Artigos

INTRODUCTION
One of the strategies adopted to contain the spread of COVID-19 was social distancing 1,2. Prominent among the measures recommended was for various kinds of work to be performed from home3,4, which had impacts on how men and women workers were required to organise their work and lives5. In that scenario, it became more common to engage in housework, with many taking on care for the home and children in a context where schools were closing and third party support, from maids and relatives, was lacking6.
These working arrangements during the pandemic have been associated with certain adverse effects on mental health3,5,7,8. On the other hand, the perception of greater autonomy in managing time can have positive effects on job satisfaction9,10, which is strongly associated with mental health111. Indeed, data from 28 European Union countries show advantages and disadvantages of remote work during the pandemic, which vary with demographic and work-related factors12.
It has been suggested that gender differences exist in relations between remote work and health8. The activity of caring for the family is attributed primarily to women, who thus suffer different impacts from that affecting men13. One English study of a sample mostly engaged in remote work showed that, among those who had no prior mental health problems, being a woman, under 45 years old, working part-time and having two dependents were among the predictors of stress and depressive symptoms; the men, meanwhile, reported more conflict between personal life and work14. Similarly, the need for social distancing can lead to a worsening of existing mental health inequalities between men and women8.
In countries such as Brazil, where care for home and children is preponderantly women’s responsibility15, the absence of time and place boundaries between work and home life during the pandemic is likely to have had greater impact on women4. Studies of time use during the pandemic in various countries, including Brazil, described women’s devoting more time to demands of the home, especially when they had children16. The authors of a study of work activities pursued at home in the context of the COVID-19 pandemic argued that the attribution of positive aspects to remote work may derive, among other factors, from a lack of attention to gender issues, which are rarely considered in studies4. A study of workers in remote work situations during the COVID-19 pandemic showed that, among both men and women, lack of control over work time was associated with stress, anxiety and depression17.
Considering that (i) remote work during the pandemic entails a working all day in a setting that demands extra home care and (ii) housework is done mostly by women, the hypothesis of this study is that women find it more difficult to reconcile job and housework than men and, accordingly, are more likely to display mental suffering. This study examines the associations of hours spent on remote work and on housework independently, and also hours spent on the two types of work combined, with gender and mental health – symptoms of anxiety, stress and depression – of workers in remote work situations during the COVID-19 pandemic.
METHODS
Study population
The Longitudinal Study of Adult Health (ELSA-Brasil) is a Brazilian cohort followed in order to assess the incidence and progression of chronic diseases, focusing on cardiovascular diseases and diabetes, among civil servants from six different institutions in Brazil. This cross-sectional study used data from a study supplementary to ELSA-Brasil designed to assess the short- and long-term impact of COVID-19 and social policies to control it on the health of ELSA-Brasil participants. Between July 2020 and February 2021, the ELSA-Brasil cohort participants at the Rio de Janeiro, Salvador, Belo Horizonte, Espírito Santo and Porto Alegre study sites were sent invitations to answer online questionnaires by way of an application developed especially for the study, with the assistance of a trained, certified team, resulting in a total sample of 5639 respondents. This is a subsample of the ELSA-Brasil obtained through voluntary adherence17. Of these, 3043 (54%) were active workers who responded to job-related questions. Those who reported not being engaged in remote work (n = 725) were excluded. The final study sample comprised 2318 participants (1163 women and 1155 men).
Variables
Description
Remote working hours (RWHs) was evaluated by the question: “On average, how many hours a week do you spend working at home, not counting housework?” Terciles were used as cutoff points and the variable was categorised into “short RWHs”, “medium RWHs” and “long RWHs”.
Housework hours (HWHs) was evaluated by the question: “Since the start of social distancing, on average how many hours a week do you spend on housework?” Terciles were used as cutoff points and the variable was categorised into “short HWHs”, “medium HWHs” and “long HWHs”.
Total working hours (WHs) was evaluated by combining remote working hours and housework hours. The variable was produced by adding weekly remote work and housework hours. Terciles were used as cutoff points and the variable was categorised into “short WHs”, “medium WHs” and “long WHs”.
Outcome
Symptoms of anxiety, stress and depression were evaluated by applying the Depression, Anxiety and Stress Scale (DASS-21). The DASS-21 comprises three Likert-type subscales of four scores (ranging from 0: “Does not apply to me” to 3: “Applies to me very much or most of the time”). Each subscale comprises 7 items, designed to evaluate states of depression, anxiety and stress18. Scores on each subscale were calculated by adding the items, multiplying by two and categorising into 5 groups: normal, mild, moderate, severe and extremely severe. Based on the literature19-21, for this study, the “mild”, moderate”, “severe” and “extremely severe” categories were grouped by each of the three symptoms (depression, anxiety and stress), so as to produce dichotomous variables (symptom absent; symptom present).

