Systematic Review of Interventions Supported by ICT for the Prevention and Treatment of Occupational Stress

Santiago NARVEZ, ngela M. TOBAR and Diego M. Lpez1 Telematics Engineering Research Group, University of Cauca, Colombia
Abstract. Problem: Stress-related disorders have become one of the main problems of public health in many countries and of worldwide organizations and they are expected to become more common in the forthcoming decades. Objective: the aim of this article is to do a systematic review and a descriptive evaluation of the interventions supported by ICT for the prevention and treatment of occupational stress. Materials and Methods: a systematic review of five databases (EBSCO, The Cochrane Library, PubMed, ScienceDirect and IEEEXplorer) related to interventions for the prevention and treatment of occupational stress supported by ICT was carried out in order to obtain articles in either English or Spanish, published throughout the last ten years. The search was limited to the abstracts, key words, and titles of the articles. Results: this article provides the reader with a systematic description of 21 studies about interventions on occupational stress supported by ICT. The following factors were considered for the analysis: impact of the intervention, design of the study, type of intervention, purpose of the intervention, type of instrument for the measurement of occupational stress, and type of ICT used. Conclusions: the systematic review demonstrated that interventions supported by ICT for the prevention and treatment of occupational stress are scarce. Keywords. Occupational stress, Burnout, ICT, web

Introduction Stress-related disorders have become one of the main problems of public health in many countries and of worldwide organizations and they are expected to become more common in the forthcoming decades [1]. These disorders impact the social and economic environment of both individuals and organizations [2]. There are countless situations and environments that can generate stress: for example, the family environment and the occupational environment, the latter being widely studied as a stress generator [3]. According to WHO [4], occupational stress can be an individuals reaction to an imbalance between the demands of the workplace and their capacities. This can cause depression and anxiety which in turn can generate illness, absenteeism, and reduction in employers productivity [5]. Occupational stress is generally associated with the term burnout and, regardless of their differences; both terms will be used indistinctively in this article.
1

Corresponding Author: Diego M. Lpez, Full Professor, Telecommunications Department, University of Cauca. Calle 5 No 4-70, Popayn, Colombia; Email: dmlopez@unicauca.edu.co.

The interventions applied to occupational stress can be classified according to their category [6]: individual and organizational. Furthermore, the interventions can also be classified according to their purpose such as [6]: identification, primary prevention methods, secondary prevention methods, and tertiary prevention or treatment. According to Schaufeli et al (7), there are few well-designed studies concerning the intervention of occupational stress. In addition, these studies have demonstrated that the interventions studied benefit only a reduced number of people and are carried out by an instructor in a given place. The use of Information and Communication Technologies (ICT) can help to improve the efficiency of the interventions since it is possible to carry them out at a larger scale, regardless of time, place, or group of people [10]. In the same way, the user can access information in a quick, easy, and confidential manner [11]. The aim of this article is to do a systematic review and a descriptive evaluation of the interventions supported by ICT for the prevention and treatment of occupational stress.

1. Materials and methods 1.1. Databases and search keywords A systematic review of five databases [EBSCO, The Cochrane Library, PubMed, ScienceDirect and IEEEXplorer) related to interventions for the prevention and treatment of occupational stress supported by ICT was carried out in order to obtain articles either in English or Spanish, published during the last ten years. An analysis of the articles references list found in the databases was also carried out. The research was carried out at the end of 2013 and the beginning of 2014. The keywords used to represent occupational stress were: burnout, work-related stress, occupational stress, job-related stress, workplace stress, and professional stress; the keywords used to identify interventions were: intervention, prevention, therapy, psychotherapy, management, rehabilitation, and education; and the keywords used to refer to ICT were: ICT, internet, web, mobile applications, informatics, and computer assisted. The search was limited to the abstracts, keywords, and titles of the articles. 1.2. Selection criteria The following inclusion criteria were established: articles published after 2003 either in English or Spanish published in scientific journals. Similarly, the methodology used for the intervention should be detailed in the study. Articles that didnt use ICT intensely in the interventions or that didnt focus on occupational stress were excluded. 1.3. Synthesis of data Each study was classified according to the therapy used and the effect of the intervention compared to a controlled state. In order to do that, a three-level stress scale was designed. The symbol + was used to represent a positive effect of the intervention on stress; the symbol - was used to represent a negative effect; and the symbol I was used to represent an indeterminate effect. The acronym DNA (Does Not Apply) was used for studies under development that did not give conclusive results or that did not assess the effect of the intervention.

