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Abstract Background Despite growing interest in workplace mental health interventions, evidence of their effectiveness is mixed. Implementation science offers a valuable lens to investigate the factors influencing successful implementation. However, evidence synthesis is lacking, especially for small-to-medium-sized enterprises (SMEs) and for specific work sectors. The objectives of this review are to establish the scope of research with explicit analysis of implementation aspects of workplace mental health interventions and to identify barriers and facilitators to implementation in general and within SMEs and selected sectors. Methods A systematic scoping review and meta-synthesis of mixed methods process evaluation research from 11 databases, with the evaluation of methodological quality (MMAT) and confidence in findings (CERQual), was conducted. We selected information-rich studies and synthesised them using domains within the Nielsen and Randall implementation framework: context, intervention activities, implementation; and mental models. Results We included 43 studies published between 2009 and 2022, of which 22 were rated as information-rich to be analysed for barriers and facilitators. Most studies were conducted in healthcare. Facilitators reflecting ‘high confidence’ included: relevant and tailored content, continuous and pro-active leadership buy-in and support, internal or external change agents/champions, assistance from managers and peers, resources, and senior-level experience and awareness of mental health issues. Healthcare sector-specific facilitators included: easy accessibility with time provided, fostering relationships, clear communication, and perceptions of the intervention. Stigma and confidentiality issues were reported as barriers overall. Due to the small number of studies within SMEs reported findings did not reach ‘high confidence’. A lack of studies in construction and Information and Communication Technology meant separate analyses were not possible. Conclusions There is dependable evidence of key factors for the implementation of workplace mental health interventions which should be used to improve implementation. However, there is a lack of studies in SMEs and in a larger variety of sectors. Systematic review registration Research Registry ( reviewregistry897 ).

Abstract Background Well-organised and managed workplaces can be a source of wellbeing. The construction, healthcare and information and communication technology sectors are characterised by work-related stressors (e.g. high workloads, tight deadlines) which are associated with poorer mental health and wellbeing. The MENTUPP intervention is a flexibly delivered, multi-level approach to supporting small- and medium-sized enterprises (SMEs) in creating mentally healthy workplaces. The online intervention is tailored to each sector and designed to support employees and leaders dealing with mental health difficulties (e.g. stress), clinical level anxiety and depression, and combatting mental health-related stigma. This paper presents the protocol for the cluster randomised controlled trial (cRCT) of the MENTUPP intervention in eight European countries and Australia. Methods Each intervention country will aim to recruit at least two SMEs in each of the three sectors. The design of the cRCT is based on the experiences of a pilot study and guided by a Theory of Change process that describes how the intervention is assumed to work. SMEs will be randomly assigned to the intervention or control conditions. The aim of the cRCT is to assess whether the MENTUPP intervention is effective in improving mental health and wellbeing (primary outcome) and reducing stigma, depression and suicidal behaviour (secondary outcome) in employees. The study will also involve a process and economic evaluation. Conclusions At present, there is no known multi-level, tailored, flexible and accessible workplace-based intervention for the prevention of non-clinical and clinical symptoms of depression, anxiety and burnout, and the promotion of mental wellbeing. The results of this study will provide a comprehensive overview of the implementation and effectiveness of such an intervention in a variety of contexts, languages and cultures leading to the overall goal of delivering an evidence-based intervention for mental health in the workplace. Trial registration Please refer to Item 2a and registration ISRCTN14104664. Registered on 12th July 2022.

