Asian Nursing Research 9 (2015) 265e270
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Asian Nursing Research
journal homepage: www.asian-nursingresearch.com
Research Article
Relating Factors for Depression in Korean Working Women:
Secondary Analysis of the Fifth Korean National Health and Nutrition
Examination Survey (KNHANES V)
Kyung-Jae Lee, MD, 1 Jeung-Im Kim, RN, PhD 2, *
1
Department of Occupational & Environmental Medicine, Soonchunhyang University Hospital, College of Medicine, Soonchunhyang University, Seoul,
South Korea
2
School of Nursing, College of Medicine, Soonchunhyang University, Chonan, South Korea
a r t i c l e i n f o
s u m m a r y
Article history:
Received 10 September 2014
Received in revised form
23 May 2015
Accepted 9 July 2015
Purpose: The purpose of this study was to investigate the health behaviors and risk factors for selfreported depression in Korean working women.
Methods: This study adopted a secondary analysis from the fifth Korean National Health and Nutrition
Examination Survey (KNHANES-V) for the Health Examination Survey and Health Behavior Survey, using
stratified, multi-stage, cluster-sampling design to obtain a nationally representative sample. Data were
gathered on extensive information including sociodemographic, occupational characteristics, health
behaviors and depression. Multiple logistic regression analysis was employed to compute the odds ratio
(OR) between health behaviors and depression to identify the health behaviors and the risk factors for
depression with adjustment for the complex sample design of the survey.
Results: The prevalence rate of depression was 15.5% among working women. Depression was more
common in older female workers and in those with part-time job. Current smokers were significantly
more likely to be depression-positive. In a multiple logistic regression analysis, significant variables of
depression were marital status (OR ¼ 2.02; 95% CI [1.05, 3.89]), smoking status (OR ¼ 1.55; 95% CI [1.01,
2.38]), stress (OR ¼ 0.20; 95% CI [0.15, 0.26]), employment condition (OR ¼ 1.77; 95% CI [1.34, 2.33]) and
health status (OR ¼ 2.10; 95% CI [1.53, 2.87]).
Conclusions: Based on the study, factors leading to depression were marital status, current smoking,
stress, employment condition and self-reported health status. Further studies are expected to unravel the
characteristics of stress. Health care providers for women need to evaluate underreported depression
and change their associated health behaviors. Also it is necessary to establish preventive strategies for
female workers to control the negative effect of depression in the workplace.
Copyright © 2015, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Keywords:
depression
risk factors
working women
Introduction
Lifetime prevalence rates for any psychological disorder are
higher than previously thought; they are increasing in recent cohorts and affecting nearly half the population [1]. Depression in the
workplace may lower work productivity and increase maladjustment in daily professional life, resulting in rising disability and
depression-related absence [2e6].
* Correspondence to: Jeung-Im Kim, RN, PhD, School of Nursing, Soonchunhyang
University, 31 Soonchunhyang 6-gil, Dongnam-ku, Chonan, 31538, South Korea.
E-mail address: [email protected]
Depression is a significant contributor to the global burden of
disease and affects people in all communities across the world.
According to the World Health Organization, depression is estimated to affect 350 million people globally [7] and can be a significant source of morbidity. This is true particularly among
working women suffering from negative thoughts, self-denial that
comes with everyday experiences, and losing hope to face the
future. Changes in the workplace structure over the past years
may have contributed to increased stress and psychiatric
morbidity [2].
Depression is not only the most common women's mental
health problem but may be more persistent in women than men,
although further research is needed to establish the veracity of this
assertion. Women are two to three times more likely to experience
http://dx.doi.org/10.1016/j.anr.2015.07.002
p1976-1317 e2093-7482/Copyright © 2015, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
266
K.-J. Lee, J.-I. Kim / Asian Nursing Research 9 (2015) 265e270
depression than men are [8]. The gender gap is probably influenced
by hormonal fluctuations and psychosocial factors, including stress
of multiple work and family responsibilities, sexual and physical
abuse, sexual discrimination, lack of social support, and traumatic
life experiences [9]. While depression in working woman has not
gotten the interest of many researchers, its prevalence and risk
factors have not been studied substantively. In Korea, there are few
reports of depression among women working in small
manufacturing industry [10,11]. However, studies that use a nationwide sampling are rare.
