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 Table of Contents  
Year : 2019  |  Volume : 35  |  Issue : 1  |  Page : 57-63

Study of depression, anxiety and stress among Class IV workers in a medical college in Delhi

Department of Community Medicine, Maulana Azad Medical College, Delhi, India

Date of Submission06-Aug-2017
Date of Decision23-Mar-2018
Date of Acceptance16-Jun-2018
Date of Web Publication27-Mar-2019

Correspondence Address:
Dr. Prachie Garg
Maulana Azad Medical College, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_85_17

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Context: India contributes significantly to the global burden of mental illnesses in the world. Class-IV workers tend to have poor socioeconomic status, low levels of education, and long erratic working shifts. However, there is a lack of studies to assess their mental health and its impact on quality of life (QOL), especially in the Indian context. Aims: The objectives of the current study were to (i) assess the levels of depression, anxiety, and stress among Class-IV workers in a medical college of Delhi, (ii) study the association of sociodemographic variables with depression, anxiety, and stress levels, and (iii) assess the impact of these psychometric variables on overall health and QOL. Materials and Methods: A cross-sectional study was conducted in a medical college of Delhi where Class-IV workers were interviewed using a sociodemographic questionnaire and psychometric tools such as DASS-21 and Short Form Survey-12 (v2) (QualityMetric). Statistical analysis included prevalence data, multivariate binary logistic regression, and multiple linear regression. Results and Conclusions: The prevalence of depression, anxiety, and stress in Class-IV workers was found to be 17%, 15%, and 6%, respectively. The results showed that workers belonging to upper middle socioeconomic class were less likely to have depression than upper lower class (odds ratio [OR] = 0.048, 95% confidence interval [CI] = 0.003–0.866). Workers educated till primary level were more likely to have anxiety than those educated till high school and beyond (OR = 8.736, CI = 1.28–59.64). Those commuting longer distances from home to workplace daily were less likely to have depression (OR = 0.017, CI = 0.00–0.735) and anxiety (OR = 0.059, CI = 0.004–0.851). High levels of depression, anxiety, and stress had a negative impact on the overall QOL as well (P = 0.001).

Keywords: Anxiety, depression, education, quality of life, socioeconomic class, stress

How to cite this article:
Garg P, Kumar R. Study of depression, anxiety and stress among Class IV workers in a medical college in Delhi. Indian J Soc Psychiatry 2019;35:57-63

How to cite this URL:
Garg P, Kumar R. Study of depression, anxiety and stress among Class IV workers in a medical college in Delhi. Indian J Soc Psychiatry [serial online] 2019 [cited 2021 May 6];35:57-63. Available from: https://www.indjsp.org/text.asp?2019/35/1/57/255000

  Introduction Top

Depression, anxiety, and stress constitute a significant proportion of illnesses in the occupational health (OH) setting.[1] India had recorded the highest overall prevalence of major depression in the world at 36%, according to the World Health Organization in 2011,[2] and a lifetime prevalence of 5.25% in adults as per the NMHS (2015–2016).[3] A meta-analysis of 15 epidemiological studies on psychiatric morbidity in India (2010) yielded prevalence rate (per thousand) for anxiety disorders is around 16.5%.[4] In India, the prevalence of high level of stress was reported at 59.5% and occupational stress to be 93.3% in a study in 2011 which also found that most stressors were work related.[5] Mental health disturbance in an occupational setting leads to increased absenteeism, reduced productivity, and increased costs[6],[7] apart from causing significant morbidity. Depression and anxiety disorders have been reported to markedly compromise the individual quality of life (QOL) and psychosocial functioning,[8],[9] causing significant impairment even at subthreshold levels.[9] It affects not just the individuals but also their immediate family members with high risk of developing somatic and psychological problems, especially in caregivers,[10] including spouses and children,[11] thus affecting the society at large.

