant 3, Málaga, age 42) Relaxation techniques.This refers to how GRUSE showed them techniques of relaxation and their benefits to reduce stress.Women tried to apply relaxation techniques to cope with the multiple demands faced by «modern women» and the feeling of not having time to do everything.
When you notice that your stress level is up… I take the time and say «come on, it' s time to relax.»It does become a daily practice.(Participant 3, Málaga, age 42) Emotional expression.This strategy allows them to express their thoughts and feelings, providing a way to control them.In the case of the participants, the importance is in the fact that it involves the expression of feelings and thoughts opposed to gender norms, which made them feel limited or damaged.

DISCUSSION
This study has made it possible to assess part of the impact of GRUSE on the participants through semi-structured interviews.The participants interviewed show that this strategy facilitates the acquisition of new coping strategies to deal with the problems of daily life by applying a gender perspective and higher perceived well-being.Well-being can be described as the positive appraisal of life and feeling good.It includes the presence of positive emotions and moods, the absence of negative emotions, satisfaction with life, fulfilment and positive functioning (Diener, 2000;Eid & Larsen, 2008;Frey & Stutzer, 2002).Economic well-being, social well-being, development and activity, emotional well-being, psychological well-being, satisfaction with life, participation in activities and work are some aspects included in well-being (Diener, 2000;Keyes, 2002).These aspects were present in the participants' narratives following their participation in GRUSE, which entailed observing both problem-focused and emotion-focused coping strategies.The former serves to change the relationship between people and their situations through mechanisms such as Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention problem solving, decision-making, and direct action (Folkman & Lazarus, 1980).Consistent with the literature (Burton et al., 2010;Hathaway et al., 2008;McGrady et al., 2009;Velasco, 2009), this study has identified that strategies such as questioning, gender awareness, acting on the problem, self-determination, social relations, labour market insertion and leisure lead to improvements in the interviewees' perceived well-being.Emotion-focused strategies aim to manage emotions; for example, by modifying the meaning of an outcome (Folkman & Lazarus, 1980).Participants have shown that relativising problems, accepting and living in the present, the application of relaxation techniques, and emotional expression have a positive impact on their well-being (Moreno-Peral et al., 2020).Expressing one' s emotions and own ideas implies being aware of and attending to one' s own needs, thoughts and knowledge, so that they are no longer neglected beings.It involves a closer connection with oneself and not adhering to the notion of beating oneself up, or, as on participant put it: «being stabbed seven times inside» (Participant 1, Sabiote, 52 years old).Participants learn how to cope with mental health problems linked to gender: «you feel great» (Participant 1, Sabiote, 52 years old).In this regard, Casado & Botello (2018, p. 110) indicate: … taking into account that women tend to be inside, in the private sphere, they are socialised to be silent, and a gender conflict arises: women have historically been denied the word, we have been denied the ability to express our complaints with words, not only because the word is the power of men, but because many of our discomforts have to do with the fulfilment of a gender mandate that we have not dared to question.In this context the body is very wise, it tries to speak, it cries out through symptoms.
Encouraging the practice of questioning, within the GRUSE groups, is essential to build a modern subjectivity, allowing them to distance themselves from faith and what has been naturalised, opening up possibilities to be creative and to transform their identity.However, as Cislaghi & Heise (2020) point out, for women this situation implies not aligning themselves with the norm, which can lead to conflict within, but also with others.
Strategies focused on the problem -such as acting on the problem or self-determination, and those focused on the emotion -such as relativising, accepting and living in the present -allow them to recognise their life and the present.They entail assuming one' s own agency in solving problems and feeling able to face them through concrete actions.They focus on recognising one' s own needs, interests, and their development.The participants step away from certain gender norms, internalised through gender-differential socialisation, to begin to develop a sense of self-esteem that is distinguished from the https://doi.org/10.14198/ALTERN.24318Antonio Iáñez-Domínguez, Elena Morales-Marente y Marisol Palacios-Gálvez valuations of others (Casado & Botello, 2018;Lagarde, 2005;Moreno-Peral et al., 2020;Ryan & Deci, 2017).
GRUSE, as a group strategy, came to represent a space in which participants became gender-aware.It led them to reformulate themselves and their lives, finding new explanations for their experiences, and the possibility of developing their creativity in the face of guilt and fear, allowing them to pursue new life projects.It represented a start of being-for-themselves (Lagarde, 2005).This transformation was not necessarily accompanied by changes in the contexts surrounding them, so it was not always welcomed or supported.New contradictions then emerged; this is gender syncretism.This contradiction, when recognised and understood, can be used as a resource and a positive key to identity (Cislaghi & Heise, 2020;Lagarde, 2005).At the relational level, it can lead to well-being derived from a change by establishing new relationships, or modifying or ending existing ones.It implies analysing the impact that interactions with other people have on one' s well-being and making decisions about them.It involves thinking about one' s own well-being, without harming other people, and ceasing to identify solitude with desolation.Some participants began to combine care and housework with paid work outside the home.They presented role overload, but also the beginning of a life project of their own that was personally and professionally enriching.In addition, earning their own salary implied a certain financial independence, an essential step towards personal autonomy (Coria, 2015;Lagarde, 2005).

