Article Summary 2 full pages with a single space. APA formate and proper intext citation.

Article Summary 2 full pages with a single space. APA formate and proper intext citation. RESEARCH Open Access

Interventions for the prevention and
management of occupational stress injury
in first responders: a rapid overview of
reviews
Jesmin Antony1, Raman Brar1, Paul A. Khan1, Marco Ghassemi1, Vera Nincic1, Jane P. Sharpe1,
Sharon E. Straus1,2 and Andrea C. Tricco1,3*

Abstract

Background: First responders are a high-risk population for occupational stress injuries as they often encounter
prolonged stress within their line of work. The aim of this rapid overview of reviews is to summarize existing
evidence on interventions for the prevention and management of occupational stress injury (OSI) in first
responders.

Methods: MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Library were searched for
systematic reviews examining the impact of prevention, rehabilitation, and resilience-building strategies targeting
frontline community safety personnel in February 2019. Pairs of reviewers screened titles and abstracts followed by
full-text articles and conducted data abstraction and quality appraisal using the AMSTAR II tool. To ensure a rapid
overview process, the search strategy was limited to the last 10 years, quality appraisal of reviews and abstraction of
study-level data was completed by one person and verified by another, and the quality of the individual primary
studies was not appraised. The findings were summarized descriptively.

Results: A total of 14 reviews with 47 unique primary studies were found after screening 1393 records. A majority
of studies targeted OSI in police officers (78.7%), followed by firefighters (17%) and correctional officers (4.3%). Of
the 47 included primary studies, 24 targeted prevention of OSI (i.e., resilience training, stress management, suicide
prevention, and other health promotions) and 23 targeted rehabilitation (i.e., drug therapy, psychotherapy, and
other therapies). Prevention strategies including resilience training programs had positive outcomes, while suicide
prevention and psychotherapy interventions reported mixed results.

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* Correspondence: Andrea.Tricco@unityhealth.to
1Knowledge Translation Program, Li Ka Shing Knowledge Institute, St.
Michael’s Hospital, 209 Victoria Street, East Building, Toronto, Ontario M5B 1
W8, Canada
2Department of Geriatric Medicine, University of Toronto, Toronto, Ontario,
Canada
3Epidemiology Division, Dalla Lana School of Public Health and Institute for
Health, Management, and Evaluation, University of Toronto, Toronto, Ontario,
Canada

Antony et al. Systematic Reviews (2020) 9:121
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(Continued from previous page)

Conclusions: Some promising interventions targeting the prevention and rehabilitation of OSI among police
officers, firefighters, and correctional officers were identified in the included studies, and these results will serve as a
basis for the development of evidence-based strategies to mitigate future risks in this population. However, several
gaps were also identified in this area that will require further investigation prior to widespread implementation of
effective interventions.

Systematic review registration: PROSPERO CRD42019125945

Keywords: First responders, Interventions, Occupational stress injury, Police, Firefighters

Background
Occupational (or operational) stress injury (OSI) de-
scribes a broad range of psychological and other condi-
tions resulting from duties performed on the job that
interferes with a person’s professional and personal life,
including anxiety, depression, and post-traumatic stress
disorder (PTSD) [1, 2]. First responders are a particularly
susceptible population to these injuries, as they often en-
counter high-risk situations and must deal with daily,
routine stressors within their line of work [3]. Although
there is a large amount of literature on OSI among first
responders, research has traditionally reported on mili-
tary personnel, due to the extremely high rates of PTSD
and associated conditions they experienced in the late
twentieth century and early 2000s [4–6]. More recently,
research focus has shifted to include paramedics and
emergency medical services (EMS), noting that this
population has similar patterns of stress injury as those
seen in veterans [7, 8]. However, there has been less
focus on groups categorized as frontline community
safety personnel, such as police officers and firefighters,
and especially correctional officers and coroners.
The impact and cost of OSI are well-documented.

