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. 2023 May 5;60(2):178–184. doi: 10.29399/npa.28170

Systematic Review and Meta-analysis of Depressive Symptom Severity of Employed and Unemployed Women in Turkey

Eylem Yılmaz 1,✉, Enes Uyar 2, Fatma Yıldız 3, Ferhan Dereboy 4
PMCID: PMC10242285  PMID: 37287558

Abstract

Introduction:

Depression which is one of the mood disorders, causes a decrease in the work that requires participation during the day, and affects interpersonal relationships. It is known to be a fairly common mental disorder, especially among women. The aim of this systematic review is to investigate the effect of women’s employment status on the severity of depressive symptoms in Turkey.

Method:

We searched the databases of YÖK Thesis Center, ULAKBIM, Web of Science and Scopus to detect those studies aiming to compare the employed women with housewives in terms of the depressive symptoms measured with validated self-report scales in Turkish.

Results:

Of the 283 studies reported in Turkish or English as an article or dissertation, 10 met the inclusion criteria for meta-analysis. The random effects meta-analysis conducted with R 4.0.1, meta and metafor package revealed a slight and statistically nonsignificant effect of the employment status on women’s depressive scores (g=-0.13 95% Confidence Interval [CI] [-0.41, 0.14]). Heterogeneity between studies was estimated at a high level (I2=90.3% 95% CI [84.3%, 94%]). Results of the meta-regression analyses implied that neither the sample size (R2=0.00%) nor the publication year (R2=5.58%) were among the main sources the heterogeneity. The findings suggest that the risk of having depressive symptoms is nearly same in employed women as in housewives.

Discussion:

Hence, employment status is unlikely to be among the main factors leading to relatively higher prevalence of depression among women.

Keywords: Depression, employed women, Turkey, unemployed women

INTRODUCTION

Depression is one of the most common psychological disorders that affects interpersonal relationships and decreases the efficiency in the work done, where a decrease is seen in the work that needs to be attended during the day (1,2). In a large-scale study, the lifetime prevalence of depression was found to be 16.2% in the United States (3). A study conducted in Turkey, Binbay et al. (2014) reported that the prevalence of depression in women in Turkey was between 7.3% and 42.2% in line with prevalence findings obtained from different cities (4). The reason for such a wide prevalence range is that the study samples were composed of participants in different life stages such as adolescence, menopause and pregnancy.

Many factors play a role in the development of depression including: genetic predisposition, low level of education, being a woman, having weak social networks, and other disorders that affect functionality (5). As in many psychopathologies, the gender factor is also important in depression. Differences in sex hormones may cause cognition, emotion and behavioral differences between the sexes (6). Daily life imposes different roles on people and the tasks and behavioral patterns associated with these roles. One of these roles is to be employed or unemployed. While unemployed women are busy with household and family chores, employed women may also face some problems related to business life. Participation in business life is an increasing trend among women over the years. Although this life has some positive effects on women such as economic independence and socialization, it may also have negative effects. It is possible to consider various situations such as harassment, working for low wages, and gender discrimination among these problems (7,8). The reasons mentioned indicate that both groups are faced with different sources of stress and that perceived stress can have negative consequences on mental health, regardless of working status.

Highlights

  • Depression symptoms of women in Turkey were evaluated according to their employment status.

  • This study is the first meta-analysis study on this subject.

  • The difference between the depression symptoms of the two groups was calculated as g=-0.13 95% CI [-0.41, 0.14].

  • The confidence interval of the summary effect crossed zero, the difference was small in effect size and insignificant.

  • Employment status of women has a small and insignificant effect on depression scores.

According to the Turkish Statistical Institute (TurkStat) 2020 data, over 30 million people participate in the labor force, while 67.6% of men and 30.8% of women participating in the labor force. In other words, while two-thirds of men participate in the workforce, meanwhile this rate is less than one-third for women (9). The reasons why women are less involved in business life than men include various factors such as education level, child care, gender discrimination and cultural factors (10). In addition, according to 2018 TurkStat data, while the annual average regular gross wage earning for women is 43,866 TL, it is 47,515 TL for men (11). Although they do almost the same jobs and work at the same time, this 10% wage difference between the sexes is remarkable. In summary, women are less involved in business life than men. However, employed women work for lower wages than men. All these indicate that employed women can be affected by the stress in business life.

