Good morning, everyone. Welcome to session 308 on an initiative to safeguard and promote the mental health of workers, part one, burden and best practices. This session is linked to the session 315 that will be this afternoon, in which we will discuss interventions and increasing awareness, reducing stigma and lowering barriers to mental health care. On behalf of my co-moderator, Dr. Thomas Cunningham and our speakers, we look forward to the opportunity to share updates on efforts in the initiative thus far. My name is Sudha Pandale and I'm an occupational medicine physician in the division of science integration at the National Institute for Occupational Safety and Health and will serve as the moderator for these presentations. While not able to participate in AOHC in person this time, we very much appreciate all the conference organizers working to make the virtual participation possible. This session will end with a QA component and so we ask that questions be held until that time and we will also address virtual questions then. And we also ask everyone in the room to please use a microphone because that way we can all hear those of us presenting virtually. Before we begin, I would like to thank Drs. Kent Enger and Lee Newman for being on-site representatives of our team for this and the associated session this afternoon. So before I begin, I do have to note a disclaimer that the findings and conclusions in this session are those of the authors and do not necessarily represent the views of the National Institute for Occupational Safety and Health, the Colorado School of Public Health, the Oregon Health and Science University and the University of Ottawa or the Indiana University. Next, I would like to just describe our objectives today. We would like to present some of the elements of the Health Worker Mental Health Initiative. We hope that after the presentation, those of you participating will understand some of the approaches that are being used to characterize the burden and nature of mental health outcomes in health workers. And hopefully we'll be able to discuss some of the evidence-based for interventions, best practices and resources that have been found thus far to be relevant regarding mental health issues in workers. This is just an overview of how the presentations will flow. And Dr. Tom Cunningham, Suzanne Marsh and Kent Anger will address these objectives through their presentations. These timings are approximate, but we will be sticking to this agenda to the best of our ability. So our- Well, lovely. Your pictures are actually covering the top right of the slide. So you can't really see what's on the top right of the slide very well. Okay, let me see if I can remove this. How's that? Is that better? Much. Okay, sorry about that, everyone. Thank you. So our first presentation will be by Dr. Thomas Cunningham. And it is- Hold on here. I'm not able to move the slides. There we go. And it's titled the NIOSH Initiative for Health Workers and we'll present an overview of this effort. Dr. Cunningham is a senior behavioral scientist in the Division of Science Integration of the National Institute for Occupational Safety and Health and serves as the scientific lead of the Health Worker Mental Health Initiative. His research addresses intervention development and research translation for safety and health applications in construction, healthcare and small business sectors. I now ask Dr. Cunningham to begin his presentation. Thank you, Sudha. And thanks everybody for being here today. I'm sorry I can't be with you in person, but really excited to be able to talk to you today about our Mental Health Initiative for Health Workers. Next slide, please. So why are we having this session today? Well, a pretty big reason why has to do with the American Rescue Plan of 2021 when NIOSH received funding specifically to deliver a national awareness and education campaign to safeguard and improve the mental health of health workers. Now, this funding was largely in response to the COVID-19 pandemic and the obvious toll that it was taking on the mental health and wellbeing of our health workforce. And I think it's important to note right up front here what we mean when we say a health worker. Now, this includes many of the familiar roles we think of when it comes to providing patient care, clinicians, physicians, nurses, frontline health workers as we would think of them. But we also include several support roles that are often overlooked in intervention and research efforts. Jobs such as home health aides or patient care aides, nursing assistants, lower wage positions that may be encountering even worse rates of poor mental health outcomes. We also include many other roles such as first responders, public health workers, behavioral health workers and community health workers. So it's a pretty significant workforce that we're trying to address here. Next slide, please. So why has NIOSH been tasked with this important work? Well, we have roughly over 30 years of experience at NIOSH in addressing workplace stress and conducting intervention research. And specifically, we have four programs at NIOSH that provide the scientific underpinnings for the work that we're doing within this initiative. And specifically, our healthcare and social assistance sector program provides us with all sorts of important connections into the healthcare sector. The total worker health, the healthy work design and wellbeing cross-sector program and the work organization and stress research programs all provide us the expertise and the underpinnings that we need around mental health. We know that with the NIOSH approach to any worker issue is to minimize the hazardous elements of any job. For example, it's not enough to overcome 10 to 12 hours of just ridiculously stressful and overwhelming work with a referral to an EAP program. So we know we have to take it up to the systems level or the organization level here to have a meaningful impact. Next slide, please. So the focus for our health worker mental health initiative is really squarely on employers primarily. We want to equip employers and empower workers to be able to promote safer and healthier workplaces through interventions, recommendations and capacity building. We focus on employers because we know they're the ones who have the power to make changes in the workplace when it comes to things like workplace flexibility, job demands and control, ability to take time away from work. So they're the primary audience, but we also want to put useful tools in their hands that will reach the hands of workers as well. Next slide, please. So this graphic provides us sort of an overview of what the main objectives are for this initiative. As I mentioned at the beginning, our mandate from Congress is to generate a national awareness and education campaign. And you see that represented here as one of our main objectives. But there is no off the shelf, ready to go communication campaign that NIOSH could push out the door. So we have a lot of foundational work that we've had to get in place in order to support the development of such a communication campaign. So starting in the upper right, one of our first objectives is to better understand and characterize the mental health burden that health workers are up against. And not only the burden that they've experienced during the COVID-19 pandemic and thereafter, but recognizing the burden that existed prior to the COVID-19 pandemic. And our colleague here, Suzanne Marsh, is gonna tell us a bit more about that in her next presentation. Another objective that we've established is to assimilate the evidence base around what are the best evidence-based interventions? What are the best practices? What are people currently doing to address mental health among the health workforce? And some of our presentations today, including that from Dr. Kent Anger coming up, we'll dig into this much deeper. We hope that this will provide sort of a basis for what our communications campaign will focus on for content. Another objective we have is to take advantage of our existing and new partnerships. So not only do we take advantage of several longstanding partnerships that NIOSH has established across many of the programs I've already described, but we've also worked with many of our colleagues at the CDC Injury Prevention Center to take advantage of some of their existing partnerships as well. Another main objective we've identified is to identify and adapt new tools. We wanna support the development of new screening tools, new ways to get resources into people's hands more quickly and more efficiently. And then finally, the overall objective here is around generating awareness, around carrying messages directly to the healthcare employer and health worker audience that we know we wanna reach. Next slide, please. So now I'm just gonna kind of give you a brief update on the activities we've completed and what we think are the next steps that we have coming. So around understanding health worker burden, Suzanne will tell you much more about this, but we've been doing sort of an ongoing review of published mental health surveillance data, which is limited at best. We've had some ongoing analyses of some of the BRFSS data that Suzanne will describe. And we've also been working to adapt and broaden some existing surveillance tools, such as the quality of work-life survey and the worker wellbeing questionnaire. Next steps for us are going to be to continue to watch these data and