The Efficacy of Resilience Training Programs a Systematic Review Ppt

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The Efficacy of Resiliency Training Programs: A Systematic Review and Meta-Analysis of Randomized Trials

• Aaron L. Leppin,
• Pavithra R. Bora,
• Jon C. Tilburt,
• Michael R. Gionfriddo,
• Claudia Zeballos-Palacios,
• Megan M. Dulohery,
• Amit Sood,
• Patricia J. Erwin,
• Juan Pablo Brito,
• Kasey R. Boehmer

x

• Published: October 27, 2014
• https://doi.org/10.1371/journal.pone.0111420

Figures

Abstruse

Importance

Poor mental health places a brunt on individuals and populations. Resilient persons are able to adapt to life'due south challenges and maintain high quality of life and office. Finding effective strategies to eternalize resilience in individuals and populations is of interest to many stakeholders.

Objectives

To synthesize the evidence for resiliency training programs in improving mental health and capacity in 1) various adult populations and 2) persons with chronic diseases.

Information Sources

Electronic databases, clinical trial registries, and bibliographies. Nosotros also contacted study authors and field experts.

Written report Selection

Randomized trials assessing the efficacy of whatsoever program intended to enhance resilience in adults and published after 1990. No restrictions were made based on consequence measured or comparator used.

Data Extraction and Synthesis

Reviewers worked independently and in duplicate to extract study characteristics and data. These were confirmed with authors. We conducted a random furnishings meta-analysis on available data and tested for interaction in planned subgroups.

Main Outcomes

The standardized mean deviation (SMD) effect of resiliency training programs on i) resilience/hardiness, 2) quality of life/well-being, iii) cocky-efficacy/activation, iv) depression, 5) stress, and half dozen) feet.

Results

Nosotros found 25 pocket-sized trials at moderate to loftier risk of bias. Interventions varied in format and theoretical approach. Random effects meta-analysis showed a moderate outcome of generalized stress-directed programs on enhancing resilience [pooled SMD 0.37 (95% CI 0.18, 0.57) p = .0002; I² = 41%] inside 3 months of follow up. Improvement in other outcomes was favorable to the interventions and reached statistical significance later on removing ii studies at high risk of bias. Trauma-induced stress-directed programs significantly improved stress [−0.53 (−1.04, −0.03) p = .03; I² = 73%] and depression [−0.51 (−0.92, −0.10) p = .04; I² = 61%].

Conclusions

We found evidence warranting depression confidence that resiliency training programs have a pocket-size to moderate effect at improving resilience and other mental health outcomes. Further study is needed to ameliorate define the resilience construct and to design interventions specific to it.

Citation: Leppin AL, Bora PR, Tilburt JC, Gionfriddo MR, Zeballos-Palacios C, Dulohery MM, et al. (2014) The Efficacy of Resiliency Grooming Programs: A Systematic Review and Meta-Analysis of Randomized Trials. PLoS Ane 9(ten): e111420. https://doi.org/10.1371/journal.pone.0111420

Editor: Alexandra Kavushansky, Technion - Israel Establish of Engineering, State of israel

Received: May vii, 2014; Accepted: September 23, 2014; Published: Oct 27, 2014

Copyright: © 2014 Leppin et al. This is an open up-access article distributed under the terms of the Artistic Eatables Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors ostend that all information underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Data files.

Funding: The authors received no specific funding for this piece of work. However, this publication was made possible past CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily correspond the official view of NIH. The funder had no role in written report design, data collection and analysis, decision to publish, or grooming of the manuscript.

Competing interests: One of the authors, Every bit, has published extensively in this topic and has written a book nigh resilience. As did not conceptualize this project or any function of its approach, only was sought out for expertise and management.

Introduction

Rationale

Resilience has been defined equally the ability of individuals to absorb life's challenges and to acquit on and persevere in the face of arduousness. [one] Overlapping extensively with the concept of hardiness, psychological resilience personifies and reflects characteristics of toughness, elasticity, and the ability to recover. Although the term has been used in many disciplines and applied to many contexts, a contempo concept analysis defined resilience as the "process of effectively negotiating, adapting to, or managing significant sources of stress or trauma."[2].

