A Short-Term Intervention to Reduce Stress Levels in Workplace for Office Worker at UEFA—The Union of European Football Associations in Nyon/Switzerland

Background: Today, according to the WHO, workplace stress is particularly common. Several medical and scientific studies have shown that workplace stress can have a serious impact on overall health, a triggering or aggravating factor for many diseases and pathological conditions. This study was conducted to investigate the effects of a stress-reducing eight-week workshop and online messages campaign on office workers. Methods: To collect data of this quasi-experimental study with pre- and post-test, DASS-21 (Depression Anxiety Stress Scale) was used (only part stress; 14 items). For eligible samples, stress-reducing workshops and online messages were held for 8 weeks by a specialist. Data were analyzed using SPSS version 20. Results: Of the 68 participants at the beginning, 43 participants were able to follow up on the 8-week campaign. The drop of participants must be explained by the sudden Covid-19 situation and the postponement of the UEFA EURO 2020 football activities. Overall, 13 of 14 items of stress perception had a decreased score number from pre-test to the post-test results in participants. The test results revealed that there was a significant difference mean of stress score before and after the participants got the campaign with the p-value less than 0.001. The mean difference was 4.18. It meant that after the campaign the mean of the stress score decrease was 4.18. Conclusion: The intervention at the workplace of office employees at UEFA, the United European Football Association, has shown that simple specific lifestyle behaviors, wrapped up in weekly workshops and online messages over a period of eight weeks, significantly reduced stress and stress-related conditions in office employees and improved positive dimensions of mental health and stress-related behavior. This campaign can be applicable to office workers of any type of organization or company.


Introduction
Stress is part of everyday life, it is a reaction of the body to strong mental, physical or psychological demands where the organism mobilizes all available forces and energies to cope with the situation. This mechanism has been programmed into the human genome since time immemorial. Bodies are designed with a set of automatic responses to deal with stress: fight or flight effect. When a person realized that he or she is stressed, they will have a stress response which is a rapid and automatic process [1]. Today's life rhythms and demands are often challenging and require intense physical and psychological efforts in order to be sustained [2]. It affects people differently and individuals differ in their stress vulnerability. The effect of stress includes physiological, emotional, cognitive, and behavioral change [3].
An individual person reacts to physical and mental strain by activating interconnected neuroendocrine circuits. Neuroendocrine circuits governing energy balance and stress regulation [4]. This response allows the body to face and deal with the challenge and re-establish the homeostatic equilibrium. If the individual perceives a harmful stimulus as too intense, or its duration as too long, he may fail coping with it, and incur maladaptation. In this case, the stress response does not resolve into a state of balance (either similar or new, i.e., adapted, compared with the state before stress hits), neuroendocrine parameters remain altered, and illness may ensue [2]. Today, most of the time, the pathophysiological complications of disease arise from stress and the subjects exposed to stress, e.g., those that work or live in stressful environments, have a higher risk of many health disorders. Stress can be either a triggering or aggravating factor for many diseases and pathological conditions [1].

Chronic Stress and Health
Neuroendocrine dysregulation by stress may damage practically all organs and tissues. Chronic stress seems to have an effect on brain structure as it is linked to changes in certain brain areas, consisting of volume variations and physical modifications of neuronal networks [5] [6] and may increase vulnerability to psychological and psychiatric disorders [7]. Chronic stress has an impact on the immune system [8]. Psychological stress can induce the acute phase response commonly associated with infections and tissue damage and increase the levels of circulating cytokines (substances secreted by cells of the immune system) and of various biomarkers of inflammation [9]. Diseases whose development has been linked to both stress and inflammation include cardiovascular dysfunctions, diabetes, cancer, autoimmune syndromes and mental illnesses such as depression and anxiety disorders [10]. Chronic stress is a high risk factor for atherosclerosis and refers to the non-specific systemic reaction that occurs when the body is stimulated by various internal and external negative factors over a long period [11]. Furthermore, research has confirmed the correlation between atherosclerosis and cardiovascular events [12]. Stress is a potential contributor to chronic hyperglycemia in type 2 diabetes mellitus (T2DM) and has long been shown to have major effects on metabolic activity [13]. Stress-induced increases in glucose cannot be metabolized properly [14]. Ongoing stress weakens the immune system and the potential for immune cells to control cancers has been recognized for many decades and there is clear evidence that therapeutic blockade of specific immune-suppressive mechanisms is enough to make a real difference in survival for patients with several different advanced cancers [15] [16].
And, last but not least, chronic stress may play a critical role in the manifestation of Alzheimer's disease (AD) and is increasingly recognized as a factor that can influence the development and progression of AD [17].
Workers' and employees' good health and well-being are vital for workplace competitiveness and productivity, a long life and a high quality of life. In the case of illnesses caused by heightened occupational stress, priority should be given to preventive interventions with the purpose of creating and maintaining work conditions respectful of human physiological, emotional and social needs [18].

