Abstract
Objectives. To identify work-related factors associated with depressive symptoms and probable major depression in primary care teams.
Methods. Cross-sectional study among primary care teams (community health workers, nursing assistants, nurses, and physicians) in the city of São Paulo, Brazil (2011–2012; n = 2940), to assess depressive symptoms and probable major depression and their associations with job strain and other work-related conditions.
Results. Community health workers presented higher prevalence of probable major depression (18%) than other primary care workers. Higher odds ratios for depressive symptoms or probable major depression were associated with longer duration of employment in primary care; having a passive, active, or high-strain job; lack of supervisor feedback regarding performance; and low social support from colleagues and supervisors.
Conclusions. Observed levels of job-related depression can endanger the sustainability of primary care programs.
Public Health implications. Strategies are needed to deliver care to primary care workers with depression, facilitating diagnosis and access to treatment, particularly in low- and middle-income countries. Preventive interventions can include training managers to provide feedback and creating strategies to increase job autonomy and social support at work.
The high prevalence of depressive symptoms among health care workers has been noted as a matter of great concern because it has repercussions for workers (disability, impaired productivity, and suicide) and patients (malpractice, prescription errors, and adverse patient health outcomes).1–3
Some occupational stressors have been highlighted as harmful for the mental health of health care workers, including lengthy work hours, number of night shifts,4 psychological demands related to dealing with patients, and number of years working in emergency units.5 Studies have also depicted the role of job strain in compromising health care workers’ mental health. Having a job characterized by low autonomy and high psychological demands has been associated with depression and emotional exhaustion.6
Recently, researchers have reported that supervisors’ leadership styles affect the mental health of health care workers. For instance, leadership styles that provide personal attention, psychological support, and performance feedback were found to be negatively associated with the incidence of mental disorders among health care workers7 and to be positively linked to well-being and job satisfaction.8,9 Furthermore, supervisor leadership styles that are classified as nonlistening or self-centered were associated with depressive symptoms among employees.10 To the best of our knowledge, previous studies carried out in primary care settings have not investigated the relationships among work-related stressors, supervisors’ leadership style, and depression among primary care teams, including community health workers (CHWs).
Most research evaluating the mental health of health care workers has been conducted in hospitals.4,11 The few existing studies that addressed workers in primary care settings focused on investigating depression among physicians.12,13 Investigations involving other categories, such as CHWs, nurses, and nursing assistants, are scarce. In the global context, where primary care is still expanding, particularly in low- and middle-income countries (LMICs), enhancing knowledge about primary care workers’ mental health and work-related stressors is fundamental for primary care sustainability.
In 1994, Brazil’s Ministry of Health created the Family Health Program (FHP) to reorganize primary care across the country. Each FHP team comprises 1 physician, 1 nurse, 2 nursing assistants, and 4 to 6 community health workers, and is responsible for delivering care to an enrolled population of 2000 to 4000 people. The FHP has been expanded over the past 20 years, and presently it comprises almost 400 000 primary care workers and covers more than 120 million people across the country.14 It has become a model for primary care programs in several LMICs in Asia, Africa, and Latin America.15,16
We evaluated the relationships of depressive symptoms and probable major depression in FHP teams with job strain, performance feedback, and other work-related factors in the city of São Paulo, Brazil, the largest urban area in South America, with 11.3 million inhabitants, 45% of which is covered by the FHP.17 São Paulo is a particularly valuable site for such investigation because it is a large metropolis in an LMIC where there are wide social and health inequalities that are also found in other large urban centers in LMICs, and where a large-scale primary care program has been implemented.
METHODS
We conducted a survey in the city of São Paulo—the Panorama of Primary Health Care Workers in São Paulo, Brazil: Depression, Organizational Justice, Violence at Work, and Burnout Assessments (PANDORA-SP) study18—from October 2011 to November 2012. To select FHP clinics that would yield our sample, we first stratified existing FHP clinics in São Paulo according to the 10 provider organizations, covering 4 regions of the city. Each provider organization coordinated from 1 to 12 FHP clinics, and each FHP clinic had from 1 to 12 FHP teams. From the list of all FHP clinics in São Paulo, we randomly selected 66, stratified by region and proportional to the number of FHP clinics in each provider organization. We then invited all FHP team staff (doctors, nurses, nursing assistants, and CHWs) in each selected FHP clinic to participate in the study. Because according to FHP job contracts in São Paulo the first 3 months of employment is a probation period, we excluded FHP workers who had been employed for less than 3 months, to avoid biased responses from individuals concerned about retaining their jobs at the end of that probation period.
