Reducing occupational psychological distress: a randomized controlled trial of a mailed intervention

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1 HEALTH EDUCATION RESEARCH Vol.21 no Theory & Practice Pages Advance Access publication 25 January 2006 Reducing occupational psychological distress: a randomized controlled trial of a mailed intervention Abstract There are increasing levels of psychological distress among general practitioners (GPs). The purpose of this study is to evaluate the effectiveness of a mailed intervention to reduce distress among at-risk GPs. A questionnaire was sent to 1356 GPs from eight Divisions of General Practice. Out of 819 (60%) who responded, 233 GPs were recruited with scores indicative of psychological distress. These GPs were randomized to intervention (n 5 120) or control (n 5 113). The intervention consisted of a simple letter feeding back and interpreting the psychological score together with a self-help sheet. During the study, an educational program was offered to GPs by Divisions of General Practice. The main outcome measure used was changes in psychological distress (General Health Questionnaire 12) score after 3 months. Significance was set at P < Initial analysis of the data showed borderline significance (P ). However, analysis of the data post hoc excluding GPs who participated in the educational program showed a significant reduction in psychological distress (P ). It appears that there may have been a dilution of the intervention effect. Mailed interventions are a cost-effective way of reaching at-risk GPs 1 PO Box 313, Cotton Tree, Queensland 4558, Australia and 2 Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, 4229 Australia *Correspondence to: J. Holt. ripplemakers@bigpond.com Jackie Holt 1 * and Chris Del Mar 2 and may contribute to a reduction in psychological morbidity. Introduction There is considerable concern regarding the increasing rate of occupational stress and its impact on health. Australian studies have identified that stress is prevalent in a range of occupations and that its cost, in terms of workers compensation and human suffering, is rising rapidly [1 3]. In response to this, a range of individual and organizational stress interventions have been developed. Traditionally, the focus was on the development of individualcentered strategies such as educational programs. However, there has been increased attention on the need for broader organizational approaches which offer more sustainable solutions to stress reduction [4 6]. While environmental approaches may be effective in addressing the underlying causes of maladaptive occupational stress and strain, individual strategies are still important to support people who are experiencing immediate psychological distress. The medical profession is not exempt from occupational or personal stress. Prevalence rates of stress and psychological distress among general practitioners (GPs) have been raised as a concern [7 12]. A systematic review of occupational stress management interventions found that the most effective individual-centered interventions for the reduction of stress and psychological distress are based on cognitive behavioral strategies [4]. These can be delivered in a number of ways: individual counseling, group-based education and support and Ó The Author Published by Oxford University Press. All rights reserved. For permissions, please journals.permissions@oxfordjournals.org doi: /her/cyh076

2 J. Holt and C. Del Mar peer programs. However, rigorous evaluation of these strategies for doctors is limited, none specifically for GPs [5]. We were concerned that many of these groupbased education programs discussed in the studies were voluntary and might preferentially attract GPs least in need (an example of the inverse care law) [13]. Group-based programs are limited to the number of people they can reach and may also be expensive to conduct. Divisions of General Practice often rely on external funding, particularly from pharmaceutical companies, to conduct group-based training. There has been recent discussion in the medical media about the need for guidelines to ensure that pharmaceutical-sponsored education is ethical and unbiased [14]. One low-cost method to reach at-risk populations is via mailed tailored interventions. Mailed interventions are more likely to be successful if they incorporate the findings from the Transtheorectical Model of Change. The Transtheorectical Model outlines five key stages of individual change: precontemplation, contemplation, preparation, action and maintenance [15]. For those who are not ready to take action (such as attend an educational program or seek counseling), there are specific strategies that can be tailored to the first three stages. These include conscious raising, emotional arousal and self-evaluation [16]. Tailoring information that includes these elements enhances the likelihood of the mailed information to be successful if the individual is able to incorporate personal objectives and the knowledge and skills are immediately relevant and can be transferred to his/her everyday life. Mailed interventions based on cognitive behavioral strategies have been evaluated with a range of personal health and lifestyle issues, including nutrition, smoking, exercise and cancer [17 20]. We could find few studies that evaluated the effectiveness of mailed interventions on psychological health [20 23]. The results of these studies were inconsistent, with one finding no improvement [22], while the other two reported decreased stress levels [21, 23]. It was noted in the studies where a reduction was noted that mailed intervention was an effective method to reach groups identified as at risk of high levels of distress. Across all the studies, mailed interventions were more likely to be effective if they included personalized information that included feedback on individual assessments, such as results of questionnaires [17 20, 23], accompanied by selfhelp material [19, 21], were based on cognitive behavioral strategies [21, 24, 25] and included selfreflective writing activities [26]. We therefore decided to design an evaluation of a mailed tailored intervention targeted at GPs who had psychological distress. We believed that this low-cost alternative may provide an effective strategy to reduce psychological distress among those GPs who would not usually seek group-based education. Methods Study population We extended an invitation to participate in the study to all Divisions of General Practice in one Australian state. Divisions of General Practice are local organizations, funded by the Australian Government to improve health outcomes for patients by encouraging GPs to work together and link with other health professionals. There are 120 Divisions of General Practice covering all of Australia. Eight Divisions of General Practice volunteered for the program. An extra division was recruited from another state following the withdrawal of one that previously volunteered. They provided a list of a total of 1458 GPs. After 102 were deleted because of moves, retirement, holidays or maternity leave, 1356 GPs were left. There were then ; Australian GPs [27] so our denominator represented ;7% of the total Australian GP population. Recruitment We sent a baseline questionnaire containing nine demographic questions, a psychological distress detection questionnaire and a space for general qualitative comments, together with a consent form and an explanatory sheet about the research, to 502

