Background
Lazarus and Folkman have defined psychological stress as ". . . a particular relationship between person and the environment that is appraised by a person as taxing or exceeding his or her resources and endangering his or her well-being" (Lazarus 1984). According to another definition, work-related stress is an adverse reaction to excessive pressures or other demands at the workplace, which can lead to a combination of physiological (e.g. hypertension), psychological (e.g. depression), and behavioural reactions, including alcoholism, smoking, and absenteeism (Bergerman 2009). Most employees are familiar with stress at work, but when these physiological, psychological and behavioural stress reactions progress into a chronic state of tension, the result can be serious negative health consequences such as burnout and somatic illness (Backé 2012; Kawakami 2006). Work-related stress is a complex phenomenon because of the social, demographic and occupational causal factors involved. It exerts a real toll on economies worldwide to both organizations and society through absenteeism, turnover, diminished productivity and medical, legal and insurance costs. It is difficult to calculate the costs associated with work-related stress due to the complexity of the condition and numerous confounding factors. However, total costs are generally estimated to be around 1% to 3% of Gross Domestic Product (GDP) ( EU-OSHA 2014; Rosch 2001 ). A conservative estimate by the European Union estimated the direct costs associated with work-related stress atabout EUR 20 billion annually in the EU-15 ( Levi 2000 ). Considering broader societal and indirect costs, it has been estimated that job stress costs the United States economy USD 300 billion annually ( Rosch 2001).
Employees seldom have the power to reorganise or decrease their workload in order to control their work stress levels (Clot 2008). If the enterprise is also unable or unwilling to implement measures at the organisational level, the only recourse workers have is to act on an individual level. But the real or perceived time limitations that people experiencing work-related stress often have also make it difficult for them to physically attend a stress management programme. Thus, web-based stress management programmes have emerged as way to increase access for people affected by stress, and at a lower cost than traditional, face-to-face interventions. Web-based approaches to deliver or assist in psychological and behavioural health interventions have multiplied in the past several years (Proudfoot 2011), with several advantages over their office-based counterparts, including the ability to tailor services to individual needs, ensure confidentiality, increase access and convenience, and reduce cost (Andersson 2009; Andrews 2010; Carey 2009; Mohr 2010).
Description of the condition
The prevalence of work-related stress continues to increase, causing mental symptoms and diseases (depression, post-traumatic stress disorder, suicide attempts, etc.), musculoskeletal disorders and cardiovascular diseases (Kivimäki 2013; Van Rijn 2009). It can also increase direct and indirect costs to employers, including health care costs and lost productivity. The Health and Safety Executive reported that in 2011 and 2012, the prevalence of work-related stress, depression and anxiety in the United Kingdom was 1400 cases per 100,000 working people; 40% of all cases of work-related illnesses were attributed to stress (Bergerman 2009). The effects of work-related stress can be measured using proxy indicators such as sick leave (Moreau 2004), work disability (Ahola 2009) or return to work (RTW). A British survey reported that, on average, each person suffering from work-related stress was absent from work 24 days annually in 2011 and 2012, while an American survey cited anxiety and stress as the cause of 25 days' absence every year (Report on the American Workforce 2001). However, other signs that indicate a prevalence of work-related stress are more difficult to quantify, such as presenteeism, which means attending work while sick ( Cooper 2008).
Description of the intervention
An occupational stress management intervention is any activity or programme that seeks to reduce the presence of work-related stressors or reduce the negative impact of exposure to these stressors (Ivancevich 1990). Stress prevention programmes vary by their strategic focus: primary, secondary and tertiary strategies (Bergerman 2009), and whether they are individual or group programmes.
Stress management interventions may focus on the individual, the organisation or both (DeFrank 1987). Common techniques include relaxation or meditation, biofeedback, cognitive-behavioural therapy (CBT), exercise, time management and employee assistance programmes.
Finally, interventions differ by their delivery method. The increasing prevalence of the Internet worldwide has provided a cheap, widely accessible alternative to deliver health promotion services (Lintonen 2008). The advent of web-based interventions (Internet-delivered modules, computerised therapy, smartphone applications and even text messages) has also sparked research into their effectiveness on stress-related outcomes in both occupational and non-occupational groups (Hoke 2003; Shimazu 2005; Zetterqvist 2003). Some participants even prefer web-based programmes over traditional programmes (Cook 2007; Mangunkusumo 2007).
How the intervention might work
Worker-focused stress management techniques aim to provide employees with better skills to reduce the incidence of stress (primary stress prevention) and cope with the effect of stressors (secondary prevention). Primary prevention interventions aim to improve work skills, such as time management, problem solving and communication to prevent or minimise exposure to stressors, that is, situations, feelings and thoughts that lead to and maintain a stress response. Secondary prevention interventions can include teaching relaxation techniques to release tension, providing tools to identify or recognise stress symptoms, altering the way in which employees think and behave when confronted with stress (CBT) and using exercise as a means to release stress. In other words, these interventions aim to help workers handle the stress response better. By learning these strategies, employees may avoid stressors or reduce the effect of stress, both of which may result in less lost work time. Prolonged stress at work can result in burnout and a diagnosis meriting sick leave. In this event, tertiary stress prevention programmes (e.g. counselling) aim to treat symptoms of existing stress-related problems and enable return to work (Bergerman 2009).
Web-based stress management interventions make use of the same principles and models as face-to-face stress management interventions, employing such techniques as CBT, relaxation, time management or problem solving skills training, but they are delivered via e-mail, a website or a stand-alone computer programme (Griffiths 2006; Ruwaard 2007; Zetterqvist 2003). Web-based stress management interventions can vary according to the device providing access (e.g. computer, laptop or mobile device), the type(s) of media used (e.g. text, graphics, animations, audio and video) and the degree of therapist involvement (e.g. from entirely self-help or remote client-therapist interaction) (Proudfoot 2011).
With regard to measuring the effectiveness of stress management interventions, psychological indicators (e.g. levels of anxiety, depression, stress and burnout), physiological measures (e.g. blood pressure or weight) and organisational indicators (e.g. absenteeism or productivity) may all be useful (Richardson 2008).
Why it is important to do this review
Studies have reported web-based stress management as a promising intervention for reducing stress (Bessell 2002; Cavanagh 2004). One ongoing study aims to assess the efficacy and cost-effectiveness of web-based interventions for stress management in employees, but the study protocol does not list absenteeism as an outcome (Heber 2013). In a meta-analysis of organisational-level (non-web-based) interventions, three out of the seven studies identified reported a statistically significant reduction in absenteeism (Bergerman 2009). However, in an earlier systematic review of face-to-face stress management interventions, the meta-analysis of four studies that measured absenteeism did not show that the interventions had a significant effect (Van der Klink 2001). A recently updated Cochrane systematic review found evidence that CBT and relaxation interventions can reduce stress in healthcare workers (Ruotsalainen 2015).
However, little is known about the effects of stress prevention on reducing sick leave and increasing return to work or whether stress management interventions could prevent the recurrence of stress symptoms. It is important to do this review because we do not know if web-based stress management programmes are equal to, better than or worse than face-to-face stress management programmes.