Occupation is a fundamental right, enabling social interaction
and financial support for the individual. However, it is an undeniable source of stress, with consequences for physical and
mental health [1]. Work stress precipitates depression and anxiety in previously healthy young workers [12]. Current work
schedule [1], work intensity [10], work and home stress are
associated with anxiety and depression symptoms in both men
and women [13]. Although most of workers feel blue day by day,
they might not report their feelings. Less than half of those who
meet diagnostic criteria for psychological disorders are examined
by doctors [8]. To process the study, we use the term “depression”
from here on, not according to the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), but according to selfreported depression.
According to the annual report on the economically active
population survey 2010, the participation rate of the economically
active working women was 49.4%, which translates to 10,256,000
people in Korea [14]. It is a lower level compared to 68.4% in United
States, 63.2% in Japan, 61.8% in Organization for Economic Cooperation Development countries [15]. Ultimately the proportion
of Korean working women was at a relatively lower level. The
strategies employed for working women are necessary to improve
their physical, social, and mental health in their workplace. However, few studies on female working population have been conducted in Korea [16,17].
In light of what has been reported, it is clear that the link between work and depression is complex among the many potential
factors leading to depression. The study addresses three points.
First, we used a nation-wide cross-sectional study data to solve the
limitation of localized samples investigating this issue. Second, we
considered the multifactorial influences of sociodemographics and
occupational variables to predict the prevalence of depression.
Third, the study also analyzed health behaviors such as health
status, sleeping hours and smoking status.
The aim of this study was to identify the prevalence of depression and to estimate the health behaviors and risk factors associated with depression in working women using the Fifth Korean
National Health and Nutrition Examination Survey (KNHANES-V).
national districts were selected for the Health Interview Survey,
and 192 national districts were selected for the Health Examination
Survey and Health Behavior Survey. Approximately 22e26 households from each district were included. The weighted sample for
the KNHANES-V reflected the sampling fraction and nonresponse
bias adjustments. Additional weight adjustments mirrored the
structure of the 2012 sex and age specific population. A sample size
of 4,803 female workers aged above 20 years was selected.
Whereas a total number of 2,936 participated in the study, about 37
women who reported missing data or were working in a minority
employment field such as agriculture and fishing were excluded
from this study. Finally, 2,899 eligible respondents were included in
the analysis.
Ethical consideration
This study did not need the approval of the institutional review
board because it used de-identified data on the KNHANES-V which
was open to the public through the website as a governmentapproved statistical survey and informed consent was obtained
from all persons who participated in this survey [18].
Measurement and data collection
Education was categorized as elementary, middle school, high
school and university or higher. Marital status was divided into
three categories, single, married, and divorced/widowed/separated.
While household income was classified into quartile, smoking
status was classified into three groups (never, former, and current).
Drinking status was classified into two groups (never, yes). Job type
was classified into four categories (professionals, office workers,
sales and service workers, and technical and labor workers) and
employment condition was divided into part time and full time.
The KNHANES online repository consisted of four comprehensive questionnaires, including a Health Interview Survey, a Health
Examination Survey, a Health Behavior Survey, and a Nutrition
Survey. Study variables were collected from the Health Interview
Survey and Health Behavior Survey. In those surveys, data were
collected by trained interviewers. Subjective health status was
measured by one question, answered as “good” or “poor”. Stress
was also evaluated by one question with four possible responses:
never, controllable, stressful, or uncontrollable. The outcome variable “depression” was assessed through responses to the question,
“During the recent 12 months, have you ever felt sad or hopeless
almost every day for 2 weeks in a row that you stopped doing some
usual activities?”
Data analysis
Methods
Study design
This study was a secondary analysis design using populationbased data from a nation-wide cross-sectional health survey, the
KNHANES-V from January 2010 to December 2012.
