Associations between interactional justice, supervisors’ support, and depressive symptoms among primary care nursing workers: a cross-sectional study in Brazil

Associations between interactional justice, supervisors’ support, and depressive symptoms among primary care nursing workers: a cross-sectional study in Brazil | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Associations between interactional justice, supervisors’ support, and depressive symptoms among primary care nursing workers: a cross-sectional study in Brazil Carolina de Lima Cottafava, Jamili Joana de Melo Calixto, Andrea Tenorio Correia da Silva This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6184538/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background High prevalence of depressive symptoms among primary care workers has been pointed out in previous studies. However, the relationship of leadership aspects and the mental health of nursing workers in Primary Health Care (PHC) has been overlooked. We aimed to estimate the prevalence of depressive symptoms among nursing workers and to investigate the associations between interactional justice, supervisor support, and depressive symptoms among nurses and nursing-assistants in PHC. Methods we conducted a cross-sectional study, with a representative sample of professionals from the Family Health Strategy (FHS) in the city of São Paulo, Brazil. Sixty-six UBS were randomly selected, including 351 teams and 953 nursing professionals (306 nurses and 647 technicians). The Patient Health Questionnaire (PHQ-9) was used to assess, with scores ≥ 10 being classified as probable major depression. We used the Brazilian version of the Organizational Justice Perception Scale to assess interactional justice and the Job Stress Scale to address support from supervisor. The associations between sociodemographic variables, stressful life events, work characteristics, and depressive symptoms were analyzed using Poisson regression with robust variance. Results The prevalence of probable major depression was 25.6%. The variables associated with the risk of probable major depression were being women, having reported low interactional justice (prevalence ratio = 1.53), and low supervisor support (prevalence ration = 1.96). Conclusion Reporting low interactional justice and receiving insufficient support from supervisors might jeopardize nursing workers’ mental health. Leadership training could be a strategy to mitigate depressive symptoms among PHC nursing. Organizational justice Work stress Primary Health Care Health Personnel Depressive symptoms Depression Introduction The prevalence of depression among health workers ranges from 25.0–30.5% (1,2), reaching 54.7% among Primary Health Care (PHC) workers (3). The repercussions of depression among health workers include absenteeism, sleep disorders, burnout, suicidal ideation (1), reduced quality of care, threats to patient safety, and malpractice (3). Depression is therefore a public health problem of major concern to health care managers. Some work-related factors can increase the risk of depressive symptoms among health workers, including work overload characterized by high psychological demands (4), low autonomy, and low supervisor support (5). These factors represent aspects of the job stress model proposed by Karasek and Theorell (1). Furthermore, interpersonal conflicts, workplace violence, and organizational justice have been associated with factors that increase the risk of depressive symptoms in health workers (6). From this perspective, the three dimensions of organizational justice must be mentioned: distributive justice – perceived fairness regarding outcomes and rewards; procedural justice – perceived fairness regarding the formal procedures of organization, including decision-making processes, and interactional justice – quality of interpersonal relationships between managers and workers, including treatment with respect and dignity (7). The essential attributes of PHC as a level of care for health systems are being the entry point to the system, the coordination of care, and the promotion integrated and longitudinal care (8). This approach has been identified as a fundamental strategy for improving health outcomes (9). Brazil has one of the largest PHC programs in the world, the Family Health Strategy (ESF in the Portuguese acronym) (10). Currently, more than 132 million people are registered with the ESF throughout the country (11). Each family health team is composed of a doctor, a nurse, two nursing technicians, and four to six community health agents (11). There are 1,224 family health teams in the city of São Paulo, the largest urban center in South America, with 45% of the city’s population being registered with these teams (12). This region is therefore appropriate for investigating the mental health of PHC workers. Despite the importance of PHC workers in improving health outcomes of the attended populations, few studies have investigated the association between interactional justice, supervisor support, and depressive symptoms among nursing workers in PHC. Therefore, the aim of this study was to investigate the relationships between interactional justice, supervisor support, and depressive symptoms in nursing professionals from family health teams in the city of São Paulo. Methods Study design and sample This is a cross-sectional study that investigated the mental health of PHC workers in the city of São Paulo. Sixty-six Basic Health Units were randomly selected to participate in the study, which included 351 family health teams. Nursing workers (nurses and nurse technicians) who had been working in these teams for more than 3 months were invited to participate. Finally, 306 nurses and 647 nurse technicians participated in the study. The response rate was 87% for nurses and 92.2% for nurse technicians. Depressive symptoms Depressive symptoms were analyzed using the Patient Health Questionnaire-9 (PHQ-9), validated for Brazilian Portuguese. This instrument is composed of nine items according to the criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for the diagnosis of depression (13). The WHO indicates this instrument for depression screening and follow-up at PHC services. The study conducted in Brazil to assess the discriminant validity of the PHQ-9 obtained an area under the ROC curve of 0.998 (p < 0.001), sensitivity of 77.5%, and specificity of 86.7% (14). The PHQ-9 assigns scores from 0 to 3 to the frequency of depressive signs and symptoms in the past 2 weeks, as follows: 0 = not at all; 1 = several days; 2 = more than half the days, and 3 = nearly every day. The severity of depression is scored from 0 to 27 points. Based on the PHQ-9 scores obtained, applying a cut-off point of 10, the participants were divided into two categories: without probable major depression and with probable major depression (13). Sociodemographic variables The following sociodemographic characteristics of the participants were investigated: sex, age, race/skin color (self-reported), marital status, and profession. Stressful life events The history of stressful life events in the past 12 months was also investigated since such events are associated with depression (15). For assessment, eight