Individual‐level interventions for reducing occupational stress in healthcare workers

Sietske J Tamminga; Lima M Emal; Julitta S Boschman; Alice Levasseur; Anilkrishna Thota; Jani H Ruotsalainen; Roosmarijn MC Schelvis; Karen Nieuwenhuijsen<sup>a</sup>; Henk F van der Molen<sup>a</sup>

doi:10.1002/14651858.CD002892.pub6

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Figure 1

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Funnel plot (1.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)

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Figure 4

Funnel plot (1.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention))

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Figure 5

Funnel plot (2.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention))

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Figure 6

Funnel plot (4.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention))

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Analysis 1.1

Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)

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Analysis 1.2

Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 1.3

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Analysis 1.4

Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 4: Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)

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Analysis 1.5

Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 5: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 1.6

Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 6: Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)

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Analysis 2.1

Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)

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Analysis 2.2

Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 2.3

Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 3: Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)

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Analysis 2.4

Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 4: Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)

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Analysis 3.1

Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)

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Analysis 3.2

Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 3.3

Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 3: Any symptoms of stress‐related outcome (follow‐up >12 months)

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Analysis 3.4

Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 4: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 4.1

Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)

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Analysis 4.2

Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 4.3

Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 3: Any symptoms of stress‐related outcome (follow‐up > 12 months)

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Analysis 4.4

Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 4: Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)

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Analysis 4.5

Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 5: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 4.6

Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 6: Psychological symptoms: anxiety and depression (follow‐up > 12 months after the end of the intervention)

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Analysis 5.1

Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months)

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Analysis 5.2

Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 5.3

Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 3: Psychological symptoms: anxiety and depression (follow‐up up to 3 months)

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Analysis 5.4

Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 4: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)

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Analysis 6.1

Comparison 6: ‘Combination of interventions’ vs focus one's attention on the experience of stress (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months)

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Analysis 6.2

Comparison 6: ‘Combination of interventions’ vs focus one's attention on the experience of stress (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)

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Summary of findings 1. An intervention in which one's attention is on the experience of stress (feelings, thoughts, behavior) compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers

Outcomes	*Anticipated absolute effects^ (95% CI)**	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
An intervention in which one's attention is on the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers
Patient or population: healthcare workers Setting: various healthcare settings Intervention: an intervention in which one's attention is on the experience of stress Comparison: no intervention/wait list/placebo/no stress‐reduction intervention
Outcomes	Effect with an intervention in which one's attention is on the experience of stress	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
Stress symptoms (follow‐up up to and including 3 months after end of intervention)	SMD 0.37 lower (0.52 lower to 0.23 lower)	3645 (41 RCTs)	⊕⊕⊝⊝ Low¹	On the short term, an intervention in which one's attention is on the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 4.6 fewer (6.4 fewer to 2.8 fewer) points on the MBI‐emotional exhaustion scale².
Stress symptoms (follow‐up > 3 to 12 months after end of intervention)	SMD 0.43 lower (0.71 lower to 0.14 lower)	1851 (19 RCTs)	⊕⊕⊝⊝ Low¹	On the medium term, focus one's attention on the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 5.3 fewer (8.7 fewer to 1.7 fewer) points on the MBI‐emotional exhaustion scale³.
Stress symptoms (follow‐up >12 months after end of intervention)	no effect estimate	68 (1 RCT)	⊕⊝⊝⊝ Very low ²	The evidence is very uncertain about the long‐term effect on stress symptoms of focusing one's attention on the experience of stress.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardized mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹ The certainty of the evidence was downgraded by two levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) in combination with some inconsistency and suspicion of publication bias. ² The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) and very serious imprecision (small sample size, the confidence interval includes both a benefit and a harm). ³ The MBI‐Emotional exhaustion scale has a total score of 54 and we used the mean score (23.6) and standard deviation (12.2) of the control healthcare workers population in Fiol DeRoque 2021 as reference for interpreting the effect sizes. A score below 18 points is regarded as a low score on emotional exhaustion and a score above 36 as a high score on emotional exhaustion (Maslach 1996).