Setting and sample
The basis for this investigation lies with the KNHANES-V, which
is a government-approved statistical survey by the Korea Centers
for Disease Control and Prevention [18]. A stratified multistage
cluster-sampling design was used to obtain a nationally representative sample of the Korean population for the survey. About 576
Descriptive statistics were used to examine the distribution of
sociodemographic and occupational characteristics and health behaviors. Chi-square test and t test were used to estimate the difference in the existence of depression by background
characteristics. Multiple logistic regression analysis was performed
to identify the health behaviors and risk factors associated with
depression after simple logistic regression analysis using PASW
statistics 21.0 (SPSS Inc., Chicago, IL, USA). The odds ratio (OR) and
95% confidence intervals (CI) were calculated and all p values were
considered to be statistically significant at less than 0.05. All estimates were calculated based on sample weights, which were
evaluated by taking into consideration the stratified and cluster
variables to generate the analysis-plan file. The analysis was
adjusted for the complex sample design of the survey [18].
K.-J. Lee, J.-I. Kim / Asian Nursing Research 9 (2015) 265e270
Results
Table 2 Occupational Characteristics and Health Behaviors by Self-reported Depression
(N ¼ 2,899).
Sociodemographic characteristics and self-reported depression
Characteristics
Among 2,899 participants, 15.5% reported by themselves as
having depression. The sociodemographic and occupational background characteristics of the respondents, divided by self-reported
depression, are shown in Tables 1 and 2. The mean age of the respondents was 43.63 years. About 59.7% of them were married
while 62.4% of them were in the third or highest levels of household
income. About 75.8% of the respondents had an education of high
school or higher.
Self-reported depression was significantly different by age
(t ¼ 2.30, p < .05), educational levels (c2 ¼ 18.18, p < .01), marital
status (c2 ¼ 19.95, p < .01), and household income (c2 ¼ 16.71,
p < .01). Self-reported depression was more common in older female workers when taking into consideration into the mean age
(p < .05). Less educated women who had a middle school level of
education or lower had a higher proportion of depression than
well-educated women had (p < .01). Married or single women had
less depression when compared to those who were divorced,
widowed, or separated (p < .01). Self-reported depression was
more prevalent in the lowest level of household income than in the
higher levels (p < .01) (Table 1).
Occupational characteristics, health behaviors and self-reported
depression
Self-reported depression was more popular in part-time positions than in full-time positions (c2 ¼ 13.80, p < .01). The higher
proportion of current smokers were significantly observed in the
depression-positive group than in the depression-negative group
Table 1 Sociodemographic Characteristics by Self-reported Depression (N ¼ 2,899).
Characteristics
Total
n (%)
Self-reported depression
No
n (%)
c2/tb
p
Yes
n (%)
Age (yr)
20e29
579 (26.7)
502 (85.0)
77 (15.0)
30e39
669 (21.4)
589 (87.2)
80 (12.8)
40e49
659 (25.4)
562 (85.3)
97 (14.7)
50e59
561 (16.8)
449 (81.0)
112 (19.0)
60
431 (9.7)
362 (81.1)
69 (18.9)
M ± SD
43.63 ± 14.17 43.37 ± 14.20 45.06 ± 13.99
Educational level
Elementary
530 (14.2)
427 (78.6)
103 (21.4)
Middle school
300 (10.0)
247 (81.0)
53 (19.0)
High school
992 (38.0)
847 (85.6)
145 (14.4)
University
1,077 (37.8)
943 (86.5)
134 (13.5)
Marital status
Single
668 (28.7)
588 (87.5)
80 (12.5)
Married
1,859 (59.7)
1,586 (84.5)
273 (15.5)
a
Others
372 (11.6)
290 (77.0)
82 (23.0)
Household income
Lowest
375 (11.0)
302 (78.4)
73 (21.6)
Second
722 (26.5)
595 (82.5)
127 (17.5)
Third
915 (33.2)
798 (86.9)
117 (13.1)
Highest
887 (29.2)
769 (85.9)
118 (14.1)
Residence area
Town & Myeon
433 (14.7)
372 (86.1)
61 (13.9)
Dong
2,466 (85.3)
2,092 (84.2)
374 (15.8)
Housing type
Apartment
1,375 (40.6)
1,184 (85.7)
191 (14.3)
Others
1,524 (59.4)
1,280 (84.0)
244 (16.0)
Total
2,899 (100.0) 2,464 (84.5)
435 (15.5)
a
267
11.08 .088
Total
