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The Benefits of Interventions for Work-Related Stress sample essay

Objectives. This quantitative metaanalysis sought to determine the effectiveness of occupational stress–reducing interventions and the populations for which such interventions are most beneficial. Methods. Forty-eight experimental studies (n = 3736) were included in the analysis. Four intervention types were distinguished: cognitive–behavioral interventions, relaxation techniques, multimodal programs, and organizationfocused interventions. Results. A small but significant overall effect was found. A moderate effect was found for cognitive–behavioral interventions and multimodal interventions, and a small effect was found for relaxation techniques. The effect size for organization-focused interventions was nonsignificant. Effects were most pronounced on the following outcome categories: complaints, psychologic resources and responses, and perceived quality of work life. Conclusions. Stress management interventions are effective. Cognitive– behavioral interventions are more effective than the other intervention types. (Am J Public Health. 2001;91:270–276)

Jac J. L. van der Klink, MD, MSc, Roland W. B. Blonk, PhD, Aart H. Schene, PhD, MD, and Frank J. H. van Dijk, PhD, MD The efficacy and cost-effectiveness of interventions designed for patients with emotional difficulties is a relevant topic in general practice.1 Such considerations also apply in occupational health care. With the increases in workloads of the past decades, the number of employees experiencing psychologic problems related to occupational stress has increased rapidly in Western countries.2 At the societal level, costs are considerable in terms of absenteeism, loss of productivity, and health care consumption. In Britain, it is estimated that 40 million workdays are lost to the nation’s economy owing to mental and emotional problems.3 At the individual level, there are costs in terms of high rates of tension, anger, anxiety, depressed mood, mental fatigue, and sleep disturbances.

These problems, usually referred to in aggregate as distress, are often classified as neurasthenia, adjustment disorders, or burnout. Incidence rates in the Netherlands vary from 14 to 50 cases per year per 1000 patients.4 Interventions designed to reduce occupational stress can be categorized according to focus, content, method, and duration. In regard to focus, interventions can be categorized as (1) aiming to increase individual psychologic resources and responses (e.g., coping) or (2) aiming to change the occupational context. The first category of intervention is usually referred to as stress management training. However, stress management is the common denominator of an assortment of interventions ranging from relaxation methods5 to cognitive– behavioral interventions6,7 and client-centered therapy.8 The second category refers to interventions such as organizational development9,10 and job redesign.11

We distinguished 4 intervention types according to categorizations used in previous reviews12–14: cognitive–behavioral approaches, relaxation techniques, multimodal interventions, and organization-focused interventions. Cognitive–behavioral approaches aim at changing cognitions and subsequently reinforcing active coping skills.6,7 Relaxation techniques focus on physical or mental relaxation as a method to cope with the consequences of stress. Multimodal interventions emphasize the acquisition of both passive and active coping skills. The fourth intervention type involves a focus on the organization as a whole. Several reviews have been conducted of interventions designed to reduce occupational stress.2,5,12,14–16 The general finding of these reviews is that such interventions are effective.

However, the reviews have been qualitative in nature and thus provide limited information on which type of intervention is most effective and for whom. Recently, Bamberg and Busch conducted the first meta-analysis on occupational stress–reducing interventions.17 However, they included only cognitive–behavioral interventions in their quantitative analyses. In the present quantitative review, the following research questions were posed: (1) Are stress interventions effective, as suggested by qualitative reviews of the literature? (2) If so, which type of stress intervention is most effective, and on which outcome measures? In addition to these research questions, exploratory analyses were conducted to determine what moderator variables (e.g., job characteristics, preventive/remedial nature of interventions, length of treatment) were related to the effectiveness of the interventions.

Search and Inclusion Criteria

Two strategies were used to locate appropriate studies. First, 4 databases—Medline (1966–1996), ClinPsych (1980–1996), Current Contents (1997), and Nioshtic (1970– 1996)—were used to conduct a computerized search. Three groups of terms were composed for this search: (1) terms linked to stress-related psychologic problems (psychologic stress, work stress, job stress, neurasthenia, burnout, minor psychiatric problems, mental fatigue, minor depression, neurosis, distress, nervous breakdown, and adjustment disorder), (2) terms related to the intervention (therapy, treatment, protocol, program, intervention, primary care, prevention, and employee assistance program), and (3) terms related to the population (employee, occupational, vocational, rehabilitation, work, job, absenteeism, and sickness leave).

Within each group of terms, searches were added. Subsequently, these searches were combined. Second, a manual search of relevant reviews, book chapters, and articles was conducted, with the objective of finding relevant references missed in the computerized search. To be included in our database, a study had to meet several criteria. First, the intervention was required to be specifically designed to prevent or reduce psychologic complaints related to occupational stress. Second, in terms of the target population, participants had to be recruited from the working population because of imminent or already-manifested stressrelated psychologic problems not diagnosed as involving a major psychiatric disorder (e.g., depression or posttraumatic stress disorder) or a stress-related somatic disorder (e.g., hypertension, coronary heart disease).

