Participatory work place intervention for stress prevention in primary health care. A randomized controlled trial

Figures & data

Figure 1. Flow chart for the study.

Figure 2. The logic model of the study.

Table 1. Steps in the intervention.

Main steps	Content	Example from this study
(1)Formation of one or more design teams.	Consisting of representatives for employees. Design teams inform and collect input from the rest of employees between the design groups meetings.	One design team for every profession (seven teams), and one overarching design team.
(2)Identification of objectives.	Identification of important and desirable results for the group and/or organization. General in nature.	Overarching objectives: right quality of care; good deliverability; continuous skills development; motivating and health promoting work environment.
(3)Development of indicators.	Operationalization of results. Objective, quantifiable measures of output.	Example of deliverability indicators for the subgroup of medical secretaries: Total number of completed dictations per day and month. Current “waiting time” per dictation. Number of visits at the reception per day, etc.
(4)Approval from management.	Management agrees with objectives and the operationalization.	The management followed and continuously approved the work of the group.
(5)Development of contingencies.	Operationalization of relation between results and evaluation. Graphic utility function.	80% of phone calls answered represents only minimum level of acceptable performance, neither good nor bad. See also Appendix 1 for an example.
(6)Approval by management.	Management agrees with contingencies.
(7)Development of feedback reports.	Collection of data on indicators, printed feedback reports distributed to employees.	See Figure 4 for an example.
(8)Conducting of feedback meetings.	Core components: information on results, evaluations of results for the determined time-period and, if needed, improvement/development of new strategies.	Some subgroups conducted some feedback meetings. See information about intervention fidelity.
(9)Monitoring over time.

Table 2. Descriptive data, intervention and control group, at baseline measurement (M1), 6-month (M2) and 12-month (M3) follow-up.

	(M1)		(M2)		(M3)
	Interv.	Control	Interv.	Control	Interv.	Control
Variable	n = 49	n = 40	n = 50	n = 47	n = 55	n = 50
Sex, n (%)
Female	42 (86)	33 (83)	41 (82)	40 (85)	46 (84)	44 (88)
Male	7 (14)	7 (17)	9 (18)	7 (15)	9 (16)	6 (12)
Age, years, mean (SD)	44.4 (12.2)	48.2 (10.6)	45.9 (12.7)	45.8 (10.9)	45.1 (11.8)	45.6 (11.2)
Working hours^a, mean (SD)	37.3 (5.8)	37.8 (4.6)	36.9 (6.2)	36.1 (6.7)	37.1 (5.2)	37.5 (8.1)
Overtime work, mean, (SD)	5.3 (6.5)	5.5 (7.3)	6.6 (11.5)	4.7 (6.3)	4.7 (5.8)	4.9 (5.7)
Overall health^b, mean (SD)	1.94 (0.8)	1.97 (0.8)	2.04 (0.8)	2.00 (0.7)	2.07 (0.9)	2.04 (0.7)
Formal ed. level, n (%)
Comprehensive school	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Secondary school	9 (18)	6 (15)	6 (12)	9 (19)	6 (11)	8 (16)
University education	39 (80)	32 (80)	43 (86)	37 (79)	45 (82)	40 (80)
Higher academic ed.	1 (2)	2 (5)	1 (2)	1 (2)	4 (7)	2 (4)
Type of household, n (%)
One person household	8 (16)	8 (20)	11 (22)	3 (6.5)	10 (18)	5 (10)
Single parent	0 (0)	2 (5)	0 (0)	3 (6.5)	2 (4)	3 (6)
Couple without children	15 (31)	15 (37.5)	14 (28)	19 (40)	14 (25)	19 (38)
Couple with children	26 (53)	15 (37.5)	25 (50)	22 (47)	29 (53)	23 (46)
Years at this organization, n (%)
Less than 10 years	10 (20.5)	1 (2.5)	14 (28)	4 (8)	9 (16)	4 (8)
1–2 years	12 (24.5)	10 (25)	8 (16)	7 (15)	14 (26)	6 (12)
3–5 years	10 (20.5)	13 (32.5)	10 (20)	14 (30)	15 (27)	17 (34)
6–10 years	8 (16)	6 (15)	8 (16)	10 (21)	9 (16)	11 (22)
More than 10 years	9 (18.5)	10 (25)	10 (20)	12 (26)	8 (15)	12 (24)
Profession, n (%)
Nurse	13 (27)	12 (30)	16 (32)	15 (32)	18 (33)	15 (30)
Physiotherapist	7 (14.5)	5 (12.5)	7 (14)	9 (19)	7 (13)	9 (18)
Physician	10 (20.5)	3 (7.5)	10 (20)	1 (2)	12 (22)	3 (6)
Medical secretary	6 (12)	5 (12.5)	4 (8)	6 (13)	4 (7)	7 (14)
Midwife	4 (8)	4 (10)	3 (6)	4 (8.5)	3 (5)	4 (8)
Laboratory technician	3 (6)	2 (5)	3 (6)	3 (6.5)	4 (7)	3 (6)
Assistant nurse	3 (6)	3 (7.5)	3 (6)	3 (6.5)	3 (5)	3 (6)
Counselor	2 (4)	3 (7.5)	2 (4)	3 (6.5)	2 (4)	3 (6)
Manager/Assist. Man.	1 (2)	2 (5)	2 (4)	2 (4)	2 (4)	2 (4)
Dietitian	0 (0)	1 (2.5)	0 (0)	1 (2)	0 (0)	1 (2)
How many years at current position, n (%)
Less than 1 year	5 (10)	2 (5)	5 (10)	3 (6)	5 (9)	4 (8)
1–2 years	8 (16)	4 (10)	6 (12)	5 (11)	7 (13)	5 (10)
3–5 years	11 (22.5)	10 (25)	11 (22)	7 (15)	14 (25.5)	11 (22)
6–10 years	11 (22.5)	7 (17.5)	8 (16)	9 (19)	8 (14.5)	5 (10)
More than 10 years	14 (29)	17 (42.5)	20 (40)	23 (49)	21 (38)	25 (50)

