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Hindawi Publishing CorporationJournal of Environmental and Public HealthVolume 2012, Article ID 515874, 21 pagesdoi:10.1155/2012/515874
Review Article
A Synthesis of the Evidence for Managing Stress at Work:A Review of the Reviews Reporting on Anxiety, Depression,and Absenteeism
Kamaldeep S. Bhui, Sokratis Dinos, Stephen A. Stansfeld, and Peter D. White
Centre for Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London,London E14NS, UK
Correspondence should be addressed to Kamaldeep S. Bhui, [email protected]
Received 19 May 2011; Revised 3 August 2011; Accepted 5 August 2011
Academic Editor: David Vlahov
Copyright © 2012 Kamaldeep S. Bhui et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.
Background. Psychosocial stressors in the workplace are a cause of anxiety and depressive illnesses, suicide and family disruption.Methods. The present review synthesizes the evidence from existing systematic reviews published between 1990 and July 2011. Weassessed the effectiveness of individual, organisational and mixed interventions on two outcomes: mental health and absenteeism.Results. In total, 23 systematic reviews included 499 primary studies; there were 11 meta-analyses and 12 narrative reviews. Meta-analytic studies found a greater effect size of individual interventions on individual outcomes. Organisational interventions showedmixed evidence of benefit. Organisational programmes for physical activity showed a reduction in absenteeism. The findingsfrom the meta-analytic reviews were consistent with the findings from the narrative reviews. Specifically, cognitive-behaviouralprogrammes produced larger effects at the individual level compared with other interventions. Some interventions appeared tolead to deterioration in mental health and absenteeism outcomes.Gaps in the literature include studies of organisational outcomeslike absenteeism, the influence of specific occupations and size of organisations, and studies of the comparative effectiveness ofprimary, secondary and tertiary prevention. Conclusions. Individual interventions (like CBT) improve individuals’ mental health.Physical activity as an organisational intervention reduces absenteeism. Research needs to target gaps in the evidence.
1. Introduction
Although work provide a range of benefits such as increasedincome, social contact, and sense of purpose, it can also havenegative effects on mental health, particularly in the formof stress. The National Institute of Occupational Safety andHealth in the US (NIOSH) [1] estimate the following:
(i) 40% of American workers reported their job was veryor extremely stressful,
(ii) 25% view their jobs as the number one stressor intheir lives,
(iii) three fourths of American employees believe thatworkers have more on-the-job stress than a genera-tion ago.
Given the global recession, financial strain, and job loss-es, greater work stress might have adverse consequences inUK. The most recent data from the NHS information centrein UK suggest an increase in the suicide rate for the first timesince 1998. The number of people committing suicide roseby 329 to 5,706 in 2008. The rate among men increased from16.8 per 100,000 in 2007 to 17.7 per 100,000 in 2008. Thisincrease is being interpreted by politicians and the public asa consequence of the global and national recession, increasedjob insecurity, risk of loss of jobs, and also stress at work,where the demands on the existing workforce have increased(The Independent, 18th November, 2010).
Approximately 11 million people of working age in UKexperience mental health problems. 11.4 million workingdays were lost in UK in 2008/2009 due to work-related stress,depression, or anxiety [2]. There are also indirect costs,
2 Journal of Environmental and Public Health
Table 1: Model for categorising stress management interventions (adapted from de Jonge and Dollard) [17].
Level Primary prevention Secondary prevention Tertiary prevention Outcome measures
Organisational
Improving workcontent, fitnessprogrammes, andcareer development
Improvingcommunication anddecision making andconflict management
VocationalRehabilitation andoutplacement
Productivity, turn-over,absenteeism, and financial claims
Individual andOrganizationalinterface
Time management,improvinginterpersonal skills,and Work/homeBalance
Peer support groups,coaching, and careerplanning
Posttraumatic stressassistanceprogrammes andgroup psychotherapy
Job stressors such as demands,control, support, role ambiguity,relationships, change, withburnout
Individual
Pre-employmentmedical examinationand didactic stressmanagement
Cognitive behaviouraltechniques andrelaxation
Rehabilitation aftersick leave, disabilitymanagement, casemanagement, andindividualpsychotherapy
Mood states, psychosomaticcomplaints, subjectiveexperienced stress, physiologicalparameters, sleep disturbances,and health behaviours
for example, through “presenteeism” when employees areat work but are too unwell to function fully [3]. Stress atwork also can lead to physical illness, psychological distressand illness, and sickness absence [3, 4]. Stress, depression,or anxiety accounts for 46% of days lost due to illness andare the single largest cause of all absences attributable towork-related illness [5]. Psychosocial work stressors such asjob strain, low decision latitude, low social support, highpsychological demands, effort-reward imbalance, and highjob insecurity have all been implicated as causes of workstress-related anxiety and depressive illnesses [6]. However,psychosocial work stressors can only be tackled by organisa-tional and systemic strategies and policies.
2. The Conceptualisation of Occupational Stress
In order to consider the evidence base, there needs to be someagreement on the meaning of work stress. A popular modelof stress considers “inputs” such as job characteristics; forexample, excess demands, low control, poor social support,adverse life events such as bereavement or divorce, and addi-tional demands outside of work such as carer responsibilitiesfor a dependent relative or spouse [7–10]. Stress has alsobeen recognised by symptoms or “outputs” such as tension,frustration, or emotional distress. An alternative approachis to theorise that stress is a manifestation of the poor fitbetween a person and their environment [11]. Stress is thenseen to arise due to a discrepancy between the inputs andoutputs and the mediating appraisal of stress, personal skillsto manage it, and environmental demands and rewards.Transactional models, as those proposed by Lazarus [12] andCox and Ferguson [13], conceptualise stress as somethingthat unfolds over time within a series of transactions betweenthe person and their environment. Stress is, therefore, elicitedand maintained by the individual’s actions and perceptionsas well as the characteristics of their work environment.
The specific conceptualisations of stress adopted influ-ence the way interventions are constructed to tackle specificmechanisms in order to alter stress and its manifestations.