see, are we able to move the needle at all on any of these mental health outcomes? And also to create some products here that can help share that information. Next slide. As I mentioned, one of our main areas of activity has been around assimilating the evidence base to support this effort. And one of the things we did very early on this past year was to publish a request for information. This was a document that went into the federal register asking the public to share with us, what are your best practices? What are the interventions that you're using? What are the approaches that you're using? What are the barriers that you're coming up against as you address mental health among the health workforce? We received over 121 comments on this request for information, just a really rich source that's currently under analysis by others that are working on Kent's assimilation team. And we're learning some very interesting findings right away and hearing from healthcare workers themselves that some of the things that they're looking for help with aren't gonna be solved with additional therapy sessions or referrals to counseling. They're talking about very sort of basic needs like solving scheduling issues or adequate staffing levels or having better pay. Next steps for what we expect to see come next here are to complete draft reports that describe this evidence-based and start developing some evidence-based resources for communication campaign products. But as I mentioned, Kent will tell us much more about this in his portion. Next slide, please. We've been working to create several new partnerships for NIOSH. I'll just mention a couple, one being the National Action Alliance for Suicide Prevention. This is a group we were introduced to by our Injury Prevention Center colleagues. And we have quickly learned that they have a vast network of key players across the health workforce that we need to be connected with. We've also been working closely with partners We've also been working closely with partners in labor as well as across other federal agencies. I'll just mention specifically HRSA who also has significant funding that they have been supporting grants around workforce resilience training efforts as a part of the American Rescue Plan. So we're excited to be connected with them on this effort as well. Next slide, please. So another objective I mentioned was to identify or adapt tools. And to support this objective, we've funded several projects early on. And I'll just mention a couple of them here. Early on, we funded a cooperative agreement with the American Hospital Association to identify best practices around suicidality identification screening and resource development and best practice identification among their hospital members. We've also funded intervention research at several of our total worker health centers of excellence that were funded on a five-year cycle this past fall. What we expect to do going forward here, of course, we'll continue to explore new grant and cooperative agreement opportunities. And we'd like to try to convene several of the funded researchers across both NIOSH and HRSA to identify some early wins that this research is producing. Next slide, please. Finally, this is all driving towards a pretty significant communications campaign for NIOSH. Some of the work we've already done is to scan recent campaigns, see what's already out there. I'll tell you one that we noticed very quickly was one that CDC supported in the course of the COVID-19 pandemic, the How Right Now campaign that CDC continues to support. We've also hosted a call to action webinar this past November where the US Surgeon General, Dr. Vivek Murthy joined John Howard, our director, along with representatives from SEIU and from the Mayo Clinic in a call to action around health worker, mental health and wellbeing. We're working quickly to award a contract very soon to actually carry out this entire communication campaign as well. So we're excited to see that contractor come on board so that we can start to pass on the knowledge that we've been developing and turn that into some tangible products. Next slide, please. So in the meantime, as we develop this campaign, if you'd like to follow along with these developments, I'll just note where we're posting information currently about our communication campaign and this mental health initiative here at the Work Stress and Mental Health page for healthcare workers that you see on your screen. And next slide. And that wraps up my introductory overview. I'm happy to pass it back to Dr. Pandale. Thank you. Thank you, Dr. Cunningham, for that excellent overview of the initiative. Just for the audience's information, Dr. Cunningham will be participating in the QA time at the end of the session for any questions. We will move on now to our next presentation, which will be by Ms. Suzanne Marsh. She will be presenting a talk titled Characterizing the Burden and Nature of Mental Health Outcomes Among Health Workers. Ms. Marsh is a research statistician and serves as the team lead for the special studies team in the Surveillance and Field Investigations Branch in the Division of Safety Research at NIOSH. She is a subject matter expert on fatal and non-fatal occupational injury surveillance and research and is currently leading analytic work to examine issues related to mental health among various worker groups. I now ask Ms. Marsh to begin her presentation. Thank you. So good afternoon or good morning, depending on where you are located. My name, as Suda mentioned, is Suzanne Marsh and I am with the National Institute for Occupational Safety and Health. It's a real honor to be with you today. I'm pleased to have the opportunity to present a summary of NIOSH's efforts to characterize the burden and nature of mental health outcomes among healthcare workers. Next slide. So as Tom mentioned in his introduction, the goal of this initiative is to improve the mental health and wellbeing of the nation's health workers. We are doing this through a series of activities, including prevention, awareness, and intervention. My presentation is going to focus on that upper right quadrant of the circle, understanding the burden that healthcare workers face related to poor mental health outcomes. We use the terms health worker and healthcare worker interchangeably. However, for the remainder of my presentation, I'm going to refer to these workers as healthcare workers. And in many cases, this phrase will be abbreviated HCW on the slides. Next slide, please. To date, most research that's been conducted on the mental health of healthcare workers has largely focused on those frontline healthcare workers, including physicians, residents, and nurses. Although we've included support staff in the analysis that I'm going to be discussing in just a few minutes, research on support staff, including housekeeping, maintenance, and patient aid workers, those who may be in lower paying jobs is generally omitted. The research that has been conducted suggests that problems related to mental health among healthcare workers include anxiety, depression, post-traumatic stress, burnout, and these issues often lead to the worst outcome, and that is suicide. Furthermore, as Tom noted, we are looking at and including public health workers. We've excluded them in the analysis that I'm going to present, but these public health workers often face many of the same demands and stressors. However, public health workers are often omitted from research on the mental health and wellbeing of healthcare workers. As with most research, the findings of the various studies that have been done, they do vary by study, health outcomes, as well as population. Next slide, please. As part of the larger initiative that Tom described in his introduction, our efforts to date have included an analysis of pre-pandemic data, as well as various literature scans. As was noted, the objective of these efforts has been to spotlight the personal, social, and economic burden of adverse mental health outcomes. Next slide, please. So I'm going to take the next few minutes to describe healthcare worker burden based on pre-pandemic data. Next slide. For this study, we use data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, or BRFSS. This is a population-based telephone survey of non-institutionalized U.S. adults that's administered by each state and territory with technical assistance from CDC. For those not familiar with the BRFSS, there's a core survey that contains questions about chronic health conditions and asks the respondents to self-rate their health. There are optional models, including a module that contains industry and occupation information. This information is collected for respondents who are employed for wages, out of work for less than one year, or self-employed, and is collected through open-ended questions. What kind of work do you do? Followed by, what kind of business or industry do you work in? Unfortunately, many of these optional modules are not consistently used by all states or across years. In our case, our study period, which covered 2017 to 2019, there were only 22 to 30 states that opted to include this particular module. So the data that I'm going to be presenting over the next couple of minutes is not going to be generalizable beyond the states that we analyzed. Next slide, please. To explore mental health outcomes among healthcare workers, we selected all healthcare workers within the healthcare industry using coded industry and