Industrial Health 2009, 47, 173–182 Original Article
The Effects of a Stress Inoculation Training
Program for Civil Servants in Japan: a Pilot
Study of a Non-randomized Controlled Trial
Mariko KAWAHARADA1, 2*, Eiji YOSHIOKA2, Yasuaki SAIJO3,
Tomonori FUKUI2, Takeji UENO4 and Reiko KISHI2
1Department of Comprehensive Development Nursing, Faculty of Health Sciences, Hokkaido University, Kita
12, Nishi 5, Kita-ku, Sapporo 060-0812, Japan
2Department of Public Health, Graduate School of Medicine, Hokkaido University, Japan
3Department of Health Science, Asahikawa Medical College, Japan
4Department of Social Work, School of Social Welfare, Hokusei Gakuen University, Japan
Received August 11, 2008 and accepted November 27, 2008
Abstract: The aim of this study was to examine the effects of a stress inoculation training pro-
gram for civil servants through a non-randomized trial. We divided 140 civil servants into two
groups (an intervention group and a waiting list control group), and carried out three sessions
with the intervention group at intervals of four weeks. The sessions included lectures on respons-
es to stress and coping skills, problem-solving training, group discussions and self-monitoring.
Data from 65 subjects in the intervention group and 63 subjects in the waiting list group were
analyzed using two-way analysis of covariance (ANCOVA). The intervention group showed sta-
tistically significant development of problem-solving skills and positive cognition, with a signifi-
cant effect remaining one month after the intervention. The effect sizes in the intervention group
showed a small-to-medium change in problem-solving coping and small changes in positive cog-
nitive coping. However, no interventional effects were seen in terms of response to stress and
health competence. As the number of existing studies on job stress management for workers is
limited, further research in this field is necessary, including examination of the frequency and
methods of intervention sessions, the effects of intervention by gender, etc.
Key words: Stress management, Stress inoculation training, Coping, Health competence, Stress
response, Civil servants
Introduction is also considered a problem of great importance5).
The relationships between job stress and physical and
The present situation surrounding the mental health of mental disorders6–11) and the adverse health effects caused
Japanese workers shows no signs of improvement. About by certain psycho-social work-related factors have been
60% of employees are reported to feel strong anxiety, reported in numerous studies. The development of stress
frustration and stress toward their working life1), and the research since the 1980s has given rise to numerous pro-
incidence of mental health problems in the workplace is grams aimed at putting scientific achievements into prac-
reported to be increasing2). Workers’ compensation tice12), and intervention research on stress management
claims for mental illness and suicide related to stress in for workers has also been carried out13–15). Stress-man-
the workplace are also on the rise3, 4), making stress man- agement intervention is defined as a technique designed
agement a vital issue of occupational health in Japan. In to help employees modify their appraisal of stressful sit-
European countries and the U.S., job stress management uations or deal more effectively with the symptoms of
stress13). Murphy reviewed stress-management tech-
*To whom correspondence should be addressed. niques used in worksite studies, and reported that train-
174 M KAWAHARADA et al.
ing in cognitive-behavioral skills produced the most con- reduced through the use of SIT. In the one study involv-
sistent effects on psychological outcomes, especially on ing insurance company employees25), it was reported that
anxiety13). Van der Klink et al.14) conducted meta-analy- SIT improved subjects’ coping ability, although no
sis of randomized controlled trials designed to reduce job changes were observed in psychological health. In a study
stress in workers with psychological problems, and report- on SIT interventions involving law students, the method’s
ed that a cognitive-behavioral approach was the most effects on improving anxiety, general stress and irra-
effective in reducing complaints, improving the perceived tionality were reported26).
quality of work and enhancing psychological resources In Japan, a growing number of civil servants undergo
and responses. Cognitive behavioral therapy has also therapy due to mental disorders for periods of one month
been used in the treatment of depression16), and has or longer3). The aim of this study was to examine the
recently been reported as effective in treating anxiety dis- effects of a stress inoculation program to train civil ser-
orders and other mental conditions17) as well as prevent- vants in coping, health competence and response to stress.
ing recurrent depression18). The cognitive behavioral It is common to apply problem-solving methods in the
component was developed to teach individuals various workplace rather than limiting them to stress management,
forms of active coping strategy (e.g. cognitive restructur- meaning that they are familiar to Japanese workers27).