There are substantial direct and systemic costs, such as
cost to individuals affected and their primary caregivers,
cost of healthcare providers for treatment of OSI-related
ailments, and the cost of lost labor and productivity of
officers taking medical or stress leave [3]. This project
was commissioned by the Ontario Ministry of Commu-
nity Safety and Correctional Services (MCSCS), to assess
the utility of interventions currently implemented at the
workplace targeting OSI as a first step to the develop-
ment of evidence-based action plans to mitigate future
risks in this population.
To address this need for evidence, we conducted a

rapid overview of reviews (hereafter called overview)
summarizing the usefulness of existing strategies for the
prevention and management of OSI targeting frontline
public/community safety personnel.

Methods
An overview (i.e., a synthesis of systematic review find-
ings) is an effective method to systematically gather,

appraise, and summarize existing evidence on a broad
topic that has been well-studied, and identify gaps in the
research efforts to date [9]. This overview includes sys-
tematic reviews targeting first responders or frontline
community safety personnel, including police officers,
firefighters, correctional officers, and coroners, with a
focus on prevention and rehabilitation of OSI.
To ensure methodological rigor, the review team

followed guidelines outlined by the Cochrane Handbook
chapter regarding Overview of Reviews [10, 11] and ap-
plied the Preferred Reporting Items for Overviews of
Systematic Reviews Including Harms (PRIO-harms)
checklist (Additional File 1) for transparency of our
methods [12]. However, to meet the rapid, 10-week
timeline needs of our primary knowledge user (MCSCS),
some streamlined steps were taken. Specifically, the
search strategy was limited to reviews in English pub-
lished in the past 10 years (2009 onwards), and rather
than appraising the methodological quality of each re-
view in duplicate, one person appraised the included re-
views and another verified the appraisal for accuracy. As
such, the methodology was considered to be a rapid (or
streamlined) overview.

Protocol registration
A protocol for the overview was developed a priori and
registered on the PROSPERO database (registration no.
CRD42019125945). However, upon starting the review, a
few minor modifications were made to the outlined
methods. For example, we added “rapid” to the title of
the overview of reviews for transparency of methods,
and we chose to define first responders using inclusive
terminology relevant to the MCSCS (i.e., frontline pub-
lic/community safety personnel).

Eligibility criteria
Study eligibility criteria developed using the PICOS
(population, intervention, comparator, outcome, and
study) approach [13] were as follows:

Population
Populations of interest included frontline community
safety personnel (i.e., police and firefighters), coroners/

Antony et al. Systematic Reviews (2020) 9:121 Page 2 of 20

https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019125945&ID=CRD42019125945

https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019125945&ID=CRD42019125945

forensic pathologists, and correctional service employees.
As it was not of relevance to our knowledge user, re-
views that only included EMS personnel were not in-
cluded. However, reviews including a mix of frontline
community safety personnel were included.

Interventions
Interventions of interest were prevention strategies (e.g.,
training and learning approaches, standards of practice,
surveillance of risk factors, self-assessments, screening
protocols), rehabilitation (e.g., therapeutic interventions,
digital interventions, pharmaceutical interventions, psy-
chological interventions, organizational support systems,
peer support programs), and resilience-building strat-
egies (e.g., shifting organizational culture, mental health
promotion, overcoming organizational barriers, leader-
ship/management training, overcoming stigma) targeting
OSI.

Comparators
Any comparisons to the interventions listed above, in-
cluding usual care or no treatment, were eligible for
inclusion.

Outcomes
Primary outcomes of interest were the effects of the in-
terventions on mental health status, including but not
limited to the following: OSI, trauma, anxiety, depres-
sion, mood, addiction/substance abuse, PTSD, stigma,
suicidal ideation/behavior, time lost from work, and
physiological responses to trauma such as increased
pulse/heart rate or fatigue/sleepiness. Healthy and mal-
adaptive habits and general health and job satisfaction
outcomes were also considered.

Study design(s)
Included studies were systematic reviews, defined by the
Cochrane Handbook as a systematic synthesis of empir-
ical evidence [11] of interventions.

Others
Our literature search was limited to reviews published in
English in the last 10 years; however, individual studies
included in these reviews were not restricted by publica-
tion date.