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Summary of findings 2. An intervention in which one's attention is away from the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers

Outcomes	*Anticipated absolute effects^ (95% CI)**	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
An intervention in which one's attention is away from the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers
Patient or population: healthcare workers Setting: various healthcare settings Intervention: an intervention in which one's attention is away from the experience of stress Comparison: no intervention/wait list/placebo/no stress‐reduction intervention
Outcomes	Risk with an intervention in which one's attention is away from the experience of stress	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
Stress symptoms (follow‐up up to and including 3 months after end of intervention)	SMD 0.55 lower (0.70 lower to 0.40 lower)	2366 (35 RCTs)	⊕⊕⊝⊝ Low ¹	On the short term, an intervention in which one's attention is away from the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 6.8 fewer (8.6 fewer to 4.9 fewer) points on the MBI‐emotional exhaustion scale².
Stress symptoms (follow‐up > 3 to 12 months after end of intervention)	SMD 0.41 lower (0.79 lower to 0.03 lower)	427 (6 RCTs)	⊕⊕⊝⊝ Low ¹	On the medium term, an intervention in which one's attention is away from the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 5.0 fewer (9.7 fewer to 0.4 fewer) points on the MBI‐emotional exhaustion scale².
Stress symptoms (follow‐up >12 months after end of intervention)	‐	(0 RCTs)	‐	No studies reported the long‐term effect on stress symptoms of focusing one's attention away from the experience of stress.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardized mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹ The certainty of the evidence was downgraded by two levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) in combination with some inconsistency and suspicion of publication bias. ³ The MBI‐emotional exhaustion scale has a total score of 54 and we used the mean score (23.6) and standard deviation (12.2) of the control healthcare workers population in Fiol DeRoque 2021 as reference for interpreting the effect sizes. A score below 18 points is regarded as a low score on emotional exhaustion and a score above 36 as a high score on emotional exhaustion (Maslach 1996).

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Summary of findings 3. An intervention in which the focus is on work‐related risk factors on an individual level compared to no intervention/no stress‐reduction interventionfor stress reduction in healthcare workers

Outcomes	*Anticipated absolute effects^ (95% CI)**	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
An intervention in which the focus is on work‐related risk factors on an individual level compared to no intervention/no stress‐reduction intervention for stress reduction in healthcare workers
Patient or population: healthcare workers Setting: various healthcare settings Intervention: an intervention in which the focus is on work‐related risk factors on an individual level Comparison: No intervention/no stress‐reduction intervention
Outcomes	Effect with an intervention in which the focus is on work‐related risk factors on an individual level	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
Stress symptoms (follow‐up up to and including 3 months after end of intervention)	no effect estimate	87 (3 RCTs)	⊕⊝⊝⊝ Very low ¹	The evidence is very uncertain about the short‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms.
Stress symptoms (follow‐up > 3 to 12 months after end of intervention)	no effect estimate	152 (2 RCTs)	⊕⊝⊝⊝ Very low ²	The evidence is very uncertain about the medium‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms.
Stress symptoms (follow‐up >12 months after end of intervention)	no effect estimate	161 (1 RCT)	⊕⊝⊝⊝ Very low ²	The evidence is very uncertain about the long‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardized mean difference; MD: mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹ The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias), inconsistency and very serious imprecision (small sample size, the confidence interval includes both a benefit and a harm). ² The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) and very serious imprecision (small sample size, the confidence interval includes both a benefit and no effect).