Third, an experimental or quasi-experimental design involving a no-treatment control group had to be used. Within the quasi-experimental studies, we required that the experimental group and the control group be recruited from identical populations and have identical baseline values on dependent variables. In this high-quality group of primary studies, we applied no ranking for methodological quality aspects because the consequent choice of a weighting factor in the quantitative analyses would introduce an element of subjectivity. Fourth, outcome variables had to be well defined and of sufficient reliability. Finally, we required that the study be published as a journal article in English.


The variables used in the meta-analysis included intervention-related variables, outcome variables, and population characteristics. February 2001, Vol. 91, No. 2

Intervention-related variables were (1) type of intervention, (2) total number of hours, (3) number of weeks, and (4) number of sessions. The latter 3 variables could be considered indexes of the intensity and extent of the intervention. Because they were relevant in assessing the cost-effectiveness and practical applicability of a program, we used these variables as moderators in the exploratory analyses. As described earlier, 4 intervention types were included; 3 involved a focus on individuals and 1 involved a focus on the organization. In several reviews, a third focus has been discerned: the interaction between the individual and the organization.14,18 Thus far, however, intervention studies conducted with this focus have been uncontrolled.19

The outcome variables included were placed into 5 categories: (1) quality of work life, including such aspects as job demands, work pressure, job control, working conditions, and social support from management and colleagues; (2) psychologic resources and responses, including measures of self-esteem, mastery, beliefs, and coping skills20; (3) physiology, including measures such as tension, electromyographic activity, (nor)adrenaline, and cholesterol level; (4) complaints, including stress or burnout rates or symptoms, somatic symptoms, and mental health status and symptoms (because of their significance in general health practice, depressive symptoms and anxiety symptoms were considered as separate subcategories); and (5) absenteeism.

A number of population characteristics, such as sex, age, years of employment, occupational status, and baseline stress level, may be important moderators of treatment effects and thus may provide information on which types of interventions are effective and for whom. However, for most of these characteristics, the specific information required was not available in the studies; the exceptions were baseline stress level and occupational status. The predictive influence of these characteristics on treatment effects was investigated in a number of exploratory analyses.

In line with Newman and Beehr12 and with Murphy,2 2 baseline stress level categories were distinguished, preventive and remedial. In the present meta-analysis, a study was considered preventive if no participant selection had taken place in regard to stress levels. A study was considered remedial if participants were selected by means of a criterion. As noted by Karasek and Theorell, occupational status may be indicative of level of job control.20 On the basis of Karasek and Theorell’s ratings, we categorized study samples as “high control” or “low control.” Two studies involving samples with mixed occupations were classified as low control because most of the participants in these studies had low-control jobs.21,22 Two studies were excluded from these exploratory analyses because of a lack of sufficient information.23,24

Statistical Analysis

The Advanced BASIC Meta-Analysis program25 was used in conducting statistical analyses. In this program, several statistics (e.g., F, t, r, and P) can be entered, and a product–moment correlation is obtained. These effect size correlations are transformed to Fisher z scores. Subsequently, mean Fisher z scores are calculated and transformed back to effect size (r) values. If F or t values were reported, we used these values; if such values were not reported, they were computed if the required information was available. If this computation was not possible, P values were used; effects reported as nonsignificant were rated as P=0.5.26 A problem in meta-analyses is that studies with a relatively large number of outcome measures disproportionately affect the metaanalytic results.

To counteract this problem, Rosenthal and Rubin27 proposed a method of computing a mean effect size in which the intercorrelation of outcome measures is taken into account.25(pp45–47) For all analyses, outcome variables were combined according to this method. We used all outcome measures reported in a study in calculating effect sizes. We report effect sizes in Cohen’s d, which can be derived directly from r values. Cohen’s d represents the standardized mean difference between the intervention group mean and the control group mean. Thus, a d value of 1 indicates that the intervention group performed 1 standard deviation above the control group on a particular outcome variable.

Description of Studies

Forty-eight studies10,21–24,28–67 conducted between 1977 and 1996 met the inclusion criteria; findings from these studies were published in 45 different articles. None of the 48 studies had a curative orientation in the usual sense (i.e., target population consisting of people seeking help). Four studies were considered remedial, because there was selection in regard to baseline stress level. Forty-one studies involved employees with jobs categorized as high in job control. Five studies evaluated an organizationfocused intervention, 18 evaluated a cognitive– behavioral intervention, 17 evaluated a relaxation technique, and 8 evaluated a multimodal approach. In all studies, several outcome analyses were conducted. The result was 99 intervention–outcome combinations.

American Journal of Public Health 271

Twenty of the studies involved a followup assessment. In most cases, follow-up was either uncontrolled or reported in a way that allowed no retrieval of statistical metrics. Therefore, only the first postintervention assessment was included in the meta-analysis. The mean interval between preintervention and postintervention assessment was 9 weeks for interventions that focused on individuals (SD= 6 weeks). This deviation was merely due to dif- ferences in intervention duration. Differences in interval between intervention types were not significant. The interval for organizationfocused programs was considerably longer (38 weeks) owing to longer program durations and longer postintervention assessment intervals. Pretest-to-posttest dropout rates varied from 0% to 40%. The mean dropout rate for programs that focused on individuals was 11%; differences between intervention types were nonsignificant. Organization-focused programs had a mean dropout rate of 26%.

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