The impact of a primary care stress management and wellbeing programme (RENEW) on occupational participation: A pilot study

Abstract

Introduction

Stress has been identified as a risk factor in both physical and mental illness and can negatively impact on an individual’s ability to participate in daily occupations. There has been an increased emphasis on addressing mental health in a primary care context using a health promotion approach. The purpose of this pilot study was to explore the acceptability of a primary care 6-week stREss maNagemEnt and Well-being (RENEW) programme.

Method

This pilot study used a mixed methods convergent parallel design. Twelve individuals with self-reported experiences of stress participated in the programme. The Canadian Measure of Occupational Performance, Hospital Anxiety and Depression Scale, and visual analogue scales for stress, concentration, sleep and appetite were administered at three time points. A focus group and individual interviews explored participants’ experiences of the programme and impact on occupational participation.

Results

There were statistically significant improvements in occupational performance and satisfaction, anxiety and self-reported stress. Study participants reported that attendance at the programme increased their awareness of stress and gave them strategies to manage their stress.

Conclusion

The positive findings from this pilot study suggest that the RENEW programme has potential as a health promotion intervention in primary care that warrants further investigation.

Keywords

Stress stress management occupational participation primary care health promotion occupational therapy

Introduction

Stress is a phenomenon experienced by all individuals and is considered necessary to enhance occupational performance (Hughes and Parker, 2014). However, stress is harmful if an individual perceives they do not have adequate resources to cope with challenging life events (Cotton, 1990). Chronic, enduring stress can lead to, and exacerbate, physical and mental health disorders. The World Health Organization (WHO) recommends the use of health promotion activities to reduce the impact of stress and to develop coping strategies (WHO, 2008). A primary care-based stress management programme was developed to increase participants’ understanding of the impact of stress on occupational performance and to develop self-management strategies for stress. A pilot study was carried out to explore if the programme assisted participants to manage their stress and to explore their perceptions of the programme.

Literature review

Stress has been described as a process in which perceived demands exceed an individual’s coping resources, thereby impacting on their ability to participate in society (American Occupational Therapy Association, 2007). It can be triggered by acute life events such as bereavement and chronic triggers such as social isolation and work dissatisfaction (Brown and Rosellini, 2011). Stress can manifest physiologically, resulting in cardiovascular and gastrointestinal problems (Hawksley, 2007). Psychological symptoms include anxiety, impaired attention and difficulties with problem-solving. Stress is also associated with behavioural changes, including chronic procrastination and increased use of prescription drugs and alcohol (Schulman-Green et al., 2012).

Occupational therapy research in this area has identified the complexities of stress and contributory occupational risk factors that may lead to stress-related illnesses, including an imbalance in the occupations an individual engages in, a lack of opportunity to engage in occupations and engaging in non-meaningful or unsatisfying occupations (American Occupational Therapy Association, 2007; Cole and Tufano, 2008). Stress can have a significant impact on an individual’s occupational participation, hindering their ability to get a job, perform at work, support themselves and maintain family relationships and social contact (Hughes and Parker, 2014).

Mild to moderate levels of stress can have a protective effect on humans and enhance productivity and performance (Scott, 2010)_. However, chronic stress contributes to the development and progression of physical and mental health problems, including cardiovascular disease, musculoskeletal disorders and depression (Brown and Rosellini, 2011). Several approaches are used to manage stress including medical and pharmacological treatment, cognitive–behavioural therapy, educational interventions and support groups (Lehrer et al., 2007). Self-management, frequently used with individuals with chronic diseases, promotes the development of knowledge and skills to manage the medical, role and emotional impact of chronic conditions such as anxiety and stress. It combines education and goal-setting to support individuals to make positive health behaviour changes to manage their health (Lorig and Holman, 2003). Stress self-management involves the provision of a range of techniques used to help individuals recognise and cope with their stress (Lane and Carroll, 2007).

The World Health Organization (WHO) recommends that early interventions are significantly more effective in improving mental health than treating individuals with established mental health disorders (WHO, 2008). An increased focus has therefore been placed on mental health promotion to enable individuals to manage signs of stress early before they become chronic issues. Gupta et al. (2018) contended that support for positive mental health is required by all people. It is recommended, therefore, that health promotion activities take place within a primary care context as primary care services are the initial point of contact for health provision in the community (American Occupational Therapy Association, 2007). Stress management strategies used in a primary care context include relaxation techniques, mindfulness, cognitive–behavioural therapy and education on the impact of exercise and nutrition on reducing the impact of stress (Dolbier and Rush, 2012).

