From conflict to understanding depression: theoretical perspective
Role conflict and women’s depression
Conceptually, a role originates from expectations about behaviour for a position in a social structure, and role conflicts occur as a result of incompatible behavioural expectancies of role-relevant others . Given the widespread prevalence of depression and its accompanying negative consequences, the relationship between role conflicts and depression has witnessed growing academic interest . Drawing on COR theory, individuals are motivated to protect the resources they value, but when such efforts fail, employees may experience depression, as they feel incapable of coping with high demands [21, 22]. Previous research has pointed out the tension between the resources underlying role conflicts, as participation in a specific role will lead to more interference among multiple roles due to resource competition [22, 28].
The current study also suggests the need for a nuanced role conflict-depression model, which covers various kinds of role conflicts. Generally, there are two sorts of role conflict: inter-role conflict and intra-role conflict. Inter-role conflict is a clash between the multiple requirements of two or more roles, and intra-role conflict involves incompatible demands within the same role . Inter-role conflict includes family-to-work conflict (FWC), which involves stress caused by the family responsibilities interfering with work-related responsibilities, and work-to-family conflict (WFC), which occurs when work-related stress interferes with family-related responsibilities . Organizational role conflict (ORC) is a typical type of and well documented intra-role conflict, that involves attempting to meet the distinct expectations of multiple authorities in an organization [29, 30].
It is noteworthy that the role conflict perspective is important for understanding female depression . Working women suffer from greater work-family conflict than men, as traditional gender roles assume that family roles are primary for women and that work roles are secondary . Women often face higher ORC because gender stereotyping has excluded women from professional work and arranges the bulk of the low-level tasks for them . Therefore, to obtain a precise understanding of depression in working women, FWC, WFC and ORC should be included in studies of women’s depression.
Role conflict and depression of female health care and social service providers
The importance of studying the antecedents of depression among health care and social service providers is demonstrated in the prevalence of depression among them and its negative consequences. Previous studies have provided evidence that health care and social service providers suffer from role conflicts, which are related to their mental health problems. First, health care and social service providers are often expected to fulfil a caregiver role in their family as well, which means more family life responsibilities, leading to work-family conflict and depression . Second, it has been well documented that health care and social service providers face ORC pressure, especially in the era of neoliberal reform . Conflict requests from clients, governments, and organizations contribute to depressive symptoms .
Scholars are increasingly interested in role conflict in cultural contexts different from western individualism [32, 33]. According to the sociologist Xiaotong Fei, Chinese society has emerged as a fundamentally rational society with a hierarchy of social ranks . Clan culture in China emphasizes male dominance in the family . Influenced by this cultural dimension of male dominance, Chinese women voluntarily and involuntarily combine paid work with domestic work [36, 37], leading to a higher level of work-family conflict than men experience. Since the enforcement of the universal two-child policy in 2016, more female workers have found themselves caught in the dilemma of whether to raise a child or be promoted, which exacerbates their WFC and worsens their mental health . The masculine culture also shows in the workplace, where Chinese female social workers undertake more emotional labor than male social workers, causing organizational role conflict and psychological problems among them . ORC has also been shown to predict the emergence of depressive symptoms in Chinese female nurses . Therefore, we propose the following:
H1. FWC is directly and positively associated with the depression of female health care and social service providers.
H2. WFC is directly and positively associated with the depression of female health care and social service providers.
H3. ORC is directly and positively associated with the depression of female health care and social service providers.
Mediation model development
The role conflict-burnout-depression link
While assessing the independent effects of role conflict is of primary importance, another promising direction for investigation is suggested by previous studies , i.e., whether burnout mediates the relationship between role conflicts and depression. According to COR theory, role conflicts can lead to burnout and trigger chronic mental disorders (e.g., depression) because the basic motivation to protect resources is threatened or denied . Therefore, COR theory serves as a heuristic model for the role conflict-burnout-depression link.
Among the three dimensions of burnout, in line with COR theory and previous research, reduced personal accomplishment is a result of burnout rather than a distinct symptom, and role conflicts has a stronger relation with emotional exhaustion and cynicism than reduced personal accomplishment [42, 43]. A recent study also pointed out that exhaustion and cynicism are core components that affect social welfare workers in China, while personal accomplishment is not . Therefore, we chose to limit our analysis to emotional exhaustion and cynicism in our model.
