A Cognitive Behavioural Intervention Programme to Improve Psychological Well-Being

In e na ional Jou nal o En i onmen al Resea ch and Public Heal h A icle A Cogni i e Beha iou al In e en ion P og amme o Imp o e Psychological Well-Being Bi gi a Ojala 1,2,*, Clas-Håkan Nygå d 1, Heini Huh ala 1, Philip Bohle 3and Seppo T. Nikka i 2,4 1Facul y o Social Science, Heal h Uni , Uni e si y o Tampe e, 33014 Tampe e, Finland; Clas-Hakan.Nyga d@s a .u a. i (C.-H.N.); Heini.Huh ala@s a .u a. i (H.H.) 2Tullinkulma Occupa ional Heal h Uni , 33100 Tampe e, Finland; Seppo.Nikka i@s a .u a. i 3Tasmanian School o Business and Economics, Uni e si y o Tasmania, P i a e Bag 84 Hoba , Tasmania 7001, Aus alia; [email protected] 4Facul y o Medicine and Heal h Technology, Tampe e Uni e si y, 33100 Tampe e, Finland *Co espondence: [email p o ec ed]; Tel.: +358-40-5000-392 Recei ed: 12 No embe 2018; Accep ed: 23 Decembe 2018; Published: 29 Decembe 2018   Abs ac : Psychosocial isk ac o s ha e inc eased in oday’s wo k en i onmen , and hey h ea en wo k abili y. Good wo kplace a mosphe e, psychosocial suppo , he abili y o cope wi h s ess, and skills and knowledge a e all connec ed o mo e success ul coping. Fas e changes in he wo k en i onmen and an inc eased wo kload can lead o a chain o a igue and illness. The aim o his s udy was o e alua e a cogni i e beha iou al in e en ion as an ea ly ehabili a ion s a egy o imp o e employees’ well-being, in in e en ion g oup N446 and in con ol g oup N116. The well-being measu es used we e he Be gen Bu nou In en o y (BBI 15), U ech Wo k Engagemen Scale (UWES), and dep ession and s ess sc eening ques ions. Da a we e ob ained by a sel - epo su ey a baseline and a a nine-mon h ollow-up. Di e ences we e analysed wi hin and be ween g oups. The esul s sugges ha cogni i e beha iou al in e en ion as an ea ly ehabili a ion p og amme will inc ease employees’ well-being measu ed by BBI 15, UWES, and dep ession and s ess sc eening ques ions. In he in e en ion g oup, he o al BBI 15 sco e (p< 0.01) and each o he h ee subdimensions o bu nou (exhaus ion, cynicism, and sense o inadequacy) dec eased a ollow-up. Men al heal h issues a e he commones easons o sick lea e and ea ly e i emen . We need ways o p e en hese issues. Keywo ds: s ess; occupa ional heal h; in e en ion; bu nou ; well-being 1. In oduc ion Wo k is changing, and so a e wo k- ela ed occupa ional haza ds [ 1 ]. Wo k- ela ed psychosocial ac o s a e conside ed a new ype o occupa ional haza d. They include wo k cha ac e is ics and demands, o e load and men al s ess, wo ke s’ oppo uni ies o in luence wo k asks and p ocedu es, hei use o knowledge and skills, and di icul y and hu y a wo k [1,2]. These ac o s inc easingly in luence wo ke s’ capaci y o cope a wo k. A p olonged disc epancy be ween employees’ capaci ies and wo k demands may p oduce bu nou , which consis s o h ee main symp oms: Exhaus ion, cynicism, and educed p o essional e iciency. Bu nou is ypically associa ed wi h absen eeism, sick lea e, job u no e o physical heal h issues [ 3 – 5 ]. App oxima ely 5% o he Finnish popula ion su e om dep ession annually, and he e is a ecip ocal ela ionship be ween bu nou and dep ession symp oms [6,7]. Pa icipa o y in e en ions ha ocus on he indi idual as well as on he o ganisa ional le el ha e been shown o be e ec i e in ea ing bu nou [ 8 ]. Success ul in e en ion p og ammes agains In . J. En i on. Res. Public Heal h 2019,16, 80; doi:10.3390/ije ph16010080 www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2019,16, 80 2 o 11 bu nou can be enhanced wi h e eshe cou ses [ 9 ]. I is also impo an o ecognise di e en bu nou pa e ns and o ocus ac i i ies e ec i ely [10–12]. Employee engagemen can be buil a wo k h ough meaning ul expe iences and by enabling wo ke s o unde s and why hey a e doing he wo k. In he heal h sec o , people usually desc ibe hei wo k as meaning ul and aluable. E e ybody asc ibes meanings o hei wo k— o example, o he na u e o he wo k ole, and o he ela ionships ha hey build wi h o he s—and hese ha e implica ions o hei expe iences o wo k. Employees a e usually ully engaged in con ex s whe e a sou ce o meaning ulness is p esen . Ag eeable