Cahill [14], Cooper et al. [15], and Marine et al. [16] describecategories of stress management interventions that target theindividual or the organisation and specify actions at primary,secondary, or tertiary preventive levels (see Table 1) [17].Individual interventions include stress awareness training orcognitive behavioural therapy for psychological and emo-tional stress. Organisational interventions are those thataffect whole populations or groups of people and includeworkplace adjustments or conflict management approachesin a specific organisation. Some interventions target both theindividual and organisation, for example, policies to secure abetter work-life balance and peer-support groups. Primaryinterventions aim to prevent the causal factors of stress,secondary interventions aim to reduce the severity or dura-tion of symptoms, and tertiary or reactive interventions aimto provide rehabilitation and maximise functioning amongthose with chronic health conditions [18].
Although preventive interventions are often advocated,what is the evidence of benefit? The evidence of effectiveinterventions to protect individual mental health and reduceorganisational absenteeism rates is difficult to summarise in amanner that is of practical relevance. Therefore, the purposeof this paper is to take the highest level of research evidence(systematic reviews providing narrative synthesis or meta-analyses) and synthesise this evidence to identify the keyfindings and gaps in the literature on the effectiveness of dif-ferent stress management interventions for preventing anx-iety and depression as the main cause of absenteeism. Con-sequently, this review of systematic reviews focuses on com-mon mental health problems (anxiety, depression) and ab-senteeism.
Undertaking a review of systematic review is challengingmethodologically for two reasons; there is not a conventionalaccepted process to produce a meta-review or meta-synthesisacross different types of systematic reviews, for differentoutcomes, and different complex interventions which maydefy drawing a singular scientific conclusion that requires allsources of heterogeneity be overlooked [19]. Secondly, theambition of the review and the form the findings take have,
Journal of Environmental and Public Health 3
Table 2: Databases searched.
Medline 1950 to November Week 3 2008 (N = 2,470)
PsychInfo 1806 to January Week 2 2009 (N = 1,911)
Embase 1980 to 2009 Week 02 (N = 2,313)
Cochrane database of systematic reviews 4th quarter 2008 (N = 110)
ACP Journal Club 1991 to December 2008 (N = 12)
Cochrane Central Register of Controlled Trials 4th quarter 2008 (N = 432)
Cochrane Methodology Register 4th quarter 2008 (N = 3)
Allied and Complementary Medicine 1985 to January 2009 (N = 335)
British Nursing Index 1985 to January 2009 (N = 41)
Health management information consortium October 2008 (N = 218)
in part, to reflect the subject matter and the types of interven-tions that are being reviewed. So, for complex interventionsfor managing stress at work, there will be organizationaland individual interventions, and different disciplinary ap-proaches to the task of meta-synthesis of narrative findings.The notion of a meta-synthesis of narrative findings is itselfcontested by different qualitative research disciplines fromwhich such approaches have evolved [20, 21]. The purposeof this paper is then to draw together literature and findingswhich are consistent across reviews and methodologicallyvariant studies, where this is possible in order to demonstratethe strength of the findings. However, given the complexnature of interventions to tackle stress at work and thatstress itself and mental health are so ill-defined in studies,we also wish to highlight findings that emerge from a criticalcomparison of reviews; we also wish to highlight the findingsthat are pertinent to well-defined common mental disorders(anxiety and depressive states); we also wish to acknowledgethat narrative synthesis (or meta-synthesis, as it is sometimescalled) may reveal complexities in the field of study suchthat the findings cannot be neatly expressed as a singlestatement of efficacy or effectiveness, but that interventionsmight need to be developed to target specific subpopulations.The findings can, thus, signal the methodological issues thatfuture research must tackle.
3. Methods
The review identified all systematic reviews of evidenceon stress management interventions in the workplace andsummaries, tabulated extracted, and then synthesized theevidence for the relative merits of different interventions.Consistent with previous work, we restricted the review topapers published since 1990, as recency in the literature isimportant to ensure the evidence is related to contemporaryconcepts of stress and work, and to ensure the current workconditions are represented in the evidence synthesis, ratherthan historical work conditions. The databases searched arelisted in Table 2.
The search terms used were:
“psychological ill health or anxiety or stress or distressor burnout,”
“stress management or intervention or rehabilitationor prevention,”
“work or job or employee or sick leave or occupa-tion or workplace adjustments or employee assistanceprogrammes.”
3.1. Inclusion and Exclusion Criteria. The criteria used for in-clusion were
(a) english language articles,
(b) reviews published from 1990 to July 2011,
(c) systematic reviews,
(d) reviews with data/narrative synthesis,
(e) meta-analyses.
The articles excluded were
(a) theoretical and educational reviews,
(b) those published prior to 1990.
3.2. Types of Reviews. The total number of reviews initiallyretrieved after excluding duplicates was 7845 (see Table 1).Twenty three reviews that met the inclusion criteria included499 primary studies/publications. Data were extracted usingthe headings set out in Table 3 by two researchers workingindependently. A third researcher checked for and resolvedany discrepancies with reference to the original publications.
3.3. Outcome Domains. The reviewed studies included manyoutcomes which ranged from physical health measures (e.g.,cardiovascular measures) to psychological and psychiatricmeasures (e.g., well-being, psychological distress, burnout,general mental health, anxiety, depression, stress, psychiatricsymptoms, and psychosomatic symptoms) to organisationalmeasures (e.g., employee satisfaction, motivation, absen-teeism). In this paper, we focus only on articles reporting, (a)individual outcomes of symptoms of anxiety and depression(including severe stress if measured by a specific rating scaleof anxiety and depression) or anxiety and depressive illnessformally assessed using specific diagnostic or psychometricmeasures and (b) absenteeism as an important organisa-tional outcome as this has an economic cost to the employer.
4 Journal of Environmental and Public Health
We included key words of anxiety and depression andsevere stress as inclusion criteria, but many studies and re-views are not flagged on this basis, and the findings pertain-ing to these outcomes are often hidden in tables of results.Piloting showed that searches specifically for anxiety anddepression did not easily permit us to identify all studies thatmight include anxiety and depression as outcomes; this wasonly possible after reviewing the full-text paper. Thus, wekept our original searches broad in order to be satisfied allsuch paper that met our inclusion criteria would be included.