When conceptualized in this way (i.e. equally a response to stress or trauma), it is practically helpful to briefly consider the position resilience holds within a relevant stress model, such as Lazarus' Transactional Model of Stress and Coping. Co-ordinate to this model, [3] many of the events that incorporate the experience of life (i.e. illness, loss, trauma, new jobs or demands) can be considered "stressors." In the absence of the resources needed to cope with and manage these stressors, people experience their effects in the form of reduced mental–and to a bottom extent physical–health. According to Lazarus' model, then, the value of personal resilience lies in its potential equally an internal resource for mitigating the negative furnishings of stress and for maintaining mental health through adversity [4].

Indeed, poor mental health places major constraints on the well-existence, productivity, and prosperity of individuals, communities, and nations. [5] Every bit such, there is widespread interest in better understanding and applying the mechanism by which resilience is able to avoid these constraints and promote health. [6]–[9] The predictors and effects of resilience have been examined among those living with chronic illness, overcoming traumatic experiences, and prospering in stressful work environments. Overall, research suggests that resilience is a modifiable construct and non an inherent, immovable trait of individuals. To the extent this is true, the potential public health touch on of identifying and translating a reliable and efficacious method of achieving resilience in people is groovy.

Resiliency can be thought of every bit the process of achieving resilience. Clinicians, researchers, patients, public health agencies, governments, and others are investing heavily in mechanisms aimed at facilitating resiliency. Primal among these, "resiliency training programs" are a loosely divers group of interventions that systematically seek to heighten resilience in individuals or groups. To our cognition, no single accepted theoretical framework or consensus statement exists to guide the development or awarding of these programs. Furthermore, despite international use and testing, at that place remains little clarity related to what is fundamentally required for a program to exist considered resiliency preparation, permit lone for information technology to be considered constructive. Indeed, one could argue that, without more guidance and understanding, the field runs the risk of overtranslating and/or diffusing its efforts.

To better sympathise the efficacy of resiliency preparation programs and to provide data that tin can do good determination makers in directing hereafter study, we sought to acquit a systematic review and meta-assay. Clinically, nosotros were particularly interested in the role resiliency grooming might play in improving the lives and health of patients with chronic weather condition.

Objectives

Our primary objective was to synthesize the evidence of resiliency preparation programs in improving resilience, quality of life, and self-efficacy and in reducing low, stress, and feet in adults. A secondary aim was to determine the efficacy of these programs in patients with chronic conditions.

Methods

A published protocol [10] (PROSPERO registration number CRD42014007185) guided the conduct of this review, which we report in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Argument [xi].

Eligibility Criteria

Eligible studies were randomized controlled trials published in any language assessing the efficacy of whatsoever plan designed to develop or heighten resilience (or a related construct, "hardiness") in adults. Eligible studies had to depict an intention to affect resilience or hardiness in their rationale or design. No eligibility restrictions were made based on the type of comparator used, the length of follow-up, or the outcomes measured. Studies that only evaluated dissemination and/or implementation of resiliency training programs were ineligible.

Data Sources

In conjunction with an experienced inquiry librarian (PJE), we searched the following electronic databases from 1990 to January xiv, 2014: PubMed, Scopus, EBSCO CINAHL, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Library, Web of Science, and Ovid PsycINFO. The complete electronic search strategy is available in Supplement S1. Nosotros also searched clinical trial registries, contacted experts and study authors, and hand searched bibliographies.

Report Selection

After receiving formal instruction and piloting a small sample, a squad of 7 reviewers (ALL, PRB, MRG, KRB, MMD, JBP, CZP) worked in duplicate and independently to screen out clearly ineligible papers by reading titles and abstracts and using a web-based software (Distiller SR). To aid in the identification of ongoing studies, reviewers were instructed to include study protocols of potentially eligible trials during this phase. Whatever conflicts warranted retrieval of a full text copy of the article and inclusion into the 2nd stage of screening. During this phase, two reviewers (ALL, PRB) independently examined full text versions of candidate papers to decide final eligibility (kappa = 0.78). Study protocols were excluded at this stage after extraction of relevant writer contact information; all conflicts were resolved by consensus.

Data Collection

After piloting a standardized data extraction course, ii reviewers (ALL, PRB) worked independently and in duplicate to extract details about the included trials' participants, interventions, controls, outcomes, and risks of bias. Specific data extracted included the trial writer, year of publication, setting, study objective, and blazon (patients, students, workforce, other) and demographics (age, gender, race) of participants. We extracted descriptions of the format and theoretical footing of the intervention and comparator, particularly noting whether the comparator was a well-matched attention control vs. not. We extracted data on the number of participants approached, enrolled, randomized, and analyzed when this was available. We extracted mail-intervention means and standard deviations for half-dozen, a priori determined patient-reported outcome domains at both short (longest follow upwardly≤3 months) and long (longest follow up ≥6 months) durations of follow-up.