questions were scored as follows: 0 = no event; 1 = one event; 2 = two events, and 3 = three or more events in the last year. The following stressful life events were analyzed: serious illness, hospitalization, serious financial problems, forced change of residence, dissolution of a romantic relationship, and death of a close relative. Job Stress Scale The short version of the Job Stress Scale, validated and adapted to Brazilian Portuguese, was used to assess the dimensions of social support (16). These authors reported an intraclass correlation of 0.88 for demand, of 0.87 for control, and of 0.80 for social support. Cronbach’s alpha was 0.79 for demand, 0.67 for control, and 0.85 for social support. The scale possesses 17 items and is composed of three sections: (1) five items to assess work-related psychological demand; (2) six items to assess the control dimension, and (3) six items to assess social support, which examine relationships with colleagues and supervisors. For the dimension of social support at work, the response options range from strongly disagree (1) to strongly agree (4). The median score obtained for each dimension is used to was used to divide the participants into two groups (low and high). The present study analyzed the social support dimension because it is directly related to the management practices of the supervisor/coordinator and can provide information on measures aimed at improving management styles. Organizational justice The validated Brazilian Portuguese version of the Organizational Justice Perception Scale (17) was used to measure organizational justice. This scale consists of 20 items and is arranged according to the distribution of statements in the three dimensions of organizational justice (distributive, procedural, and interactional). Six statements address the distributive justice dimension, while seven questions each refer to the other dimensions (procedural and interactional justice). Responses are rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Interactional justice refers to the quality of interactions between employees and their immediate supervisors (18). We decided to analyze interactional justice in the present study because it addresses how relationships are established between local managers and health professionals and can therefore provide direct recommendations for management practices in health services. Statistical analysis First, descriptive analysis was performed to examine the distributions of the variables and the frequencies of categories, and to confirm consistency of the data. Next, bivariate analysis was applied to analyze the strength of the association between each explanatory variable and the outcome, followed by multiple analysis. Chi-squared statistics were used to test the null hypotheses that no association exists between two variables and their categories, with Yates correction for profession, sex, interactional justice, and supervisor support and Pearson correction for age, marital status, and stressful life events. The criterion for including variables in the multiple models was a p-value in bivariate analysis ≤ 0.10. The selected variables were then tested one by one in the multiple models and only those that remained significant were kept in the final model (p ≤ 0.05). Poisson regression with robust variance was used to estimate the associations of sociodemographic and work variables with depressive symptoms. Prevalence ratios (PRs) and their respective confidence intervals were estimated. Poisson regression with robust variance was chosen to minimize overestimation of the associations since the outcome had a high prevalence. Results The sample consisted of 953 nursing professionals; 32.1% were nurses and 67.9% were nurse technicians. There was a predominance of women (90.6%) aged 31 to 40 years and self-reported white race/skin color. At least one stressful life event in the 12 months preceding the interview was reported by 40% of the sample. Scores consistent with low supervisor support and low interactional justice were found in 65.2% and 45.9% of the participants, respectively. The prevalence of probable major depression was 25.6%. Sex, stressful life events, interactional justice, and supervisor support showed a significant association with probable major depression. Further descriptive data on the sample are presented in Table 1 . Table 1 Distribution of participants according to probable major depression, sociodemographic characteristics, work-related characteristics, and stressful life events (N = 953). Variable / Category N (%) Without depressive symptoms n (%) Probable major depression n (%) p-value Total 953 (100) 709 (74.4) 244 (25.6) Profession 0.616 a Nurse 306 (32.1) 224 (73.2) 82 (26.8) Nurse technician 647 (67.9) 485 (75.0) 162 (25.0) Sex 0.003 a Male 90 (9.4) 79 (87.7) 11 (12.2) Female 863 (90.6) 630 (73.0) 233 (27.0) Age (years) 0.288 b 18–30 204 (21.4) 148 (72.5) 56 (27.4) 31–40 426 (44.7) 310 (72.7) 116 (27.2) 41–50 236 (24.8) 180 (76.2) 56 (23.7) ≥ 51 87 (9.1) 71 (81.6) 16 (18.3) Marital status 0.601 b Single 243 (25.5) 184 (75.7) 59 (24.2) Widowed 11 (1.2) 2 (18.1) 9 (81.1) Married/Cohabiting 585 (61.4) 438 (74.8) 147 (25.1) Divorced 114 (12.0) 79 (69.2) 35 (30.7) Race/Skin color 0.885 b White 424 (44.5) 314 (74.0) 110 (26.0) Yellow 20 (2.1) 14 (70.0) 6 (30.0) Brown 349 (36.6) 264 (75.6) 85 (24.3) Black 160 (16.8) 117 (73.1) 43 (26.8) Stressful life event in the past 12 months < 0.001 b None 381 (40.0) 333 (87.4) 48 (12.5) 1 309 (32.4) 226 (73.8) 83 (26.1) 2 164 (17.2) 97 (59.1) 67 (40.8) ≥ 3 99 (10.4) 53 (53.5) 46 (46.4) Interactional justice < 0.001 a Low 437 (45.9) 282 (64.5) 155 (35.4) High 516 (54.1) 427 (82.7) 89 (17.2) Supervisor support < 0.001 a Low 621 (65.2) 419 (67.4) 202 (32.5) High 332 (34.8) 290 (87.3) 42 (12.6) a : Yates chi-squared b : Pearson’s chi-squared Table 2 shows the adjusted PRs and their respective 95% confidence intervals. Participants who reported one or more stressful life events had a 2.5-fold higher risk of probable major depression. The perception of low interactional justice increased the risk of probable major depression by 53% and participants with low support from supervisor had nearly twice the risk of probable major depression than those with high support (PR = 1.96). Table 2 Adjusted prevalence ratios and respective 95% confidence intervals according to the final Poisson regression model with robust variance. Probable major depression Variable / Category Adjusted PR 95% CI p-value Sex 0.01 Male 1.00 - Female 2.17 1.18–3.98 Stressful life event in the past 12 months < 0.01 None 1.00 - One or more 2.44 1.11–3.34 Interactional justice < 0.01 High 1.00 - Low 1.53 1.17–2.01 Support from supervisor < 0.01 High 1.00 - Low 1.96 1.39–2.76 Model adjusted for age, race/skin color, marital status, and profession. PR = prevalence ratio CI = confidence interval Discussion We found a high prevalence of probable major depression among PHC nursing workers in the city of São Paulo. Women and participants with low interactional justice and low support from supervisor were more likely to have probable major depression. Studies have shown that the prevalence of depression among PHC workers varies widely across countries, with