3.4. Analysis. Table 3 presents descriptive information on thetwenty three reviews including the dates of published stud-ies/papers included in the reviews, the number of publishedstudies/papers, the prevention level (i.e., primary, secondary,and tertiary), whether the interventions were targeting theindividual (I) or the organisation (O) level, and which levelthe outcomes specified: individual mental health (I) and/orabsenteeism (O).
Due to the heterogeneity of the published reviews interms of the methodology used (i.e., meta-analyses versusnarrative synthesis or meta-narratives), the analysis and syn-thesis of meta-analytic reviews is reported first (see Table 4;11 reviews), then the narrative synthesis reviews (Table 5; 12reviews), each annotated to indicate individual and organ-isational interventions, and individual and organisationaloutcomes (see Table 3).
Including narrative reviews permitted evaluation of in-depth information that might be overlooked in meta-analyticreviews, as this information is important for constructingappropriate interventions and implementing them in orderto prevent severe stress and anxiety and depression at work.For example, components of an appropriate organisationalintervention will be difficult to capture in a meta-analyticreview given these interventions will vary between organi-sations; only in-depth descriptions can capture the compo-nents that can then be considered for similar organisationalcontexts.
For meta-analyses, the effect sizes and original conclu-sions are presented, along with the outcomes used, wherethese were reported (Table 4). For narrative reviews, wepresent the key narrative conclusions (or evidence summarystatement), along with the number of studies finding im-provement (↑), deterioration (↓), or no effect (↔). This wasdone for the same two outcomes: mental health and for ab-senteeism (Table 5).
Judgements about the number of studies finding a posi-tive, negative or no effect in the narrative synthesis were chal-lenging, as many studies tended to use words such as stress,psychological distress, psychosomatic disorders interchange-ably, and negative findings may not have been reported. Weonly rated studies as having effects on mental health (anxietyand depression), where it was clear they had used a specificmeasure of mental disorders or severe stress either alone oras part of a composite measure of mental health and well-being. Where there was doubt, we did not include the studyin the data. This is an advance on existing reviews which tendto group all types of stress, including that associated with
anxiety and depression, and other types of measures of stresssuch that the findings are interpreted with reference to a largenumber of emotional and health states. We felt this approachwould not permit us to isolate the findings of relevance tothe preventing common mental disorders which are the mostimportant cause of sickness-related absenteeism.
4. Results
Eleven reviews included meta-analyses [16, 22–31]; 12 in-cluded a systematic or literature review [32–43] with meta-narrative conclusions (see Table 5).
As set out in Table 3, of the twenty three reviews, fourreported on individual interventions only (three with a meta-analysis) [26, 27, 31, 36]; three of these assessed their impacton individual and organisational outcomes [26, 31, 36],whilst the other one assessed impact on individual outcomesonly [27]. There were three reviews that examined the effect-iveness of only organisational interventions [24, 32, 40]. Ofthese, Parkes and Sparkes [40] and Bond et al. [24] reviewedorganisational outcomes, whereas Egan et al. [32] reportedon individual outcomes.
Six reviews included studies that looked separately atindividual and organisational interventions in the same stud-ies [16, 37, 39–42]. Of these, Mimura and Griffiths [39]reported only on individual outcomes, the rest reported onboth individual and organisational outcomes. The remainingseven reviews assessed interventions at both individual andorganisational levels [23, 25, 29, 30, 33–35]. Of these, onelooked only at organisational outcomes [34], and one lookedat individual outcomes [28]. There were no studies that as-sessed interactions between the two levels of outcome.
4.1. Reviews Reporting Meta-Analysis of Effect Sizes. Elevenreviews [16, 22–31] reported effect sizes from meta-analyses(Table 4) on mental health and absenteeism. The overallimpression from the meta-analytic reviews is that the effectsize is greater at the individual level for individual interven-tions compared with organisational interventions, and thatorganisational or mixed interventions can also impact on themental health of individuals.
4.2. Individual Outcomes: Mental Health. Of these elevenreviews, six showed that individual interventions lead to ben-efit on individual mental health outcomes [16, 23, 25–27,31]. Five reviews of organisational interventions [16, 23, 25,28, 30] together showed mixed evidence of benefit on indi-vidual outcomes; thus Richardson and Rothstein [23] andvan der Klink et al. [25] showed no benefit, whilst Marineet al. [16], Martin et al. [28] and van Wyk and Pillay-VanWyk [30] showed some benefit. Richardson and Rothstein[23] and van der Klink et al. [25] also reviewed mixed inter-ventions, both of which showed benefit at the individual levelon mental health status.
4.3. Organisational Outcomes: Absenteeism. Four reviewsfound individual interventions did not impact on absentee-ism [23, 25, 28, 30]. There was mixed evidence of benefit
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cati
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pute
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back
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cati
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ary
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icia
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tun
eth
emto
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ted
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ner
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sor
31 Not
rep
orte
d
8 Journal of Environmental and Public Health
Ta
ble
3:C
onti
nu
ed.
Au
thor
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rch
date
s)R
esea
rch
aim
orqu
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nti
onle
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Inte
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Ou
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pe
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rven
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sre
view
edN
o.of
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dies
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hie
and
Will
iam
s20
03(1
987–
1999
)
Red
uci
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kre
late
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olog
ical
illh
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ess
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nce
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sica
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ivit
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cial
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lem
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pati
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lth
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g
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ffith
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ards
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eeff
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inte
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s
11 Not
rep
orte
d
Edw
ards
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Bu
rnar
d20
03(1
966–
2000
)
Syst
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stre
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for
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Supp
ort,
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cati
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avio
ur
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g
77 Not
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orte
d
Van
der
Klin
ket
al.2
001
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6–19
96)
Eff
ecti
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ess
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crea
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ort
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ptom
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onde
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rted
)
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gan
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port
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tore
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ken
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ent
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gst
udi
es
Not
rep
orte
d
Van
der
Hek
and
Plo
mp,
1997
(198
7–19
94)
Eval
uat
eth
eeff
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enti
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atic
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vidu
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-env
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Org
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dre
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24 4on
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ss,5
onan
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onde
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sion
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nte
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,an
d1
onst
ress
Journal of Environmental and Public Health 9
Ta
ble
3:C
onti
nu
ed.