Although there is evidence to support self-management interventions in chronic diseases such as arthritis and diabetes, there is limited evidence on the effectiveness of self-management in mental health (Cook et al., 2009). In Australia, a 9-week self-management intervention delivered individually or in groups, the Optimal Health Program (OHP), was developed for individuals with chronic and enduring mental illness (Gilbert et al., 2012). The overall aim of the OHP was to provide participants with knowledge and skills to manage several aspects of mental health. It is delivered by a multidisciplinary team including nursing and allied health staff. A study to test the effectiveness of OHP reported significant improvements in health and social functioning for its participants (Gilbert et al., 2012). However, the OHP was designed for individuals with chronic mental health who were attending mental health services, and therefore it is not a health promotion intervention aimed at managing early signs of stress to prevent its development into chronic stress. Thomas et al. (2016) emphasised the importance of primary care-based early interventions to promote positive mental health for people of all ages.

In a Swedish study, Eklund et al. (2017) tested the impact of a lifestyle intervention programme Balancing Everyday Life (BEL) on activity participation and wellbeing for individuals with a variety of enduring mental illnesses including psychoses, mood disorders and neuropsychiatric disorders who were attending specialised community-based psychiatric services. BEL was a group-based programme consisting of 12 sessions delivered over 16 weeks. The overall aim of the intervention was to promote occupational balance and engagement. The programme resulted in significant improvements in occupational engagement, occupational balance and symptom severity by completion of the intervention when compared with a care as usual group. However, at 6-month follow up there were fewer significant differences between the two groups. This programme indicates the benefit of self-management programmes; however, it was aimed at individuals with chronic mental health diagnoses and did not specifically measure the impact of the intervention on levels of stress or anxiety.

It appears therefore that a gap exists for a primary care-based early intervention for stress management aimed at people with self-reported stress, with the purpose of providing individuals with knowledge and strategies to manage the early signs of stress. A 6-week stREss maNagemEnt and Well-being programme (RENEW) was therefore developed as a primary care-based health promotion intervention. The aims of RENEW were to increase individuals’ understanding of stress, to facilitate the development of stress management strategies and improve occupational participation. This pilot study was therefore carried out to explore if RENEW had any impact on participants’ occupational performance and satisfaction, perceived stress and to test the acceptability of RENEW to individuals attending the programme. Study objectives included:

To explore the impact of RENEW on participants’ occupational performance and satisfaction, levels of anxiety and depression, and self-reported stress, appetite, sleep and concentration.

To explore participants’ experiences of stress and their opinions of RENEW as a primary care-based intervention to provide knowledge and skills to manage stress.

Method

Intervention

RENEW is a 6-week programme co-facilitated by an occupational therapist and social worker, with input from physiotherapy and a dietician. The weekly content, designed by two of the authors (JC and MK), was based on Cotton’s integrated approach to stress management (Cotton, 1990) and is outlined in Table 1. The weekly format of RENEW consisted of education and information sharing, and goal-setting. This format is similar to other occupational focused self-management programmes (Garvey et al., 2015; O’Toole et al., 2013).

Table 1.

Weekly content of RENEW.

Week	Content
Week 1	Introduction to RENEW programme and principles of self-management Overview of stress and impact on occupational performance and satisfaction Self-assessment of occupational balance and daily stress triggers
Week 2	Physiological responses to stress Lifestyle factors that impact on stress Impact of leisure activities on stress Trial of relaxation strategies Agree ‘homework’ assignment
Week 3	Review ‘homework’ from previous week Psychological responses to stress Introduction to principles of cognitive–behavioural strategies to reduce stress Trial of relaxation strategies Agree ‘homework’ assignment
Week 4	Review ‘homework’ from previous week Physical and mental health benefits of exercise (physiotherapy-led) Trial of relaxation strategies Agree ‘homework’ assignment
Week 5	Review ‘homework’ from previous week Healthy eating and stress (dietician) Panic attacks: explanation and management strategies Trial of relaxation strategies Agree ‘homework’ assignment
Week 6	Review ‘homework’ from previous week Fatigue management and stress Sleep hygiene strategies Community-based resources to manage stress

Study design

The Medical Research Council (MRC) recommends a phased approach in assessing the effectiveness of a complex intervention starting with a number of pilot studies and progressing to a definitive intervention study (Craig et al., 2013). Pilot studies are carried out to test interventions, identify suitable outcome measures, examine the acceptability of an intervention and gather data to establish a sample size for larger evaluations of an intervention (Thabane et al., 2010). This study was therefore a pilot study to examine the acceptability of a 6-week stress management intervention to community-dwelling individuals.

The design for this pilot study was a convergent parallel mixed methods approach. This was considered suitable for the exploratory nature of the study as it involves the simultaneous collection of both quantitative and qualitative data, and analysis, in the research period (Cresswell, 2011). This approach gives equal importance to both quantitative and qualitative data and enables the researchers to form an overall interpretation of the data (Cresswell, 2011).