n (%)
Self-reported
depression
No
n (%)
Job type
Professionals
742
Office workers
563
Sales & service
655
workers
Technical & labor
939
workers
Employment condition
Full-time job
2,114
Part-time job
785
Smoking state
Never
2,538
Former
161
Current
200
Alcohol drinking state
No
350
Yes
2,549
Sleeping (hours per day)
7
1,705
<7
1,194
Stress
Never to
919
controllable
Stressful to
1,980
uncontrollable
Health status
Good
2,438
Poor
461
Total
2,899
c2
p
Yes
n (%)
(25.4)
(20.8)
(24.0)
657 (87.2) 85 (12.8)
480 (84.2) 83 (15.8)
546 (82.6) 109 (17.4)
(29.8)
781 (83.8) 158 (16.2)
(74.3)
(25.7)
1,824 (86.0) 290 (14.0)
640 (80.2) 145 (19.8)
13.80
(84.4)
(6.7)
(8.9)
2,189 (86.3) 349 (13.7)
121 (74.0) 40 (26.0)
154 (75.4) 46 (25.6)
38.27 < .001***
(12.1)
(87.9)
295 (85.1) 55 (14.9)
2,169 (84.4) 380 (15.6)
0.10
.756
(60.0)
(40.0)
1,480 (86.6) 225 (13.4)
984 (81.3) 210 (18.7)
15.18
.002*
(34.0)
(66.0)
6.33
.250
.001**
645 (70.0) 274 (30.0) 240.71 < .001***
1,819 (92.0) 161 (8.0)
(83.6) 2,144 (87.5) 294 (12.5) 102.51 < .001***
(16.4)
320 (69.1) 141 (30.9)
(100.0) 2,464 (84.5) 435 (15.5)
*p < .05. **p < .01. ***p < .001.
(p < .001). Significant difference was observed in daily sleeping
hours between depression-positive and depression-negative
women (c2 ¼ 15.18, p < .01). Compared to those who had responded “never” to “controllable stress”, stressed workers showed less
cases of self-reported depression (c2 ¼ 240.71, p < .001). Selfreported depression was more common in women having selfreported poor health status (c2 ¼ 102.51, p < .001) (Table 2).
Associating factors of self-reported depression
2.30
.022*
**
18.18 .004
19.95 .001**
16.71 .009**
1.05
.422
1.38
.245
Others included respondents who were divorced, widowed and separated. bBy
unpaired t test and Chi-square test.
*p < .05. **p < .01.
To estimate the health behaviors and the risk factors associated
with depression, we performed simple and multiple logistic
regression analysis.
In a simple logistic regression models, increased levels of education, household income and stress were significantly related to a
decreased risk of depression. Significant variables of self-reported
depression were education, marital status, household income,
smoking, stress, sleeping, employment condition, self-reported
health status and job type (p < .05). Higher educated women or
those having a higher economic level had less depression.
Compared with single women, those divorced, widowed or separated showed increased risk of depression (OR ¼ 2.09) and current
smokers were significantly more linked to depression than nonsmokers (OR ¼ 1.90) while alcohol did not show significant result.
In case of stress, those who had “never” to “controllable” stress
showed less reported depression than “stressful” to “uncontrollable” stress (OR ¼ 0.20, 95% CI [0.16, 0.26]). The ORs for sleeping
hours and self-reported health status were 1.49 (95% CI [1.16, 1.92])
and 3.13 (95% CI [2.35, 4.17]). Women with a part-time job had 1.5
times greater possibility of experiencing depression than those
with a full-time job. Compared with professionals, sales and service
268
K.-J. Lee, J.-I. Kim / Asian Nursing Research 9 (2015) 265e270
Notably, smoking is a predictive factor to depression for Korean
working women in this study. The finding is consistent with a study
conducted on Japanese working women at manufacturing enterprises [22]. Moreover, the study established that current smokers
were significantly more linked to depression than nonsmokers
among female workers were. It is interesting to note that there is
some relation between smoking and depression. The best-fitting
causal model was one in which nicotine dependence led to
increased risk of depression [23]. Early life exposure to cigarette
smoke is associated with an increased risk of depression midlife,
with the relation primarily mediated by active smoking. These
findings support a role for early life cigarette exposures in shaping
smoking and depression risks in later life and provide some support
for the direction of smoke exposure influence on depression [24]. It
seems that the evidence is stacked against nicotine as a mood lifter,
despite widely-held beliefs to the contrary.
