EMPLOYEE ASSISTANCE PROGRAMME: A WORKPLACE INTERVENTION FOR PSYCHOLOGICAL HEALTH AND SICKNESS ABSENCE MARZUKI ISAHAK THESIS SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PUBLIC HEALTH FACULTY OF MEDICINE UNIVERSITY OF MALAYA KUALA LUMPUR 2013 UNIVERSITY OF MALAYA Original literary work declaration Name of Candidate: MARZUKI BIN ISAHAK (I.C/Passport No: 790615-07-5789) Registration/Matric No: MHC 090019 Name of Degree: Doctor of Public Health Title of Project Paper/Research Report/Dissertation/Thesis (“this Work”): EMPLOYEE ASSISTANCE PROGRAMME: A WORKPLACE INTERVENTION FOR PSYCHOLOGICAL HEALTH AND SICKNESS ABSENCE. Field of Study: PUBLIC HEALTH (OCCUPATIONAL HEALTH) I do solemnly and sincerely declare that: (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title of the Work and its authorship have been acknowledged in this Work; (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutes an infringement of any copyright work; (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (“UM”), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by any means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM. Candidate’s Signature Date Subscribed and solemnly declared before, Witness’s Signature Date Name: Designation: ii Abstract Background: The Employee Assistance Programme (EAP) for stress is an individual approach worksite-based programme to improve psychological health of the workers. However, the scientific evidence on effectiveness of EAP is still controversial. Most EAP providers claim that the EAP gave positive impacts on personal health and work performance. However, records from employers show a contradictory finding based on their sickness absence, worker’s compensation and incomplete work days data. Evidences from Asian countries on this matter were still scarce. In Malaysia, there was no published study on the effectiveness of EAP. Objectives: The objective of this study was to determine the effectiveness of EAP in the improvement of workers psychological health status and sickness absence. Methods: This is a randomised-controlled trial conducted among 150 workers in a public university in Kuala Lumpur. There were 75 participants in both intervention and comparison group respectively. Information on socio-demographic data and self- perceived depression, anxiety and stress using DASS-21 questionnaire was administered at baseline. Biochemical, anthropometry and clinical data were measured pre- intervention. Sickness absence data also was obtained from the Human Resource Department. Psychological work exposures were measured via Job Content Questionnaire (JCQ). EAP interventions given were consisting of stress management workshop, two sessions of individual counselling and relaxation therapy for the period of six months. As for the comparison group, only self-help stress management pamphlet was given to them. All the indicators were repeated in both groups post-intervention. Results: The participants mean ages were 43.0 and 44.2 years old for intervention and comparison group respectively. The majority of participants in both groups were females, Malay ethnicity and in support group of occupational class. The baseline self- perceived psychological symptoms mean score in intervention group were 5.36, 6.35 iii and 7.89 for depression, anxiety and stress respectively. In comparison group, their mean score for self-perceived depression, anxiety and stress were 4.95, 5.87 and 7.59 respectively. There was similar proportion of high job strain of 21.3% in both groups. Both groups showed a baseline sickness absence rate of more than 2 days over 6 months period. After the intervention, there were significant improvement in self-perceived depression (p <0.001), anxiety (p <0.001) and stress (p <0.001) score among intervention group as compared to comparison group. Serum cortisol also showed a significant reduction in intervention group post-intervention (p<0.05). However, all the other biochemical, anthropometry, clinical and sickness absence indicators did not show significant difference after the intervention. As for work psychological exposures, EAP managed to significantly reduce participants’ job demand (p<0.01) and increase co-workers support (p<0.05). Conclusion: EAP for stress has shown to significantly improve self-perceived depression, anxiety and stress symptoms. Our results proved that EAP is effective in Malaysia especially among university workers. Trial Registration: IRCT201102275923N1 Funding: Postgraduate Research Grant, University of Malaya Keywords: Stress Management Programme, Stress, Depression, Anxiety, University. iv