Introduction
In the rapidly changing work environment influenced by economic globalization and the rise of neoliberal policies and managerialism, health care and social service providers (e.g., nurses, teachers, physicians, psychologists, and social workers) can experience higher rates of depression than the general population [
1,
2]. According to studies conducted in mainland China, the prevalence of depressive symptoms among health care and social service providers was estimated to be 25.9-38% [
3,
4]. Depression has been found to be associated with the professional attitudes (e.g., turnover intentions, job satisfaction, organizational commitment) of health care and social service providers and is associated with impaired quality and security of the service provided [
5]. As the majority of health care and social service providers are women and evidence show that female health care and social service providers are at risk of a higher level of depression than male health care and social service providers [
6], investigating females’ experiences may provide insights into the nature of depression for people working in the social service sector.
Empirical evidence has consistently indicated that women with depression disorder outnumber men at a ratio of 2:1 [
7]. Following Phyllis Chesler’s influential study
Women and Madness in suggesting that gender is embedded in the construction of the concepts of madness and mental disorder, feminist scholarship has argued most successfully in its accounts of why women may be depressed. Feminist paradigms document women’s depression as a function of gendered expectations that are inherent in their stressful social roles, including marriage, motherhood, employment and so forth [
8,
9]. Previous research demonstrates that more than one-third of the gender differences in depression among medical workers are explained by work-family conflict [
10]. In addition to workload, employed women have to address family needs (e.g., child care, housework), resulting in them genuinely suffering more distress than men [
11]. We adopt a feminist perspective to explore the relationship between role conflicts and female health care and social service providers’ depression.
Furthermore, previous studies have highlighted that burnout is a mediating state that accelerates negative mental health effects and leads to depression [
12]. Burnout is a long-term psychological response to chronic emotions and stress related to work, manifested by emotional exhaustion, cynicism (personality disintegration), and reduced personal accomplishment [
12]. Empirical research has suggested that health care and social service providers may experience higher levels of role conflicts and resultant burnout than general occupational groups [
13]. However, recent studies have noted that the relationship between work-family conflict and burnout is rarely researched in social services [
14]. This paucity leaves a research gap that we attempt to address by examining whether burnout mediates role conflicts in depression.
In addition, there is a small but powerful literature on the relationship between family stress and depression in working people [
15]. Marriage and motherhood have been put forward as risk factors for women’s depression [
9,
16], with young married women with small children deemed to be at particularly high risk [
17]. In addition, researchers are now examining whether family resources are significantly associated with reduced depression [
18]. A number of studies report that marriage acts as a protective factor to buffer psychological distress [
19], with divorced or separated individuals at higher risk of depression than married individuals [
20]. Therefore, marriage and motherhood as moderators should be considered to establish mechanisms that link the role conflicts of female health care and social service providers to the construction of their depression.
Conservation of resources (COR) theory has been widely adopted in burnout and distress research. COR theory states that individuals are motivated to protect the resources they value, but when such efforts fail, depression may occur as employees feel incapable of coping with high demands [
21,
22]. Drawing on COR theory, this article aims to take broad theoretical and empirical strokes examining the effect of role conflicts on female health care and social service providers’ depression, whether burnout as a psychological response to stress related to work mediates the relationship between role conflicts and depression, and how family resources (marriage and motherhood) moderate the conflict-burnout-depression link among female health care and social service providers. We used data from the China Social Work Longitudinal Study (CSWLS) in 2019 [
23], a large-scale, continuous sampling survey and research project in China targeting the development and trends of social work, to provide insights into the social service industry. Previous research shows that social workers report twice the level of distress as those in comparable occupational roles (e.g., psychiatrists) [
13,
24]. In mainland China, social workers play major roles in community integrated social services; e.g., the Guangdong Civil Affair Department established 407 social work stations in 2017-2020, and each station enrolled 6 social workers [
25]. To date, most research on the mental health of health care and social service providers has focused on role conflicts within organizations, ignoring the perspective of work-family interference. By incorporating multiple role conflicts and a feminist perspective into our model, we provide a more nuanced understanding of depression among female health care and social service providers, who make up the majority of health care and social service providers.
Discussion and implications
Drawing on conservation of resources theory, this study examined the relationship between different types of role conflicts and depression faced by female social workers, and found the mediating role of burnout and the moderating role of marriage and motherhood. First, the results support the hypothesis that FWC and WFC are directly and positively associated with the depression of female health care and social service providers. It has been previously observed that in addition to workload, employed women have to address family needs (e.g., children care, housework), resulting in their genuinely suffering more distress than men [
11]. Since the traditional gender division of labor assigns more housework to women, female health care and social service providers face a stronger work-family conflict. In addition, family needs directly lead to female health care and social service providers’ depressive symptoms.
Second, we found that burnout (exhaustion and cynicism) fully mediated the effects of ORC on depression and partially mediated the effects of WFC on depression. The present work thus echoes previous findings that burnout was a full mediation of the relationships between work-related pressure and depression symptoms among consultants [
41] and teachers [
15]. Specifically, FWC had only a direct effect on depression, ORC had only an indirect effect on depression, and WFC had both direct and indirect effects on depression. This appears to align with the work outlined by Amstad et al. [
45], arguing that work interferences with family were more strongly associated with work-related than family-related outcomes, and family interferences with work were more strongly associated with family-related than work-related outcomes. Burnout is an important factor associated with work-related role conflict and depression among health care and social service providers.