Abstract Background Small and medium-sized enterprises (SMEs) face major financial losses due to mental health issues affecting employees at all levels but seldom apply programs to promote wellbeing and prevent mental health issues among employees. To support the development of a multi-country workplace-based mental health intervention for SMEs (MENTUPP), a multinational consultation study was conducted. The study aimed to examine the experiences and needs of SMEs concerning the promotion of employee wellbeing, and the prevention and management of non-clinical mental health problems in workplaces. Methods A survey consisting of open and closed questions was designed to assess key informants’ opinion about the acceptability, the use, and the implementation of interventions to promote wellbeing and prevent mental health issues in the workplace. Academic experts and representatives of SME organisations, specific sector organisations, labour or advocacy groups, and occupational health organisations across the nine MENTUPP intervention countries (eight European countries and Australia) were invited to complete the survey. Data were collected via the online platform Qualtrics. Sixty-five of 146 informants responded, representing a 44.5% response rate. Descriptive statistics were used to analyse the quantitative data and qualitative data were analysed through thematic analysis. Results Measures to create mentally healthy workplaces were most used in SMEs, while more specific mental health interventions, such as training staff on how to promote wellbeing, were hardly used. Managers lack resources to implement mental health interventions and are concerned about employees spending too much time on these interventions during working hours. Receiving information about the economic benefits of mental health interventions and hearing successful testimonials from other SMEs can persuade managers otherwise. Employees have concerns about confidentiality, discrimination and stigma, and career opportunities when using such interventions. Conclusions The study identifies a variety of challenges, needs and possibilities related to implementing mental health interventions in SMEs. Employers need to be convinced that investing in mental health in the workplace is worth their time and money. This requires more studies on the (cost-)effectiveness of mental health interventions. Once employers are engaged, their knowledge and competencies about how to implement such interventions should be increased and privacy concerns of employees to participate in them should be addressed.

OBJECTIVE: This study aimed to systematically review the effectiveness of organizational-level interventions in improving the psychosocial work environment and workers’ health and retention.METHODS: We conducted an overview of systematic reviews on organizational-level interventions published between 2000 and 2020. We systematically searched academic databases, screened reference lists, and contacted experts, yielding 27 736 records. Of the 76 eligible reviews, 24 of weak quality were excluded, yielding 52 reviews of moderate (N=32) or strong (N=20) quality, covering 957 primary studies. We assessed quality of evidence based on quality of review, consistency of results, and proportion of controlled studies.RESULTS: Of the 52 reviews, 30 studied a specific intervention approach and 22 specific outcomes. Regarding intervention approaches, we found strong quality of evidence for interventions focusing on “changes in working time arrangements” and moderate quality of evidence for “influence on work tasks or work organization”, “health care approach changes”, and “improvements of the psychosocial work environment”. Regarding outcomes, we found strong quality of evidence for interventions about “burnout” and moderate quality evidence for “various health and wellbeing outcomes”. For all other types of interventions, quality of evidence was either low or inconclusive, including interventions on retention.CONCLUSIONS: This overview of reviews identified strong or moderate quality of evidence for the effectiveness of organizational-level interventions for four specific intervention approaches and two health outcomes. This suggests that the work environment and the health of employees can be improved by certain organizational-level interventions. We need more research, especially about implementation and context, to improve the evidence.

Abstract Background There is a gap between the necessity of effective mental health interventions in the workplace and the availability of evidence-based information on how to evaluate them. The available evidence outlines that mental health interventions should follow integrated approaches combining multiple components related to different levels of change. However, there is a lack of robust studies on how to evaluate multicomponent workplace interventions which target a variety of outcomes at different levels taking into account the influence of different implementation contexts. Method We use the MENTUPP project as a research context to develop a theory-driven approach to facilitate the evaluation of complex mental health interventions in occupational settings and to provide a comprehensive rationale of how these types of interventions are expected to achieve change. We used a participatory approach to develop a ToC involving a large number of the project team representing multiple academic backgrounds exploiting in tandem the knowledge from six systematic reviews and results from a survey among practitioners and academic experts in the field of mental health in SMEs. Results The ToC revealed four long-term outcomes that we assume MENTUPP can achieve in the workplace: 1) improved mental wellbeing and reduced burnout, 2) reduced mental illness, 3) reduced mental illness-related stigma, and 4) reduced productivity losses. They are assumed to be reached through six proximate and four intermediate outcomes according to a specific chronological order. The intervention consists of 23 components that were chosen based on specific rationales to achieve change on four levels (employee, team, leader, and organization). Conclusions The ToC map provides a theory of how MENTUPP is expected to achieve its anticipated long-term outcomes through intermediate and proximate outcomes assessing alongside contextual factors which will facilitate the testing of hypotheses. Moreover, it allows for a structured approach to informing the future selection of outcomes and related evaluation measures in either subsequent iterations of complex interventions or other similarly structured programs. Hence, the resulting ToC can be employed by future research as an example for the development of a theoretical framework to evaluate complex mental health interventions in the workplace.

