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Diferencias de género en la relación entre factores personales intrínsecos y la
sintomatología ansiosa y depresiva de una población trabajadora
Gender differences in the relationship between intrinsic personal factors and
the anxious and depressive symptomatology of a working population
Fátima Méndez-López1,2 , Priscila Matovelle-Ochoa3, Marta Domínguez-García2,4* & Beatriz
Pascual-de la Pisa5,6
1Grupo de Investigación en Atención Primaria, Instituto de Investigación Sanitaria de Aragón. (IIS
Aragón), Zaragoza, España.
2Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud (RICAPPS), Instituto
de Salud Carlos III, Madrid, España.
3Servicio de Geriatría Hospital San Juan de Dios, Zaragoza, España.
4Servicio Aragonés de Salud (SALUD), Zaragoza, España.
5Unidad de Gestión Clínica de Camas, Distrito Sanitario Aljarafe-Sevilla Norte, Servicio Andaluz de
Salud, Camas, Sevilla, España.
6Departamento de Medicina, Facultad de Medicina de Sevilla, Sevilla, España
* Corresponding autor: mardoga5@gmail.com
Recibido 2023-10-03. Aceptado 2023-11-04
Resumen
Introducción: Los trastornos afectivos son un problema de salud con un gran impacto en el
funcionamiento psicosocial y calidad de vida de las personas que los sufren. Por ello, el objetivo de
este estudio fue analizar la analizar diferencias por género en la asociación entre los factores
personales intrínsecos y la sintomatología depresiva y ansiosa de una población trabajadora.
Métodos: Se realizaron análisis descriptivo, bivariante y multivariante de datos de 242 individuos en
edad laboral activa, entrevistados entre julio de 2021 y julio de 2022. El resultado primario fue la
gravedad de la sintomatología depresiva y ansiosa como variable continua. Resultados: La prevalencia
de síntomas depresivos en nuestra muestra es del 22,22% en mujeres y del 6,54 en varones, mientras
la prevalencia de sintomatología ansiosa fue similar en ambos sexos (21,50% en varones y 25,19% en
mujeres). En varones, la alta autoestima (β = −0,300; p=0,022) y una mayor edad (β = −0,210; p=0,031)
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son factores protectores de sintomatología depresiva y, la alta autoestima (β = −0,269; p=0,005) y la
alta activación (β = −0,031; p=0,049) en la sintomatología ansiosa. Mientras, en las mujeres, una
mayor autoeficacia y un mayor sentido de coherencia son factores protectores de la sintomatología
depresiva (β = −0,250, p=0,004; β = −0,244, p=0,005) y ansiosa (β = −0,254, p=0,004; β = −0,178,
p=0,040). Conclusión: Las mujeres trabajadoras tienen más sintomatología depresiva y ansiosa que
sus homólogos masculinos. Existen diferencias entre hombres y mujeres en los factores personales
intrínsecos que influyen en los síntomas depresivos y ansiosos.
Palabras clave: salud mental; depresión; ansiedad; determinantes sociales de la salud; Roles de
género.
Abstract
Introduction: Affective disorders are health problems with a significant impact on the psychosocial
functioning and quality of life of people who suffer from them. Therefore, the objective of this study
was to analyse gender differences in the association between intrinsic personal factors and depressive
and anxious symptoms in a working population. Methods: Descriptive, bivariate, and multivariate
analyses were performed on data from 242 individuals of active working age interviewed between
July 2021 and July 2022. The primary outcome was the severity of depressive and anxiety symptoms
as a continuous variable. Results: The prevalence of depressive symptoms in our sample is 22.22% in
women and 6.54% in men, while the prevalence of anxious symptoms was similar in both sexes
(21.50% in men and 25.19% in women). In men, high self-esteem (β = −0.300; p=0.022) and older age
(β = −0.210; p=0.031) are protective factors for depressive symptoms, and high self-esteem
(β = −0.269; p=0.005) and high activation (β = −0.031; p=0.049) in anxious symptomatology.
Meanwhile, in women, greater self-efficacy and a greater sense of coherence are protective factors
for depressive (β = −0.250, p=0.004; β = −0.244, p=0.005) and anxious symptoms (β = −0.254, p=0.004;
β = −0.178, p=0.040). Conclusion: Women workers have more depressive and anxious symptoms than
their male counterparts. There are differences between men and women in the intrinsic personal
factors that influence depressive and anxious symptoms.
Keywords: mental health; depression; anxiety; Social Determinants of Health; Gender roles.
INTRODUCTION
Affective disorders are a major and growing health problem with significant morbidity worldwide
(WHO, 2021). Currently, affective disorders have a significant impact on the quality of life of 246
million people with major depressive disorders and 374 million people with anxiety disorders
worldwide (Santomauro et al., 2021). These disorders are more prevalent or diagnosed in women
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than in men. For example, according to reports from the World Health Organization (WHO) (2021),
depressive symptoms affect 5.1% of women compared to 3.6% of men, and anxious symptoms affect
4.6% of women compared to 2.6% of men.
These syndromes are characterised by a significant clinical impairment in an individual's cognition,
emotional regulation, or behaviour (WHO, 2019). Furthermore, they result from complex social,
psychological, and biological interactions. They are associated with significant distress or impairment
in personal, familial, social, educational, occupational, or other important areas of functioning
(Sekhon & Gupta, 2022).