Abstrak Latar belakang: Program Bantuan Pekerja (EAP) bagi tekanan psikologi adalah program di tempat kerja yang direka khas untuk meningkatkan kesihatan psikologi dan fizikal. Keberkesanan program ini masih lagi menjadi persoalan ramai terutamanya dari pihak majikan. Kebanyakan pembekal EAP mendakwa bahawa EAP memberi impak positif ke atas kesihatan diri dan prestasi kerja. Walau bagaimanapun, rekod daripada majikan menunjukkan terdapat percanggahan berdasarkan rekod cuti sakit dan tuntutan pampasan oleh pekerja. Kajian dari negara-negara Asia mengenai perkara ini masih sukar didapati. Di Malaysia, masih tiada kajian yang dilakukan sebelum ini bagi menilai keberkesanan EAP terhadap kesihatan fizikal, psikologikal dan kadar cuti sakit. Objektif: Objektif kajian ini adalah untuk menentukan keberkesanan EAP dalam peningkatan status kesihatan psikologi dan fizikal pekerja dan pengurangan cuti sakit. Kaedah: Kajian ini merupakan kajian rambang terkawal (randomised-contolled trial) yang dilakukan di kalangan 150 pekerja di sebuah universiti awam di Kuala Lumpur. Terdapat 75 orang peserta masing-masing di dalam kumpulan intervensi dan kumpulan perbandingan. Di awal penyelidikan, maklumat latar belakang sosio- demografi dan tahap kemurungan, kebimbangan dan tekanan melalui soal selidik DASS-21 telah diperolehi. Maklumat data biokimia, antropometri dan klinikal diukur sebelum intervensi diberikan. Data cuti sakit juga telah diperolehi dari Jabatan Sumber Manusia. Pendedahan kepada risiko psikologi di tempat kerja juga telah diukur dengan menggunakan soal selidik kandungan kerja (JCQ). Intervensi yang diberikan adalah bengkel pengurusan stres, dua sesi kaunseling individu dan terapi relaksasi bagi tempoh enam bulan. Bagi kumpulan kawalan, hanya risalah pengurusan tekanan emosi v diberikan kepada mereka. Selepas intervensi, semua penunjuk diukur sekali lagi dalam kedua-dua kumpulan. Keputusan: Purata umur peserta kajian adalah 43.0 dan 44.2 tahun masing-masing di kumpulan intervensi dan perbandingan. Kebanyakan peserta kajian di dalam kedua-dua kumpulan adalah wanita, berketurunan Melayu dan bekerja di dalam kumpulan sokongan. Paras awal purata markah simptom psikologi di dalam kumpulan intervensi adalah 5.36, 6.35 dan 7.89 masing-masing untuk kemurungan, keresahan dan tekanan. Manakala di dalam kumpulan perbandingan pula, purata markah untuk kemurungan, keresahan dan tekanan masing-masing adalah 4.95, 5.87 dan 7.59. Peratusan peserta yang terdedah kepada tekanan kerja yang tinggi adalah sama di antara kedua-dua kumpulan iaitu 21.3%. Kedua-dua kumpulan juga mencatatkan purata cuti sakit yang hampir sama iaitu 2.23 (kumpulan intervensi) dan 2.01 (kumpulan perbandingan) hari dalam tempoh 6 bulan. Selepas intervensi, terdapat penurunan yang signifikan dalam tahap kemurungan (p <0.001), keresahan (p <0.001) dan tekanan (p <0.001) di kalangan kumpulan intervensi berbanding dengan kumpulan kawalan. Kandungan serum kortisol juga menunujukkan penurunan yang signifikan di kalangan peserta di dalam kumpulan intervensi (p<0.05). Walau bagaimanapun, petunjuk biokimia yang lain, antropometri, klinikal dan cuti sakit tidak menunjukkan perbezaan yang signifikan selepas intervensi. Bagi pendedahan kepada risiko psikologi di tempat kerja, EAP berjaya mengurangkan beban kerja (p <0.01) dan meningkatkan sokongan rakan sekerja (p <0.05). Walau bagaimanapun, ia juga meningkatkan kebarangkalian untuk terdedah kepada salah satu faktor risiko iaitu kemahiran kerja yang rendah (p <0.01). Kesimpulan: EAP untuk tekanan emosi telah terbukti dapat menurunkan kadar kemurungan, keresahan dan tekanan. Keputusan ini juga membuktikan bahawa EAP berkesan untuk diaplikasi di Malaysia terutamanya dikalangan pekerja universiti awam. vi Pendaftaran Kajian: IRCT201102275923N1 Pembiayaan: Geran Penyelidikan Siswazah, Universiti Malaya. Kata kunci: Program pengurusan stress, Tekanan, Kemurungan, Keresahan. Universiti vii Acknowledgements Firstly, I would like to acknowledge and express my sincere appreciation to my content supervisor, Dr Azlan Darus, Senior Lecturer in Occupational and Environmental Health Unit, Department of Social and Preventive Medicine, University of Malaya for his strong guidance, support and encouragement throughout the study. I would also like to express my deepest thank to my methods supervisor, Dr Moy Foong Ming, Associate Professor in Epidemiology and Biostatistics Unit, Department of Social and Preventive Medicine, University of Malaya for her useful suggestions, strong support and expert statistical guidance. I would like to express my deepest appreciation and gratitude