Abstract
This study sought to investigate whether association between customer verbal abuse and depressive symptoms differed by workload. We conducted a cross-sectional survey of 795 cosmetics sales workers at department store in South Korea. Experience of customer verbal abuse over the past one month was measured by using a yes/no question. Depressive symptoms during the preceding week were assessed by using 20 items from the Center for Epidemiologic Studies-Depression scale. Workload during the past week was measured by asking the number of customers a worker dealt with on average in a day and classified into two categories: 1) Low (15 people or less), and 2) High (more than 15 people). Cosmetics sales workers’ experience of customer verbal abuse was associated with a higher prevalence of depressive symptoms (PR: 1.37, 95% CI: 1.15–1.63). After being stratified by workload, customer verbal abuse showed a statistically significant association with depressive symptoms among high workload groups (PR: 1.46, 95% CI: 1.19–1.79), whereas the association was not statistically significant among low workload group (PR: 1.23, 95% CI: 0.91–1.65). Our findings suggest that experience of customer verbal abuse could have a negative influence on depressive symptoms among high-workload cosmetics sales workers in South Korea.
Keywords: Customer verbal abuse, Depressive symptoms, Workload, Workplace violence, Sales workers, South Korea
Introduction
Workplace violence is defined as “any action, incident or behavior that departures from reasonable conduct in which a person is assaulted, threatened, harmed, injured in the course of, or as a direct result of, his or her work” by International Labor Organization1). Among the types of workplace violence, verbal abuse has been known as the most frequently experienced violence by workers2, 3). Also, customers have been reported as the main perpetrator of violence experienced by workers dealing with people3,4,5).
Most of the studies focused on violent events experienced by healthcare workers who have frequent contact with patients and families6,7,8,9,10,11,12), while little attention has been paid to customer verbal abuse against sales workers. Interpersonal service workers, including sales workers, routinely have face-to-face contact with large numbers of customers, which exposes them to various forms of customer violence3). Among these workers, sales workers could be vulnerable to verbal abuse while explaining, promoting, calculating, and packing the products. For example, a study of US workers reported that retail sales workers showed one of the highest risks of exposure to workplace violence and suggested further research13). Also, a study of South Korea found that prevalence of workplace violence was higher among service and sales workers than other occupations including professionals14).
Documented evidence indicated that experience of workplace violence from customers could have a negative influence on worker’s mental health4, 15,16,17). For example, a systematic review reported that customer violence was associated with workers’ emotional exhaustion18). Also, a study of substitute drives found that customer verbal abuse is related to depressive symptoms19). Another study of service and sales workers also showed that experience of clients’ adverse behaviors was associated with depression and anxiety20).
Furthermore, there is some evidence that demanding workload could worsen the mental health problem of sales workers who were exposed to customer verbal abuse. A previous study found that high quantitative demands at work were associated with work-related threats among workers in human service sectors21). Also, studies found that work intensity was associated with mental health problems among French22) and Korean workers23). However, to our knowledge, no study has focused on how the experience of customer verbal abuse was related to depressive symptoms among sales workers, and whether the association differed by workers’ workload. Therefore, we analyzed nationwide dataset from Korean cosmetics sales workers in a company to answer the following questions:1. Is there an association between the experience of customer verbal abuse and depressive symptoms among cosmetics sales workers in Korea?2. Does the association differ by the number of customers a worker dealt with?
Methods
Study population
We conducted a cross-sectional survey of cosmetics sales workers at department stores across the country in South Korea. This survey aimed to investigate the work environment and health status among Korean cosmetics sales workers at the department store24, 25). In conjunction with the Korean Federation of Service Workers’ Union, paper-based survey questionnaires were mailed to all workers through the internal system of a cosmetics company consisting of 8 brands (N=1152). Data were collected from 4th September to 21st September in 2018. The response rate was 80.3% (N=925). Informed consent was obtained from all individual participants included in the study after providing respondents with an explanation of the research purpose and asking about their willingness to participate. After removing the data with missing values for depressive symptoms, customer verbal abuse, workload, and potential confounders, the size of the study population was 795. This study was approved by the Institutional Review Board of Korea University (1040548-KU-IRB-18–50-A-3).
Measures
Experience of customer verbal abuse
Experience of customer verbal abuse was measured by using a question “Over the past 1 month, have you ever experienced verbal abuse from a customer?” Respondents could answer ‘yes’ or ‘no’.
Depressive symptoms
Depressive symptoms during the preceding week were assessed by using 20 items from the Center for Epidemiologic Studies-Depression scale, which has been validated for use with the Korean general population26). Respondents could answer from 0 (‘less than one day per week’) to 3 (‘five to seven days per week’) for each of 20 questions. Summed scores ranged from 0 to 60. Following established procedures, respondents with a score of 16 or more were defined as having depressive symptoms27). Cronbach’s α was 0.930 for 20 items from the CES-D.