Covariables
Age (in complete years), marital status (married/cohabiting; single/separated/widowed), per capita income (in reals), schooling (up to complete secondary; higher education /specialisation; masters/doctorate), caring for children and/or ill and/or elderly persons (No; Yes).
Data analysis
In describing the study sample, categorical variables were expressed as absolute and relative frequencies, while continuous variables were expressed as means and standard deviations (SDs). Associations between variables were tested using the Pearson chi-square test for categorical variables and the Mann-Whitney test for numerical variables. Odds ratios (ORs) and their respective 95% confidence intervals (95% CI) were estimated by means of logistic regression models adjusted for age, income and marital status and specified on the basis of variables that showed associations in the bivariate analyses. As interaction (p < 0.05) was found between gender and the different kinds of working hours in their association with mental health outcomes, ORs were estimated for each stratum of working hours and gender combined, taking men with short working hours as the reference category (that is, the stratum with least risk of the outcome). In other words, for the associations between working hours (RWHs, HWHs and WHs) and mental suffering (symptoms of depression, anxiety and stress), each of the three types of working hours (RWHs, HWHs and WHs) was grouped by participant gender, so as to obtain a six-category variable: Men with short RWHs, Men with medium RWHs, Men with long RWHs, Women with short RWHs, Women with medium RWHs and Women with long RWHs. The same classification method was used for HWHs and WHs.
All statistical analyses were stratified by gender and performed using the software R, version 3.6.1.
RESULTS
The study participants were 1163 women and 1155 men. As compared with the men, the women were younger (54.9 [SD = 7.3] vs 55.5 [SD = 7.5] years), more often single/separated/widowed (48.6% vs 19.2%), had higher income (5020.7 [SD = 3533.7] vs 4652.1[SD = 2943.7] reals), more schooling (89.5% vs 87.2% with higher education or more) and cared more often for children and/or ill and/or elderly people (39.1% vs 34.8%). The three symptoms of mental suffering were statistically more present among the women than among the men – depression (24.7% vs 18.7%), anxiety (20.4% vs 10.6%) and stress (20.1% vs 11.7%), respectively (Table 1).
As regards remote work and housework, the women were found, on average, to spend more hours on housework (15.4 hours/week vs 12.0 hours/week; p < 0.01) and total work (35.9 hours/week vs 32.8 hours/week; p = 0.01) than the men, while no statistically significant difference was found as regards remote work (20.5 hours/week vs 20.6 hours/week; p = 0.624). In the presence of anxiety symptoms, the women returned larger percentages than the men of long RWHs (38.1% vs 24.8%) and long WHs (41.9% vs 26.8%). In the presence of stress symptoms, percentage long RWHs was larger among the women than among the men (42.7% vs 30.8%) (Table 2).
Table 3 shows the results from the regression models for the associations between working hours and mental suffering, adjusted for age, income and marital status. As compared with men with short HWHs, the odds of displaying symptoms of depression were found to be greater among men with long HWHs (OR = 1.54; 95% CI: 1.02;2.32), women with medium HWHs (OR = 1.55; 95% CI: 1.04;2.31) and women with long HWHs (OR = 1.71; 95% CI: 1.17;2.55). In addition, women with long WHs were 1.5 more likely (OR = 1.51; 95% CI 1.03;2.24) to display symptoms of depression than men with short WHs.
Statistically significant results were also found for anxiety symptoms. As compared with men with short RWHs, women with short, medium or long RWHs, returned greater odds of displaying anxiety symptoms. Similarly, women with short, medium or long HWHs were more likely to display anxiety symptoms than men with short HWHs. Both men with long RWHs (OR = 0.40; 95% CI: 0.21;0.69) and those with long WHs (OR = 0.47; 95% CI: 0.26;0.82) returned higher odds of displaying anxiety symptoms than men with short working hours (Tables 3).
As compared with men with short working hours, the odds of reporting stress symptoms were higher among women with medium or long RWHs than among those with medium or long HWHs (Table 3).