iden i ies wi h clea oles, impo an wo k ela ionships, challenging wo k, suppo i e leade ship, and he pu sui o ewa ds all inc ease engagemen . Employees’ engagemen can hus be imp o ed by supe iso s, leade s, human esou ces s a , and o he co-wo ke s. Unde hese condi ions, wo ke s do hei bes , a e loyal o hei employe , and a e willing o be lexible i he wo k so equi es [ 13 ]. I has been shown ha he quali y o nu ses’ wo k imp o es wi h such engagemen [14]. Job s ain may p ecipi a e clinical dep ession among employees, acco ding o a e iew o six s udies wi h a o al o 27,461 pa icipan s and 914 inciden cases o clinical dep ession [ 5 ]. In some o ganisa ions, bes p ac ices o managing wo kplace s ess ha e included con ex -speci ic in e en ions, combined o ganisa ional and indi idual in e en ions, a pa icipa i e app oach, and a change in cul u e [ 15 ]. When o ice employees we e alloca ed o social and physical en i onmen al in e en ion g oups, social–en i onmen al in e en ion showed an imp o emen in ask pe o mance, whe eas physical en i onmen al in e en ion showed an imp o emen in abso p ion [ 15 ]. Wo kplace-based, high-in ensi y psychological in e en ions may imp o e wo k disabili y ou comes o wo ke s wi h common men al heal h condi ions [ 16 , 17 ]. Howe e , in a me a-analysis o e ec s o occupa ional s ess managemen in e en ion p og ammes, cogni i e beha iou al he apy (CBT) in e en ions consis en ly p oduce la ge e ec s han o he ypes o in e en ion [18]. The CBT model o in e en ion encou ages indi iduals o ac by hemsel es o achie e hei own goals by suppo ing hem o ake ac ions owa ds hose goals [ 18 ]. CBT has been ound o be e ec i e in imp o ing wo k- ela ed s ess, dep ession, anxie y, ch onic pain, ch onic a igue synd ome, and insomnia. I has also been ound o inc ease wo k engagemen wi hin a wo king popula ion [19]. Bu nou e lec s a nega i e ela ionship o hos ili y and aliena ion be ween he pe son and his/he job, he posi i e opposi e o which is engagemen , a ela ionship o econcilia ion, and accep ance [ 20 ]. We conduc ed a p ospec i e s udy o e alua e he e ec s o a CBT in e en ion o imp o e employees’ well-being, as measu ed by ou come o ques ionnai es on psychosocial a iables om posi i e and nega i e di ec ions. 2. Ma e ial and Me hods 2.1. Pa icipan s In 2011–2014, ou ou pa ien in e en ion s udy ec ui ed a o al o 779 municipal employees. Pa icipan s we e olun ee s who me he inclusion c i e ia o he s udy: Being employed in he public sec o and wo king as pe manen o long- e m empo a y s a wi h a leas one yea o se ice. The s udy was a nine-mon h ollow-up designed o s udy he causal impac o he in e en ion on an in e en ion g oup, wi h a con ol g oup ha did no ake pa in he in e en ion. O he 779 o al pa icipan s, 594 ook pa in he in e en ion g oup and 185 in he con ol g oup. Con ol g oup membe s had he oppo uni y o ake pa in he in e en ion a e hey had answe ed ollow-up ques ionnai es be o e he in e en ion s a ed. The in e en ion sessions las ed o ou mon hs, wi h one session e e y wo weeks; i e mon hs a e ha came he ollow-up es s and g oup mee ings. The in e en ion was conduc ed du ing paid wo king hou s, and pa icipan s we e equi ed o commi o he en i e p og amme. O he 779 pa icipan s, 80% we e women and 20% we e men. The mean age o subjec s was 49.9 yea s ( ange 21–64 yea s). The e we e no s a is ically signi ican di e ences be ween he In . J. En i on. Res. Public Heal h 2019,16, 80 3 o 11 in e en ion g oup and he con ol g oup in age, gende , body mass index, ma i al s a us o yea s o wo k expe ience (Table 1). Howe e , he e was a di e ence in educa ion: The in e en ion g oup had less oca ional aining han he con ol g oup. The subjec s we e ec ui ed om di e en oca ional a eas o he in e en ion p og amme. The la ges pa icipa ion o women came om heal h se ices (37.3%), and o men om cons uc ion and anspo (70.4%) (Table 2). Table 1. Backg ound cha ac e is ics o s udy popula ion. NIn e en ion NCon ol p Age (yea s) 578 49.2 (7.8) 173 48.1 0.205 Gende , emale (%) 463 80.1 138 79.8 1 Ma ied (%) 578 56.6 173 61.5 1 Yea s o p o essional expe ience 547 19.2 (10.1) 165 18.2 (10.6) 0.702 Educa ion No oca ional aining (%) 38 7.1 