3 Reducing occupational psychological distress eligible GPs in May One reminder letter was sent in June 1999: 819 responded (60%). GPs whose score was indicative of psychological distress were recruited into the trial. Instrument used to detect psychological distress The General Health Questionnaire 12 (GHQ-12) is a well-validated instrument for detecting psychological distress. It can also be used as a repeated measure to detect changes in psychological distress levels within the same population [28, 29]. A threshold score of 3 for screening enables a balance of both sensitivity and specificity (the GHQ-12 variance-weighted mean sensitivity and specificity are 89% and 80%, respectively) [27, 28]. Scores below the threshold are not indicative of psychological distress. However, scores above the threshold are classified as indicating psychological morbidity. Scores can be broken into two subcategories: a score between the chosen threshold score and a score of 7 indicating mild to moderate levels of psychiatric disturbance and a score of 8 and over suggesting clinical psychiatric symptoms [31]. Based on this, the scores were classified as 0 2 = none to mild, 3 7 = mild to moderate and 8 12 = moderate to severe psychological distress. The time interval between baseline and post-intervention questionnaire was 6 months. The intervention was sent 3 months after the baseline questionnaire. Randomization procedure Two hundred and thirty-three GPs were eligible for the trial with 120 allocated to the intervention group and 113 to the control group. Mean comparison of the baseline GHQ-12 scores of both groups showed no significant difference prior to the intervention (P = 0.09). Mailed intervention We designed a letter tailored to feedback the GP s own score from the GHQ-12 with a brief interpretation of the score and a self-help sheet entitled Self, Relationships and Work. The letter indicated whether his/her score fell into one of three categories: none to mild, mild to moderate and moderate to severe. The self-care sheet was customized to address concerns identified by GPs through the baseline questionnaire. The major issues raised were the commonality of feelings of distress among GPs, work overload and time management and the balance between work and family. The self-care sheet was presented in a newsletter style which included some consciousness raising comments about doctors health and emotional arousal through self-evaluation and self-reflective writing activities. During the study period, Divisions of General Practice also offered an educational program designed to address psychological well-being among GPs entitled You and Your Practice. Potential confounding effect of the educational program During the trial, a GP health program entitled You and Your Practice was offered by each Division of General Practice to their GPs. Fourteen GPs from the intervention group and 12 from the control group enrolled in this voluntary educational program. As the materials in the educational program and the mailed intervention were similar, it was decided not to send the GPs from the intervention group to the mailed intervention. That is, we did not want some participants to have completed two interventions, while others in the group only experienced one. It was felt that this may dilute any possible intervention effect of the mailed intervention. However, all data were analyzed by intentionto-treat. This means that even though the participants did not receive the mailed intervention, their data were analyzed as they were initially intended (as part of the randomization process) to be part of the trial. Analysis of the data was conducted for the whole group and then again excluding the data from the GPs who enrolled in the education program. GPs in the study were sent the post-intervention questionnaires in December 1999, with a reminder 1 month later if they had not responded. The participant flow for the study is outlined in Fig. 1. Analysis Demographic characteristics were analyzed using chisquare tests (significance set at P < 0.05). GHQ