rates ranging from 19.1–50.7%. Factors such as sex, stressful situations at work, stressful life events, lack of supervisor support, insufficient social support, and low organizational justice have been associated with a higher risk of depression (19–21). Regarding sex, the higher risk of depression among women corroborates the results of other studies (4, 22). Some authors suggest that the double workload of women, at work and at home, could explain the higher prevalence of depressive symptoms compared to men (23). Interactional justice is one of the dimensions of the Organizational Justice Model and refers to the way employees are treated by their superiors and coworkers (21). Like our results, a study conducted in Japan showed that the perception of low interactional justice was associated with a five-fold increase in the odds of major depression in the past 12 months (21). Another study found an association between organizational justice and psychological distress, in which the higher the level of organizational injustice, the poorer the mental health. The results showed that organizational justice was a strong predictor of psychological distress (24). With respect to supervisor support, participants who reported insufficient support were more likely to have major depression than workers who reported high support. According to the model proposed by Karasek and Theorell (25), supervisor support at work helps reduce the negative effects of high demands and low control and thus contributes to improving mental health. Supervisors who provide emotional support and feedback can reduce stress and its impact on mental health. On the other hand, a lack of support can increase the risk of depressive symptoms (26). It is worth noting that the types of leadership involving supervisor support and periodic feedback, such as transformational and authentic leadership, have been associated with a lower risk of work-related mental suffering and with a reduction in depressive symptoms (27). The combination of support from supervisors, recognition, autonomy, and effective communication is associated with lower risks of depression (28). Regarding stressful life events, several studies have reported an association between these events and depressive symptoms (29). Events such as financial hardship, exposure to violence, death of a loved one (30), and serious illnesses can cause mental suffering and progress to depression. These events cause a feeling of loss, insecurity, lack of control, fear, and mistrust, which can have a negative impact on mental health (29). Strengths and limitations of the study The strengths of the study include its representative sample and a high response rate, as well as the adjustment of the model for stressful life events that are not work-related and could affect the risk of depression. Another strength of the study is the choice of Poisson regression with robust variance for association analysis. Since the prevalence of the outcome is high, Poisson regression was used to minimize overestimation of the association 31 . Our study is one of the first to analyze associations of interactional justice and support from supervisor with depressive symptoms among PHC nursing workers in Brazil. One limitation of this study is its cross-sectional design, which does not permit to analyze cause-effect relationships. In addition, depressive symptoms may have been underestimated since workers who were absent from work due to depression were not included. Another limitation is the possibility of reverse causality, in which participants with depressive symptoms are more likely to classify interactional justice as low. Conclusion The present results have repercussions for the management of health services, especially for PHC. The observation of a higher risk of depression among workers with low supervisor support and low interactional justice highlights the need for implementing measures designed to improve manager and supervisor skills, including communication skills, with a focus on organizational justice and proving support for healthcare workers. Such measures could help mitigate mental suffering among PHC nursing workers and thus affect the quality of care. Abbreviations PHC Primary Health Care FHS Family Health Strategy UBS Basic Health Units PHQ 9-The Patient Health Questionnaire WHO World Health Organization DSM Diagnostic and Statistical Manual of Mental Disorders Declarations Ethical approval and consent to participate This study was carried out in line with the principles. Approval was granted by the Research Ethics Committee of the Faculty of Medicine of the University of São Paulo. The study was carried out after obtaining informed consent from the all participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions ATCS participated in the study design, data collection, data analysis and interpretation, supervised methodology, writing and revision; CL participated in data analysis and interpretation, writing and revision; JJMC participated in data interpretation, writing and revision. All authors reviewed and approved the final version. Acknowledgements Not applicable. Author details 1 Faculty of Medicine of Jundiaí – Jundiaí (SP), Brazil. 2 University of São Paulo – São Paulo (SP), Brazil. 3 Faculdade de Ciências Médicas da Santa Casa de São Paulo References Rotta DS, Pinto MH, Lourenção LG, Teixeira PR, Gonsalez EG, Gazetta CE. Anxiety and depression levels among multidisciplinary health residents. Rev da Rede Enferm do Nord [Internet]. 29 de junho de 2016;17(3):372. Available at: http://periodicos.ufc.br/rene/article/view/3472/2715 Sampaio LR, Oliveira LC de, Pires MFDN. Empatia, depressão, ansiedade e estresse em Profissionais de Saúde Brasileiros. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6184538","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":433731807,"identity":"3ee742cc-85bb-4061-aca1-f44bbbe7fd3d","order_by":0,"name":"Carolina de Lima Cottafava","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIie3PsQrCMBCA4ZNAXA6zBiz6CpGCk+jDBJyCroqDg4OL4OyLdHK40sEl7pUuasFN0CfQtLO0ujnkH0IC+cgFwOf7yxpncmsAzU15xFY9YYqcQUALUGz4N6S8CdKUBGqJWCeN5LkfoNjd4/xphgEHdrmmFURaDUS3McpsolUcaTcYD0NTQRRMyZUgZKYv44g5grxdSUTuXqEXdk+2IMsviCwGI0KVYkGSeiJT94oljT1rQnWMDshZzV/EVrPHjIadzsH2zvNoMRLN1SWvIh9iv133+Xw+34fei/RKcMAyp9oAAAAASUVORK5CYII=","orcid":"","institution":"Faculdade de Medicina de Jundiaí","correspondingAuthor":true,"prefix":"","firstName":"Carolina","middleName":"de Lima","lastName":"Cottafava","suffix":""},{"id":433731808,"identity":"a6a45b89-3904-431f-b501-c2b1e55265e2","order_by":1,"name":"Jamili Joana de Melo Calixto","email":"","orcid":"","institution":"Faculdade de Medicina de Jundiaí","correspondingAuthor":false,"prefix":"","firstName":"Jamili","middleName":"Joana de Melo","lastName":"Calixto","suffix":""},{"id":433731809,"identity":"67dcdf10-d5ac-40ad-bb61-69171c62ec48","order_by":2,"name":"Andrea Tenorio Correia da Silva","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"Tenorio Correia da","lastName":"Silva","suffix":""}],"badges":[],"createdAt":"2025-03-08 14:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6184538/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6184538/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79377194,"identity":"9b7b5130-337f-483d-b473-1b3f2a22ccd0","added_by":"auto","created_at":"2025-03-27 15:31:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":859582,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6184538/v1/c2a8a315-ddc1-4aba-9598-0c0052565858.