9 5.3 0.61 Voca ional school (%) 344 64.3 108 63.9 Uni e si y o applied science (%) 55 10.3 25 14.8 Uni e si y deg ee (%) 98 18.3 27 16 To al 535 100 169 100 Table 2. Main occupa ions o s udy popula ion. In e en ion Con ol Female % Male % Female % Male % N N N N Heal h se ice 173 37.3 0 0 53 38.4 0 0 Cons uc ion and anspo 0 0 81 70.4 0 0 22 62.9 Educa ion and day ca e 69 14.9 9 7.8 22 15.9 4 11.4 O he se ices 68 14.7 0 0 18 13.1 0 0 Food se ices 66 14.3 0 0 21 15.2 0 0 O ice wo k 48 10.4 7 6.1 18 13.1 0 0 Managemen specialis 39 8.4 18 15.7 6 4.3 9 25.7 To al 463 100 115 100 138 100 35 100 In he in e en ion g oup, 446 (75.1%) comple ed he ques ionnai es a bo h baseline and ollow-up. The e we e missing esponses in 148 cases. In 28 o hese, he e was na u al mo emen , such as changes o wo kplace, absence, changes o job, and dea h. Nine een cases did no wan o ake pa in he s udy, and 101 answe ed incomple ely a he baseline o ollow-up. In he con ol g oup, 116 (62.7%) answe ed a baseline and ollow-up, he e was na u al mo emen wi h six pa icipan s, and 63 answe ed incomple ely a baseline o ollow-up (Figu e 1). In . J. En i on. Res. Public Heal h 2019,16, 80 4 o 11 In . J. En i on. Res. Public Heal h 2018, 15, x FOR PEER REVIEW 4 o 11 Figu e 1. Pa icipan s in his s udy. 2.2. In e en ion An in e disciplina y, goal-o ien ed mul i-p o essional eam (a doc o , an occupa ional physio he apis , an occupa ional psychologis , and a nu se) acili a ed each in e en ion subg oup. The o al in e en ion g oup was b oken down in o smalle subg oups o he pu poses o he in e en ion. Goals we e se wi h he pa icipan s, who each de ined hei own goals o imp o e hei wo k abili y. The subg oups me egula ly o ou mon hs (one day e e y wo weeks). A e a u he i e mon hs, he e was he ollow-up, which consis ed o a h ee-hou subg oup mee ing. The in e en ion consis ed o di e en educa ional componen s— o example, ela ed o physical aining, i was impo an ha all pa icipan s unde s ood hei own physical es esul s and how o imp o e hei ae obic condi ion, muscle s eng h, balance, and coo dina ion. Physical aining included iden i ying se e al aspec s o one’s physical condi ion and conduc ing p ac ices based on hose aspec s, such as ae obic aining ocused on one’s pulse le el, o aining o s eng h, balance, and coo dina ion. Du ing g oup e lec ion, all pa icipan s sha ed hei expe iences o las wo-week pe iod, p o iding eedback on wha ha e hey done o achie e hei goals. Wo k well- being is in di ec connec ion o he wo k and coping a wo k. Pa icipan s analysed hei e e yday wo k- ela ed p oblems and ound ways o unde s and changes a wo k and change- ela ed phenomena and hey lea ned new p oblem-sol ing skills and skills o alk wi h hei supe iso s a wo k abou hei wo k and de elop wo k ela ionships in e e yday li e. Wo k- ela ed p oblem- sol ing skills we e p ac ised by analysing he elemen s o one’s wo k. Skills o alk and de elop wo k ela ionships in e e yday li e we e p ac ised by s a ing ecommended con e sa ions in he wo kplace wi h one’s supe iso conce ning one’s wo k and i s daily challenges. Pa icipan s had expe ience on how o se sho - and long- e m indi idual goals and wha kind o changes a e ealis ic in hei li e si ua ion. Municipal employees 14,500 In e en ion 594 Comple ed all he ques ionnai es a he beginning and ollow-up 446 (75.1%) Con ol 185 Comple ed all he ques ionnai es a he beginning and ollow-up 116 (62.7%) To al numbe o pa icipan s 779 (5.4%) 148 missing esponses: - 28 na u al mo emen - 19 did no wan o pa icipa e - 101 did no comple e all o he ques ionnai e (24.9%) 69 missing esponses: - 6 na u al mo emen - 63 did no comple e all o he ques ionnai e (37.3%) Figu e 1. Pa icipan s in his s udy. 2.2. In e en ion An in e disciplina y, goal-o ien ed mul i-p o essional eam (a doc o , an occupa ional physio he apis , an occupa ional psychologis , and a nu se) acili a ed each in e en ion subg oup. The o al in e en ion g oup was b oken down in o smalle subg oups o he pu poses o he in e en ion. Goals we e se wi h he pa icipan s, who each de ined hei own goals o imp o e hei wo k abili y. The subg oups me egula ly o ou mon hs (one day e e y wo weeks). A e a u he i