Knitting together an Initial Programme Theory of a stress management intervention

Introduction:
Work-related stress is a major health concern for European workers, significantly impacting both
individuals and society. In Denmark, it is a leading cause of long-term sick leave. Many Danish
Occupational Health Clinics offer a Cognitive Behavioural Therapy (CBT)-based stress
management intervention for workers diagnosed with work-related stress, referred by their general
practitioners. The intervention is delivered in groups of eight-nine participants over three months,
under the guidance of experienced psychologists. While CBT-based interventions have been
extensively researched and found effective in reducing stress symptoms, most studies focus on
quantitative outcomes like stress reduction and return-to-work (RTW) rates. There is, however,
limited understanding of the underlying reasons why these interventions work (or not), for whom,
and in what circumstances. This study aims to fill this gap by exploring the causal mechanisms
driving the effectiveness of a CBT-based stress management intervention delivered at the
Occupational Health Clinic in Odense University Hospital, Denmark.
Methods:
We applied a realist evaluation approach, which is theory-driven and focuses on understanding
why an intervention works (or not), for whom, and in what circumstances. To develop the initial
programme theory (IPT), we used a multi-step process: i) a document review to thoroughly
describe the intervention; ii) stakeholder interviews to understand the assumptions of programme
managers; iii) informal literature scoping to identify evidence from similar interventions; iv)
integration of formal theories to explain how and why the intervention may be effective; and v) a
stakeholder workshop to finalize the IPT.
The realist data analysis focused on identifying how external contexts and internal mechanisms
generated outcomes. Formal theories were used as scaffolds to build rough IPTs in a process of
abductive thinking (imagining hypotheses) and retroductive theorizing (hypothesizing about hidden
mechanisms) using if, then, because statements.
Findings:
The developed model identifies key support systems at personal, interpersonal, and institutional
levels, and their contextual forces that influence the activation of intervention mechanisms. Comechanisms related to the group format and the role of the psychologists were also identified.
These co-mechanisms generate outcomes that activate the central mechanisms; improved
interaction, enhanced self regulation and modified intermediate beliefs in a ripple effect ultimately
generating the outcomes; flexible coping, reduced stress symptoms and RTW.
Discussion:
The IPT provides a detailed map of how the CBT-based stress management intervention works,
highlighting the crucial role of contextual factors and co-mechanisms in influencing its
effectiveness. This model offers valuable insights into what works (or not), for whom, and in what
circumstances, going beyond traditional CBT frameworks to provide a deeper understanding of the
intervention.
Dissemination:
This IPT will be published in a scientific journal, contributing to the field of work-related stress
interventions. The IPT will support a subsequent realist evaluation, allowing for further testing and
refinement, ultimately enhancing the design and implementation of work-related stress
management interventions.
Impact:
The IPT provides a comprehensive understanding of how CBT-based stress management
interventions function, incorporating both formal theory and contextual factors. It will also offer
practical guidance for psychologists to tailor CBT-based interventions more effectively to individual
patient needs.