ing including re-framing and thought replacement, plan- Against such a background, the acquisition of problem-
ning, seeking social support). solving coping behavior is considered a skill that is eas-
Preventive approaches to mental health management in ier for Japanese workers to adopt compared with other
Japan are rather limited, and very little research has been management skills.
conducted based on population strategy19). Presently, the
possibility of interventional prevention in the field of Method
occupational health using a cognitive-behavioral approach
is gathering attention20, 21). This study examined a cog- Subjects and study design
nitive-behavioral approach as an effective method of pre- The subjects of this study were 140 public organiza-
ventive stress-management intervention against a back- tion office workers who wished to participate in stress
ground of increasing mental health problems among management training (referred to below as the training)
workers. designed as part of a job training program. The subjects
The intervention program in this study was developed were recruited from 32 departments, and represented 15%
in line with the principles of Stress Inoculation Training of all the staff in each department. Seventy participants
(SIT), an inclusive form of cognitive-behavioral therapy were assigned to the intervention group, and the other half
focused on developing immunity to stress22). SIT aims were assigned to the waiting list control group, which was
to help individuals develop and acquire coping techniques set to undergo the training one month after the interven-
to be used not only in solving immediate problems but tion group. Participants were assigned to groups accord-
also for dealing with future difficulties. Specifically, indi- ing to their preference, and those happy to join either
viduals are encouraged to learn a number of techniques group were assigned at random by the health management
including cognitive restructuring, self-monitoring, prob- staff.
lem resolution and relaxation to build confidence in their Before starting the intervention in September of 2006,
stress-coping skills, and to use these techniques and build written explanations of the purpose and details of the
a tolerance to stress factors. SIT consists of three inter- research were distributed to the subjects along with ques-
locking and overlapping phases: 1) conceptualization, 2) tionnaires. A total of 68 responses from the intervention
skill acquisition and rehearsal, 3) application and follow- group (a response rate of 97.1%) and 66 from the wait-
through. The goals of SIT are to help subjects build cop- ing list control group (a response rate of 94.3%) were col-
ing skills, enhance their confidence in and utilization of lected. Three sessions were carried out with the inter-
their coping repertoire, and enhance their level of resis- vention group from September through November with a
tance to stress. In this study, coping skills, health com- four-week interval between each two sessions. A post-
petence and reactions to stress were used as indexes to test was conducted immediately after the intervention, and
evaluate the effects of intervention. Changes in partici- a follow-up test was conducted one month after the inter-
pants’ attitudes toward behavioral modification were also vention. The subjects in the waiting list control group
evaluated to examine whether they could apply their cop- were asked to self-evaluate their responses to stress using
ing techniques in daily life. a stress response checklist distributed with the question-
SIT has been noted for its effects on the management naire before the research started. The checklist contained
of anxiety, anger and pain13, 22). In studies involving a graph on which the participants were asked to mark
teachers23) and nurses24), it was reported that anxiety was their self-evaluated stress response results. From the
Industrial Health 2009, 47, 173–182
THE EFFECTS OF A STRESS INOCULATION TRAINING PROGRAM 175
Fig. 1. The flow of participants through the study.
intervention group, 68 individuals participated in one or explanation of stress, and were asked to self-evaluate their
more sessions. After the training finished, 65 responses present responses to stress, job stressors and coping skills
from the intervention group (a response rate of 95.6%) using the questionnaires distributed in advance. Next,
and 63 from the waiting list control group (a response they listened to a lecture on mental and physical reactions
rate of 95.5%) were collected. Data from 65 intervention to stress and coping as an intermediate stress factor. At
group members who had participated in the training and the end of the session, the participants were asked to keep
returned the pre- and post-test questionnaires and data a self-monitoring diary28) until the next session. The diary
from 63 waiting list control group members who had was designed to enhance their awareness of the stressful
returned all the questionnaires were analyzed (Fig. 1). situations that occur in their everyday lives. The subjects
Among the 65 subjects from the intervention group, 57 were asked to record stressful experiences, their feelings,
individuals (a follow-up response rate of 87.7%) returned physical reactions, thoughts, coping actions and the results
their follow-up questionnaires one month after the inter- of such actions, and whether any better alternatives could
vention. be used to cope with each situation.