e mon hs, he e was he ollow-up, which consis ed o a h ee-hou subg oup mee ing. The in e en ion consis ed o di e en educa ional componen s— o example, ela ed o physical aining, i was impo an ha all pa icipan s unde s ood hei own physical es esul s and how o imp o e hei ae obic condi ion, muscle s eng h, balance, and coo dina ion. Physical aining included iden i ying se e al aspec s o one’s physical condi ion and conduc ing p ac ices based on hose aspec s, such as ae obic aining ocused on one’s pulse le el, o aining o s eng h, balance, and coo dina ion. Du ing g oup e lec ion, all pa icipan s sha ed hei expe iences o las wo-week pe iod, p o iding eedback on wha ha e hey done o achie e hei goals. Wo k well-being is in di ec connec ion o he wo k and coping a wo k. Pa icipan s analysed hei e e yday wo k- ela ed p oblems and ound ways o unde s and changes a wo k and change- ela ed phenomena and hey lea ned new p oblem-sol ing skills and skills o alk wi h hei supe iso s a wo k abou hei wo k and de elop wo k ela ionships in e e yday li e. Wo k- ela ed p oblem-sol ing skills we e p ac ised by analysing he elemen s o one’s wo k. Skills o alk and de elop wo k ela ionships in e e yday li e we e p ac ised by s a ing ecommended con e sa ions in he wo kplace wi h one’s supe iso conce ning one’s wo k and i s daily challenges. Pa icipan s had expe ience on how o se sho - and long- e m indi idual goals and wha kind o changes a e ealis ic in hei li e si ua ion. In . J. En i on. Res. Public Heal h 2019,16, 80 5 o 11 On each in e en ion day, he e we e discussions o he issues a ec ing pa icipan s’ wo k abili y. E e y mee ing s a ed wi h indi idual e lec ions on he p e ious wo weeks, including hings ha had been success ul, as well as challenging si ua ions. G oups we e di ec ed o y o ind solu ions o challenging si ua ions, a he han o concen a e on p oblems; o analyse hei own wo k wi h ools ha would help hem o see changes in hei wo king li es om a new pe spec i e; o s a con e sa ions wi h hei supe iso s acco ding o hei own in e es s; and o plan hei own pa hs owa ds hei goals. Pee suppo was a ailable du ing he g oup con e sa ions, which we e desc ibed as e y meaning ul by he pa icipan s. The g oup discussions we e well ecei ed by he pa icipan s. I was conside ed impo an ha lea ning should be ans e ed o e e yday heal h- ela ed ac i i ies as soon as possible, o acili a e long- e m e ec s. The hy hm o sessions suppo ed his sel - eliance: The sessions we e e e y wo weeks, and be ween sessions, e e ybody ollowed hei own schedule. This p ocess made i possible o implemen p ac ices a ound all he ele an issues in e e yday li e. This would be less easy in ins i u ional ehabili a ion, whe e pa icipan s usually spend longe pe iods away om o dina y li e si ua ions. 2.3. S udy The s udy was a nine-mon h ial o es ima e he causal impac o he in e en ion on an in e en ion g oup, wi h a no- ea men con ol g oup ha did no ake pa in he in e en ion. Only da a om pa icipan s who had esponded o all ques ions du ing he in e en ion and ollow-up we e included in he da a analysis. In i a ions o pa icipa e in he in e en ion and con ol g oups we e sen ou o hese employees h ough hei wo kplace managemen . Since his in e en ion was unde aken a an ea ly, p e-clinical s age, he e was no need o a medical ce i ica e o ake pa . The main pu pose was o o e an oppo uni y o in e en ion o hose who needed some suppo o main ain hei own wo k abili y. This app oach ensu ed ha he in e en ion was o e ed a a ime he pa icipan s belie ed was app op ia e o hem. Pa icipan s we e selec ed o he in e en ion by occupa ional heal h se ice p o essionals who had knowledge o he pa icipan s’ medical his o ies, oge he wi h he pa icipan s’ employe s, who we e awa e o hei wo k demands and wo kloads. Selec ion o in e en ion was hus unde aken collabo a i ely be ween occupa ional heal h se ice p o essionals and he employe . The employe , howe e , made he inal decision as o whe he he pe son could ake paid lea e om wo k on he ou pa ien in e en ion days. Employe s paid he cos s o he implemen a ion, and employees ook pa du ing paid wo k hou s. Social secu i y paid compensa ion o he wage cos s. Widely