Measures
Depressive symptoms and probable major depression.
We evaluated depressive symptoms by using the Brazilian version of the 9-item Patient Health Questionnaire (PHQ-9),19 a widely used screening instrument for depression. The PHQ-9 comprises the depression module of the Primary Care Evaluation of Mental Disorders, which was developed on the basis of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria.20 Participants stated whether they had experienced symptoms associated with depression within the previous 2 weeks for 9 questions, corresponding to the symptoms considered for a diagnosis of major depression by the DSM-IV criteria. The possible answers and respective scores for each symptom are “not at all” (0), “several days” (1), “more than half the days” (2), and “nearly every day” (3). The PHQ-9 scores allowed us to classify participants into 3 categories: “no depressive symptoms,” “depressive symptoms,” and “probable major depression.”19
Following the precedent of previous studies, we classified participants as having depressive symptoms if 2 to 4 symptoms associated with depression were present more than half the days in the past 2 weeks and only 1 of those symptoms was depressed mood or anhedonia; and classified participants as having probable major depression if 5 or more symptoms associated with depression were present more than half the days in the previous 2 weeks and at least 1 of those symptoms was depressed mood or anhedonia.21 The Brazilian validation of the PHQ-9 was conducted by using the diagnosis of major depression by the Mini International Neuropsychiatric Interview as standard. The PHQ-9 found sensitivity of 77.5% (95% confidence interval [CI] = 61.5, 89.2), specificity of 86.7% (95% CI = 83.0, 89.9), positive predictive value of 57.8% (95% CI = 53.2, 62.4), and negative predictive value of 94.3% (95% CI = 92.1, 96.4).19
Job strain.
We measured job strain by using the Brazilian version of the Karasek and Theorell Job Content Questionnaire,22 a 17-item questionnaire with 3 sections: (1) the work-related psychological demands (job demand) dimension has 5 items to measure the conflicting demands and quantitative aspects of the job (time and speed for performing tasks), (2) the decision latitude (job control) dimension includes 6 items to evaluate decisional authority and skill discretion, and (3) the social support from colleagues and supervisors at work (job support) dimension, comprising 6 items. With respect to internal validity, the Cronbach α was 0.79 for job demand, 0.67 for job control, and 0.85 for social support. For the demand and control dimensions, the answer options are displayed as a 1-to-4 Likert scale, ranging from “frequently” to “never/almost never.” In a similar way, the social support subscale has 4 answer options arranged in a Likert scale, ranging from “strongly agree” to “strongly disagree.”
According to the Karasek and Theorell model, first we used the median value obtained in each subscale (job demand, job control, and social support) to divide the participants into 2 groups, “low” or “high.” In our sample, these median values were 16 for demand, 16 for control, and 19 for social support. Then, the combination of demand and control levels produces 4 job strain categories labeled as low-strain job (low demand and high control), passive job (low demand and low control), active job (high demand and high control), and high-strain job (high demand and low control). Social support is classified as “low” or “high” independently of job strain category.
Previous studies that investigated the demand–control model and addressed cultural differences found that stress–strain relationships are generalizable across cultures. However, there are almost no data from Africa and South America.23
Other work-related characteristics.
We examined whether primary care workers were receiving performance feedback from their supervisors by asking participants to read the sentence “My supervisor gives me feedback about how I have been performing my job, in order to do it better” and to choose an answer according to a 1-to-5 Likert scale: “strongly disagree” (1), “disagree” (2), “neither agree nor disagree” (3), “agree” (4), and “strongly agree” (5). We classified workers who chose “strongly disagree” or “disagree” as “not receiving feedback.” We classified participants who selected “neither agree nor disagree” as “not defined.” Finally, we classified participants as “receiving feedback” if they chose “agree” or “strongly agree.” We also investigated the following work-related factors: professional category (CHW, nursing assistant, nurse, or physician), length of employment in the FHP, and working in deprived areas. There are many deprived areas in São Paulo, sometimes referred to as favelas or marginalized communities, with varying degrees of infrastructure such as sanitation, electricity, and legal titles to the land; these areas are broadly similar to what are called slums in English-speaking countries.
Socioeconomic variables and stressful life events.
