Proactive Resilience Programmes for Improving Resilience and Psychological Adaptation in Employees in High-Risk Occupations: A Systematic Review.

Abstract

Background: Promoting positive mental health is important due to its beneficial influence on not only educational attainment, productivity, employment and earnings, but also social cohesion, engagement, and quality of life. Individuals employed in occupations associated with high stress levels and extreme conditions (such as the police, fire and rescue services, health and social services, and the military) commonly report stress-related mental health conditions arising from their exposure to multiple traumas. Thus, especially for individuals employed in occupations associated with high stress and extreme conditions is resilience important for the ability to continued functioning. Proactive resilience interventions might work by strengthening behaviors, thoughts, and actions and thereby improve psychosocial well-being in case of experiencing traumatic work-related events.

Objectives: What are the effects of proactive resilience programmes offered to employees in high-risk occupations on resilience and psychological adaptation?

Search methods: The database searches were carried out in November 2024, and other sources were also searched in November 2024. We searched to identify both published and unpublished literature. A date restriction from 1990 and onwards was applied.

Selection criteria: The intervention was proactive resilience programmes offered to employees in high-risk occupations. The outcomes of primary interest were resilience and psychological adaptation (stress, anxiety, depression and PTSD symptoms). Studies that used a control group were eligible, whereas qualitative approaches were not.

Data collection and analysis: The number of potentially relevant studies was 18,803. Two hundred and forty-two studies, reported on a total of 220 trials containing 227 comparisons met the inclusion criteria. One hundred and eighty-five comparisons were used in the data synthesis. Eight comparisons had a critical risk of bias and were not used in the data synthesis. Twenty-three comparisons were from studies that did not report data in a form that enabled the calculation of effect sizes and standard errors, and our attempts to request the data from study authors produced no answers, and finally, 11 comparisons were not used as there were no relevant outcomes reported. Meta-analyses were conducted on each outcome and each time point separately. All analyses were inverse variance weighted using random effects statistical models. The effect size used was standardised mean difference (SMD).

Main results: Comparisons used in the data synthesis came from 33 different countries. The timespan of studies was 17 years, from 2006 to 2023. The average number of treated participants analysed was 126, ranging from 7 to 6, 739 per comparison. The majority of comparisons analysed participants from health occupations (71%), followed by military (14%) and police (9%). Only 3% analysed firefighters and first responders and the final 3% did not fall into any of the above categories. The majority of studies were randomised controlled trials. The weighted average SMDs for resilience, stress, anxiety, depression and PTSD symptoms in the short term were 0.43 [95% CI 0.32 to 0.55], 0.42 [95% CI 0.30 to 0.55], 0.28 [95% CI 0.18 to 0.37], 0.28 [95% CI 0.17 to 0.39], and 0.11 [95% CI 0.01 to 0.22]. In the long term the weighted average SMDs for resilience, stress, anxiety, depression and PTSD symptoms were 0.67 [95% CI 0.29 to 1.06], 0.20 [95% CI 0.04 to 0.37], 0.17 [95% CI -0.02 to 0.36], 0.14 [95% CI -0.04 to 0.31], and 0.13 [95% CI -0.03 to 0.28]. Evidence of statistical heterogeneity was found in all meta-analyses indicating inconsistency of results across comparisons. The 95% prediction intervals included negative values, reflecting that the distribution of effect sizes spanned both positive and negative effect sizes. We performed multiple regressions where possible and single factor subgroup analyses otherwise. We were, however, not able to explain heterogeneity in any of the analyses. We found evidence that age, gender and duration measured in hours have an impact. However, there was no clear pattern for the impact of moderators. The impact did not show up in all meta-analyses/for all outcomes and the sign of the impact was not consistent across outcomes. We found no evidence that occupation, theoretical foundation of intervention or setting (delivered in a group, individually, online) had an impact on any outcome at any time point. We included as secondary outcomes alcohol and drug use, but found no evidence of effects, mainly due to a paucity of data in the long term.

Authors’ conclusions: Our results indicate that proactive resilience interventions may improve resilience, stress, anxiety, depression and PTSD symptoms in the short term. There is also evidence to suggest that the effects on resilience and stress are maintained in the long term but not the effects on anxiety, depression and PTSD symptoms. The overall certainty of evidence varied from low to very low in the short term and from moderate to very low in the long term. There is a need for more rigorously conducted studies. None of the included comparisons was rated overall low risk of bias. Further, lack of data reported that enabled the calculation of effect sizes and standard errors also point to the need of future trials reporting according to methodological criteria for rigour. Future trials should not merely report on the statistical significance of their findings but should provide their results in sufficient detail to allow their inclusion in systematic reviews examining the magnitude of effects. Moreover, consideration should be made to which types of outcomes are most relevant. Considering the interventions aim at improving resilience it is remarkable that only 106 comparisons of 185 possible actually reported on resilience outcomes.