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thor
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rch
date
s)R
esea
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aim
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Inte
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Ou
tcom
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rven
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view
edN
o.of
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dies
Mu
rphy
,199
6(1
974–
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)St
ress
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agem
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inw
ork
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:Acr
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view
ofth
eh
ealt
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ects
PP
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OSy
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atic
Pro
gres
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ogn
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iou
ral,
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ltim
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dm
isce
llan
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s
64 18on
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ety,
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ptom
s,20
onst
ress
,6on
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essi
on,7
onab
sen
teei
sm,a
nd
1on
psyc
hol
ogic
aldi
stre
ss
Sau
nde
rset
al.,
1996
(197
7–19
91)
Th
eeff
ect
ofin
divi
dual
stre
ssin
ocu
lati
ontr
ain
ing
for
anxi
ety
and
perf
orm
ance
PP
II,
OM
eta
anal
ysis
Stre
ssin
ocu
lati
ontr
ain
ing:
con
cept
ual
isat
ion
and
edu
cati
on,
skill
acqu
isit
ion
and
reh
ears
alth
enap
plic
atio
nan
dfo
llow
thro
ugh
37 7on
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hol
ogic
aldi
stre
ss,
9on
test
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ety,
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spee
chan
xiet
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onco
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ter
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han
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onte
ach
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voca
tion
alst
ress
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indu
ced
stre
ss,
and
1on
soci
alan
xiet
y
Gig
aet
al.,
2003
(199
0–20
01)
Th
eim
pact
ofst
ress
man
agem
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inte
rven
tion
son
the
indi
vidu
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dth
eor
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-bas
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ly
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view
Indi
vidu
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elax
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em
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dem
ploy
eeas
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ram
me
Indi
vidu
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ort
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sica
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gn/r
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onab
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onst
ress
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anxi
ety
Cau
lfiel
det
al.,
2004
(199
3–20
03)
Toin
vest
igat
eem
piri
calr
esea
rch
into
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pati
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stre
ssin
terv
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ons
con
duct
edin
Au
stra
liaP
PI,
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stem
atic
revi
ew
Indi
vidu
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elf-
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agem
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nin
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cide
nt
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uca
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rede
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h,
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stre
ss,a
nd
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Pen
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cGu
ire,
Leit
e,20
09(e
lect
ron
icse
arch
eson
12/5
/08
Han
dse
arch
es19
73–1
990)
Psyc
hos
ocia
lin
terv
enti
ons
for
prev
enti
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hol
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oble
ms
inla
wen
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toffi
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ice
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egar
dle
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ntr
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PP SP
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revi
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syst
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view
oftr
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Exe
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rven
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dps
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inte
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ed,a
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con
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ta3
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inte
rven
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san
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tops
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inte
rven
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s
On
lytw
ost
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esh
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ych
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mea
sure
sas
outc
ome
10 Journal of Environmental and Public Health
Ta
ble
3:C
onti
nu
ed.
Au
thor
(sea
rch
date
s)R
esea
rch
aim
orqu
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onP
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nti
onle
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Inte
rven
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Ou
tcom
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pe
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Inte
rven
tion
sre
view
edN
o.of
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dies
Mar
tin
2009
Pu
blis
hed
1997
–200
0
Met
a-an
alys
isof
effec
tsof
hea
lth
prom
otio
nin
terv
enti
onin
the
wor
kpla
ceon
depr
essi
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dan
xiet
ysy
mpt
oms
PP
+SP
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eta-
anal
ysis
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obic
and
wei
ght
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hav
iou
rm
odifi
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mpu
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Acc
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ssio
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Journal of Environmental and Public Health 11
Ta
ble
3:C
onti
nu
ed.
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date
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esea
rch
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orqu
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edN
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ects
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terv
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ons
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port
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11(1
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nal
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ksit
eex
erci
se,a
supe
rvis
ored
uca
tion
prog
ram
onm
enta
lhea
lth
prom
otio
n,“
ALi
fest
yle
Inte
rven
tion
Via
Em
ail”
(Aliv
e!),
extr
are
stbr
eak
tim
efo
rw
orke
rsen
gage
din
hig
hly
repe
titi
vew
ork,
am
ult
idis
cipl
inar
yoc
cupa
tion
alh
ealt
hpr
ogra
mm
e,a
mu
ltic
ompo
nen
th
ealt
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omot
ion
prog
ram
me,
part
icip
ator
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oces
ses,
expo
sure
tobl
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enri
ched
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ersu
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hit
elig
ht)
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da
tele
phon
ein
terv
enti
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ogra
mfo
rde
pres
sed
wor
kers
14st
udi
eson
pres
ente
ism
RC
Ts=
ran
dom
ised
con
trol
led
tria
ls.
12 Journal of Environmental and Public Health
Ta
ble
4:E
ffec
tive
nes
sof
SMIs
byle
vela
nd
outc
ome
ofin
terv
enti
on(r
esu
lts
base
don
lyon
met
a-an
alys
es).
Inte
rven
tion
Indi
vidu
alO
rgan
isat
ion
alM
ixed
/un
spec
ified
Ou
tcom
eIn
divi
dual
Org
anis
atio
nal
Indi
vidu
alO
rgan
isat
ion
alIn
divi
dual
Org
anis
atio
nal
Park
san
dSt
eelm
an,
2008
Ou
tcom
e:ab
sen
teei
sm
Wel
lnes
spr
ogra
mm
eeff
ect
size
(mea
ndi
ffer
ence
betw
een
thos
ew
ith
and
wit
hou
ta
wel
lnes
spr
ogra
mm
e,w
eigh
ted
for
sam
ple
size
)
d=−0
.3,9
5%C
I:−0
.48,
−0.2
2∗∗∗
Ric
har
dson
and
Rot
hst
ein
,200
8G
HQ
,STA
I,
SCL-
90,v
ario
us
anxi
ety
mea
sure
s;T
Q4,
anxi
ety
mea
sure
byB
endi
ng
1956
CB
Tfo
rov
eral
lpsy
chol
ogic
alou
tcom
esco
mbi
ned
d=
1.15
4∗∗
An
xiet
yd=
2.39
0∗∗∗
For
psyc
hol
ogic
alou
tcom
esco
mbi
ned
d=
0.50
7∗∗∗
An
xiet
yd=
0.61
1∗∗∗
Abs
ente
eism
d=
0.21
3
Org
anis
atio
nal
(su
ppor
tgr
oups
and
part
icip
ator
yac
tion
grou
ps)
for
psyc
hol
ogic
alou
tcom
esco
mbi
ned
d=
0.13
4
Men
talH
ealt
hd=
0.16
7
Org
anis
atio
nal
supp
ort
grou
psan
dpa
rtic
ipat
ory
acti
ongr
oups
for
abse
nte
eism
d=−0
.159
Stre
ssd=
7.27
∗∗∗
An
xiet
yd=
0.67
8∗∗∗
Men
talH
ealt
hd=
0.44
1∗∗∗
Bon
det
al.,
2006
Mor
eco
ntr
olle
adto
redu
ced
abse
nte
eism
4st
udi
esd=−.