Session 2 (Cognitive-behavioral skill development phase)
Intervention program The second session was aimed at learning skills that
The stress management program of this study was would help the participants cope with stress. It consist-
developed using the concepts of SIT22) and included the ed of a lecture, cognitive restructuring training and train-
three phases of education, cognitive-behavioral skill ing in problem-solving skills. During the cognitive
development, and relaxation training and practice. restructuring training, the participants learned to modify
Following these phases, three one-hour sessions were held the thoughts that automatically occur to them in stressful
with four-week intervals between them. The sessions situations and develop a well-balanced way of thinking
were led by an occupational health physician (a psychol- using their diary records. Problem-solving training was
ogist) and an occupational health nurse during working conducted in pairs, and also used the stressful experiences
hours in a meeting room of the enterprise. brought up by the participants. At the end of the session,
Session 1 (Education phase) the subjects were asked to keep a self-monitoring diary
The purpose of the first session was to enhance the sub- until the next session. The diary was designed to help
jects’ understanding of the concept of stress and aware- them notice good events in their daily lives and develop
ness of their own stress. The participants were given an positive self-attitudes, and was also intended to stimulate
176 M KAWAHARADA et al.
their actions and reduce stress. The participants were the Brief Job Stress Questionnaire (BJSQ)33) scored on a
asked to record daily positive events that they experienced four-point Likert scale. The stress response scale had the
and their feelings at the time of those events. They were following six subscales: vigor (three items), anger (three
also asked to record the actions they took consciously to items), fatigue (three items), anxiety (three items), depres-
cope with daily stress and their feelings at the time of sion (three items), and somatic stress response (eleven
those actions. items). Scores on vigor were unified with those of the
Session 3 (Relaxation training and practice phase) other subscales by reversing the figures obtained from the
The third session was aimed at learning to apply stress- responses. A higher total score meant a higher response
coping skills, including relaxation, in daily life. After a to stress.
lecture on the meaning and methods of relaxation29), the
participants practiced breathing techniques and methods Other measures
for relaxation in the workplace. Next, the subjects were Demographic and stress-related variables that could
divided into groups of four and engaged in group dis- have influenced the results of the intervention were mea-
cussions on effective methods of coping with stress in sured to examine the differences in characteristics
daily life using their self-monitoring diary records. The between the intervention and waiting list control groups.
group discussion method helps develop more realistic and Demographic information on the participants was
effective ways of coping by enabling participants to learn obtained through questions on gender, age, marital status,
from other people’s coping experiences. present diseases, official position, amount of sleep per
day, regular exercise, smoking habits and hobbies.
Ethical Considerations Stress-related variables included job stress factors (sev-
To guarantee anonymity, each participant was asked to enteen items) and social support (three items: supervisors,
create a six-digit ID number and use it instead of his/her co-workers and family) from the Brief Job Stress
name when completing the questionnaires, which were Questionnaire (BJSQ)33) scored on a four-point Likert
submitted in sealed envelopes and opened directly by the scale. Eight additional items on non-job stress were
researchers. The study was conducted with permission drawn up by the authors of this study using the table of
from and in line with the ethical regulations of the Board psychological loads outside work from the Judgment
of Ethics for Medical Studies at Hokkaido University’s Guidelines on Conformation of Mental Disorders and
Graduate School of Medicine. Other Occupational Injuries34), and were scored using a
Measurement Scales Stress-coping skills were assessed using the Japanese
Outcome measures version of the Sense of Coherence Scale (SOC) (thirteen
1) Primary outcome measure items)35) scored on a seven-point Likert scale. The SOC
Coping was assessed using the Ways of Coping scale had the three subscales of comprehensibility, man-
Checklist (WCCL) (47 items)30) scored on a four-point ageability and meaningfulness.
Likert scale. The coping scale had the following six sub-
scales: problem-solving (fourteen items), positive cogni- Statistical Analysis
tive coping (ten items), seeking social support (six items), First, the baseline demographic and stress-related vari-
wishful thinking (six items), self-blame (four items), and ables of the intervention and waiting list control groups
avoidance (seven items). Higher scores indicated a high- were analyzed using χ2 testing and t-testing. Next, inten-
er level of coping. The original sample size estimate was tion to treat analysis was performed to ascertain the
64 people per study group, which would have detected a effects of intervention. These effects were evaluated by
difference of 15% in the primary outcome measure comparing the responses to stress, stress-coping skills and
(assuming that α =0.05 and β =0.20). health competence of the intervention and waiting list
2) Secondary outcome measures control groups at the pre- and post-survey stages.