^aPer week.

^bSingle question from General Health Questionnaire (GHQ) (1). (Scores 1–5).

Table 3. Group-level monthly ratio between the total number of tasks (Tasks) and the total number of hours worked (Time); Time and total number of visits (including home visits, group visits, etc.); Time and total number of administrative tasks (Admin); Time and total number of telephone calls taken (Phone); and total number of patients on unit list (List) and Time. The results are given for the intervention group (I) and the control group (C).

Month^a	Tasks/Time		Time/Visits		Time/Admin		Time/Phone		List/Time
Year/Month	I	C	I	C	I	C	I	C	I	C
1305	1.57	1.23	1.43	1.38	2.08	2.67	1.86	3.13	2.54	1.98
1306	1.47	1.34	1.60	1.32	2.04	2.31	2.18	3.06	2.99	2.57
1307	1.74	1.44	1.41	1.15	1.76	2.19	1.64	2.85	3.65	2.84
1308	1.58	1.25	1.50	1.35	2.07	2.66	1.78	3.32	2.90	2.29
1309	1.39	1.24	1.67	1.38	2.39	2.69	2.04	3.26	2.38	2.00
1310	1.50	1.29	1.57	1.38	2.39	2.82	2.01	3.63	2.01	1.73
1311	1.41	1.21	1.63	1.42	2.28	2.85	2.14	3.47	2.27	1.92
1312	1.46	1.21	1.66	1.49	2.10	2.61	1.98	3.44	2.66	2.33
1401	1.48	1.27	1.69	1.42	2.15	2.40	1.87	3.11	2.13	1.90
1402	1.48	1.23	1.65	1.43	2.22	2.70	1.87	3.08	2.31	2.04
1403	1.49	1.31	1.69	1.37	2.25	2.40	1.78	2.97	2.17	1.89
1404	1.50	1.29	1.69	1.32	2.15	2.61	1.79	3.13	2.21	2.08
1405	1.53	1.25	1.69	1.40	2.10	2.64	1.76	3.11	2.31	2.01
1406	1.60	1.25	1.63	1.43	1.90	2.56	1.69	3.29	2.61	2.27
1407	1.64	1.37	1.58	1.24	1.90	2.30	1.61	3.01	3.14	2.77
1408	1.47	1.23	1.77	1.42	2.27	2.68	1.77	3.23	2.50	2.24
1409	1.44	1.17	1.69	1.48	2.26	2.79	1.92	3.60	2.14	1.75

^aM0 was in May 2013, M1 September 2013, M2 March 2014, and M3 September 2014.