Among these factors, stressful work conditions predict poor mental health, and there is growing
concern that such conditions contribute to the population burden of two common psychiatric
disorders: major depression and generalised anxiety disorder (Melchior et al., 2007). On the other
hand, according to the effort-reward model at work, the risk of presenting stress and psychosomatic
disorders would occur when reward factors, such as salary, esteem, professional promotion, or job
security, do not compensate for effort. work (Cabrera Armijos et al., 2022; Siegrist, 1996).
Depressive symptomatology has been associated with disability in terms of decreased productivity
("presenteeism"), absenteeism, job turnover, and unemployment, as well as early retirement, low
quality of life, and increased risk of myocardial infarction (Magnusson Hanson et al., 2009). Job
demands that exceed the individual's coping abilities are perceived as stressful and could influence
the risk of psychiatric disorder through biological, psychological, psychosomatic, and behavioural
mechanisms (Melchior et al., 2007).
Furthermore, certain personal factors in health-promoting behaviour influence physical and mental
well-being (Lakshmi et al., 2023). Among these factors, health literacy (Sørensen et al., 2015), patient
activation (Hibbard et al., 2005), resilience (Campbell-Sills & Stein, 2007), self-efficacy (Sherer et al.,
1982), self-esteem (Bailey, 2003) and the sense of coherence (Antonovsky, 1993) stand out as
elements that significantly influence our physical and emotional health.
Health literacy is defined as the population's knowledge, motivation, and individual capabilities to
understand and make decisions about the promotion and management of their health (Sørensen et
al., 2015). Improving health literacy positively affects people's emotional state, with a moderately
positive effect on reducing symptoms of depression and anxiety (Magallón-Botaya et al., 2023).
Patient activation refers to an individual's ability and capacity to manage their health condition and
the confidence to assume this responsibility (Hibbard et al., 2005). Individuals with high activation
levels have a greater ability for self-care, better health, and fewer depressive symptoms (Blakemore
et al., 2016).
Resilience is a positive adaptation to adverse life events and events (Campbell-Sills & Stein, 2007)
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People with high resilience can better cope with adverse life situations, leading to better overall
health outcomes, such as lower depressive and anxious symptoms and lower mortality (Smith &
Hollinger-Smith, 2015; To et al., 2022).
Self-efficacy is represented as a feeling of confidence in one's ability to cope with certain stressors in
life (Sherer et al., 1982). People with high self-efficacy have better emotional regulation and more
effective psychosocial functioning (Milanovic et al., 2018; Schönfeld et al., 2017).
Self-esteem is a positive or negative feeling about oneself and is built through the evaluation of one's
attributes (Bailey, 2003). Adults with high global self-esteem are likelier to have greater physical,
mental, occupational, and social well-being. Low self-esteem is related to emotional problems and
substance abuse (Orth et al., 2012).
Finally, a sense of coherence refers to an individual's disposition toward values essential to her well-
being and life experiences (Antonovsky, 1993). People with a strong sense of coherence are likelier to
maintain good mental health (Giglio et al., 2015). Promoting the population's participation in coping
with diseases and self-care of their health is a key element in the health of the population in general
and especially the population with affective disorders (WHO, 2022). It is necessary to investigate
further how psychological constructs, beliefs, and people's self-care capacity can affect people's well-
being or discomfort and contribute to a healthier life from a mental health perspective. Furthermore,
it is important to evaluate longitudinal changes in these factors and affective disorders, given their
association with increased comorbidity and mortality (Zhang et al., 2009). The analysis of the
association of psychological constructs and the mental health of individuals and communities
provides evidence that will better address and prevent these prevalent problems and promote their
improvement from a more global and holistic perspective.
According to primary care clinical data from the National Health System (2021), the decade between
the ages of 30 and 40 is the most common stage of presenting depressive and anxious symptoms.
These problems are more common in women than in men at this age (depression: 4.2% vs 2.0%;
anxiety: 10% vs 5.7%, respectively). Furthermore, at this age, these symptoms significantly impact
people's work, economic and family activities (WHO, 2023). Therefore, this study aims to analyse
gender differences in the association between intrinsic personal factors (health literacy, patient
activation, resilience, self-efficacy, self-esteem, and sense of coherence) and Depressive and anxious
symptoms of a working population.
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METHODS
Study design
This research project is an analysis of secondary data (Wickham, 2019) collected from a prospective
longitudinal cohort (Méndez-López et al., 2023) whose main objective is to analyse the relationship
between psychological constructs (self-efficacy, activation, health literacy, resilience, personality
traits, sense of coherence, self-esteem) and the presence of depressive and anxious symptoms. The
initial data of this cohort were collected between July 2021 and July 2022 in primary care health
centres (PHC) in Aragon and registered in the ISRCTN Registry before the start (ISRCTN12820058).
Participants and procedure
The study population was participants between 35-65 years old, members of a prospective
longitudinal cohort conducted in Aragon (Méndez-López et al., 2023), with a good level of Spanish
and who agreed to participate in the study voluntarily and signed the informed consent. The exclusion
criteria were having a terminal illness, cognitive dysfunction, dementia, or any significant illness that
could seriously interfere with participation in the study.