Sample

Inclusion criteria for RENEW were individuals over 18 years, living independently in the community, not attending psychiatric services and reporting experiencing stress. Participation was by self-referral and the programme was advertised in various locations in the community, including a family resource centre, health centres, welfare centres and local shops. Individuals who were interested in attending RENEW were requested to contact the primary care centre where RENEW was delivered.

Data collection

Levels of anxiety and depression were measured by the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983). The HADS has proved inter-rater and test–retest reliability and is appropriate for non-clinical, primary care populations (Herrmann, 1997).

Occupational performance and satisfaction were measured with the Canadian occupational performance measure (COPM) (Law et al., 1990). The COPM is a reproducible measure, with satisfactory to excellent reliability, validity and responsiveness (Carswell et al., 2004). The COPM has been used with individuals in primary care and community-based settings.

Although visual analogue scales provide limited information, there is evidence to suggest that they are a useful method of collecting self-reported subjective information regarding mood and quality of life (House et al., 2012). Participants’ self-rated levels of sleep, concentration and appetite were measured on a self-report visual analogue scale of 1 = no difficulty to 10 = extreme difficulty.

Quantitative measures were carried out at three time points: prior to the start of RENEW (T1), immediately following RENEW (T2) and 3 months later (T3).

Qualitative data were collected through a focus group and semi-structured interviews. The focus group took place on the last day of RENEW with all participants. It lasted 50 minutes and was facilitated by an independent occupational therapist with no involvement in the delivery of RENEW. Focus groups are relevant when investigating clients’ attitudes and experiences as they promote idea generation and encourage discussion (Hollis et al., 2002). Semi-structured interviews were carried out with all participants at the 3-month follow-up (Bowling, 2009). An interview schedule included open-ended questions exploring the perceived impact of RENEW on participants’ stress and occupational participation.

Data analysis

Quantitative data were analysed using the Statistical Package for the Social Sciences (SPSS) version 20. Given the pilot nature of this study data analysis was mainly descriptive. Non-parametric statistics were used to explore if changes occurred in anxiety or occupational participation between the three test times using the Wilcoxon signed rank test (Portney and Watkins, 2009). Cohen’s effect size was calculated for all measures: 0.2 is a small effect; 0.5 is a moderate effect and 0.8 a large effect (Cohen, 1988).

The focus group and the interviews were recorded and transcribed verbatim by the researchers. Transcripts were sent to participants to provide them with the opportunity to ensure accuracy of the content and make modifications if necessary (Hollis et al., 2002). Qualitative data were analysed using six stages of thematic analysis as described by Braun and Clarke (2006).The researchers first familiarised themselves with the data by reading the transcribed focus group and three interviews together as a team. Codes were generated by marking interesting features of the data using a pen and paper sorting approach. These individual codes were then applied to the remaining interviews, which the researchers coded individually. The researchers then came together and reviewed any new codes generated through individual analysis. This enabled the researchers to reach a consensus on the final list of codes. Codes were grouped into themes reflecting the aims of the research. These themes were reviewed and specifically defined and named (Green and Thorogood, 2009).

Trustworthiness

Lincoln and Guba (1985) identified four approaches to establishing trustworthiness of qualitative studies as credibility, conformability, dependability and transferability. Credibility was ensured through the use of triangulation as different methods of data collection were used and the data were analysed by each of the researchers individually and as a team. Member checking was adopted as transcripts were sent to participants to ensure accuracy. Confirmability was achieved through continuous peer review and seeking review from an experienced qualitative researcher who was not involved in the study. This ensured that interpretations drawn by the researchers reflected the data accurately.

Results

This section begins with presentation of demographic characteristics of the programme participants. The findings of this study are then presented in two parts. Part one presents the quantitative findings on participants’ stress and anxiety levels, and occupational performance and satisfaction. Part two provides qualitative findings on participants’ experiences of RENEW and their perceptions of its impact on occupational participation.

Part 1: Programme participants

Thirty individuals made telephone contact with programme facilitators expressing an interest in participating in RENEW. Following discussion regarding the content and format of RENEW, 22 individuals made an appointment to attend for pre-programme assessments. Eighteen of the 22 individuals attended their appointment and 15 were considered suitable for participation in the programme indicating a 50% recruitment rate. Three individuals attended the first week only. The remaining 12 people attended the six weeks of the programme, which is a retention rate of 80% (12/15). Twelve people completed all six weeks of the programme. Just over 75% of participants attended at least five sessions of RENEW (Table 2).

Table 2.

Weekly attendance at RENEW.