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations between interactional justice, supervisors’ support, and depressive symptoms among primary care nursing workers: a cross-sectional study in Brazil","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe prevalence of depression among health workers ranges from 25.0\u0026ndash;30.5% (1,2), reaching 54.7% among Primary Health Care (PHC) workers (3). The repercussions of depression among health workers include absenteeism, sleep disorders, burnout, suicidal ideation (1), reduced quality of care, threats to patient safety, and malpractice (3). Depression is therefore a public health problem of major concern to health care managers.\u003c/p\u003e \u003cp\u003eSome work-related factors can increase the risk of depressive symptoms among health workers, including work overload characterized by high psychological demands (4), low autonomy, and low supervisor support (5). These factors represent aspects of the job stress model proposed by Karasek and Theorell (1). Furthermore, interpersonal conflicts, workplace violence, and organizational justice have been associated with factors that increase the risk of depressive symptoms in health workers (6). From this perspective, the three dimensions of organizational justice must be mentioned: distributive justice \u0026ndash; perceived fairness regarding outcomes and rewards; procedural justice \u0026ndash; perceived fairness regarding the formal procedures of organization, including decision-making processes, and interactional justice \u0026ndash; quality of interpersonal relationships between managers and workers, including treatment with respect and dignity (7).\u003c/p\u003e \u003cp\u003eThe essential attributes of PHC as a level of care for health systems are being the entry point to the system, the coordination of care, and the promotion integrated and longitudinal care (8). This approach has been identified as a fundamental strategy for improving health outcomes (9). Brazil has one of the largest PHC programs in the world, the Family Health Strategy (ESF in the Portuguese acronym) (10). Currently, more than 132\u0026nbsp;million people are registered with the ESF throughout the country (11). Each family health team is composed of a doctor, a nurse, two nursing technicians, and four to six community health agents (11). There are 1,224 family health teams in the city of S\u0026atilde;o Paulo, the largest urban center in South America, with 45% of the city\u0026rsquo;s population being registered with these teams (12). This region is therefore appropriate for investigating the mental health of PHC workers.\u003c/p\u003e \u003cp\u003eDespite the importance of PHC workers in improving health outcomes of the attended populations, few studies have investigated the association between interactional justice, supervisor support, and depressive symptoms among nursing workers in PHC. Therefore, the aim of this study was to investigate the relationships between interactional justice, supervisor support, and depressive symptoms in nursing professionals from family health teams in the city of S\u0026atilde;o Paulo.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and sample\u003c/h2\u003e \u003cp\u003eThis is a cross-sectional study that investigated the mental health of PHC workers in the city of S\u0026atilde;o Paulo. Sixty-six Basic Health Units were randomly selected to participate in the study, which included 351 family health teams. Nursing workers (nurses and nurse technicians) who had been working in these teams for more than 3 months were invited to participate. Finally, 306 nurses and 647 nurse technicians participated in the study. The response rate was 87% for nurses and 92.2% for nurse technicians.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDepressive symptoms\u003c/h3\u003e\n\u003cp\u003eDepressive symptoms were analyzed using the Patient Health Questionnaire-9 (PHQ-9), validated for Brazilian Portuguese. This instrument is composed of nine items according to the criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for the diagnosis of depression (13). The WHO indicates this instrument for depression screening and follow-up at PHC services. The study conducted in Brazil to assess the discriminant validity of the PHQ-9 obtained an area under the ROC curve of 0.998 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), sensitivity of 77.5%, and specificity of 86.7% (14).\u003c/p\u003e \u003cp\u003eThe PHQ-9 assigns scores from 0 to 3 to the frequency of depressive signs and symptoms in the past 2 weeks, as follows: 0\u0026thinsp;=\u0026thinsp;not at all; 1\u0026thinsp;=\u0026thinsp;several days; 2\u0026thinsp;=\u0026thinsp;more than half the days, and 3\u0026thinsp;=\u0026thinsp;nearly every day. The severity of depression is scored from 0 to 27 points. Based on the PHQ-9 scores obtained, applying a cut-off point of 10, the participants were divided into two categories: without probable major depression and with probable major depression (13).\u003c/p\u003e\n\u003ch3\u003eSociodemographic variables\u003c/h3\u003e\n\u003cp\u003eThe following sociodemographic characteristics of the participants were investigated: sex, age, race/skin color (self-reported), marital status, and profession.\u003c/p\u003e\n\u003ch3\u003eStressful life events\u003c/h3\u003e\n\u003cp\u003eThe history of stressful life events in the past 12 months was also investigated since such events are associated with depression (15). For assessment, eight questions were scored as follows: 0\u0026thinsp;=\u0026thinsp;no event; 1\u0026thinsp;=\u0026thinsp;one event; 2\u0026thinsp;=\u0026thinsp;two events, and 3\u0026thinsp;=\u0026thinsp;three or more events in the last year. The following stressful life events were analyzed: serious illness, hospitalization, serious financial problems, forced change of residence, dissolution of a romantic relationship, and death of a close relative.\u003c/p\u003e\n\u003ch3\u003eJob Stress Scale\u003c/h3\u003e\n\u003cp\u003eThe short version of the Job Stress Scale, validated and adapted to Brazilian Portuguese, was used to assess the dimensions of social support (16). These authors reported an intraclass correlation of 0.88 for demand, of 0.87 for control, and of 0.80 for social support. Cronbach\u0026rsquo;s alpha was 0.79 for demand, 0.67 for control, and 0.85 for social support. The scale possesses 17 items and is composed of three sections: (1) five items to assess work-related psychological demand; (2) six items to assess the control dimension, and (3) six items to assess social support, which examine relationships with colleagues and supervisors. For the dimension of social support at work, the response options range from strongly disagree (1) to strongly agree (4). The median score obtained for each dimension is used to was used to divide the participants into two groups (low and high). The present study analyzed the social support dimension because it is directly related to the management practices of the supervisor/coordinator and can provide information on measures aimed at improving management styles.