Study selection
Our search strategy was developed by an information
specialist and peer-reviewed by another using the Peer
Review of Electronic Search Strategies (PRESS) checklist
[14]. MEDLINE, EMBASE, PsycINFO, CINAHL, Web of
Science, and Cochrane Library databases were searched
on February 17, 2019, for relevant reviews. The search
was limited to include English-language reviews

published in the past 10 years (i.e., 2009 onwards). The
search strategy for MEDLINE can be found in Appendix
B (Additional File 1). To further ensure that all relevant
reviews were included, the reference lists of included re-
views were scanned for additional citations.
Titles and abstracts (level one) and full-texts (level

two) were screened for relevance by two reviewers inde-
pendently using the synthesi.SR tool [15] developed by
the Knowledge Translation Program, St. Michael’s Hos-
pital of Unity Health Toronto. To ensure consistency
among reviewers, one pilot test was conducted prior to
both levels of screening. This entailed screening of 100
citations by the team at level one with 86% agreement
and screening of 20 full-text articles at level two result-
ing in 75% agreement. Subsequently, pairs of reviewers
proceeded to screen the remaining articles independ-
ently at each level of screening. Discrepancies were re-
solved through discussion or by a third reviewer when
necessary.

Data abstraction
A standardized data abstraction form was developed
based on predefined eligibility criteria. Data from each
review were abstracted on characteristics (e.g., year of
conduct, number of included studies, type of included
study designs, sample size), interventions examined (e.g.,
type of intervention, duration, frequency), and outcomes
examined (e.g., name of outcome, outcome measure/def-
inition). The team piloted the data abstraction form on
five articles. After meeting and discussing discrepancies,
pairs of reviewers independently abstracted data from
the included articles. Discrepancies were resolved by a
third reviewer.
In order to supplement the review-level data and pro-

vide the commissioning agency with more information
on the interventions and outcomes examined, the review
team took an additional step of abstracting relevant data
from each of the primary studies, including specific
components of the interventions and effect sizes and sig-
nificance levels of the outcomes examined. These data
were abstracted by one reviewer and verified by a second
reviewer. A table was also created to determine the ex-
tent of overlap in primary studies included across the
reviews.

Quality appraisal
AMSTAR 2 (A Measurement Tool to Assess Systematic
Reviews version 2) [16] is a 16-item critical appraisal
tool that we utilized to assess the methodological quality
of all included reviews. An experienced reviewer inde-
pendently read and appraised the risk of bias for each re-
view, while a second reviewer verified the results.
Discrepancies were resolved by discussion or by a third
reviewer, if needed. Response options for the AMSTAR

Antony et al. Systematic Reviews (2020) 9:121 Page 3 of 20

2 included “yes,” “partial yes,” and “no.” In order to reply
“yes” or “partial yes,” the review had to meet all of the
criteria specified by the tool. A “no” was used to indicate
that the criteria for either “yes” or “partial yes” were not
met or there was an absence of the item overall.
An overall score was also given to each review to indi-

cate whether the review was of high, moderate, low, or
critically low quality. The overall score was based on the
number of “no” responses to the pre-defined critical
checklist items (items 2, 4, 7, 9, 11, 13, 15), indicating
“critical flaws” within the review’s design or conduct.
The maximum score a review could receive was “high”
quality if there were no critical flaws, then “moderate”
quality if there was one critical flaw, followed by “low”
quality if there were two critical flaws, and the lowest
possible score on the tool was “critically low” quality if
there were more than two critical flaws.

Data synthesis
The results of the included reviews and primary studies
are summarized descriptively. The data are presented in
tables to allow for comparisons across populations, in-
terventions, and outcomes in the following results
section.

Results
Literature search
A comprehensive database search identified 1377 re-
cords, with an additional 16 located through scanning
the reference lists of the included reviews. In total, 1393
titles and abstracts were screened for eligibility at level
one and 121 full-text articles at level two. Fourteen rele-
vant reviews (including 47 unique primary studies) met
eligibility criteria and data were abstracted from these
articles. The full study flow, with reasons for exclusion,
is provided in Fig. 1.