2.

Results

57 studies were initially gathered as a result of the search of keywords in the databases. From these 57 studies 36 were excluded: 14 studies were not selected because they did not use ICT in the intervention, rather in other stages of the study. For example, they used Internet for the recruitment of participants and the development of surveys to identify occupational stress. Other 19 studies were not selected because they did not focus on occupational stress but on stress in general. The remaining 3 studies were excluded because they did not describe the methodology of the intervention. It was found that the Cognitive Behavioral Therapy (CBT) was applied in 10 out of 21 selected articles. The Problem Solving Therapy (PST) was applied in one study; other types of therapies (motivational interviews, professional identity training programs, support groups, relaxation techniques, self-help therapies, and acceptance and compromise therapies) were found in another 5 interventions. Finally, in another 5 studies a combination of previously mentioned therapies was applied. All of the articles were published between 2004 and 2013. The effects of the interventions on occupational stress are presented in Table 1. The majority of the studies included a control group (76.19%). The interventions were carried out in the United States of America (23.81%), Sweden (19.5%), the Netherlands (14.29%), Japan (14.29%), Germany (9.52%), Great Britain (4.76%), Finland (4.76%), China (4.76%), and other European countries (4.76%).
Table 1. Effect of the interventions on occupational stress a. Study Billings (2008) (12) Brattberg (2006) (13) Brattberg (2007) (14) Eisen (2008) (15) Farzanfar (2012) (16) Geraedts (2013) (17) Grime (2004) (18) Hasson (2005) (1) Hasson (2010) (19) Heber (2013) (5) Kawakami (2006) (20) Lappalainen (2013) (21) Leung (2010) (22) Proshaska (2008) (23) Ridge (2011) (24) Type of Therapy CBT PST Other + + + + DNA + + + DNA DNA I + + + + + + The effect of the intervention was not measured. It carried out a retrospective assessment of the factors influencing the decision of participating and continuing in the study. Study under development. Not statistically significant. + Not statistically significant. Not statistically significant. The effect of the intervention was not measured; it measured the experience of the user. Comments

Ruwaard + (2007) (25) Shimazu Not statistically significant. I I (2005) (26) Thiart (2013) DNA Study under development. (27) Van Straten + + (2008) (28) Weingardt + (2009) (29) Yamagishi Not statistically significant. + (2008) (30) a +, positive effect, -, negative effect, I, indeterminate effect, DNA, Does Not Apply.

2.1. General statistics of the effect and use of ICT From analyzing the effect of the interventions, it was noted that 12 of the studies had a positive effect on the occupational stress, 3 studies had a positive effect but they were not statistically significant, 2 studies had an indefinite effect, and 4 studies did not apply because they were either under development or did not measure the effect of the intervention. 17 of the studies found used interventions supported by web technologies, one used an Interactive Voice Response (IVR) [16], one used an interactive program [18], another used email [25], and one more used a combination of ICT (Web, mobile applications, and sensors) [21]. Among the interventions supported by Web technologies, 52.94% (9 studies) had a positive effect on the occupational stress; 17.65% (3 studies) had a positive effect but not was statistically significant; 11.76% (2 studies) had an indeterminate effect, and 17.65% (3 studies) did not apply. For the remaining interventions, the effect of the intervention was not measured in the study that used an IVR; rather, the experience of the user was measured. The intervention that made use of an interactive program had a statistically significant positive effect, similar to the interventions that made use of email and those that made use of the combination of ICT. The detailed analysis of the different interventions organized according to the type of therapy used is presented below. 8 of the studies found used interventions supported by Web technologies [1], [12], [13], [14], [15], [19], [27], [29], one used an interactive program [18], and the other used e-mail [25]. All the interventions were focused individually on participants; 3 were focused on primary prevention, 3 on secondary prevention, and 4 were focused on the treatment of occupational stress. The time period of the interventions ranged from 2 to 52 weeks (average d=17.8 weeks and SD=14.87); 7 programs finished before the fourth month. From analyzing the effect of the interventions, it was noted that 60% (6 studies) reported they found a positive effect on occupational stress, 20% (2 studies) described positive effects but they were not statistically significant (20%), and the remaining 20% (2 studies) did not apply. For example, from each type of ICT used in the interventions, Billings et al [12] carried out a Web intervention that included multimedia elements to treat stress, depression, anxiety and substance abuse. Notwithstanding, stress was decreased amongst 65% of the participants who only once had access to the materials related to stress. Grime et al [18] developed an interactive computerized program called Beating the Blues by means of which they were able to decrease participants stress