To select the cohort participants, a stratified selection was conducted by age, sex, and population
distribution in urban and rural areas concerning the data from the Aragon census of the National
Institute of Statistics (2021). The purpose of this stratification was to provide maximum diversity to
the sample while ensuring the representativeness of the population. The cohort was recruited in two
PHC centres (one rural, Daroca, and another urban, Arrabal neighbourhood of Zaragoza). Following
the stratification criteria, individuals were randomly selected from the list of users of the participating
health centres.
The selected participants were contacted by letter or telephone, where they were fully informed of
the study. Those who showed interest in participating voluntarily made an appointment at their usual
health centre to complete the questionnaires. The study adhered to the STROBE Initiative
(Strengthening the Reporting of Observational Studies in Epidemiology) (von Elm et al., 2008).
The sample size was established in the prospective longitudinal cohort study on which this secondary
data analysis is based. It established itself at 290 participants, according to the prevalence of
depressive and anxious symptoms as the primary variable. Finally, 505 people were assessed for
eligibility, of which 400 participants were included in the DESVELA cohort in Aragón (Méndez-López
et al., 2023), exceeding the sample size requirement. For the present study, the 242 cohort
participants of active working age were included.
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Instruments
Sociodemographic information
Participant information was collected on sex, age, habitual residence (urban, rural), marital status
(single/divorced/widowed, or in a relationship), education (none/primary or secondary/university),
occupation (employed, self-employed), type of working day (continuous, part-time, irregular or
shifts), and economic level of the family unit (measured through the minimum interprofessional wage
(SMI)) through an ad hoc questionnaire. In addition, the time dedicated to personal roles and weekly
hours dedicated to work, household chores, and caring for minors or dependents were recorded.
Work stress was measured using the effort-reward imbalance questionnaire (ERI, Spanish version)
(Siegrist et al., 2004, 2009). It consists of 23 Likert-type items and records information on the worker's
perception of their work situation concerning extrinsic effort, professional reward, and the degree of
overinvolvement experienced by the worker. A higher score implies greater work stress. The validated
Spanish version has a Cronbach's α value of 0.80 (Muñoz-Navarro et al., 2017) The internal
consistency of the ERI in our sample was 0.72.
Depressive and anxious symptoms.
The presence and severity of depression symptoms were assessed using the Patient Health
Questionnaire (PHQ-9, Spanish version) (Kroenke & Spitzer, 2002), which measures the presence and
severity of depression. Severity levels included no depression (0 to 4), mild depression (5 to 9),
moderate depression (10 to 14), moderately severe depression (15 to 19), and severe depression (20
to 27). The validated Spanish version has a Cronbach's α value of 0.80 (Muñoz-Navarro et al., 2017).
The internal consistency of the PHQ-9 in our sample was 0.80.
The presence and severity of anxiety symptoms were measured using the Generalized Anxiety
Disorder (GAD-7, Spanish version) (Spitzer et al., 2006). It consists of seven multiple-choice questions,
and each answer is scored on a scale ranging from 0 to 3. Each item describes one of the typical
symptoms of generalized anxiety disorders. Severity levels included no anxiety (0 to 4), mild anxiety
(5 to 9), moderate anxiety (10 to 14), and severe anxiety (15 to 21). The validated Spanish version has
a Cronbach's α value of 0.93 (Garcia-Campayo et al., 2010). Our sample's internal consistency was
high (Cronbach's α = 0.83).
Personal factors on health-promoting behaviour.
Health literacy was measured using the European Health Literacy Questionnaire (HLS-EU-Q16,
Spanish version) (Sørensen et al., 2015). Higher scores (after transforming each into a dichotomous
response) (range 0-16) indicate a higher level of health literacy: inadequate or problematic levels of
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health literacy (0-12) and sufficient or adequate health literacy (13- 16). In its Spanish version,
Cronbach's α is 0.98 (Nolasco et al., 2020). Internal consistency in our sample was high (α =0.88).
Patient activation was assessed using the Patient Activation Questionnaire (PAM-13, Spanish version)
(Hibbard et al., 2005). Higher scores indicate a higher level of patients' activation to address their
health (range 0-100) and place the individual in one of four activation levels: "Disengaged and
Overwhelmed" (0 - 47.0), " Become aware, but keep fighting." (47.1 - 55.1), "Take action" (55.2 - 67.0)
and "Maintain behaviours and move forward" (67.1 - 100). In its Spanish version, Cronbach's α is 0.7
(Moreno-Chico et al., 2017). Internal consistency in our sample was high (α =0.89).
Resilience was measured using the Connor-Davidson Resilience Scale (CD-RISC-10, Spanish version)
(Campbell-Sills & Stein, 2007). This scale score on the questionnaire was the sum of the responses
obtained for each item (range 0-40), with higher scores indicating the highest level of resilience. The
validated Spanish version has a Cronbach's α value of 0.85 (Notario-Pacheco et al., 2011). The internal
consistency of our sample was 0.86.
Self-efficacy was assessed using the General Self-Efficacy Scale (GSES-12, Spanish version) (Sherer et
al., 1982). The final score of the questionnaire was the sum of the responses obtained in each item
(range 12-60), and the highest scores indicated the highest level of self-efficacy. The validated Spanish
version has a Cronbach's alpha value of 0.69 (Herrero et al., 2014). The internal consistency in our
sample was acceptable (α =0.76).
Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES, Spanish version (Rosenberg,
1965). The scale ranges from 0 to 30. Scores between 15 and 25 are within the normal range; scores
less than 15 suggest low self-esteem. The validated Spanish version has a Cronbach's α of 0.85
(Martín-Albo et al., 2007). The internal consistency in our sample was acceptable (α = 0.78).
The sense of coherence was measured using the Sense of Coherence Scale (SOC-13, Spanish version)
(Antonovsky, 1993). It measures the sense of coherence, understandability, manageability and
meaning. Higher scores (after reversing the reversed items) (range 13-91) indicate a greater sense of
coherence. The validated Spanish version has a Cronbach's α of 0.83 (Moreno, B., Alonso, M., &
Álvaréz, 1997). The internal consistency in our sample was acceptable (α =0.76).
Data analysis
The normal distribution of the results was verified using the Kolmogorov-Smirnov test. A descriptive
analysis was performed to determine the characteristics of the sample: frequencies (n) and
percentages (%) for categorical variables, mean (M) and standard deviation (SD) for continuous
variables. Secondly, bivariate analyses were conducted using the chi-square test for qualitative
variables and the Student's t-test for continuous variables, aiming to compare the different variables
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between men and women. Furthermore, to analyse the associations between the anxiety (GAD-7)
and depressive (PHQ-9) symptomatology score and all variables, correlations were performed using
the Pearson correlation coefficient (Pearson's r for the relationship between two continuous variables
and point biserial correlation rpb for the relationship between a continuous variable and a
dichotomous variable) (Sheskin, 2020).
Third, the multivariate analysis was performed with ordinary linear regression, using the stepwise
variable selection method, with a probability of entering the model of 0.05 and a probability of
remaining in the model of 0.10 (Núñez et al., 2011). The dependent variable was the score on the
depressive symptomatology scale (PHQ-9) and the anxiety symptomatology scale (GAD-7). All
independent variables (sociodemographic and personal factors related to health behaviour variables)
were entered into the regression models (Hamilton, 1994), each time eliminating the least correlated
variable. The sociodemographic variables were classified into two categories to be included in the
multiple regression. Multicollinearity (Variance Inflation Factor (VIF) and tolerance values were
assessed for the different linear regressions.
Ethical Issues
This study was approved by the Clinical Research Ethics Committee of Aragon (PI20/302) and was
developed in accordance with the standards of the Declaration of Helsinki. The collection, processing,
communication, and transfer of personal data of all participating subjects complied with the
provisions of the General Data Protection Regulation (EU) (GDPR 2016/679) and Organic Law 3/2018
on Data Protection Personal. Informed consent was obtained from all participants. All subjects
allowed their data to be anonymized and used solely for the purposes and publication of the results
of this study.
RESULTS
Of the 400 individuals included in the initial cohort in Aragon, 242 participants between 35 and 65
with active employment status were included in this study (Figure 1). The characteristics of this
population are shown in Table 1
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Figure 1
Recruitment and selection flowchart of participants.
The average age of the analysed sample is 49.43 years, with a slight predominance of the female sex
and greater participation from the urban environment. In addition, there is a greater tendency for
women to be employed workers with a working day with fixed hours. Of the 50 self-employed
participants, 92% considered their schedule irregular, while of the 186 employees, 44.8% reported it
as irregular. As expected, women dedicate significantly more hours to domestic tasks than men. There
are no differences regarding the rest of the sociodemographic variables.
22.22% of the women in our samples present depressive symptoms, while only 6.54% of the men
present it. Meanwhile, the presence of anxious symptoms manifests itself in a similar way in both
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sexes (21.50% in men and 25.19% in women). Regarding intrinsic personal factors, women are more
health-active than men, and greater health literacy stands out. There is greater work stress among
women workers compared to men (Table 1). Specifically, women register a higher degree of
overinvolvement and extrinsic effort than men.