The outcomes collected were patient-reported measures inside the domains of one) resilience, hardiness, or power to cope; ii) quality of life or well-being; 3) patient activation, self-efficacy, or confidence for affliction management; 4) depression; 5) stress; and 6) anxiety. A consensus of the authors was used to determine whether outcomes measured were appropriate for inclusion inside a given domain. Each outcome was assigned a rating of "advisable," "inappropriate," or "questionable" (see Appendix D). But a unmarried outcome was accepted within each domain for a given trial; when multiple outcomes existed inside a single domain, a bureaucracy was used that prioritized validated and frequently reported measures. When not reported, we calculated standard deviations from confidence intervals and standard errors and, when necessary, we estimated sample sizes from reported degrees of freedom. Nosotros imputed standard deviations in three cases [12]–[fourteen] by using reported standard deviations from other trials using the same measure. To remain conservative, we used the largest standard deviation for each measure that we could observe, prioritizing studies in comparable populations [15]–[17].

Afterward extracting data, we emailed a standardized, pre-populated spreadsheet to all study authors to ane) confirm the accuracy of our extraction, ii) define any missing information and, iii) inquire about other potentially eligible trials. Authors were given 10 days to answer earlier a second email was sent. If no response was received after the second email, nosotros conducted an cyberspace search to place an alternative email or method of contact; if fruitful, a final contact attempt was made before declaring the author unreachable.

Intervention Categorization

Early in the review process, it became clear to u.s. that written report authors used diverse conceptual approaches when applying their training programs. For example, we found a particular dichotomizing stardom betwixt programs based on the blazon of stress they sought to mitigate. Specifically, programs intending to impact trauma-induced stress (i.e. as might occur in individuals with post-traumatic stress disorder afterward a major ending or tragic event) were very different in terms of approach used and outcomes evaluated from those intending to impact more generalized, every-day stresses. To assist in the organization, conceptualization, and analysis of the programs, we developed an ad hoc classification framework ( Figure 1). This framework broadly classified training programs based on 1) whether they sought to mitigate generalized or trauma-induced stress, 2) whether they focused on developing resilience every bit an end goal or every bit a mediating variable, 3) whether they were designed to be used in single/specific or multiple/general populations, and four) whether they were intended to be administered universally or in a targeted fashion (i.e. only "as needed").

Risk of Bias Within Studies

Risk of bias was assessed for each trial independently by 2 team members (AL, Pb) using the Cochrane Collaboration's Tool. [18] Specifically, we considered the quality of the randomization sequence generation; whether treatment arm allocation was concealed; the type and quality of blinding of participants, personnel, and outcome assessors; the degree and potential impact of missing information; the likelihood of incomplete reporting; and the potential part of conflicting interests. In cases where the intervention was explicitly intended to bear on resilience and no measure of resilience was reported, we considered the study to be at high risk of selective reporting. We judged the potential impact of all biases on a given study's reported outcomes and identified those studies at highest risk of bias. Particular weight was given to the impact of missing data, which was a well-distributed variable beyond studies. Conflicts in judgment were resolved through discussion and consensus.

Information Synthesis

To let pooling of effects across different measures of similar constructs, we converted the differences in post-intervention means to standardized mean differences (SMDs). Considering of differences in the conceptual approaches of resiliency training programs designed to mitigate generalized stress compared to those specifically designed to touch post-traumatic stress–and in differences in the underlying psychobiology of these states–we elected, before looking at the data, to analyze these categories of programs separately. For both types of programs, when possible, we conducted a random furnishings meta-analysis of the SMDs within each of the six outcome domains collected. We assessed for between trial heterogeneity in excess of run a risk by calculating the I² statistic. [19] We used RevMan Version 5.2 statistical software [20] for all analyses. Studies not reporting outcomes within the a priori domains or not reporting them at the level of the randomized participants (east.m. reporting changes in team or group civilisation as measured in unlike post-intervention samples) were not included in the meta-analyses.

Risk of Bias Across Studies

Considering included trials were small in size and few in number, it was inappropriate to assess for publication bias through planned funnel plot analyses. [21] Rather, we used global assessments of the body of evidence to postulate on its impact.