occupation data. We used non-healthcare workers outside of healthcare as the comparison group. So a little bit later on, I'm going to draw some particular attention to public health workers, but for the purposes of this study, workers that were involved in the public administration of health programs are included in the non-healthcare worker group that was used for comparison purposes. We calculated unadjusted and adjusted prevalences for specific conditions and used the adjusted prevalence ratios for comparison purposes. The adjusted prevalence ratios were adjusted for age, sex, and race ethnicity. Next slide, please. So what did we find when we analyzed the BRFSS data? We found a sample of almost 38,000 healthcare workers responded to the survey. Almost half worked for hospitals, almost a third for ambulatory settings, a 10th worked for skilled nursing care facilities, and another 8% for home health agencies. Next slide. Before I get into the details of the mental health findings, I wanted to define a couple of measures that we used in our analysis. We were particularly interested in self-rated health respondents 18 and older, and that self-rated response would have been fair or poor. We were interested in those reporting physical distress. In other words, those who reported their physical health was not good for at least 14 of the past 30 days. And finally, mental distress was defined as stress, depression, and problems with emotions for at least 14 of the past 30 days. Next slide, please. We also were interested in those reporting activity limitations for at least 14 out of the past 30 days. These limitations included poor mental or physical health that prevented usual activities. We also analyzed details on respondents who had been told by a healthcare provider that they had a depressive disorder, including depression, major or minor depression, or dysenthymia. Finally, we explored those reporting insufficient sleep, which was defined as less than an average of seven hours of sleep per 24-hour period. I should point out that while we analyzed data for those who were employed or self-employed, the questions that we explored regarding various mental health concerns did not specify whether these issues were related to work, associated with work, or otherwise. Next slide, please. This slide provides the comparisons of those six health conditions that I just described. So the non-healthcare workers are the blue bar, and the healthcare workers are depicted by the green bar. As you can see, none of the differences were terribly large. Non-healthcare workers were slightly more likely to report fair or poor health and frequent physical distress. On the other end, healthcare workers were more likely to report diagnosed depression and insufficient sleep. In the middle, the two groups had similar percentages of frequent mental distress and activity limitations. Next slide, please. So we explored those same six health conditions by specific occupation for healthcare workers and compared those findings to non-healthcare workers. Just to make sure that you know what we're talking about, the light blue bar is diagnosing practitioners. The green bar is treating practitioners. The maroon bar is technologists and technicians. The gray bar is support workers. And finally, the darker blue bar is non-healthcare workers. We found something that really kind of stood out to us. In almost all six of the conditions, healthcare support workers were more likely to report having fair or poor health, physical or mental distress limitations on activity, and insufficient sleep. However, these same workers may also be more likely to experience certain socioeconomic disadvantages that are not fully explained by occupation, and those things may be further impacting our findings. Conversely, health diagnosing practitioners reported the lowest percentages for the six health conditions compared to the other occupation groups. Next slide, please. So there are certain limitations related to the BRF assessed data. First, data are self-reported and may be impacted by a certain amount of response bias. Questions related to mental health are not comprehensive. We also are unable to assess the duration or severity of depression as this is not part of the survey. Finally, as I noted at the outset, the industry and occupation module is an optional module, so the data that I presented is not nationally representative and is only reflective of the states that reported data from 2017 to 2019. Next slide, please. So as I mentioned at the outset, a second part of our efforts involved a literature scan. Next slide. Before I review the findings of the literature scan, I want to mention that while we are providing data on mental health prior to and during the pandemic, the information that I'm presenting in these sections is from different sources, and thus should not be compared. We use the BRF assessed to look at pre-pandemic data, and the next series of results are based on results of various studies that were identified that were conducted during the pandemic. This slide highlights just some of the issues that healthcare workers experienced. It's no surprise that issues related to mental health have skyrocketed. Over 90% of healthcare workers surveyed reported feeling stressed from June to September 2020. Nurses, women, and younger healthcare workers reported more severe psychological symptoms in studies published from December of 2019 through April of 2020. And the pooled prevalence of healthcare workers with moderate depression and PTSD was calculated to be at 22% based on various studies that were published between December 2019 and August 2020. Next slide. An umbrella review of various systematic reviews on mental health of healthcare workers was conducted in March of 2021 comparing the prevalence of anxiety among healthcare workers in general and specifically among physicians and nurses. The study found that the prevalence of anxiety among healthcare workers in general ranged from 22 to 33% while physicians had prevalence of anxiety ranging from 17% to 20% and nurses had a prevalence of anxiety that ranged from 23 to 27%. Burnout, workplace stress, difficult working conditions like long hours, fatigue, violence, substance use disorder risks and injury risk including the risk for suicide have been part of the healthcare landscape for decades. The baseline risk for mental health challenges was already elevated. Next slide, please. Next slide. That same umbrella review conducted in March of 2021 found that the prevalence of depression was higher than the prevalence of anxiety. The prevalence of depression among healthcare workers in general ranged from 18% to 36% while physicians had a prevalence of depression of 40% and nurses had a prevalence of depression of 28%. Sorry. You can go ahead and go to the next slide. Thank you. In a 2021 future of work and nursing survey that assessed mental health conditions during COVID, 22% of the 400 frontline nurses surveyed reported thinking about leaving their positions. They reported that at least five factors were impacting their decision including insufficient staffing, workload, the emotional and physical toll and not feeling supported. Next slide. So this slide compares surveys that were implemented for two different time periods, August 20 through September 2 of 2021 and more recently January 8 through January 29, 2022. And this survey was conducted among nurses. The survey asked questions about current mental health. Although four months did not make a huge difference in feelings of stress, frustration and exhaustion, you can see that in January of this year, a higher proportion of nurses reported having extremely stressful, disturbing or traumatic experiences related to COVID. And I will note that there was not a timeframe regarding this experience. Next slide. In a study of physician burnout that was conducted in the fall of 2020, 69% of the physicians reported feeling down, blue or sad. 20% reported severe depression and 13% reported having thoughts of suicide. Next slide. Finally, and as I mentioned previously, a survey of public health workers was conducted from March 29 through April 16 of 2021. This survey investigated the presence of depression, anxiety, post-traumatic stress and suicidal ideation among state, tribal, local and territorial public health workers during the pandemic. Just over 26,000 public workers responded to the survey. Fifty-three percent reported having at least one of the mental health conditions that I just mentioned in the two weeks prior to completing the survey. There are currently plans to repeat the survey this year, so it's going to be interesting to compare the results from 2022 to 2021. Next slide. Next slide. Mental health, needless to say, is a huge black box. So we face many, many challenges when attempting to conduct research on this topic. First, there is not a single comprehensive surveillance system that we can tap into to explore this topic. Mental health itself is an incredibly broad topic and can present in multiple types of conditions. Finally, it's clear from the literature that there isn't one single assessment method or instrument that researchers can use to study mental health. Next slide. So I just wanted to make a few points as I wrap up. I think we all recognize that the research on this topic is incredibly fragmented. Based on the data from the BRFSS, of all of the occupations in healthcare, healthcare support workers who tend to have lower-paying jobs may be at