Table 1
Sociodemographic, personal, and mental health characteristics of the sample
Variable
Total (n=242)
Men (n=107)
Women (n=135)
p-
value
Age, years; M ± SD
49.43 ± 7.73
48.70 ± 7.71
50.01 ± 7.72
0.190
Municipality, n (%)
Urban
147 (60.74)
57 (53.27)
90 (66.67)
0.047
Rural
95 (39.26)
50 (46.73)
45 (33.33)
Marital status, n
(%)
With a partner
186 (76.86)
81 (75.70)
105 (77.78)
0.760
Without a partner
56 (23.14)
26 (24.30)
30 (22.22)
Education, n (%)
None or primary
207 (85.54)
90 (84.11)
117 (86.67)
0.586
Secondary or tertiary
35 (14.46)
17 (15.89)
18 (13.33)
Weekly hours of paid work, M ± SD
39.06 ± 11.64
40.66 ± 13.79
37.79 ± 9.46
0.056
Weekly hours of housework, M ± SD
13.44 ± 7.81
11.04 ± 5.92
15.35 ± 8.61
<0.00
1
Weekly hours of caregiving, M ± SD
10.74 ± 15.95
10.00 ± 14.49
11.33 ± 17.04
0.522
Worker type, n (%)
Employee
192 (79.34)
77 (71.96)
115 (85.19)
0.016
Self-employed
50 (20.66)
30 (28.04)
20 (14.81)
Type of working
day, n (%)
Fixed full-time schedule
110 (37.30)
37 (34.57)
73 (54.07)
0.003
Irregular
schedule/departure/shifts
132 (70.25)
70 (65.42)
62 (45.92)
Monthly household
income, n (%)
<2 IMW
89 (36.78)
37 (34.58)
52 (38.52)
0.592
>2 IMW
153 (63.22)
70 (65.42)
83 (61.48)
Self-efficacy (GSES-12), M ± SD
46.35 ± 5.47
46.62 ± 4.66
46.13 ± 6.04
0.488
Resilience (CD-Risc-10), M ± SD
28.60 ± 6.32
28.52 ± 5.91
28.66 ± 6.65
0.869
Patient activation (PAM-13), M ± SD
63.08 ± 16.44
60.74 ± 15.81
64.94 ± 16.75
0.047
Health literacy (HLS- EU-Q16), M ± SD
14.30 ± 2.00
13.87 ± 2.35
14.64 ± 1.61
0.003
Sense of coherence (SOC-13), M ± SD
57.73 ± 6.60
58.00 ± 6.44
57.52 ± 6.74
0.580
Self-esteem (RSES), M ± SD
34.54 ± 3.73
34.66 ± 3.65
34.45 ± 3.81
0.660
Depressive
symptoms (PHQ-9),
n (%)
No depression (≤4)
205 (84.71)
100 (93.46)
105 (77.78)
<0.00
1
Mild (5-9)
26 (10.74)
7 (6.54)
19 (14.07)
Moderate (10-14)
6 (2.48)
0 (0)
6 (4.44)
Moderate-severe (15-19)
3 (1.24)
0 (0)
3 (2.22)
Severe (≥27)
2 (0.83)
0 (0)
2 (1.48)
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Anxious symptoms
(GAD-7), n (%)
No anxiety (≤4)
185 (76.45)
84 (78.50)
101 (74.81)
0.016
Mild (5-9)
45 (18.60)
21 (19.63)
24 (17.78)
Moderate (10-14)
8 (3.31)
2 (1.87)
6 (4.44)
Severe (≥21)
4 (1.65)
0 (0)
4 (2.96)
Work stress (ERI), M ± SD
38.47 ± 5.09
37.30 ± 5.15
39.40 ± 4.86
0.002
Extrinsic effort
15.17 ± 2.84
14.49 ± 2.68
15.72 ± 2.87
0.001
Professional reward
9.51 ± 2.03
9.59 ± 1.86
9.47 ± 2.16
0.669
Overinvolvement
13.77 ± 2.84
13.23 ± 2.63
14.21 ± 2.95
0.009
Note. CD-RISC-10: Connor-Davidson Resilience Scale; SD: Standard deviation; ERI: Effort-Reward Imbalance Scale; GAD-7:
Generalized Anxiety Disorder Scale; GSES-12: Generalized Self-Efficacy Scale; HLS-EU-Q16: “European Health Literacy
Survey”; M, medium; n, frequency; %, percentage; PAM-13: Patient Activation Measurement Questionnaire; PHQ-9:
Patient Health Questionnaire; RSES: Rosenberg Self-Esteem Scale; IMW: Interprofessional Minimum Wage; SOC-13:
Antonovsky Sense of Coherence Scale. Statistically significant values (p≤0.05) are marked in bold.
Analysing more deeply the relationship between affective disorders and the sociodemographic and
personal characteristics of men workers and women (Table 2), we found that women who lived in
rural areas, with a level of primary education or none and an irregular working day had more
depressive symptoms, while, in men, depressive symptoms are associated with high values of work
stress. No relationship was found between depressive symptoms (PHQ-9) and the rest of the
sociodemographic characteristics in men. Concerning intrinsic personal factors, depressive
symptomatology in women is associated with lower scores in self-efficacy, sense of coherence, and
self-esteem. In contrast, in men, depressive symptomatology is associated with lower scores in the
sense of coherence and self-esteem.
On the other hand, our data shows that self-employed women had more anxiety symptoms. In
contrast, men with a full-time schedule, more significant work stress and more excellent work
overinvolvement have higher anxiety symptom scores. Women with anxious symptoms were the
women with the lowest scores in self-efficacy, resilience, sense of coherence, and self-esteem. No
relationship was found between anxious symptomatology (GAD-7) and the personal characteristics of
men (Table 2)
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Table 2
Bivariate correlations of depressive and anxiety symptoms, sociodemographic and personal factors
Variables
Depressive symptoms (PHQ-9)
Anxious symptoms
(GAD-7)
Men
Women
Men
Women
Age, years
-0.185
0.001
-0.156
0.011
Municipality (Urban)
0.001
-0.209*
0.167
-0.122
Marital status (With a partner)
-0.143
0.147
-0.069
-0.035
Education (Secondary or tertiary)
0.051
-0.180*
0.141
-0.090
Worker type (Self-employed)
0.164
-0.058
0.082
-0.174*
Type of working day (Fixed full-time Schedule)
0.135
-0.181*
0.281**
-0.099
Monthly household income (>2 IMW)
-0.104
-0.073
-0.118
0.020
Weekly hours of paid work
-0.013
0.083
-0.048
0.022
Weekly hours of housework
-0.180
-0.043
-0.050
-0.064
Weekly hours of caregiving
-0.040
0.025
0.002
0.044
Self-efficacy (GSES-12)
-0.173
-0.292**
-0.173
-0.288**
Resilience (CD-Risc-10)
-0.089
-0.183
-0.067
-0.266**
Patient activation (PAM-13)
-0.074
-0.104
-0.148
-0.142
Health literacy (HLS- EU-Q16)
0.003
-0.135
0.027
-0.059
Sense of coherence (SOC-13)
-0.217*
-0.282**
-0.068
-0.224**
Self-esteem (RSES)
-0.282**
-0.247**
-0.311
-0.176*
Work stress (ERI)
0.169
0.656
0.197*
0.508
Extrinsic effort
0.227
-0.026
0.135
0.060
Professional reward
-0.011
-0.105
-0.029
-0.143
Overinvolvement
0.215*
0.123
0.270*
0.174
Note. CD-RISC-10: Connor-Davidson Resilience Scale; ERI: Effort-Reward Imbalance Scale; GAD-7: Generalized Anxiety
Disorder Scale; GSES-12: Generalized Self-Efficacy Scale; HLS-EU-Q16: “European Health Literacy Survey”; PAM-13: Patient
Activation Measurement Questionnaire; PHQ-9: Patient Health Questionnaire; RSES: Rosenberg Self-Esteem Scale; IMW:
Interprofessional minimum wage; SOC-13: Antonovsky Sense of Coherence Scale. Statistically significant values (p≤0.05)
are marked in bold; *p<0.05; **p<0.01; ***p<0.001.