Additional Analyses

Nosotros conducted planned subgroup analyses based on whether one) the report participants had a chronic disease and 2) whether the trial had an attending command comparator. Because of heterogeneity in the format, structure, and theoretical approaches of programs, and the small number of trials for a given result, we were unable to formally assess the furnishings of intervention characteristics on outcomes.

Nosotros conducted sensitivity analyses based on the appropriateness of the included outcome (i.e. whether the result was rated every bit "questionable" for inclusion inside a given domain), whether the study was judged at loftier risk of bias, and whether any required data was imputed.

Results

Study Pick

The study menstruation diagram is presented in Figure 2. The electronic database search generated 516 candidate citations. Through title and abstract screening, nosotros identified 68 potentially eligible trial reports or protocols. For these, we retrieved and reviewed full text versions, resulting in the inclusion of 22 trials. A complete list of total text papers reviewed and rationale for exclusion is provided in Supplement S1. 2 additional trials were obtained through protocol author contact and one ongoing, eligible trial was identified through adept contact. Thus, the terminal sample consisted of 25 randomized trials ([13], [fourteen], [22]–[42]; Sharma, unpublished data; and Burton, unpublished information). Authors responded to contact for 17 of the included studies but were often unable to provide additional data or information. A method of contact could non be identified for one written report author [13].

Report Characteristics

A summary of the included trials' characteristics, including the theoretical ground and operational format of all interventions is presented in Tabular array 1. In full general, studies were small and conducted at unmarried centers in various populations. Interventions varied widely in format, duration, and theoretical footing. Self-directed, electronic interventions; individual coaching or training sessions; and grouping courses and sessions were all tried with some efficacy beyond varying outcomes. V studies evaluated programs designed to mitigate trauma-induced stress, while the remainder sought to impact stress more than by and large. Most trials were explicit in describing their intention to impact resilience, while three were less direct in describing this desire. [22], [33], [36] Two studies sought to touch resilience just as a mediator of a broader psychological construct. [30], [39] The theoretical bases of the tested interventions ranged from the use and application of well-established and/or resilience specific models and frameworks (i.eastward. The 5 C's of Resilience, The Resilience Model, Lazarus' Stress Model, etc.) to less clear and/or combined theoretical approaches cartoon on broadly applicable strategies of stress management, attention interpretation, coping, and/or cognitive behavioral therapy. Most studies were of a wait-list command design, although 10 used an attention command.

Risk of Bias Within Studies

A summary of the risk of bias within each written report is presented in Supplement S1. The take a chance of bias was judged to exist moderate to high (agreement = 81%) for most studies. Unclear or incomplete reporting of methods and/or a loftier risk of missing data was frequently seen. In some cases, total numbers of subjects randomized and losses to follow-upwards were not reported and almost all studies conducted per protocol analyses. Seven studies were judged to have a especially high risk of bias.([13], [26], [xxx]–[32], [34] and Burton, unpublished) We could not dominion out a potential conflict of interest in six studies [26], [30], [33], [34], [36], [39].

Results of Individual Studies

In general, resiliency training showed benefit in a number of mental health domains across various populations at ≤iii months of follow-up. In a number of cases, cardinal variables needed for meta-analysis were non reported and could not exist reliably imputed or obtained through author contact. To ensure the comprehensiveness of this review, nosotros have summarized the results of all included studies in Tabular array 1. For any given upshot, there was never more than than ane study reporting at a follow-up fourth dimension ≥half dozen months. This precluded planned meta-analyses of the long-term effectiveness of resiliency preparation programs.

Meta-analyses

Beyond thirteen contributing trials (782 participants), random effects meta-analysis showed an overall benefit of generalized stress-directed resiliency preparation in improving resilience in individuals inside 3 months of follow-upwardly [pooled SMD 0.37 (95% CI 0.18 to 0.57) p = .0002; I² = 41%]. The estimated effect of these programs on quality of life and low was also favorable but not statistically pregnant. Trauma-focused resiliency preparation programs showed a moderate effect in reducing stress symptoms [pooled SMD −0.53 (−1.04 to −0.03) p = .04; I^two = 73%] and a moderate upshot in reducing depression [pooled SMD −0.51 (−0.92 to −0.10) p = .02; I² = 61%]. A variety of measures were used within each of the outcome domains extracted. Supplement S1 details the measures used and our rationale for including them in the pooled estimates of effect. A forest plot of the effects of resiliency grooming programs on resilience, divided into subgroups based on the presence of a well-matched attention control is presented in Figure three. Wood plots for all other analyses can be constitute in Supplement S1. The complete results of the a priori meta-analyses, summarized by consequence size, are presented in Table 2.

