Validity evidence of the Depression, Anxiety, and Stress Scale in Brazilian nursing workers

Oliveira, Samuel Andrade de; Santin Júnior, Lacir José; Fracarolli, Isabela Fernanda Larios; Martins, Bianca Gonzalez; Campos, Juliana Alvares Duarte Bonini; Marziale, Maria Helena Palucci; Deodato, Sergio Joaquim; Rocha, Fernanda Ludmilla Rossi

doi:10.37689/acta-ape/2025AO0003261

Brasil

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Original Article • Acta Paul Enferm 38 • 2025 • https://doi.org/10.37689/acta-ape/2025AO0003261i linkcopy

Validity evidence of the Depression, Anxiety, and Stress Scale in Brazilian nursing workers

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives To investigate the validity evidence of the Depression, Anxiety, and Stress Scale (DASS-21) and to analyze the prevalence of depression, anxiety, and stress symptoms in a sample of Brazilian nursing workers.

Methods This was a cross-sectional study with non-probability convenience sampling. A total of 4053 Brazilian nursing workers participated in the study. The psychometric properties of DASS-21 were assessed by analysis of the validity based on the internal structure (factorial, convergent, and discriminant construct validity, invariance of the factorial model, and reliability); relationships with external measures (positive and negative convergent validity of the depression, anxiety, and stress factors with the emotional impairment, job satisfaction, and individual and occupational variables); and response process of the items (analysis of the differential item functioning in distinct subgroups). Data reliability was certified by estimating the ordinal alpha coefficient and the composite reliability. The prevalence of depression, anxiety, and stress symptoms was estimated based on recommendations from the original authors of DASS-21.

Results During validation of the internal structure, the confirmatory factor analysis showed that the fit of the sample to the original DASS-21 model was adequate and the strong measurement invariance of the model was confirmed in different groups. Analysis based on external measures showed that the depression, anxiety, and stress factors had positive and moderate-strong correlations with the emotional impairment domain and negative and moderate correlations with the job satisfaction construct. Analysis of the pattern of response to items confirmed the uniformity and stability of the instrument for the sample. Regarding symptoms, the high prevalence of extremely severe levels of depression, anxiety, and stress was highlighted among participants.

Conclusion DASS-21 presented adequate validity and reliability to assess depression, anxiety, and stress symptoms among Brazilian nursing workers.

Occupational health; Depression; Anxiety; Stress, psychological; Psychometrics; Psychiatric Status Rating Scales; Nurse practitioners; Surveys and questionnaires; Brazil

Samples	n	Λ	TLI	CFI	RMSEA [90%CI]	SRMR	AVE	CR	α
DASS-21 Total	4053	0.640-0.904	0.975	0.977	0.058 [0.057-0.060]	0.032	0.629-0.697	0.921-0.941	0.919-0.938
DASS SOHM	4053	0.639-0.905	0.967	0.971	0.079 [0.077-0.081]	0.036	0.629-0.697	0.921-0.941	0.919-0.938
DASS Test	2024	0.638-0.908	0.972	0.975	0.075 [0.072-0.078]	0.035	0.626-0.699	0.920-0.941	0.918-0.939
DASS Validation	2029	0.641-0.902	0.965	0.969	0.080 [0.078-0.083]	0.039	0.626-0.699	0.920-0.941	0.919-0.938
DASS Female	3484	0.624-0.903	0.966	0.970	0.080 [0.078-0.082]	0.037	0.623-0.694	0.919-0.940	0.917-0.937
DASS Male	543	0.709-0.924	0.981	0.983	0.065 [0.059-0.070]	0.033	0.671-0.726	0.934-0.948	0.930-0.946
DASS Treatment	1076	0.614-0.880	0.958	0.963	0.082 [0.079-0.086]	0.045	0.606-0.667	0.914-0.933	0.908-0.928
DASS No treatment	2964	0.624-0.902	0.967	0.971	0.076 [0.073-0.078]	0.037	0.608-0.687	0.915-0.938	0.911-0.936