Stress Management
Effective techniques for stress management typically include healthy lifestyle behaviors and lifestyle measures favoring relaxation that improve physical health, such as nutrition, exercise, sleep or even regular sun exposure, but may also incorporate strategies that improve cognitive and emotional functioning [19].
Mindfulness practices which originates from practices of Buddhism, enjoysgreat interest from a variety of healthcare and epidemiological researchers [20].
Interventions, such as the mindfulness-based stress reduction provide partic-

Stress at Workplace
Workplace stress is particularly common (WHO, Apr 22, 2020) and work-related stress is a serious occupational health problem [26] [27]. It is the harmful physical and emotional responses that can happen when there is a conflict between job demands on the employee and the amount of control an employee has over meeting these demands. In general, the combination of high demands in a job and a low amount of control over the situation can lead to stress [28] [29].
People spend much of their time at work, and the work environment has a strong impact on psycho-physiological and social wellbeing. Today, stress at work is one of the major costs to companies and countries, deeply affecting productivity [30]. Stress in the workplace can have many origins or come from one single event. Every employee is an individual with his professional and personal lives bringing different factors that may influence their reactions to conditions in the workplace. It is generally believed that some stress is okay, but when stress occurs in amounts that people cannot handle, both mental and physical changes may occur (CCOHS, 2018, [28]

Study Aim/Objective
The study was conducted to investigate and compare the levels of stress experienced by office employees before and after a short-term stress-reducing intervention and to provide new insights for possible and practical stress-reducing measures.

Methods
The eight week study, carried out in March/April 2020, is a quasi-experimental study with pre-test and post-test that was approved by the Board of UEFA-the Union of European Football Associations-who wants to reassure their employees that the board is aware of their potential stress level and has decided to share with them on how to reduce stress level in the workplace with the help of an anti-stress campaign onsite. Selected participants are all volunteer (subjects = 68). The campaign was advertised on the UEFA Health Website. Participants were required to be 21 or older, able to complete the eight week workshop/online process, and able to complete study data collection forms online. Participants were excluded if they couldn't guarantee to attend the intervention on a regular basis (minimum seven weeks), were on stress medications, or had previously participated in a stress reduction program (less than 1 year).
The research instrument was an eight week campaign of eight stress-reducing specific workshops and online messages:  [49].
Note: the eight selected stress-reducing intervention topics have all been examined in many studies, were easy and problem-free to carry out, and were well received by the participants (Description/details see Annexe 1).
Stress levels (using questionnaires) were collected at week 0 (pre-test) and week 8 (post-test). To collect data, DASS (Depression, Anxiety, Stress, Scale) questionnaire was used, the international scientific recognized self-report scale designed to measure the negative emotional state of depression, anxiety and stress composed by a 42-item questionnaire. In the present UEFA study, stress was the only concern, hence, the DASS questionnaire was shortened by disregarding the anxiety and depression parts. The stress scale (14 items) is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient (Annexe 2). As for working conditions, the Likert scale was used, a psychometric scale commonly involved in research that employs questionnaires to measure attitudes or opinions, widely used as an approach to scaling responses in survey research, where respondents are asked to rate items on a level of five agreements: strongly agree; agree; neutral (neither agree/nor disagree); disagree; strongly disagree (Annexe 2). For statistical analysis, the obtained data were analyzed using SPSS for Windows 20. According to the established normality, paired sample t-test will be used for comparing the results before and after the intervention. The threshold of significance was set at p < 0.05.