Risk of Bias Beyond Studies

The potential for publication and reporting bias was judged to be high. Of the 22 studies explicitly describing a desire to impact personal resilience, ten failed to report an outcome measuring this construct. This was characteristic of trauma-directed [24], [29], [31], [35] and resilience-mediated [30], [39] training programs, which may take been less focused on resilience as a primary outcome. Ane study explicitly described a resilience-directed intervention and reported a resilience outcome in i paper, [25] only described the intervention's purpose differently and reported different outcomes in other papers that were non captured by our initial database search. [12], [43] Of the six studies judged to have a potential disharmonize of involvement, 4 failed to report a resilience issue. Although the overall risk of bias for included studies was judged to be high, it was somewhat lower among the 18 studies contributing to the meta-analyses.

Subgroup analyses

Among generalized stress-directed resiliency training programs, planned subgroup analyses based on whether an attention control was used or whether participants had a chronic disease failed to show a significant divergence in intervention effect. Among studies evaluating trauma-directed resiliency grooming programs, both the non-attending-controlled and chronic disease subgroups comprised a single study conducted in patients with postal service-traumatic stress disorder (PTSD). [29] This study was significantly more effective at reducing depression (interaction p = .03), stress (interaction p<.01) and feet (interaction p = .02) than the other trauma-directed resiliency training programs. When a subgroup consists of a single study, however, observed effects are difficult to interpret and of limited value.

Sensitivity Analyses

Sensitivity analyses based on whether an included outcome was rated as "questionable" for pooling ceremoniousness did non change interpretations. Of the seven studies judged to be at the highest risk of bias, 3 ([thirteen], [34] and Burton, unpublished) contributed at to the lowest degree one issue to the meta-analyses. Removal of the study by Sadow [13] did not change interpretation of the self-efficacy outcome. Removal of the studies by Abbott [34] and Burton (unpublished) withal, independently resulted in increased estimates of the effect of resiliency training and reductions in heterogeneity across all included outcomes [resilience (Burton only), quality of life (Abbott just), and depression, stress, and anxiety (both Burton and Abbott)]. The study by Abbott lost well-nigh half of its sample to follow up and conducted an intention to care for (ITT) assay; this likely underestimates the effectiveness of the intervention. The study by Burton used a cluster-randomized design that allocated participants by clusters co-ordinate to type of employment and geographic location. The distribution of clusters was markedly unbalanced at baseline, withal, and the treatment arms experienced different stressors at key points of data collection. Removing both of these studies from the analyses acquired the estimated benefits in quality of life, depression, and stress to attain statistical significance. The furnishings of their exclusion are summarized in Table 3.

Give-and-take

Summary of Findings

In full general, the body of randomized trial bear witness supports a modest but consequent benefit of resiliency training programs in improving a number of mental wellness outcomes within three months of follow-up. When excluding studies rated at high risk of bias, the estimated benefits are larger, more consistent, and more than pregnant. Nonetheless, the overall methodological quality of included trials was depression and several were poorly reported. Nosotros found no interaction with effect based on whether participants had chronic medical conditions. Although not statistically significant, nosotros did place a reduction in measured benefit in attention-controlled trials. Included studies were likewise small in number and size, which limits our power to draw conclusions in high confidence.

In that location remains a lack of clarity related to what critically defines a resiliency training program. Programs are operationalized in diverse ways and lack a common theoretical or scientific specificity. The field also lacks a consistent approach to measurement [44] and it is often unclear whether outcomes chosen are sufficiently specific to the intervention. We adult a training program framework that helps to organize the operational approaches that take been taken in intervention pattern.

Comparison With Prior Research

To our noesis, this is the first systematic review and meta-analysis of resiliency preparation programs in adults, although a prior meta-assay of a particular resiliency training plan for children showed a similar effect in improving depression. [45] Our findings are also consequent with recent meta-analyses of meditation and mindfulness-based programs that showed efficacy in improving stress, depression, and well-existence outcomes in clinical populations. [46]–[48] The effect sizes in these studies were comparable to those seen in our review, and may propose similar value for resiliency training in patients with chronic conditions. Our subgroup analyses back up this decision.