used ques ionnai es wi h es ablished eliabili y and alidi y we e used. Ques ionnai es we e comple ed a he beginning o he in e en ion and du ing ollow-up. All ques ionnai es we e adminis e ed o he in e en ion and con ol g oups a he same ime: Be o e he in e en ion and a e nine mon hs, jus be o e he moni o ing day. The s udy was app o ed by he e hics commi ees o he Pi kanmaa Hospi al Dis ic and he Uni e si y o Tampe e (No: R11068). W i en in o med consen was ob ained om all s udy pa icipan s. 2.4. Measu emen The measu emen ools used in his s udy we e he Be gen Bu nou In en o y (BBI) and he U ech Wo k Engagemen Scale (UWES). All measu emen s we e aken a baseline du ing he in o ma ion session (au umn 2011); he in e en ion g oup comple ed he measu emen s a he ollow-up es mee ing, and he same measu emen s we e aken o he con ol g oup a he same ime (au umn 2014). The in e en ion and con ol subg oups who answe ed he ques ionnai es we e om he same wo k uni s. Each ques ion, including pe sonal in o ma ion, such as name and social secu i y numbe , was numbe ed. The ques ionnai es we e sa ed in olde s, and he olde s we e a chi ed acco ding o heal hca e equi emen s. The da a we e s o ed in a passwo d-p o ec ed Excel ile, wi h pe sonal in o ma ion emo ed, o s a is ical es s. In . J. En i on. Res. Public Heal h 2019,16, 80 6 o 11 BBI 15 was used o measu e bu nou . I includes h ee sub-dimensions: Exhaus ion ( i e i ems), cynicism ( i e i ems), and sense o inadequacy ( i e i ems). The in e nal alidi y o his es has been p e iously desc ibed [ 20 , 21 ]. The pe cen iles o age and gende a e p esen ed in he manual: Ze o o 74 indica es no bu nou , 75 o 84 indica es sligh bu nou , 85 o 94 indica es mode a e bu nou , and 95 o 100 indica es se ious bu nou . In his s udy, we conside ed only he o al sum o BBI 15 and i s subdimensions. The BBI 15 measu emen can be used in esea ch and occupa ional heal h con ex s, because BBI 15 has high i em–scale eliabili ies and good concu en alidi y among manage s in Finland and Es onia [3,22]. UWES 9 was used o de ine h ee dimensions o wo k engagemen : Vigou ( h ee i ems), dedica ion ( h ee i ems), and abso p ion ( h ee i ems) [ 3 ]. Pe sons wi h high igou sco es epo high ene gy, a e willing o in es high e o in hei wo k, and display men al esilience while wo king; pe sons wi h high sco es on dedica ion a e inspi ed by hei wo k, see hei wo k as impo an , and eel p ide in hei wo k; pe sons wi h high sco es on abso p ion epo gi ing ull a en ion o hei wo k, and he majo i y ind i di icul o de ach om wo k. The UWES assesses a men al s a e o accomplishmen , which is he opposi e o bu nou [ 3 , 22 ]. In e co ela ions be ween he h ee UWES scales exceed 0.65, and he in e nal consis ency o C onbach’s α is equal o he c i ical alue o 0.70 [23,24]. UWES 9 was de eloped by Schau eli and Bakke in he Ne he lands [24,25]. Two ques ions we e used o sc een o dep ession: (1) “Du ing he las mon h, ha e you o en been wo ied, dismal, dep essed o hopeless? Answe yes o no”; (2) “Du ing he las mon h, ha e you o en been wo ied abou expe iencing a lack o in e es o unwillingness o accomplish hings? Answe yes o no”. One o mo e a i ma i e answe s indica ed p obable dep ession [ 26 ]. The s ess sc eening ques ion consis ed o a single i em: “S ess e e s o a si ua ion in which a pe son eels ense, es less, ne ous o anxious, o whe e i is di icul o sleep because o issues cons an ly on you mind/due o wo y. A e you cu en ly expe iencing his kind o s ess?” The ques ion was answe ed on a scale om one (no a all) o i e ( e y much) [27]. 