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOrganizational justice\u003c/h2\u003e \u003cp\u003eThe validated Brazilian Portuguese version of the Organizational Justice Perception Scale (17) was used to measure organizational justice. This scale consists of 20 items and is arranged according to the distribution of statements in the three dimensions of organizational justice (distributive, procedural, and interactional). Six statements address the distributive justice dimension, while seven questions each refer to the other dimensions (procedural and interactional justice). Responses are rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Interactional justice refers to the quality of interactions between employees and their immediate supervisors (18). We decided to analyze interactional justice in the present study because it addresses how relationships are established between local managers and health professionals and can therefore provide direct recommendations for management practices in health services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFirst, descriptive analysis was performed to examine the distributions of the variables and the frequencies of categories, and to confirm consistency of the data. Next, bivariate analysis was applied to analyze the strength of the association between each explanatory variable and the outcome, followed by multiple analysis. Chi-squared statistics were used to test the null hypotheses that no association exists between two variables and their categories, with Yates correction for profession, sex, interactional justice, and supervisor support and Pearson correction for age, marital status, and stressful life events.\u003c/p\u003e \u003cp\u003eThe criterion for including variables in the multiple models was a p-value in bivariate analysis\u0026thinsp;\u0026le;\u0026thinsp;0.10. The selected variables were then tested one by one in the multiple models and only those that remained significant were kept in the final model (p\u0026thinsp;\u0026le;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003ePoisson regression with robust variance was used to estimate the associations of sociodemographic and work variables with depressive symptoms. Prevalence ratios (PRs) and their respective confidence intervals were estimated. Poisson regression with robust variance was chosen to minimize overestimation of the associations since the outcome had a high prevalence.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe sample consisted of 953 nursing professionals; 32.1% were nurses and 67.9% were nurse technicians. There was a predominance of women (90.6%) aged 31 to 40 years and self-reported white race/skin color. At least one stressful life event in the 12 months preceding the interview was reported by 40% of the sample. Scores consistent with low supervisor support and low interactional justice were found in 65.2% and 45.9% of the participants, respectively.\u003c/p\u003e \u003cp\u003eThe prevalence of probable major depression was 25.6%. Sex, stressful life events, interactional justice, and supervisor support showed a significant association with probable major depression. Further descriptive data on the sample are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of participants according to probable major depression, sociodemographic characteristics, work-related characteristics, and stressful life events (N\u0026thinsp;=\u0026thinsp;953).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable / Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout depressive symptoms \u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProbable major depression\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e953 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e709 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e244 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfession\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.616\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e306 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e224 (73.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e647 (67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e485 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e162 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (87.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e863 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e630 (73.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e233 (27.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.288\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e148 (72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e426 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e310 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e116 (27.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236 (24.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (23.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71 (81.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.601\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e243 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e184 (75.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (81.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/Cohabiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e585 (61.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e438 (74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e147 (25.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35 (30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace/Skin color\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.885\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e424 (44.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e314 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e110 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYellow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e349 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e264 (75.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117 (73.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStressful life event in the past 12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e381 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e333 (87.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e309 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e226 (73.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164 (17.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97 (59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46 (46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInteractional justice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e437 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e282 (64.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e155 (35.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e516 (54.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e427 (82.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89 (17.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupervisor support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e621 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e419 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e202 (32.