Received: 2 November 2022 | Revised: 12 December 2022 | Accepted: 4 January 2023 DOI: 10.1111/jocn.16634 REVIEW Effects of eHealth interventions on stress reduction and mental health promotion in healthcare professionals: A systematic review Yolanda López-­Del-­Hoyo PhD, Associate Professor1,2,3 | Selene Fernández-­Martínez MD, PhD student | Adrián Pérez-­Aranda PhD, Research Fellow1,4 1 | Alberto Barceló-­Soler PhD, Research Fellow1,5 | Marco Bani PhD, PsyD, Research Fellow6 | Selena Russo 6 7,8 PhD, PsyD, Research Fellow | Fernando Urcola-­Pardo PhD, Lecturer | Maria Grazia Strepparava PhD, PsyD, Associate Professor6,9 | Javier García-­Campayo PhD, Professor1,2,10 1 Institute of Health Research of Aragon (IIS Aragón), Miguel Servet University Abstract Hospital, Zaragoza, Spain Aims: To evaluate the effectiveness of eHealth interventions to reduce stress and 2 Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS) promote mental health in healthcare professionals, and to compare the efficacy of RD21/0016/0005, Zaragoza, Spain different types of programs (guided vs. self-­guided; ‘third-­wave’ psychotherapies vs. 3 Department of Psychology and other types). Sociology, University of Zaragoza, Zaragoza, Spain Background: Healthcare workers present high levels of stress, which constitutes a 4 Department of Basic, Developmental risk factor for developing mental health problems such as depression and anxiety. and Educational Psychology, Autonomous eHealth interventions have been designed to reduce these professional's stress con- University of Barcelona, Cerdanyola del Vallès, Spain sidering that the characteristics of this delivery method make it a cost-­effective and 5 Navarra Medical Research Institute very appealing alternative because of its fast and easy access. (IdiSNA), Pamplona, Spain 6 Design: A systematic review of quantitative studies. School of Medicine and Surgery, University of Milano –­Bicocca, Monza, Methods: A comprehensive database search for quantitative studies was conducted Italy in PubMed, EMBASE and Cochrane (until 1 April 2022). The systematic review was 7 Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain conducted in accordance with the PRISMA and SWiM reporting guidelines. The qual- 8 Research Group Water and ity of the studies was assessed using the National Heart, Lung and Blood Institute Environmental Health (B43_20R), tools. University Institute of Research in Environmental Science of Aragon, Results: The abstracts of 6349 articles were assessed and 60 underwent in-­depth re- University of Zaragoza, Zaragoza, Spain view, with 27 fulfilling the inclusion criteria. The interventions were classified accord- 9 Clinical Unit "Psicologia Clinica", ing to their format (self-­guided vs. guided) and contents (‘third-­wave’ psychotherapies Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy vs. others). Twenty-­t wo interventions emerged, 13 of which produced significant 10 Psychiatry Department, Faculty posttreatment reductions in stress levels of health professionals (9 self-­guided, 8 of Medicine, University of Zaragoza, Zaragoza, Spain ‘third wave’ psychotherapies). Significant effects in improving depressive symptoma- tology, anxiety, burnout, resilience and mindfulness, amongst others, were also found. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd. 5514 |  wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2023;32:5514–5533. | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LÓPEZ-­DEL-­HOYO et al. 5515 Correspondence Adrián Pérez-­Aranda, Institute of Health Conclusion: The evidence gathered in this review highlights the heterogeneity of Research of Aragon (IIS Aragón), Miguel the eHealth interventions that have been studied; self-­guided and ‘third-­wave’ psy- Servet University Hospital, Zaragoza, Spain. chotherapy programs are the most common, often with promising results, although Email: aparanda@iisaragon.es the methodological shortcomings of most studies hinder the extraction of sound conclusions. Protocol registration: PROSPERO CRD42022310199. No Patient or Public Contribution. KEYWORDS eHealth, health personnel, healthcare professionals, mental health, online interventions, stress, systematic review, telehealth 1 | I NTRO D U C TI O N What does this paper contribute to the wider global community? Health professionals normally present high levels of stress which have been accentuated by the COVID-­19 pandemic (Greenberg • This review draws attention to the need of offering et al., 2020; Pfefferbaum & North, 2020). Stress refers to the indi- healthcare professionals accessible resources to take vidual non-­specific response caused by stressors, including physi- care of their own mental health. This review has found ological and psychological responses (Kruk et al., 2019). In addition that different eHealth interventions have been designed to the main stressors that healthcare workers usually deal with (e.g., for this purpose, although the high degree of heteroge- long shifts, emergency situations, exposure to human suffering), the neity and the methodological shortcomings of some COVID-­19 pandemic forced many health professionals to make extra studies hinder the comparison amongst them. efforts, and the frequency of distressful work-­related events such • To maximise the effects of eHealth interventions, it is as workplace violence and lawsuits has increased notably in the last proposed to design self-­guided programs with some 2 years (Chirico et al., 2022; Magnavita et al., 2021). Such levels of sus- punctual online support from an external professional: tained stress represent a risk factor for developing mental health prob- this format could benefit from the flexibility of a self-­ lems, including anxiety disorders, depression, somatoform disorders, guided intervention whilst lowering the risk of losing post-­traumatic stress disorders and even suicidal ideation (Karasu adherence to it. et al., 2021; Williamson et al., 2018). The World Health Organisation (WHO) has formally recognised that health professionals are at risk of developing mental health and proved to be effective in reducing various psychopathological problems, especially if they work in public health, primary care, symptoms, also in samples of health professionals (Aranda Auserón emergency services and intensive care units (Cullen et al., 2020; et al., 2018; Asuero et al., 2014; Brinkborg et al., 2011; Chirico, 2021; WHO, 2020). The reported high levels of stress amongst health- Kriakous et al., 2021; Rudaz et al., 2017). care workers not only represent a threat to their individual health These interventions used to employ the classic face-­to-­f ace for- but also have consequences on the organisation and societal level mat (group or individual therapy), but in the last years, particularly since psychological distress has been clearly associated with an due to the COVID-­19 pandemic, electronic health (eHealth) inter- increase in absenteeism and turnover intention in healthcare ventions have proliferated; eHealth refers to health services and workers (Chirico et al., 2021; Lavoie-­Tremblay et al., 2022). It is, information delivered or enhanced through the Internet and related therefore, highly relevant to find effective ways to help health technologies (Eysenbach, 2001). Different types of digital health professionals to reduce and manage their levels of stress, not services can be found: telehealth, mobile APPs, serious games and only to improve their well-­b eing and job performance but also to wearable technology are some examples (Liu et al., 2011). The char- prevent a potential shortage of professionals and the subsequent acteristics of this delivery method make it a cost-­effective and very overload of healthcare systems. appealing alternative because of its fast and easy access (Eriksson Different approaches have been designed for this aim; interven- et al., 2018). Health professionals often have to deal with schedules tions based on cognitive behavioural therapy (CBT), which includes that are difficult to reconcile with attending therapy sessions limit- techniques such as relaxation, time management or problem-­solving, ing their access to the needed support (Gruber et al., 2021). eHealth have proved to be effective in reducing stress and other psycho- programs have resulted effective for reducing stress and promoting pathological symptoms such as anxiety and depression in different mental health in different populations, such as relatives of patients clinical populations (Cuijpers et al., 2014; Kowalik et al., 2011; Lewis with severe mental disorders (Barbeito et al., 2020), informal care- et al., 2020). The so-­called ‘third wave’ CBT psychotherapies, which givers (Suntai et al., 2021), and even medical students (Yogeswaran are based on the promotion of mindfulness, acceptance, compassion & El Morr, 2021), amongst others, which means that these inter- and spirituality, have been increasingly popular over the last decades ventions may also be beneficial for health professionals. Therefore, | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 5516 LÓPEZ-­DEL-­HOYO et al. considering the need of finding effective evidence-­based programs (e.g. nurses, physicians, psychologists, social workers, etc.) were addressed at promoting healthcare workers' mental health (Chirico included; studies conducted on students, informal caregivers, & Magnavita, 2020), it is deemed relevant to review and assess the or hospital workers who were not healthcare providers were quality of the studies conducted on this topic. excluded. The intervention needed to be fully delivered via an The main aim of this systematic review was to assess the ef- electronic device (e.g. smartphone, computer, tablet); it could be fectiveness of different types of eHealth interventions to reduce guided or unguided, but the whole program had to be completely stress in healthcare professionals, and secondarily, to evaluate their remote (i.e. no in-­p erson sessions or mixed interventions). For effects on other mental health-­related outcomes such as depres- what concerns to the outcome, the study had to explicitly refer sive symptomatology, anxiety, burnout, resilience, and ‘third wave’ to a quantitative measure of psychological stress. Other men- psychotherapy-­related variables. The interventions