higher risk in mental health conditions. The BRFSS study that I summarized earlier found that workers in this occupation are largely female, have relatively high percentages of African-American workers, have low educational attainment, and or have low household incomes. Many of these workforces are subject to multiple stressors, from discrimination to restricted occupational options, but are often understudied in the mental health research. Thirdly, while the pre-pandemic research suggested that healthcare workers faced adverse mental health conditions, the pandemic has certainly exacerbated and magnified the issues healthcare workers face. And finally, as we work to continue to understand the burden of adverse mental health among healthcare workers, we need to also bring, we need to also be considering interventions, best practices, and current resources that healthcare workers can tap into. Next slide. I appreciate your attention, and I will turn it back over to Dr. Pandani. Thank you, Ms. Marsh, for that detailed review of your current work, looking at burden among health workers, in particular using the BRFSS data, as well as a snapshot of some of the literature that currently exists, and we can all see how complex the issue is. For the audience's information, Ms. Marsh will also be participating in the QA time at the end for any specific questions on this aspect of the information. At this point, we are going to take a moment to switch screens. Our next presentation will be from Dr. Kent Anger. It is titled Evidence-Based Interventions, Best Practices, and Current Resources. Dr. Anger is the Associate Director for Applied Research and a Senior Scientist Professor at the Oregon Institute of Occupational Health Sciences at the Oregon Health Sciences University and Portland State University School of Public Health. Dr. Anger has conducted research and published extensively in areas related to chemical and non-chemical occupational exposures, research and design of intervention strategies for the prevention of work-related illnesses and injuries, and is currently leading a major component, the assimilation of evidence component for the Mental Health and Health Worker Initiative. This work is targeted to collating and understanding current evidence regarding interventions and best practices for mitigating mental health issues in the worker population, and Dr. Anger will be focusing on that in his presentation. I will be asking Dr. Anger to begin his presentation once we switch screens, so I will stop sharing right now, and hopefully you can begin there. Okay. Thank you, Sudha. Thank you, Kent. Okay. So, welcome, everybody. I'm Kent Anger, and I do my presentations on a Mac. I use a font named Chalkboard. Chalkboard apparently becomes comic when it moves to the PC, and I did check it last night. I put it on the PC. I looked at it, but I didn't see it in this form, so with apologies, and I hope you'll hang with me for this, because I do respect the subject and respect the audience, and that is not what's intended. It may appear from the font. So, at any rate, it shows the funding down at the bottom. I have a contract from NIOSH to do this work. My two colleagues, Jen Dimoff, who's a specialist in mental health, and Lindsey Allony, who's a specialist in systematic reviews, the three of us worked on this systematic review, and the same comment about the authors are responsible for what's in the presentation, not the organizations. So, what was the scope of the review? It was really to develop an accurate and comprehensive assessment of proven interventions, really meaning evidence-based interventions, and best practice and resources currently available for the prevention of adverse mental health outcomes in the healthcare workforce. Who's our target audience? Well, it's people who run healthcare systems and health systems, safety and health, and HR departments. So, I think it's you. I think it's you in the audience. So, as I go through this presentation, as we're doing this for you, if you see things that you say, gee, I wish Ken had asked that question. I wish he'd look at these questions. Please come up to me afterwards and tell me that, because in the end, this becomes a report and a publication. But again, we are doing it focused on you, so any suggestions would be really appreciated. And my email is on at the end of the presentation as well. Okay. So, what was our systematic review? What methods did we use? Well, the definitions are on the screen. The target population, those were the terms we used. I'm sure you're all familiar with systematic reviews. Mental health, the terms in the middle that we used, and the contractions that we searched for. And then intervention. How did we determine if the publication was an intervention? So, those were the terms that we used to search. And the search sources, the databases that we went to are the ones that are shown on the screen. Obviously, important ones would be PubMed and PsychInfo for these kinds of search, for this kind of search. So, the search timeline was performed in two ways. The first one ended in September of 2021, and the second one through March of 2022. This presentation reports just on the first search through September of 2021. And the one for, through 2022 is in progress. We also, in that second review, looked at the NIOSH Total Worker Health Centers, of which, one of which I was the director of, founding director of one of the centers. So, we looked at their research as well. So, all the relevant literature from wave one, which is reported here, brought into Zotero and Covidence to do the search process. And the screening strategy, the articles were gathered and screened for relevance, first by Lindsay, a senior research associate. And then, we imported the articles into Covidence, and then further screened them, title and abstract. And we did it blinded. So, when two authors were reviewing each one, if one did it, when one did it first, the second one didn't see what the first one said before they got through it, they got through theirs. And in that full-text review, the next full-text review, which again was blinded with two or three authors, we use, we would decide on inclusion or exclusion to meet the criteria. And then, we applied the Downs and Black from 98 quality ratings. There are actually 27 items in that quality rating. We dropped out a couple that were just related to clinical trials, and went through and reviewed every article against those 25 quality rating issues. And then, we rated our confidence. We made a confidence rating at the end. Having just done the Downs and Black review, what confidence did we have that the results that the author wrote in the publication reflected what you would find if you implemented that same intervention in your organization? And so, that was a qualitative review, but it was based on a quantitative review that had just happened before that. So, what about inter-rated reliability? Well, we set reliability expectations, and when we got particularly to the full-text review and to the DNB ratings, we had good correspondence or good reliability, we felt, with each other. So, we felt that we had met our expectations. So, I think you can see that at the back. We started with 4,728 publications. Actually, Lindsey's the one who started with those. She went through them, and then, at the end, we ended up with 54 studies after going through those steps in the lower left. So, 54 interventions done on mental health improvements, and done, there were interventions and then published in the peer-reviewed literature. The gray literature ended up not yielding much of anything. It was just the peer-reviewed literature that reviewed things we felt were, met our expectations. So, looking at, then, the number of articles, of those 54 articles, they're on the left-hand side of the screen. The quality rating from Downs and Black is on the left, and our confidence rating is in the middle, and I'm going to kind of concentrate on that, because it's just easier to kind of get your mind around four parts, instead of 25 different numbers. So, of those that were rated 4 or 3.5, and a 3.5 rating meant, one of the raters rated it as a 4, and the other rated it as a 3, so 3.5. So, of those four, seven articles were rated 4, and six articles, 3.5. And then, as you move down to lower ratings, lower confidence, you see where the numbers show up there. Now, remember, these are our ratings of the articles. It means the articles were, gave us a certain amount of information. It doesn't mean that the interventions they were using, necessarily, was bad or good. This is how well did the article present, study that particular intervention. So, I caution you to remember that we're not saying that the intervention is bad. We're saying, in some cases, the article has insufficient information to let us give it a high rating. Okay, when did these publications come out? So, most of them came out in 2020 and 2021, and that worried us a little bit, because we thought, maybe, as when COVID hit, people kind of said, we need to do an intervention. We've got problems here. We need to do something, and, geez, we should analyze, we should evaluate it. So, let's do an evaluation. We've got to get through IRB. Maybe they didn't, you know, maybe they didn't do as much as they might in developing the study. So, we thought, what's the confidence that we had across the years? And so, I've kind of arbitrarily organized it by years, and showing our confidence