We evaluated socioeconomic characteristics (gender, age, self-reported skin color, marital status, educational level, and monthly income) and stressful life events in the previous 12 months, because they are well-known correlates of depression in Brazil.24 The stressful life events investigated were the following: death of a close relative, financial strain, severe disease, hospitalization, forced change of residence, disruption of a love relationship, and exposure to violence.
Statistical Analysis
Because we randomly selected FHP clinics rather than workers directly, we adjusted for clustering in both the bivariate and multivariate regressions. We considered each FHP clinic a cluster. We used Stata version 13.0 (StataCorp LP, College Station, TX) to perform all analyses. We performed a χ2 test and calculated odds ratios (ORs) with 95% CIs to evaluate the associations of depressive symptoms and probable major depression with work-related variables.
We performed multinomial logistic regression to assess the variables associated with our outcome (no depressive symptoms, depressive symptoms, and probable major depression). First, we performed a bivariate analysis and we included all variables at P < .20 in the multivariate model. We maintained those variables that remained with a statistically significant association with the outcome variable in the multivariate analysis in the final model.25 We also examined variations in the magnitude of ORs to build the final model.
RESULTS
We assessed 351 primary care teams. The number of teams per primary care center ranged from 1 to 12 (mean 6.0; SD = 2.1). Of 3141 eligible workers, 2940 (93%) completed the interview. Of the nonparticipants (n = 201), 58 were on sick leave and 143 refused to participate. Characteristics of the participants are shown in Table 1. The mean age of participants was 36.7 years (SD = 9.6), and the sample was predominantly women and community health workers. Most participants (61.2%) reported having experienced at least 1 stressful life event in the previous 12 months. The prevalence of depressive symptoms was 36.3% (95% CI = 34.6, 38.1) and the prevalence of probable major depression was 16% (95% CI = 14.6, 17.2). Community health workers had a higher prevalence of probable major depression (18%; Table 1).
TABLE 1—
Characteristics of Participants and Work-Related Variables, and Bivariate Analysis for Associations With Depressive Symptoms and Depression (n = 2940): São Paulo, Brazil, 2011–2012
| Depressive Symptoms |
Probable Major Depression |
|||||
| Variables | Participants, No. (%) | No Depressive Symptoms, No. (%) | No. (%) | P | No. (%) | P |
| Participants’ characteristics | ||||||
| Gender | < .001 | < .001 | ||||
| Female | 2661 (90.5) | 1225 (46.0) | 982 (36.9) | 454 (17.0) | ||
| Male | 279 (9.5) | 177 (63.4) | 87 (31.2) | 15 (5.4) | ||
| Age group, years | < .001a | < .001a | ||||
| 18–29 | 804 (27.4) | 353 (43.9) | 309 (38.4) | 142 (17.7) | ||
| 30–39 | 1186 (40.3) | 509 (42.9) | 461 (38.9) | 216 (18.2) | ||
| 40–49 | 637 (21.7) | 352 (55.7) | 200 (31.4) | 85 (13.3) | ||
| 50 or older | 313 (10.6) | 188 (60.1) | 99 (31.6) | 26 (8.3) | ||
| Skin color | .31 | .01 | ||||
| White | 1239 (42.2) | 606 (48.9) | 461 (37.2) | 172 (13.9) | ||
| Brown | 1112 (37.8) | 543 (48.8) | 381 (34.7) | 188 (16.9) | ||
| Black | 527 (17.9) | 224 (42.5) | 204 (38.7) | 99 (18.8) | ||
| Asian | 62 (2.1) | 29 (46.8) | 23 (37.1) | 10 (16.1) | ||
| Marital status | .31 | .02 | ||||
| Married | 1817 (61.8) | 894 (49.2) | 646 (35.5) | 277 (15.2) | ||
| Single | 801 (27.2) | 364 (45.4) | 312 (38.9) | 125 (15.6) | ||
| Widowed | 55 (1.9) | 24 (43.6) | 21 (38.2) | 10 (18.2) | ||