Background According to the Medical Research Council (MRC) framework, the theorisation of how multilevel, multicomponent interventions work and the understanding of their interaction with their implementation context are necessary to be able to evaluate them beyond their complexity. More research is needed to provide good examples following this approach in order to produce evidence-based information on implementation practices.Objectives This article reports on the results of the process evaluation of a complex mental health intervention in small and medium enterprises (SMEs) tested through a pilot study. The overarching aim is to contribute to the evidence base related to the recruitment, engagement and implementation strategies of applied mental health interventions in the workplace.Method The Mental Health Promotion and Intervention in Occupational Settings (MENTUPP) intervention was pilot tested in 25 SMEs in three work sectors and nine countries. The evaluation strategy of the pilot test relied on a mixed-methods approach combining qualitative and quantitative research methods. The process evaluation was inspired by the RE-AIM framework and the taxonomy of implementation outcomes suggested by Proctor and colleagues and focused on seven dimensions: reach, adoption, implementation, acceptability, appropriateness, feasibility and maintenance.Results Factors facilitating implementation included the variety of the provided materials, the support provided by the research officers (ROs) and the existence of a structured plan for implementation, among others. Main barriers to implementation were the difficulty of talking about mental health, familiarisation with technology, difficulty in fitting the intervention into the daily routine and restrictions caused by COVID-19.Conclusions The results will be used to optimise the MENTUPP intervention and the theoretical framework that we developed to evaluate the causal mechanisms underlying MENTUPP. Conducting this systematic and comprehensive process evaluation contributes to the enhancement of the evidence base related to mental health interventions in the workplace and it can be used as a guide to overcome their contextual complexity.Trial registration number ISRCTN14582090.

Objectives Increasing access to mental health support is a key factor for treating mental disorders, however, important barriers complicate help-seeking, among them, mental health related stigma being most prominent. We aimed to systematically review the current evidence for interventions focusing on reducing stigma related to mental health problems in small and medium enterprises (SMEs).Design Systematic review with a focus on interventions targeting mental health related stigma in the workplace in accordance with PRISMA guidelines. The methodological quality of included articles was assessed using the Quality Assessment Tool for Quantitative Studies Scale.Data sources PubMed, Ovid Medline, PsycINFO, Scopus, and Cochrane databases and Google Scholar were searched from January 2010 until November 2022.Eligibility criteria for selecting studies We included experimental or quasi-experimental studies about workplace interventions aiming to reduce stigma, where the outcomes were measured in terms of stigmatisation against depression, anxiety and/or other mental health problems.Data extraction and synthesis Records were screened by two independent reviewers after inspecting titles and abstracts and a full-text read of the articles to assess whether they meet inclusion criteria. The results were synthesised narratively.Results We identified 22 intervention studies, 3 with high quality, 13 with moderate quality and 6 with weak quality. Only 2 studies included SMEs, but no study focused on SMEs exclusively . The mode of delivery of the intervention was face to face in 15 studies, online in 4 studies and mixed in 3 studies. We found a significant reduction in stigmatising attitudes in almost all studies (20/22), using 10 different instruments/scales. Effects seemed to be independent of company size. Online interventions were found to be shorter, but seemed to be as effective as face-to-face interventions.Conclusions Although we did not find interventions focusing exclusively on SMEs, it is likely that antistigma interventions also will work in smaller workplaces.Trial registration PROSPERO: ID: CRD42020191307