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Summary of findings 4. A combination of individual‐level interventions compared to no intervention/wait list/no stress‐reduction intervention for stress reduction in healthcare workers

Outcomes	*Anticipated absolute effects^ (95% CI)**	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
A combination of individual‐level interventions compared to no intervention/wait list/no stress‐reduction intervention for stress reduction in healthcare workers
Patient or population: healthcare workers Setting: various healthcare settings Intervention: a combination of individual‐level interventions Comparison: no intervention/wait list/no stress‐reduction intervention
Outcomes	Effect with a combination of individual‐level interventions	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
Stress symptoms (follow‐up up to and including 3 months after end of intervention)	SMD 0.67 lower (0.95 lower to 0.39 lower)	1003 (15 RCTs)	⊕⊕⊝⊝ Low ¹	On the short term, a combination of individual‐level interventions may result in a reduction in stress symptoms. The standardized mean difference translates back to 8.2 fewer (11.7 fewer to 4.8 fewer) points on the MBI‐Emotional exhaustion scale⁴.
Stress symptoms (follow‐up > 3 to 12 months after end of intervention)	SMD 0.48 lower (0.95 lower to 0.00)	574 (6 RCTs)	⊕⊕⊝⊝ Low ²	On the medium term, a combination of individual‐level interventions may result in a reduction in stress symptoms, but the evidence does not exclude no effect. The standardized mean difference translates back to 5.9 fewer points (11.7 fewer to no difference) on the MBI‐Emotional exhaustion scale⁴.
Stress symptoms (follow‐up >12 months after end of intervention)	no effect estimate	88 (1 RCT)	⊕⊝⊝⊝ Very low ³	The evidence is very uncertain about the long‐term effect of a combination of individual‐level interventions on stress symptoms.
CI: confidence interval; SMD: standardized mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹ The certainty of the evidence was downgraded by two levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) in combination with some inconsistency and suspicion of publication bias. ² The certainty of the evidence was downgraded by two levels for very serious risk of bias (lack of blinding; i.e. performance bias) and inconsistency. We did not downgrade for imprecision, as the wide confidence interval is due to the inconsistency between study results. ³ The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) and very serious imprecision (small sample size, the confidence interval includes both a benefit and a harm). ⁴ The MBI‐emotional exhaustion scale has a total score of 54 and we used the mean score (23.6) and standard deviation (12.2) of the control HCW population in Fiol DeRoque 2021 as reference for interpreting the effect sizes. A score below 18 points is regarded as a low score on emotional exhaustion and a score above 36 as a high score on emotional exhaustion (Maslach 1996).

Summary of findings 4. A combination of individual‐level interventions compared to no intervention/wait list/no stress‐reduction intervention for stress reduction in healthcare workers

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Comparison 1. ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot	41	3645	Std. Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.52, ‐0.23]

1.1.1 No intervention	29	2434	Std. Mean Difference (IV, Random, 95% CI)	‐0.35 [‐0.53, ‐0.16]
1.1.2 Wait list	9	619	Std. Mean Difference (IV, Random, 95% CI)	‐0.52 [‐0.80, ‐0.25]
1.1.3 Placebo	1	436	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.21, 0.16]
1.1.4 No stress‐reduction intervention	2	156	Std. Mean Difference (IV, Random, 95% CI)	‐0.33 [‐1.19, 0.53]
1.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	19	1851	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.71, ‐0.14]

1.2.1 No intervention	11	1271	Std. Mean Difference (IV, Random, 95% CI)	‐0.46 [‐0.90, ‐0.02]
1.2.2 Wait list	6	480	Std. Mean Difference (IV, Random, 95% CI)	‐0.53 [‐0.83, ‐0.24]
1.2.3 No stress reduction intervention	2	100	Std. Mean Difference (IV, Random, 95% CI)	0.16 [‐0.23, 0.56]
1.3 Any symptoms of stress‐related outcome (follow‐up >12 months) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.4 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention) Show forest plot	8	742	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.58, 0.03]

1.4.1 No intervention	7	482	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.68, 0.11]
1.4.2 Wait list	1	260	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.53, ‐0.04]
1.5 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