Results
The result in Table 1 described the participants' characteristics in week 1 before the health campaign was given to participants, and week 8, after the health campaign was given to participants. In week 1, the total participants were 68. But af-   year did not participate in week 8. That made the percentage in week 1 was highest in participants who already work in UEFA less than 1 year (38.2%) while in week 8 was highest in participants who already worked for 2 -5 years (41.9%).
More than 80% of participants were full-time employment both in week 1 and week 8 (83.8% and 81.4%). Table 2 reported the participants' working conditions before the health campaign was given. As seen in Table 2   As for stress perception, 13 of 14 items of stress perceptions had an increasing number of participants who answer "never" from pre-test to the post-test result ( Table 4). The item "I felt that I was rather touchy" had the same percentage in "never" answer pre and post. But the percentage of participants who often felt that they were rather touchy decreased and moved to "sometime". The important point here, the result showed there were 7 items that no one participant answered "almost always" in the post-test after before in the pre-test there were participants who answered, "almost always". The items were "I tended to overreact situations", "I felt myself getting upset rather easily", "I found myself getting impatient when I was delayed in any way (e.g., lifts, traffic lights, being kept waiting)", "I found it hard to wind down", "I found it difficult to tolerate interruptions to what I was doing", "I was intolerant of anything that kept me from getting on with what I was doing", and "I found myself agitated".

The Kolmogorov-Smirnov with Lilliefors Correction Test and Shapiro-Wilk
Test to test the normality distribution of difference score of stress perception between pre-and post-test on health campaign showed p-value more than 0.05.
It meant the distribution was assumed normal. That was why the analysis of the

Discussion
Today, stress has become a recognizable mode of reaction in an increasingly dif- been confirmed in previous studies, that endorse yoga practice [39], physical exercise [37], meditation [50], or breathing exercises [35]. This study suggests complementary simple and practical daily measures that are also worthy of inclusion in preventive guidelines. Regarding the limitation of the study, the heterogeneity of the eight different lifestyle measures makes it difficult to recommend any specific practice. The effect is more likely to be in the sum of all measures and/or in the individual preference for one or the other weekly intervention. It should however be noted that all participants voluntarily took part in the study and were self-motivated to do so.

Conclusion
The intervention at the workplace of office employees at UEFA, the United Eu-

Annexe 1: Description of the Eight Stress-Reducing Intervention Topics, UEFA Campaign
The eight selected stress-reducing intervention topics have all been examined in many studies, were easy and problem-free to carry out, and were well received by the participants. 1) Drinking enough water is a simple measure to specifically prevent stress.
Hypernatremia is a common electrolyte problem that is defined as a rise in serum sodium concentration to a value exceeding 145 mmol/L. It is strictly defined as a hyperosmolar condition caused by a decrease in total body water (TBW) relative to electrolyte content [32]. Hypernatremia most often occurs in people who are stressed. Current results, in agreement with previous studies, strongly suggest that acute hypernatremia limits stress responding [33].
2) Slow and deep breathing activates the parasympathetic nervous system. The sympathetic nervous system functions like a gas pedal in a car. It triggers the fight-or-flight response, providing the body with a burst of energy so that it can respond to perceived dangers. The parasympathetic nervous system acts like a brake. When the parasympathetic nervous system is activated, it produces a calm and relaxed feeling in the mind and body [34]. People can learn to trigger their parasympathetic nervous system by slow and deep breathing to immediately reduce their sense of anxiety and stress [35]. The psycho-physiological changes in brain-body interaction observed in most of meditative and relaxing practices rely on voluntary slowing down of breath frequency [34] [51]. Slow breathing techniques seem to interact with the cardio-respiratory system by increasing HRV and RSA, suggesting thus a strong involvement of the parasympathetic nervous system [36] [52].
3) According to many studies, regular exercise works as well as medication for some people to reduce symptoms of stress, and the effects can be long lasting.
One vigorous exercise session can help alleviate symptoms for hours, and a regular schedule may significantly reduce stress over time. The benefits of aerobic exercise like walking, running, dancing include an increased heart rate. When your heart rate is accelerated, your body releases endorphins, natural opiates that make people feel good and relaxed [37] [53]. In recent years, several medical and scientific studies on yoga exercises proved it to be very useful in the treatment of stress symptoms [38]. Yoga means the unity of mind and body, which has been used in Eastern Societies since thousands of years ago and has recently received much attention from Western countries [54]. Yoga has an effective role In the present UEFA study, stress is the only concern, hence, the DASS questionnaire is shortened by disregarding the anxiety and depression parts. The stress scale (items) is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.
Please read each statement and select the answer that indicates how much the statement applied to you over the past 7 days. There are no right or wrong answers. Do not spend too much time on any statement, but please answer each question.

Working/Job Conditions Questionnaire (Only Pretest)
Likert scale is a psychometric scale commonly involved in research that employs questionnaires to measure attitudes or opinions. It is the most widely used approach to scaling responses in survey research. With this scale, respondents are asked to rate items on a level of five agreements: Strongly agree; Agree; Neutral (neither agree/nor disagree); Disagree; Strongly disagree.