1195
%C
I:−.
15to−.
08
Smal
lan
dsi
gnifi
can
t
Mor
esu
ppor
tle
ads
tole
ssab
sen
teei
sm1
stu
dyd=−1
695
%C
I:−.
24to−.
09
Smal
lan
dsi
gnifi
can
tC
omm
un
icat
ion
lead
sto
less
abse
nte
eism
d=−.
23Sm
all-
to-m
ediu
meff
ect
and
sign
ifica
nt
Journal of Environmental and Public Health 13
Ta
ble
4:C
onti
nu
ed.
Inte
rven
tion
Indi
vidu
alO
rgan
isat
ion
alM
ixed
/un
spec
ified
Ou
tcom
eIn
divi
dual
Org
anis
atio
nal
Indi
vidu
alO
rgan
isat
ion
alIn
divi
dual
Org
anis
atio
nal
Mar
ine
etal
.,20
06
Mea
sure
sof
stat
ean
dtr
ait
anxi
ety
STA
I,G
HQ
,Bec
k
Pers
on-d
irec
ted
inte
rven
tion
sve
rsu
sco
ntr
ol:
Stat
ean
xiet
y:W
MD
=−9
.42,
CI:−1
6.92
to−1
.93
Trai
tan
xiet
yW
MD
=−6
.91;
95%
CI:−1
2.80
,−1.
01
Fin
din
gssu
stai
ned
inm
ediu
mte
rm:
Stat
ean
xiet
y:W
MD
=−0
.831
,C
I:−1
1.49
to−5
.13
Trai
tan
xiet
y:W
MD
=−4
.09,
CI:−7
.6to−0
.58
GH
Q:p
erso
ndi
rect
edin
terv
enti
ons
did
not
redu
cesy
mpt
oms:
WM
D=
−11.
87,C
I:−2
7.24
to3.
49
GH
Qsy
mpt
oms
redu
ced
follo
win
gco
mbi
nat
ion
ofkn
owle
dge
skill
str
ain
ing,
prog
ram
me
plan
nin
g
WM
D:−
2.9,
CI:
−5.1
6to−0
.64.
An
xiet
yn
otm
easu
red
Oth
ersi
ngl
est
udi
esu
sin
gSC
Lan
dG
HQ
did
not
chan
gere
sult
s
Van
der
Klin
ket
al.,
2001
Not
liste
d
CB
Ton
anxi
ety
d=
0.70
∗∗∗
Rel
axat
ion
onan
xiet
yd=
0.25
∗
Sum
mat
ion
onan
xiet
yd=
0.54
∗∗∗
CB
Ton
depr
essi
ond=
0.23
Rel
axat
ion
onde
pres
sion
d=
0.11
Sum
mat
ion
onde
pres
sion
d=
0.33
∗∗
CB
Ton
abse
nte
eism
d=−0
.18
Rel
axat
ion
onab
sen
teei
smd=−0
.09
Sum
mat
ion
onab
sen
teei
smd=−0
.12
Dep
ress
ion
d=
0A
bsen
teei
smd=
0
An
xiet
yd=
0.50
∗∗∗
Dep
ress
ion
d=
0.59
∗∗∗
Sau
nde
rset
al.,
1996
Mea
sure
sof
stat
eor
trai
tan
xiet
y,ST
AI.
Oth
ers
not
liste
d
Perf
orm
ance
anxi
ety
r=
0.50
9∗∗
Stat
ean
xiet
yr=
0.37
3∗∗
Pen
alba
,McG
uir
e,Le
ite,
2009
(ele
ctro
nic
sear
ches
on12
/5/0
8
Han
dse
arch
es19
73–1
990)
On
epr
imar
ypr
even
tion
stu
dyB
ackm
an(1
997)
:men
tali
mag
ing
trai
nin
gve
rsu
sco
ntr
ol
14 Journal of Environmental and Public HealthT
abl
e4:
Con
tin
ued
.
Inte
rven
tion
Indi
vidu
alO
rgan
isat
ion
alM
ixed
/un
spec
ified
Ou
tcom
eIn
divi
dual
Org
anis
atio
nal
Indi
vidu
alO
rgan
isat
ion
alIn
divi
dual
Org
anis
atio
nal
SCL-
90de
pres
sion
subs
cale
GH
Q
Dep
ress
ion
outc
ome:
MD
(fixe
deff
ect)−2
.14,
CI:−4
to−0
.28
aten
dpo
int
(in
favo
ur
ofin
terv
enti
on)
18m
onth
sla
ter:
MD
=−0
.97,
CI:−2
.43
to0.
49
GH
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tcom
e:M
D=
2.74
,C
I:0.
78–4
.7(i
nfa
vou
rof
con
trol
)
18m
onth
follo
wu
p:M
D=
1.3,
CI:−0
.61
to3.
21
On
ese
con
dary
prev
enti
onst
udy
inte
rven
tion
vers
us
con
trol
:N
orve
ll(1
993)
Dep
ress
ion
:MD=−7
.32,
CI:−1
1.79
to−2
.85
infa
vou
rof
inte
rven
tion
An
xiet
y:M
D=−3
.1,C
I:−6
.94
to0.