| Separated | 267 (9.1) | 120 (44.9) | 90 (33.7) | 57 (21.3) | ||
| Educational level | .38a | .03a | ||||
| 4 y | 75 (2.5) | 35 (46.7) | 24 (32.0) | 16 (21.3) | ||
| 8 y | 1017 (34.5) | 480 (47.2) | 360 (35.4) | 177 (17.4) | ||
| Technical course | 914 (31.0) | 438 (47.9) | 326 (35.7) | 150 (16.4) | ||
| College | 524 (17.8) | 255 (48.6) | 193 (36.8) | 76 (14.5) | ||
| Postgraduation | 410 (13.9) | 194 (47.3) | 166 (40.5) | 50 (12.2) | ||
| Monthly income, US$ | .58a | < .001a | ||||
| 200–500 | 1521 (51.7) | 674 (44.3) | 561 (36.9) | 286 (18.8) | ||
| 501–1000 | 702 (23.9) | 367 (52.3) | 233 (33.2) | 102 (14.5) | ||
| 1001–2000 | 232 (7.9) | 127 (54.7) | 79 (34.1) | 26 (11.2) | ||
| ≥ 2001 | 485 (16.5) | 234 (48.2) | 196 (40.4) | 55 (11.3) | ||
| Stressful life events | < .001a | < .001a | ||||
| None | 1142 (38.8) | 706 (61.8) | 343 (30.0) | 93 (8.1) | ||
| 1 | 965 (32.8) | 457 (47.3) | 358 (37.1) | 150 (15.4) | ||
| 2 | 537 (18.3) | 175 (32.6) | 231 (43.0) | 131 (24.4) | ||
| ≥ 3 | 296 (10.1) | 64 (21.6) | 137 (46.3) | 95 (32.1) | ||
| Work-related variables | ||||||
| Profession | .95 | < .001 | ||||
| Physician | 217 (7.4) | 109 (50.2) | 90 (41.5) | 18 (8.3) | ||
| Nurse | 306 (10.4) | 138 (45.1) | 126 (41.2) | 42 (13.8) | ||
| Nursing assistant | 647 (22.0) | 350 (54.1) | 207 (32.0) | 90 (13.9) | ||
| CHW | 1770 (60.2) | 805 (45.5) | 646 (36.5) | 319 (18.0) | ||
| Length of employment | .08a | < .01a | ||||
| 3 mo to < 2 y | 999 (33.9) | 524 (37.4) | 337 (31.5) | 138 (29.4) | ||
| 2–6 y | 1075 (36.6) | 472 (33.7) | 422 (39.5) | 181 (38.6) | ||
| > 6 y | 866 (29.5) | 406 (28.9) | 310 (29.0) | 150 (32.0) | ||
| Deprived area | .04 | .39 | ||||
| No | 1010 (34.3) | 509 (50.4) | 342 (33.8) | 159 (15.7) | ||
| Yes | 1930 (65.5) | 893 (46.3) | 727 (37.7) | 310 (16.0) | ||
| Feedback from supervisor | < .001 | < .001 | ||||
| Yes | 1864 (63.4) | 998 (71.2) | 644 (60.2) | 222 (47.3) | ||
| Not defined | 529 (18.0) | 214 (15.2) | 199 (18.6) | 116 (24.7) | ||
| No | 547 (18.6) | 190 (13.5) | 226 (21.1) | 131 (27.9) | ||
| Social support | < .001 | < .001 | ||||
| High | 1189 (40.4) | 753 (63.3) | 346 (29.1) | 90 (7.6) | ||
| Low | 1751 (59.6) | 649 (37.0) | 723 (41.3) | 379 (21.6) | ||
| Job stress | < .001 | < .001 | ||||
| Low strain | 947 (32.2) | 625 (44.6) | 257 (24.0) | 65 (13.9) | ||
| Passive | 882 (30.0) | 444 (31.7) | 344 (32.2) | 94 (20.0) | ||
| Active | 517 (17.6) | 175 (12.5) | 231 (21.6) | 111 (23.7) | ||
| High strain | 594 (20.2) | 158 (11.3) | 237 (22.2) | 199 (42.4) | ||
Note. CHW = community health worker. P value according χ2 test.
Trend P.
The CHWs presented a greater proportion of “low-control job” than the other participants, whereas physicians and nurses had greater proportions of “high-demand job” (Table 2). Almost 60% of the sample presented low social support from colleagues and supervisors (Table 1), nurses and nursing assistants having greater proportions of low social support (Table 2). Twenty percent of the sample presented a high-strain job (high demand and low control), and 30% a passive job (low demand and low control; Table 1). The CHWs presented a greater proportion of passive job and low-strain job, and nurses presented a higher proportion of active job than the other primary care workers (Figure 1). Depressive symptoms and probable major depression were significantly associated with having a passive, active, or high-strain job and with receiving low social support (Table 3). Those with low social support (adjusted odds ratio [AOR] = 3.01; 95% CI = 2.20, 4.12) and those with an active (AOR = 5.13; 95% CI = 3.46, 7.59) or a high-strain job (AOR = 6.70; 95% CI = 4.60, 9.73) had stronger associations with probable major depression.