Weekly attendance	Proportion of participants (n)
All six sessions	33% (4)
Five sessions	43% (5)
Four sessions	16% (2)
Three sessions	8% (1)

The majority of participants were women, single and not in paid employment (Table 3). The mean age of participants was 52.6 years.

Table 3.

Demographic information of RENEW participants.

Number of participants: 12
Age (years)	52.6 (9.8)
Mean (SD)
Relationship status	2
Married	6
Single	2
Partner	1
Separated	1
Widowed
Living situation	6
Alone	1
With partner	5
With family
Education level
Primary level	2
Second level
• Intermediate certificate (age 16 years approx.)	4
• Leaving certificate (age 18 years approx.)	3
Third level	3
Productivity	3
Paid employment	4
Volunteering/seeking employment	5
Not engaged with vocational activities

Statistically significant differences were found between T1 and T2 for all measures except COPM satisfaction and appetite visual analogue scale. All measures continued to improve from the start of RENEW to the 3-month follow-up with four measures showing statistically significant improvements.

Table 4.

Median scores all measures and P values.

	Time 1 (n = 12) Median (IQR)		Time 2 (n = 12) Median (IQR)		Time 3 (n = 12) Median (IQR)		Time 1/time 2 P value (d)	Time 1/time 3 P value (d)	Time 2/time 3 P value (d)
HADS
Anxiety	13	(6.75)	8.5	(4)	8.5	(8.75)	0.011* (0.5)	0.005*(0.6)	0.837 (0.04)
Depression	7.5	(3)	6	(5)	6.5	(6.5)	0.024* (0.5)	0.161 (0.3)	0.918 (0.02)
COPM
Performance	2.7	(1.5)	5.6	(2.75)	5.8	(4.8)	0.006* (0.6)	0.041* (0.4)	0.937 (0.01)
Satisfaction	3.6	(3.75)	6	(3.1)	6	(4.9)	0.016* (0.5)	0.045* (0.4)	0.638 (0.1)
Visual analogue scales
Concentration	5.5	(2.5)	7	(3.75)	6	(3.5)	0.026* (0.5)	0.261(0.2)	0.120 (0.3)
Sleep	4.5	(4)	8	(4.75)	7	(4)	0.028* (0.5)	0.324 (0.2)	0.320 (0.2)
Appetite	4.5	(6.5)	6	(4.75)	7.5	(5)	0.223 (0.2)	0.072 (0.4)	0.121 (0.3)
Stress	6.5	(2.5)	5.25	(3.25)	5	(1.75)	0.025* (0.5)	0.048* (0.4)	0.591 (0.1)

d: Cohen’s effect size.

P ≤ 0.05.

Scoring guide: Components of stress scales: 1 = no difficulty; 10 = extreme difficulty.

HADS: 0–7 non-case; 8–10 borderline case; 11 + case.

Although the COPM satisfaction score was not significantly different between T1 and T2, it was significantly different from baseline at the 3-month follow-up. Only one measure showed no significant change at any of the three time points, namely the appetite visual analogue scale. Table 4 outlines median scores for all measures at the three data collection times and corresponding P values.

Using the COPM measure, participants identified particular areas of their lives that were impacted on by stress which they wished to address. The majority of goals were related to leisure occupations such as: engaging in social outings, participating in hobbies and increasing physical exercise. Productivity-related goals were identified by six participants such as engaging in voluntary activities and further education. Four participants set self-care-related goals such as eating at regular intervals and showering more frequently.

Part 2: Participants’ experiences of the programme

Three themes emerged from qualitative data analysis: (a) increased awareness of stress and its impact of occupational participation; (b) benefits of peer support; and (c) programme content and structure. Data are identified as originating from the focus group (FG) or the follow-up interviews (Int).

Increased awareness of stress and its impact of occupational participation

The main aim of the programme was to increase participants’ understanding of stress and provide them with strategies they could use to reduce their stress and anxiety. Participants discussed an increased awareness of stress.

P8: The awareness of what stress can do. The damage it can do is just horrific and if you don’t go and do something about it, how much more damage it can do. (FG)

P6: You learned to relax, to bring yourself down, to breathe slower and to realise what’s going on in your body – stress and tension and panic. You can change it. (FG)

In a follow-up interview, P5 stated: ‘I didn’t understand how you manage stress and going to the course taught me how to relax’.

Participants discussed the benefit of the ‘ocean liner’ activity used in the programme, which requires participants to examine their occupational balance. This activity was discussed during the focus group and interviews, with one participant discussing the impact it had for him.