rating, which, remember, reflects the Downs and Black quantitative rating, and, as you see, as it moves towards the right, when you get to 2021, our confidence ratings were still high of the articles that came out then. So, maybe they rushed to get it done, but maybe the IRBs really helped and said, we'll give you, get you through quickly, and so, our confidence ratings remained high for even the most recent studies. Okay, how many of them were which design types did these 54 articles have? Well, 12 of them were RCTs and 35 of them were quasi-experimental, meaning, of course, that they probably did a baseline in most cases, then they did an intervention with a group, and then they did testing afterwards to see if there was an impact or an effect. And so that was a typical quasi-experimental study, still a solid design, but not a randomized design. And then you can see there were others as well. The number of people, of participants, ranged from 11 to 2,080. And most of them were in the 50 or less category, about a fair number of them, 22 of them were in that category. And as you look down at the other numbers, you see those with large numbers of subjects or participants, there weren't a lot of those. Where'd they come from? Where were these things conducted? They were conducted in, 19 of them were conducted in the United States and a fair number in Italy and Canada, and then the rest kind of spread out around the world. Everybody, it seemed like every country said, we need to do an intervention and did it over this period of time. And our search was not bounded at the beginning. We searched from the beginning of time or the beginning of databases, all interventions that met our criteria until again, through September, and now more recently, through 2022. And we've included them. Now, some of these studies were conducted in cultures and in health systems, way different from the United States. But those, some of them were quite intriguing, quite interesting, were well done, and they may have relevance. We felt we shouldn't be making the decisions for you, that you should have the information and you should make the decisions about what were the best studies, or what would be the relevant studies or interventions for you. And I'll say that two of my favorites came from South Africa and Ethiopia, and they were solid. So they're all in the report that we're gonna put out there for you to look at. Where were they conducted? Well, 39 in hospital settings and 14 were online or telecounseling, and then a few other, one was done at home. So what kind of interventions were they? How do we categorize them? Well, individual coping skills, a lot of them were focused on teaching individual coping skills to the participants. 20 of them, 20 of the articles or interventions had that. Those that had peer support and teams, there were 11. Those were focused on system or disorders. There were 10 of those. And some of them targeted the whole system. And sometimes they were symptom-related, but they were cut across the whole system. So we kind of categorized them that way. And then a few of them were just medical or pharmaceutical, kind of tertiary interventions. And speaking of that, what prevention type were they? How might we describe them? Well, if we think of them as primary, secondary, or tertiary, we categorize them in that way and sort of as a clinician would, we thought. And we're still kind of working with these categories to make sure that they really are clear because you had to do a lot of interpretation as you looked at the article. What tools do they have? What was in their sort of mind as what they were trying to accomplish? How far down the road were people in it? So these are, I guess, a little bit squishy, but still generally characterized as either primary, prevention, secondary, where they were kind of responding to the development, like with counseling, and then tertiary, where people were really seriously ill and they were trying to fix the problem at the end. But a lot of them, as you can see, kind of cut across categories for us. So who was in these studies? Well, mostly nurses. Most of the studies had nurses and other caregiver groups, physicians, pharmacists, various technicians, kinds of people who were working in the hospitals, and some of them just didn't even have any data on who they were studying, so that was worrying. But that's kind of the way that, what we found in these articles. But basically, nurses were the most frequently studied group and most of the studies had nurses and other groups as well, and other job titles as well. Okay, what outcomes were targeted? What were we looking for as mental health outcomes or symptoms? And we categorized, we found 35 and we began with a whole batch of large list and then we looked in the articles and anywhere we found an article, something that was measured as an outcome in an article, then we include it in the column in our spreadsheet that we developed for this. And so there are 35 of those outcomes that we put into 10 categories. And the categories are in yellow that you can see on the left and then the individual outcomes under them are categorized, are in white in the smaller letters. And two of them, depression and anxiety, were categories and outcomes unto themselves. And the others had kind of multiple things we thought could be categorized within the overall symptoms. So general health and well-being, stress and strain, depression, anxiety, burnout and compassion, fatigue, emotions and attitudes, resilience and coping, mindfulness, self-efficacy and self-esteem and civility and relationships. So those were the outcomes we were looking at. And I will say that in most of the studies, surveys that were adequate or well-validated surveys of these measures were used and they had good Cronbach's alpha scores as well. Not all, but the preponderance of them, the measurements were solid. Okay, what outcomes were targeted frequently? Well, the same ones that Suzanne talked about in her review that she just gave to you. And they're identified by asterisks in it. Stress, anxiety, burnout, depression and so forth. So looking at the first line, 24 studies addressed stress. They measured stress within the study and the intervention was designed to improve or reduce stress. Anxiety, same thing. You get down to mindfulness, they were designed to improve mindfulness or general health, they were designed to improve general health. And you can see that the studies focused on some of the most important outcomes. Again, the asterisk identifies those symptoms or outcomes that Suzanne mentioned in her previous presentation. So there were also some workplace measures in these studies, not a lot. The most frequently used one was intervention experience. So 20 studies looked at intervention experience, surveyed them. Of course, that wasn't a standardized survey, that was kind of like an ad hoc sort of survey. But there weren't a lot of organizational measures, I guess is sort of the summary of that point of this. So how long did the effect happen? Once you did the intervention, say you measured at baseline, then you then measured afterwards, how long did that measure, or when were those measurements taken? How long did they measure that the effect took place? And the answer is that most of them had a baseline and they measured at three and or six months. A very small percentage measured at a longer time frame after that, 12 months and or more. And then there were some that just had descriptive statistics. So we would have hoped that they would have measured a longer period of time, but this is what they measured. So, oh boy, this didn't translate, this didn't translate even worse. So I'm afraid of, because what I was trying to do was cover up all the detail at the bottom and just have you stick with the information at the top. So I'm sorry about that. It did work on the PC that I looked at on last night after I uploaded it. The PC here, I'm not so happy with. So, stress and anxiety. How many significant findings, looking at the first row of the column, the mental health outcome is stress, and the number of significant findings, so there's 14 studies that found significant improvements in mental health. What about the impact? What about the effect size? Not so many articles provided effect size information, and so what I've tried to do in here is put the number of where they reported effect size. So in that first row with stress, six of the studies reported the effect sizes, and if you look to the right, then two of them were small effect sizes, two were medium, and two were large. And of course, the information about the criteria that were used to set small, medium, or large are covered up by the graphic that's up there, but if you know Cohen's effect size, that's the most frequently used measure, and that that's not shown on the screen is that a small effect size was 0.2 up to 0.49, a medium effect size was 0.5 up to 0.79, and a large effect size was 0.8 or higher. So then if you look down at anxiety, there were 12 significant findings. So 12 studies found significant improvements in anxiety after they conducted their intervention, and of those, one was in a large effect size, one was in a small, and most of them were, or the four of them were medium. As you look down at depression, nine significant findings, four effect sizes, two medium and two large. So depression had pretty substantial effect sizes of the studies that studied them. And I wasn't really gonna spend any time on the rest of