Determinants of Depressive Symptoms Among Rural Health Workers: An Application of Socio-Ecological Framework

Figures & data

Figure 1 Socio-ecological framework.

Note: Bronfenbrenner U,Toward an experimental ecology of human development, American Psychologist Association, 32, 7, 513, 1977, reprinted with permission from APA.⁷⁷

Table 1 Associations Between Demographic Characteristics and Depressive Symptoms Among Rural Health Workers

Variable	Total (N=394)	Mild–Major Depressive Symptoms (N=170)	Normal	p
Age (mean±SD)	40.86±6.53	42.01±5.74	39.98±6.95	0.002
Gender, n (%)
Male	103 (100)	39 (37.9)	64 (62.1)	0.26
Female	291 (100)	131 (45)	160 (55)
Marital status
Single	30 (100)	9 (30)	21 (70)	0.13
Married	364 (100)	161 (44.2)	203 (55.8)
Family history of mental illness
Yes	62 (100)	41 (66.1)	21 (33.9)	0.000
No	331 (100)	128 (38.7)	203 (61.3)
Saying daily prayer
Yes	385 (100)	166 (43.1)	219 (56.9)	0.93
No	9 (100)	4 (44.4)	5 (55.6)
Belief in oneself as a religious person
Yes	371 (100)	156 (42)	215 (58)	0.07
No	23 (100)	14 (60.9)	9 (39.1)
Educational level
Elementary	57 (100)	31 (54.4)	26 (45.6)	0.22
Secondary	82 (100)	42 (51.2)	40 (48.8)
High school	196 (100)	79 (40.3)	117 (59.7)
University education	59 (100)	18 (30.5)	41 (69.5)
Smoking
Yes	20 (100)	10 (50)	10 (50)	0.52
No	374 (100)	160 (42.8)	214 (57.2)
Having had a childbirth in the previous 3 years
Yes	42 (100)	21 (50)	21 (50)	0.48
No	249 (100)	110 (42.2)	139 (55.8)
Having had menopause in the previous 3 years
Yes	9 (100)	8 (88.9)	1 (11.1)	0.007
No	282 (100)	123 (43.6)	159 (56.4)

Table 2 Characteristics of the Factors Derived from Exploratory Factor Analysis

Factor (Subscale)	Number of Items	Range	Mean (SD)	Kurtosis	Skewness	Floor Effect (%)	Ceiling Effect (%)
F1: Personal factors	5	5–25	18.55 (3.8)	0.416	−0.548	0	0.2
F2: Interaction with villagers	2	2–10	7.46 (1.4)	−0.335	−0.554	4.4	1.3
F3: Interaction with colleagues/monitoring and evaluation	4	4–20	13.84 (2.2)	0.063	−0.421	0	0.2
F4: Culture and environment of village	6	6–30	16.8 (2.7)	−0.169	0.191	0.4	6.3
F5: Reinforcing factors	2	2–10	3.62 (0.81)	2.1	1.0	0	0.2
F6: Family/colleague support	3	3–15	11.46 (1.9)	0.29	−0.64	0.7	7.1
F7: Work load and roles interference	2	2–10	5.78 (1.04)	0.37	0.35	0.3	2.1

Table 3 Rotated Factor Pattern Coefficients for Variable Solutions (24 Items) of the SEF Factors

	Factors*	F1**	F2	F3	F4	F5	F6	F7
a2	Do you have the necessary skills (like communication skills and practical skills) to perform the RHW tasks?	0.809
a4	In your opinion, are you a useful and valuable staff in the health system?	0.789
a3	Considering your current job abilities and literacy, can you perform the new circulars, announced by the health ministry?	0.758
a1	Are you interested in your job as a RHW?	0.700		−0.324	−0.345
d1	Do you feel success in your job, as a RHW?	0.673		−0.481	−0.344
c1	Do the customs and culture in the village impede you in developing satisfactory relationships with people while performing your tasks?		0.798
b3	During formal/informal relationships, do the villagers cause discomfort for you?		0.737					0.304
d3	Does the monitoring of your supervisors improve your abilities?			−0.846
d4	Are you satisfied with the mode of supervisors’ guidance and instruction while monitoring sessions?			−0.821
d5	Are your job activities supervised based on previously delivered checklists?	0.340		−0.679
b1	Are you glad from being with your colleagues?	0.380		−0.514	−0.305			−0.365
c3	Do you like the village you are working in?	0.373		−0.381	−0.758
c5	Do you enjoy living in the village?			−0.356	−0.735
c4	Do you like the customs and the culture of the village you are working in?	0.331	0.364	−0.316	−0.723
c2	Do the facilities existing in the village meet your living needs?				−0.633
c8	When dealing with problems, do the villagers support you?				−0.508	0.416	0.495
d8	Are you satisfied with the physical environment of your health house (in terms of size, temperature, equipment and so on)?				−0.470
d6	Have you ever been encouraged for your efforts by your boss?					0.712
d7	Has your organization ever implemented recreational and welfare programs for you?					0.709
c6	When dealing with problems, does your family support you?	0.354					0.805
b2	Does your family cause discomfort for you?						0.687
c7	When dealing with problems, do your colleagues support you?			−0.387	−0.428		0.663
d2	Are you overloaded with your job responsibilities?							0.692
c9	Has your job caused you to not play well your other roles (like your mother/father role or your husband/wife role) in your life?							0.634
	Initial eigenvalues	5.67	2.14	1.52	1.45	1.29	1.21	1.03
	Rotation sums of squares	3.03	2.78	2.35	1.86	1.67	1.33	1.28
	Percent of variance explained	23.63	8.92	6.35	6.08	5.38	5.06	4.31
	Cronbach’s α	0.809	0.65	0.72	0.74	0.51	0.61	0.49