TABLE 2—
Frequencies of Job Stress Dimensions and Feedback According to the Professional Category: São Paulo, Brazil, 2011–2012
| Variable | Community Health Workers, No. (%) | Nursing Assistants, No. (%) | Nurses, No. (%) | Physicians, No. (%) |
| Control | ||||
| Low | 1023 (57.8) | 338 (52.2) | 48 (15.7) | 67 (30.8) |
| High | 747 (42.2) | 309 (47.8) | 258 (84.3) | 150 (69.2) |
| Demand | ||||
| Low | 1178 (66.5) | 427 (66.0) | 117 (38.2) | 107 (49.3) |
| High | 592 (33.5) | 220 (34.0) | 189 (61.8) | 110 (50.7) |
| Social support | ||||
| Low | 1014 (57.3) | 425 (64.7) | 196 (64.1) | 116 (53.5) |
| High | 756 (42.7) | 222 (34.3) | 110 (35.9) | 101 (46.5) |
| Feedback | ||||
| Yes | 283 (16.0) | 156 (24.1) | 63 (20.6) | 45 (20.8) |
| Not defined | 328 (18.5) | 117 (18.1) | 37 (12.1) | 47 (21.6) |
| No | 1159 (65.5) | 374 (57.8) | 206 (67.3) | 125 (57.6) |
FIGURE 1—
Type of Job Strain According to Family Health Program Professional Category: São Paulo, Brazil, 2011–2012
Note. CHW = community health worker.
TABLE 3—
Associations of Participants’ Characteristics, Work-Related Variables, and Depression, According to the Multinomial Multiple Regression Final Model (n = 2940): São Paulo, Brazil, 2011–2012
| Depressive Symptoms |
Probable Major Depression |
|||
| Variable | AOR (95% CI) | P | AOR (95% CI) | P |
| Participants’ characteristics | ||||
| Gender | .001 | < .001 | ||
| Female (Ref) | 1 | 1 | ||
| Male | 0.55 (0.41, 0.74) | 0.24 (0.13, 0.44) | ||
| Age group, y | < .001a | < .001a | ||
| 18–29 (Ref) | 1 | 1 | ||
| 30–39 | 0.96 (0.80, 1,16) | 0.90 (0.66, 1.22) | ||
| 40–49 | 0.59 (0.44, 0.77) | 0.45 (0.31, 0.65) | ||
| ≥ 50 | 0.50 (0.36, 0.71) | 0.24 (0.12, 0.45) | ||
| Stressful life events | < .001a | < .001a | ||
| None (Ref) | 1 | 1 | ||
| 1 | 1.59 (1.31, 1.93) | 2.31 (1.75, 3.04) | ||
| 2 | 2.67 (2.02, 3.54) | 5.07 (3.64, 7.07) | ||
| ≥ 3 | 3.83 (2.98, 4.93) | 8.34 (6.0, 11.6) | ||
| Work-related variables | ||||
| Profession | .93 | .001 | ||
| Physician (Ref) | 1 | 1 | ||
| Nurse | 0.75 (0.49, 1.15) | 0.99 (0.48, 2.04) | ||
| Nursing assistant | 0.46 (0.32, 0.67) | 0.77 (0.40, 1.49) | ||
| CHW | 0.83 (0.58, 1.17) | 1.96 (1.07, 3.60) | ||
| Length of employment | .004 | < .001 | ||
| 3 m to < 2 y (Ref) | 1 | 1 | ||
| 2–6 y | 1.52 (1.24, 1.86) | 1.62 (1.20, 2.18) | ||
| > 6 y | 1.58 (1.23, 2.03) | 2.36 (1.66, 3.33) | ||
| Deprived area | .34 | .87 | ||
| No (Ref) | 1 | 1 | ||
| Yes | 1.19 (0.97, 1.46) | 1.09 (0.81, 1.46) | ||
| Feedback from supervisor | .01 | < .001 | ||
| Yes (Ref) | 1 | 1 | ||
| Not defined | 1.13 (0.90, 1.42) | 1.69 (1.20, 2.36) | ||
| No | 1.40 (1.13, 1.73) | 1.90 (1.44, 2.51) | ||
| Social support | .001a | < .001a | ||
| High (Ref) | 1 | 1 | ||
| Low | 1.93 (1.63, 2.28) | 3.01 (2.20, 4.12) | ||
| Job stress | .001 | < .001 | ||
| Low strain (Ref) | 1 | 1 | ||
| Passive | 1.74 (1.39, 2.17) | 1.66 (1.19, 2.33) | ||
| Active | 2.53 (1.91, 3.35) | 5.13 (3.46, 7.59) | ||
| High strain | 2.55 (1.95, 3.34) | 6.70 (4.60, 9.73) | ||
Note. AOR = adjusted odds ratio; CHW = community health worker; CI = confidence interval. Multinomial regression. Final model adjusted by gender, age group, stressful life events, profession, length of employment, deprived area, feedback from supervisor, social support, and job stress.