Review characteristics
The 14 included reviews were conducted from 2009 to
2019 and the corresponding authors were predominantly
located in Australia (42.9%) and the United States (USA)
(28.6%), followed by Canada (14.3%), the Netherlands
(7.1%), and the United Kingdom (UK) (7.1%) (Table 1).
Of the 14 included reviews, only two included a single
population group of police officers, the other 12 in-
cluded mixed populations (e.g., military workers, nurses,
volunteers).
Within the 14 reviews, we identified 47 unique pri-

mary studies, examining both a relevant first re-
sponder population and an intervention targeting OSI.
The majority of the studies focused on police (78.7%)
and firefighters (17%) with only a small percentage fo-
cusing on correctional services (4.3%). No relevant
coroner/forensic pathologist studies were found and

none of the included studies reported multiple rele-
vant populations. In total, 11 of the 47 included stud-
ies overlapped, 10 of which were found in two of the
included reviews, and 1 was found in 4 of the included
reviews as presented in Appendix C (Additional File
1). The majority of included primary studies were
RCTs (40.4%), followed by observational (19.2%),
quasi-experimental (14.9%), NRCT (12.8%), case re-
ports (10.6%), and a descriptive study (2.1%). All were
conducted between 1979 and 2017.

Summary of included reviews
Table 2 summarizes the 14 included reviews. Although
many of these reviews included a large number of pri-
mary studies, only a small subset was directly relevant to
this overview. The excluded primary studies (Additional
File 1) either included populations that were not relevant
to our overview (e.g., non-first responder populations)
or did not include interventions targeting OSI (e.g.,
study on the prevalence of PTSD). The citations of the
47 relevant primary studies included in our overview are
listed in Table 2 and further details on each study can
be found below.

Quality appraisal of included reviews
A summary of the quality appraisal results of the 14 in-
cluded reviews using the AMSTAR 2 tool can also be
found in Table 2. A more detailed quality appraisal table
can be found in Appendix D (Additional File 1), which
includes the responses for each of the 16 items on the
AMSTAR 2 tool. Two of the reviews could not be ap-
praised for quality because they did not find studies
reporting results of an intervention. The majority of the
reviews were rated critically low (71.4%) or low (14.3%)
in terms of the overall review quality. Two reviews were
rated moderate (14.3%) quality. The most common crit-
ical flaws within the low-quality reviews were the lack of
a protocol or an a priori design (item 2) and no list of
excluded studies (item 7). A large portion of the low-
quality reviews did not complete a risk of bias assess-
ment for their included studies (item 9), and therefore,
risk of bias was also not considered when interpreting
the results (item 13).

Data synthesis
Since the included systematic reviews provided few de-
tails on the interventions and outcomes assessed in their
primary studies, we abstracted this information from the
relevant primary studies themselves. In the following
section, the 47 unique primary studies reporting any
intervention are organized by study population.

Antony et al. Systematic Reviews (2020) 9:121 Page 4 of 20

Police
Twelve reviews included 37 unique studies examining
interventions targeting OSI in police officers. Summaries
of the included police primary studies are presented in
Appendix E1 (Additional File 1), including the studies’
objectives, methods, results, and conclusions.

Firefighters
Interventions for firefighters were examined in six re-
views, including eight primary studies, and summarized
in Appendix E2 (Additional File 1).

Correctional services
The two intervention studies for correctional officers we
found in two reviews are summarized in Appendix E3
(Additional File 1).

Interventions and outcomes examined
In this section, the 47 primary studies are categorized by
intervention type and a summary of each study, includ-
ing relevant outcomes, is provided below. A description
of each of the study populations, interventions, and

Fig. 1 Rapid overview of reviews flow chart

Antony et al. Systematic Reviews (2020) 9:121 Page 5 of 20

findings are also presented in Table 3 (prevention inter-
ventions) and Table 4 (rehabilitation interventions).

Prevention interventions
Prevention strategies were explored in 24 primary stud-
ies. Twenty-one of these studies included police (officers,
recruits, veterans, management and support staff), 2 fo-
cused on firefighters, and 1 study was conducted with
correctional staff.