Notes: *F1: Personal factors, F2: Interaction with villagers, F3: Interaction with colleagues/monitoring and evaluation, F4: Culture and environment of village, F5: Reinforcing factors, F6: Family/colleague support, F7: Work load and roles interference. Extraction method: principal component analysis; rotation method: varimax with Kaiser normalization. **The greatest factor loadings are shown in bold.

Table 4 Socio-Ecological Framework (SEF) by Different Degrees of Depressive Symptoms Among Rural Health Workers

Level of SEF	Factors/Constructs	Beck’s Depression Inventory (BDI-13)-Short Form					p
		Total, M (SD)	Non-Depressed, M (SD)	Minor, M (SD)	Moderate, M (SD)	Major, M (SD)
		N=394 (100%)	N=224 (56.8%)	N=65 (16.4%)	N=78 (19.7%)	N=27 (6.8%)
Personal factors	Personal factors	18.55 (3.8)	19.6 (3.9)	18.45 (3.7)	16.9 (3.2)	14.85 (4.1)	≤0.001
Interpersonal factors	Interaction with villagers	7.46 (1.4)	7.78 (1.6)	7.5 (1.3)	6.64 (1.1)	7.02 (1.2)	≤0.001
Organizational factors	Interaction with colleagues/monitoring and evaluation	13.84 (2.2)	14.44 (2.4)	13.88 (2.2)	12.72 (1.7)	12.08 (1.4)	≤0.001
	Reinforcing factors	3.62 (0.81)	3.72 (0.89)	3.66 (0.85)	3.26 (0.64)	3.62 (0.84)	=0.102
	Work load and roles interference	5.78 (1.04)	5.3 (0.9)	4.64 (0.7)	4.5 (0.6)	4.66 (0.7)	≤0.001
Community factors	Culture and environment of village	16.8 (2.7)	17.64 (2.9)	17.52 (2.7)	15.06 (1.4)	13.62 (0.91)	≤0.001
	Family/colleague support	11.46 (1.9)	11.58 (2.1)	10.95 (1.7)	9.69 (1.4)	8.25 (1.1)	≤0.001

Abbreviations: M, mean; SD, standard deviation.

Table 5 Contributions (Direct, Indirect and Total) of Socio-Ecological Framework (SEF) to Depressive Symptoms Among Rural Health Workers

Variable/Component		Direct			Indirect			Total
		Coefficient	SC^*	p^**	Coefficient	SC	p	Coefficient	SC	p
Personal-level factors		−2.32	−0.30	<0.001	0.062	0.008	0.111	−2.26	−0.29	<0.001
Interpersonal-level factors	Interaction with villagers	−0.47	−0.07	0.052	–	–	–	−0.47	−0.07	0.052
Organizational-level factors	Interaction with colleagues/monitoring and evaluation	−0.078	−0.01	0.770	–	–	–	−0.078	−0.01	0.770
	Reinforcing factors	0.45	0.054	0.067	–	–	–	0.45	0.05	0.067
	Work load and roles interference	−0.74	−0.10	<0.001	−0.11	−0.015	0.071	−0.86	−0.11	<0.001
Community-level factors	Culture and environment of village	−0.099	−0.01	0.767	−0.14	−0.017	0.079	−0.24	−0.03	0.434
	Family/colleague support	−1.28	−0.18	<0.001	−0.104	−0.015	0.077	−1.38	−0.20	<0.001
Belief in oneself as a religious man/woman		3.43	0.13	<0.001	–	–	–	3.43	0.13	<0.001
Family history of mental illness		−1.48	−0.09	<0.01	–	–	–	−1.48	−0.09	<0.01
Age		−0.019	−0.02	0.564	–	–	–	−0.019	−0.02	0.564
Female gender		1.69	0.12	<0.001	−0.118	−0.008	0.090	1.57	0.11	<0.001
Saying daily prayer		−0.043	−0.001	0.917	–	–	–	−0.043	−0.001	0.917
Education level		−0.56	−0.08	<0.01	–	–	–	−0.56	−0.08	<0.01
Income		−0.84	−0.12	<0.001	–	–	–	−0.84	−0.12	<0.001
Not smoking		−0.80	−0.02	0.190	–	–	–	−0.80	−0.02	0.190
Having chronic illness		−1.64	−0.09	<0.001	–	–	–	−1.64	−0.09	<0.001

Note: **The statistically significant contributions are shown in bold.

Abbreviation: *SC, standardized coefficient.

Figure 2 Standardized coefficients and relations of socio-ecological framework (SEF)-based factors with depressive symptoms among rural health workers in Iran.

Abbreviation: IF, indirect factors.

Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32(7):513. doi:10.1037/0003-066X.32.7.513

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