To further analyse the magnitude of the correlation and the increase in depressive and anxious
symptomatology scores (PHQ-9 and GAD-7) associated with sociodemographic and personal
characteristics, different multivariate linear regression models were conducted (Tables 3 and 4).
We found that, in men, high self-esteem (β = −0.300; p=0.022) and older age (β = −0.210; p=0.031) are
protective factors against depressive symptoms, while, in women, greater Self-efficacy
(β = −0.250; p=0.004) and a greater sense of coherence (β = −0.244; p=0.005) are favourable factors
for having less depressive symptoms (Table 3).
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Table 3
Regression models of depressive symptomatology scores according to the PHQ-9 scale with sociodemographic data and
personal factors as predictors.
Model
Unstandardised
coefficient
Standardised
coefficients
t
p-
value
95% CI
of B
Collinearity Statistics
B
SE
β
Tolerance
VIF
(Constant)
9.503
2.240
4.243
<0.001
[5.058;
13.949]
Self-esteem (RSES)
-0.158
0.051
-0.300
-3.123
0.002
[-0.259; -
0.058]
0.985
1.015
Age
-0.054
0.024
-0.210
-2.188
0.031
[-0.102; -
0.005]
0.985
1.015
(Constant)
20.503
3.795
5.402
<0.001
[12.991;
28.015]
Self-efficacy (GSES-
12)
-0.180
0.061
-0.250
-2.966
0.004
[-0.300;
-0.060]
0.968
1.033
Sense of coherence
(SOC-13)
-0.156
0.054
-0.244
-2.893
0.005
[-0.262;
-0.049]
0.968
1.033
Note. β: Standardized coefficients; B: Unstandardized regression coefficient; SE: standard error; F: F statistic; GSES-12:
Generalized Self-Efficacy Scale; CI: confidence intervals; PHQ-9: Patient Health Questionnaire; R2: Total variance; RSES:
Rosenberg Self-Esteem Scale; SOC-13: Antonovsky Sense of Coherence Scale; t: t-test; VIF: Variance inflation factor.
Statistically significant values (p≤0.05) are marked in bold; *p<0.05; **p<0.01; ***p<0.001.
On the other hand, as seen in Table 4, we found that, in men, high self-esteem (β = −0.269; p=0.005)
and high activation (β = −0.031; p=0.049) are protective factors for anxious symptomatology;
however, that full-time working is a predictor of having more significant anxious symptomatology
(β = 0.248; p=0.010). Meanwhile, in women, greater self-efficacy (β = −0.254; p=0.004) and a greater
sense of coherence (β = −0.178; p=0.040) are favourable factors for having less anxious symptoms, the
same as in depressive symptoms.
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Table 4
Regression model of anxiety symptom scores according to the GAD-7 scale with sociodemographic data and personal factors
as predictors.
Model
Unstandardised
coefficient
Standardised
coefficients
t
p-value
95% CI
of B
Collinearity Statistics
B
SE
β
Tolerance
VIF
(Constant)
10.276
2.479
4.145
<0.001
[5.121;
14.590]
Self-esteem (RSES)
-0.192
0.067
-0.269
-2.869
0.005
[-0.324;
-0.059]
0.979
1.021
Type of working day
(Fixed full-time
Schedule)
1.367
0.521
0.248
2.622
0.010
[0.332;
2.403]
0.961
1.041
Patient activation
(PAM-13)
-0.031
0.015
-0.186
-1.988
0.049
[-0.061;
-0.001]
0.977
1.024
(Constant)
17.885
3.749
4.770
<0.001
[10.464;
25.305]
Self-efficacy
(GSES-12)
-0.177
0.060
-0.254
-2.955
0.004
[-0.296;
-0.059]
0.968
1.033
Sense of coherence
(SOC-13)
-0.110
0.053
-0.178
-2.072
0.040
[-0.216;
-0.005]
0.968
1.033
Note. β: Standardized coefficients; B: Unstandardized regression coefficient; SE: standard error; F: F statistic; GSES-12:
Generalized Self-Efficacy Scale; CI: confidence intervals; GAD-7: Generalized Anxiety Disorder Scale; R2: Total variance;
RSES: Rosenberg Self-Esteem Scale; SOC-13: Antonovsky Sense of Coherence Scale; t: t-test; VIF: Variance inflation factor.