were classified tal health-­related outcomes (e.g. depressive symptoms, anxiety, in two axes (guided vs. unguided, and ‘third wave’ psychotherapy-­ burnout, etc.) reported in the studies were included as second- based vs. the rest) for the sake of comparing them and identifying ary outcomes in the present review, as long as stress was also re- potential differences in terms of efficacy. ported. RCTs, non-­r andomised trials and single-­arm studies were eligible for inclusion. Only published research studies written in English were eligible. The search strategy did not establish a time 2 | M E TH O D S horizon, considering that the development of new eHealth inter- ventions increased during and after the pandemic, but some were 2.1 | Design developed previously. A systematic review of quantitative studies, including randomised controlled trials (RCTs), nonrandomised trials, and single-­arm stud- 2.4 | Search outcomes ies, was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-­Analyses (PRISMA) and After the duplicates were removed, a total of 6349 articles were the synthesis without meta-­analysis (SWiM) reporting guidelines identified and screened by three reviewers; the full-­text manuscripts (PRISMA Checklist and SWiM items can be found in Appendix, for 60 studies were then reviewed, of which 27 met the inclusion Table S1; Campbell et al., 2020; Page et al., 2021). The review pro- criteria (Figure 1). These articles were published between 2007 and tocol was registered with an international register of systematic re- 2021, and they had been conducted across 14 different countries. views (PROSPERO ID: CRD42022310199). Twelve studies were RCTs, three were non-­randomised trials, and 11 were single-­arm studies. Only 8 studies reported follow-­up assess- ments, ranging from 1 to 6 months. 2.2 | Data sources and search strategy A total of 4480 healthcare providers were included across the 27 studies; whilst most of the studies combined different professionals, The searches were conducted between February and April 2022. nurses were the most represented subgroup in 7 of them. Twenty-­ The systematic review search was guided by the population, inter- one studies reported the sex distribution of their sample: females vention, comparison and study design (PICOS) criteria, which can be represented 100% of the sample in three of them and at least 75% in found in the Appendix (Table S2). A comprehensive search was con- 14. The format of the intervention (18 self-­guided vs. 4 guided) and ducted in three online databases: PubMed, EMBASE, and Cochrane. its theoretical background (12 ‘third wave’ psychotherapy-­based vs. Search terms were adapted to each database and are detailed in the 10 others) was identified to compare the effects of different types Appendix S1. of eHealth programs. All the reviewed studies assessed perceived Relevant studies were sought from trial registries (clini​caltr​ials. levels of stress in their samples, along with some other mental gov) and reference lists of included studies were searched to identify health-­related variables that were included in the present review as additional studies. The titles and abstracts of all potentially eligible secondary outcomes. studies identified from the search were reviewed against the inclusion and exclusion criteria by three reviewers (SFM, APA, and ABS). The full texts of all potential studies were then independently screened 2.5 | Quality appraisal by three reviewers (SFM, APA, and ABS) and disagreements were re- solved through discussion with a fourth reviewer (YLH). A quality assessment was undertaken for included studies by two reviewers (MB and SR); disagreements were solved by a third re- viewer (MGS). It was conducted using the Heart, Lung, and Blood 2.3 | Eligibility criteria Institute assessment tools: one for controlled intervention studies and one for single-­arm studies. The quality assessment is provided in Regarding the inclusion criteria, only those studies in which the the Appendix (Tables S3 and S4) along with a link to the assessment sample was completely or mostly formed by healthcare providers tools and its items. | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LÓPEZ-­DEL-­HOYO et al. 5517 F I G U R E 1 PRISMA diagram of study flow. [Colour figure can be viewed at wileyonlinelibrary.com] 2.6 | Data abstraction be found in the Appendix, Table S6). Most of these interventions (n = 18) were self-­guided, that is, they did not count on any instruc- For each study, the following data were extracted and presented tor who conducted any part of the program. Guided interventions in tables: in Table 1, the study design, sample, intervention, were presented in a group format through a teleconference plat- comparator(s), duration of the intervention, follow-­up assessment, form. Most self-­guided interventions were web-­based (n = 14), stress assessment, and other mental health-­related outcomes; in whilst three were presented as smartphone APPs and one was based Table 2, the intervention, intragroup and intergroup changes in on text messages. The duration of the interventions was heteroge- stress posttreatment and, if the study included it, changes in the neous, ranging from only 1 day to 3 months, although most of the follow-­up assessment, and a brief outline of the main findings; and programs had a duration between 2 and 6 weeks. The contents of in the Appendix (Table S5), the same information for the second- the interventions were at least partially based on ‘third wave’ psy- ary outcomes (i.e., other mental health-­related variables). Different chotherapy principles (e.g. mindfulness, compassion, acceptance, measures of intervention effect were included, considering the high mind–­body skills) in 12 programs, whilst the rest presented a variety heterogeneity of the studies reviewed; p values were considered the of techniques based on different conceptual backgrounds, with CBT standardised metric. being present in 4 programs. The most used measure of stress was the Perceived Stress Scale (PSS; Cohen et al., 1983), followed by the stress subscale of 2.7 | Synthesis the Depression, Anxiety, and Stress Scales (DASS-­21; Lovibond & Lovibond, 1995). Only two studies did not use a validated question- A narrative synthesis, which adopts a textual approach to summarise naire to evaluate stress but a visual analogue scale. Other mental-­ the findings of systematic reviews, was performed in accordance health-­related variables included in the studies were depressive with the Economic and Social Research Council (ESRC) methods pro- symptomatology, anxiety, burnout, resilience and ‘third wave’ gram guidance on narrative synthesis in systematic reviews (Popay psychotherapy-­related variables, amongst others. et al., 2007). The study outcomes and results were tabulated in Tables 2 and Table S5. 3.2 | Study quality 3 | R E S U LT S The overall quality of the 27 included studies was rated as fair. Only 8 (29.6%) included studies (4/16 controlled trials and 4/11 3.1 | Summary of the findings single-­arm studies) were rated as good, whilst 11 (40.7%; 7/16 controlled trials and 4/11 single-­arm studies) were rated as poor. The 27 studies reviewed tested the efficacy of 22 eHealth inter- For controlled trials, the risk of bias was mainly due to a lack of ventions that addressed health professionals' stress, which differed blinding, the high dropout rate at the endpoint (>20%), or the lack in terms of format and contents (see Table 1 and a summary can of sample size/power calculation. For the single-­arm studies, the TA B L E 1 Description of the studies reviewed | 5518 Post-­ Stress Secondary Reference Study design Sample (% females) e-­health intervention(s) (n) Comparator(s) (n) treatment Follow-­up assessment outcomes Barrett and RCT N = 42 (88%) ACT (n = 22) –­ 2 weeks No PSS GHQ Stewart (2021) Age = 37.12 (SD = 12.18) • Self-­guided MBI Ireland Professions: • Web-­based program WAAQ 26 social workers • ‘Third-­wave’ 10 nurses 3 sessions 4 radiation therapists CBT (n = 20) 2 medical doctors • Self-­guided • Web-­based program • Not ‘third-­wave’ (CBT) 3 sessions Concilio et al. (2021) RCT N = 22 (95.5%) Resilience and stress messages Medical facts messages 6 weeks No PSS CD-­RISC USA Age range: 21–­3 0 years (n = 11) (n = 11) SSS Newly graduated nurses • Self-­guided • Self-­guided Intention to leave (1st year of hire) • Smartphone text messages • Smartphone text • Not ‘third-­wave’ (motivational messages messages) • Not ‘third-­wave’ (informative message) Dincer and RCT N = 72 (88.9%) The emotional freedom Passive control group 20 min No Subjective STAI Inangil (2021) Age = 33.45 (SD = 9.63) techniques (n = 35) (n = 37) units of BS Turkey Nurses involved in the • Guided 15 min with distress treatment of COVID-­19 • Videoconference indications to stay (SUDs) patients • Not ‘third wave’ (acupressure “comfortable and techniques) calm” One group session of 20 min Divya et al. (2021) Single-­arm N = 92 (58.7%) Online Sudarshan Kriya Yoga –­ 4 days 40 days after DASS-­21 DASS-­21 India pre-­post-­ Age = 43.1 (SD = 11.1) workshop (n = 92) finishing the (Stress) (Depression and follow-­up Doctors, podiatrists, • Guided workshop anxiety) study dentists, chiropractors, • Videoconference PSQI psychologists, • ‘Third wave’ CD-­RISC optometrists, nurses Four 2-­h long sessions SWLS and social workers Dutton and Single-­arm pre-­ N = 31 (93%) BREATHE: Stress management for –­ 8 weeks No NSS –­ Kozachik (2020) post study Age range 30–­49 (mostly) nurses (n = 31) USA Nurses and nursing • Self-­guided assistants working on a • Web-­based program rehabilitation unit with • Not ‘third wave’ older adults (psychoeducation and different stress-­management tools, not specified) 6 modules LÓPEZ-­DEL-­HOYO et al. 