In the international literature, there are studies focusing on the difference in the severity of depressive symptoms between employed and unemployed women. While some studies dealing with this issue report that there is no difference between the two groups in terms of depressive symptom severity (12,13), some studies report that unemployed women experience more severe depressive symptoms (14–18), while some studies reported that employed women experience more severe depressive symptoms (19). In a review study examining the relationship between women’s and men’s employment status, marital status, having children, perceived control levels and mental health measures, with a total sample of 3543 people were compared; it was determined that housewives in two of the three studies and unemployed women in one had more mental problems (20).

The fact that the aforementioned review covers past studies and is weak in terms of reflecting the current situation reveals the necessity of a new systematic review study. When the literature was examined, no study was found in which the findings of different studies conducted in Turkey were compiled. In order to eliminate this gap, it was thought that a systematic review and meta-analysis should be carried out on the effect of being involved in business life on mental health among women living in Turkey.

METHOD

Before the relevant literature review process, the project protocol was saved in the PROSPERO archive (registration number: CRD4202123157). The systematic review study was carried out with the guidance of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (21). The literature search was carried out in the YÖK National Thesis Center with the keywords “çalışan ve çalışmayan kadın” (employed and unemployed woman) and ULAKBIM databases with the keywords “depression” and “çalışan ve çalışmayan kadın” (employed and unemployed woman). In order to be able to access previously conducted studies both in our country and abroad, the language of the publication must be either English or Turkish with the keywords “depression AND employed women AND unemployed women”. Scopus and Web of Science databases were scanned and the suitability of the keywords was checked from the Medical Subject Headings (MeSH) database. Since there was no review study on this subject in our country, no time limit was determined and all studies from the past until December 2020, when the screening was carried out, were examined. Three researchers scanned the selected databases with the specified keywords. After the elimination based on the article titles and summary readings, the full text reading of the remaining studies was undertaken by two researchers, considering the inclusion and exclusion criteria. The agreement in the inclusion decision between the two researchers was calculated to be high (κ=0.85). In case of disagreement, an inclusion or exclusion decision was made according to the evaluation of the third researcher.

Selection of Studies

As criteria for inclusion of studies, the following were taken into consideration: i) whether the study was a research article or thesis study written in Turkish or English, ii) whether it was made in Turkey, iii) whether the study sample included both employed and unemployed women groups, iv) whether the measurement tools used to evaluate the severity of depressive symptoms consisted of self-report scales with proven validity and reliability in our country, and v) whether the sample of the study was taken from a non-clinical population. The reason for excluding studies involving clinical samples is that other pathological processes other than working status may play a role in the severity of depressive symptoms in individuals diagnosed with depressive disorder.

Studies that did not meet the following criteria were not excluded: i) the studies were conducted in countries other than Turkey, ii) the language of publication was in languages other than Turkish or English, iii) the publication was a review article, book chapter or conference paper, iv) the study sample did not reflect both the employed and unemployed female population, v) the assessment tools used to measure the severity of depressive symptoms did not have proven validity and reliability in the Turkish sample or were not self-report scales (e.g. clinician assessment or physical measurements), and vi) the study sample was selected from the clinical population.

The flowchart of the studies included in the meta-analysis, taking into account the determined inclusion and exclusion criteria, is shown in Figure 1.

Figure 1.

Figure 1

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Compilation process of studies examining the difference in depressive symptom severity of employed and unemployed women in Turkey.