6in
favo
ur
ofin
terv
enti
on
All
prev
enti
onve
rsu
sco
ntr
olpo
sth
ocse
lect
edou
tcom
es:
Dep
ress
ion
:(B
ackm
an,1
977;
Nor
vell,
1993
)
Dep
ress
ion
outc
ome:
MD
=−0
.8,
CI:−1
.36
to−0
.24,
infa
vou
rof
inte
rven
tion
Mar
tin
2009
Pu
blis
hed
1997
–200
0
Stan
dard
ised
mea
sure
s,an
xiet
y,de
pres
sion
and
com
posi
tem
easu
re
CE
S-D
BSI
Dep
ress
ion
:SM
D=
Smal
lbu
tsi
gnifi
can
teff
ect:
Dep
ress
ion
:SM
D=
0.28
,CI:
0.12
–0.4
4
An
xiet
y:SM
D=
0.29
,CI:
0.06
–0.5
1
Sin
gle
tria
lofs
tres
sm
anag
emen
tpr
ogra
mm
e:de
pres
sion
:SM
D=
0.69
Dep
ress
ion
:SM
D:0
.31,
CI:
0.1–
0.51
An
xiet
y
SMD
:0.2
5,C
I:0.
03–0
.53
Impr
ovem
ent
mai
nta
ined
atfo
llow
up
(on
ly9
of17
stu
dies
repo
rtfo
llow
up)
5st
udi
esh
addi
ffer
ent
met
hod
s:
Dep
ress
ion
insm
okin
gce
ssat
ion
tria
l:w
orse
nin
gSM
D=−0
.08
(on
CE
SDsc
ale)
,no
diff
eren
cein
BSI
outc
omes
ofde
pres
sion
:SM
D=
0.03
,an
xiet
ySM
D=
0.05
Journal of Environmental and Public Health 15T
abl
e4:
Con
tin
ued
.
Inte
rven
tion
Indi
vidu
alO
rgan
isat
ion
alM
ixed
/un
spec
ified
Ou
tcom
eIn
divi
dual
Org
anis
atio
nal
Indi
vidu
alO
rgan
isat
ion
alIn
divi
dual
Org
anis
atio
nal
Con
n20
09
(ele
ctro
nic
sear
ches
1969
–200
7)
Moo
d(s
elfr
epor
t-m
easu
ren
otre
port
ed)
Wor
kat
ten
dan
ce
Un
clea
rw
hic
hst
udi
esth
atw
ere
rep
orte
dco
ntr
ibu
ted
toth
eeff
ect
size
s,an
dw
het
her
they
use
din
divi
dual
oror
gan
isat
ion
alin
terv
enti
ons
Moo
d
2gr
oup
post
test
:mea
nof
effec
tsi
ze(M
ES)
:0.1
3,C
I:−0
.05
to0.
31(N
S)
2gr
oup
pre-
and
post
test
:ME
S=
0.21
,CI:
0.07
to0.
36∗∗
Trea
tmen
tpr
ean
dpo
st:
ME
S+
0.31
,CI:
0.22
to0.
4∗∗∗
Wor
kat
ten
dan
ce:
2gr
oup
post
test
:ME
S=
0.19
,CI:
0.11
to0.
27∗∗∗
2gr
oup
pre
pos
tte
st:
ME
S=
0.05
,CI:−0
.19
to0.
29
Trea
tmen
tpr
ep
ost
test
:M
ES
0.02
,CI:−0
.08
to0.
13(N
S)
Wor
kpla
cein
terv
enti
ons
had
bett
erre
sult
s,as
did
inte
rven
tion
inpa
idti
me,
stu
dies
wit
hon
site
fitn
ess
faci
litie
s
Van
Wyk
(201
0)
Stat
ean
dtr
ait
anxi
ety
inde
x
Car
eer
iden
tity
trai
nin
gin
one
stu
dydo
esn
otim
prov
ean
xiet
yin
nu
rses
:mea
ndi
ffer
ence
:−0
.06,
CI:−0
.44
to0.
32
Von
Bae
yer’
s3
sess
ion
stre
ssm
anag
emen
ttr
ain
ing
show
edm
argi
nal
ben
efit.
Stan
dard
ised
mea
ndi
ffer
ence
:−1
.45,
CI:−2
.67
to0.
22
Wei
r(1
997)
asse
ssed
effec
tof
man
agem
ent
inte
rven
tion
toim
prov
epr
oces
sco
nsu
ltat
ion
betw
een
nu
rse
man
ager
san
dst
affon
mea
nh
ours
abse
nce
ofst
affin
aco
mm
un
ity
hos
pita
lNo
diff
eren
ce:m
ean
diff
eren
ce=
20.3
5,C
I:−1
0.65
to51
.35
Noo
rdik
(201
0)
Spec
ific
outc
omes
not
liste
d
Abs
ente
eism
not
give
nas
sepa
rate
outc
ome
from
wor
kfu
nct
ion
Eff
ects
onA
nxi
ety
2st
udi
esin
met
a-an
alys
is,
SMD
=−0
.54,
CI:−1
.26
to0.
16
Gro
up
expo
sure
CB
Tan
dm
edic
atio
nve
rsu
son
lym
edic
atio
n:S
MD
=0.
87,
CI:
0.34
to1.
39
Exp
osu
rein
vivo
and
med
icat
ion
vers
us
only
med
icat
ion
:1,C
I:0.
52to
1.49
Larg
eeff
ect
size
d(>
0.8)
judg
edto
indi
cate
sign
ifica
nt
resu
ltw
ith
out
form
alst
atis
tica
ltes
ts
KE
Y:d=
effec
tsi
ze,S
MD
=st
anda
rdis
edm
ean
diff
eren
ce,W
MD
=w
eigh
ted
mea
ndi
ffer
ence
,CI=
con
fide
nce
inte
rval
.∗∗∗
P=
0.00
1,∗∗
P=
0.01
,∗P=
0.05
.W
hen
inte
rven
tion
typ
esar
en
otsp
ecifi
edth
ein
terv
enti
onsu
mm
edin
the
resp
ecti
vece
llar
em
ult
iple
and
too
man
yto
list.
Bol
dde
not
esa
stat
isti
cally
sign
ifica
nt
outc
ome.
16 Journal of Environmental and Public Health
Ta
ble
5:St
udi
esof
inte
rven
tion
sre
ach
ing
nar
rati
veco
ncl
usi
ons
wit
hou
tm
eta-
anal
yses
ofeff
ect
size
s.