Statistically significant values (p≤0.05) are marked in bold; *p<0.05; **p<0.01; ***p<0.001.
DISCUSSION
This study analysed the association between anxious and depressive symptoms and
sociodemographic, work, and personal characteristics (resilience, self-efficacy, sense of coherence,
patient activation, health literacy, and self-esteem) in a sample of men workers and women. The
behaviour of the different factors that influence depressive and anxiety symptoms is other in men
than in women workers.
Women workers spend much more time on domestic tasks, have more significant work stress, and
have more severe symptoms of depression and anxiety than men. These results coincide with Breij et
al. (2022), longitudinal investigation of 313 workers, which also demonstrates greater dedication to
informal care and household chores in the female sex, while higher income and a more significant
number of working hours were associated with the male sex (not statistically significant in our data).
Breij et al. (2022), also observed that the female sex was significantly associated with more depression,
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a fact already confirmed in the literature. Furthermore, a recent systematic review suggests that
inequalities in the division of unpaid labour expose women to a greater risk of poorer mental health
than men (Ervin et al., 2022). Theorell et al. (2014) study conducted in a population of 2,731 male and
3,446 female workers from Sweden aged 16-64 years, reported women with higher levels of job strain
than men and job strain was as strongly related to depressive symptoms among men as well as among
women.
Specifically in our findings, in women, depressive symptoms were associated with living in rural areas,
a level of primary education or less, and an irregular workday. In previous research, female
participants with higher education reported a lower prevalence of depressive symptomatology and
significantly less knowledge and stigma around depressive symptomatology than participants with
lower educational levels (Lopez et al., 2018). However, in our multiple linear regression models, the
level of education does not influence the anxious and/or depressive symptomatology of women
workers or men. On the other hand, in men, anxious symptoms were associated with a continuous
fixed working day schedule. Furthermore, in older men, the presence of depressive symptoms is
lower, while working a continuous fixed day is a predictor of having more significant anxiety
symptoms. Previous research suggests that older men workers tend to report higher levels of
resilience, lower depressive symptoms, and satisfaction with their work than younger employees (Hsu,
2018). Shiri et al. (2022) systematic review indicated that flexible working increases employees'
control over work hours and has beneficial effects on depressive symptoms, burnout, fatigue,
psychological distress, and emotional exhaustion.
On the other hand, there is greater work stress among women workers compared to men. Specifically,
women register a higher degree of overinvolvement and extrinsic effort than men. However, in men,
depressive symptoms were associated with high levels of work stress, while anxious symptoms were
associated with greater work stress and more excellent work overinvolvement. This association was
not statistically significant in women. In line with these findings, Álvares y Gómez (2011) suggests that
women are subject to high levels of stress due to role overload both at work (long work hours, labour
market) and in the family (family role and domestic work). Meanwhile, as Gómez (2012) points out,
men value the work role positively; they see work as a means of maintenance, fulfilment, and constant
satisfaction thanks to the achievements and learning it provides them. She also mentions that
overinvolvement in their work role can generate work stress in men. In line with these results, a
longitudinal study of male working adults in Korea associated incident depressive and anxiety
symptoms with more significant job stress and demand, job insecurity, lack of reward, and discomfort
in their organisational climate (S. Kim et al., 2020; S.-Y. Kim et al., 2020).
Regarding intrinsic personal factors, women are more health-active than men, and greater health
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literacy stands out. These results coincide with Lee et al.(2015) cross-sectional study, in which Korean
women indicated a higher level of health literacy than men in understanding medical forms,
instructions on medication bottles, and written information offered by healthcare providers.
Furthermore, previous evidence shows how gender influences patient activation, as in Paukkonen et
al. (2021) cross-sectional study in which women evaluated and gave greater importance than men to
planning and decision-making, information and knowledge, motivation and encouragement, and
family participation in their health.
Specifically, in women, anxious and depressive symptoms were associated with lower scores in self-
efficacy, resilience, sense of coherence, and self-esteem. Furthermore, in women, greater self-efficacy
and a greater sense of coherence have the potential to promote a lower presence of depressive and
anxiety symptoms. These results were recently observed in Dong et al. (2023) cross-sectional, in which
3,177 health workers participated. It was observed that social support and self-efficacy had a
significant negative influence on depressive and anxious symptoms. These results also agree with
those obtained in the cross-sectional study conducted on 500 Korean workers, in which lower self-
efficacy, among other factors, affected the workers' depressive symptoms (Park & Lee, 2023).
Regarding resilience, in the study by Sardella et al. (2022) involving 108 Italian adults, women reported
lower levels of psychological resilience compared to men. Furthermore, the high correlation of lower
levels of psychological resilience with higher levels of depressive, anxiety and stress symptoms was
highlighted. Concerning previous research on the sense of coherence, Lelek-Kratiuk & Szczygieł (2022)
evaluated gender differences in adults in Poland; it was identified that the purpose of coherence was
negatively and weakly/moderately correlated with mental health in women.