Self-management skills were assessed using the Analysis of covariance (ANCOVA) with repeated mea-
Perceived Health Competence Scale (PHCS), which is surements was used to test the statistical significance of
comprised of eight items (such as “I am capable of man- the effects of intervention (time × group) for each indica-
aging my health”)31) scored on a five-point Likert scale. tor. In addition, ANCOVA with repeated measurements
A higher total score represents a higher ability to modi- was conducted after adjustment by sex, age, level of daily
fy one’s habits and behavior. PHCS is considered effec- exercise, present diseases and SOC. To evaluate the sus-
tive as a general evaluation index for health education tainability of the effects of intervention, the pre-test data
programs aimed at the promotion of health32). and data from the follow-up one month after the inter-
Response to stress was assessed using 29 items from vention of 57 participants who had completed all the ques-
Industrial Health 2009, 47, 173–182
THE EFFECTS OF A STRESS INOCULATION TRAINING PROGRAM 177
tionnaires were compared using ANCOVA with repeated significantly after intervention in comparison to those
measurements (time × group). The results were adjusted beforehand, and a significant difference remained after
by sex, age, level of daily exercise, present diseases and adjustment. There was no significant effect for health
SOC. Although no significant difference was found competence. No significant effect was found for the sub-
between the sex, present disease and SOC variables of the scales of response to stress (vigor, anger, fatigue, anxi-
intervention and waiting list control groups, they were ety, depression and somatic stress response). Table 4 pre-
included in the adjustment for their potential influence on sents the sustainability of the effects of intervention
the effects of intervention. Finally, the effect size was through comparison of the pre-test and follow-up results
calculated for each variable using Cohen’s d (based on for the variables that changed significantly after the inter-
the mean values before and after intervention). A p value vention. In coping, there was a significant difference after
of <0.05 was considered to be significant. For the six adjustment for problem-solving and positive cognitive
subscales of the BJSQ, Bonferroni correction was applied coping.
and the significance level was set at p<0.008 (0.05 ÷ 6). Using Cohen’s d guidelines for interpreting effect
All analyses were performed using SPSS statistical soft- sizes36), the intervention group showed a small-to-medi-
ware (version 13.0). um change in problem-solving coping and small changes
in positive cognitive coping, seeking social support and
Results self-blame, while the wait list control group showed small
changes in self-blame, wishful thinking and avoidance
Comparison of Pre-survey Variables (see Table 5).
There were significant differences in the levels of daily
exercise between the intervention and waiting list control Discussion
groups (Table 1). No significant difference was found in
stressors, social support, response to stress, sense of Coping is a method of dealing with stress, and is impor-
coherence or health competence (Table 2). tant as a stress-related parameter37). Active behavior (e.g.,
planning, seeking social support) and active cognition
Effects of Intervention among All Participants (looking for meaning in an illness, cognitive re-framing)
The pre- and post-survey results are presented in are reported to have a positive effect on patients with
Table 3. In coping, the scores for problem-solving and chronic diseases and improve their levels of self-
positive cognitive coping in the intervention group rose respect15). In this research, problem-solving coping
Table 1. Demographic variables of participants
Intervention group (n=65) Waiting list control group (n=63)
number % number %
Sex male 53 81.5 55 87.3 0.369
female 12 18.5 8 12.7
Age* 38.1 (± 8.0) 41.2 (± 9.9) 0.054
Marital status married 46 70.8 47 74.6 0.627
unmarried 19 29.2 16 25.4
Official position staff 28 43.8 19 30.6 0.112
middle manager 28 43.8 27 43.6
manager 8 12.4 16 25.8
Sleeping per day (hours)* 6.1 (± 0.7) 6.3 (± 1.0) 0.309
Present disease yes 9 13.8 12 19.0 0.427
no 56 86.2 51 81.0
Regular exercise yes 28 43.1 15 23.8 0.021
no 37 56.9 48 76.2
Smoking status yes 23 35.3 21 33.3 0.502
quit 12 18.5 17 27.0
no 30 46.2 25 39.7
Hobby yes 51 78.5 53 84.1 0.412
no 14 21.5 10 15.9
*Mean ± SD.