them, I was gonna leave them covered and just show you that there's more detail in there. Unfortunately, my hopes were undone. So same thing here. So what about interventions that reduced stress? So just looking at the intervention that reduced stress. So the first one that's on, the first line was mindfulness or cognitive-based, published in 2021, done in the UK. And there were, our confidence rating was four, so our confidence in it was high. And the hours per participant is the next number, 16. So the intervention took each participant 16 hours to go through, to be intervened upon. So what's really important about this number is if you're a hospital system and you want to implement this particular intervention, you know it's gonna take 16 hours for everybody who does it. So you look at the number of nurses and physicians and all the people that you want to be in that intervention, multiply their salaries by this number of hours, you know what it's gonna cost you. What it doesn't tell you is how long it takes to sort of put the intervention in place. That is something that we couldn't really pull out of the information, but you can. We have a little bit of comments about that towards the end. So the second one was another mindfulness-based study. That was resilience training, 2018 in the United States. High confidence rating, hours per participant, 22. It also was a medium effect size and it was a secondary prevention. And then the next one was focused on consciousness. The FOCO intervention, and there they didn't have an effect size. But it was primary prevention. I'm just gonna pull the rest of them off. So you'll see that there are two large effect sizes and that was acceptance and commitment, the ACT intervention, and then there was a stress management and resilience. These are kind of mindfulness-based approaches and they both had large effect sizes. But we also don't know how long they took because there wasn't enough information about it. So if I'm a hospital administrator and I'm worried about stress, I'd say, okay, there are some solid interventions out there. They were done in some cases in the United States or the UK with a similar culture, some of them that had large effect sizes were done in Ireland and the US, again, fairly similar culture. I'm confident that I have something to work with. I think that's kind of the conclusion I would come to if I were in what I imagine to be your shoes. Hope I'm right. So the rest of them I really wasn't gonna show just to show you that there were detail. This one worked out right. This is on how many interventions worked out reduced anxiety. Well, the top four were rated four or 3.5. They're mindfulness-based. This is the first one, telecounseling, the second one. The third one from Brazil is cannabidiol, if I'm pronouncing that correctly, I'm not sure. And then the fourth one was acupressure. Kind of the advantage to cannabidiol is it was done at home so it didn't take any time. Of course, if I'm a hospital administrator, am I really gonna wanna ask, report to my board that I'm asking everybody to take cannabis? I don't know. Those are not shoes I'm in so I don't know if that's a good idea or a bad idea. It is a tertiary prevention type but there are two medium effect sizes and those are the cannabidiol, if I'm pronouncing that correctly, and acupressure with team skills that were done in Brazil and in Turkey. Well, there are a bunch more, some with medium effect sizes. So there are a lot of studies that did address anxiety. So now how many interventions addressed depression, another important symptom or mental health problem that was confronted during the pandemic. And here, these are the top rated ones from our confidence rating. You can see which countries they're from. You'll see that you're seeing some of the same interventions, right? Because most of the interventions looked at multiple mental health symptoms. They attempted to address multiple mental health symptoms. And so mindfulness, cognitive-based, that one you've seen before several times, had a medium effect size. Again, it took 16 hours. Telecounseling, done in India, published in 2021, had four, had a high confidence rating, took only 1.5 hours and it was a secondary prevention type. But they didn't report an effect size and we couldn't calculate it from the data that they provided in the study. So repetitive transcranial magnetic stimulation done in 2016 in Korea. The amount of time it took was about two hours. It had a large effect size from their report and of course it's tertiary prevention type. And so there are a variety of possible interventions, again, that address depression. And here are some of the others that I, just to show you that there are more in the group. What about burnout? Another big symptom that was concerning that was addressed by multiple interventions. And the first one, occupational health support was done in the Netherlands. High confidence rating, didn't take long. Secondary prevention types, but we don't have an effect size for it. So we know that it's significantly reduced burnout. The statistics in most cases were pretty solid in all these studies and as well as, as best as we could assess them. And so there's a fairly significant effect. There is a significant effect there. Same with acupressure plus some kind of mindfulness or emotional control kinds of training. And then there's another one, acceptance and commitment therapy or ACT and cognitive behavioral intervention. And that too, that had a medium effect size. There are others that affected burnout, but there weren't other with effect sizes that we could report to you. Okay, so you've seen a bunch of these. I know there's a lot on the screen. They're actually more readable than I feared they were gonna be. And so to summarize at the end of that, for the high quality studies with significant findings, medium to large impacts on key healthcare problems, what are the ones that we had the most confidence in that the studies, if you repeated them, would find the same results? We're not saying we like these interventions. We're not saying they're good or bad interventions. We're saying that what they did, you judge whether they're good or bad for your system, that they are the ones that had significant impacts. And there are two of the mindfulness-based studies. Actually, the, well, the ones that say mindfulness-based resilience training and mindfulness-based training, again, it worked on my computer at home. And the smartphone-based resilience training, that's one study, just two conditions within one study, two separate groups. And then the last two are transmagnetic stimulation and cannabidiol therapy. So that's so far. With our next search that we've done, we do have more studies that fall into the high confidence rating, at least one more, and we probably will have 15 more interventions. So 54 here, 15 more. Will some fall into the same category, perhaps? Well, let's look at these interventions now, these ones that had high impact and significant findings and are looking at important outcomes. And let's see which ones they affected. Well, the first one, mindfulness cognition-based, you can see the outcomes. They affected well-being. We're really pleased to see well-being. It's a positive. They were increasing well-being. That was really good news and had a large effect size. Depression, medium. Stress, medium. Anxiety, self-compassion. Mindfulness. So getting people to become mindful. A mindfulness intervention, in some cases, was to improve a mindful quality in a person. So it seems like there are sort of two different sides of the same coin. One's the intervention, the other's the outcome. And then for the mindfulness-based resilience study, they addressed stress, effectively well-being, stress, emotional exhaustion, and self-compassion. And the mindfulness-based approach affected all of those, and those are the effect sizes shown there. Remember, that was a two-part study, and that's the one that had the smartphone-based study as well in it. In the smartphone-based part of the group, they had improvements in well-being and in self-compassion, whereas the other condition affected all of them, and those are the effect sizes that you see on the right. Transcranial magnetic stimulation, depression and strain, both large effect sizes. Cannabidiol, anxiety and depression, both medium effect sizes. So these are the interventions that had impact and the things that they affected. And I think from a good sort of positive standpoint, at least the first two, they really did affect a lot of different outcomes that are important to us that we've seen are problematic in serious problems in COVID times. So where were they done? Just to remind you of that, and whether they were secondary or tertiary, and none of them were primary intervention, so they weren't trying to get in in front of the problem. They were getting in at the time when the problem had developed, so they're trying to get in interventions. And then when things had gotten really seriously, had gone south, they were bringing in tertiary interventions. Okay, what about primary prevention? There were some that were primary prevention that tried to get ahead of problems, and they're listed on the ones that had confidence ratings, the highest confidence ratings of ours. There were four of them. There were a couple of more that had lower confidence ratings, but you can see those. They were conducted in Canada, Brazil, the United States, and again in Canada. And each