Higher prevalence of depression, anxiety, and stress has been reported among those with low standard of living.[12],[13] However, studies done in school-going children and adolescents in India[14] have also shown high levels of negative emotional states in those belonging to wealthier, more affluent families. All the studies for evaluating this relationship have been done on large, nonclinical samples of either adolescents[4] or general population,[12] including studies in the Indian scenario[14] but none specifically in Class-IV employees (cleaning staff, security guards, peons, lab attendants, etc.)[15] who constitute the lowermost strata among workers and are thus at a higher risk of developing these conditions. There has been less number of studies done in Class-IV workers to assess their mental health and its associated factors. They usually have lower socioeconomic status, poor family income, and low levels of education,[16] as reported by a study on Class-IV workers in a tertiary care hospital in Mumbai. They also reported moderate level of job satisfaction among them.[17] However, these studies have not assessed factors associated with mental health specifically catering to this section of workers. Studies in heterogeneously aged populations have shown that low educational levels are significantly associated with both anxiety and depression, and this protective effect tends to accumulate with time.[18] Psychological illnesses are also closely associated with work-related stressors.[5] Studies have shown that long commuting distances to workplace independently increases the perceived stress level while controlling for personal and other work-related characteristics.[19] Long working hours have also been associated with increased levels of psychological stress[20] and increased risk of depression and anxiety.[21] However, such studies are lacking in the Indian context, especially in relation with Class-IV workers who tend to have longer working hours and erratic shifts.

These data are important to provide consensus for framing government policies to improve mental health of Class-IV workers and other sections of the population in general, including providing healthy workplace environment, and access to psychological counseling and OH services.[1],[22] Since these workers are underrepresented in terms of data available on mental health along with its significant impact on individual, occupational, and societal aspects, this study was conducted to generate new data and supplement existing information in this context.

  Materials and Methods Top

Study basis and study design

It is a cross-sectional type of study which was conducted over a period of 3 months from April to June 2017 in Maulana Azad Medical College, New Delhi. The ethical clearance for the study was taken from the Departmental Scientific Committee.


The study was conducted on a total of 113 Class-IV workers (81 males and 32 females) working in Maulana Azad Medical College who were available during the period of study. They were explained about the purpose and method of study, and written informed consent from the willing participants was obtained in Hindi. Workers who were not available after three stipulated meetings or three personalized visits were excluded from the study.

Study tools

The participants were interviewed personally using predesigned questionnaires which were translated in Hindi. It included as follows:

Sociodemographic questionnaire

It enquired about general information such as age and sex. It also included three variables namely education, occupation, and total monthly family income, which were used to calculate category on the Modified Kuppuswamy's socioeconomic scale[23] for the year 2016. They were also enquired about the number of working hours in a day and their daily commuting distance to workplace.

Short-form health survey-12

It is an indicator of overall health status and QOL consisting of 12 questions assessing eight parameters: physical functioning, bodily pain, general health perception, role limitation due to physical health, role limitation due to emotional problems, vitality, mental well-being, and social functioning. Each item has a different range of responses measured on a Likert scale and is converted using an algorithm[24] to calculate physical component score and mental component score, which measures the physical QOL and mental QOL, respectively. The final score is an arithmetic mean of these two subscores. No cutoff scores are presented for SF-12.[25],[24] It has been validated[26] and widely used in various clinical[27] and nonclinical[28] samples.

Depression anxiety stress-21

It is a set of 21-item self-report questionnaire used to measure the negative emotional states of depression, anxiety, and stress.[29] Each subscale comprises seven statements regarding how the test subject was feeling over the last week and responses are recorded on a 4-point Likert scale which is added to obtain the total score for each subscale and is then used to grade its severity. For the purpose of this study, each subscale was converted into dichotomous variables, i.e., grouped into normal and abnormal based on the standard cutoff scores, which has also been validated by previous studies.[6],[30] Scores less than or equal to 9, 7, and 14 were set as normal levels of depression, anxiety, and stress, respectively. It has been widely used among various populations, age groups, and validated among clinical and nonclinical samples across India.[7],[31] The Hindi version of depression anxiety stress (DASS) has also shown fairly high validity and reliability scores, similar to the original scale in English.[32] Since suicidality is not assessed by the DASS, it was also asked separately at the end of the questionnaire.