178 M KAWAHARADA et al.
Table 2. Comparison of psychometric variables at baseline
Intervention group Waiting list control group
Work stressors 63.0 (± 1.0) 63.5 (± 8.8) 0.760
Non-work stressors 0.6 (± 0.8) 0.8 (± 1.2) 0.143
Supervisor 7.5 (± 1.7) 7.6 (± 1.6) 0.826
Co-workers 7.3 (± 2.0) 7.3 (± 1.5) 0.864
Family 5.3 (± 1.9) 5.3 (± 1.9) 0.983
Sense of coherence 55.4 (± 10.6) 54.9 (± 10.7) 0.172
Problem-solving 36.5 (± 6.8) 38.0 (± 5.6) 0.161
Positive cognitive coping 26.8 (± 4.6) 27.1 (± 3.4) 0.700
Seeking social support 15.3 (± 4.2) 15.2 (± 3.7) 0.866
Self-blame 8.8 (± 3.0) 9.3 (± 2.9) 0.287
Wishful thinking 12.0 (± 3.8) 13.0 (± 3.6) 0.113
Avoidance 14.8 (± 3.2) 15.1 (± 2.5) 0.604
Health competence 25.9 (± 6.4) 25.0 (± 4.5) 0.892
Psychological stress response
Vigor 8.8 (± 2.3) 9.0 (± 2.3) 0.651
Anger 6.1 (± 2.3) 5.8 (± 2.6) 0.424
Fatigue 6.0 (± 2.3) 6.1 (± 2.4) 0.819
Anxiety 5.5 (± 2.1) 5.9 (± 2.2) 0.290
Depression 9.9 (± 3.6) 10.3 (± 3.8) 0.487
Somatic stress responses 18.6 (± 5.4) 17.9 (± 5.0) 0.494
Mean ± SD.
Table 3. Intervention effects on stress response, coping and health competence
Intervention group (n=65) Waiting list control group (n=63) Intervention Effect
Variables Pre Post Pre Post (non-adjusted) (adjusted)
Mean (SD) Mean (SD) Mean (SD) Mean (SD) F-value p-value F-value p-value
Problem-solving 36.5 (± 6.8) 38.9 (± 6.5) 38.0 (± 5.6) 37.8 (± 5.4) 10.057 0.002 12.552 0.001
Positive cognitive coping 26.8 (± 4.6) 27.5 (± 4.2) 27.1 (± 3.4) 26.8 (± 4.1) 2.537 0.114 4.865 0.029
Seeking social support 15.3 (± 4.2) 16.0 (± 4.1) 15.2 (± 3.7) 15.2 (± 3.8) 1.415 0.236 2.594 0.110
Self-blame 8.8 (± 3.0) 8.3 (± 2.8) 9.3 (± 2.9) 8.6 (± 2.9) 0.276 0.600 0.443 0.507
Wishful thinking 12.0 (± 3.8) 12.3 (± 3.8) 13.0 (± 3.6) 12.2 (± 4.1) 5.428 0.024 6.984 0.009
Avoidance 14.8 (± 3.2) 14.8 (± 3.2) 15.1 (± 2.5) 14.4 (± 3.2) 1.477 0.227 1.864 0.177
Health competence 25.9 (± 6.4) 26.9 (± 6.5) 25.0 (± 4.5) 25.0 (± 5.4) 1.740 0.190 2.102 0.150
Psychological stress response
Vigor 8.8 (± 2.3) 8.6 (± 2.2) 9.0 (± 2.3) 9.0 (± 2.1) 0.325 0.569 0.209 0.648
Anger 6.1 (± 2.3) 6.5 (± 2.4) 5.8 (± 2.6) 5.6 (± 2.0) 2.957 0.088 1.483 0.226
Fatigue 6.0 (± 2.3) 6.2 (± 2.8) 6.1 (± 2.4) 5.9 (± 2.3) 1.184 0.279 1.106 0.295
Anxiety 5.5 (± 2.1) 5.4 (± 2.0) 5.9 (± 2.2) 5.9 (± 2.2) 0.009 0.924 0.076 0.783
Depression 9.9 (± 3.6) 10.5 (± 3.6) 10.3 (± 3.8) 10.4 (± 3.5) 1.266 0.263 1.491 0.224
Somatic stress responses 18.6 (± 5.4) 18.7 (± 6.3) 17.9 (± 5.0) 18.5 (± 5.7) 0.232 0.631 0.181 0.671
ANCOVA was adjusted for age, sex, regular exercise, present disease, and SOC.
