Workplace mental health promotion unraveled: development and first implementation of an integrated approach to evaluate complex interventions

Background
The escalating prevalence of mental health disorders globally underscores an urgent need for comprehensive research and effective interventions. The World Health Organization's 2022 report reveals a concerning statistic: 13% of the global population suffers from mental disorders, with anxiety and depression being the most prevalent. These conditions not only lead to significant increases in morbidity and mortality but also exacerbate social stigma and economic burdens. The COVID-19 pandemic has further amplified these challenges, with preliminary estimates indicating a surge of more than 25% in the incidence of these disorders within a single year. Despite this growing crisis, mental health research remains underfunded and underprioritized, constituting only 4.6% of global health research. The workplace is identified as a critical setting for mental health promotion due to its substantial impact on individuals' mental wellbeing. However, there is a notable lack of interventions targeting mental health in the workplace, especially within small and medium enterprises (SMEs), highlighting a significant research gap.
Mental health interventions in the workplace embody a complex array of factors due to the diverse nature of work environments, individual differences among employees, and the multifaceted aspects of mental health issues themselves. These interventions often require a nuanced understanding of various components, including the interaction between workplace dynamics and individual characteristics, and the impact of contextual factors. According to the Medical Research Council (MRC) framework, evaluating such complex interventions demands equally sophisticated approaches that can capture the breadth and depth of these variables. It necessitates the use of theory-driven approaches to provide a structured framework to map out and empirically test the causal processes and expected outcomes of interventions, allowing for a detailed exploration of how and why initiatives work. Similarly, comprehensive process evaluation tools that assess interventions' implementation aspects provide a holistic view considering contextual impacts. These frameworks are particularly apt for projects which involve multiple countries and sectors, and aim to address a wide range of mental health outcomes at various levels, as they have the potential to capture the complexity and dynamic nature of workplace mental health interventions.
Objectives
The overarching objectives of this dissertation are multifaceted and delineated as follows. Initially, this thesis endeavors to construct a robust program theory, laying the groundwork for the assessment of complex mental health interventions within occupational environments. This entails a detailed elucidation of the essential elements, dynamics, and contextual determinants that modulate the efficacy of these interventions. Subsequently, the dissertation seeks to harness the empirical findings from the outcome evaluation of the MENTUPP pilot study, aiming to shed light on sector-specific and individual variances that are pivotal for the success of complex mental health initiatives in workplace contexts. Furthermore, it proposes to apply the program theory alongside a comprehensive implementation framework, enhancing the depth of analysis concerning the outcome evaluation results. Ultimately, the dissertation aspires to critically appraise and refine the program theory, with the ambition of establishing it as an exemplar for subsequent scholarly inquiries into workplace mental health intervention strategies.
Method
The context of this study is the MENTUPP pilot, a complex mental health intervention that was implemented in SMEs of three work sectors in nine countries. A Theory of Change (ToC) framework was systematically formulated and empirically examined, incorporating contributions from stakeholders across a spectrum of academic disciplines. This process was informed by the synthesis of findings from six systematic literature reviews and further enriched by insights garnered through a survey disseminated amongst experts. Subsequently, the ToC was synergistically integrated with an enhanced version of the RE-AIM framework, facilitating the identification of predominant uncertainties encountered during the implementation phase. This holistic methodological approach enabled the rigorous evaluation of variables such as reach, effectiveness, adoption, implementation, acceptability, appropriateness, feasibility, and maintenance. Through this comprehensive analysis, a nuanced understanding of the contextual influences on the intervention was achieved, significantly advancing the body of knowledge regarding its efficacy and impact.
Main findings
This research elucidates the formulation and operationalization of a ToC for evaluating a complex mental health intervention within occupational settings, underscoring the advantage of its integration with a thorough process evaluation. The findings indicate a pronounced disparity in the psychosocial challenges faced by blue-collar workers and those occupying lower leadership positions when compared to white-collar workers and individuals in higher managerial roles. This discrepancy, is seen as people in blue-collar jobs and those in lower-ranking positions face more psychosocial stressors, correlating with deteriorated mental health and heightened stigmatization. These disparities highlight the necessity for tailored interventions, emphasizing that appropriately customized approaches hold the potential to achieve similar objectives across various work sectors and job positions.
In the thesis's discourse, it is articulated that modifications at the organizational level may manifest over an extended timeframe relative to changes at the individual level. It was observed that participants might initially encounter negative impacts on psychosocial aspects following the intervention's implementation, preceding the realization of the anticipated positive outcomes. Factors facilitating the implementation process include the heterogeneity of intervention materials, backing from research officers, and the establishment of a coherent implementation strategy. In contrast, significant barriers encompass difficulties in discussing mental health topics, technological adaptation challenges, assimilating the intervention within daily operations, and limitations brought forth by the COVID-19 pandemic. The identification of key stakeholders across the development, implementation, and evaluation phases of workplace mental health interventions has been pivotal. The developed integrated approach for navigating the complexities of evaluation is critically examined against prior methodologies employed in analogous scenarios, culminating in strategic recommendations aimed at mental health practitioners, organizational leaders, and policymakers.