Statistical analysis

A quantitative data analysis was performed. The data were collected and compiled using Microsoft Excel 2010 and analyzed using the Statistical Package for the Social Sciences (SPSS) version 22.0 (IBM Corp., Chicago, IL, USA, 2010).[33] Descriptive statistics of mean, median, standard deviation, range, frequency, and percentages were calculated for all the variables. Multivariate analysis was done using binary logistic regression to test the relationship of each of DASS-21 subscales with all the demographic variables using odds ratio (OR) with 95% confidence intervals (CIs), with CI not including 1 to be significant.[34] Finally, multiple linear regression was done to determine the effect of each of DASS subscales (categorical-independent variables) on the average SF-12 scores (continuous-dependent variable).[35]

  Results Top

Sociodemographic characteristics and prevalence of depression, stress, and anxiety

The data of a total of 113 workers were analyzed out of the total 221 workers, covering 51% of the total universe. There were 72% (n = 81) male and 28% (n = 32) female respondents. Around 51% (n = 58) population belonged to upper lower class and 51% (n = 58) were educated till high school and beyond. Most workers were employed as cleaners (47%, n = 53) and security guards (39%, n = 44). Majority of them commuted <10 km (72%, n = 81) daily to reach workplace. Most workers had to work 8 h or less (48%, n = 54) daily (excluding one holiday per week). The highest prevalence was found for anxiety which was 17%, followed by depression 15% and stress 6%, with levels for males being 15%, 15%, 4% and females 22%, 22%, 9%, respectively.

Relationship of depression anxiety stress-21 subscales with sociodemographic variables

Multivariate analysis using binary logistic regression was done for the relationship of DASS-21 subscales with each of the demographic variables while controlling for other variables, i.e., age, sex, occupation, education, socioeconomic class, number of working hours in a day, and distance from workplace. The results showed that certain variables were found to be significantly related to depression and anxiety levels, however none with stress. Workers belonging to upper middle socioeconomic class were 0.048% (OR = 0.048, P = 0.04) times likely to have depression than those belonging to upper lower class. Similarly, those educated till primary level only (till V class) were 8.736 times more likely to have anxiety than the ones educated till high school or beyond (OR = 8.736, P = 0.027). Further, workers traveling 10–19 km distance from home to workplace were 0.017 times likely (OR = 0.017, P = 0.034) to have depression and 0.06 times likely (OR = 0.06, P = 0.038) to have anxiety compared to those traveling <10 km. Middle-aged workers (30–44 years) were 5.547 times more likely to have depression than the ones aged 45 years or older (OR = 5.547, P = 0.049) [Table 1], [Table 2], [Table 3].
Table 1: Relationship of sociodemographic variables with depression levels using multivariate analysis (binary logistic regression) (n=113)

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Table 2: Relationship of sociodemographic variables with anxiety levels using multivariate analysis (binary logistic regression) (n=113)

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Table 3: Relationship of sociodemographic variables with stress levels using multivariate analysis (binary logistic regression) (n=113)

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Effect of depression, anxiety, and stress on overall quality of life

A multiple linear regression model was conducted to analyze the effect of DASS-21 subscales on the overall QOL (SF-12 score). The model indicated good level of predictability (R = 0.733) and was a suitable model fit (R2 change = 0.537). Around 52.4% of the variation in SF-12 scores can be accounted for by the DASS-21 subscales (R2 = 0.524). The results showed that each of the DASS-21 subscales was found to be negatively related to the SF-12 score; i.e., by every standard deviation increase in levels of depression, anxiety, and stress scores, there was a decrease of 0.355, 0.307, and 0.272 standard deviations of SF-12 score, respectively (P = 0.001) [Table 4].
Table 4: Effect of depression, anxiety, and stress on quality of life using multiple linear regression analysis

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  Discussion Top

The aim of the study was to assess the levels of depression, anxiety, and stress among Class-IV workers and study their relationship with demographic variables, mainly education, socioeconomic status, occupation, number of working hours, and daily commuting distance. Finally, its impact on overall QOL was also assessed.