increased as a result of intervention, and the effect within this study was based on a number of typical stress-
remained one month after the intervention. Problem-solv- ful situations that participants often experienced in the
ing therapy is reported to be effective in improving workplace. The fact that these problem situations were
depressive symptoms38). The problem-solving training very familiar to the participants explains the effectiveness
Industrial Health 2009, 47, 173–182
THE EFFECTS OF A STRESS INOCULATION TRAINING PROGRAM 179
Table 4. Intervention effects on stress response, coping and health competence at the pre- and follow-up (after 1 month)
Intervention group (n=57) Waiting list control group (n=63) Intervention Effect
Variables Pre Follow-up Pre Follow-up (non-adjusted) (adjusted)
Mean (SD) Mean (SD) Mean (SD) Mean (SD) F-value p-value F-value p-value
Problem-solving 36.3 (± 7.1) 38.2 (± 6.2) 38.0 (± 5.6) 37.6 (± 5.9) 6.752 0.011 8.756 0.004
Positive cognitive coping 26.6 (± 4.7) 27.2 (± 4.7) 27.1 (± 3.4) 26.5 (± 3.8) 3.050 0.083 4.742 0.032
Seeking social support 15.1 (± 4.1) 16.0 (± 4.0) 15.2 (± 3.7) 15.5 (± 3.5) 0.939 0.334 1.444 0.232
Self-blame 8.6 (± 2.9) 8.7 (± 2.9) 9.3 (± 2.9) 8.8 (± 2.7) 2.327 0.130 3.509 0.064
Wishful thinking 12.0 (± 3.8) 12.1 (± 3.6) 13.0 (± 3.6) 13.0 (± 3.7) 0.041 0.839 0.781 0.379
Avoidance 14.9 (± 3.3) 14.5 (± 3.7) 15.1 (± 2.5) 14.9 (± 3.1) 0.109 0.741 0.011 0.915
Health competence 25.6 (± 6.4) 26.1 (± 6.4) 25.0 (± 4.5) 25.3 (± 4.6) 0.027 0.871 0.279 0.598
Psychological stress response
Vigor 8.8 (± 2.4) 8.8 (± 2.2) 9.0 (± 2.3) 9.2 (± 1.8) 0.325 0.570 0.925 0.338
Anger 6.1 (± 2.3) 6.3 (± 2.5) 5.8 (± 2.6) 5.6 (± 2.3) 1.392 0.240 0.440 0.508
Fatigue 6.0 (± 2.4) 6.0 (± 2.4) 6.1 (± 2.4) 6.0 (± 2.1) 0.679 0.618 0.847 0.359
Anxiety 5.4 (± 2.0) 5.3 (± 2.1) 5.9 (± 2.2) 5.8 (± 2.3) 0.104 0.748 0.023 0.881
Depression 10.0 (± 3.7) 10.3 (± 3.8) 10.3 (± 3.8) 10.6 (± 3.9) 0.015 0.901 0.297 0.587
Somatic stress responses 18.4 (± 5.4) 18.6 (± 5.9) 17.9 (± 5.0) 18.0 (± 5.2) 0.056 0.813 0.012 0.913
ANCOVA was adjusted for age, sex, regular exercise, present disease, and SOC.
Table 5. Comparison of effect sizes
Intervention group Waiting list control group
Variables Cohen’s d Cohen’s d
Post Follow-up Post Follow-up
Problem-solving 0.361 0.261 –0.036 –0.070
Positive cognitive coping 0.159 0.086 –0.080 –0.166
Seeking social support 0.169 0.169 0 0.083
Self-blame –0.172 –0.103 –0.241 –0.178
Wishful thinking 0.079 0.027 –0.207 0
Avoidance 0 0.116 –0.244 –0.071
Health competence 0.155 0.031 0 0.066
of the training. —including wishful thinking— was observed. This can
Although the effect size was small, there was found a be considered an effect of the stress reaction self-moni-
significant effect in positive cognitive coping due to inter- toring applied to the group. The adoption of this self-
vention. Positive thinking is known as an effective emo- monitoring in the stress management program may
tional coping technique. This may indicate that the newly increase the effects obtained from the program.