Data Analysis

The meta-analysis of the including studies was carried out using the “meta” and “metaphor” packages in the R 4.0.1 program. The g parameter suggested by Hedges (1981) was used to determine the effect sizes and the summary effect of the primary studies (22). The reason for this is that the Cohen d and population effect size may be overestimated in small samples, causing bias (23). While calculating the effect size, unemployed women were determined as the control group, and a positive Hedge g value indicated more severe depressive symptoms in employed women. A random effect model was used in the meta-analysis since it was predicted that the effect of the working status on the severity of depressive symptoms in women in Turkey could be normal distribution around an average rather than a single effect size. In the interpretation of the effect sizes in the g obtained, using the standards suggested by Cohen’s d (1988), g values between 0.20 and 0.49 were interpreted as small, values between 0.50 and 0.79 were interpreted as medium, and values of 0.80 and above were interpreted as large effects (24). The forest plot of the meta-analysis is given in Figure 2. For the heterogeneity assessment, the variance between studies (τ2) was calculated by the REML (restricted maximum likelihood) method, and the 95% confidence interval (CI) was calculated by the Hartnupp-Knapp method. The values of I2, indicating the rate of heterogeneity between studies, are negligible (I2=0–25%), low (I2=26–49%), moderate (I2=50–74%) or high (I2=75–100%), in line with the standards proposed by Higgins et al. (2003) (25). In order to evaluate the possible sources of heterogeneity, meta-regression analysis was performed by re-coding (mean centering) the variables of publication year and sample size according to the mean values.

Figure 2.

Figure 2

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Meta-analysis of the difference in severity of depressive symptoms of employed and unemployed women in Turkey (Forest Chart).

RESULTS

The descriptive characteristics of 10 studies conducted in Turkey that were included in the systematic review of employed and unemployed women are shown in Table 1.

Table 1.

Descriptive characteristics of 10 studies included in the meta-analysis

Author and year of study City where participants live Evaluation tool used Sample size Results
Başkan et al., 2016 Denizli Beck Depression Inventory 301 women (150 employed, 151 unemployed) unemployed >employed p<0.001**
Bilgin, 1990 Adana Beck Depression Inventory 261 women (161 employed, 99 unemployed) unemployed >employed p<0.001**
Çilli et al., 2004 Konya Symptom Checklist (SCL-90) 144 women (76 employed, 68 unemployed) unemployed >employed p>0.05
Gemci, 2017 Istanbul Brief Symptom Invetory 81 women (41 employed, 40 unemployed) unemployed >employed p>0.05
Gözübüyük Bayraktaroğlu, 2010 Istanbul Beck Depression Inventory 200 women (99 employed, 101 unemployed) unemployed >employed p>0.05
Kaya, 2019 throughout Turkey Beck Depression Inventory 407 women (216 employed, 191 unemployed) unemployed >employed p<0.001**
Mavric et al., 2016 Ankara Beck Depression Inventory 200 women (100 employed, 100 unemployed) unemployed >employed p<0.05*
Tetikli Nart, 2019 Istanbul Beck Depression Inventory 262 women (108 employed, 154 unemployed) employed >unemployed p>0.05
Uçak, 2018 Istanbul Beck Depression Inventory 166 women (85 employed, 81 unemployed) unemployed >employed p>0.05
Uluçay, 2018 Antalya The Depression Anxiety and Stress Scale 210 women (105 employed, 105 unemployed) unemployed >employed p>0.05
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*

p<0.05,

**

p<0.001.

The samples of four of the 10 included studies (26–35) were drawn from women living in Istanbul. In the remaining studies, data were collected from women in Ankara, Adana, Antalya, Denizli and Konya. The sample of only one study consisted of women throughout Turkey. In order to measure the severity of depressive symptoms, the Beck Depression Inventory was used in the majority of studies (70%), and the Symptom Checklist (SCL-90) was used in one of the remaining three studies, the Short Symptom Inventory, which is the short form of this scale in one, and the Depression-Anxiety-Stress Scale in one. Scores from only the depression sub-dimension of the scales excluding the Beck Depression Inventory were included in the analysis. Using the effect sizes reported by individual studies, a meta-analysis was conducted to examine the effect of working status of women in Turkey on the severity of depressive symptoms.

The total number of participants of the 10 studies included in the meta-analysis was 2232 (51.12% working women, 48.88% non-working women). According to the meta-analysis, the difference between the severity of depressive symptoms observed between employed and unemployed women was g=-0.13 95% CI [-0.41; 0.14]. The difference between employed and unemployed women did not appear to be significant, as the CI of the summary effect crossed zero.

The true heterogeneity value of I2 is 90.3% 95% CI [84.3%; 94%], which indicates a high level of heterogeneity.