Suicide prevention (n = 4 studies) Four studies exam-
ining suicide prevention programs involving various in-
terventions were included. The Together for Life
program (Mishara et al., 2012) [44] was a comprehensive
suicide prevention strategy targeting the Montreal Police
Force. The intervention involved training for all officers,
supervisors, and union representatives, as well as estab-
lishing a volunteer helpline and a publicity campaign.
Twelve years after implementing the program, the study

reported a statistically significant decrease in suicide
rates in Montreal police (− 78.9%; p = 0.008) and a sta-
tistically significant reduction in suicide rates post-
program compared to police in other provinces (p =
0.007). Another suicide prevention program for police
officers described by Welch and colleagues [45] in South
Africa also found reduced depression, PTSD, and suicide
numbers post-intervention; however, statistical signifi-
cance was not tested. Similarly, a report was published
describing the Badge of Life Psychological Survival for
Police Officers Program (BOL); however, the effective-
ness of this program on suicide rates was not evaluated
[43]. Finally, Finney et al.’s [42] quasi-experimental study
found no statistically significant differences in suicide
rates after the implementation of a suicide prevention
program to educate firefighters about suicide.

Resilience training (n = 4 studies) Two studies ex-
plored effective resilience programs in junior officers.
Arble et al. [31] examined a program designed to in-
crease resilience and build coping mechanisms while re-
ducing trauma. Each session in the quasi-experimental
study used audio recordings and scripts to take new po-
lice officers through a sequence of imagined scenarios
beginning with a relaxation scenario and building up to
an enhanced trauma scenario. After the program, a sta-
tistically significant increase in the use of positive coping
strategies like humor (mean change = 0.78; p = 0.02)
and positive reframing (0.61; p = 0.02), as well as statisti-
cally significant decreases in anxiety (− 0.42; p = 0.02)
and substance abuse (− 0.39; p = 0.04) were reported in
the new officers. Similarly, in a randomized trial [32], a
group of rookie police officers (i.e., 1 year of experience
on the Swedish police force) with trauma resilience
training was compared to a group that received regular
training. The resilience training involved education ses-
sions, imagery training, and mental skills rehearsal and
resulted in statistically significantly less negative mood
(mean change = − 1.11; p = 0.03), but no change in posi-
tive mood when compared to the control officers.
Mindfulness-based resilience training (MBRT) was