Interestingly, the study established stress in female workers is
less associated with the risk of depression. A systematic review and
meta-analysis of 485 studies with a combined sample size of
267,995 individuals established that job satisfaction was an
important factor in psychological problems, burnout, self-esteem,
depression, and anxiety [25]. Theorell et al [26] reported job
strain was as strongly related to depressive symptoms among men
as among 3,446 working women in Sweden. Work-related stress is
linked to work schedule [1], and work intensity [10]. The result of
stress in this study is not consistent with the results of the above
research. The respondents in this study are working women and
the question asked is not “work stress” but “life stress”. Thus, the
reason for the differences in study results is a limitation in this
study.
Moreover, it is not certain but we guess from a new study result
that people have significantly lower levels of stress at work than at
home. These low levels of cortisol may help explain a long-standing
finding that has always been hard to reconcile with the idea that
work is a major source of stress: People who work have better
mental and physical health than their nonworking peers. Many
people find home life more stressful than work, work is good for
workers had 1.4 times while technical and labor working women
had 1.3 times higher risk of self-reported depression, although the
differences were not statistically significant.
In a multiple logistic regression analysis after adjustment, significant variables of self-reported depression were marital status
(OR ¼ 2.02; 95% CI [1.05, 3.88]), smoking (OR ¼ 1.55; 95% CI [1.01,
2.38]), stress (OR ¼ 0.20; 95% CI [0.15, 0.26]), employment condition (OR ¼ 1.77; 95% CI [1.34, 2.33]) and self-reported health status
(OR ¼ 2.10; 95% CI [1.53, 2.87]). Those who were divorced, widowed
or separated, smoking currently, had no stress or controllable
stress, had a part-time job and with poor health showed increased
risk of depression in this study (Table 3).
Discussion
Although the participation rate of economically active working
women has increased in Korea, studies on female working population have not been widely conducted. This study reports that the
prevalence rate of depression and predicting factors to depression
among Korean female workers aged above 20 was 15.5%. This rate is
similar to a study carried out in Italy [1]. According to a Canadian
national survey [19], the lifetime prevalence of depression ranged
from 12.8% to 16.6% in all people and was 8.9% in men and 16.5% in
women. However, the prevalence of depression in female workers
was 28.8% in the electronics industry in Thailand [20]. The higher
prevalence of depression in female workers probably reflects their
different role in society. In reality, women are faced with a “double
burden”, that is, having to dedicate themselves to both work and
family [21].
The study demonstrated that significant variables of depression
are marital status, smoking, stress, employment condition and selfreported health status by multiple logistic regression analysis.
Present findings suggest that marital status plays a role in the risk
for depression. Compared with single women, those divorced,
widowed or separated showed increased risk of depression. In
public workers, marital status is affecting depression in working
women in Italy, too [1].
Table 3 Odds Ratio for Self-reported Depression in Korean Working Women (N ¼ 2,899).
Independent variables
Classification
Self-reported depression
Unadjusted
OR
Age (yr; reference: 20e29)
Educational level (reference: elementary)
Marital status (reference: single)
Household income (reference: lowest)
Smoking (never to former)
Alcohol drinking (never)
Stress (never to controllable)
Sleeping ( 7 hours)
Employment condition (full-time)
Health status (good)
Job type (reference: professionals)
Note. CI ¼ confidence interval; OR ¼ odds ratio.
*p < .05. **p < .01. ***p < .001.