In order to investigate the possible causes of heterogeneity, the effects of publication year and sample size variables on heterogeneity were examined by meta-regression method. The purpose of evaluating the publication year of the studies was to examine the effects of social changes (eg, women’s participation in working life, improvement in working conditions, etc.). Meta-regression results are given in Table 2. Accordingly, the publication year and sample size of the studies were insufficient to explain the heterogeneity of the observed effect sizes (R2 value is 0.00% and 5.58%, respectively).

Table 2.

Results of meta-regression analyzes

Models Covariants B se (B) z p (z) τ2 (sh) Residual I2 R2
Model 1 intercept -0.1335 0.1367 -0.9762 0.3290 0.1656 (0.0971) 89.63% 5.58%
publication year 0.0199 0.0154 1.2909 0.1967
Model 2 intercept -0.1326 0.1487 -0.8921 0.3723 0.1992 (0.1130) 90.99% 0.00%
sample size -0.0004 0.0017 -0.2111 0.8328
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The averages of the year of publication and sample size variables were re-coded (mean centering) and analyzed. se: standard error.

DISCUSSION

Some characteristics inherent to woman cause them to face the risk of depression. One of these factors is sociocultural factors. Social life provides a role for everyone, each role has advantages as well as disadvantages (36). Being a working woman or a housewife are some of these roles. Depression levels are one of the issues where women belonging to these two groups are compared. Findings on whether depression symptoms differ between working and non-working women are varied. When the literature on the subject is examined, it is seen that there are studies that found a significant difference between the two groups in terms of the severity of depressive symptoms, as well as studies in which no difference was reported between the groups (27,37–41).

As a result of the meta-analysis study, it was determined that the employment status of women in Turkey had a small and non-significant effect on the severity of depressive symptoms (g=-0.13). Accordingly, whether women are employed or not and the roles they acquire accordingly have a negligible effect on their depression scores. The absence of a significant effect of working status on the severity of depressive symptoms can be evaluated in terms of both individual factors and working status. People’s perspectives affect their living conditions thus these conditions assign certain roles to people. What affects the well-being of individuals is related to the quality of these roles rather than the quantity (42). Being employed or not may not make a difference in this respect. Another perspective is related to the stress-creating features brought by both business life and work. The fact that working women have an income, though it is not lucrative, may not create a difference in income distribution and this may lead to similarity between the two groups. Employment in lower-paying jobs may neither provide adequate independence nor a voice for women. In addition, working women may face situations such as psychological violence (mobbing), working for low wages, and gender discrimination in the workplace (7). The lives of unemployed women can be relatively monotonous, and dealing with housework and childcare can lead to not being able to spare time for oneself. Not being able to contribute to the home economy and lack of socialization opportunities are some of the situations that unemployed women may encounter (8). These disadvantages of both taking part in and not taking part in business life show that almost every woman can encounter stressful events. As a matter of fact, all of these may provide an explanation for the lack of a significant effect of working status on depressive symptoms.

The fact that women work outside the home for wages is a novelty that came after the industrial revolution (43). The fact that women are more involved in business life in Turkey has some positive and negative effects. As in the world, the biggest obstacle for women to work outside the home in our country is the inequality in the division of labor within the family. The fact that a woman who participates in business life for financial reasons works both at home and at workplace can cause problems (44). Some of the working women cannot receive support from their spouses in terms of child care and housework. In addition, there are differences between genders in business life due to reasons such as job discrimination specific to women and men, social roles assigned to women, physical characteristics of women, low education level of women, belief that women’s workforce is insufficient, women’s working life is intermittent, and women’s solidarity among both genders is weak (45). All these reasons make us think that the depressive symptoms seen among working women in Turkey may be due to the current socio-cultural situation. On the other hand, it is known that many women who do not work in Turkey actually work at home. The labor that women spend at home is very important for the production of male workforce and society (46). Unemployed women are engaged in domestic chores such as cooking, cleaning and child care. Regardless of their working status, every person needs to be appreciated for their hard work. For unemployed women, this appreciation is at the mercy of the spouse (28), and this relationship affects women’s mental health.