Abstract Background Pupils´ aggressive behaviour towards teachers is a serious problem which is slowly gaining attention and has been found to be linked to burnout. However, prospective studies investigating the role of stress and social support from colleagues and supervisor are lacking. Therefore, the aims of the present study were 1. to investigate the association between pupils´ aggressive behaviour and burnout among Danish primary and lower secondary school teachers, 2. to investigate whether the association between pupils´ aggressive behaviour and burnout depends on the level and duration of stress, and 3. to investigate whether social support from colleagues or a supervisor at the work place has a mitigating effect on the association between pupils´ aggressive behaviour and burnout among teachers. Methods This study is a longitudinal study using data from 1198 teachers collected in two survey rounds at an interval of 1-year. Teacher-reported aggressive behaviour in pupils measured as harassment, threats, and violence towards teachers was collected at baseline. Burnout was measured at follow-up. The analyses were performed using multilevel logistic regression. Results Statistically significant associations between harassment, threats, or violence and burnout 1 year later were found (all ORs 1.6) after adjustment for potential confounders. After further adjustment for stress, the estimates attenuated to ORs between 1.4 and 1.5, and were also statistically significant. Pupils´ aggressive behaviour in combination with low support from colleagues increased the risk of burnout, whereas the risk of burnout increased among those experiencing pupils´ aggressive behaviour in combination with receiving high support from the supervisor. Conclusions The results indicate associations between all three types of pupils´ aggressive behaviour and burnout among teachers in Danish primary and lower secondary schools. Stress explained only a minor part of the association between teachers’ perceptions of pupils’ aggressive behaviour and burnout in teachers, and the results regarding social support were conflicting. The results of this study emphasize the growing need for preventive initiatives directed towards pupils´ aggressive behaviour, and future research should focus on exploring in depth how to support and prevent burnout in teachers exposed to aggressive behaviour.

Abstract Background Mental health problems are common in the working population and represent a growing concern internationally, with potential impacts on workers, organisations, workplace health and compensation authorities, labour markets and social policies. Workplace interventions that create workplaces supportive of mental health, promote mental health awareness, destigmatise mental illness and support those with mental disorders are likely to improve health and economical outcomes for employees and organisations. Identifying factors associated with successful implementation of these interventions can improve intervention quality and evaluation, and facilitate the uptake and expansion. Therefore, we aim to review research reporting on the implementation of mental health promotion interventions delivered in workplace settings, in order to increase understanding of factors influencing successful delivery. Methods and analysis A scoping review will be conducted incorporating a stepwise methodology to identify relevant literature reviews, primary research and grey literature. This review is registered with Research Registry (reviewregistry897). One reviewer will conduct the search to identify English language studies in the following electronic databases from 2008 through to July 1, 2020: Scopus, PROSPERO, Health Technology Assessments, PubMed, Campbell Collaboration, Joanna Briggs Library, PsycINFO, Web of Science Core Collection, CINAHL and Institute of Occupational Safety and Health (IOSH). Reference searching, Google Scholar, Grey Matters, IOSH and expert contacts will be used to identify grey literature. Two reviewers will screen title and abstracts, aiming for 95% agreement, and then independently screen full texts for inclusion. Two reviewers will assess methodological quality of included studies using the Mixed Methods Appraisal Tool and extract and synthesize data in line with the RE-AIM framework, Nielson and Randall’s model of organisational-level interventions and Moore’s sustainability criteria, if the data allows. We will recruit and consult with international experts in the field to ensure engagement, reach and relevance of the main findings. Discussion This will be the first systematic scoping review to identify and synthesise evidence of barriers and facilitators to implementing mental health promotion interventions in workplace settings. Our results will inform future evaluation studies and randomised controlled trials and highlight gaps in the evidence base. Systematic review registration Research Registry ( reviewregistry897 )