Third, as theoretically tested, FWC was directly associated with the depression of female health care and social service providers, whereas WFC largely had an indirect but significant effect on their depression. A possible explanation could be that family stress affects depression in female health care and social service providers more directly and profoundly. However, descriptive statistics showed that married female health care and social service providers who have children reported lower levels of depression. A multiple-group analysis further indicated that family resources may play a moderating role in the conflict-burnout-depression link and that being unmarried and having no child were risk factors for depression in female health care and social service providers. This reflects the paradoxical principle of conservation of resources theory that resource loss and resource gain occur simultaneously for people facing stressful events and daily stressful situations [
22]. In conditions of high losses, efforts that result in small gains may elicit positive expectancy and hope, and reinforce further goal-directed efforts [
73]. Therefore, marriage and motherhood may act as “family clientelism” for female health care and social service providers who are married and have children and that “family’s resources or capabilities allow it to thrive in the face of significant risk” [
74]. On the one hand, family clientelism has negative consequences on married and childbearing female health care and social service providers, as FWC is directly associated with their depression. On the other hand, through women’s insertion within the institution of marriage and motherhood, the reciprocal exchange relationship established that the psychological wellbeing of these women increased, with less cynicism and less depression.
Based on COR theory, stress occurs when people fail to gain central or key resources (e.g., marriage, child) after significant effort, which can trigger burnout and depression [
21,
22]. Previous studies indicate that marriage acts as a protective factor in mitigating psychological distress [
19], and in Chinese society, family recognition and support for one’s career are highly valued [
75]. For unmarried and infertile female health care and social service providers, they have not yet entered marriage and motherhood as expected by social norms, this “step out of line” means they do not enter the asymmetric relationships of family clientelism. Consequently, unmarried and infertile female health care and social service providers have fewer family resources than married women with children when they face significant work-related risks (role conflicts and burnout) and are more vulnerable to depression symptoms.
Thus, a further explanation for the higher level of depression among female health care and social service providers who were unmarried and had no children is that not only do they have difficulty accessing resources of marriage and family compared to married female workers with children, but their unmarried and childless status may even exacerbate their loss of resources in a male-dominated culture that emphasizes women’s role as wives and mothers. Based on COR theory, a possible explanation for the higher depression level of female health care and social service providers who were unmarried and had no children might be that they were faced with a more profound threat and greater depletion of valued resources than those who were married and had a child. Through an analysis of the causes of depression among female health care and social service providers, we argue that the patriarchal family structure reproduced itself as an embodied, internalized mechanism through the depression of female health care and social service providers, perpetuating sex-role stereotypes in which the family role is primary for women and work roles are secondary [
19,
56]. The present work is consistent with the feminist view of depression, which has been quite successful in its accounts of how societal factors build women’s depression [
8,
9].
Implications
The findings of the study highlights the importance of having organizational policies that reduce the work-family conflict and ORC experienced by female health care and social service providers to increase their mental wellbeing. This study supports the existence of two key avenues for reducing depression: burnout and family. This provides managers with evidence to foster an organizational culture conducive to preventing burnout and depression among female health care and social service providers. The finding that burnout is a significant factor associated with work-related role conflicts and depression among female health care and social service providers suggests that managers can increase awareness of burnout issues, and design more effective strategies to lessen and prevent work-related stress.
It is critical for managers and other organizational stakeholders to know how to foster supportive policies between work and family. Such labor policies should also be placed in the context of social work, particularly in a context where the workforce is feminized and where conflicts may arise within and between disciplines. Work-family-friendly work policies have inspired a very important and rapidly growing line of research [
18,
76], policymakers and managers can help social workers develop effective strategies for coping with the demands emanating from their work and family domains, such as fostering supportive relationships at work and home, facilitating effective and timely communication in a trusting environment with family members, and setting clear expectations and setting aside ‘me’ time [
18]. Organizational policies, including day-care centres for children, homecare for sick and elderly relatives, and flexible work time for workers, would be helpful.
We suggest that a supportive work environment that values gender equality may help female health care and social service providers manage role conflicts better and promote their mental health. On the one hand, female health care and social service providers should be encouraged to enhance bonds with their own families, develop family resilience and seek family resources. On the other hand, we emphasize that by increasing various aspects of organizational support, female health care and social service providers could be more liberated to choose work life as they like rather than relying on marriage and motherhood to receive non-work resources. Drawing on our findings, our implications for female health care and social service providers who experienced depression and sought feminist therapy [
77] emphasize an exploration of their inner resources and capacity for self-care, self-healing and transcending sex-role stereotyping. These policies would make a real difference to reduce burnout and depression of female health care and social service providers and may increase the service quality they provide.
Limitations
There are limitations to our study. First, the study was limited by the method of collecting cross-sectional data, which made it difficult to distinguish the causal mechanisms between role conflicts and depression as well as the specific mechanisms by which burnout plays a mediating role in the role conflict-depression relationship. Second, the present study was exclusively based on a self-report inventory rather than a diagnostic interview and was thus not immune to common method bias. We chose this method based on previous data demonstrating that anonymity is necessary to accurately ascertain depressive symptoms among medical professionals. Nonetheless, it would be important to validate these findings using in-person diagnostic interviews. Third, as previous studies have indicated that the personal vulnerability characteristics of people who enter the profession may be associated with a high level of burnout and depression, this study did not consider personality factors [
13,
78]. Finally, previous studies have shown that other health care and social service providers who are also heavily feminized (e.g., occupational therapy, physical therapy, pharmacy, nursing) have a high rate of depression [
2]. However, due to our data limitations, they were not included in this research. In future studies, a larger and more representative sample should be used.
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