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e332 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e290 (87.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e: Yates chi-squared\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003e: Pearson\u0026rsquo;s chi-squared\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the adjusted PRs and their respective 95% confidence intervals. Participants who reported one or more stressful life events had a 2.5-fold higher risk of probable major depression. The perception of low interactional justice increased the risk of probable major depression by 53% and participants with low support from supervisor had nearly twice the risk of probable major depression than those with high support (PR\u0026thinsp;=\u0026thinsp;1.96).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted prevalence ratios and respective 95% confidence intervals according to the final Poisson regression model with robust variance.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eProbable major depression\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVariable / Category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAdjusted PR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.18\u0026ndash;3.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStressful life event in the past 12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11\u0026ndash;3.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInteractional justice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.17\u0026ndash;2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupport from supervisor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.39\u0026ndash;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModel adjusted for age, race/skin color, marital status, and profession.\u003c/p\u003e \u003cp\u003ePR\u0026thinsp;=\u0026thinsp;prevalence ratio\u003c/p\u003e \u003cp\u003eCI\u0026thinsp;=\u0026thinsp;confidence interval\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe found a high prevalence of probable major depression among PHC nursing workers in the city of S\u0026atilde;o Paulo. Women and participants with low interactional justice and low support from supervisor were more likely to have probable major depression.\u003c/p\u003e \u003cp\u003eStudies have shown that the prevalence of depression among PHC workers varies widely across countries, with rates ranging from 19.1\u0026ndash;50.7%. Factors such as sex, stressful situations at work, stressful life events, lack of supervisor support, insufficient social support, and low organizational justice have been associated with a higher risk of depression (19\u0026ndash;21). Regarding sex, the higher risk of depression among women corroborates the results of other studies (4, 22). Some authors suggest that the double workload of women, at work and at home, could explain the higher prevalence of depressive symptoms compared to men (23).\u003c/p\u003e \u003cp\u003eInteractional justice is one of the dimensions of the Organizational Justice Model and refers to the way employees are treated by their superiors and coworkers (21). Like our results, a study conducted in Japan showed that the perception of low interactional justice was associated with a five-fold increase in the odds of major depression in the past 12 months (21). Another study found an association between organizational justice and psychological distress, in which the higher the level of organizational injustice, the poorer the mental health. The results showed that organizational justice was a strong predictor of psychological distress (24).\u003c/p\u003e \u003cp\u003eWith respect to supervisor support, participants who reported insufficient support were more likely to have major depression than workers who reported high support. According to the model proposed by Karasek and Theorell (25), supervisor support at work helps reduce the negative effects of high demands and low control and thus contributes to improving mental health. Supervisors who provide emotional support and feedback can reduce stress and its impact on mental health. On the other hand, a lack of support can increase the risk of depressive symptoms (26).\u003c/p\u003e \u003cp\u003eIt is worth noting that the types of leadership involving supervisor support and periodic feedback, such as transformational and authentic leadership, have been associated with a lower risk of work-related mental suffering and with a reduction in depressive symptoms (27). The combination of support from supervisors, recognition, autonomy, and effective communication is associated with lower risks of depression (28).\u003c/p\u003e \u003cp\u003eRegarding stressful life events, several studies have reported an association between these events and depressive symptoms (29). Events such as financial hardship, exposure to violence, death of a loved one (30), and serious illnesses can cause mental suffering and progress to depression. These events cause a feeling of loss, insecurity, lack of control, fear, and mistrust, which can have a negative impact on mental health (29).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cp\u003eThe strengths of the study include its representative sample and a high response rate, as well as the adjustment of the model for stressful life events that are not work-related and could affect the risk of depression. Another strength of the study is the choice of Poisson regression with robust variance for association analysis. Since the prevalence of the outcome is high, Poisson regression was used to minimize overestimation of the association\u003csup\u003e31\u003c/sup\u003e. Our study is one of the first to analyze associations of interactional justice and support from supervisor with depressive symptoms among PHC nursing workers in Brazil.\u003c/p\u003e \u003cp\u003eOne limitation of this study is its cross-sectional design, which does not permit to analyze cause-effect relationships. In addition, depressive symptoms may have been underestimated since workers who were absent from work due to depression were not included. Another limitation is the possibility of reverse causality, in which participants with depressive symptoms are more likely to classify interactional justice as low.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present results have repercussions for the management of health services, especially for PHC. The observation of a higher risk of depression among workers with low supervisor support and low interactional justice highlights the need for implementing measures designed to improve manager and supervisor skills, including communication skills, with a focus on organizational justice and proving support for healthcare workers. Such measures could help mitigate mental suffering among PHC nursing workers and thus affect the quality of care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily Health Strategy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBasic Health Units\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e9-The Patient Health Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was carried out in line with the principles. Approval was granted by the Research Ethics Committee of the Faculty of Medicine of the University of São Paulo. The study was carried out after obtaining informed consent from the all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eATCS participated in the study design, data collection, data analysis and interpretation, supervised methodology, writing and revision; CL participated in data analysis and interpretation, writing and revision; JJMC participated in data interpretation, writing and revision. All authors reviewed and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eFaculty of Medicine of Jundiaí – Jundiaí (SP), Brazil.