Workload
Workload, defined as the number of customers a worker dealt with, was measured by a question “During the past week, how many customers did you serve on average in a day?” Respondents could answer among nine responses: 1) 0–5 people, 2) 6–10 people, 3) 11–15 people, 4) 16–20 people, 5) 21–25 people, 6) 26–30 people, 7) 31–40 people, 8) 41–50 people, 9) 51 people or more. Based on the median value, the responses were grouped into two categories: 1) Low workload (15 people or less), 2) High workload (more than 15 people).
Potential confounders
We selected eight variables (i.e., sex, age, job position, year of work experience, number of team members, working hours per week, type of cosmetics products, and brand of department store) as potential confounders. All respondents were classified as female or male. Age was coded into four categories (i.e., 19–24 yr old, 25–29 yr old, 30–34 yr old, 35 yr old or more). Job position was coded into three groups: (i.e., Manager, Assistant manager, and Staff). Years of work experience was classified into three groups (i.e., 3 yr or less, 4–9 yr, 10 yr or more). Number of team members was assessed and coded into four groups (i.e., 1–2, 3, 4, 5 or more). Working hours per week were divided into three groups (i.e., 40 or less, 41–52, 53 or more). Type of cosmetics products was coded into three categories (i.e., Skincare, Color makeup, Others). Brand of department store was measured by six groups (i.e., A, B, C, D, E, others).
Statistical analysis
A χ2 test was used for comparing the prevalence of depressive symptoms and customer verbal abuse across different groups. A Poisson regression model with robust error variance was applied to examine whether the experience of customer verbal abuse was associated with depressive symptoms after controlling for potential confounders. Given the high prevalence of depressive symptoms among the study population (>10%), applying the rare disease assumption, odds ratios from the logistic regression model would overestimate prevalence ratios in a cross-sectional study28). To assess multicollinearity among the covariates, Variance Inflation Factors (VIFs) were calculated. The mean VIF was 2.24, and the highest VIF value was 5.26. Since all VIF values were below 10, the potential for multicollinearity was less of a concern. All covariates were included as categorical variables in the analysis. Results were presented as prevalence ratios (PRs) with 95% confidence intervals (CIs). All analyses were performed with STATA/SE version 18 (Stata Corp., College Station, TX, USA).
Further, we conducted a sensitivity analysis by changing the cut-off score for depressive symptoms. While the original cut-off score of 16 is widely used and validated for the CES-D scale, some studies have suggested that a higher cut-off score of 20 may be more appropriate by reducing a trade-off between sensitivity and specificity29). After defining the respondent who had 20 or higher score for the CES-D scale having depressive symptoms, we investigate whether customer verbal abuse was associated with depressive symptoms, and whether the association differs by workload.
Results
Table 1 shows the distribution of the study population and the prevalence of depressive symptoms and customer verbal abuse by potential confounders. Overall, 42.0% of cosmetics sales workers reported depressive symptoms. The prevalence of depressive symptoms was higher among workers who were younger, had lower job positions, had a shorter years of work experience, working 53 or more hours per week, and worked in color makeup brands. 20.6% of cosmetics sales workers experienced customer verbal abuse during the past 1 month. Experience of customer verbal abuse was more prevalent among workers who were 30–34 yr old, had a higher job position, and worked longer hours.
Table 1. Distribution of study population, and prevalence of depressive symptoms and customer verbal abuse by key covariates among cosmetics sales workers in South Korea (N=795).