acquired coping skills were strengthened by intervention. Health competence is understood as a form of self-effi-
To enhance active cognition, self-monitoring diaries were cacy for health management. The Perceived Health
used to encourage the participants to look back on their Competence Scale (PHCS) was developed to enable
automatic thoughts in stressful situation, and cognitive re- assessment of the ability to modify one’s own daily habits
framing.This may explain the improvement of inefficient and behavior related to health39). The scale is used as a
thinking within the study. The scores for wishful think- general evaluation index for health education programs
ing in the intervention group showed a significant differ- aimed at health promotion. Generalized self-efficacy
ent, compared to the waiting list control group. Wishful (GSE) is defined as the impression that individuals are
thinking is reported to be based on negative attitude29). capable of performing in a certain manner or attaining a
In the waiting list control group, although the effect size certain goal40). Individuals with high GSE are reported
was small, a reduction in negative management behavior to be capable of taking effective problem-solving action,
180 M KAWAHARADA et al.
and a connection between GSE and health-related behav- study makes it impossible to draw conclusions. Further
ior has been proven41). On the other hand, task-specific research with a larger number of participants is necessary
SE (TSE), in comparison to GSE39), is understood as an to enable examination of differences by gender.
index with a higher ability to predict changes in behav- The limitations of this study must also be mentioned
ior. PHCS evaluates self-efficacy for health-management, here. First, the effects of intervention were examined by
and stands between GSE and TSE31) (i.e., it is not as spe- comparing the intervention and waiting list control groups
cific as TSE, but deals with more limited health-man- without conducting random allocation. Individuals who
agement issues than GSE). No change was observed in chose to receive intervention first might have had greater
PHCS evaluation as a result of the intervention in this expectations regarding stress management in addition to
study. Stress inoculation and graded exposure can engen- reasons related to their jobs. The analysis was conduct-
der a subject’s sense of self-confidence22). Stress man- ed with adjustment for demographic variables, and the
agement training should ensure that the subject receives influence of differences between the groups on the study
and responds to feedback on the natural consequences of results cannot be denied. Accordingly, it is necessary to
his or her efforts at coping. The feedback on positive conduct randomized intervention testing in the future.
changes brought about by individual efforts may have Second, the participants in both the intervention and wait-
been insufficient in this study. ing list control groups were chosen from the same sec-
The stress response level in this study was approxi- tions, which may have influenced the results. Equal pro-
mately the same or slightly lower than the mean value portions of participants from each group complied with
obtained from a national survey of Japanese workers42). the policy of the enterprise, but those in the waiting list
The intervention program in this study did not lead to a control group may have heard the details of the inter-
reduction in response to stress. Previous stress manage- vention from their co-workers in the intervention group.
ment interventions involving healthy subjects demon- To conclude, the stress management intervention with-
strated results for stress response reduction that do not in this study (based on a stress inoculation training pro-
coincide with each other. The cognitive-behavioral stress gram for civil servants) resulted in a statistically signifi-
management conducted by Gaab et al. on students before cant increase in problem-solving coping and positive cog-
an examination43) was effective in controlling anxiety nition — an effect that remained one month after the inter-
caused by the test, but there was no significant difference vention. The effect sizes in the intervention group showed
in depression between the groups. Some effects of stress a small-to-medium change in problem-solving coping and
management on improving stress reaction in the work- small change in positive cognitive coping. On the other
place have also been reported13, 14, 44). However, inter- hand, no intervention-related effects were observed in the
vention programs for post-office workers45), teachers46) areas of response to stress and health competence. As
and white-collar workers in the private sector47) had no preventive interventional studies targeting healthy work-
significant effect on job stress and response to stress. In ers remain rather scarce in Japan, further research in this
the present study, the absence of any intervention-related field is necessary, including examination of the frequen-
effect on reactions to stress could be explained by the cy and methods of intervention sessions, the effects of
small effect of coping skills, which may not be enough intervention by gender, and randomized controlled trial
to influence such reactions. SIT is effective in prevent- interventions.
ing the exacerbation of reactions to stress and in reduc-
ing such reactions by forming coping techniques to effec- Acknowledgements
tively deal with stressful events22). In this study, health
education was provided to a large group of 70 individu- We would like to thank the health management staff
als, and the effect of intervention was found to be small. and employees of the targeted enterprise for their partic-
However, although group guidance produces a smaller ipation in this study.
effect than individual guidance, it has the advantage of
targeting larger numbers of people in terms of the degree References
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