CONCLUSIONS
To summarise, the new strategies deployed and facilitated through their participation in the GRUSE groups showed that the participants embarked on a journey in which they ceased to be guided by being-for-others and denaturalising gender norms, and took their first steps towards being-for-themselves (Lagarde, 2005).As a result, they expressed higher perceived well-being and the deployment of new coping strategies to deal with the problems of everyday life.
This study offers various contributions.On the one hand, the findings are consistent with the literature: they reveal the existence of gender norms related to the participants' mental health problems (Vinagre-González et al., 2020).The participants were able to reduce these problems through the type of group work undertaken by the GRUSE.Moreover, this group intervention carried out at Andalusia PHC centres enabled women to develop new coping strategies and identify their personal assets, and those they bring to the community, resulting in improved perceived well-being.Group work facilitated participants' https://doi.org/10.14198/ALTERN.24318 Coping strategies for dealing with gender norms that negatively impact women' s mental health.An evaluation of a group intervention identification, peer learning, and mutual recognition of their gender condition.In addition, it implied a non-medicalised approach to mental health problems that was more closely linked to living conditions than to biological causes.The strategy also allowed participants to politicise their life experiences and understand them within the social context in which they unfolded.
As a limitation to the strategy, the intervention focused on the individual and did not aim to change the context in which gender norms are generated.The scope is, thus, limited, since the socio-political context that generates mental health problems linked to gender remained unchanged.Other limitations of this study are the impossibility of generalising the results, and the fact that the assessment was carried out at a specific moment in time.Therefore, no conclusions can be drawn regarding the permanence of coping strategies over time.
Two of the implications of this work for social policies are the assessment of the suitability of incorporating this type of strategy -based on non-medicalising health resources developed through group work, and with a gender perspective -into the portfolio of public health services; as well as assessing the relevance of carrying out GRUSE with men, in a way that addresses the gender mandates in which they are socialised and which influence their mental health.Thirdly, linking the implications for public policies and for social work professionals, we would suggest providing specific training in the processes behind the construction of femininity, and the influence of gender and mental health on the social and health care system.
Regarding future lines of research, it would be of interest to include different levels of intervention and prolong them over time, as suggested by Velasco et al. (2007).Likewise, it would be valuable to establish qualitative measurements over time to explore any changes in the participants' feedback and experiences.

FUNDING SOURCES
This work was funded through the Call for grants for Biomedical and Health Sciences Research, Development and Innovation for 2016, issued by the Secretaría General de Investigación, Desarrollo e Innovación en Salud [General Secretariat of Research, Development and Innovation in Health], of the Consejería de Salud de la Junta de Andalucía [Ministry of Health of the Regional Government of Andalusia], which grants subsidies for the financing of Research.In this case it funded the project «Análisis del impacto de los Grupos Socioeducativos de Atención Primaria (GRUSE) en la salud mental de las mujeres y en el Sistema Sanitario Público de Andalucía» [Analysis of the

I
started working, and when I saw myself working, then I thought «no more».So, I felt very strong when I felt financially independent… when you're financially independent you can move on.If I had been financially independent, I wouldn't have spent 30 years with this person… (Participant 4, Málaga, age 58) I exercise my mind much more.It forces me to take care of other things and not think about how bad I've been or about what may happen… (Participant 6, Dos Hermanas, age 41)

Table 2 .
Profiles of the interviewees

Table 3 .
Themes obtained from the analysis Source: own elaboration.https://doi.org/10.14198/ALTERN.24318 «Well, if I have the choice» … That' s enough.Not hurting anyone… It' s no longer the same, it' s your own outlook, really, if you truly want that… and if you want it, then you do it, and if you don't want it, then never mind.(Participant 2, Cádiz, age 51) I asked the psychiatrist to tell me, I wanted to stop, so I could say, let' s see, you look bad, but I felt able to face this, I said «No, I have to face it without pills, because reality is reality, without pills,» because I didn't want to be sleeping all day, no, no, no.I don't want that.I want to be out and about, and I want to have fun.When I'm out and I'm with my friends, I feel really good.Where I feel bad is at home.(Participant 4, Málaga, age 58) That brings you closer.(Participant 1, Sabiote, age 52) I wasn't aware of the toxic relationship I was in until I started to open my eyes… And I decided to leave my home, and found a place to rent.I left.I made a sudden decision, and since then I've put on weight and gained in mental health… Yes, it is a burden to carry, a weight on your shoulders… a lot of emotional weight and guilt and everything.The first person is my ex-husband, who was the biggest weight to carry, and I broke free, I broke free.(Participant 6, Dos Hermanas, age 41) Things aren't as important as I used to think before, and… if I can't do this, I relax and do it tomorrow.(Participant 8, Sabiote, age 44) I became more relaxed by letting things go a little, being more … looking at myself more… not giving as much importance to things… tidying the house, which is normal… it doesn't matter if you leave the dishes for two days.(Participant 7, Alcalá de Guadaíra, age 56) https://doi.org/10.14198/ALTERN.24318AntonioIáñez-Domínguez,Elena Morales-Marente y Marisol Palacios-GálvezThe best thing is to express what you think, freely, it' s the best thing there is.On top of that, it makes you feel great, because it no longer hurts inside to say «I'm telling you something, or I'm listening to something that is stabbing me seven times inside».(Participant 1, Sabiote, age 52) a problem is spinning in your head, in my case at least, I get a really big headache.Of course, the way you feel emotionally is closely linked to the pain.So, it doesn't surprise me that when people put things that they're being taught into practice, pain and stuff disappear.(Participant9, Dos Hermanas, age 56) A salvation… Yes, yes, for me it was [referring to the group]… and after the group.The social worker told me «you have to study something too» because I haven't studied because I haven't been able to study either.«Youhave to study», so I also did a course to become an assistant, I did that too.(Participant 4, Málaga, age 58) When