30e39
40e49
50e59
60
Middle school
High school
University
Married
Others
Second
Third
Highest
Office workers
Sales & service workers
Technical & labor workers
0.83
0.98
1.33
1.32
0.86
0.62
0.57
1.28
2.09
0.77
0.55
0.60
1.90
1.06
0.20
1.49
1.51
3.13
1.28
1.43
1.32
95% CI
[0.55,
[0.68,
[0.93,
[0.89,
[0.57,
[0.44,
[0.42,
[0.95,
[1.43,
[0.53,
[0.37,
[0.42,
[1.31,
[0.74,
[0.16,
[1.16,
[1.18,
[2.35,
[0.84,
[0.99,
[0.94,
1.24]
1.40]
1.90]
1.95]
1.30]
0.86]
0.79]
1.74]
3.04]
1.12]
0.81]
0.86]
2.75]
1.50]
0.26]
1.92]
1.93]
4.17]
1.93]
2.07]
1.86]
Adjusted
p
OR
.362
.902
.121
.162
.478
.005*
.001**
.109
< .001***
.174
.002**
.006**
.001**
.756
< .001***
.002**
.001**
< .001***
.248
.057
.111
0.71
0.94
1.09
0.76
0.85
0.61
0.66
1.66
2.02
1.04
0.86
0.88
1.55
1.23
0.20
1.20
1.77
2.10
1.34
1.03
0.90
95% CI
[0.39,
[0.50,
[0.56,
[0.35,
[0.52,
[0.36,
[0.36,
[0.95,
[1.00,
[0.68,
[0.56,
[0.55,
[1.01,
[0.83,
[0.15,
[0.92,
[1.34,
[1.53,
[0.84,
[0.66,
[0.57,
1.31]
1.77]
2.13]
1.68]
1.40]
1.03]
1.22]
2.90]
3.88]
1.59]
1.33]
1.41]
2.38]
1.80]
0.26]
1.57]
2.33]
2.87]
2.15]
1.62]
1.43]
p
.273
.842
.795
.498
.528
.064
.185
.073
.036*
.858
.496
.584
.044*
.302
< .001***
.187
< .001***
< .001***
.220
.900
.651
K.-J. Lee, J.-I. Kim / Asian Nursing Research 9 (2015) 265e270
our health and perhaps we should replicate aspects of it at home
[27]. Therefore further studies are expected to unravel the characteristics of stress, includes occupational stress or home stress,
and occupational category, and personality to stress.
Findings from the present study suggest employment condition
as a predictor of depression. The findings are associated with a
Korean study describing female workers under permanent workers
or precarious employment, and with change in employment status
and new-onset depression based on workers' previous employment status [28].
In the end, this study acknowledges that self-reported depression is more common in women having self-reported poor health
status. Future studies are required to investigate the exact mechanisms by which, employment change produces poor clinical outcomes among female workers, with more consideration that
women's health could be disproportionately affected by the labor
market and workplace flexibility [29]. On the other hand, depression in female workers may be influenced negatively by quality of
life and result in lower work productivity in the workplace and
rising maladjustment in daily working life [11]. Moreover, depression among married working women differs by psychostimulating
and social role, in addition to occupational class and family life cycle
[30], incivility of patients [31] and we should consider social roles
for female workers to solve their psychosocial problems.
The present study has several limitations. The cross-sectional
design, for instance, has a weak cause and effect relationship between depression and the risk factors. In addition, the measurement of symptoms and other variables using a questionnaire was
unreliable because it is highly likely to allow for the possibility of
subjective response that is not in line with medical diagnosis. There
is also the impression that the current study results were influenced by unmeasured confounding factors related to depression.
By and large, the present study is limited owing to the unreliability
of secondary data, analysis and dichotomous variable of depression.
While the study was based on well-designed national survey as
representative data in Korea, further research is required to
establish a strong cause and effect relationship between depression
and the risk factors. According to DSM-IV it is warranted to
establish preventive strategies for controlling the negative effect of
depression in the workplace.
Conclusion
This paper is significant when it comes to highlighting the need
for careful psychiatric assessment of working women. Moreover,
the study was expected to highlight current smoking status and
depression. With the increased number of working women, the
health consequences of working women have become an important health issue in Korea. As such, factors associated with
depression need to be highlighted and addressed accordingly,
especially smoking and stress.
The study concludes self-reported depression are affected by
marital status, current smoking, stress, employment condition and
self-reported health status in Korean working women. Health care
providers for women need to evaluate underreported depression and
change their associated health behaviors. Ultimately, further studies
are required to establish a strong cause and effect relationship between depression and the risk factors in working women. However, it
is necessary to establish preventive strategies for female workers to
control the negative effect of depression in the workplace.
Funding
This work was supported by Soonchunhyang University
Research Fund (No. 20120681).
269
Conflicts of interest
The authors declare no conflict of interest.
Acknowledgments
The authors would like to thank all study participants of this
national survey for voluntary participation and the Korea Centers
for Disease Control and Prevention for this investigation of the
KNHANES-V.
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