Table 4. The difference in the quantitative workload between the intervention group (I) and the control group (C). T-test for dependent observations.

	Mean I	Mean C	M Diff	p	95% CI	Effect size
Tasks/Time	1.515	1.268	.246	000	.130; .363	1.472
Time/Visits	1.620	1.377	.244	088	−038; .526	.604
Time/Admin	2.135	2.576	−.441	001	−.692; -.190	−1.228
Time/Phone	1.863	3.217	−1.353	000	−1,726; -.981	−.2.541
List/Time	2.525	2.154	.371	.569	−1.684; .942	.198

Table 5. Descriptive data for the outcome variables and the variables used in the analysis as covariates, at baseline measurement (M1) and at the 6-month (M2) and 12-month (M3) follow-ups.

	M1^a		M2^a		M3^a
	Intervention n = 49 (50)	Control n = 40 (47)	Intervention n = 50 (51)	Control n = 47 (50)	Intervention n = 55 (59)	Control n = 50 (53)
Outcome	M (Std.)	M (Std.)	M (Std.)	M (Std.)	M (Std.)	M (Std.)
Job strain^b (0/1, 1 = job strain)	73.5%	55.0%	50.0%	51.1%	63.6%	60.0%
Job demand, (1–5)	3.7 (0.5)	3.5 (0.7)	3.6 (0.6)	3.4 (0.6)	3.7 (0.6)	3.4 (0.6)
Job control, (1–5)	2.7 (0.6)	2.8 (0.7)	2.9 (0.7)	2.8 (0.7)	2.8 (0.7)	2.8 (0.7)
Effort–reward ratio (>1 = imbalance)	0.8 (0.2)	0.9 (0.3)	0.8 (0.2)	0.8 (0.2)	0.8 (0.2)	0.9 (0.2)
Effort (6–24)	15.6 (3.2)	14.9 (3.3)	15.2 (2.6)	14.5 (2.9)	15.5 (3.0)	15.1 (3.0)
Reward (11–44)	34.9 (4.3)	33.1 (5.1)	36.5 (4.0)	33.4 (4.5)	35.6 (4.1)	32.7 (4.2)
Overcommitment (6–24)	13.1 (4.3)	12.8 (4.0)	13.2 (4.4)	12.1 (4.0)	13.1 (4.4)	12.3 (4.0)
Sleep diff^c (1–5)	2.3 (0.9)	2.3 (1.0)	2.3 (1.0)	2.2 (0.8)	2.2 (1.0)	2.2 (1.0)
Recovery (1–5)	3.5 (1.0)	3.7 (1.0)	3.8 (1.0)	3.7 (0.8)	3.7 (1.0)	3.7 (0.9)
Depression (0–21)	3.0 (2.9)	2.7 (2.6)	3.4 (3.5)	2.6 (2.0)	3.4 (3.6)	2.7 (2.5)
Exhaustion (8–32)	18.6 (4.4)	17.8 (4.6)	18.8 (4.9)	18.0 (3.8)	18.7 (4.8)	18.2 (4.6)

^an = xx means n answered AHA questionnaire; within brackets n that answered ERI questionnaire.

^bFor Job strain % of population under strain is displayed, instead of M and Std.

^c Sleep difficulties due to thinking about work.

Table 6. Interaction analysis for the intervention group, effort as outcome.