2.5. Da a Collec ion The p ima y measu emen ools used in his s udy we e quan i a i e, like he Be gen Bu nou In en o y (BBI15) and he U ech Wo k Engagemen Scale (UWES). The in e en ion and con ol g oups who answe ed hese ques ionnai es we e om he same wo k uni and hey had he same c i e ia o aking pa o he in e en ion. A he ime o he i s measu emen s illing, he e was no any g oup di ision. We ied o andomise hese g oups, bu we did no o ally succeed because o wo king condi ions. All measu emen s we e aken a baseline in he in o ma ion session o he in e en ion o bo h g oups; he in e en ion g oup comple ed he measu emen s a he ollow-up es mee ing, and he same measu emen s we e pos ed o he con ol g oup a he same ime. The ques ionnai es we e dis ibu ed o s udy pa icipan s in au umn 2011 and au umn 2014. The pa icipan s could ill in he ques ionnai es du ing hei wo king hou s. 2.6. S a is ical Analyses Di e ences be ween he g oups a baseline we e es ed using he Mann–Whi ney U es o chi-squa e es o ca ego ical a iables. Wi hin-g oup compa isons be ween baseline and nine-mon h ollow-up sco es we e pe o med using he Wilcoxon signed- anks es . The main e ec s and in e ac ions o he sco es o he in e en ion and con ol g oups a baseline and ollow-up we e es ed using epea ed measu es analysis o a iance. pValues o less han 0.05 we e conside ed s a is ically signi ican . The da a analysis was pe o med wi h SPSS 23.0 so wa e (IBM Co po a ion, A monk, NY, USA). In . J. En i on. Res. Public Heal h 2019,16, 80 7 o 11 3. Resul s The esul s con ain only hose answe s whe e all i ems had been illed in a he beginning and end o he s udy. Baseline, ollow-up, and he changes be ween baseline alues and ollow-up o he in e en ion and con ol g oups a e shown in Table 3 o he BBI 15 and UWES. Table 3. In e en ion and con ol g oups a baseline and ollow-up on o al Be gen Bu nou In en o y (BBI) 15 and U ech Wo k Engagemen Scale (UWES) and all i ems, and changes in BBI 15 and UWES, ela ed ac o s. BBI 15 Baseline Follow-Up Change om Baseline p-Value Di e ence in Changes be ween G oups In e en ion G oup N= 425, Con ol G oup N= 109 Mean SD Mean SD To al BBI 15 In e en ion 36.9 11.8 33.9 12.3 −3 <0.001 0.023 Con ol 37.6 12.2 37.5 14.4 0.1 0.912 Exhaus ion (5 i ems) In e en ion 13.2 4.8 12.1 5.2 −1.1 <0.001 <0.001 Con ol 12.9 4.6 13.1 5.3 0.2 0.477 Cynicism (5 i ems) In e en ion 10.6 4 10 4 −0.6 <0.001 0.927 Con ol 11.2 4.2 11 5.1 0.2 0.622 Sense o inadequacy (5 i ems) In e en ion 13.1 4.8 11.8 4.9 −1.3 <0.001 0.016 Con ol 13.6 4.9 13.4 5.5 0.2 0.68 UWES 9 Baseline Follow-Up Change om Baseline p-Value Di e ence in Changes be ween G oups In e en ion G oup N= 446, Con ol G oup N= 116 Mean SD Mean SD To al UWES 9 In e en ion 4.3 1.1 4.5 1.1 0.2 <0.001 0.711 Con ol 4.2 1 4.4 1.1 0.2 0.142 Vigou (3 i ems) In e en ion 4.3 1 4.5 1 0.2 <0.001 0.555 Con ol 4.2 1 4.4 1 0.2 0.154 Dedica ion (3 i ems) In e en ion 4.4 1.1 4.6 1.1 0.2 <0.001 0.919 Con ol 4.4 1.1 4.5 1.1 0.1 0.054 Abso p ion (3 i ems) In e en ion 4.1 1.1 4.3 1.1 0.2 <0.001 0.659 Con ol 4.1 1 4.3 1.1 0.2 0.232 No es: Wi hin-g oup changes in in e en ion and con ol g oups a e nine mon hs (2) we e compa ed wi h baseline (1). Di e ence in changes be ween g oups measu ed by analysis o a iance. Table shows only answe s whe e all i ems we e illed in a he beginning and end o he s udy. To al BBI 15 alues o he in e en ion g oup we e 36.9 (s anda d de ia ion (SD) 11.8) a baseline and 33.9 (SD 12.3) a ollow-up. The change om baseline was − 3.0 (p< 0.001). Values o he con ol g oup we e 37.6 (SD 12.2) a baseline and 37.5 (SD 14.4) a ollow-up. The change om baseline was 0.1 (p= 0.912). The di e ence in changes be ween g oups was s a is ically signi ican (p= 0.023). In he in e en ion g oup, he o al BBI 15 sco e (p< 0.01) and each o he h ee subdimensions o bu nou (exhaus ion, cynicism, and sense o inadequacy) dec eased a ollow-up. The e was no co esponding dec ease in BBI 15 sco es o he con ol g oup. The di e ence in changes be ween g oups in BBI 15 sub-sco es was s a is ically signi ican o exhaus ion (p< 0.001), bu no o cynicism (p= 0.927) o sense o inadequacy (p= 0.016). To al UWES 9 alues o he in e en ion g oup we e 4.3 (SD 1.1) a baseline and 4.5 (SD 1.1) a ollow-up (p< 0.001). Values o he con ol g oup we e 4.2 (SD 1.0) a baseline and 4.4 (SD 1.1) a ollow-up (p= 0.142). The e was no di e ence in changes (0.2) be ween he g oups (p= 0.711), al hough he change in p- alue was signi ican in he in e en ion g oup (N= 446) compa ed wi h he con ol g oup (N= 116). The o al UWES 9 sco e and all h ee o i s dimensions o wo k engagemen imp o ed in he in e en ion g oup (p< 0.001). The e was also a simila imp o emen in o al UWES sco es and wo o i s dimensions ( igou and abso p ion) compa ed wi h he con ol g oup (0.2), change