P9: The ocean liner handout was very good. It’s just a diagram showing you the different areas of your life and how much of an effect each of those elements has on your well-being. I was shocked when I looked at that and discovered how unbalanced my life really was. (FG)

During the focus group and follow-up interviews, participants described how their stress affected them on a daily basis,

P4: Stress disrupts my life. The more stressed you become, the harder a thing is to do. It sort of handicaps me. It affects my ability to think and analyse things. (FG)

P6: I don’t have time to stop and think to de-stress and then I end up like a volcano ready to erupt. (FG)

One participant described how stress affected her appetite,

P5: I stopped eating, I got afraid of food. It was stress and anxiety. (FG)

During the follow-up interview, this participant described how she changed her eating habits,

P5: I would have had breakfast standing up at the sink. The programme taught me that that’s my time to sit down and don’t answer the phone and talk to nobody. And I still do that. I never took the time to eat and now I do. (Int)

Participants identified the role of RENEW in facilitating occupational participation. During the focus group, one participant described an increased awareness of activities available in the community and how they re-engaged with these activities following RENEW.

P7: I suddenly realised there’s loads of things that I used to do that I just don’t do now. One of them was walking, so I went walking. That was directly from the group and it was lovely. (FG)

P5: And I stuck with the six weeks and it was absolutely fantastic and it has helped me, it has taught me to deal with things and to do things, like I just stopped going out and now I’m back out. It has done wonders for me. (FG)

Another participant identified how she replaced attending RENEW every week by engaging in other occupations.

P12: What I do now is, instead of missing here (attending the programme), I get on the train and go somewhere instead of sitting at home. (Int)

Benefits of peer support

A recurring topic of discussion for participants during the focus group and follow-up interviews was how they valued support received from other group members during the programme. One of the main benefits identified by participants related to meeting others with similar experiences of stress.

P5: Well I found it very good, because you don’t realise, you think you’re on your own, you think that you’re the only one that’s suffering. I’m suffering from stress and panic attacks and you think that you’re the only one that’s suffering. I never realised until I came here there are other people out there like you. (FG)

P3: I thought it was just something happening to me but it’s not. The amount of people that are suffering with it. And to be able to talk to the people here was really good for me and to know I’m not the only one. (FG)

P6: To know that you’re not alone. (FG)

P10: Everybody is terrific and so supportive and would back you 100%. (FG)

Participants also discussed learning from others about stress and ways of managing stress.

P1: Listening to everybody and their different situations… we worked together as a team. (FG)

P8: My whole mind was just cluttered up with everything and all of a sudden it became totally decluttered and it was brilliant and it was through talking to each other and listening. (FG)

Participants described feeling comfortable to speak openly about their stress ‘without feeling foolish or stupid’ (P10, FG). Comparisons were made by participants between the support they received from family members and that which they received from their peers. The focus group participants discussed feeling embarrassed talking to family members about their stress and anxiety: ‘Your family are the last people you want to go to’ (P6, FG). One participant concluded,

P7: It’s probably easier for people to come into a room full of people they don’t know and talk. (FG)

Acceptability of content and format of RENEW

Overall, participants were positive about the content and format of RENEW. Various elements of the programme were discussed such as content, goal-setting, the duration of RENEW and resources provided.

When discussing the content of RENEW, participants believed that all content included was relevant,

P10: They covered everything that I needed and I think it suited everybody in the group. Different people need different things, but everything was interesting and we all learned something every week. (FG)

The inclusion of the psychological impact of stress was considered beneficial,

P4: One session that was very good was ways to manage your anger and not to be so severe on yourself. I tend to be very critical and hard on myself and that puts you under stress too. (FG)

Input from other health professionals was also valued by participants,

P9: It was good to meet a physiotherapist and a nutritionist, and just to hear them speak because you need the knowledge really now, you do. (FG)

Participants discussed the value of goal-setting during the programme,

P2: Setting goals writing them down, putting the plan into action is key to achieving the goals. I thought it was great. (Int)

Another participant discussed achieving her goal,

P5: My goal was to go for a coffee with my friend. Every Friday we used go for a coffee but I hadn’t been for weeks before I came here and then maybe after four weeks or five weeks here, I did it. I was thrilled that I did it. (FG)

She described the factors that facilitated achieving her goal,

P5: I think listening to the girls (facilitators) talking and listening to everybody and it’s when somebody is telling you ‘you can do it’.

When asked about the 6-week duration of RENEW some participants indicated they would prefer if it was longer,

P12: It should be longer and the reason I’m saying that is because we were given so much self-confidence that it could go on a bit longer to keep that going. (FG)

P4: Yeah, longer. About three to four weeks longer. (FG)

The majority of participants valued the resources provided. One participant discussed how she was using the handouts provided during the programme,

P7: The handouts were good to refer to. I’ve kept every one so that when we leave here you’ve got them. I make sure that my file is somewhere that I can see it as a reminder of what to do. (Int)

Six participants identified positive experiences using the relaxation and breathing techniques which were practised weekly during the programme with one person stating that ‘the relaxation really helped. It was the best thing ever’ (P10, Int). At the end of the programme each participant was provided with a CD which contained relaxation strategies. In a follow-up interview one participant discussed the value of this.