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 1 (Continued) Post-­ Stress Secondary Reference Study design Sample (% females) e-­health intervention(s) (n) Comparator(s) (n) treatment Follow-­up assessment outcomes Eriksson et al. (2018) RCT N = 101 (96%) Mindful and self-­compassion Wait-­list control 6 weeks No PSS SMBQ Sweden Age = 36.2 (SD = 8.2) program (n = 52) (n = 49) SCS Psychologists • Self-­guided FFMQ LÓPEZ-­DEL-­HOYO et al. • Web-­based program • ‘Third wave’ 6 modules, 10 hours of training Finlay-­Jones Single-­arm N = 37 (89%) Self-­compassion cultivation –­ 6 weeks 12 weeks after PSS SCS et al. (2017) pre-­post-­ Age 32.61 program (n = 37) end of the DASS-­21 AHI Australia follow-­up Psychology trainees • Self-­guided intervention (Stress) DERS study (postgraduate • Web-­based program DASS-­21 (Anxiety psychologists) • ‘Third wave’ and Depression) 6 modules, 1–­2 h each one Fiol-­DeRoque RCT N = 482 (83.2%) PsyCovid (n = 248) Generic mental 2 weeks No DASS-­21 DASS-­21 et al. (2021) Age 41.37 (SD = 10.40) • Self-­guided health care (Stress) (Depression and Spain Healthcare providers • Smartphone APP recommendations Anxiety) working with COVID • ‘Third wave’ + CBT (n = 234) DTS patients: nurses, • Self-­guided MBI-­HSS physicians, and nurse • Smartphone APP ISI assistants • Not ‘third wave’ GSES Gollwitzer RCT N = 129 Mental Contrasting with Passive control group 3 weeks No PSQ UWES-­9 et al. (2018) Age = 40.22 (SD = 10.18) Implementation Intentions (n = 47) BOSS Germany Nurses (n = 41) Instructions to “explore • Self-­guided your wishes to • Web-­based program reduce your stress” • Not ‘third wave’ (self-­ regulation technique based on conscious imagery strategies) Modified Mental Contrasting (n = 41) • Self-­guided • Web-­based program • Not ‘third wave’ (same as MCII, but the participants had to make explicit where and when they were going to engage with the MCII exercises) | 5519 (Continues) 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 1 (Continued) | 5520 Post-­ Stress Secondary Reference Study design Sample (% females) e-­health intervention(s) (n) Comparator(s) (n) treatment Follow-­up assessment outcomes Hersch et al. (2016) RCT N = 104 (87.5%) BREATHE: Stress Management for Wait-­list (n = 52) 3 months No NSS SDS USA Age = 41 (range 22–­65) Nurses (n = 52) CWSS Nurses • Self-­guided NJSS • Web-­based program • Not ‘third wave’ (psychoeducation and different stress-­management tools, not specified) 6 modules for nurses; 7 for nurse managers Hosseinzadeh RCT N = 49 (55.1%) Cognitive therapy and Wait-­list (n = 21) 4 weeks 1 month after DASS-­21 SCS Asl (2021) Age = 33.06 (SD = 6.02) mindfulness-­based program finishing the AAQ-­II Turkey Social workers working at a (n = 28) program social services center • Guided • Videoconference • ‘Third wave’ + CBT 4 sessions plus 10–­20 min of daily meditation as homework (70 min per session) Jakel et al. (2016) Quasi-­ N = 25 (76%) Provider Resilience mobile Wait-­list control group 6 weeks No ProQOL –­ USA experimental Age range = 18–­35 application (n = 16) (n = 9) Oncology nurses • Self-­guided • Smartphone APP • Not ‘third wave’ (psychoeducation and different stress-­management tools, not specified) Kemper et al. (2015) Quasi-­ N = 218 (73%) Mind–­Body Skills Training Online course on 12 weeks No PSS CAMS-­R USA experimental Age = 28 (SD = 9.5) (n = 60) herbs and dietary SCS Professionals: • Self-­guided supplements (n = 7) CCCS 26 dietetics • Web-­based program • Self-­guided IRI 77 medicine • Included ‘third wave’ • Web-­based program SCBCS 29 nursing psychotherapy contents • Not ‘third wave’ 51 social work 12 one-­hour modules 14 one-­hour modules 45 others organised in 4 general topics: No treatment (n = 36) 1. focused attention meditation 2. mindfulness meditation 3. positive affect meditation 4. guided imagery-­hypnosis LÓPEZ-­DEL-­HOYO et al. 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 1 (Continued) Post-­ Stress Secondary Reference Study design Sample (% females) e-­health intervention(s) (n) Comparator(s) (n) treatment Follow-­up assessment outcomes Kemper and Single-­arm pre-­ N = 513 Mind–­Body Skills Training –­ 1h No Visual analog MBI Khirallah (2015) post study Professionals: (n = 60) scale (VAS) CAMS-­R USA 73 dietitian • Self-­guided PSS MAAS LÓPEZ-­DEL-­HOYO et al. 169 nurse • Web-­based program BRS 152 physician/physician • Included ‘third wave’ IRI assistant psychotherapy contents 103 social work Twelve 1-­hour modules, of which 69 researcher 5 were completed by at least 271 others 100 individuals and thus included in the analyses: 1. Introduction to stress and resilience 2. Autogenic training 3. Guided imagery-­hypnosis for pain, insomnia and changing habits 4. Introduction to mindfulness 5. Mindfulness in daily life Kemper and Single-­arm pre-­ N = 379 (85%) Focused attention meditation –­ 1h No Numeric rating Numeric rating Rao (2017) post study Professionals: training (n = 379) scale (from scale (from 0 USA 116 nurse • Self-­guided 0 to 10) to 10) to assess 81 physician • Web-­based program relaxation and 39 social work, • ‘Third wave’ (part of the resilience psychologist, or licensed Mind–­Body Skills Training) PANAS counsellor 3 one-­hour modules, only one FS 143 other assessed stress changes: 1. Introduction to stress, resilience and relaxation response Ketelaar et al. (2014) Single-­arm pre-­ N = 128 (77%) e-­mental health interventions –­ 3 months No DSQ NWFQ The Netherlands post study Age = 40 (SD = 12) (n = 128; n = 26 logged QEEW Occupation: at least once in an online 89 nurse program) 12 nurse practitioner • Self-­guided 27 allied health • Web-­based program professional • Not ‘third wave’ (personalised feedback + recommendation of CBT-­based programs: Psyfit, Strong at work, Colour your Life, Do not Panic Online, Drinking less) | 5521 (Continues) 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 1 (Continued) | 5522 Post-­ Stress Secondary Reference Study design Sample (% females) e-­health intervention(s) (n) Comparator(s) (n) treatment Follow-­up assessment outcomes Lee et al. (2018) RCT N = 37 (100%) Mind–­Body Training (n = 19) Wait-­list control group 4 weeks No KOSS SCL-­90-­R Republic of Korea Age: • Self-­guided (n = 18) RSES MBT: 36.77 (SD = 8.18) • Web-­based program STAXI Control: 34.07 (SD = 6.28) • ‘Third wave’ PANAS Health care providers Once per day, 5 days per week, 10 min sessions Jung et al. (2016) Quasi-­ N = 87 (100%) Mind–­Body Training (n = 42) No intervention control 8 weeks –­ SRI CSI Lee et al. (2020) experimental Age: • Self-­guided group (n = 45) 1 month after KOSS STAXI Republic of Korea MBT: 35.0 (SD = 8.20) • Web-­based program intervention EIQ Control: 36.6 (SD = 7.6) • ‘Third wave’ ended PANAS Female healthcare Once per day, 5 days a week, CD-­RISC providers, mostly 10 min sessions nurses N = 56 Age: MBT: 36.20 (SD = 8.17) Control: 35.00 (SD = 6.74) Mistretta RCT N = 60 (86.7%) Mindfulness-­based resilience In-­person Mindfulness-­ 6 weeks 3 months DASS-­21 DASS-­21 et al. (2018) Age = 46 (SD = 12.6) training APP (n = 23) based Resilience (stress) (depression and USA Healthcare workers with • Self-­guided training (n = 22) anxiety) at least 5 points on • Smartphone APP • Guided WHO-­5 the DASS-­21 stress • ‘Third wave’ • In-­person program MBI-­HSS subscale Self-­guided, every 7–­10 days • ‘Third wave’ SCS participants can select one No intervention control COS of four possible topics: sleep, group (n = 15) PANAS happiness and positivity, energy and focus and productivity Osman et al. (2021) Single-­arm N = 47 Brief online mindfulness-­based –­ 4 weeks No PSS MAAS South Africa pre-­post Age = 34 (IQR = 18) intervention (n = 47) aMBI quantitative 46% medical doctors and • Guided study + trainees • Videoconference qualitative 16% psychologists, 14% • ‘Third wave’ analysis physiotherapists, 14% 1-­hour weekly group sessions. occupational therapists 10% other allied health (podiatrist, chiropractor and two radiographers) LÓPEZ-­DEL-­HOYO et al. 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 1 (Continued) Post-­ Stress Secondary Reference Study design Sample (% females) e-­health intervention(s) (n) Comparator(s) (n) treatment Follow-­up assessment outcomes Rao and Single-­arm pre-­ N = 273 (84% females) Focused attention meditation -­ 1h No PSS PROMIS Kemper (2017) post-­study Age: not reported training (n = 273) IRI LÓPEZ-­DEL-­HOYO et al. USA 34% registered nurses • Self-­guided SEND 20% physicians • Web-­based program 14% trainees • ‘Third wave’ (part of the 14% social workers 5% Mind–­Body Skills Training) registered dietitians 3 one-­hour modules, only one 27% others assessed stress changes: 1. Autogenic training Smoktunowicz RCT N = 1240 Different variations of the Med-­ –­ 6 weeks 6 months PSS PHQ9 et al. (2021) Age = 36.21 (SD = 10.18) Stress program (3 for after the UWES Poland 36.13% physicians • Self-­guided those end of the PSDC 24.84% nurses • Web-­based with intervention 7.50% dentists • Not ‘third wave’ only one 5.24% midwives Cultivation process: Self-­efficacy module) 5% paramedics + social support modules 15.4% other medical (n = 311) professionals Enabling process: Social support + self-­efficacy modules (n = 311) Self-­efficacy module (n = 309) Social support module (n = 309) Wang et al. (2021) Single-­arm pre-­ N = 210 (58.7% females) Mindfulness decompression and –­ 3 months No DASS-­21 DASS-­21 China post study Age: 127 (60.48%) psychoeducation program (stress) (depression and between 20–­25 years (n = 210) anxiety) old. • Self-­guided + counselling MBI Anaesthesia, paediatric, • Web-­based program + chat internal medicine and (APP) surgical residents • ‘Third wave’ 8 sessions of mindfulness 30–­ 45 min + psychoeducational counselling once a week, 1–­3 h Wright (2018) Single-­arm pre-­ N = 10 (100%) Benevolent Midwifery Project –­ 4 weeks No PSS CSES USA post study Age = 40 (range 31–­6 4) (n = 10) Midwives • Self-­guided • Web-­based program • ‘Third wave’ 16 modules (5–­3 0 min each), minimum 4 days per week | 5523 (Continues) 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 5524 LÓPEZ-­DEL-­HOYO et al. risk of bias was related to the lack of information on the sample's representativeness, no sample size calculation, and lack of blind- ness of people assessing outcomes. Secondary outcomes BJSQ BJSQ AMS ACL 3.3 | Effects of the eHealth interventions on stress assessment 3.3.1 | Self-­guided vs. guided interventions Stress JSBQ JSBQ These results are presented in Table 2, and a summary can be found in Table S6. Of the 18 self-­g uided interventions that were the training the training tested in the reviewed studies, 7 were compared to a passive 1 month after 4 weeks after finished finished Follow-­up control group. Four interventions, all of which were web-­b ased programs, resulted superior to passive comparators for reducing stress: the BREATHE program (Hersch et al., 2016), which also presented significant effects in a subsequent pre-­p ost single-­arm treatment study (Dutton & Kozachik, 2020); the Mindful Self-­C ompassion 3 weeks 3 weeks Post-­ Online Program (Eriksson et al., 2018); the Mental Contrasting with Implementation Intentions program (Gollwitzer et al., 2018); and the Mind–­B ody Skills Training (Kemper et al., 2015), a pro- gram whose individual modules also presented acute pre-­p ost ef- Waiting list (n = 30) Comparator(s) (n) fects on stress (Kemper & Khirallah, 2015; Kemper & Rao, 2017; Rao & Kemper, 2017). A similar program (i.e. Mind–­B ody Training) was tested with inconclusive results: it resulted superior to the control group both posttreatment and in a follow-­up assessment –­ (Jung et al., 2016; Lee et al., 2020), but another study reported no significant effects (Lee et al., 2018). The Provider Resilience Career Identity training (n = 30) Internet Navigware: Assertion in Mobile APP (Jakel et al., 2016) and the Career Identity Training e-­health intervention(s) (n) the Workplace (n = 32) (Yamagishi et al., 2008) did not result superior to their respective • Web-­based program • Web-­based program passive control conditions. • Not ‘third wave’ • Not ‘third wave’ 60-­min sessions 70-­min sessions Three RCTs compared the eHealth program to an active con- • Self-­guided • Self-­guided trol group; two of them tested the efficacy of APPs (Fiol-­D eRoque et al., 2021; Mistretta et al., 2018), and both presented effects with tendencies close to statistical significance; the other was a text message-­b ased intervention which was not superior to the comparator (Concilio et al., 2021). Two more studies were RCTs, but in this case comparing different variations of the same in- Age = 33.0 (SD = 7.1) Age = 32.7 (SD = 7.1) Sample (% females) terventions, such as the Med-­Stress program (Smoktunowicz et al., 2021), all of which reduced stress (although one version, the “cultivation process”, presented better outcomes), or comparing Nurses Nurses N = 60 N = 32 two different online programs, such as web-­b ased ACT and web-­ based CBT (Barrett & Stewart, 2021), both of which reduced stress equally. Single-­arm pre-­ post study The remaining studies did not include a control group; some re- Study design ported significant reductions in stress posttreatment, such as the Self-­compassion Cultivation Program (Finlay-­Jones et al., 2017), RCT TA B L E 1 (Continued) with effects that lasted 12 weeks after the end of the program; and the Benevolent Midwifery Project (Wright, 2018), which reported some positive preliminary effects. On the contrary, other eHealth et al. (2008) et al. (2007) programs did not produce significant pre-­post reductions in stress: Reference Yamagishi Yamagishi the CBT-­based programs assessed by Ketelaar et al. (2014), the Japan Japan Mindfulness Decompression and Psychoeducation Program (Wang TA B L E 2 Effects of the interventions on the primary outcome (stress) Intervention(s) [vs. Post-­treatment Post-­treatment intergroup Follow-­up intragroup Follow-­up Ref. comparator] intragroup changes changes changes intergroup changes Summary of the main findings 2 Barrett and Web-­based ACT vs. Web-­ F = 7.30, p = .010, F = 0.64; p = .430; η = .016 –­ –­ Both interventions significantly reduced stress Stewart (2021) based CBT η 2 = .154 (PSS) posttreatment, but no differences were observed between groups LÓPEZ-­DEL-­HOYO et al. Concilio et al. (2021) Supportive text messages –­ Bayes factor = 2.366 –­ –­ No significant differences between the two vs. medical facts text groups were observed in the primary messages outcome (PSS) Dincer and Online EFT session vs. –­ Wilcoxon test = 16.58, p < .001 –­ –­ The EFT group achieved a statistically significant Inangil (2021) control group pre-­post change in stress (SUDs) whilst the control group did not Divya et al. (2021) SKY online workshop p < .001, d = 0.57 –­ p = .490 –­ Significant reductions were observed in stress (DASS-­21 Stress) posttreatment with a medium effect size, but no effect was observed in the follow-­up Dutton and BREATHE online program t = 2.30, p = .026 –­ –­ –­ Significant reductions were observed in the NSS Kozachik (2020) total score Eriksson et al. (2018) Mindful Self-­Compassion –­ F = 11.64, p < .001, d = 0.59 –­ –­ The online program reduced stress levels (PSS) Online Program vs. significantly compared to the control group, wait-­list control with a medium effect size Finlay-­Jones Online Self-­compassion PSS: t = 3.16, –­ PSS: t = 2.92, p = .005, –­ Significant reductions were observed in et al. (2017) cultivation program p = .002, d = 0.48 stress (PSS and DASS-­21 Stress) both d = 0.52 DASS-­21 Stress: posttreatment and in the 12-­week follow-­up DASS-­21 Stress: t = 2.79, p = .007, assessment, mostly with medium effect sizes t = 5.15, d = 0.46 p < .001, d = 0.85 Fiol-­DeRoque PsyCovid APP vs. Control –­ Z = −0.06 [−0.14 to 0.01], –­ –­ The PsyCovid APP did not produce significant et al. (2021) APP p = .050 reductions in stress (DASS-­21 Stress) compared to the control APP, although a tendency close to significance was observed Gollwitzer et al. (2018) MCII vs. no treatment –­ t = 2.39, p = .019, η2 = .053 –­ –­ The MCII was superior to the no-­treatment MCII vs. IIMCII t = 1.30, p = .198, η 2 = .016 condition (large effect size) in stress IIMCII vs. no treatment t = 1.09, p = .277, η 2 = .012 reduction (PSQ & BOSS-­II). No significant differences were observed when comparing MCII and IIMCII. This latter was not superior to the no-­treatment condition Hersch et al. (2016) BREATHE vs. Wait-­list –­ t = −2.954, p = .003 –­ –­ Participants of the BREATHE program reported significantly greater reductions than the control group on the NSS total score | 5525 (Continues) 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 2 (Continued) | 5526 Intervention(s) [vs. Post-­treatment Post-­treatment intergroup Follow-­up intragroup Follow-­up Ref. comparator] intragroup changes changes changes intergroup changes Summary of the main findings 2 Hosseinzadeh Mindfulness online vs. –­ F = 3.22, p = 0.79, η = .065 –­ F = 3.84, p = .069, Although the experimental group had a decrease Asl (2021) Wait-­list η 2 = .070 in the stress scores (DASS-­21) at both the post-­test and follow-­up, these were not significant compared to the control group Jakel et al. (2016) Provider Resilience Mobile –­ p = .500 –­ –­ No significant differences in the level of stress APP vs. Wait-­list (ProQOL) were observed between both groups Kemper et al. (2015) MBST online vs No-­MBST –­ p = .006 –­ –­ The MBST group significantly reduced their (i.e., no treatment or levels of stress (PSS) compared to the no-­ HDS online course) MBST group Kemper and MBST modules: p = .02 –­ –­ –­ Significant acute reductions in stress (VAS and Khirallah (2015) 1. Introduction to stress p = .0001 PSS) were observed right after finishing the and resilience two modules 2. Autogenic training Kemper and Focused attention training p < .010 –­ –­ –­ Acute effects on stress were reported (numeric Rao (2017) modules: scale rating) after completing the module Introduction to Stress, resilience, and relaxation response Ketelaar et al. (2014) EMH t = 1.65, p = .102, –­ –­ –­ Although stress (DSQ) decreased both in the EMH-­logged at least once d = 0.14 complete sample and in the subsample who in the online program t = 1.12, p = .273, logged on at least to an EMH intervention, d = 0.23 this was not significant Lee et al. (2018) Mind–­Body Training vs. –­ t = 1.90, p = .080 –­ –­ There were no significant changes in Wait-­list t = −1.38, p = .190 occupational stress (KOSS) over time for any of the groups Jung et al. (2016) Mind–­Body training –­ SRI –­ SRI: p = .021 Significant reductions were observed in the [Pre-­post] program vs. No [week 4]: F = −10.29, p = .014 KOSS: p = .807 intervention group in the three assessment & Lee et al. (2020) intervention [week 8] F = −14.68, p = .002 points (mid-­program, post-­treatment, and [Follow-­up] KOSS 1-­month follow-­up) in stress (SRI), but not in [week 4]: F = −2.03, p = .073 job stress (KOSS) [week 8] F = −0.33, p = .810 LÓPEZ-­DEL-­HOYO et al. 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 2 (Continued) Intervention(s) [vs. Post-­treatment Post-­treatment intergroup Follow-­up intragroup Follow-­up Ref. comparator] intragroup changes changes changes intergroup changes Summary of the main findings Mistretta et al. (2018) Mindfulness-­based p > .050, d = 0.50 p > .050 p > .050, d = 0.13 p > .050 The APP reduced stress (DASS-­21 Stress) resilience intervention p > .050, d = 0.19 p > .050, d = 0.29 post-­treatment, but not significantly after LÓPEZ-­DEL-­HOYO et al. APP correcting for multiple testing. The in-­person vs. program did produce significant reductions no intervention in stress both posttreatment and in the Mindfulness-­based p < .050, d = 0.59 p < .050, d = 0.62 follow-­up, although not significant compared resilience intervention to the other groups APP vs. in person mindfulness-­ based resilience program Osman et al. (2021) Online mindfulness-­based p < .001 –­ –­ –­ Significant reductions in stress levels (PSS) were intervention observed posttreatment Rao and Guided imagery modules: p < .001 –­ –­ –­ Significant acute reductions in stress (PSS) were Kemper (2017) Autogenic training observed right after finishing the module Smoktunowicz Cultivation process –­ d = 0.21 –­ d = 0.41 Stress (PSS) was reduced by all the different et al. (2021) vs. d = 0.24 variations of the program. The cultivation Social support only d = 0.24 program resulted superior to the “social Cultivation process support only” condition posttreatment, vs. and it was superior to all the others in the Self-­efficacy only follow-­up Cultivation process vs. Enabling process Wang et al. (2021) Mindfulness p > .050, d = 0.40 –­ –­ –­ No significant effects of the intervention on decompression and stress (DASS 21 Stress) were observed psychoeducation posttreatment online program Wright (2018) Benevolent Midwifery –­ –­ –­ –­ Improvement in reported levels of perceived Project (Not reported) stress (PSS) of 25% compared to baseline Yamagishi et al. (2007) Internet Navigware: All p values > .290 –­ All p values > .085 –­ No significant reductions in stress (subscales of Assertion in the the JSBQ) were reported Workplace program Yamagishi et al. (2008) Career identity program All p values > .100 All p values > .090 JSBQ Personal –­ Significant reductions in some stress-­related vs. Wait list relationships: aspects (subscales of the JSBQ) were p < .050 observed in the follow-­up assessment. No JSBQ Support from significant differences between the study | others: p < .010 groups were reported at posttreatment Note: The questionnaires' abbreviations and their bibliographic reference can be found in pages 15–­21 of the Annex. 