OBJECTIVE: This review aimed to examine systematically the epidemiological evidence linking work-related exposure to violence and threats thereof with risk of mental disorders and mental ill-health symptoms. METHODS: We searched PubMed, EMBASE, PsycINFO and Web of Science to identify original studies that provide quantitative risk estimates. The evidence was weighted according to completeness of reporting, potential common method bias, and bias due to differential selection and drop out, selective reporting, and misclassification of exposure and outcome. RESULTS: We identified 14 cross-sectional and 10 cohort studies with eligible risk estimates, of which 4 examined depressive disorder and reported an elevated risk among the exposed [pooled relative risk (RR) 1.42, 95% confidence interval (CI) 1.31–1.54, I^2=0%]. The occurrence of depressive and anxiety symptoms, burnout and psychological distress was examined in 17 studies (pooled RR 2.33, 95% CI 3.17, I^2=42%), and 3 studies examined risk of sleep disturbance (pooled RR 1.22, 95% CI 1.09–1.37, I2=0%). In most studies, common method bias and confounding could not be ruled out with confidence and strong heterogeneity in most outcome definitions invalidate the strict interpretation of most pooled risk estimates. CONCLUSION: The reviewed studies consistently indicate associations between workplace violence and mental health problems. However, due to methodological limitations the causal associations (if any) may be stronger or weaker than the ones reported in this study. Prospective studies with independent and validated reporting of exposure and outcome and repeated follow-up with relevant intervals are highly warranted.

ObjectivesThis systematic review assesses the scientific evidence regarding the effectiveness of organisational-level workplace mental health interventions on stress, burnout, non-clinical depressive and anxiety symptoms, and wellbeing in construction workers.MethodsEligibility criteria were randomized controlled trials (RCTs), cluster randomized controlled trials (cRCTs), controlled or uncontrolled before- and after studies published in peer-reviewed journals between 2010 and May 2022 in five databases (Academic Search Complete, PsycInfo, PubMed, Scopus and Web of Science). Outcomes were stress, burnout and non-clinical depression and anxiety symptoms, and wellbeing (primary) and workplace changes and sickness absenteeism (secondary). Quality appraisal was conducted using the QATQS scale, a narrative synthesis was applied. The protocol was published in PROSPERO CRD42020183640 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020183640.Main resultsWe identified five articles (four studies) with a total sample size of 260, one cRCT, one controlled before- and after study, and two uncontrolled before- and after studies. The methodological quality of one study was rated as moderate, while for three studies it was weak. One study showed significant effects of a work redesign programme in short-term physiological stress parameters, one study showed a significant employee perceived improvement of information flow after supervisor training and one study showed a substantial non-significant decline in sick leave. There was no significant effect on general mental health (SF12) nor on emotional exhaustion. The focus of all studies was on physical health, while detailed mental health and wellbeing measures were not applied.Main conclusionsThe evidence for the effectiveness of organisational-level workplace mental health interventions in construction workers is limited with opportunities for methodological and conceptual improvement. Recommendations include the use of a wider range of mental health and wellbeing outcomes, interventions tailored to the specific workplace and culture in construction and the application of the principles of complex interventions in design and evaluation.