| Distribution | Depressive symptoms | Experience of customer verbal abuse | ||||
|---|---|---|---|---|---|---|
| N (%) | N (%) | p-value* | N (%) | p-value* | ||
| Total | 795 (100.0) | 334 (42.0) | 164 (20.6) | |||
| Sex | 0.65 | 0.925 | ||||
| Female | 760 (95.6) | 318 (41.8) | 157 (20.7) | |||
| Male | 35 (4.4) | 16 (45.7) | 7 (20.0) | |||
| Age (yr) | <0.001 | 0.039 | ||||
| 19–24 | 158 (19.9) | 80 (50.6) | 31 (19.6) | |||
| 25–29 | 275 (34.6) | 130 (47.3) | 43 (15.6) | |||
| 30–34 | 171 (21.5) | 64 (37.4) | 44 (25.7) | |||
| 35 or more | 191 (24.0) | 60 (31.4) | 46 (24.1) | |||
| Job position | 0.001 | 0.003 | ||||
| Manager | 202 (25.4) | 63 (31.2) | 54 (26.7) | |||
| Assistant manager | 174 (21.9) | 74 (42.5) | 43 (24.7) | |||
| Staff | 419 (52.7) | 197 (47.0) | 67 (16.0) | |||
| Years of work experience | 0.001 | 0.108 | ||||
| 3 or less | 251 (31.6) | 125 (49.8) | 42 (16.7) | |||
| 4–9 | 289 (36.4) | 123 (42.6) | 60 (20.8) | |||
| 10 or more | 255 (32.1) | 86 (33.7) | 62 (24.3) | |||
| Number of team members | 0.097 | 0.152 | ||||
| 1–2 | 127 (16.0) | 54 (42.5) | 21 (16.5) | |||
| 3 | 255 (32.1) | 96 (37.6) | 62 (24.3) | |||
| 4 | 138 (17.4) | 53 (38.4) | 32 (23.2) | |||
| 5 or more | 275 (34.6) | 131 (47.6) | 49 (17.8) | |||
| Working hours per week | 0.009 | 0.021 | ||||
| 40 or less | 152 (19.1) | 64 (42.1) | 19 (12.5) | |||
| 41–52 | 513 (64.5) | 200 (39.0) | 114 (22.2) | |||
| 53 or more | 130 (16.4) | 70 (53.8) | 31 (23.8) | |||
| Type of cosmetics products | <0.001 | 0.055 | ||||
| Skincare | 429 (54.0) | 149 (34.7) | 77 (17.9) | |||
| Color makeup | 343 (43.1) | 175 (51.0) | 84 (24.5) | |||
| Others | 23 (2.9) | 10 (43.5) | 3 (13.0) | |||
| Brand of department store | 0.338 | 0.178 | ||||
| A | 299 (37.6) | 128 (42.8) | 67 (22.4) | |||
| B | 185 (23.3) | 81 (43.8) | 37 (20.0) | |||
| C | 218 (27.4) | 91 (41.7) | 39 (17.9) | |||
| D | 48 (6.0) | 20 (41.7) | 11 (22.9) | |||
| E | 26 (3.3) | 11 (42.3) | 9 (34.6) | |||
| Others | 19 (2.4) | 3 (15.8) | 1 (5.3) | |||
*p-value of the χ2 test comparing the prevalence of depressive symptoms and customer verbal abuse across different groups.
Cosmetics sales workers’ experience of customer verbal abuse was statistically significantly associated with depressive symptoms after adjusting for potential confounders (Table 2). A higher prevalence of depressive symptoms was observed among cosmetics sales workers who experienced customer verbal abuse (PR: 1.37, 95% CI: 1.15–1.63), compared to those who did not experience customer verbal abuse. In the sensitivity analysis, the association became stronger and remained statistically significant (Supplementary Table 1, PR:1.53, 95% CI: 1.24–1.89).
Table 2. Association between the experience of customer verbal abuse and depressive symptoms among cosmetics sales workers in Korea (N=795).
| Customer verbal abuse | Distribution | Prevalence of depressive symptoms | Model 1 | Model 2 | Model 3 | |||
|---|---|---|---|---|---|---|---|---|
| N (%) | N (%) | PR | 95% CI | PR | 95% CI | PR | 95% CI | |
| No | 631 (79.4) | 247 (39.1) | 1 | Referent | 1 | Referent | 1 | Referent |
| Yes | 164 (20.6) | 87 (53.1) | 1.36** | 1.14, 1.61 | 1.41*** | 1.19, 1.67 | 1.37*** | 1.15, 1.63 |
Model 1: Unadjusted, Model 2: Adjusted for sex and age, Model 3: Model 2+ job position, year of work experience, number of team members, working hours per week, type of cosmetics products, and brand of department store. **p<0.01, ***p<0.001.
Furthermore, we examined the association between customer verbal abuse and depressive symptoms after being stratified by workload (Table 3). Among the high workload group, the experience of customer verbal abuse showed a statistically significant association with depressive symptoms (PR: 1.46, 95% CI: 1.19–1.79). Whereas the association was not statistically significant among low workload group (PR: 1.23, 95% CI: 0.91–1.65). We observed a similar trend in the sensitivity analysis, and the association was statistically significant only among the high workload group (Supplementary Table 2).