5527 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 5528 LÓPEZ-­DEL-­HOYO et al. et al., 2021), and the Internet Navigware: Assertion in the Workplace Freedom Techniques session (Dincer & Inangil, 2021), the program (Yamagishi et al., 2007). Mental Contrasting with Implementation Intentions (Gollwitzer For what concerns to guided interventions, these were as- et al., 2018), and the BREATHE program (Hersch et al., 2016) re- sessed in 4 studies, two of which compared the program to a con- sulted superior to the comparators, whilst the Provider Resilience trol group; the Emotional Freedom Techniques session reduced Mobile APP (Jakel et al., 2016) and the Career Identity Training stress significantly compared to the control condition (Dincer & (Yamagishi et al., 2008) did not. Similarly, the text message-­b ased Inangil, 2021), whilst the guided mindfulness program tested by intervention to promote resilience did not result superior to the Hosseinzadeh Asl (2021) did not result superior to the wait-­list active control condition (Concilio et al., 2021). The study con- control group, neither posttreatment nor in the follow-­up assess- ducted by Smoktunowicz et al. (2021) compared different versions ment. The remaining two interventions were tested in single-­arm of the Med-­Stress program, finding that the “cultivation process” studies: a 4-­day workshop on Sudarshan Kriya Yoga produced version was the most effective for reducing stress. On its part, significant effects posttreatment that were not maintained in the web-­b ased CBT reduced stress, although no more than web-­b ased follow-­up assessment (Divya et al., 2021), and a brief mindfulness-­ ACT (Barrett & Stewart, 2021), whilst the Internet Navigware: based intervention produced significant reductions posttreatment Assertion in the Workplace program (Yamagishi et al., 2007) and (Osman et al., 2021). the CBT-­b ased programs offered by Ketelaar et al. (2014) did not produce any significant effects on stress. 3.3.2 | ‘Third wave’ psychotherapy-­based interventions vs. other approaches 3.4 | Effects of the eHealth interventions on other mental health-­related outcomes Ten interventions (8 self-­guided and 2 guided) were fully based on ‘third wave’ psychotherapy principles (e.g. mindfulness, compassion, 3.4.1 | Depressive symptoms mind–­body skills) and 2 programs (one self-­guided and the other guided) combined them with classic CBT techniques; in total, 12 in- Depressive symptomatology was assessed in 7 studies; 3 interven- terventions included ‘third wave’ psychotherapy contents. tions produced significant reductions posttreatment: the guided When compared with passive control groups, the study groups Sudarshan Kriya Yoga workshop (Divya et al., 2021), the online self-­ undergoing the Mindful Self-­Compassion Online Program (Eriksson compassion cultivation program (Finlay-­Jones et al., 2017), and the et al., 2018) and the Mind–­Body Skills Training (Kemper et al., 2015) mindfulness decompression and psychoeducation program (Wang obtained significant benefits, whilst the Mind–­Body Training pre- et al., 2021). None of these studies was compared to control condi- sented both positive (Jung et al., 2016; Lee et al., 2020) and no tions; Smoktunowicz et al. (2021) did compare different versions of significant effects (Lee et al., 2018). A guided mindfulness pro- the Med-­Stress program but found no differential effects on depres- gram was not superior to the passive control group (Hosseinzadeh sion. Two interventions were tested in a follow-­up assessment and in Asl, 2021). The APPs developed by Mistretta et al. (2018) and Fiol-­ both cases, the effects were no longer observed (Divya et al., 2021; DeRoque et al. (2021) were compared to active control groups Finlay-­Jones et al., 2017). The interventions tested in the remain- and, despite showing some effects, these did not reach statistical ing three studies (Fiol-­DeRoque et al., 2021; Mistretta et al., 2018; significance. Amongst those studies in which intragroup effects Yamagishi et al., 2007) did not produce significant reductions in de- were reported, web-­based ACT (Barrett & Stewart, 2021), the self-­ pressive symptoms. compassion Cultivation Program (Finlay-­Jones et al., 2017), some individual modules of the Mind–­Body Skills Training (Kemper & Khirallah, 2015; Kemper & Rao, 2017; Rao & Kemper, 2017), the 3.4.2 | Anxiety symptoms Benevolent Midwifery Project (Wright, 2018), the guided work- shop on Sudarshan Kriya Yoga (Divya et al., 2021), and the brief Anxiety was included as an outcome in 8 studies. The emotional mindfulness-­based intervention tested by Osman et al. (2021) pre- freedom techniques guided session (Dincer & Inangil, 2021) and the sented positive results on stress reduction, whilst the Mindfulness Mindful-­B ody Training (Lee et al., 2018) resulted superior to their Decompression and Psychoeducation Program (Wang et al., 2021) respective control groups for reducing anxiety posttreatment. did not. Long-­term effects were reported in the studies conducted The guided Sudarshan Kriya Yoga workshop (Divya et al., 2021), by Finlay-­Jones et al. (2017) and Lee et al. (2020); however, three the brief online guided imagery training (Rao & Kemper, 2017), ‘third wave’ eHealth interventions resulted not effective in the fol- and the mindfulness decompression and psychoeducation pro- low-­up assessments (Divya et al., 2021; Hosseinzadeh Asl, 2021; gram (Wang et al., 2021) produced significant reductions in anxi- Mistretta et al., 2018). ety levels posttreatment. On the other hand, the PsyCovid APP Amongst the 10 interventions (9 self-­g uided, 1 guided) (Fiol-­D eRoque et al., 2021) only produced significant effects on not based on ‘third wave’ psychotherapy principles, 5 were those health professionals who attended to a psychotherapy or compared to passive control groups. The guided Emotional consumed psychotropic medications compared to a control APP, | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LÓPEZ-­DEL-­HOYO et al. 5529 and the mindfulness-­b ased resilience training APP did not present presented both posttreatment and in the follow-­up assessment significant effects on anxiety compared to those who underwent a (Jung et al., 2016; Lee et al., 2020), and Wright (2018) reported sim- similar in-­p erson intervention or were in a no-­intervention control ilar effects of the mindfulness and yoga-­based intervention in their group (Mistretta et al., 2018). Two studies included follow-­up as- pre-­post single-­arm study. sessments; the effects observed posttreatment by the Sudarshan Kriya Yoga workshop were no longer reported after 40 days, whilst the online self-­compassion cultivation program, which did 3.4.5 | Mindfulness and self-­compassion not produce significant reductions in anxiety posttreatment, pre- sented a significant effect in the 12 weeks follow-­up (Finlay-­J ones Changes in mindfulness levels were assessed in 4 studies; all of et al., 2017). them studied ‘third wave’ psychotherapy-­related interventions which produced significant improvements posttreatment (Eriksson et al., 2018; Kemper et al., 2015; Kemper & Khirallah, 2015; Osman 3.4.3 | Burnout et al., 2021). Two of the studies observed that the tested interven- tions were superior to their respective control groups (Eriksson The impact of the intervention on burnout levels was reported in et al., 2018; Kemper et al., 2015). No follow-­up assessments were 7 of the studies reviewed. Five of them observed significant re- conducted. ductions in this outcome: web-­based ACT and web-­based CBT Self-­compassion was assessed in 5 studies; again, all of them (Barrett & Stewart, 2021), and the mindfulness decompression and were ‘third wave’ psychotherapy-­based programs, and in all psychoeducation program (Wang et al., 2021) produced significant cases, significant effects were observed posttreatment (Eriksson reductions posttreatment; also, the study conducted by Osman et al., 2018; Finlay-­Jones et al., 2017; Hosseinzadeh Asl, 2021; et al. (2021) reported effects on the emotional exhaustion and per- Kemper et al., 2015; Mistretta et al., 2018). Four of these studies sonal accomplishment facets of burnout, but not on depersonaliza- included a control group, and the tested intervention resulted supe- tion. Moreover, the mindful and self-­compassion program (Eriksson rior in all cases. In the follow-­up assessments, the effectiveness of et al., 2018) and the guided session teaching emotional freedom the mindfulness-­based resilience training APP studied by Mistretta techniques (Dincer & Inangil, 2021) produced significant improve- et al. (2018) was no longer significant, but the self-­compassion cul- ments in burnout compared to control groups. None of these studies tivation program (Finlay-­Jones et al., 2017) and the guided mindful- conducted a follow-­up assessment. The two remaining studies did ness program (Hosseinzadeh Asl, 2021) did maintain their effects on not report significant effects on burnout of the eHealth interven- self-­compassion. tions, both consisting of ‘third wave’ psychotherapy-­based smart- phone APPs (Fiol-­DeRoque et al., 2021; Mistretta et al., 2018). 