in dedica ion in he in e en ion g oup was also 0.2, and in he con ol g oup, 0.1. I is possible ha he ques ionnai e i sel ac ed as in e en ion and led o some posi i e change. Howe e , he e we e no s a is ically signi ican di e ences in he changes in any UWES sco es om baseline o ollow-up be ween he g oups, because he change om baseline was e y simila in bo h g oups (Table 3). In . J. En i on. Res. Public Heal h 2019,16, 80 8 o 11 The composi e sco e o he wo dep ession sc eening i ems dec eased signi ican ly om baseline o ollow-up o he in e en ion g oup (N= 451), in which 6.4% o sco es inc eased, 13.3% dec eased, and 80.3% we e a he same le el as baseline (p= 0.001). The e was no signi ican change o he con ol g oup (N= 115), in which 12.2% o sco es inc eased, 7.8% dec eased, and 80% we e a he same le el as baseline (p= 0.405). The composi e sco e o he one s ess sc eening ques ion compa ed wi h he baseline showed signi ican di e ences in he ollow-up o he in e en ion g oup (N= 445): 39% inc eased, 15.5% dec eased, and 45.5% we e a he same le el as baseline (p< 0.001). In he con ol g oup (N= 117), 24% inc eased, 26% dec eased, and 50% we e a he same le el as baseline (p= 0.596). 4. Discussion The p incipal inding o his s udy is a s a is ically signi ican imp o emen in se e al measu es o psychosocial well-being (BBI 15, UWES, s ess, dep ession) o pa icipan s who comple ed he cogni i e beha iou al in e en ion p og amme. No co esponding changes we e iden i ied in he con ol g oup. The e was a signi ican ly g ea e change in BBI 15 om baseline o he in e en ion g oup han o he con ol g oup. The UWES ques ionnai es seemed o p oduce nea ly he same imp o emen in bo h he in e en ion and con ol g oups, al hough he imp o emen in he con ol g oup was no s a is ically signi ican because o he g oup size. Fac o s associa ed wi h social p ocesses a wo k seem o be c ucial o bu nou as measu ed by BBI 15. Bu nou is connec ed o job demands, a lack o job esou ces, and heal h p oblems. When in e en ion leads o posi i e changes in pa icipan s’ physical condi ion o wo k en i onmen , pa icipan s ha e been shown o be able o modi y hei sel -pe cep ions, esul ing in psychological and beha iou al changes, such as inc eased sel -app o al, sel -me cy, and ecogni ion o hei inne needs and limi s [28–30]. I seems ha he e ec s o ou cogni i e beha iou al in e en ion o imp o e employees’ well-being was able o mee some challenges in he imp o emen o a i udes as measu ed by BBI 15. The UWES 9, used o de ine h ee dimensions o wo k engagemen , showed signi ican imp o emen in he in e en ion g oup, o whom goals we e se in collabo a ion wi h he pa icipan s, and e e y pa icipan de ined hei own goals o imp o e hei wo k abili y. An ea lie s udy also sugges ed ha ocusing on wo k engagemen migh bene i he indi idual. Employees who seem o pe o m be e ha e ele a ed le els o ene gy and iden i ica ion wi h hei wo k [29]. All h ee UWES dimensions we e a a e age le els a he beginning and ollow-up, al hough abso p ion inc eased o an ele a ed le el in bo h he in e en ion and con ol g oups. I may be ha he ques ionnai e ac ed as an in e en ion o bo h g oups, ega dless o o he in e en ions [30,31]. The composi e o wo dep ession sc eening i ems showed signi ican imp o emen a ollow-up o he in e en ion g oup. This esul con as s somewha wi h ea lie e idence ha he use o sc eening o dep ession is associa ed wi h only a modes inc ease in i s ecogni ion. I used alone, sc eening ques ionnai es o dep ession appea o ha e li le o no impac on he managemen o dep ession [ 25 ]. Howe e , ou in e en ion was pe o med a e ini ial sc eening and appea ed o in luence dep essi e hough s posi i ely. The s ess sc eening consis ed o a single ques ion, and s ess was lowe a e he in e en ion. This esul is in line wi h p e ious indings ha cogni i e beha iou al s ess managemen in e en ions a e mo e e ec i e han o he in e en ion ypes [32]. The p ac ical poin o in e en ion is o be awa e o he di e en p o iles among employees ega ding adjus men s in he wo k and non-wo k demands hey ace. I is impo an o c ea e in e en ions o suppo wo k cul u es o di e se ways o wo king, because he e is no single op imal