Table 3. Stratified analysis of the association between experience of customer verbal abuse and depressive symptoms by workload among cosmetics sales workers in Korea (N=795).
| Customer verbal abuse | Low workload (N=451) | High workload (N=344) | ||||||
|---|---|---|---|---|---|---|---|---|
| Total | Prevalence of depressive symptoms | PR | 95% CI | Total | Prevalence of depressive symptoms | PR | 95% CI | |
| N (%) | N (%) | N (%) | N (%) | |||||
| No | 366 (81.2) | 128 (35.0) | 1 | Referent | 265 (77.0) | 119 (44.9) | 1 | Referent |
| Yes | 85 (18.9) | 37 (43.5) | 1.23 | 0.91, 1.65 | 79 (23.0) | 50 (63.3) | 1.46*** | 1.19, 1.79 |
All of the models were adjusted for sex, age, job position, year of work experience, number of team members, working hours per week, type of cosmetics products, and brand of department store. ***p<0.001.
Discussion
This study found that approximately 20% of cosmetics sales workers in South Korea experienced customer verbal abuse during the past 1 month. Workers’ experience of verbal abuse at work has been found to be related to turnover intention and job performance30). Our result also suggests that cosmetics sales workers who experienced customer verbal abuse were more likely to report depressive symptoms after controlling for potential confounders including number of team members. These findings are consistent with previous studies of other types of workers including bank employees31), emergency medical service providers32), and medical residents33).
Notably, we found that the association between customer verbal abuse and depressive symptoms could differ by worker’s workload. Customer verbal abuse showed a statistically significant association with depressive symptoms only among high workload groups. These results could be explained in several ways. First, the experience of customer verbal abuse could act as a double burden for workers with a demanding workload. Workers who had to deal with many customers may not have been able to choose to stop working and take a break, even when they were verbally abused by the customers. Previous research has indicated that workload could lead to a higher risk of health problems34, 35).
Second, workers who had to deal with many customers may have experienced more serious violence or have been exposed to frequent violence. In our results, high workload group showed a higher proportion of experiencing customer verbal abuse than low workload group (23.0% vs. 18.9%), although the difference was not statistically significant. Previous studies have reported that workers with a high workload may experience more frequent or severe forms of workplace violence36,37,38,39,40,41). This might be possible because high workload limits the capacity of workers and their colleagues to effectively cope with or respond to verbal abuse, considering that support from co-workers could buffer association between heavy workload and exposure to violence41).
On the other hand, we observed a statistically non-significant association between customer verbal abuse and depressive symptoms among cosmetics sales workers with low workload. This result could imply that a lesser workload might mitigate the negative influence of customer verbal abuse on worker’s mental health. However, our results should be interpreted with caution in that the prevalence of depressive symptoms in our study population was relatively high (>40%). This is further emphasized by a parallel study using the same dataset, which found that cosmetics saleswomen were approximately six times more likely to experience depressive symptoms than general working women in Korea24). Therefore, further study is necessary to explore the work environment that could be detrimental to depressive symptoms among cosmetics sales workers.
In October 2018, the revised Occupational Safety and Health Act (OSHA) came into effect, mandating employers to intervene to prevent mental health problems of their interpersonal service workers42). Several studies have investigated the role of worker protection systems in reducing customer violence following the implementation of revised OSHA43, 44). Nevertheless, further studies are needed to investigate the effectiveness of the law in reducing customer violence and related organizational factors, such as staffing adequacy, to ensure OSHA can function properly in protecting workers’ mental health. Additionally, guidelines within companies might be helpful for workers to cope with customer violence even under high workloads. However, in our additional analysis, over 50% of our study population reported that guidelines for customer violence existed at their workplace but these guidelines were not helpful (Supplementary Table 3). Therefore, it is also necessary for future studies to investigate the effectiveness of guidelines for coping with customer violence and its influence on workers’ health.
This study has several limitations. First, because of the lack of information about temporal order between customer verbal abuse and depressive symptoms in the cross-sectional design, we could not be free from the possibility of reverse causation. For example, workers having depressive symptoms could have been sensitive to conflict and reported it as a violent situation. Second, because a single-item measurement was used to assess customer verbal abuse, we could not consider the frequency and severity of violent events. Third, measuring customer verbal abuse based on self‐report might lead to recall bias such that workers with episodes of depressive symptoms might be more likely to remember their experience of customer verbal abuse compared to those without depressive symptoms. Fourth, the classification of the workload variable was based on its distribution within our study population. This data-driven approach might limit the generalizability of our results to other contexts where distribution of workload differs.
Despite these limitations, a higher response rate enabled us to investigate the experience of customer verbal abuse and its consequences among sales workers in a cosmetics company. This study suggests that the workload might play a critical role in the association between customer verbal abuse and depressive symptoms among cosmetics sales workers in South Korea.
Funding
None.
Conflict of Interests
The Authors declare that there is no conflict of interest.
Supplementary Material
Acknowledgments
The authors are grateful toward Korean Federation of Service Worker’s Union’s support for collecting the data.
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