Previous investigations have provided evidence of the role of the conflict-burnout-depression link. Existing studies highlight that burnout is a mediating state that accelerates the negative effects of mental health (such as anxiety and drops in self-esteem) and leads to depression . A meta-analysis focused on work-family conflict, and its various outcomes has shown a positive relationship between FWC, WFC and burnout ; a recent literature review pointed out that work-family conflict made employees feel less control and predicted higher burnout . Regarding ORC, research evidence consistently supports its positive correlation with burnout, as both increased work demands and decreased work resources predict burnout .
The role of the conflict-burnout-depression link among health care and social service providers
Empirical evidence has revealed that emotional exhaustion and cynicism are prevalent among health care and social service providers , which also bring about a series of negative consequences, including depression and anxiety, poor-quality care, absenteeism and turnover . Substantial research has focused on the relationships between FWC, WFC, ORC, burnout, and depression among service providers, with mixed results. First, previous findings suggest that ORC is correlated with health care and social service providers’ emotional exhaustion and cynicism . An ORC-burnout-depression connection has also been found among physicians . Second, previous research on service providers has pointed out that both WFC and FWC are related to burnout and found a stronger impact of the two on burnout than on depression . Meanwhile, previous studies have pointed out gender differences in the role conflict-burnout relationship, as females report higher levels of burnout than men due to lower levels of decision latitude and self-esteem, as well as higher levels of work-family conflict . A study on Chinese female service providers conducted by Wang et al.  pointed out that female service workers are more susceptible to WFC than male service workers, and both WFC and FWC were positively related to their emotional exhaustion and cynicism. Therefore, we propose the following:
H4. Emotional exhaustion mediates the relationship between role conflicts (H4a: FWC; H4b: WFC; H4c: ORC) and depression among female health care and social service providers.
H5. Cynicism mediates the relationship between role conflicts (H5a: FWC; H5b: WFC; H5c: ORC) and depression among female health care and social service providers.
The moderating role of marriage and motherhood on female health care and social service providers’ depression
As mentioned above, a multiplicity of roles straddled does not always result in role conflicts but depends on whether a particular role provides resources and role requirement conflicts . That is, a model that considers particular roles as well as both the benefits and conflicting needs of these roles may be necessary to predict the role conflict-burnout-depression link. In industrialized economies, the social roles of females are often organized as homemakers and the primary caretakers of children, while males are more likely to become primary family providers and to assume full-time roles in the paid economy . To obtain a better understanding of the depression of female health care and social service providers, we tested two possible moderators of the associations in the model: (a) marriage and (b) motherhood.
The heated debate about whether marriage is a “health hazard” for women turns on conflicting evidence of the relationship between marriage and depression. A recent review documented that married people tend to report a higher level of mental health, as they have more psychosocial resources, and unmarried people are more vulnerable to strain due to a lack of spouse support . A previous study also indicated the emotional benefits of marriage for both men and women, suggesting that marriage is associated with enhanced mental health [53, 54]. For health care and social service providers, previous research has also reported that divorced, separated, and never-married social workers are more likely to report depression .
However, previous studies provide inconsistent evidence, indicating that marriages enhance depressive symptoms. Previous research on marital status has shown that marriage is a risk factor for female depression, as marital conflict directly leads to increased depression . Similarly, a trickle of studies have revealed that married females experience a higher rate of role conflicts, resulting in job burnout and depression . Since contradictory normative beliefs limit women’s roles to household tasks in marriage, married professional women have been found to suffer from greater incompatibility between marriage and career , which also results in increased burnout. Therefore, we propose the following:
H6. Marriage moderates the role conflict-burnout-depression model, as married female health care and social service providers are more likely to experience role conflict, burnout, and depression.
Contrary to the inconsistent findings with respect to the role of marriage and its relationship with depression, there is substantial evidence that the role of motherhood enhances working mothers’ depression. Previous studies have pointed out that depression is positively related to role conflict for women with child-care responsibilities . Child-care responsibilities such as breastfeeding, physical care, and education associated with the mother’s role can interfere with working women’s work responsibilities and exacerbate their work-family conflict . Meanwhile, some studies have documented that parenting is one of the most demanding and stressful life changes individuals face, often giving rise to depressive symptoms, and postpartum depression is a typical case . A recent study on parental and job burnout in a Chinese context showed that both parenthood and job burnout have a strong positive correlation with depression . Therefore, we propose the following:
H7. Motherhood moderates the role conflict-burnout-depression relationship, as female health care and social service providers with children are more likely to experience role conflict, burnout, and depression.