Tab.1
Tab.2
Tab.3

DISCUSSION
The appraisal of remote work during the pandemic, considering hours of remote work and housework, pointed to significant associations between working hours and mental suffering, primarily among the women. In all modalities of working hours (RWHs, HWHs or WHs), women with longer working hours returned greater odds of presenting symptoms of anxiety or stress than men with short working hours. Specifically as regards symptoms of depression, the highest odds were found only among women with medium or long HWHs and long WHs.
The higher prevalence of mental suffering found here among the women is no surprise, given the findings in the literature. A review of the literature on mental health problems during the COVID-19 pandemic showed that women returned greater odds of mental suffering than men22. Similar findings (being female associated with higher levels of depression, anxiety and stress) have been observed in other populations23,24. Overall, also as regards periods prior to the COVID-19 pandemic, the literature reports that mental health problems are observed among men and women, but not in the same proportion. As found in this study, a systematic review of cohort studies carried out in Germany found that mental health outcomes are generally more frequent among women than among men, which can be attributed to biological differences and gender roles25.
The findings of this study corroborate the discussions of heightened gender inequalities under social distancing8. Reduced walking and increased time spent on childcare were associated with greater risk of depression among women in remote work. Among men, however, remote work attenuated the risk of depression26.
Remote work seems to constitute a more challenging situation for women, because women still bear greater responsibility for housework, including caring for the home and children6. Accordingly, remote working can be seen to blur work-life boundaries, which can also raise levels of stress and anxiety27. Although no differences were found between men and women as regards RWHs hours worked, the women’s HWHs was longer than the men’s. Therefore, the greater overload observed among the women resulted from housework, showing that, for women, remote working entails meeting different demands, often simultaneously, resulting in greater emotional wear. It is important to note that the recommendation to stay at home during the pandemic led whole families to live together more intensely and without respite (except during sleep). For men, on the other hand, the home environment still represents a place of few responsibilities, which became their workplace during the period of social distancing28.
This study found a striking contrast between the genders as regards the anxiety data. Taking the men with short working hours as the reference group, men with long RWHs and long WHs returned less than half the odds of displaying anxiety symptoms, while among the women, the corresponding odds were practically double (RWHs) or more than double (WHs). When thinking about this intriguing finding, it should be considered that these are cross-sectional data, analysis of which began on the assumption that overwork can affect mental health. On the other hand, however, it can be supposed that gender differences do exist in relations between working hours and mental health, so that anxiety may have influenced how men conducted their working day. In that light, men with anxiety symptoms would be less likely to work long remote and total hours, which would explain the study findings. This is one possibility among others, to be explored in future studies.
Although conducted during the pandemic period, this study contributes to the gender discussions that are still incipient in the literature as a whole. As regards work activities performed at home, most studies did little to address gender-related aspects, hindering full comprehension of the impacts of remote work on health during social distancing4. Generally speaking, considering that HWHs are longer among women than among men15,29 and that it is women who continue to be overloaded with housework, which has adverse effects on mental health30, it is possible that remote work is more difficult for women than for men. On the other hand, some women’s assessment is that the possibility of working from home strengthens family ties and leaves more time for physical and leisure activities31. Accordingly, the findings of this study offer more input to discussions of gender differences.
The study also has its limitations. Despite the cross-sectional nature of the analyses, the direction of the association examined here, considering hours worked to be the exposure, rests on the plausibility of such relations, in that there are reasons to suppose that more time devoted to remote work and to housework leads to mental suffering. Note, however, the findings as regards anxiety: there, the association with working hours (in remote work and total hours) may have been in the opposite direction. In addition, people with different mental health-related problems before the onset of the pandemic may have been more vulnerable to adverse mental health outcomes25. It is also noteworthy that in the Brazilian context, the lack of alignment between the WHO recommendations to reduce transmission of the virus and the measures adopted in the country made it difficult to control the pandemic, which may have contributed to the mental suffering of the population. Another important limitation has to do with sources of stress and determinants of mental disorders during the pandemic, which were not addressed in this study. Loss of friends and relatives, fear of falling ill and dying, concern over one’s own health and that of people who are close are other factors that can affect mental health. Gender differences are also observed in that context, in that not only has housework been increased by the recommendations for sanitising environments and food, but also the role of caregiver exposes women to greater risk of infection through more intensive contact with relatives who are ill32-34. Also, as this study is based on a subsample of the ELSA-Brasil obtained by voluntarily completing an online questionnaire, it is possible that a self-selection bias occurred.
Despite the divergences among municipal, state and federal spheres in the approach to coping with the pandemic, also with regard to the recommendation of social distance, this sample of civil servants from universities and a research institution started remote work right at the beginning of the pandemic, which suggests a homogeneity regarding the remote work practice addressed in the present study.
In short, this study highlights the fact that, in remote work during the pandemic, the various modalities of working hours (RWHs, HWHs and WHs) are associated with mental suffering, particularly among women. Incorporation of a gender approach in studies contributes to recognition of health inequalities between men and women.

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