of them was intended to develop prevention at the beginning when problems were developing, but none of them had effect sizes that they reported. So that was really, we wished they had effect sizes, and they could have calculated them, they just didn't provide us the information that we could calculate them for them. What are the outcomes that they improved? Mental health stigma, mental health stress, sleep exhaustion, self-compassion, depression, and so forth. And finally, the last one, absenteeism. So there was primary prevention, the effect sizes were not there, so we know they had significant improvements in these measures, but how much of an effect, we're not so sure about. Okay. Okay, now you're ready to pick a tool, you're ready to pick an intervention, right? You've got your symptom, your problems in your hospital, you know what you want to help your employees with, and you found an intervention you think looks good, you know, this kind of intervention would be effective, and in my group here, I'm comfortable with this thing. Are the toolkits there? Is the material in the publications, or reference to the publications, that you can take those and then implement them? Because if they're not, you've got to figure it out for yourself, right? You've got to take the publication, you've got to call the author, da-da-da, and I've written every author where they didn't have information about it to ask them about it, and I'm gathering that information. Some have responded. So those ones that had sort of highly rated successful interventions, one of them had a guide and prep, that was the mindfulness-based cognitive therapy, and the other three had the ability to replicate or implement the intervention. The mindfulness-based resiliency training had a course facilitator's guide that's available from the author. You could write, it was in the publication, you could write to the author, and I did write for that, and it looked like a pretty solid publication. The magnetic stimulant, transmagnetic stimulation, I mean, I don't know much about this, so if I'm kind of off, a little off base on this, I don't know, I'm sorry, but in the article it showed the placement for the stimulation, so I think you could replicate it with contacting the author about it. Then cannabidol, well, it's just twice a day, 150 milligrams taken at home. So that's doable. So what about the primary prevention? My previous slide, these were actually separated, so they're in yellow, the ones that did primary prevention, beyond silence, the first one, there's actually a two-day program available from the author, and they will come for $300 and give that program, or maybe they'll do it online, I'm not sure which, but they'll give it to your organization, if it's a large organization. If it's small, they'll do that for $150. So there's a resource out there that'll do that, but there were precious few of those in all these ones that we saw. Very few of them actually had the, well, none of them had a toolkit, very few of them had the materials or information that you could just take from the publication, off the shelf, and just plop it in place in your system. Okay, is this sufficient? Do you have sufficient resources? Well, despite the promise of these interventions, we do feel that there are some significant challenges. Very few interventions employed primary prevention strategies, and the ones that did were not particularly effective. Most interventions were focused on self-care, coping, placing most of the responsibility on the employee, of course. There's little evidence of how long the intervention was effective. I mean, typically, like one of them was a weight loss intervention, right? How long does that, well, it works right at first, and then people kind of go back. So measuring for three to six months is not as long as we think, you know, you'd really want. To be confident the intervention will be there for the long term for you. And a few studies addressed higher order contextual factors, such as mental health climate, workplace stigma surrounding mental health. What wasn't well addressed particularly was manager-focused mental health promotion training. Worker-focused mental health literacy training, there was a little bit of that, but not much of either of those. Worker-support mental health intervention programs and anti-stigma interventions and job redesign. There was one of those, it was a failure. So what do we have for you? Do we have a cornucopia of wonderful options that you can take and go and put in place in your system? Or do we have kind of a desert out there with not a lot of? So I will say it's not the former. The cornucopia of options is not there. You don't have a huge number of them, but you do have some options there. What are the key takeaways? So first of all, only 54 studies met our criteria. We'll increase probably by another 15 when we finish the review, because so many of them have come out recently. The smallest number of studies scored a high quality rating in our quality review. The majority of studies published during COVID were published during COVID, over 50 percent of them. But again, they were not low-quality studies. They were in the same range of quality as the ones that had come before. So there are a lot of them, but they're still solid. And then most were focused on individuals, fixing people, not systems. Fixing people, not systems. An example being the resiliency ones. The majority were kind of mainstream, what I'm a psychologist would consider fairly mainstream mindfulness with a few one-offs, some that are just very different. The one, there's art therapy. There's the puppy study. That's where they brought dogs. It's in the United States. They brought dogs in for the caretakers to take some time off to decompress. It wasn't a well-presented study, but it was. So there are some of those, too. So there's a range of them. So there's a large concentrations of interventions that are focused on mindfulness. That was really the biggest concentration. And the most frequently studied outcomes are the ones you'd want to be the most frequently studied or intervened on outcomes, and they're listed up there on the screen. Most studies used well-validated measures. That's really a real plus of these studies is that you can trust that the measures were solid. And again, solid means they're validated and they have good Chromebox alpha scores. Most measure changes only up to three to six months. So there are some good interventions, but especially during COVID, with no time to develop a thorough study, some of them didn't get high confidence ratings in our evaluations of the studies, but the interventions may have been very good. So probably we've underestimated the results of these that could be accomplished by these interventions. However, we think it'd be wise to look beyond healthcare, the healthcare industry, and look for effective mental healthcare interventions in other industries as well. And we're doing that now. So there's my email address. And again, if there are, I think Sudha will take over for questions next, but again, if you have comments about things that you wished I had done in this search, or the three of us had done, please come tell me about it. I'd be really pleased to hear that. Thank you. Thank you, Kent, for that. It's no fair. People on screen don't get a round of applause. I'm going to start sharing our screen back here in a moment. Just need to do one thing. So thank you so much again for that presentation. We really appreciate all the effort that you and your team are putting into this really important task as far as gathering information and understanding what the current knowledge base is with regards to the interventions people have tried to employ. We are going to open up for, we have a few minutes for questions here. And so we had a little bit of chat going on. I think there was one question on the, from the virtual audience about the practical difference between diagnosing and treating providers. And I believe that Suzanne and Tom had provided a response where the practical difference is that health diagnosing individuals included physicians and surgeons, whereas health treating individuals included categories, occupational categories, categories of physical therapists or registered nurses. And then there was a comment line that people liked your font, Kent, so they found it relaxing. If there are any questions from the room, we can take that from you. Absolutely. Please proceed. Please go ahead. So I, is this on? So I have a question for Tom Cunningham and a comment for Kent and his work. So Tom, on May 20th, the NAM's Action Collaborative for Clinician Wellbeing is planning on launching its national plan to address a lot of these issues. Certainly their consensus study had a lot of evidence in it. I would hope that their national plan for action also has. So my question is, what's the interaction between the NIOSH initiative and the NAM's initiative? Well, thank you for your question. I can tell you we've been following along with the progress NAM has been making all the way along here. We're really fortunate, actually, our discussant for these sessions, David Weissman, is a representative for NIOSH to that collaborative. So it's probably a better question for David, and I think he's on with us right now in case he might want to jump in on this. Sure. So, Lee, I've been involved in a work group with the National Academies and Cha Cha Cheng has also been involved from NIOSH. And we've seen