Stress prevention at work- the SPA project. Prevention of stress-related mental ill-health in the workplace

Stress-related mental ill-health is, together with musculoskeletal disorders, the predominant cause of production loss and absenteeism, both in Sweden and internationally. The risk factors for developing stress-related mental ill-health are today well known. However, less is known about how we can successfully treat or prevent mental ill-health through interventions at workplaces.

Effectiveness of an organizational intervention in primary care

The study consisted of two parts, a randomized controlled trial (RCT) and a process evaluation. The aim of the RCT was to explore whether a participatory, organizational intervention can reduce work-related risk factors, and thereby prevent stress-related ill health. The intervention examined in this trial was “Productivity Measurement and Enhancement System” or ProMES, an extensively studied intervention for productivity enhancement. However, its effect on the experience of stress is not established, even though there are some indications in other studies that it could have preventive effects. ProMES addresses work organization and environment, i.e., work-related risk factors such as absence of influence and control, insufficient interaction with co-workers, unclear and conflicting tasks, insufficient participation in decision-making, and insufficient feedback. The primary outcome in the trial was job strain. Secondary outcomes were effort–reward imbalance, exhaustion, sleep, and recovery.

The aim of the process evaluation was to describe the intervention implementation process, to examine the influence of the contextual factors and to explore the participants' experiences of working with the method used. We used mixed method design, the UK Medical Research Council (MRC) guidance for process evaluation and the Consolidated framework for implementation research (CFIR) for the exploration of context.

During the study, we monitored participants' stress levels using a single item stress question administered by weekly text messages. We also examined the relationship between the stress experience and objective organizational measures of workload.

Statistically significant support for the effect of ProMES on job strain, effort-reward imbalance, exhaustion, sleep or recovery could not be found. The process evaluation showed that the intervention was not fully implemented, due to several contextual barriers such as staff shortage. No definitive conclusions can therefore be drawn about its effects. However, during the project, several lessons were learned. One of them was that employees already showing signs of exhaustion need special consideration when designing an intervention. Furthermore, these employees showed more rapid changes in their experience of stress from week to week, possibly demonstrating reduced resilience to additional stress. Another lesson learned was that the employees’ experience of stress was associated with objectively measured quantitative workload. Administrative tasks seemed to be more strongly associated with stress than patient related tasks. Managing to complete fewer tasks per hour worked was associated with increased stress. Finally, the single-item stress measure (SISQ), administered by weekly SMS messages, is a valid and reliable measure of experienced stress, in a Swedish population of predominantly female primary health care employees. It can be administered by SMS messages in a work context and be useful in predicting sick-leave and exhaustion one year later.

The effect of a workplace stress prevention intervention on the productivity of workers and the cost effectiveness of the intervention

Health problems due to long term stress, today account for a significant share of the health problems among the Swedish and European population and it has been increasing the last decade. Psychosocial factors at the workplace have shown to be responsible for a large part of this increase. Systematic reviews show that there is little known about the interventions used, both by the OHS and in general, to prevent stress related health problems at the workplace by targeting psychosocial factors. The Stress Prevention at Work (SPA) project at Karolinska Institutet was established due to this. The aim of the project is to evaluate the effectiveness of a productivity-enhancing intervention (ProMES) with a participatory approach on reducing stress related health problems and on increasing productivity at the workplace. ProMES is used and recommended by the ILO (International Labor Organization) and has previously shown to improve productivity in different types of organizations and continents. However, little is known about its effect on reducing production loss due to stress related health problems at the workplace. Moreover, not much is known regarding the cost-effectiveness of the intervention.

A randomized controlled trial is performed within the health care sector, partly to investigate the effect on reducing production loss due to health problems and work environment problems at the workplace. In addition to evaluating the effectiveness of the intervention a cost-effectiveness evaluation will also be performed.

Grants and researchers

The study was supported by AFA Insurance and Swedish Research Council for Health, Working life and Wellfare (Forte) and Karolinska institutet. 

The research group: Bozana Johansson. Irene Jensen, Lydia Kwak, Charlotte Wåhlin, Christina Björklund and Emmanuel Aboagye


Arapovic-Johansson, B., Jensen, I., Wåhlin, C., Björklund, C., & Kwak, L. (2020). Process Evaluation of a Participative Organizational Intervention as a Stress Preventive Intervention for Employees in Swedish Primary Health Care. International Journal of Environmental Research and Public Health, 17(19), 7285. https://doi:10.3390/ijerph17197285

Arapovic-Johansson, B., Wåhlin, C., Hagberg, J., Kwak, L., Axén, I., Björklund, C. & Jensen, I. (2020). Experience of Stress Assessed by Text Messages and Its Association with Objective Workload-A Longitudinal Study. International Journal of Environmental Research and Public Health, 17(3), 680.

Arapovic-Johansson, B. (2020). Stress prevention at work: intervention effectiveness and implementation process evaluation. Doctoral theses. Karolinska Institutet, Stockholm.

Arapovic-Johansson, B., et al., Participatory workplace intervention for stress prevention in primary health care. A randomized controlled trial. European Journal of Work and Organizational Psychology, 2018: p. 1-16.

Arapovic-Johansson, B., et al., Work-related stress assessed by a text message single-item stress question. Occupational Medicine, 2017. 67(8): p. 601-608.


Bozana Johansson

Postdoctoral researcher
C6 Institute of Environmental Medicine

Emmanuel Aboagye

Postdoctoral researcher
C6 Institute of Environmental Medicine