4 J. Holt and C. Del Mar Assessed for eligibility (n = 1458) Fig. 1. Participant flow. Baseline questionnaire (including GHQ-12) sent to all 1356 eligible GPs in the recruited Divisions in May/June 1999 Allocated to intervention (n = 120) Sent in September 1999 Received allocated intervention (n = 106) Did not receive allocated intervention (n = 14) Reason as these GPs had also enrolled in a voluntary educational program being conducted at the same time. Materials used were the same RCT participants who did not respond (n = 42) Analysed (n = 78) 819 GP responded 233 GPs GHQ-12 score of 3 and over, randomized Excluded (n = 102). Not available during research period due to retirement, holidays or had moved Allocated to control (n = 113) Post-intervention questionnaire (including GHQ-12) sent to all 819 who responded to baseline questionnaire in December 1999 Total respondents (n = 606) Respondents to RCT component (n = 161) RCT participants who did not respond (n = 30) Analysed (n = 83) scores were analyzed using mean comparisons and t-tests. A University of Queensland Ethics Committee provided clearance. Data could be analyzed for 161 GPs (69%) who returned the post-intervention questionnaire. Results Following the intervention, the mean GHQ-12 score dropped from 6.12 in the control group to 3.87, a difference of For the intervention 504

5 Reducing occupational psychological distress Table I. Changes in mean GHQ-12 scores of psychological distress from baseline to post-intervention Mean GHQ-12 score Control Intervention Difference of means (95% CI) P-value... analyzed by intention-to-treat (n = 83) (n = 78) Baseline (ÿ0.61, 0.78) Post-intervention (0.04, 2.17) Change (ÿ0.07, 2.27) analyzed after excluding data from 26 GPs a (n = 72) (n = 66) Baseline (ÿ0.78, 1.06) Post-intervention (ÿ2.48, ÿ0.12) Change (0.18, 2.70) 0.03 a GPs who volunteered for the education program and were therefore ineligible to receive the intervention. group, it fell from 6.17 to 2.78, a difference of The difference of the means showed borderline significance (P = 0.05) (Table I). We repeated the analysis after excluding the results of 26 GPs who enrolled in the education program. The analysis showed that following the intervention, the mean GHQ-12 score dropped from 6.06 in the control group to 4.06, a difference of For the intervention group, it fell from 6.20 to 2.76, a difference of The difference of means showed a significant reduction in psychological distress (P = 0.03) (Table I). As can be seen, both groups experienced the phenomenon referred to as statistical regression to the mean. Selecting participants based on a high score means that it can be expected that the average score will be lower regardless of any intervention. This results in an overall regression to a mean score for both groups. This occurred in the research project, where both control and intervention groups demonstrated a decrease in mean GHQ-12 scores. However, analysis of the mean difference of the amount of change showed that despite the regression effect, the intervention demonstrated a statistically significant effect. Data from the demographic details and educational program have been reported elsewhere [32]. The results showed that 62% of GPs who enrolled in the education program scored 2 or less on the GHQ- 12, indicating none to little psychological distress. The mean GHQ-12 prior to the program was 2.96 with a post-mean GHQ-12 of This represented a small improvement in psychological distress. This result confirmed our suspicion that educational programs often preach to the converted. A longer term follow-up study would add strength to this research. This could take the form of a stepwise more progressively focused approach which could include mailing GPs their post-intervention results and then asking whether they would like to access more resources either online or via mail or via more traditional approaches such as individual- or group-based programs. A series of time-spaced surveys would enable the assessment of any incremental improvements, as well as provide a medium for ongoing dialogue about current stressors. Discussion Mailed interventions represent one of the least expensive, but potentially valuable, interventions to reduce stress. It is well suited to GPs and other occupational groups with very high workloads, who typically would not participate in more structured, time-consuming stress management programs. The results also confirm the concern that educational programs tend to attract GPs who, in the main, are not suffering from psychological distress. As educational programs can be expensive to set up and maintain, the cost-effectiveness in terms of total reduction in psychological distress is questionable. In cost-benefit terms, tailored mailed 505