drafts of the plan, which will be coming out really soon. And it's really an excellent plan. It's really well-founded on what evidence there is. And the focus, of course, is largely on burnout, because the focus is on resilience and burnout. But I think you'll be really pleased when you see it. Thank you. So my other comment is, Canada seems to have been way ahead of the U.S. in terms of psychological safety at work. As you may know, they actually published a kind of a standard, it's a voluntary standard around psychological safety. Have a toolkit, and also have excellent training for employees and supervisors around how to deal with mental health issues in the workplace. With a series of like two to three minute video scenarios with various types of problems that range from how should a supervisor deal with someone who looks down, how should they approach them, to someone coming back and saying, I've been out, I tried to commit suicide, how should they interact, et cetera. So they're really excellent, and certainly if you haven't seen them, I suggest you take a look at them. Thanks, Bob. I appreciate that. My colleague, Jen Dimoff, is from Canada at the University of Ottawa, and I'm sure she's an associate or involved with that and knows about that. But I made a note, and we'll make sure that that gets into this process. Thanks for bringing it up. Appreciate it. Excellent presentation. My name is Michael Caldwell from Meharry Medical College in Nashville, Tennessee. We're very interested in the issue of alcohol. And I do have a question for Suzanne about the BRFSS, if that included alcohol in it. Please go to poster 542. We at Meharry Medical College will be launching, will be the official US licensee for Dry January USA. It's going to be a plug-and-play tool that anyone can use, and we're really looking to partner. Obviously, we haven't done any studies to know if there's best practices, but there has been a lot of work. It's come out of England from Alcohol Change UK. It's been around eight years, and there is some good data online. But we're just interested, Suzanne, if you could help provide me any insight into the BRFSS and whether alcohol use was measured. This was my first sort of experience with the BRFSS. Off the top of my head, I'm not 100% certain if alcohol use is included in the survey itself. We did not look at it, though. I mean, I can tell you that we did not look at it in the study. Maybe one of my colleagues have a little bit more background. Tom, do you know? Yeah. Yeah, I do recall seeing binge drinking included as an item in there. But based on some previous work that Sharon Silver had shared with us, it didn't seem that health care workers were binge drinking at rates at or above the rest of the working population. So it didn't seem worthy of inclusion among those other factors, admittedly limited factors that we could pull from the BRFSS data. Thank you. I'll take a picture of your poster and send it to Suda. Okay, so it's on the PDF 542 on the swap card. Thank you, Kent. Yeah, you can go to the swap card. Thanks. Thank you all for your presentations. Wonderful. Two questions for you. One, I believe that Black and Downs checklist doesn't- Pardon me. I'm sorry. Whoever is speaking, could you speak a little louder or closer to the mic? I can get closer to the microphone. Thank you so much. I thank you all. And thank you again for a wonderful presentation. I have two questions for you. I believe that Black and Downs checklist does not include any look at who's sponsoring or funding research. Correct. Correct. Correct. And for things like cannabidiol and the transcranial stimulation, I'd hope that that would be something you look at before recommending that hospitals advise their employees to take two gummies every night. That's one just thought. My question I'm more interested in, and I wonder if your second wave will address, is just the growing interest in the concept of moral injury in healthcare workers. Healthcare workers, unlike many stress populations during COVID particularly, have been often asked to do things and work in conditions that put them at high risk for moral injury. And I think that as a particular source of behavioral and mental health problems in this population is really important to look at. Yeah. That's a really good point. And that specific, I don't know that there's a measure of that, and that may be kind of the issue there. But I think it does get addressed in a couple of those measures. The compassion fatigue, and there are a couple of others that maybe it gets touched by, but I think it probably isn't. It isn't there. That's a good point. And on the other point, we're not making recommendations. We're just talking about what's available out there. We do give quality evaluations of the studies, but we don't endorse the interventions particularly. And to us, it's really up to the hospital system to make those decisions. And I will admit, when I first realized, oh my gosh, that's going to come up in the top four, I blanched. Do I really want to be standing up in front of this group? And so, I tried to carefully say, we're not recommending things, but we also don't want to take the choice away from the people who would be making the choice. So I appreciate it. Thank you. Excellent. Good afternoon. Debbie Sullivan from Phoenix, Arizona. I have one question and just one anecdotal statement. So the question is about the inclusion of healthcare workers. I know you mentioned specifically nurses and some other roles. And I just wondered if advanced practice providers, such as nurse practitioners and physician assistants, were included in any of those other healthcare workers? They were included. And when the report comes out, there will be more complete information than I showed on the slide in there on each of the studies and what the population included. Great. Thank you. Good question. This is an anecdotal observation that I wanted to share. But in one of the slides that you had, Dr. Enger, that listed some of the interventions, I noticed that weight loss was on one of those slides. And again, anecdotal information, but I'm a health coach for a weight loss program. And we've seen such a resurgence, or not a resurgence is the wrong word, an increase in business early first quarter of 2022 directly related to clients who gained weight during the past year or two and are very committed to now losing weight. And the underlying reason usually isn't just the altruistic, oh, I want to get healthier. It is specifically because they feel so many areas of their life are out of control. And this is one thing they can control. So just an interesting kind of twist on why that intervention may be working. It gets to the issue of they feel like they can be in control of something because there's so much out of their control. So thank you for the presentation. Yeah. You're welcome. That's a great comment. And that particular intervention, there's only one that addressed that, was a primary prevention one. It was working with people at a primary prevention level. And we thought highly of that intervention, I must admit. So thanks for that nuance of information. Excuse me, Kent. I'm sorry to interrupt. I just want to let everyone know, I'm happy to stay online. And I'm not sure about the rest of our panel, but I suspect some folks are able to. If there are more questions, we have to be done, I believe, shortly. We were officially over three minutes ago. So I just wanted to let people know we are aware of that. And I also wanted to thank David Weissman and Bernice Pesco-Salido, who are going to be presenting in our afternoon session, for joining us to listen in and comment. And to thank all of you who are participating, we hope this information was helpful. And invite you to join us for the afternoon session. I suspect some of you want to go have your lunch there in Utah. So we are happy to continue, though, as long as the program allows us a few more minutes with questions. Thank you. Why don't you say it at the mic? So we do have one more in-person question, Suda. Thank you for the presentation. Is there any consideration of the overestimation of the measurement of the health outcome of the interventions based on the, I know you had like a very spotty limited number of studies during the pandemic, but based on high turnover rates and the participants willing to stay in the studies, having already higher resilience, maybe higher receptiveness to these interventions? Is there any consideration of that? Like how do you think about the participants that fell out of these studies early on? Yeah. Well, that's really a good question, because there were a number of studies that had people falling out of them, for sure. And you may well be right. Most studies, not too many studies were intent to treat where their statistics addressed everybody who started the study. Most of them addressed just people who finished the study. So I don't think there's an answer to your question, unfortunately. It's a concern. And they may be the ones who need the intervention the most. So I appreciate your concern over that. I wish we had an answer for it. So thanks. But noted. Okay. I think that's it. Suda, thank you. Okay. Thanks, everybody. Okay.

healthcare workers

evidence-based interventions

workplace policies

organizational support

peer support

mental health resources

stress management programs

work-life balance

COVID-19 pandemic

coping skills

burnout

general well-being

primary prevention strategies