	M1 effort^c=7	M1 effort = 10	M1 effort = 15	M1 effort = 19	M1 effort = 22
Diff. Effort M3^a – M2^b	−2.04	−1.29	−0.06	0.93	1.67
95% CI	−4.06; −0.01	-−2.73; 0.14	−0.73; 0.61	0.06; 1.80	.29; 3.06
p	.049	.078	.866	.035	.017

^a12 month follow up.

^b6 month follow up.

^cEffort range: 6–24.

Table 7. Interaction analysis, reward as outcome. Difference in reward between the control and the intervention groups for different values of baseline (M1) exhaustion as measured by Oldenburg Burnout Inventory (Olbi^a).

	M1 Olbi = 9	M1 Olbi = 17	M1 Olbi = 18	M1 Olbi = 22	M1 Olbi = 29
Diff. Reward Contr-Interven	−5.97	−1.35	−0.77	1.55	5.60
95% CI	−8.05; −3.90	-−2.42; −0.27	−1.88; 0.35	3.17; 1.86	2.57; 8.63
P	.001	.014	.178	.062	.001

^aOlbi range: 8–32; (0–17.59 non-exhaustion; 17.60–21.99 mild exhaustion; 22–32 severe exhaustion).

Table

	Unadjusted			Adjusted
Variableª	b	95% CI	p	b	95% CI	p
	Job strain			Job strain
Group^b	.001	−.290; .292	.996	−.054	−.315; .206	.682
Job strain at baseline^c				1.144	.547; 1.741	.001
Exhaustion at baseline				.026	−.005; .057	.104
M4-M3				.139	−.053; .331	.156
	Job Demand			Job Demand
Group^b	.209	.001; .417	.049	.083	−.061; .227	.260
Job Demand at baseline				.729	.586; .871	.001
Exhaustion at baseline				.015	−.005; .035	.143
M4-M3				.089	−.003; .182	.059
	Job Control			Job Control
Group^b	.024	−.224; .271	.850	.046	−.118; .210	.582
Job Control at baseline				.895	.760; 1.031	.001
Exhaustion at baseline				−.006	−.026; .015	.598
M4-M3				−.007	−.116; .102	.900
	ERI			ERI
Group^b	−.037	−.103; .029	.269	.003	−.052; .059	.903
ERI at baseline				.411	.278; .544	.001
Exhaustion at baseline				.008	−.001; .017	.087
Overcommitttment				−.002	−.012; .008	.658
M4-M3				.032	−.005; .070	.093
	Effort			Effort
Group^b	.578	−.389; 1.525	.242	.231	−.660; 1.122	.612
Effort at baseline				.609	.450; .767	.001
Exhaustion at baseline				−.005	−.139; .128	.940
Overcommitttment				.017	−.143; .176	.839
M4-M3				.434	−.099; .966	.110
	Reward			Reward
Group^b	2.943	1.599; 4.286	.001	1.215	−.055; 2.485	.061
Reward at baseline				.521	.399; .644	.001
Exhaustion at baseline				−.328	−.548; -.108	.004
Overcommitttment				.222	.000; .445	.050
M4-M3				−.591	−1.402; .219	.153

ªRR for binary outcome variables are displayed in text.

^bParameter for the Intervention Group is displayed.

^cParameter for the subgroup with Job Strain is displayed.

Table

	Unadjusted			Adjusted
Variableª	b	95% CI	p	b	95% CI	p
	Sleep			Sleep
Group^a	.122	−.319; .564	.588	.097	−.303; .497	.634
Sleep diff. at baseline				.678	.425; .932	.001
Exhaustion at baseline				.020	−.046; .085	.559
M4-M3				−.064	−.356; .227	.666
	Recovery			Recovery
Group^a	−.228	−.703; .248	.348	.036	−.353; .425	.857
Recovery at baseline				−1.147	−2.393; −.540	.002
Exhaustion at baseline				.075	.019; .130	.008
M4-M3				.056	−.285; .396	.748
	Exhaustion			Exhaustion
Group^a	.575	−.992; 2.142	.472	.431	−.755; 1.616	.477
Exhaustion at baseline				.840	.704; .976	.001
M4-M3				.522	−.235; 1.279	.177

^aParameter for the Intervention Group is displayed.