In men, only depressive symptoms were associated with lower scores in the sense of coherence and
self-esteem. In the case of men, higher self-esteem has the potential to promote a lower presence of
depressive and anxiety symptoms. Furthermore, the presence of greater activation in these men is a
predictor of less or milder anxiety symptomatology. Lelek-Kratiuk et al. (2022) also identified that the
sense of coherence was negatively and weakly/moderately correlated with mental health in men. On
the other hand, Boettcher et al. (2019) evidenced in their qualitative study the influence of the norms
and roles established for men workers on their emotional state and self-esteem. These norms portray
men as highly productive and emotionally controlled workers. The self-esteem of the participants is
related to the ability to contribute and achieve their work goals, generating anxiety and anguish when
they are not able to contribute to the extent they want.
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Strengths and limitations
Based on previous studies, we now know patterns of certain psychological constructs associated with
the mental health of the working population. However, few investigations analyse whether there are
differences between men and women in the sociodemographic characteristics and personal factors
that influence the severity of depressive and anxious symptoms. Furthermore, the profile of the
participants corresponds to the most common age of depressive and anxious symptoms and where
these symptoms significantly affect people who are often of age to conduct work, economical and
complete family activities (WHO, 2023).
Several limitations should be considered in this study. First, data were collected at a single time point
rather than longitudinally, which limited the ability to draw causal inferences or determine the
direction of causal relationships. Future prospective studies with a large sample size are justified to
validate our findings (Álvarez-Hernández & Delgado-DelaMora, 2015). Extensive future intervention
research is needed to verify our hypothesised models. Second, according to the population census,
the ratio of men to women could not be achieved, as the percentage of women was higher than
estimated in the 2021 census. Current research suggests that the willingness to participate in research
is seen as significantly affected by sex, with women being more likely than men to contribute (Glass
et al., 2015). Thirdly, the survey was conducted with two types of questionnaires with different
limitations (on the one hand, self-administered and others hetero administered). On the one hand,
self-administered questionnaires give rise to possible bias due to omitting or misinterpreting
questions by not having an interviewer ask questions about the questionnaire itself. On the other
hand, hetero-administered questionnaires lose the freedom of response time and psychological
exposures, as they may feel pressured or observed by the recruiter (Choi et al., 2010; Demetriou et
al., 2015). Lastly, the symptoms of depression and anxiety. They were measured for this analysis as
continuous variables using the PHQ-9 and GAD-7 scores without considering the different levels of
depressive symptomatology qualitatively. Furthermore, these questionnaires were only measured
once, and subsequent changes in the level of these affective problems, the cumulative burden of
depressive and anxiety symptomatology, or time-varying associations with outcomes were not
tracked.
CONCLUSION
These findings contribute to the search for a relationship between the characteristics of individuals
and the presence of affective symptoms of anxiety and/or depression. Women workers have more
depressive and anxious symptoms than their male counterparts. Our findings reveal that, in men, high
self-esteem and older age are protective factors for depressive symptoms and high self-esteem and
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activation for anxious symptoms. Meanwhile, in women, greater self-efficacy and a greater sense of
coherence are protective factors against depressive and anxious symptoms.
Our findings provide new insight into personal health factors' role in affective mental health and
underscore a new approach to preventive identification and early care measures among at-risk
individuals and their families. However, more research is needed on the interrelationship between
personal factors and depressive and anxiety symptomatology. The study findings provided a
foundation for future research into the combined role of individual factors and how they affect the
severity of depressive and anxious symptomatology.
AVAILABILITY OF DATA AND MATERIALS
Data supporting the findings of this study are available from the corresponding author upon request.
CONFLICT OF INTERESTS
The authors declare that the research was conducted in the absence of any commercial or financial
relationships that could be construed as a potential conflict of interest.
FUNDING
This work was funded by the Carlos III Health Institute (ISCIII) through project PI19/01076, and had
the support of the Aragonite Group for Research in Primary Care (GAIAP, B21_23R) which is part of
the Department of Innovation, Research and University of the Government of Aragon (Spain) and the
Health Research Institute of Aragon (IIS Aragón). The funders have no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript. The funding
organization will audit the conduct of the trials once a year.
AUTHORS' CONTRIBUTIONS
Conceptualization: all authors; Methodology: F.M-L; Software: FM-L; Validation: all authors; Formal
analysis: F.M-L; Research: F.M-L; Resources: M.D-G; Data curation: F.M-L; Writing - Original draft:
F.M-L; Writing - Review and editing: all authors; Display: F.M-L; Supervision: all authors; Project
administration: F.M-L; Acquisition Financing: F.M-L; Final approved: all authors.
ACKNOWLEDGMENTS
We would like to especially thank the Aragonese Research Group in Primary Care (GAIAP, B21_23R)
which is part of the Department of Innovation, Research and University of the Government of Aragon
(Spain) and the Health Research Institute of Aragon (IIS Aragón); the Research Network on Chronicity,
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Primary Care and Health Promotion (RICAPPS, RD21/0016/0005) which is part of the Cooperative
Research Networks Oriented to Health Results (RICORS) (Carlos III Health Institute); ERDF funds
“Another way to make Europe”, Next Generation EU funds; the University of Zaragoza; and the
“Health Innovation” Action Group of the Campus of International Excellence (CEI) of the Ebro Valley
(Campus Iberus). We thank all the people who worked on the DESVELA cohort. We especially want to
thank all participants for their collaboration in this study.
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