P2: The relaxation exercises were brilliant. The CD we got was superb. I have it on my iPod and I use it still.

The quantitative findings indicate a positive impact of RENEW on participants’ occupational performance and satisfaction, their anxiety and stress between the start of RENEW and 3 months later. The qualitative findings indicate an increased understanding of stress and that participants acquired strategies to manage their stress. Validation of stress and receiving support and encouragement from other participants were identified as important elements of RENEW.

Discussion

A pilot study of a 6-week RENEW programme, delivered in a primary care context, was carried out to inform a definitive intervention trial as recommended by the MRC. Although the programme was advertised in a range of health and community centres over a 6-week period, there was a low uptake for the programme. Therefore, a future study of RENEW will require targeted recruitment methods such as contacting general practitioners (GPs) in the area, putting notices in GP practices and discussing the programme in primary care team meetings. This may increase understanding of the purpose of RENEW and therefore increase recruitment rates. The majority of participants were women, which reflects previous research reporting that women are more likely than men to avail themselves of group programmes as a method for managing mental health difficulties (Kudielka et al., 2007). Attendance of RENEW facilitators to male-specific community activities such as Men’s Sheds could increase male recruitment in future evaluations of RENEW.

One of the main aims of this pilot study was to explore the acceptability of RENEW as a primary care-based health promotion intervention. Although the programme recruitment rate was low, 12 of the 15 individuals completed the programme, with over 75% of participants attending five or more of the weekly sessions indicating that the programme was acceptable to those who attended. The content of the programme was based on Cotton’s integrated approach to stress management (Cotton, 1990). It focused on increasing participants’ understanding of the physiological and psychological responses to stress, and strategies to reduce the impact of stress. Study participants identified the content as suitable and believed that all content included was relevant for stress management. A core element of self-management programmes is providing individuals with disease-specific information to increase knowledge and understanding of the disease in order to promote self-efficacy (Lorig and Holman, 2003). It therefore appears that the content of RENEW is acceptable to individuals with self-reported stress and would be suitable to include in future studies of RENEW.

The benefits of peer support were discussed at length by participants as a contributing factor to improving their stress and increasing their activity participation. Participants discussed feeling validated in their experience of stress through talking to others with similar experiences. They also reported feeling supported by their peers throughout the programme. The study participants identified how they were more comfortable discussing their stress with group members than with family members. This is in contrast to other research which found that people experiencing mental health difficulties usually seek support from their family and/or GP (Anderson and Jane-Llopis, 2011). Perhaps the participants in this study believe that they are over-burdening family members by discussing their stress. This could be investigated in a future study.

During the focus group participants were asked for their opinions on the format of RENEW. Goal-setting was discussed positively by participants as a structured aspect of the programme which allowed them to increase their occupational participation. Participants identified how documenting goals, and identifying steps to achieve their goals, facilitated achieving their weekly goals. Goal-setting is considered an important element of self-management programmes and is required for participants to personalise knowledge gained through self-management education and to apply this knowledge to their daily routines (Lorig and Holman, 2003). Collaborative goal-setting is a well-established process in occupational therapy practice thus supporting the contribution of occupational therapists to self-management interventions.

Providing participants with resources such as educational handouts and a relaxation CD to use following completion of RENEW was valued by participants. During the focus group discussions and follow-up interviews, participants explained how this was a resource that they could refer to in the future as a reminder of the content covered during RENEW. Other self-management programmes have identified the importance of providing written information to support the sustainability of self-management strategies (O’Riordan et al., 2017; O’Toole et al., 2013). This supports the inclusion of these resources in a future trial examining the effectiveness of RENEW as a health promotion intervention.

Another aim of this pilot study was to explore the impact of RENEW on participants’ stress and occupational participation. RENEW is a stress management intervention designed to increase self-management knowledge and skills to reduce stress and facilitate occupational participation. Significant improvements were noted for both the HADS anxiety and depression categories between the beginning and end of the programme, and significant improvements were detected in anxiety at follow-up. Components of stress visual analogue scales also demonstrated significant improvements. There were no missing data for any of the measures as they were completed by the facilitators in face-to-face interviews with participants. In the 3-month follow-up interviews participants discussed feeling better equipped to manage their stress through having increased awareness and knowledge of the causes and triggers of their stress. They also identified specific stress management strategies such as relaxation and breathing, acquired during RENEW and which they were continuing to use 3 months later. This indicates sustainability of the impact of RENEW which will be investigated in a larger study.