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eUniversity of São Paulo – São Paulo (SP), Brazil.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eFaculdade de Ciências Médicas da Santa Casa de São Paulo\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRotta DS, Pinto MH, Louren\u0026ccedil;\u0026atilde;o LG, Teixeira PR, Gonsalez EG, Gazetta CE. Anxiety and depression levels among multidisciplinary health residents. Rev da Rede Enferm do Nord [Internet]. 29 de junho de 2016;17(3):372. Available at: http://periodicos.ufc.br/rene/article/view/3472/2715\u003c/li\u003e\n\u003cli\u003eSampaio LR, Oliveira LC de, Pires MFDN. Empatia, depress\u0026atilde;o, ansiedade e estresse em Profissionais de Sa\u0026uacute;de Brasileiros. Ciencias Psicol\u0026oacute;gicas [Internet]. 17 de julho de 2020; Available at: https://revistas.ucu.edu.uy/index.php/cienciaspsicologicas/article/view/2215\u003c/li\u003e\n\u003cli\u003eJulio R de S, Louren\u0026ccedil;\u0026atilde;o LG, Oliveira SM de, Farias DHR, Gazetta CE. Preval\u0026ecirc;ncia de ansiedade e depress\u0026atilde;o em trabalhadores da Aten\u0026ccedil;\u0026atilde;o Prim\u0026aacute;ria \u0026agrave; Sa\u0026uacute;de. Cad Bras Ter Ocup [Internet]. 2022;30. Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S2526-89102022000100212\u0026amp;tlng=pt\u003c/li\u003e\n\u003cli\u003eSantos KMR dos, Galv\u0026atilde;o MHR, Gomes SM, Souza TA de, Medeiros A de A, Barbosa IR. Depress\u0026atilde;o e ansiedade em profissionais de enfermagem durante a pandemia da covid-19. Esc Anna Nery [Internet]. 2021;25(spe). Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S1414-81452021000500201\u0026amp;tlng=pt\u003c/li\u003e\n\u003cli\u003eBoamah SA, Read EA, Spence Laschinger HK. Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time-lagged study. J Adv Nurs [Internet]. maio de 2017;73(5):1182\u0026ndash;95. Available at: https://onlinelibrary.wiley.com/doi/10.1111/jan.13215\u003c/li\u003e\n\u003cli\u003eda Silva ATC, Lopes C de S, Susser E, Menezes PR. Work-Related Depression in Primary Care Teams in Brazil. Am J Public Health [Internet]. novembro de 2016;106(11):1990\u0026ndash;7. Available at: https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303342\u003c/li\u003e\n\u003cli\u003eBeuren IM, Santos V dos, Marques L, Resendes M. 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The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives. Soc Sci Med [Internet]. mar\u0026ccedil;o de 2010;70(6):904\u0026ndash;11. Available at: https://linkinghub.elsevier.com/retrieve/pii/S0277953609008399\u003c/li\u003e\n\u003cli\u003ePinto LF, Giovanella L. Do Programa \u0026agrave; Estrat\u0026eacute;gia Sa\u0026uacute;de da Fam\u0026iacute;lia: expans\u0026atilde;o do acesso e redu\u0026ccedil;\u0026atilde;o das interna\u0026ccedil;\u0026otilde;es por condi\u0026ccedil;\u0026otilde;es sens\u0026iacute;veis \u0026agrave; aten\u0026ccedil;\u0026atilde;o b\u0026aacute;sica (ICSAB). Cien Saude Colet [Internet]. junho de 2018;23(6):1903\u0026ndash;14. Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S1413-81232018000601903\u0026amp;lng=pt\u0026amp;tlng=pt\u003c/li\u003e\n\u003cli\u003eATB/SMS e DAB/MS. Prefeitura de S\u0026atilde;o Paulo: Estrat\u0026eacute;gia Sa\u0026uacute;de da Fam\u0026iacute;lia - ESF. Aten\u0026ccedil;\u0026atilde;o B\u0026aacute;sica - SMS; Maio 2011.\u003c/li\u003e\n\u003cli\u003eKroenke K, Spitzer RL, Williams JBW. The PHQ-9. J Gen Intern Med [Internet]. setembro de 2001;16(9):606\u0026ndash;13. Available at: http://link.springer.com/10.1046/j.1525-1497.2001.016009606.x\u003c/li\u003e\n\u003cli\u003eSantos IS, Tavares BF, Munhoz TN, Almeida LSP de, Silva NTB da, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da popula\u0026ccedil;\u0026atilde;o geral. Cad Saude Publica [Internet]. agosto de 2013;29(8):1533\u0026ndash;43. Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S0102-311X2013000800006\u0026amp;lng=pt\u0026amp;nrm=iso\u0026amp;tlng=en\u003c/li\u003e\n\u003cli\u003eLopes CS, Faerstein E, Chor D. Eventos de vida produtores de estresse e transtornos mentais comuns: resultados do Estudo Pr\u0026oacute;-Sa\u0026uacute;de. Cad Saude Publica [Internet]. dezembro de 2003;19(6):1713\u0026ndash;20. Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S0102-311X2003000600015\u0026amp;lng=pt\u0026amp;tlng=pt\u003c/li\u003e\n\u003cli\u003eAlves MG de M, Chor D, Faerstein E, Lopes C de S, Werneck GL. Vers\u0026atilde;o resumida da \u0026ldquo;job stress scale\u0026rdquo;: adapta\u0026ccedil;\u0026atilde;o para o portugu\u0026ecirc;s. Rev Saude Publica [Internet]. abril de 2004;38(2):164\u0026ndash;71. Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S0034-89102004000200003\u0026amp;lng=pt\u0026amp;tlng=pt\u003c/li\u003e\n\u003cli\u003eMendon\u0026ccedil;a H, Pereira C, Tamayo A, Paz M das GT. Valida\u0026ccedil;\u0026atilde;o fatorial de uma escala de percep\u0026ccedil;ao de justi\u0026ccedil;a organizacional. Estud Goiania. 2003;30(1):111\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eBies, R. J. \u0026amp; Moag JS. Interactional justice: Communication criteria of fairness. Em R J Lewicki, B H Sheppard M H Bazerman (Orgs), Res Negot Organ (pp 43\u0026ndash;55) Greenwich JAI Press.\u003c/li\u003e\n\u003cli\u003eTesema MB, Woldeamanuel BT, Mekonen EB, Melese KG. Depression and its associated factors among health care workers in Saint Paul\u0026rsquo;s hospital millennium medical college, Ethiopia. Tesfa Mengist S, organizador. PLoS One [Internet]. 17 de outubro de 2024;19(10):e0300726. Available at: https://dx.plos.org/10.1371/journal.pone.0300726\u003c/li\u003e\n\u003cli\u003eKakemam E, Maassoumi K, Azimi S, Abbasi M, Tahmasbi F, Alizadeh M. Prevalence of depression, anxiety, and stress and associated reasons among Iranian primary healthcare workers: a mixed method study. BMC Prim Care [Internet]. 26 de janeiro de 2024;25(1):40. Available at: https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-024-02268-w\u003c/li\u003e\n\u003cli\u003eInoue A, Kawakami N, Tsuno K, Tomioka K, Nakanishi M. Organizational Justice and Major Depressive Episodes in Japanese Employees: A Cross-sectional Study. J Occup Health [Internet]. 28 de mar\u0026ccedil;o de 2013;55(2):47\u0026ndash;55. Available at: https://academic.oup.com/joh/article/55/2/47-55/7250515\u003c/li\u003e\n\u003cli\u003eROSEMEIRE KUCHINISKI GOMES, OLIVEIRA VB DE. Depression, anxiety and social support in nursing professionals. Bol Psicol. 