Two main themes emerged from content analysis of the diaries: signs of improvement were noted soon after the reflexology treatment, with symptoms returning later in the week, or symptoms were worsened in the first few days after treatment and improved later in the week. Participants 1 and 3 monitored the same symptoms throughout the intervention, whereas symptoms indicated by Participants 2 and 4 changed during the course of treatments.
In the final semi-structured interviews, participants were asked if there had been an improvement, a decline or no change in their stress-related symptoms. Three participants (Participants 1, 2 and 4) reported overall improvements in managing stress levels and quality of sleep; two participants (Participants 1 and 3) noted they felt their general health and well-being had improved but the other two reported no change. No participant reported having taken any time off work during the study period.
The participants’ comments about receiving treatments included ‘knowing I was having reflexology and looking forward to it, helped me get through the week… the treatments reminded me how to relax’. All participants agreed that it was important to manage stress levels and three said they would use reflexology in the workplace if it were offered to them. One participant said ‘where we can identify people with stress, it is a good way of helping them’ and another stated that ‘even if it is an hour out of work time, it brought more awareness to my physical need’. Further comments referred to the importance of having a good client–therapist relationship, for example, one participant said ‘I enjoyed it thoroughly. Knowing someone was available to help—to listen without being judgmental, helped me’ and another participant stated that ‘feeling comfortable with the therapist helped me’.
Discussion
Overall the results from the range of outcome measures used in this study identified stronger trends towards improvement than deterioration in perceived health and well-being following reflexology intervention for the four participant employees in the workplace.
Participant 1 reported consistent improvements across all outcome measures. Data from the GHQ-12 and the MYMOP2 indicated that most of the participants reported improvements in general health, perceived symptoms and quality of life at intervention and at follow-up. The combination of the GHQ-12 and the MYMOP2 with questions relating to psychological and physical health and well-being presented important information, which was supported by findings from the other data collection methods used in this study. The MYMOP2, in particular, was helpful in assessing clinical changes among participants who experienced different symptoms and is therefore a viable instrument for use in SSEDs.
While all four participants reported some positive effects there was variation between participants and some inconsistencies in the data. In the end of study interview, three participants (Participants 1, 2 and 4) reported improvements in managing their stress levels, whereas data collected using the VAS showed increased stress levels for Participants 2 and 4. It is possible that the participants distinguished between their ability to manage stress levels and their actual stress levels. The VAS data also indicated a trend towards improvement in relaxation for two participants (Participants 1 and 3) over the course of the study, which is consistent with findings from a previous study.12
There was a marked contrast between stress and relaxation levels, as indicated on the VAS, for two of the participants. Participant 1 showed the greatest decrease in stress and increases in relaxation which persisted at follow-up, whereas Participant 4 showed increased stress and decreased relaxation levels during the intervention, which improved at follow-up. When examining the effects of a yoga-based exercise programme for people with chronic poststroke hemiparesis,17 the authors suggested that differences in the outcomes demonstrated by the four participants in the study might be explained by the differing characteristics of the participants: the participant who demonstrated most improvements was the most adherent to the yoga programme. However, it is difficult to explain the differences in stress levels as reported in the current study in this way as Participants 1 and 4 both adhered to the reflexology treatments.
It was also notable that three of the participants (Participants 1, 2 and 3) reported musculoskeletal problems in the interviews at the start of the study and rated these symptoms as the worst experienced in the SC at baseline. When receiving reflexology, they all showed improvements in these symptoms, which coincided with recent research findings.13 On the other hand, anxiety has been shown to reduce in previous studies,10 and 12 while the SC data showed that it increased markedly for Participant 2 in the current study.
The following participants missed a treatment during the intervention phase which may have affected the outcome. Participant 3 showed the most improvement in scores in the GHQ-12, whereas Participant 2 showed a deterioration in scores during the same period. Whilst it was noted that Participant 3 was on holiday and was the only participant taking medication when interviewed at the start of the study, Participant 2 missed a treatment and a further session due to work commitments. This highlights the unpredictability of people who experience stress in the workplace due to demands and busy schedules. It may also suggest a lack of collaboration towards the study or commitment to improving health.
The SSED is a useful tool for exploring trends, by collecting baseline data before the intervention begins each subject acts as their own control.15 However, there are frequently pragmatic limits imposed on the length of the baseline period, as was the case in this study, which limits the reliability of the control. The therapist acting as researcher also has its own inherent limitations, in particular, there is an increased risk of biased reporting by the participants who may wish to please the therapist, although it should be noted that participants reported negative as well as positive trends.
The package of measures used in this preliminary study explored a range of outcomes and the design allowed data to be examined across baseline and intervention phases, and at follow-up. However, the greatest limitation of the SSED is that it cannot establish a causal relationship. Any of the improvements reported here may have been due to factors other than the reflexology intervention, for example, therapeutic touch, having time away from work, receiving special attention or simply experiencing something pleasant. Alternatively the participants may have been motivated towards a positive outcome if they thought it could lead to reflexology treatments being introduced into the workplace. Furthermore, the current study involved a series of reflexology treatments and the impact of the therapeutic relationship cannot be excluded. Indeed two of the participants reported that the relationship with the therapist had been an important part of the process.