Significant changes occurred in participants’ occupational performance and satisfaction between baseline and the two follow-up assessment periods. These findings are similar to those of Eklund et al. (2017), who reported significant improvements in occupational engagement for a lifestyle intervention self-management programme for individuals with enduring mental illness. RENEW participants identified goals which they wished to address prior to the programme using the COPM (Law et al., 1990). The majority of participants set COPM goals related to leisure and social engagement. In week two of RENEW, opportunities for increased engagement in leisure occupations were identified through a discussion of social and recreational activities and resources available in the local community. In the 3-month follow-up interviews participants identified new leisure occupations in which they were engaging in their community. Perhaps it was this increased engagement in leisure activities over the three months after completion of RENEW that contributed to the significant improvements in both occupational performance and satisfaction.

Many participants reported that stress reduced their occupational participation and, in turn, participating in occupations increased their stress, leading to an overall reduction in occupational engagement. Participants reported that through the use of the ‘ocean liner’ exercise, they gained insight into their occupational imbalance and how this contributes to increased stress. This link between stress and occupational participation is not a new concept (Cole and Tufano, 2008). Occupational therapists possess a unique knowledge of occupation and its impact on health and wellbeing (Yerxa, 2000). This understanding of individuals as occupational beings combined with knowledge of the link between stress and occupational participation and occupational imbalance would suggest that occupational therapists are effective co-facilitators in stress management programmes in which occupations both cause stress and contribute to stress reduction.

Limitations

The limitations of this study are those that are associated with a pilot study in that it was a small exploratory study carried out to examine the acceptability of a complex intervention to inform future studies of the intervention. Therefore, no conclusions can be drawn as yet regarding the impact of RENEW as an occupation-focused health promotion intervention in reducing stress levels for community-dwelling individuals.

Conclusion

The MRC recommends a number of pilot studies on complex interventions before progressing to a definitive intervention trial. This study therefore was a pilot study of a stress management intervention, RENEW, to examine if it was an acceptable primary care-based stress management intervention and if it resulted in changes to participants’ stress and occupational participation. The findings of this study suggest that the content and format of RENEW was acceptable to participants and therefore could be used in its current format in future studies investigating the effectiveness of RENEW. Three outcome measures were used in this pilot study: HADS, COPM and visual analogue scales for components of stress. All measures detected significant improvements before and after RENEW, with moderate effect sizes observed in the HADS and COPM. This suggests that they would be suitable measures to detect differences in a trial.

Key findings

The content and format of RENEW was acceptable to those who participated in this group-based intervention.

Changes were noted in participants’ anxiety and occupational performance and satisfaction following participation in RENEW, indicating that it may be a suitable primary care-based stress management intervention.

What the study has added

This pilot study will inform the design and implementation of a definitive intervention trial of RENEW.

Footnotes

Research ethics

Ethical approval was obtained from the Faculty of Health Sciences Research Ethics Committee, University of Dublin (2012).

Consent

Written informed consent was obtained from all participants included in the study.

Contributorship

All authors contributed to the design of the study, data collection and data analyses. Deirdre Connolly wrote the first draft of the paper and all authors reviewed and edited the manuscript and the final version of the paper.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Anderson

Jane-Llopis

(2011) Mental health and global wellbeing. Health Promotion International 26(1): 147–155.

American Occupational Therapy Association (2007) AOTA’s statement on stress and stress disorders. American Journal of Occupational Therapy 61(6): 711.

Bowling

(2009) Research Methods in Health, Investigating Health and Health Services, New York: Open University Press.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

Brown

Rosellini

(2011) The direct and interactive effects of neuroticism and life stress on the severity and longitudinal course of depressive symptoms. Journal of Abnormal Psychology 120(4): 844–856.

Carswell

McColl

Baptiste

, et al.(2004) The Canadian occupational performance measure: a research and clinical literature review. The Canadian Journal of Occupational Therapy 71(4): 210–222.

Cohen

(1988) Statistical Power Analysis for the Behavioural Sciences, 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates.

Cole

Tufano

(2008) Applied Theories in Occupational Therapy: A Practical Approach, New Jersey: Slack Incorporated.

Cook

Copeland

Hamilton

, et al.(2009) Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services 60(2): 246–249.

10.

Cotton

(1990) Stress Management: an Integrated Approach to Therapy, New York: Bruner/Mazel Inc.

11.

Craig

Dieppe

Macintyre

, et al.(2013) Developing and evaluating complex interventions: the new Medical Research Council guidance. International Journal of Nursing Studies 50(5): 585–592.