Ou
tcom
eN
um
ber
ofst
udi
es,d
ate
ran
ge,
and
key
obje
ctiv
eof
revi
ewM
H↑
MH↓
MH↔
A↑
A↓
A↔
Nar
rati
veco
ncl
usi
ons
Ega
net
al.,
2007
18st
udi
es
1981
–200
6
Psyc
hos
ocia
lan
dh
ealt
heff
ects
ofw
orkp
lace
reor
gan
isat
ion
Org
anis
atio
nal
leve
lin
terv
enti
ons
toim
prov
eem
ploy
eeco
ntr
ol
61
84
1So
me
evid
ence
ofim
prov
edm
enta
lhea
lth
asem
ploy
eeco
ntr
olin
crea
ses
and,
less
con
sist
entl
y,w
hen
dem
ands
decr
ease
Lam
onta
gne
etal
.,20
07
90st
udi
es
1990
–200
5
Job
stre
ssin
terv
enti
onlit
erat
ure
201
2021
18
Indi
vidu
alfo
cuss
ed,l
owra
tes
syst
ems
appr
oach
esar
eeff
ecti
veat
the
indi
vidu
alle
velo
nan
xiet
yan
dde
pres
sion
Org
anis
atio
nal
lyfo
cuss
edh
igh
and
mod
erat
ely
rate
dsy
stem
sap
proa
chin
terv
enti
ons
for
job
stre
sssh
owfa
vou
rabl
eim
pact
sat
both
orga
nis
atio
nal
and
indi
vidu
alle
vels
.Ofh
igh
rate
dst
udi
es,a
lmos
tal
lsh
owed
decl
ine
inab
sen
teei
sm
Th
eB
OH
RF,
2005
19ex
peri
men
tals
tudi
es
12n
onex
peri
men
tals
tudi
es
Up
un
tilA
pril
2004
Wor
kpla
cein
terv
enti
ons
for
peop
lew
ith
com
mon
men
tal
hea
lth
prob
lem
s
171
43
1
Ear
lyps
ych
olog
ical
inte
rven
tion
s,in
clu
din
gC
BT
and
ara
nge
ofst
ress
man
agem
ent
inte
rven
tion
s,ar
eeff
ecti
vefo
rco
mm
onm
enta
lhea
lth
prob
lem
s
Indi
vidu
alst
ress
man
agem
ent
appr
oach
esw
ere
effec
tive
and
pref
erab
leto
mu
ltim
odal
inte
rven
tion
sfo
rre
duci
ng
stre
ssC
BT
effec
tive
for
sick
nes
sab
sen
ces
asso
ciat
edw
ith
com
mon
men
tal
hea
lth
prob
lem
s
Edw
ards
and
Bu
rnar
d,20
03
70st
udi
es
1966
–200
0
Eff
ecti
ven
ess
ofst
ress
man
agem
ent
for
nu
rsin
gin
UK
51
1
Six
stre
ssm
anag
emen
tin
terv
enti
onst
udi
esin
UK
and
one
inT
he
Net
her
lan
dssh
owth
attr
ain
ing
inbe
hav
iou
ralt
ech
niq
ues
impr
oved
leve
lsof
sick
nes
sin
psyc
hia
tric
nu
rses
.Lev
els
ofps
ych
olog
ical
dist
ress
redu
ced
follo
win
ga
15w
eek
trai
nin
gco
urs
ein
ther
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Journal of Environmental and Public Health 17
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18 Journal of Environmental and Public Health
from organisational interventions on absenteeism. Parks andSteelman [22] and Bond et al. [24] found some evidenceof benefit, whereas Richardson and Rothstein [23] and vander Klink et al. [25] found no benefit. However, Conn et al.[29] showed clear benefit of organisational physical activityinterventions on absenteeism. There were no studies ofmixed individual-organisational interventions and impact onabsenteeism.
4.4. Reviews Reporting Narrative Conclusions. The overallconclusions from the narrative reviews support the findingsfrom the meta-analyses that individual interventions doprovide benefit at an individual level and reduce symptomsof anxiety and depression and stress, but individual interven-tions do not impact on absenteeism. However, organisationalinterventions impact at both individual and organisation-al levels. There are numerous studies of benefit on mentalhealth outcomes, whereas benefit on absenteeism is mainlyreported in one review [33] including a number of highquality studies (Table 5). Worryingly, some interventionsappeared to lead to deterioration in mental health [16, 32–35] and absenteeism [33, 36] outcomes (see Table 5). For ex-ample, Marine et al. [16] identifies smoking cessation to beassociated with depression. Although not directly mappingon to absenteeism, preliminary evidence from Cancelliereet al. [43] suggested that some workplace health promotionprogrammes can reduce presenteeism (being at work whilstunwell). Presenteeism correlated with being overweight, apoor diet, a lack of exercise, high stress levels, poor relation-ships with coworkers and management.
4.5. The Effectiveness of Specific Interventions. The differenttypes and components of interventions, and whether they areprimary, secondary, or tertiary preventive interventions, areset out in Table 3. The majority of studies were of primaryprevention. The meta-analytic reviews found that cognitivebehavioural programmes consistently produced larger effectsat the individual level compared to other types of interven-tions (e.g., relaxation). Cognitive behavioural programmeswere also suggested to be more effective by some of the nar-rative reviews [27, 31, 34–36] as well as by some of the meta-analyses [23, 25].
Murphy [36] found that multimodal interventions (orcombination strategies), which involved CBT produced themost consistent, significant results; a result which was notsupported by one meta-analytic review [25]. Overall, thereviews suggested that organisational level interventions aretoo scarce and there is also a lack of studies that assess organi-sational-level outcomes. However, two meta-analytic reviews[22, 29] found that participation in organisational wellnessprogrammes was associated with decreased absenteeism andincreased job satisfaction. These were the only meta-analyticreviews of organisational based interventions and organisa-tional-level outcomes. Finally, there are insufficient studies tocomment on the potential complementarity of interventionsthat operate at primary, secondary, and tertiary preventionlevels [33]. Four studies investigated both primary and
secondary prevention but not their interaction [23, 27, 33,34].