	Differential Item Functioning
Items	Group 1		Group 2		DIF	Pseudo R²
Items	Infit	Outfit	Infit	Outfit	p-value	McFadden	Nagelkerke
DASS1	1.114	1.138	1.197	1.330	0.101	0.000	0.001
DASS2	1.405	1.501	1.413	1.577	0.125	0.000	0.001
DASS3	1.047	1.183	1.240	1.822	0.238	0.000	0.001
DASS4	1.198	1.208	1.215	1.314	0.066	0.001	0.001
DASS5	1.176	1.216	1.105	1.093	0.088	0.001	0.001
DASS6	1.174	1.261	1.071	1.085	0.195	0.000	0.001
DASS7	1.169	1.197	1.122	1.100	0.001	0.002	0.002
DASS8	0.719	0.699	0.752	0.730	0.365	0.000	0.000
DASS9	0.788	0.771	0.857	0.830	0.000	0.003	0.003
DASS10	0.887	0.911	0.810	0.790	0.000	0.002	0.002
DASS11	0.948	0.952	0.900	0.887	0.445	0.000	0.000
DASS12	0.795	0.738	0.814	0.815	0.793	0.000	0.000
DASS13	0.756	0.742	0.743	0.718	0.117	0.000	0.000
DASS14	1.070	1.088	0.944	0.927	0.068	0.001	0.001
DASS15	0.783	0.733	0.781	0.683	0.020	0.001	0.001
DASS16	0.810	0.777	0.776	0.748	0.069	0.001	0.001
DASS17	0.899	0.902	0.855	0.830	0.000	0.002	0.002
DASS18	0.871	0.890	0.866	0.865	0.021	0.001	0.001
DASS19	0.967	0.948	1.009	0.997	0.980	0.000	0.000
DASS20	0.863	0.868	0.928	0.879	0.056	0.001	0.001
DASS21	0.926	0.899	0.966	0.893	0.378	0.000	0.000

Symptoms	Total DASS n(%)[95%CI]	female DASS n(%)[95%CI]	male DASS n(%) [95%CI]
Depression
Normal	1467(36.20) [34.72-37.68]	1240(35.59) [34.00-37.18]	222(40.88) [36.75-45.02]
Mild	445(10.98) [10.02-11.94]	387(11.11) [10.06-12.15]	56(10.31) [07.75-12.87]
Moderate	762(18.80) [17.60-20.00]	644(18.48) [17.20-19.77]	107(19.71) [16.36-23.05]
Severe	468(11.55) [10.56-12.53]	412(11.83) [10.75-12.90]	55(10.13) [07.59-12.67]
Extremely severe	911(22.48) [21.19-23.76]	801(22.99) [21.59-24.39]	103(18.97) [15.67-22.27]
Anxiety
Normal	1443(35.60) [34.13-37.08]	1197(34.36) [32.78-35.93]	240(44.20) [40.02-48.38]
Mild	232(5.72) [05.01-06.44]	202(5.80) [05.02-06.57]	30(5.52) [03.60-07.45]
Moderate	735(18.13) [16.95-19.32]	644(18.48) [17.20-19.77]	84(15.47) [12.43-18.51]
Severe	433(10.68) [09.73-11.63]	375(10.76) [09.73-11.79]	53(9.76) [07.26-12.26]
Extremely severe	1210(29.85) [28.45-31.26]	1066(30.60) [29.07-32.13]	136(25.05) [21.40-28.69]
Stress
Normal	1664(41.06) [39.54-42.57]	1400(40.18) [38.56-41.81]	257(47.33) [43.13-41.53]
Mild	458(11.30) [10.33-12.28]	388(11.14) [10.09-18.18]	65(11.97) [09.24-14.70]
Moderate	677(16.70) [15.56-17.85]	600(17.22) [15.97-18.48]	72(13.26) [10.40-16.11]
Severe	739(18.23) [17.04-19.42]	631(18.11) [16.83-19.39]	101(18.60) [15.32-21.88]
Extremely severe	515(12.71) [11.68-13.73]	465(13.35) [12.22-14.48]	48(8.84) [06.45-11.23]

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Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: actapaulista@unifesp.br

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[TFN1001] DASS: Depression, Anxiety, and Stress Scale; SOHM: second-order hierarchical model; λ: factorial weights; TLI: Tucker-Lewis index; CFI: comparative fit index; RMSEA: root mean square error of approximation; 90%CI: 90% confidence interval; SRMR: standardized root mean square residual; AVE: average variance extracted; CR: composite reliability; α: ordinal alpha coefficient; DASS treatment: psychological and/or mental treatment; DASS no-treatment: no psychological and/or mental treatment.