way o manage bounda ies be ween wo k and non-wo k. Pe son-o ien ed in e en ions ha a e ailo ed o suppo di e en p o iles a e needed [33]. Limi a ions o he S udy One limi a ion is ha he pa icipan s ep esen a ela i ely small popula ion in Finland. The in e en ion and con ol g oups we e selec ed pa ly acco ding o he pa icipan s’ own in e es s. In . J. En i on. Res. Public Heal h 2019,16, 80 9 o 11 The o e all wo kload o e e y employee in he wo kplace was conside ed du ing he selec ion p ocess by he employe . This selec ion may ha e p oduced di e ences be ween he g oups a baseline, and selec ion o he in e en ion migh be one d i e o some changes in he sco es. Supe iso s played a key ole in alloca ing pa icipan s o g oups. A andomised con ol g oup could no be used o he in e en ion because o wo kplace cons ain s. Issues ha needed o be conside ed included he ime able o he en i e p ocess, holidays, indi iduals’ wo k si ua ions, and he need o achie e a su icien numbe o pa icipan s in he in e en ion g oup— he e we e no he same numbe s o pa icipan s in he con ol g oup. Howe e , he con ol g oup was om he same wo k uni as he in e en ion g oup, and pa icipan s we e chosen as andomly as possible om ha en i onmen . Ques ion-based esea ch may su e om bias i he pa icipan s eel sa is ied wi h he se ice and he e o e espond posi i ely when hey answe he second ime. Two dimensions o he UWES 9 esul s also imp o ed in he con ol g oup, and s a is ically, he same change was signi ican in he la ge in e en ion g oup, bu no in he smalle con ol g oup; he change be ween he g oups showed no s a is ical di e ence. This kind o long-las ing se ice includes many changing a iables, which makes i di icul o de ine he causes o he esul s. A hi d measu emen poin would ha e enabled b oade s a is ical analysis. In his s udy, we had a espec able amoun o da a o ensu e i s adequacy o possible d opou s. D opou is a p e alen complica ion in he analysis o da a om ollow-up s udies, bu in his s udy, he e we e no di e ences be ween hose who esponded compa ed wi h hose who did no in e ms o age, gende , yea s o wo k o wo k uni . As pa o ou esul s sugges ha he cogni i e beha iou al in e en ion was e ec i e in inc easing employees’ well-being, we cu en ly ha e no measu es o show i s inancial bene i s o he employe . One ecen sys ema ic e iew has ound ha i is di icul o d aw conclusions abou he cos -e ec i eness o in e en ion ou comes, because o he shi ing quali y o he s udies [33]. 5. Conclusions This s udy sugges s ha a cogni i e beha iou al in e en ion achie ed signi ican imp o emen s in se e al measu es o men al heal h. The esul s imply ha his kind o in e en ion is needed o gi e ea ly suppo on men al heal h issues o he wo king-age popula ion. Ea ly ehabili a ion allows pa icipan s o play an ac i e ole while hey s ill ha e he esou ces o make changes in hei own li es. O e all, he esul s o his s udy pe mi he conclusion ha his kind o se ice does suppo wo king abili y in oday’s municipal sec o . I is impo an o ac p e en i ely while pa icipan s ha e he esou ces o play an ac i e ole. Pee suppo also has ema kable alue o inding solu ions in di e en li e si ua ions. Au ho Con ibu ions: All au ho s we e in ol ed in he de elopmen o he s udy design. B.O. was esponsible o he da a collec ion and o w i ing he manusc ip . S.T.N., C.-H.N. and P.B. pa icipa ed in he gene al coo dina ion o he s udy and co ec ed d a e sions o he manusc ip . H.H. p o ided s a is ical consul a ion. Funding: This esea ch ecei ed no ex e nal unding. Acknowledgmen s: We wish o hank all employees who pa icipa ed in his s udy, and he pe sonnel depa men o he Ci y o Tampe e. We hank Ee a Saa ela and Tullinkulma Occupa ional Heal h Uni o hei coope a ion, o conduc ing he in e en ions, and o da a managemen . Con lic s o In e es : The submi ed manusc ip does no con ain in o ma ion abou medical de ice(s) o d ug(s). No bene i s in any o m ha e been o will be ecei ed om a comme cial pa y ela ed di ec ly o indi ec ly o he subjec o his manusc ip . Re e ences 1. Spa ks, K.; Fa aghe , B.; Coope , C.L. Well-being and occupa ional heal h in he 21s cen u y wo kplace. J. Occup. O gan. Psychol. 2001,1, 489–509. [C ossRe ]