Trend P.
The majority of participants had been working in the FHP for 2 years or more (70.5%), had received feedback from their supervisors (59.6%), and had been working in deprived areas (65.5%; Table 1). In Table 3 are displayed the job-related variables significantly associated with depressive symptoms and probable major depression. The CHWs were more likely to have depressive symptoms and probable major depression than physicians, nurses, or nursing assistants. Workers who had been working for 2 years or more in the FHP had higher ORs for depressive symptoms and probable major depression than those who had been working for less time (trend P < .001). Participants who reported not receiving feedback from their supervisor were more likely to have depressive symptoms (AOR = 1.40; 95% CI = 1.13, 1.73) and probable major depression (AOR = 1.90; 95% CI = 1.44, 2.51). We did not find an association between working in a deprived area and depression.
DISCUSSION
We found a very high prevalence of depressive symptoms and probable major depression among primary care workers. The job-related variables strongly associated with probable major depression were profession (CHWs were nearly twice as likely to have probable major depression compared with physicians, whereas nurses and nursing assistants did not have an increased prevalence of probable major depression compared with physicians), length of employment in the FHP (2 years or more), job strain (passive, active, or high), low support from colleagues and supervisors, and lack of performance feedback from supervisors. Working in a deprived area and the number of people covered by the family health teams were not associated with the risk of depressive symptoms or probable major depression.
The prevalence of probable major depression in primary care workers (16%) was considerably higher than the prevalence observed in a population-based study that was also conducted in the city of São Paulo (9.4%),26 with CHWs being more likely to have probable major depression than other primary care workers. Previous studies found high prevalence of common mental disorders among CHWs.27
Some aspects of their work may explain the higher chance of probable major depression. First, CHWs are the only FHP workers who have to live in the community where they work. This may increase their workload and limit their privacy, as they are approached by the population even during nonworking hours to solve demands28 (e.g., difficulties accessing procedures in secondary care centers). Second, a previous study found that CHWs are more likely to be exposed to psychological violence at work than other primary care workers, and that was associated with increased risk of depression.18 Third, most CHW duties include home visits, providing preventive care, identifying populations’ demands and debate with their FHP team. Their job autonomy is limited, contributing to the understanding of why CHWs presented the higher proportion of passive jobs, which, according to the Karasek and Theorell model, is associated with risk of depression.29 Fourth, CHWs have lower educational level and earnings than their peer FHP team colleagues. However, in the context of the FHP, classifying primary care workers according to job grade hierarchy (administrative, professional or executive, clerical, and unskilled manual workers) could not be appropriate, because they perform some similar tasks, such as assisting the populations enrolled in the FHP, providing home care, and performing administrative work.
In LMICs, CHWs have played a key role in strengthening the link between health care providers and communities, and in reducing morbidity and mortality.16 In addition, they are considered a mitigating factor of the human resources crisis in health care in the aforementioned countries.30 Therefore, the high prevalence of depressive symptoms and of probable major depression in CHWs should be of great concern for stakeholders and policymakers, particularly in LMICs, where the deployment of CHWs is expanding.15
In our study, passive, active, and high-strain jobs were associated with depressive symptoms and probable major depression. The associations of depression with high-strain31,32 and passive jobs13,33 are consistent with previous evidence and also with the Karasek and Theorell model.29 However, the associations of depressive symptoms (AOR = 2.53; 95% CI = 1.91, 3.35) and probable major depression (AOR = 5.13; 95% CI = 3.46, 7.59) with active jobs are not in agreement with the Karasek and Theorell model, which described active jobs as having “an optimistic set of psychological outcomes.” Our results are consistent with other research conducted in Brazil that found an increased risk of mental health disorders in health workers (nurses and nursing assistants) with passive, active, and high-strain jobs, and these associations were stronger for health workers with active (prevalence ratio = 1.97) and high-strain jobs (prevalence ratio = 3.39).34 Importantly, those with high-strain jobs had an almost 3-fold increased likelihood of having depressive symptoms and more than a 6-fold increased likelihood of having probable major depression compared with those with low-strain jobs. With respect to social support, we found a higher OR for probable major depression in participants with low social support (AOR = 3.01; 95% CI = 2.20, 4.12); this result is in agreement with other research.6,8,32 According to the Karasek and Theorell model, social support at work is important for reducing the negative effects of high job demand and low job control.