1.5.1 No intervention	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
1.6 Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot	41	3645	Std. Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.52, ‐0.23]

1.6.1 Short (< 12weeks)	29	2647	Std. Mean Difference (IV, Random, 95% CI)	‐0.32 [‐0.49, ‐0.15]
1.6.2 Long (≥ 12 weeks)	12	998	Std. Mean Difference (IV, Random, 95% CI)	‐0.50 [‐0.78, ‐0.22]

Comparison 1. ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD)

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Comparison 2. ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot	35	2366	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐0.70, ‐0.40]

2.1.1 No intervention	22	1565	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐0.61, ‐0.35]
2.1.2 Wait list	8	429	Std. Mean Difference (IV, Random, 95% CI)	‐0.88 [‐1.53, ‐0.24]
2.1.3 Placebo	3	168	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.74, ‐0.12]
2.1.4 No stress‐reduction intervention	2	204	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.55, 0.00]
2.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	6	427	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.79, ‐0.03]

2.2.1 No intervention	4	312	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.98, 0.12]
2.2.2 Wait list	2	115	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.77, ‐0.03]
2.3 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention) Show forest plot	7	378	Std. Mean Difference (IV, Random, 95% CI)	‐1.07 [‐1.95, ‐0.19]

2.3.1 No intervention	2	127	Std. Mean Difference (IV, Random, 95% CI)	‐0.67 [‐1.60, 0.25]
2.3.2 Wait list	3	173	Std. Mean Difference (IV, Random, 95% CI)	‐1.89 [‐4.24, 0.46]
2.3.3 Placebo	2	78	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.79, 0.11]
2.4 Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot	35	2366	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐0.70, ‐0.40]

2.4.1 Short (<12 weeks)	33	2255	Std. Mean Difference (IV, Random, 95% CI)	‐0.52 [‐0.68, ‐0.37]
2.4.2 Long (≥ 12 weeks)	2	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.96 [‐1.48, ‐0.43]

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Comparison 3. ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1.1 No intervention	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.1.2 No stress‐reduction intervention	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

3.3 Any symptoms of stress‐related outcome (follow‐up >12 months) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.4 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 3. ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD)

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Comparison 4. ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot	15	1003	Std. Mean Difference (IV, Random, 95% CI)	‐0.67 [‐0.95, ‐0.39]

4.1.1 No intervention	10	666	Std. Mean Difference (IV, Random, 95% CI)	‐0.71 [‐1.08, ‐0.34]
4.1.2 Wait list	4	270	Std. Mean Difference (IV, Random, 95% CI)	‐0.79 [‐1.21, ‐0.38]
4.1.3 No stress‐reduction intervention	1	67	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.35, 0.61]
4.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	6	574	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐0.95, ‐0.00]

4.2.1 No intervention	3	330	Std. Mean Difference (IV, Random, 95% CI)	‐0.70 [‐1.52, 0.12]
4.2.2 Wait list	2	177	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.65, ‐0.06]
4.2.3 No stress‐reduction intervention	1	67	Std. Mean Difference (IV, Random, 95% CI)	0.00 [‐0.48, 0.48]
4.3 Any symptoms of stress‐related outcome (follow‐up > 12 months) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

4.4 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention) Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

4.4.1 No intervention	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
4.4.2 Wait list	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
4.5 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

4.6 Psychological symptoms: anxiety and depression (follow‐up > 12 months after the end of the intervention) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 4. ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD)

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Comparison 5. Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months) Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

5.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

5.3 Psychological symptoms: anxiety and depression (follow‐up up to 3 months) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

5.4 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	1	38	Std. Mean Difference (IV, Random, 95% CI)	0.24 [‐0.39, 0.88]

Comparison 5. Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress

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Comparison 6. ‘Combination of interventions’ vs focus one's attention on the experience of stress (SMD)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

6.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 6. ‘Combination of interventions’ vs focus one's attention on the experience of stress (SMD)

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