As working conditions are increasingly characterized by socio-emotional demands, interpersonal interactions and relationships, and mental requirements, at least in high-income, post-industrialized societies, work and mental health has evolved as a key topic of occupational health research (1, 2). In this editorial, we focus on three main themes within this topic: (i) identifying factors at work that contribute to the onset of mental health problems and clinical mental disorders; (ii) using work as a “therapeutic tool” for individuals with mental health problems; and (iii) conducting and evaluating intervention studies. Regarding the first theme, one of the earliest systematic reviews on work-related risk factors of common mental disorders was published in 2006 by Stansfeld & Candy in this journal (3), an article that today is a “citation classic” (876 citations in Web of Science as of 6 October 2019). The authors identified job strain and effort–reward imbalance as risk factors, while acknowledging that only few studies of high quality were available (3). Today, more high quality studies are available and recent meta-analyses reported that job strain (4) and effort–reward imbalance (5) predict incident depressive disorders, corroborating the conclusion of the pioneering 2006 review. Other reviews suggest that also low job control (6), workplace bullying (6), and job insecurity (7) may be involved in the etiology of depressive disorders. Long working hours are also discussed, however, a recent review reported that associations between long working hours and depressive symptoms were relatively small and differed between world regions (8). Currently, the World Health Organization (WHO) and the International Labour Organization (ILO) are working on parameters for estimating the global burden of depressive disorders attributable to long working hours (9). Despite this progress in research, important challenges remain, for example the overreliance on traditional cohort studies with one baseline and one follow-up measure only, and on self-reported measures of working conditions that may be affected by undetected prevalent mental health problems (10). Recent studies, using multiple exposure measures with fixed-effects analyses (11) or job exposure matrices (12) have started to address these challenges. Further, more research is needed on mental disorders other than depressive disorders, such as anxiety or adjustment disorders (10). Regarding the second theme – work as a therapeutic tool – a key publication was the report by Dame Carol Black for the British Government in 2008 on “Working for a healthier tomorrow” (13). The report argued that “work which is appropriate to an individual’s knowledge, skills and circumstances, and undertaken in a safe, healthy and supportive working environment, promotes good physical and mental health, helps to prevent ill-health and can play an active part in helping people recover from illness” (13, p67). Results from observational studies have confirmed the association between employment and better mental health (15), however, it remains unclear if being employed and re-employed influences mental health, or if better mental health increases chances for work retention and re-employment. A recent review on re-employment programs reported “some indications that re-employment programmes […] had a positive effect on quality of life” but found “no evidence for benefits concerning mental health and functioning”, thus questioning the results from the observational studies (16). In an attempt to disentangle selection and causation, Schuring et al (17) used a combination of fixed and random effects models to analyze observational data on re-employment of Dutch residents diagnosed with a mental disorder. The results indicated both selection and causation effects, with the reservations that only a small fraction of the study participants actually returned to work (8%) and that confounding by time-varying confounders could not be ruled out (17). Regarding the third theme – intervention studies aiming to protect and enhance workers’ mental health – little is known about the key for success. It is therefore welcomed that in this issue of the Scandinavian Journal of Work, Environment and Health, three reviews either solely or partly focus on this topic. Phillips and colleagues identified 50 randomized controlled trials using e-mental health interventions, including 34 of those in meta-analyses (18). The interventions focused on making changes in the individual, with about two-thirds based on cognitive behavioral therapy. The authors reported “moderate effects on stress, insomnia and burnout and small treatment effects on depression, anxiety, well-being, and mindfulness”. Bordado Sköld and colleagues conducted a systematic review on the effect of exercise interventions at work on either psychosocial working conditions or workers’ mental health (19). The 22 included studies showed large heterogeneity in terms of study design, populations, interventions and outcome measures. Consequently, the authors did not calculate pooled estimates but performed a qualitative synthesis. Some studies reported improvements in mental health scores in the intervention groups, other studies did not find any effects. Overall, the results did not provide support for the hypothesis that workplace exercise programs may be beneficial for workers’ mental health. There was also no convincing effect on psychosocial working conditions. Proper & van Oostrom conducted a “meta-review” (a systematic review of previously published reviews) on the effect of workplace health promotion interventions on metabolic risk factors and musculoskeletal and mental health (20). They identified 23 reviews, including 9 of high quality. There