2013;63:23\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003eAssis BB de, Azevedo C, Moura C de C, Mendes PG, Rocha LL, Roncalli AA, et al. Factors associated with stress, anxiety and depression in nursing professionals in the hospital context. Rev Bras Enferm [Internet]. 2022;75(suppl 3). Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S0034-71672022001000207\u0026amp;tlng=en\u003c/li\u003e\n\u003cli\u003eSun J, Yang Z, Zhu T, Jiang Z, Zheng X, Li C, et al. The impact of organizational justice on psychological distress among Chinese public hospitals nurses: A cross-sectional study. Medicine (Baltimore) [Internet]. 28 de abril de 2023;102(17):e33684. Available at: https://journals.lww.com/10.1097/MD.0000000000033684\u003c/li\u003e\n\u003cli\u003eTheorell T, Nyberg A, Leineweber C, Magnusson Hanson LL, Oxenstierna G, Westerlund H. Non-Listening and Self Centered Leadership \u0026ndash; Relationships to Socioeconomic Conditions and Employee Mental Health. Scott JG, organizador. PLoS One [Internet]. 24 de setembro de 2012;7(9):e44119. Available at: https://dx.plos.org/10.1371/journal.pone.0044119\u003c/li\u003e\n\u003cli\u003eHammer LB, Dimoff J, Mohr CD, Allen SJ. A Framework for Protecting and Promoting Employee Mental Health through Supervisor Supportive Behaviors. Occup Heal Sci [Internet]. 30 de junho de 2024;8(2):243\u0026ndash;68. Available at: https://link.springer.com/10.1007/s41542-023-00171-x\u003c/li\u003e\n\u003cli\u003eDeng J, Liu J, Guo Y, Gao Y, Wu Z, Yang T. How does social support affect public service motivation of healthcare workers in China: the mediating effect of job stress. BMC Public Health [Internet]. 5 de dezembro de 2021;21(1):1076. Available at: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11028-9\u003c/li\u003e\n\u003cli\u003eValle RBLR do, Balsanelli AP, Taminato M, Saconato H, Gasparino R. The relationship between the authentic leadership of nurses and structural empowerment: a systematic review. Rev da Esc Enferm da USP [Internet]. 2021;55. Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S0080-62342021000100803\u0026amp;tlng=en\u003c/li\u003e\n\u003cli\u003ePhillips AC, Carroll D, Der G. Negative life events and symptoms of depression and anxiety: stress causation and/or stress generation. Anxiety, Stress Coping [Internet]. 4 de julho de 2015;28(4):357\u0026ndash;71. Available at: http://www.tandfonline.com/doi/full/10.1080/10615806.2015.1005078\u003c/li\u003e\n\u003cli\u003eRodrigues IFA, Alves VP, Gomes L de O, Pereira DS, N\u0026oacute;brega O de T, Silva KHCV e. Associa\u0026ccedil;\u0026atilde;o entre eventos estressores e citocinas inflamat\u0026oacute;rias e anti-inflamat\u0026oacute;rias em pessoas idosas longevas. Rev Bras Geriatr e Gerontol [Internet]. 2021;24(2). Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S1809-98232021000200202\u0026amp;tlng=pt\u003c/li\u003e\n\u003cli\u003eCoutinho LMS, Scazufca M, Menezes PR. M\u0026eacute;todos para estimar raz\u0026atilde;o de preval\u0026ecirc;ncia em estudos de corte transversal. Rev Saude Publica [Internet]. dezembro de 2008;42(6):992\u0026ndash;8. Available at: http://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S0034-89102008000600003\u0026amp;lng=pt\u0026amp;tlng=pt\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Organizational justice, Work stress, Primary Health Care, Health Personnel, Depressive symptoms, Depression","lastPublishedDoi":"10.21203/rs.3.rs-6184538/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6184538/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHigh prevalence of depressive symptoms among primary care workers has been pointed out in previous studies. However, the relationship of leadership aspects and the mental health of nursing workers in Primary Health Care (PHC) has been overlooked. We aimed to estimate the prevalence of depressive symptoms among nursing workers and to investigate the associations between interactional justice, supervisor support, and depressive symptoms among nurses and nursing-assistants in PHC.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ewe conducted a cross-sectional study, with a representative sample of professionals from the Family Health Strategy (FHS) in the city of S\u0026atilde;o Paulo, Brazil. Sixty-six UBS were randomly selected, including 351 teams and 953 nursing professionals (306 nurses and 647 technicians). The Patient Health Questionnaire (PHQ-9) was used to assess, with scores\u0026thinsp;\u0026ge;\u0026thinsp;10 being classified as probable major depression. We used the Brazilian version of the Organizational Justice Perception Scale to assess interactional justice and the Job Stress Scale to address support from supervisor. The associations between sociodemographic variables, stressful life events, work characteristics, and depressive symptoms were analyzed using Poisson regression with robust variance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe prevalence of probable major depression was 25.6%. The variables associated with the risk of probable major depression were being women, having reported low interactional justice (prevalence ratio\u0026thinsp;=\u0026thinsp;1.53), and low supervisor support (prevalence ration\u0026thinsp;=\u0026thinsp;1.96).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eReporting low interactional justice and receiving insufficient support from supervisors might jeopardize nursing workers\u0026rsquo; mental health. Leadership training could be a strategy to mitigate depressive symptoms among PHC nursing.\u003c/p\u003e","manuscriptTitle":"Associations between interactional justice, supervisors’ support, and depressive symptoms among primary care nursing workers: a cross-sectional study in Brazil","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-27 15:23:28","doi":"10.21203/rs.3.rs-6184538/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-07T05:52:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-25T13:07:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-16T14:38:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187064068797065129033483971396084949456","date":"2025-06-16T14:20:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94468265612561103597480004230059979455","date":"2025-06-15T11:00:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-10T13:35:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5022206178109407356721181327178934397","date":"2025-04-10T12:46:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-07T13:37:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"135592523744164268162822940833499799802","date":"2025-03-25T11:48:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-19T12:16:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-17T09:59:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-14T12:07:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-14T12:06:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-03-08T14:05:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"48044c96-af17-4c97-859d-d705c2401d0a","owner":[],"postedDate":"March 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-12T02:38:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-27 15:23:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6184538","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6184538","identity":"rs-6184538","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}