6 J. Holt and C. Del Mar interventions might be an effective first step in assisting distressed workers to address workplace stress. The results of this study suggest that a tailored mailed intervention, consisting of a letter and selfcare sheet, was effective in reducing psychological morbidity among GPs. Although the a priori analysis only found a trend in benefit, the post hoc analysis showed a significant reduction in psychological morbidity. This suggests that the education program may have contributed to a dilution of the intervention effect. However, the exclusion of GPs who did not receive the intervention, even though we excluded the corresponding controls, could be considered improper. This may have introduced a bias. However, this type of intervention, as a method to reduce psychological distress, warrants further investigation. The results of this study add to the growing evidence for the effectiveness of targeted mailed interventions designed to reach at risk groups. References 1. Morehead A, Steele M, Alexander M et al. Changes at Work. The 1995 Australian Workplace Industrial Relations Survey. Canberra: Department of Workplace Relations and Small Business, Foley G, Gale J, Gavenlock L. The cost of work-related injury and disease. J Occup Health 1995; 11: Australian Occupational Health and Safety Unit. A Report on the 1997 ACTU National Survey on Stress at Work. Melbourne: ACTU, Murphy L. Stress management in work settings: a critical review of the health effects. Am J Health Promot 1996; 11: Sims J. The evaluation of stress management strategies in general practice: an evidence-lead approach. Br J Gen Pract 1997; 47: Hart P, Cooper C. Occupational stress: toward a more integrated framework. In: N Anderson, DS Ones, HK Sinangil and C Viswesvaran (eds). Handbook of Industrial Work and Organizational Psychology. London: Sage Publications, 2001, Appleton K, House A, Dowell A. A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds. Br J Gen Pract 1998; 48: Cooper CL, Rout U, Faragher B. Mental health, job satisfaction, and job stress among general practitioners. Br Med J 1989; 298: Firth-Cozens J. Individual and organizational predictors of depression in general practitioners. Br J Gen Pract 1998; 48: Sutherland V, Cooper C. Identifying distress among general practitioners: predictors of psychological ill-health and job dissatisfaction. Soc Sci Med 1993; 5: Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: Clode D. The Conspiracy of Silence: Emotional Health Among Medical Practitioner. Melbourne: Royal Australian College of General Practitioners, Hart TJ. The inverse care law. Lancet 1971; 1: Komesaroff P, Kerridge I. Ethical issues concerning the relationships between medical practitioners and the pharmaceutical industry. Med J Aust 2002; 176: Prochaska J, DiClemente C. The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood, IL: Dow Jones-Irwin, Prochaska J, Norcross J, DiClemente C. Changing for Good. A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York, NY: Quill, Harper Collins, Kreuter M, Strecher V. Do tailored behaviour change messages enhance the effectiveness of health risk appraisal? Results from a randomised trial. Health Educ Res 1996; 11: Kreuter M, Bull F, Clark E, Oswald D. Understanding how people process health information: a comparison of tailored and non-tailored weight-loss materials. Health Psychol 1999; 18: Dijkstra A, De Vries H, Roijackers J et al. Tailoring information to enhance quitting in smokers with low motivation to quit. Health Psychol 1998; 17: Campbell M, Devellis B, Strecher V, Ammerman A, DeVellis R, Sandler R. Improving dietary behaviour: the effectiveness of tailored messages in primary care settings. Am J Public Health 1994; 84: Pelletier K, Rodenburg A, Chikamoto Y et al. Managing job strain: a randomized controlled trial of an intervention conducted by mail and telephone. Am J Health Promot 1998; 12: Kawakami N, Haratani T, Iwata N et al. Effects of mailed advice on stress reduction among employees in Japan: a randomized controlled trial. Ind Health 1999; 37: Stewart D, Lickrish G, Sierra S et al. The effect of educational brochures on knowledge and emotional distress in women with abnormal Papanicolaou smears. Obstet Gynecol 1993; 81: Miller R, Berman JS. The efficacy of cognitive behaviour therapies: a quantitative review of the research evidence. Psychol Bull 1983; 94: Vallis TM. Theoretical and conceptual bases of cognitive therapy. In: Vallis TM, Howes JL, Miller PC (eds). The Challenge of Cognitive Therapy: Applications to Nontraditional Populations. New York: Plenum Press, 1991, Esterling BA, L Abate L, Murray EJ, Pennebaker JW. Empirical foundations for writing in prevention and psychotherapy: mental and physical health outcomes. Clin Psychol Rev 1999; 19:

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