In general, studies demonstrate that the severity of depressive symptoms in non-working women is higher than in working women. Tetikli Nart (2019), on the other hand, found the depressive symptom mean score of employed women to be higher than unemployed women, although it was a statistically insignificant result, and the effect observed in this study was found to be g=0.86 (33). Accordingly, it can be interpreted that the difference between the two groups is large. When the possible reasons for the difference in the result reported by Tetikli Nart (2019) were examined, it was seen that the methodological features and sample of the study were similar to those of other studies (33). The source of the study being the extreme value in the analysis has not been clarified.

The sample of most of the studies included in this study consists of employed and unemployed women living in metropolitan centers. Only in the study conducted by Kaya, reported that data were collected from women all across Turkey (33). While there were nearly 25 million women living in provincial and district centers in Turkey in 2007, the number of women living in towns and villages was around 10 million (47). In other words, the number of women living in rural areas is roughly half of the number of women living in provincial and district centers. Women residing in rural areas and employed in the agricultural sector should also be considered when investigating the difference in the severity of depressive symptoms between employed and unemployed women. There are studies from abroad that compare the depressive symptoms of women living in rural and urban areas (48–50). As a result of the literature review, since there were no studies on depressive symptoms of women living in rural areas in Turkey, either employed or not, were not included in the systematic review. It is thought that increasing the number of studies involving people living in rural areas in our country will contribute to the literature.

Limitations and Strengths

While scanning the primary studies to be included in the meta-analysis, the article search was carried out in line with the sharing between the researchers, rather than focusing on all databases separately. The analysis included not only published studies but also thesis studies that reported the situation in Turkey but were overlooked. Not using unpublished studies is called “file drawer problem” (23). One of the strengths of the research is that it overcomes this mentioned problem and includes unpublished thesis studies. The decision to put the studies into synthesis was made by two researchers unaware of each other and a possible bias was tried to be minimized by applying to a third researcher in case of disagreement.

Conclusion and Recommendations

The absence of a study compiling the severity of depressive symptoms in employed and unemployed women in Turkey reveals the importance of this systematic review. The aim of the present study was to contribute to the literature in terms of determining the situation in our country and comparing it with the data abroad. Seven of the 10 studies included in the meta-analysis consisted of thesis studies.

In the present study, the roles of women within the framework of employment status were discussed. Accordingly, there was no significant effect of working at a job or being a housewife on the severity of depressive symptoms in women. In depressive symptoms, it is beneficial to examine several variables such as age, race, family history, apart from working status. Addressing the factors mentioned in future studies will shed light on the emergence of new findings.

In countries with low socioeconomic status, less investment is made in women’s education, and women therefore experience problems due to the lack of special education in jobs that require equipment (45). It has become necessary to increase the studies on the education of women and to produce policies related to this issue. In addition, it is essential to make and implement legal regulations for gender equality and the effective solution of women’s problems in business life.

In the literature review conducted, several studies investigating the prevalence of postpartum depression in employed and unemployed women were encountered (51–54). In the future, a meta-analysis study focusing on postpartum depression experienced by employed and unemployed women in our country can be conducted.

In the primary studies included in the meta-analysis, depressive symptoms were tried to be determined through self-report scales filled in by individuals. Clinician-scored scales were not included in the meta-analysis study. It is thought that including these scales in future studies will increase the validity of the findings.

The fact that individuals living in rural areas were not included in the primary studies in this meta-analysis seems to contradict the fact that science was not founded on serving a certain group or groups. Taking measurements of individuals who cannot benefit from technological opportunities and health services or do not live in easily accessible regions should also be among the responsibilities of scientists who carry out research. According to Kağıtçıbaşı, producing a culturally valid theory contributes to the testing of the theory in different cultures and to the local theory building process (55). This is an important issue for scientists dealing with social issues in developing countries. It is very important that the meta-analysis study is carried out to satisfy scientific curiosity and deal with social problems.

Footnotes

Peer-review: Externally peer-reviewed.

Author Contributions: Concept- EY, EU, FY; Design- EY, EU, FY; Supervision- FD; Resource- (-); Materials- (-); Data Collection and/or Processing- EY, EU, FY; Analysis and/or Interpretation- EY; Literature Search- EY, EU, FY; Writing- EY, EU, FY; Critical Reviews- FD.

Conflict of Interest: The authors declared that there is no conflict of interest

Financial Disclosure: No financial support was provided for the research.

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