and depression levels. Ruwaard et al [25] carried out an intervention in which therapists established communication with the participants via email. Significant improvements were reached regarding stress and emotional exhaustion levels during the three years of monitoring. 2.2. Interventions based on other types of therapies The size of the study samples ranged from 60 to 6000 people amongst the 6 interventions that used other types of therapies. If the size of this population is considered, then an average sample of n=1120.17 with a SD=2391.74 is obtained. However, when repeating this analysis excluding the 6000 population, a more realistic size of the sample average is established, equal to n=144.20 with a SD=81.96. Only 2 studies provided information about the average age of the samples. The average age of these ranged from 31 to 45 years old. In 3 of the programs, the percentage of women fluctuated between 66% and 100%, in 2 studies it fluctuated between 35% and 37% and information was not reported in another program. 5 of the studies found used Web interventions [20], [22], [23] and one implemented an IVR [16]. In total, 5 studies carried out interventions that were focused individually on participants [5], [16], [22], [23], [30], while only one focused on the organization [20]. The focus of 2 interventions was on primary prevention, 2 on secondary prevention, and 2 on treatment. The average time period of the interventions was between 1 and 52 weeks (average d=18.67 weeks and SD=19.96), finding 3 studies that finished before the fourth month. From analyzing the effect of the interventions, it was noted that 33.33% of the interventions (2 of the studies) had a positive effect on occupational stress, 16.66% (one study) had a positive effect but it was not statistically significant, 16.66% (one study) had an indeterminate effect, and 33.33% ( two studies) did not apply. For example, from each type of ICT used in the interventions different from CBT, Leung et al [22] developed an intervention making use of a Web forum with online support groups. The participants informed that they received support from the forum finding it useful to manage stress. Farzanfar et al [16] confirmed that the participants of the study had a positive experience with the treatment since it allowed them to talk over the phone about their symptoms without any inhibition, fear or shame. 2.3. Interventions based on the combination of different therapies Five interventions based on the combination of therapies (CBT and others) were found. The size of the study sample ranged from 24 to 225 people (average n=143.2 and SD=96.12). Only 2 studies reported the age of the participants who were in a range of 45 to 47 years old. In 2 of the interviews the percentage of women was larger than 71.4%, in 2 studies the percentage was smaller than 14.2% and in one study this information was not reported. 4 of the 5 studies reported they had made use of Web interventions [17], [24], [26], [28], while Lappalainen et al [21] used a combination of Web, mobile applications, and sensors. All of the interventions were focused on participants individually. The purpose of one of the studies was the secondary prevention, other 4 studies focused on the treatment and no study focused on primary prevention. The time period of the interventions ranged from 4 to 52 weeks (average d=27 weeks and SD=19.63);

however, one of the studies did not report the time period of the intervention. Only one of the studies lasted less than 4 months. From analyzing the effect of the interventions, it was noted that 80% (4 studies) obtained positive effects on the occupational stress [17], [21], [24], [28], and 20% (one study) did not experience any improvement [26]. For example, Van Straten et al [28] designed a Web intervention based on PST and self-help therapies which resulted to be effective for reducing depression symptoms, occupational stress and for improving the quality of life. Lappalainen et al [21] designed an intervention based on CBT and acceptance and compromise therapies. This intervention showed positive effects in diverse psychological symptoms, health perception, and capacity of work selfperception.

3.