4 | DISCUSSION 3.4.4 | Resilience and stress coping Different eHealth interventions have been designed to reduce healthcare providers' stress levels and promote their mental health, Resilience was included as an outcome in 6 studies; the guided not only in the context of the COVID-­19 pandemic, since only four Sudarshan Kriya Yoga workshop (Divya et al., 2021), the brief focused studies (Dincer & Inangil, 2021; Fiol-­DeRoque et al., 2021; Gollwitzer attention meditation training (Kemper & Rao, 2017), a module of the et al., 2018; Osman et al., 2021) were explicitly framed into it, but as Mind–­Body Skills Training program (Kemper & Khirallah, 2015), and a way of providing health professionals some tools that can be easy the Mind–­Body Training (Jung et al., 2016) were reported to improve to adapt to their schedules and that can help them with their day-­ significantly the levels of resilience posttreatment. In the latter case, to-­day stress. the intervention was compared to a passive control group and re- The heterogeneity of the interventions is notable in different sulted in superior, also in the 1-­month follow-­up assessment (Lee aspects: format (guided vs. self-­guided), platform (web-­based, APP, et al., 2020). On the contrary, the Sudarshan Kriya Yoga workshop text messages), duration (from a few minutes to several weeks) and did not present significant effects in the follow-­up assessment. The contents and theoretical bases (‘third wave’ psychotherapy-­based, intervention based on supportive text messages studied by Concilio CBT, or others). The most common eHealth programs were those et al. (2021) did not produce significant effects on resilience com- self-­guided, web-­based and with ‘third wave’ psychotherapy con- pared to the control group. cepts that lasted between 2 and 6 weeks. Four eHealth programs The effects of the BREATHE program on coping with stress included in the reviewed studies met these criteria and presented compared to a waiting-­list control group were evaluated in one significant reductions in stress levels: web-­based ACT (Barrett & study, but no significant results were reported (Hersch et al., 2016). Stewart, 2021), the mindful and self-­compassion program (Eriksson The Mindful-­Body Training had significant effects on improving et al., 2018), the self-­compassion cultivation program (Finlay-­Jones some coping strategies such as problem-­solving and social support et al., 2017), and the Benevolent Midwifery Project (Wright, 2018). compared to a no-­intervention control group; these effects were Apart from these programs, 5 more self-­guided interventions, each | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 5530 LÓPEZ-­DEL-­HOYO et al. with different characteristics (i.e. duration, contents), resulted effec- that includes some occasional online guidance (e.g. telephone or tive. This highlights the promising therapeutic potential of this for- video call, text message) to foster motivation and accompany the mat for healthcare providers, which presents numerous advantages user could be a good way of finding a balance between the ben- including increased availability, flexibility and convenience, along efits of each format. Blended interventions (i.e. those which com- with high user satisfaction and acceptance (Stoll et al., 2020). bine eHealth with face-­to-­face sessions) could also be considered an Nonetheless, it cannot be overlooked that 9 self-­guided pro- alternative; however, although some studies conducted on clinical grams did not produce significant stress reduction effects; this could samples have proved their efficacy (Erbe et al., 2017), these inter- be attributed to methodological shortcomings of the studies in some ventions might not be the best fit for healthcare professionals since cases, although most of them presented at least fair quality accord- the face-­to-­face element reduces very significantly their flexibility, ing to the quality assessment conducted. Thus, different hypotheses which is considered key for this population. Another aspect that could be established: first, that smartphone APPs and text messages remains unclear is whether interventions addressed specifically at may be either too flexible or have a too subtle effect to get the in- health professionals would be more effective than generic programs dividual to engage with the contents of the intervention and delve which could be used by any given population; in their systematic into them; second, that programs which do not address stress explic- review, Pospos et al. (2018) suggested that eHealth interventions itly but indirectly through other contents may be too unspecific to should address the particular needs of healthcare providers; in the generate significant reductions in stress; and third, that self-­guided present review, only 5 studies presented specific contents for this online programs (regardless of their format and contents), precisely population (i.e. BREATHE, PsyCovid-­APP, Provider Resilience-­APP, because of their flexible nature which is considered a strength in Med-­Stress, and Career Identity Training) with different results. most cases, may favour high attrition rates, which would hinder the Thus, these hypotheses need to be tested in further studies. intervention's efficacy (Lippke et al., 2021; Stoll et al., 2020). Finally, for what concerns to the contents of the intervention, Guided eHealth interventions, on the other hand, were scarce. ‘third wave’ psychotherapies have been the most common amongst Only 4 studies tested guided programs, three of which were ‘third the reviewed studies. The efficacy of such interventions had already wave’ psychotherapy-­based, delivered via videoconferences: the been tested in samples of healthcare workers (Aranda Auserón emotional freedom techniques session (Dincer & Inangil, 2021), the et al., 2018; Asuero et al., 2014; Brinkborg et al., 2011; Kriakous Sudarshan Kriya Yoga workshop (Divya et al., 2021), the cognitive et al., 2021; Rudaz et al., 2017), and the present review corroborates therapy and mindfulness-­based program (Hosseinzadeh Asl, 2021), that, generally, eHealth ‘third wave’ psychotherapies produce sig- and the brief online mindfulness-­based intervention (Osman nificant effects not only in stress reduction, but also in other men- et al., 2021). Two of these programs were compared to passive con- tal health-­related outcomes such as depressive symptomatology, trol groups, with one resulting as superior (Dincer & Inangil, 2021) anxiety, burnout, resilience, mindfulness and compassion, amongst and the other equivalent (Hosseinzadeh Asl, 2021); follow-­up as- others. Two CBT-­based programs were also included in the reviewed sessments were included in two studies, with none of them reflect- studies with positive outcomes in terms of stress, mental health and ing significant effects on stress (Divya et al., 2021; Hosseinzadeh burnout (Barrett & Stewart, 2021) and work functioning (Ketelaar Asl, 2021). These findings do not go in line with previous research et al., 2014), whilst a variety of programs based on different concep- which reported that the changes produced by guided interventions—­ tual backgrounds resulted effective to improve stress and promote not ‘third wave’-­based—­were maintained in the long term for differ- mental health in healthcare providers. ent clinical populations (Andersson et al., 2018). This might indicate that health professionals constitute a partic- ular case in this regard; it could be hypothesised that, whilst guided 4.1 | Limitations eHealth interventions may produce a significant short-­term impact in stress reduction, this improvement could possibly be due in part This review presents notable strengths, such as conducting searches to the therapeutic alliance. Interestingly, of the five studies that as- across different scientific databases and trial registries, verifying the sessed the effects of self-­guided interventions in a follow-­up, three selection decisions by three reviewers, and assessing study qual- found that stress levels were significantly reduced (Finlay-­Jones ity. Studies reporting no effects of the intervention were found and et al., 2017; Lee et al., 2020; Smoktunowicz et al., 2021). With due included, which could indicate that this review has not been sus- caution, it could be suggested that self-­guided eHealth interventions tained to a significant publication bias. However, some limitations promote the user's autonomy, making it easier for them to incor- need to be acknowledged: first, and since this is a very topical issue, porate the recommendations and exercises practised during the it is possible that new studies were to be published soon after this program once it finishes. As previously stated, the problem with self-­ review was conducted (last search was conducted in April 2022). guided interventions is that high rates of attrition might be a con- Several study protocols on the effectiveness of different eHealth sequence of their flexibility, which would hinder detecting those at interventions on health professional's mental health were published risk for dropping out (Lippke et al., 2021). Some degree of guidance in the last years, which implies that an update of the present review has been associated with better outcomes (Baumeister et al., 2014) should be conducted when the results of such studies are available. and, thus, a mixed format, such as a self-­guided web-­based program Moreover, only studies published in English were included, which | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LÓPEZ-­DEL-­HOYO et al. 5531 may have implied that some potentially relevant studies have not C O N FL I C T O F I N T E R E S T been reviewed. None. It is noteworthy that, of the 27 studies reviewed, only 8 were assessed as presenting ‘good’ quality, whilst 11 presented ‘poor’ DATA AVA I L A B I L I T Y S TAT E M E N T quality. The results of such studies should be considered with cau- Data sharing are not applicable—­no new data are generated. tion. The statistical analyses used by the studies were in many cases heterogeneous and the results were incomplete (e.g. not reporting ORCID effect sizes), which made it very difficult to compare the efficacy of Yolanda López-­Del-­Hoyo https://orcid. the interventions that each study tested. Also, the lack of follow-­up org/0000-0002-1690-4130 assessments, only included in 8 studies, is another aspect that hin- Adrián Pérez-­Aranda https://orcid.org/0000-0002-1602-3413 ders the extraction of conclusions, since the hypotheses regarding Alberto Barceló-­Soler https://orcid.org/0000-0002-2116-9257 the possible impact of the format (i.e. guided vs. self-­guided) were Marco Bani https://orcid.org/0000-0002-6500-6513 based on very few data and should, therefore, be contrasted in fur- Selena Russo https://orcid.org/0000-0002-3024-3316 ther studies. Fernando