Our data showed higher ORs for depressive symptoms and probable major depression in participants with longer length of employment, independently of job strain. We believe that primary care workers are exposed to a complex and particular context of stressors at work, at least partly because they act within and in direct interaction with the community, lacking a possible institutional protection that may happen in secondary and tertiary health settings. Longer exposure to such stressors may have a cumulative effect and increase the likelihood of depression. We also found that lack of performance feedback from supervisors was associated with higher risk of depressive symptoms and probable major depression. Although previous studies found that leadership styles focused on psychological support and performance feedback reduced the risk of depression,8 few studies examined this relationship among health care personnel. It is possible that receiving performance feedback from supervisors contributes to enhancing primary care workers’ skills and coping strategies for dealing with job demands, which in turn may increase job satisfaction and reduce the likelihood of major depression.
The strengths of our study include the large sample size, the very high response rate, and the adjustments for several covariates, including stressful life events. To the best of our knowledge, no previous study has assessed depression and job-related stressors in all professional categories that compose primary care teams, including CHWs. Moreover, this is the first study to evaluate the relationship between performance feedback from supervisors and depressive symptoms or major depression among primary care workers.
The location of the study in São Paulo, South America’s largest urban area, makes results highly relevant to primary care teams in large urban areas of most LMICs. Nevertheless, it also confers a limitation—our results may not be generalizable to nonurban settings. Other limitations of this study must be considered. First, the prevalence of depression may have been underestimated because we did not assess workers who were absent from work because of depression. Second, we assessed the presence of depressive symptoms in the moment of the interview; thus, participants that had treated depression in the previous 12 months and recovered were in the category “no depressive symptoms.” This may have weakened the associations toward the null value. Third, the cross-sectional design restricts our ability to infer a causal association of job strain with depression. We cannot exclude reverse causation in which participants with depressive symptoms perceive their work environment as stressful. However, we can argue that our findings are in line with those of longitudinal studies.35
Several consequences of depression were depicted in previous studies: absenteeism, disability, sick leave, impaired work performance, low productivity, poor quality of care provided, turnover, and suicide.1,2 High-strain and passive jobs have been shown to be associated with sick leave,33 and low social support was associated with reduced productivity and job performance.36 Because primary care workers are the “gatekeepers” of health care systems and should ideally guarantee accessibility, longitudinality, and comprehensive care for populations, depression in these workers can endanger the sustainability of primary care programs. Hence, our findings are of great concern for policymakers, particularly in LMICs, where a human resource crisis exists in primary care.30 Policymakers must create strategies to deliver care to primary care workers with depression, facilitating diagnosis and access to effective treatment, and reducing stigma.
Programs to enhance managerial skills of primary care workers’ supervisors, such as training in leadership aspects, increasing the knowledge and practice of giving efficient performance feedback, increasing job autonomy, and reducing conflicting demands may also help to lower stress at work and the risk of depression among workers. Use of techniques to perform better teamwork and enhance social support may also be useful to prevent depression. Further research should investigate the effectiveness of such interventions on primary care workers’ mental health, productivity, and quality of care.
ACKNOWLEDGMENTS
This study was funded by the São Paulo Research Foundation (FAPESP—2010/07180-6). A. T. C. da Silva was partially funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior and by the Center for Research on Population Mental Health. P. R. Menezes was partially funded by National Council of Technological and Scientific Development.
HUMAN PARTICIPANT PROTECTION
The institutional review board of the Municipal Health Department of São Paulo and the Ethics Committee of the Medical School of the University of São Paulo approved this investigation. All participants were guaranteed privacy and confidentiality, and all participants signed an informed consent before participation. We referred to medical care those participants who required mental health assistance.
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