Discussion

Despite an abundance of literature concerning interventions on occupational stress, only few of them make use of ICT [8]. The systematic review confirmed that few interventions made use of ICT with the condition of being focused on occupational stress if compared to other systematic reviews in other areas, for example Norman et al [31]. It is possible to obtain a series of factors to consider for the design, development, and assessment of interventions supported by ICT for the prevention and treatment of occupational stress from the analysis of the systematic review: Design of the study. In general, the sample average of the interventions was 165 people with an average duration of 20 weeks. From the 17 studies that reported the gender of the population, the percentage of women was larger than 50% in 11 of the interventions. It can also be concluded that the majority of the interventions have been carried out in Europe (57.14%), United States of America (23.81%) and Asia (19.05%), countries probably more likely to find a stronger sensitivity to occupational stress. Type of Therapy. From the total of studies revised, the most frequent therapy found was CBT, with a total of 10 interventions from which 6 (60%) found positive statistically significant effects for the treatment of occupational stress [1], [12], [13], [18], [25], [29]. In contrast, only 5 interventions used a combination of therapies, but 4 of them (80%) experienced positive effects in stress levels [17], [21], [24], [28]. These statistics suggest that the combination of CBT with other types of therapies for the treatment of occupational stress could be more effective. Type of Intervention. All the interventions except for those carried out by Kawakami et al [20] were focused individually on participants, which in turn is consistent with what has been reported by Shaufeli [6]: the majority of interventions on burnout are carried out on an individual basis. Purpose of the intervention. 10 of the studies (47.62%) developed a treatment, 6 (28.57%) elaborated secondary prevention, and 5 (23.81%) developed primary prevention. This can be an effect of the studies tendency to establish a criterion to select the participants: whether they evidenced a degree of occupational stress according to the questionnaires that were used. Nevertheless, it is important to highlight the necessity of interventions for the prevention before the treatment of this syndrome since it is the cause of a significant number of negative effects and once the individual has acquired a high level of occupational stress it is difficult for them to recover.

Type of instrument used for the measurement of occupational stress. The Maslach Burnout Inventory (MBI) [32] is the occupational stress measurement instrument most widely used amongst the different interventions. The MBI was used in 6 of the studies [5], [17], [24], [28], [29]. Another instrument, the Hospital Anxiety and Depression Scale (HADS) [33], was used in 4 interventions [5], [17], [18], [28]. The Brayfield Job Satisfaction Questionnaire (BJSQ) was used in 3 studies [20], [26], [30]. The Center for Epidemiologic Studies Depression Scale (CES-D) [34] was used in 3 interventions [17], [27], [28]. In addition to these instruments, diverse complementary questionnaires were used to measure the quality of life, excess of workload, work tension, insomnia, and anxiety. Type of ICT. 17 out of 21 studies (80.95%) used the Web as the medium to carry out the interventions. Only Lappalainen et al [21] made use of mobile applications. At the moment, there is a large number of mobile applications oriented towards the management of occupational stress [25]. However, there are no formal studies that assess the efficacy of these applications. There also other projects that make use of other types of technologies for the measurement of stress; for example, Taelman et al [36] and Andersson et al [37] implemented sensor networks to measure stress but they were not evaluated on a real population. From the analysis of the different studies, it was observed that there are two main factors that affect the success of the interventions [19], [29], [38]: 1) Interactivity throughout the use of multimedia elements 2) Adaptability, which requires the content of the program to adapt to the needs of the users. In this sense, studies that design interventions adapted to the profile of the users are required. One limitation of this article was to do a systematic search by using only the abstracts, keywords, and titles of the articles, since irrelevant results were found. Thus, a search for full texts is recommended. Likewise, it is necessary to carry out a broader evaluation of the statistics on the effect of the interventions.

Acknowledgement The work is partially funded by University of Cauca (Project ID 4092) and QUIPU Program (grant D43TW008438). The authors are especially indebted to thank Alex Jadad at the Global eHealth Innovation Center in Toronto for encouraging the work.

4.

Conclusions

The growth and development of new information technologies have allowed individuals to design new interventions for the treatment of occupational stress throughout the last ten years. In this review it was discovered that the majority of the interventions are supported by the Web which facilitates users to reduce costs, time and effort, and to increase the accessibility and adaptability of the interventions [39]. Nonetheless, the use of ICT has not been entirely explored yet and consequently, individuals have not made good use of the capacities that these technologies offer. An example of this is that although in 2013 the sales of smart phones reached 990 million units [40], only one study used mobile applications to manage stress.

This article described the state of the art of recently published studies in the area of interventions on occupational stress based on ICT. This can now be considered a guide based on evidence for the design, development and evaluation of future interventions.

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