Our study reported prevalence of 17% and 15% for anxiety and depression, respectively, comparable to previous data.[36] Stress subscale positive scores had prevalence of 6%, which was found to be the lowest among all three scales. Female workers were found to have higher prevalence of these states than their male counterparts which, however, was not found to be significant in our study.[36]

We hypothesized that abnormal scores on DASS-21 are associated with low level of education and poor socioeconomic status. These were tested along with general demographic variables such as age, sex, and occupation as well. It was found that workers belonging to upper middle class were less likely to have depression than upper lower class corroborating with our hypothesis and findings of previous studies.[12],[13] This can be explained with a number of factors, including increased financial burden and lack of better resources to cope with stress that occurs due to poor socio-economic status. It was also found that workers who were educated till primary level were much more likely to have higher anxiety levels than those educated till high school or beyond, which is in line with previous studies.[18] However, depression levels were not found to be related with education levels of the workers. Further, middle-aged workers (30–44 years) were more likely to have high levels of depression than older workers.

In our third hypothesis, we expected that work-related stressors (long working hours and greater daily commuting distance to workplace) would be associated with higher perceptions of stress, anxiety, and depression. However, the study indicates that the workers who traveled longer distances from home to workplace daily were slightly less likely to have depression and anxiety as compared to those who commuted less, opposing previous studies.[19] Daily number of working hours was not found to be related with stress, anxiety, or depression as opposed to previous studies.[20],[21] This could be due to the fact that almost all the workers had a fixed working time in a day with certain workers employed exclusively for night shifts. This gives the workers adequate time to rest and replenish themselves both physically and mentally and also eliminates the negative impact of long duty hours and night shifts.

Our study has also reported significant impact of depression, anxiety, and stress on the overall QOL; i.e., with increasing levels of depression, anxiety, and stress, there is a significant decrease in the overall QOL of the workers, maximum decrease being noted for the depression scale, which was in line with previous studies.[8],[9]

These data are important to formulate several government level policies to create healthy workplace environment for these workers, including activities for promotion of mental health and reduce stigmatization; staff training to recognize indicators of occupational stress in both themselves and their colleagues; and facilitating access to evidence-based care through health service development, including easy access to OH services and vocational rehabilitation programs.[22] The clinical implications include provision of counseling sessions, creating awareness, and education regarding problem-solving techniques, stress risk assessment, and collaboration with multidisciplinary professionals including general physicians and psychologists for early identification of cases and assessment of physical and mental fitness to facilitate return to work.[1]

There is scope for further research in this area with utilization of more robust techniques to establish stronger relationship of mental illnesses with other sociodemographic variables and work-related stressors in this group of workers.[37] Other parameters of Class-IV workers, such as job satisfaction, provision of incentives, job security (in contractual workers), and timely payment, can also be assessed to provide further insight into the associated factors. Further, cost–benefit research on policies addressing mental health of these workers is required that evaluates the efficacy of these strategies to improve mental health.[38]

Limitations of the study

The study population included institution based Class-IV workers. Hence, it cannot be generalized to all sections of Class-IV workers such as hospital-based or factory-based workers as the variation in the kind of work done including emergency care and requirement of manual labor can also influence mental health.[39] In addition, a face-to-face interview method for administration of DASS was employed (despite DASS being a self-report questionnaire) due to the low level of education of the Class IV workers, but it has not been used previously and studies have also shown concern over whether the patient response styles vary between administration methods.[40] For this study, DASS-21 subscales were categorized into two groups using standard cutoff scores instead of analyzing continuous scores to increase the sensitivity which have also been evaluated by previous similar studies.[6],[29] Although it may not give exact relationship of the variables with increasing scores on DASS-21, the original standard categorization of this scale into various groups justifies this method. Other confounding factors such as family issues, physical health, or financial matters which may also influence mental health were not discussed in this study.[10],[41]

  Conclusion Top

The utility of the present study lies in pointing out significant levels of depression, anxiety, and stress among Class-IV workers ranging from 6% to 17%. Higher socioeconomic status was found to be associated with depression among workers. Low education level correlated well with abnormal anxiety levels. However, workers commuting longer distances to the workplace daily were less likely to have anxiety and depression. Higher depression levels also correlated with middle-aged workers. There is scope for various government policies to be framed to improve overall health and well-being in the occupational setting. Extensive research with utilization of more robust techniques to identify risk factors and establish their relationship with sociodemographic variables and other stressors particular to this part of the population is required.


We wish to extend our sincere gratitude to all the participants for their valuable time and responses for this study. We would also like to thank the college authorities for their kindness of giving permission to conduct this study and for their cooperation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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