to all participants as well as the UM Wellness team members who assisted in this study. This research would not have been possible without financial assistance from Post-graduate Research Funds of University of Malaya, Kuala Lumpur (Project number: PS175/2009b). Special thanks to the management of University of Malaya for allowing me to conduct this study. Last but not least, an utmost thanks to my loving wife (Sharifah Malihah Wan Mustapha), adorable children (Yusuf Irfan and Sofea Zahra), loving mother (Patimah Ahmad), caring father (Isahak Salleh) and all my family members who have always support me for my success. Thank you to all of you. Marzuki Isahak UM, Kuala Lumpur, Malaysia viii Publications The following papers have been presented and submitted from this thesis: Conference presentations: 1. Serum Cortisol and Cardiovascular Risk Factors, The 42nd Asia-Pacific Academic Consortium for Public Health Conference, November 2010, Bali, Indonesia. 2. Work Psychological Risk Factors and Job Strain among Employee in a Public University, International Society of Critical Health Psychology 7th Biennial Conference, April 2011, Adelaide, Australia. 3. Employee Assistance Programme for Stress: Psychological and Physical Impacts, The 4th Regional Conference on Occupational Health, June 2011, Kuala Lumpur, Malaysia. 4. Depression, anxiety and stress among university workers in a public university. The 1st Asia Pacific Clinical Epidemiology and Evidence-Based Medicine, July 2012, Kuala Lumpur, Malaysia. Publications: Isahak M, Darus A, Moy FM, Yasin SM, Retneswari M. Employee Assistance Programme for Stress: Psychological and Physical Impacts. Annals Academy of Med Spore (Submitted) Depression, anxiety and stress among university workers in a public university. Preventive Medicine (Submitted) Abstract proceedings Isahak M, Darus A, Moy FM, Retneswari M. Employee Assistance Programme for Stress: Psychological and Physical Impacts. Mal J Public Health Med, 2011; Vol.10; Supp. 2: 30. ix Table of Contents Original literary work declaration ................................................................ ii Abstract ....................................................................................................... iii Abstrak .......................................................................................................... v Acknowledgements ................................................................................... viii Publications ..................................................................................................ix Table of Contents .......................................................................................... x List of Figures .......................................................................................... xvii List of Tables ..............................................................................................xix List of Symbols and Abbreviations ............................................................. xx CHAPTER 1: INTRODUCTION ................................................................. 1 1.1 Background ............................................................................................................ 1 1.2 Research Problems and Public Health Significance .............................................. 3 1.3 Study Rationale ...................................................................................................... 9 1.4 Study Objectives .................................................................................................. 10 1.4.1 General objective .......................................................................................... 10 1.4.2 Specific Objectives........................................................................................ 10 1.5 Research hypotheses ............................................................................................ 10 1.6 Thesis Contributions ............................................................................................ 11 1.7 Operational definition .......................................................................................... 12 CHAPTER 2: LITERATURE REVIEW .................................................... 16 2.1 Stress, depression and anxiety.............................................................................. 16 2.1.1 Stress ............................................................................................................. 16 2.1.1.1 Definition of stress ................................................................................. 16 x