Urcola-­Pardo https://orcid.org/0000-0001-7049-8295 Maria Grazia Strepparava https://orcid. org/0000-0001-5068-8753 5 | CO N C LU S I O N Javier García-­Campayo https://orcid.org/0000-0002-3797-4218 The present review supports the potential of different eHealth REFERENCES interventions to reduce stress levels in healthcare providers. Self-­ Andersson, G., Rozental, A., Shafran, R., & Carlbring, P. (2018). Long-­ guided interventions are the most common options, normally pre- term effects of internet-­supported cognitive behaviour ther- apy. Expert Review of Neurotherapeutics, 18(1), 21–­28. https://doi. sented in a web-­based format; these programs are very flexible org/10.1080/14737​175.2018.1400381 and easy to adapt to the needs of health professionals, although Aranda Auserón, G., Elcuaz Viscarret, M. R., Fuertes Goñi, C., Güeto they might benefit from some occasional guidance to overcome Rubio, V., Pascual Pascual, P., de Murieta, S., & García de Galdeano, the common attrition problems that have been reported and that E. (2018). Evaluation of the effectiveness of a mindfulness and self-­ compassion program to reduce stress and prevent burnout in pri- hinder their efficacy. ‘Third wave’ psychotherapy-­based interven- mary care health professionals. Atencion Primaria, 50(3), 141–­150. tions were also common, generally with positive outcomes, not only https://doi.org/10.1016/j.aprim.2017.03.009 on stress reduction but also on other mental health outcomes such Asuero, A. M., Queraltó, J. M., Pujol-­Ribera, E., Berenguera, A., Rodriguez-­ as depressive symptomatology, anxiety, burnout, resilience, and Blanco, T., & Epstein, R. M. (2014). Effectiveness of a mindfulness education program in primary health care professionals: A prag- mindfulness, amongst others. Methodologically sound studies are matic controlled trial. Journal of Continuing Education in the Health required to deepen into what kind of interventions work for health- Professions, 34(1), 4–­12. https://doi.org/10.1002/chp.21211 care providers. Barbeito, S., Sánchez-­Gutiérrez, T., Becerra-­García, J. A., González Pinto, A., Caletti, E., & Calvo, A. (2020). A systematic review of online interventions for families of patients with severe mental disorders. Journal of Affective Disorders, 263, 147–­154. https://doi. 6 | R E LE VA N C E TO C LI N I C A L PR AC TI C E org/10.1016/J.JAD.2019.11.106 Barrett, K., & Stewart, I. (2021). A preliminary comparison of the efficacy Different stress-­managing eHealth resources are available for of online acceptance and commitment therapy (ACT) and cognitive healthcare providers. Self-­guided programs with occasional external Behavioural therapy (CBT) stress management interventions for so- cial and healthcare workers. Health & Social Care in the Community, guidance could be a good fit for this population. 29(1), 113–­126. https://doi.org/10.1111/hsc.13074 Baumeister, H., Reichler, L., Munzinger, M., & Lin, J. (2014). The impact AU T H O R C O N T R I B U T I O N S of guidance on internet-­based mental health interventions —­A sys- Conceptualization, YLH and SFM; methodology, SFM, ABS and APA; tematic review. Internet Interventions, 1(4), 205–­215. https://doi. org/10.1016/J.INVENT.2014.08.003 software, SFM, ABS and APA; validation, MB and SR; formal analy- Brinkborg, H., Michanek, J., Hesser, H., & Berglund, G. (2011). sis, SFM, ABS and APA; investigation, YLH and JGC; resources, YLH Acceptance and commitment therapy for the treatment of stress and JGC; data curation, SFM, ABS and APA; writing—­original draft among social workers: A randomized controlled trial. Behaviour preparation, SFM and APA; writing—­review and editing, ABS, YLH, Research and Therapy, 49(6–­7 ), 389–­398. https://doi.org/10.1016/j. brat.2011.03.009 MB, SR, FUP, MGS and JGC; visualisation, APA; supervision, JGC and Campbell, M., McKenzie, J. E., Sowden, A., Katikireddi, S. V., Brennan, S. YLH; project administration, YLH. All authors have read and agreed E., Ellis, S., Hartmann-­Boyce, J., Ryan, R., Shepperd, S., Thomas, J., to the published version of the manuscript. Welch, V., & Thomson, H. (2020). Synthesis without meta-­analysis (SWiM) in systematic reviews: Reporting guideline. The BMJ, 368, I6890. https://doi.org/10.1136/bmj.l6890 AC K N O​W L E D ​ G E ​M E N T S Chirico, F. (2021). Spirituality to cope with COVID-­19 pandemic, climate APA is the holder of a “Sara Borrell” research contract from the change and future global challenges. Journal of Health and Social Instituto de Salud Carlos III (CD20/00181). Sciences, 6(2), 151–­158. https://doi.org/10.19204/​2021/sprt2 | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 5532 LÓPEZ-­DEL-­HOYO et al. Chirico, F., Afolabi, A. A., Ilesanmi, O. S., Nucera, G., Ferrari, G., Sacco, intervention to reduce mental health problems in health care work- A., Szarpak, L., Crescenzo, P., Magnavita, N., & Leiter, M. (2021). ers during the COVID-­19 pandemic (PsyCovidApp): Randomized Prevalence, risk factors and prevention of burnout syndrome controlled trial. JMIR mHealth and uHealth, 9(5), e27039. https:// among healthcare workers: An umbrella review of systematic re- doi.org/10.2196/27039 views and meta-­analyses. Journal of Health and Social Sciences, 6(4), Gollwitzer, P. M., Mayer, D., Frick, C., & Oettingen, G. (2018). Promoting 465–­491. https://doi.org/10.19204/​2021/prvl3 the self-­regulation of stress in health care providers: An internet-­ Chirico, F., Afolabi, A. A., Ilesanmi, O. S., Nucera, G., Ferrari, G., Szarpak, based intervention. Frontiers in Psychology, 9(Jun), 1–­11. https://doi. L., Yildirim, M., & Magnavita, N. (2022). Workplace violence against org/10.3389/fpsyg.2018.00838 healthcare workers during the COVID-­19 pandemic: A systematic Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). review. Journal of Health and Social Sciences, 7(1), 14–­35. https://doi. Managing mental health challenges faced by healthcare workers during org/10.19204/​2022/WRKP2 covid-­19 pandemic. The BMJ, 368. https://doi.org/10.1136/bmj.m1211 Chirico, F., & Magnavita, N. (2020). Burnout syndrome and meta-­ Gruber, J., Prinstein, M. J., Clark, L. A., Rottenberg, J., Abramowitz, J. S., analyses: Need for evidence-­based research in occupational health. Albano, A. M., Aldao, A., Borelli, J. L., Chung, T., Davila, J., Forbes, E. comments on prevalence of burnout in medical and surgical resi- E., Gee, D. G., Hall, G. C. N., Hallion, L. S., Hinshaw, S. P., Hofmann, dents: A meta-­analysis. int. j. environ. res. public. health. 2019, 16, S. G., Hollon, S. D., Joormann, J., Kazdin, A. E., & Weinstock, L. doi:10.3390/ijerph16091479. International Journal of Environmental M. (2021). Mental health and clinical psychological science in the Research and Public Health, 17(3), 741. https://doi.org/10.3390/ time of COVID-­19: Challenges, opportunities, and a call to action. ijerp​h1703​0741 American Psychologist, 76(3), 409–­426. https://doi.org/10.1037/ Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of amp00​0 0707 perceived stress. Journal of Health and Social Behavior, 24(4), 385. Hersch, R. K., Cook, R. F., Deitz, D. K., Kaplan, S., Hughes, D., Friesen, M. https://doi.org/10.2307/2136404 A., & Vezina, M. (2016). Reducing nurses' stress: A randomized con- Concilio, L., Lockhart, J. S., Kronk, R., Oermann, M., Brannan, J., & trolled trial of a web-­based stress management program for nurses. Schreiber, J. B. (2021). Impact of a digital intervention on perceived Applied Nursing Research, 32, 18–­25. https://doi.org/10.1016/j. stress, resiliency, social support, and intention to leave among apnr.2016.04.003 newly licensed graduate nurses: A randomized controlled trial. Hosseinzadeh Asl, N. R. (2021). A randomized controlled trial of a Journal of Continuing Education in Nursing, 52(8), 367–­374. https:// mindfulness-­based intervention in social workers working during doi.org/10.3928/00220​124-­20210​714-­06 the COVID-­19 crisis. Current Psychology, 41, 8192–­8199. https:// Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & doi.org/10.1007/s1214​4-­021-­02150​-­3 Andersson, G. (2014). Psychological treatment of generalized anx- Jakel, P., Kenney, J., Ludan, N., Miller, P. S., McNair, N., & Matesic, E. iety disorder: A meta-­analysis. Clinical Psychology Review, 34(2), (2016). Effects of the use of the provider resilience mobile ap- 130–­140. https://doi.org/10.1016/j.cpr.2014.01.002 plication in reducing compassion fatigue in oncology nursing. Cullen, W., Gulati, G., & Kelly, B. D. (2020). Mental health in the COVID-­19 Clinical Journal of Oncology Nursing, 20(6), 611–­616. https://doi. pandemic. QJM: Monthly Journal of the Association of Physicians, org/10.1188/16.CJON.611-­616 113(5), 311–­312. https://doi.org/10.1093/qjmed/​hcaa110 Jung, Y. H., Ha, T. M., Oh, C. Y., Lee, U. S., Jang, J. H., Kim, J., Park, J. O., Dincer, B., & Inangil, D. (2021). The effect of emotional freedom tech- & Kang, D. H. (2016). The effects of an online mind-­body training niques on nurses' stress, anxiety, and burnout levels during the program on stress, coping strategies, emotional intelligence, resil- COVID-­19 pandemic: A randomized controlled trial. Explore, 17(2), ience and psychological state. PLoS One, 11(8), 1–­20. https://doi. 109–­114. https://doi.org/10.1016/j.explo​re.2020.11.012 org/10.1371/journ​al.pone.0159841 Divya, K., Bharathi, S., Somya, R., & Darshan, M. H. (2021). Impact of Karasu, F., Öztürk Çopur, E., & Ayar, D. (2021). The impact of COVID-­19 on a yogic breathing technique on the well-­being of healthcare pro- healthcare workers' anxiety levels. Journal of Public Health (Germany), fessionals during the COVID-­19 pandemic. Global Advances 1–­11, 1399–­1409. https://doi.org/10.1007/s1038​9-­020-­01466​-­x in Health and Medicine, 10, 216495612098295. https://doi. Kemper, K. J., & Khirallah, M. (2015). Acute effects of online mind–­body org/10.1177/21649​56120​982956 skills training on resilience, mindfulness, and empathy. Journal of Dutton, S., & Kozachik, S. L. (2020). Evaluating the outcomes of a web-­ Evidence-­Based Complementary & Alternative Medicine, 20(4), 247–­ based stress management program for nurses and nursing assis- 253. https://doi.org/10.1177/21565​87215​575816 tants. Worldviews on Evidence-­Based Nursing, 17(1), 32–­38. https:// Kemper, K. J., Lynn, J., & Mahan, J. D. (2015). What