12.

Cresswell

(2011) Designing and Conducting Mixed Method Research, 2nd ed. London: SAGE Publications.

13.

Dolbier

Rush

(2012) Efficacy of abbreviated progressive muscle relaxation in a high stress college sample. International Journal of Stress Management 19(1): 48–68.

14.

Eklund

Tjornstrand

Sandllund

, et al.(2017) Effectiveness of Balancing Everyday Life (BEL) versus standard occupational therapy for activity engagement and functioning among people with mental illness – a cluster RCT study. BMC Psychiatry 17(1): 363. DOI: 10.1186/s12888-1524-7.

15.

Garvey

Connolly

Boland

, et al.(2015) OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care: a randomized controlled trial. BMC Family Practice 16(59): 1–11. DOI: org/10.1186/s12875-015-0267-0.

16.

Gilbert

Chamberlain

White

, et al.(2012) Controlled clinical trial of a self-management program for people with mental illness in an adult mental health service – the Optimal Health Program (OHP). Australian Health Review 36(1): 1–7.

17.

Green

Thorogood

(2009) Qualitative Methods for Health Research, 2nd ed. London: SAGE Publications.

18.

Gupta

Jenkins

Spicer

, et al.(2018) How primary care can contribute to good mental health in adults. London Journal of Primary Care 10(1): 3–7.

19.

Hawksley

(2007) Work-related stress, work/life balance and personal life coaching. British Journal of Community Nursing 12(1): 34–36.

20.

Herrmann

(1997) International experiences with the hospital anxiety and depression scale- a review of validation data and clinical results. Journal of Psychosomatic Research 42(1): 17–41.

21.

Hollis

Openshaw

Goble

(2002) Conducting focus groups: purpose and practicalities. British Journal of Occupational Therapy 65(1): 2–8.

22.

House

Arruda

Andrasik

(2012) The reliability and validity of visual analog mood scales in non-english-speaking pain patients. Pain Practice: the official journal of World Institute of Pain 12(8): 626–632.

23.

Hughes

Parker

(2014) Community practice. In: Creek

Lougher

(eds) Occupational Therapy and Mental Health, 4th ed. China: Elsevier, pp. 359–373.

24.

Kudielka

Hellhammer

Kirschbaum

(2007) Sex differences in human stress response. In: Fink

(eds) Encyclopedia of Stress Vol. 3, Oxford: Elsevier, pp. 424–428.

25.

Lane

Carroll

(2007) Stress management and cardiovascular disease. In: Fink

(eds) Encyclopedia of Stress Vol. 3, Oxford: Elsevier, pp. 528–532.

26.

Law

Baptiste

McColl

, et al.(1990) The Canadian occupational performance measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy 57(2): 82–87.

27.

Lehrer

Woolfolk

Sime

(2007) Principles and Practice of Stress Management, New York: Guilford Press.

28.

Lincoln

Guba

(1985) Naturalistic Inquiry, London: SAGE Publications.

29.

Lorig

Holman

(2003) Self-management education: history, definition, outcomes and mechanisms. Annals of Behavioural Medicine 26(1): 1–7.

30.

O’Riordan R, Doran M and Connolly D (2017) The impact of a fatigue and activity management education programme for individuals with systemic lupus erythematosus. Occupational Therapy International DOI: 10.1155/2017/4530104.

31.

O’Toole

Connolly

Smith

(2013) Impact of an occupation-based self-management programme on chronic disease management. Australian Occupational Therapy Journal 60(1): 30–38.

32.

Portney

Watkins

(2009) Foundations of Clinical Research: Applications to Practice, 3rd ed. Upper Saddle River, NJ: Pearson/Prentice Hall.

33.

Schulman-Green

Jaser

Faith Martin

, et al.(2012) Processes of self-management in chronic illness. Journal of Nursing Scholarship 44(2): 136–144.

34.

Scott

(2010) Optimal Stress, New Jersey: John Wiley & Sons Inc.

35.

Thabane

Chu

, et al.(2010) A tutorial on pilot studies: the what, why and how. BMC Medical Research Methodology 10(1): 1. DOI: 1471-2288/10/1.

36.

Thomas

Jenkins

Burch

, et al.(2016) Promoting mental health and preventing mental illness in general practice. London Journal of Primary Care 8(1): 3–9.

37.

World Health Organization (2008) (2008) Integrating Mental Health into Primary Care: a Global Perspective, Singapore: World Health Organization.

38.

Yerxa

(2000) Occupational science. A renaissance of service to humankind through knowledge. Occupational Therapy International 7(2): 87–98.

39.

Zigmond

Snaith

(1983) The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 67(6): 361–370.