assessed in a longitudinal cohort study by Christopher
et al. [33]. The 8-week training program used experien-
tial exercises like body awareness scans, meditation,
martial arts, and mindful movement to introduce police
officers to the practice of mindfulness. Group classes
were supplemented with reading material and take-
home practice exercises. In this study, improvement was
seen during the program in many outcomes including a
statistically significant increase in resilience (mean
change = 0.7, p = 0.001), mindfulness (1.19; p < 0.001), mental health (0.78; p < 0.001), emotional intelligence (0.74; p = 0.01), and physical health (0.48; p = 0.04), and statistically significant decreases were noted in fatigue Table 1 Review and primary study characteristics Characteristics N (%) No. of included reviews 14 Date of publication 2009–2012 4 (28.6%) 2013–2016 5 (35.7%) 2017–2019 5 (35.7%) Country of publication Australia 6 (42.9%) Canada 2 (14.3%) Netherlands 1 (7.1%) UK 1 (7.1%) USA 4 (28.6%) No. of included primary studies 47 Study design Randomized controlled trials 19 (40.4%) Non-randomized controlled trials 6 (12.8%) Quasi-experimental 7 (14.9%) Observational 9 (19.2%) Case report 5 (10.6%) Descriptive 1 (2.1%) Population Police 37 (78.7%) Firefighters 8 (17.0%) Correctional services 2 (4.3%) Coroner/forensic pathologists 0 (0.0%) Intervention Prevention 24 (51.1%) Rehabilitation 23 (48.9%) Antony et al. Systematic Reviews (2020) 9:121 Page 6 of 20 Table 2 Review summaries Review author (year) Review country Review objective(s) Total no. of studies included in review (no. of relevant studies) Citations of relevant studies (author, year) Population(s) included in relevant studies AMSTAR 2 score Lees, T (2019) [17] Australia To review the most recent information regarding anxiety, PTSD, sleepiness, and fatigue and to identify interventions and treatments proposed to overcome work-related stressors and associated mental ill- nesses inflicting law enforcement officers. 43 (6) Arble, 2017; Chongruksa, 2012; Christopher, 2016; Oliver, 2009; Peres, 2011; Plat, 2013 Police Critically low Barger, LK (2018) [18] USA To critically review and synthesize existing literature on the impact of fatigue training on fatigue-related outcomes for emergency medical services (EMS) personnel and similar shift worker groups. 18 (4) Christopher, 2016; Holbrook, 1994; Kuehl, 2016; Sullivan, 2016 Police, firefighter Moderate Torchalla, I (2018) [19] Canada To summarize the evidence base for interventions targeting individuals with work-related post-traumatic stress disorder (PTSD), to make rec- ommendations for clinicians and ad- ministrative decision-makers involved in their rehabilitation, and to guide future research in this area. Particular attention was given to studies that were conducted in nat- uralistic clinical settings or in a workers’ compensation claim context. 11 (2) Gersons, 2000; Lansing, 2005 Police Critically low MacMillan, F (2017) [20] Australia To systematically review studies of health promotion interventions in the police force. 21 (7) Jeter, 2013; Kuehl, 2016; Norris, 1990; Norvell, 1993; Richmond, 1999; Short, 1984; Tanigoshi, 2008 Police Low Witt, K (2017) [21] Australia To summarize the international literature on the effectiveness of suicide prevention programs for protective and emergency services employees. 13 (4) Finney, 2015; Levenson, 2010; Mishara, 2012; Welch, 1998 Police, firefighter Critically low Rose, FR (2016) [22] USA To conduct a systematic review and meta-analysis with regards to the ef- fectiveness of psychological debriefing. 27 (8) Bohl, 1991; Bohl, 1995; Carlier, 2000; Harris, 2002; Leonard, 1999; Regehr, 2001; Ruck, 2013; Tuckey, 2014 Police, firefighter, correctional services Critically low Whybrow, D (2015) [23] UK To summarize current knowledge about TRiM and make recommendations for further research. 13 (2) Hunt, 2013; Watson, 2014 Police Critically low Milner, A (2014) [24] Australia To provide a systematic assessment of workplace suicide prevention activities, including short-term train- ing activities, as well as suicide pre- vention strategies designed for occupational groups at risk of suicide. 13 (1) Mishara, 2012 Police Critically low Patterson, GT (2014) [25] USA To conduct a systematic review examining the effects of stress management interventions on outcomes among police officers and recruits. 12 (12) Ackerly, 1986; Coulson, 1987; Digliani, 1994; Gersons, 2000; Ireland, 2007; McCraty, 1999; Norvell, 1993; Richmond, 1999; Shipley, 2002; Short, 1984; Tanigoshi, 2008; Wilson, 2001 Police Critically low Skeffington, PM (2013) [26] Australia To conduct a systematic review in order to identify and synthesize all 7 (3) Arnetz, 2009; Sarason, 1979; Sijaric- Voloder, 2008 Police Critically low Antony et al. Systematic Reviews (2020) 9:121 Page 7 of 20 (0.59; p < 0.001), anger (0.63; p < 0.001), burnout (0.74; p = 0.001), difficulties with emotional regulation (0.83; p = 0.01), perceived general stress (0.75; p < 0.001), organizational stress (0.72; p = 0.002), and operational stress (0.56; p = 0.007). Visuo-motor behavior rehearsal (VMBR) is a sequenced simulation intervention involv- ing a relaxation period, followed by an imagery rehearsal opportunity, and ending with a highly stressful, critical event-training scenario. Shipley et al. [34] found that participants in the VMBR group experienced statistically significantly lower anxiety (mean difference = 1.72; p < 0.05) when compared to the control group as measured by the cognitive state anxiety component of the Com- petitive State Anxiety Inventory-2 (CSAI-2) scale, but no significant differences were reported in the other two components of this scale. Stress management (n = 7 studies) Four randomized trials were conducted that evaluated stress management programs for police officers. HeartMath was a program involving 3 training sessions aimed at reducing stress, improving physiological and emotional balance, increas- ing mental clarity, and enhancing performance and qual- ity of life. McCraty et al. [37] reported improvements in some of these areas including considerable decreases in fatigue and the overall global negative emotion subscale; the latter subscale is the average of the individual scores for the …