is the impact of doi.org/10.1111/wvn.12417 online training in mind–­body skills? Journal of Evidence-­ Based Erbe, D., Psych, D., Eichert, H. C., Riper, H., & Ebert, D. D. (2017). Blending Complementary and Alternative Medicine, 20(4), 275–­282. https:// face-­to-­face and internet-­based interventions for the treatment of doi.org/10.1177/21565​87215​580882 mental disorders in adults: Systematic review. Journal of Medical Kemper, K. J., & Rao, N. (2017). Brief online focused attention med- Internet Research, 19(9), e306. https://doi.org/10.2196/JMIR.6588 itation training: Immediate impact. Journal of Evidence-­ Based Eriksson, T., Germundsjö, L., Åström, E., & Rönnlund, M. (2018). Mindful Complementary and Alternative Medicine, 22(3), 395–­4 00. https:// self-­compassion training reduces stress and burnout symptoms doi.org/10.1177/21565​87216​663565 among practicing psychologists: A randomized controlled trial of a Ketelaar, S. M., Nieuwenhuijsen, K., Gärtner, F. R., Bolier, L., Smeets, O., brief web-­based intervention. Frontiers in Psychology, 9(Nov), 1–­10. & Sluiter, J. K. (2014). Mental vitality @ work: The effectiveness https://doi.org/10.3389/fpsyg.2018.02340 of a mental module for workers' health surveillance for nurses and Eysenbach, G. (2001). What is e-­health? Journal of Medical Internet allied health professionals, comparing two approaches in a cluster-­ Research, 3(2), 1–­5. https://doi.org/10.2196/jmir.3.2.e20 randomised controlled trial. International Archives of Occupational Finlay-­Jones, A., Kane, R., & Rees, C. (2017). Self-­compassion online: A and Environmental Health, 87(5), 527–­538. https://doi.org/10.1007/ pilot study of an internet-­based self-­compassion cultivation pro- s0042​0 -­013-­0 893-­6 gram for psychology trainees. Journal of Clinical Psychology, 73(7), Kowalik, J., Weller, J., Venter, J., & Drachman, D. (2011). Cognitive be- 797–­816. https://doi.org/10.1002/jclp.22375 havioral therapy for the treatment of pediatric posttraumatic Fiol-­DeRoque, M. A., Serrano-­Ripoll, M. J., Jiménez, R., Zamanillo-­ stress disorder: A review and meta-­analysis. Journal of Behavior Campos, R., Yáñez-­Juan, A. M., Bennasar-­Veny, M., Leiva, A., Therapy and Experimental Psychiatry, 42(3), 405–­413. https://doi. Gervilla, E., García-­Buades, M. E., García-­Toro, M., Alonso-­Coello, org/10.1016/j.jbtep.2011.02.002 P., Pastor-­Moreno, G., Ruiz-­Pérez, I., Sitges, C., García-­C ampayo, J., Kriakous, S. A., Elliott, K. A., Lamers, C., & Owen, R. (2021). The ef- Llobera-­C ánaves, J., & Ricci-­C abello, I. (2021). A mobile phone-­based fectiveness of mindfulness-­based stress reduction on the | 13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16634 by Readcube (Labtiva Inc.), Wiley Online Library on [14/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License LÓPEZ-­DEL-­HOYO et al. 5533 psychological functioning of healthcare professionals: A systematic Rao, N., & Kemper, K. J. (2017). The feasibility and effectiveness of on- review. Mindfulness, 12(1), 1–­28. https://doi.org/10.1007/s1267​1-­ line guided imagery training for health professionals. Journal of 020-­01500​-­9 Evidence-­Based Complementary and Alternative Medicine, 22(1), 54–­ Kruk, J., Aboul-­Enein, B. H., Bernstein, J., & Gronostaj, M. (2019). 58. https://doi.org/10.1177/21565​87216​631903 Psychological stress and cellular aging in cancer: A meta-­analysis. Rudaz, M., Twohig, M. P., Ong, C. W., & Levin, M. E. (2017). Mindfulness Oxidative Medicine and Cellular Longevity, 2019, 1–­23. https://doi. and acceptance-­based trainings for fostering self-­c are and reduc- org/10.1155/2019/1270397 ing stress in mental health professionals: A systematic review. Lavoie-­Tremblay, M., Gélinas, C., Aubé, T., Tchouaket, E., Tremblay, D., Gagnon, Journal of Contextual Behavioral Science, 6(4), 380–­390. https://doi. M. P., & Côté, J. (2022). Influence of caring for COVID-­19 patients on org/10.1016/j.jcbs.2017.10.001 nurse's turnover, work satisfaction and quality of care. Journal of Nursing Smoktunowicz, E., Lesnierowska, M., Carlbring, P., Andersson, G., & Management, 30(1), 33–­43. https://doi.org/10.1111/jonm.13462 Cieslak, R. (2021). Resource-­based internet intervention (med-­ Lee, D., Kang, D. H., Ha, N. H., Oh, C. Y., Lee, U., & Kang, S. W. (2018). stress) to improve well-­being among medical professionals: Effects of an online mind-­body training program on the default Randomized controlled trial. Journal of Medical Internet Research, mode network: An EEG functional connectivity study. Scientific 23(1), e21445. https://doi.org/10.2196/21445 Reports, 8(1), 1–­8. https://doi.org/10.1038/s4159​8-­018-­3 4947​-­x Stoll, J., Müller, J. A., & Trachsel, M. (2020). Ethical issues in online psy- Lee, D., Lee, W. J., Choi, S. H., Jang, J. H., & Kang, D. H. (2020). Long-­ chotherapy: A narrative review. Frontiers in Psychiatry, 10, 993. term beneficial effects of an online mind-­body training program https://doi.org/10.3389/FPSYT.2019.00993/​BIBTEX on stress and psychological outcomes in female healthcare provid- Suntai, Z., Laha-­Walsh, K., & Albright, D. L. (2021). Effectiveness of remote ers: A non-­randomized controlled study. Medicine, 99(32), e21027. interventions in improving caregiver stress outcomes for caregivers https://doi.org/10.1097/MD.00000​0 0000​021027 of people with traumatic brain injury. Rehabilitation Psychology, 66(4), Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. 415–­422. https://doi.org/10.1037/rep00​00402 (2020). Psychological therapies for post-­traumatic stress dis- Wang, J., Song, B., Shao, Y., & Zhu, J. (2021). Effect of online psycho- order in adults: Systematic review and meta-­analysis. European logical intervention on burnout in medical residents from differ- Journal of Psychotraumatology, 11(1), 1729633. https://doi. ent majors: An exploratory study. Frontiers in Psychology, 12(May), org/10.1080/20008​198.2020.1729633 632134. https://doi.org/10.3389/fpsyg.2021.632134 Lippke, S., Gao, L., Keller, F. M., Becker, P., & Dahmen, A. (2021). Williamson, V., Stevelink, S. A. M., & Greenberg, N. (2018). Occupational Adherence with online therapy vs face-­to-­face therapy and with moral injury and mental health: Systematic review and meta-­ online therapy vs care as usual: Secondary analysis of two random- analysis. British Journal of Psychiatry, 212(6), 339–­3 46. https://doi. ized controlled trials. Journal of Medical Internet Research, 23(11), org/10.1192/bjp.2018.55 e31274. https://doi.org/10.2196/31274 World Health Organization (WHO). (2020). Mental health considerations Liu, C., Zhu, Q., Holroyd, K. A., & Seng, E. K. (2011). Status and trends of during COVID-­19 outbreak. mobile-­health applications for iOS devices: A developer's perspec- Wright, E. M. (2018). Evaluation of a web-­based holistic stress reduction tive. Journal of Systems and Software, 84(11), 2022–­2033. https:// pilot program among nurse-­midwives. Journal of Holistic Nursing, doi.org/10.1016/j.jss.2011.06.049 36(2), 159–­169. https://doi.org/10.1177/08980​10117​704325 Lovibond, S., & Lovibond, P. (1995). Manual for the depression anxiety Yamagishi, M., Kobayashi, T., Kobayashi, T., Nagami, M., Shimazu, stress scales. Psychology Foundation of Australia. A., & Kageyama, T. (2007). Effect of web-­based asser- Magnavita, N., Chirico, F., & Sacco, A. (2021). COVID-­19: From hospitals tion training for stress management of Japanese nurses. to courts. The Lancet, 397(10284), 1542. https://doi.org/10.1016/ Journal of Nursing Management, 15(6), 603–­607. https://doi. S0140​-­6736(21)00472​- ­4 org/10.1111/j.1365-­2834.2007.00739.x Mistretta, E. G., Davis, M. C., Temkit, M., Lorenz, C., Darby, B., & Yamagishi, M., Kobayashi, T., & Nakamura, Y. (2008). Effects of web-­ Stonnington, C. M. (2018). Resilience training for work-­related based career identity training for stress management among stress among health care workers. Journal of Occupational and Japanese nurses: A randomized control trial. Journal of Occupational Environmental Medicine, 60(6), 559–­568. https://doi.org/10.1097/ Health, 50(2), 191–­193. https://doi.org/10.1539/joh.L7086 JOM.00000​0 0000​0 01285 Yogeswaran, V., & El Morr, C. (2021). Effectiveness of online mindfulness Osman, I., Hamid, S., & Singaram, V. S. (2021). Efficacy of a brief on- interventions on medical students' mental health: A systematic line mindfulness-­based intervention on the psychological well-­ review. BMC Public Health, 21(1), 2293. https://doi.org/10.1186/ being of health care professionals and trainees during the covid-­19 s1288​9-­021-­12341​-­z pandemic: A mixed method design. Health SA Gesondheid, 26, 1–­9. https://doi.org/10.4102/hsag.v26i0.1682 Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., S U P P O R T I N G I N FO R M AT I O N Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Additional supporting information can be found online in the Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, Supporting Information section at the end of this article. T., Loder, E. W., Mayo-­Wilson, E., McDonald, S., & Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting sys- tematic reviews. BMJ, 372. https://doi.org/10.1136/bmj.n71 Pfefferbaum, B., & North, C. S. (2020). Mental health and the Covid-­19 pandemic. New England Journal of Medicine, 383(6), 510–­512. How to cite this article: López-­Del-­Hoyo, Y., https://doi.org/10.1056/nejmp​2008017 Fernández-­Martínez, S., Pérez-­Aranda, A., Barceló-­Soler, A., Popay, J., Baldwin, S., Arai, L., Britten, N., Petticrew, M., Rodgers, M., & Bani, M., Russo, S., Urcola-­Pardo, F., Strepparava, M. G., & Sowden, A. (2007). Guidance on the Conduct of Narrative Synthesis García-­Campayo, J. (2023). Effects of eHealth interventions on in Systematic Reviews. ESRC Methods Programme, January. Pospos, S., Young, I. T., Downs, N., Iglewicz, A., Depp, C., Chen, J. Y., stress reduction and mental health promotion in healthcare Newton, I., Lee, K., Light, G. A., & Zisook, S. (2018). Web-­based professionals: A systematic review. Journal of Clinical Nursing, tools and Mobile applications to mitigate burnout, depression, and 32, 5514–5533. https://doi.org/10.1111/jocn.16634 suicidality among healthcare students and professionals: A sys- tematic review. Academic Psychiatry, 42(1), 109–­120. https://doi. org/10.1007/S4059​6-­017-­0 868-­0