5. Discussion
As anticipated, the evidence was in complex form. Ourmethods of isolating findings related to anxiety and depres-sion, and partitioning the tabulation and extraction andsynthesis by individual/organisational interventions and out-comes provides a rich, complex but authentic picture of theevidence base. There are indications for which interventionsare effective and also gaps in the evidence. Reviews had totake account of many interventions that differed by theircomponents, mode of delivery and whether they targetedindividuals or organisations. This made it difficult for all ofthe reviews to compare benefits from any single interventionacross a number of studies, except for CBT or physical ac-tivity. There were also many different outcome measures forassessing anxiety and depression, and many proxy measuresof mental health, sometimes without clarity about whichoutcomes were used in the meta-analyses. In part, these werenot specified due to the way multiple outcomes were handledin the analysis. The reviews used standardised differencesincluding mean differences and mean effect sizes, and stand-ardised differences and means. Using a consistent set of out-comes to measure anxiety and depression in future primarystudies will ensure that future reviews and meta-analyses canovercome these challenges, such that different intervention,of varying complexity and modes of delivery, might becompared more directly for impacts on absenteeism and onanxiety and depression and interactions between the individ-ual and organisational impacts.
Overall, individual interventions show larger effectscom-pared with organisational interventions or mixed interven-tions; benefits are seen mainly at the individual level al-though some studies do show organisational benefits. Giventhat anxiety and depression are common, and mostly ac-count for sickness absence, it is important to develop anevidence base that is specific to these manifestations ofmental distress and illness, with an agreed range of acceptableoutcome measures and for interventions that prevent andtreat anxiety and depression promptly, as well as encour-age early return to work. A small improvement in sick-ness absence statistics might yield substantial benefits forbusiness viability and provision of services. Standardisedmethods to measure presenteeism [43] are needed. Theonly organisational intervention to show convincing effectson absenteeism was physical activity programmes [29], butmental imaging, CBT, and in vivo exposure, each have auseful role, especially in secondary prevention. Althoughbetter quality studies should be given greater weight, thequality of individual primary studies was selectively reported,making it difficult to know whether the positive findingsreflected better quality studies; certainly, CBT and physicalactivity interventions are more well defined than say stressmanagement standards or management practices or stressinoculation. Even counselling can take many forms, andthere is not a standardised process. Similarly, the duration of
Journal of Environmental and Public Health 19
the interventions and timing of measurement of outcomeswas not a characteristic on which reviews drew conclusions;we were unable to draw any metaevidence about timingunless we had looked at primary studies. Strikingly, althoughmany reviews on face value were reviewing the same evi-dence, the reviews did not all identify the same primary stud-ies, and therefore did not always reach the same conclusions;our meta-review, for the first time, brings together all of thestrongest findings. We reviewed 23 reviews, after identifying7845 potential publications for inclusion. These included499 primary studies; the majority of reviews made the pointthat drawing metanarrative or meta-analytic conclusions wasdifficult because of this diversity in outcomes, intervention,and methods. Had we undertaken a review of 499 primarystudies, it is likely we would draw the same conclusions.
Management skills training, and support for staff, alongwith methods to cope with work stress all seem relevantcomponents, but the review was not convincing about a pos-itive benefit of these and where positive impacts were seenat individual levels [16, 28]; the effect could not entirely beattributed to improved management standards or workingrelationships. There has been insufficient research on organ-isational interventions. These studies are difficult to designand implement and require further research. On the otherhand, more and more interest has been generated towardshealth promotion in the workplace (e.g., exercise) and en-couraging individuals to take ownership of health risk be-haviours and decisions about health, well-being, and familyoutside of work. This may be promising, as it requires theworkforce to maintain healthy lifestyles generally and withinthat context to consider work stress rather than considerwork as the only venue for health interventions. Organisa-tional measures to increase physical activity show promisingresults [43].
This review suggests that there is lack of evidence incomparing the relative effectiveness of stress managementinterventions that operate at both individual and organisa-tional levels, or interventions that encourage an interactiveor systemic effect, yet this might yield greater benefits at bothlevels.
However, there are still a number of evidence gaps. Moreresearch is needed in the private sector and in smaller compa-nies as well as research comparing different job types such aseducation and healthcare to examine whether they respondto the same or different intervention techniques. Similarly,research needs to take into account factors such as socioeco-nomic status, duration of any effects of interventions, andcost effectiveness. Selection bias may be an important ex-planation for our findings. For example, organisations withthe most stressful work environments are less likely to par-ticipate in research as opposed to organisations with littlestress amongst employees. Consequently, organisations withlow baseline stress levels would make any effects from tar-geted interventions more difficult to capture. However, pre-liminary support was found in one meta-analytic review thatinterventions conducted with employees at high levels ofbaseline stress appeared to be at least as effective as inter-ventions conducted with employees at low levels of baseline
stress [25]. What works for whom and the maintenance ofthese effects need further research [32].
Finally, there is a relative lack of studies with clinicallyreferred employees. We did find more of these in morerecent years (since 2008) and also reviews of health careworkers and law enforcement officers who perhaps need spe-cific attention given the unique circumstances and stressorsto which they are exposed at work. The few methodologicallyrigorous studies that have been conducted with patientshave not included nontreatment control groups but havecompared 2 treatment types. More work might, therefore,be undertaken on populations at risk using secondary andtertiary prevention interventions.
6. Conclusions
CBT was the most effective individual targeted interventionfor individual outcomes. Encouragement of physical activityat an organisational level seems to reduce absenteeism. In-terventions need to be developed that can provide consistentand stronger effects on organisational outcomes such as ab-senteeism. There were a number of gaps in the literature, par-ticularly studies investigating the influence of specific occu-pations, and different sized organisations, different sectors oforganisations (public, private, and not for profit). Studies ofmanagement practices seemed not to show strong effects, butthere are still insufficient studies in this area. There were fewstudies of secondary and tertiary prevention.
Conflict of Interests
The authors declare that they have no conflict of interests.
Authors’ Contribution
K. S. Bhui conceived of the study, was the principal inves-tigator, provided day-to-day management, and along withSD read the reviews, extracted and tabulated the data andcodrafted the paper. S. A. Stansfeld and P. D. White were thecoinvestigators to the project, and commented on and editedall drafts of the paper. All authors contributed equally to thiswork.
Acknowledgment
This work was supported by the Department of Health in UKto K. S. Bhui.
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