Strengths and Limitations

We conducted this study according to a pre-divers and published protocol. To accumulate a high quality trunk of prove, we restricted our inclusion to randomized trials and we searched databases and registries and contacted authors and experts to identify unpublished work. Still, this study has a number of limitations. First, our criteria for determining whether an intervention was a resiliency training program relied on our interpretations of the authors' descriptions. Nosotros also combined a number of measures within construct domains. Despite efforts to account for the appropriateness of this arroyo, some dubiety is inherent. The populations studied were heterogeneous and a normal distribution of outcomes was causeless in most cases; if this assumption were shown to be incorrect it would limit the validity of the pooled SMD estimates. Finally, we combined all outcomes reported within 3 months of follow-up. This approach gives a full general impression of short-term program effectiveness merely may overestimate the outcome seen by excluding studies reporting outcomes immediately postal service-intervention.

Implications

Clinicians, researchers, health policymakers, and governments are intrigued by the concept of resilience and the office it may play in promoting health and well-being. Finding reliable and effective ways to eternalize resilience in individuals and populations is thus a primal surface area of investigation. We accept summarized the randomized trial prove of programs designed to touch personal resilience.

Hereafter Report

To date, about studies related to resilience have been observational in nature. This may be an advisable approach to further ascertain the resilience construct and purposefully and scientifically design interventions to bear upon it. Research should focus on identifying a consequent and specific strategy for targeting resilience and a corresponding arroyo to measurement. When programs take clear scientific and theoretical rationale for effectiveness, they should be evaluated in larger, randomized controlled trials. In the future, comparative effectiveness studies will be needed to appraise the specific and incremental value of resiliency training as compared to alternative programs (e.g. traditional cerebral behavioral therapy, mindfulness-based interventions, etc.). These trials should as well take longer durations of follow-up to fully evaluate their effectiveness.

Conclusions

Resiliency training programs seem to have do good in improving mental health and well-being in diverse developed populations, although the quality of the randomized trial evidence precludes conclusions based in high confidence. There is no specific format, structure, or theoretical ground that defines a resiliency preparation program. In improver, no gold standard method of evaluation or measurement exists. Pregnant stakeholder interest in the potential of resiliency preparation programs warrants further study in this area. Such study should exist rationally and scientifically organized, notwithstanding, to achieve maximal value and fill key gaps in knowledge.

Supporting Information

Acknowledgments

Data Access: Dr. Aaron Leppin had full access to all the data in the written report and takes responsibleness for the integrity of the data and the accurateness of the data analysis.

The authors thank the following for confirming impressions, providing guidance or data, and/or profitable with the identification of additional studies: Nicola Burton, PhD, MPsych (Section of Homo Movement Studies; Academy of Queensland; Australia); Jennifer G. Bekki, PhD (Arizona State University; U.s.); Bianca Bernstein, PhD (Arizona Land Academy; Us); Martha Kent, PhD (Phoenix Veterans Diplomacy Health Care System; Arizona State Academy; U.s.); Anthony M Grant, PhD (Coaching Psychology Unit of measurement, University of Sydney; Commonwealth of australia); Mary Davis, PhD (Department of Psychology, Arizona State University; USA); Bengt B. Arnetz, MD, PhD, MScEpi, MPH (Dept. of Family unit Medicine and Public Wellness Sciences and Institute for Ecology Health Sciences, Wayne State University; USA and Dept. of Public Health and Nursing Sciences, Uppsala University; Sweden); James B. Avey, PhD (Dept. of Management, College of Concern, Central Washington University; USA); Raphael D. Rose, PhD (Depts. of Psychology and Psychiatry and Biobehavioral Sciences, University of California Los Angeles; USA).

Author Contributions

Contributed to the writing of the manuscript: ALL. Designed and conceptualized review: ALL JCT VMM. Developed and conducted search strategy: ALL PJE MMD CZP. Screened manufactures: ALL PRB MRG CZP MMD JPB KRB. Assessed risk of bias: ALL PRB. Conducted meta-assay: ALL. Contacted authors: ALL KRB. Rated measures, interpreted findings, and prepared manuscript: ALL JCT VMM PJE MMD CZP PRB MRG JPB KRB Equally. Approved final version: ALL JCT VMM PJE MMD CZP PRB MRG JPB KRB AS.

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Source: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0111420

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