was strong evidence for an effect of workplace health promotion programs on weight-related outcomes and the prevention of musculoskeletal disorders. Regarding mental health, Proper & van Oostrom identified 6 reviews, 4 of low and 2 of high quality. The interventions included e-mental health interventions, cognitive behavior therapy, stress management, psycho-education and physical activity. The authors conclude that there was strong evidence that e-mental health and cognitive behavior techniques had a positive effect on workers’ mental health, whereas the evidence for intervention on physical activity was less clear, echoing the conclusions by Phillips et al (18) and Bordado Sköld et al (19). What do we learn from these three reviews? First, interventions based on cognitive behavior therapy, including e-mental health interventions, seem to be an effective tool for protecting and enhancing workers’ mental health (18, 20). However, as Phillips et al noted (18), more than two-thirds of the participants in e-mental health studies were highly educated (having at least some years of university education), and jobs in knowledge-intensive occupational sectors, such as information technology, were overrepresented. Considering that mental disorders are more prevalent in individuals of lower socioeconomic position (21–23), one may be concerned that e-mental health interventions do not reach those who need help most. Further, it remains unclear if e-mental health intervention are as effective for workers with low education as they seem to be for workers with high education. Second, exercise programs at work sometimes seem to have a positive effect on mental health and other times not (19, 20), thus, no clear conclusion can be drawn. The reason for these inconsistent results are unknown as exploring these reasons was beyond the scope of the reviews (19, 20). Third, the interventions did not aim to change the work environment but rather the individual worker. In the review by Bordado Sköld (19) this was a given as the review was about exercise programs. But e-mental health interventions could have been about guidance for changing working conditions and workplace health promotion does not have to be limited to health behaviors and cognitive changes but could also target the work environment, as it has been proposed in the concepts of “Comprehensive Health Promotion” (24) and “Total Worker HealthTM” (25). However, these type of interventions did not seem to have qualified for the review on e-mental health (18) or the meta-review on workplace health promotion (20). A recent meta-review on “workplace interventions for common mental disorders” (26) identified – in agreement with the meta-review by Proper & van Oostrom (20) – cognitive behavioral therapy-based stress management as the intervention with the strongest evidence for a positive effect on workers’ mental health. The only effective intervention regarding working conditions and mental health identified in this review were interventions to increase worker control (eg, self-scheduling of shifts and gradual/partial retirement) (26). However, the evidence was weaker than for cognitive behavioral therapy. Considering the above-delineated evidence for an association between adverse working conditions and the risk of developing mental disorders (3–12) and the ongoing discussion about using work matched to one’s “knowledge, skills and circumstances, and undertaken in a safe, healthy and supportive working environment” (13) as a therapeutic tool for individuals with prevalent mental health problems and disorders (13, 15-17), it is disconcerting that organizational-level, work environment interventions to protect or enhance workers’ mental health seem either not to qualify for systematic reviews (18, 20) or, if they do, show rather weak or inconsistent results (26, 27). One reason why organizational-level interventions have not shown convincing effects regarding workers’ mental health may be that these type of interventions are highly dependent on the context in which they are implemented in (28, 29). Consequently, researchers in this field have argued for no longer only asking “What works?”, but instead “What works, for whom, under what circumstances, and how?”(30, 31). It can be regarded as a sign of scientific progress that this question is now increasingly being posed, indicating the retreat of the idea that workplace organizational interventions can be evaluated in a similar way to those of clinical trials testing the efficaciousness of a new drug (32–34). However, the real progress that still needs to be made would be to find answers to the question “What works, for whom, under what circumstances, and how?”, to report these answers in research articles, and finally to summarize these results in new types of systematic reviews and meta-analyses (35). Occupational mental health research has quite some way to go until we reach this stage.

OBJECTIVES: This randomized controlled trial (RCT) evaluated the effect of a participatory organizational intervention for improved use of assistive devices (AD) in patient transfer. METHODS: We randomly allocated 27 departments from five hospitals in Denmark to a participatory intervention (14 clusters, 316 healthcare workers) or a control group (13 clusters, 309 healthcare workers). The intervention consisted of 2×2 hour workshops with managers, the hospital’s health and safety staff, and 2–5 healthcare workers from each department. Based on an assessment of barriers and solutions conducted prior to randomization, participants developed an action plan for implementing department-specific solutions for improving the use of AD. Use of necessary AD (using digital counters as primary outcome), and general use of AD (using accelerometers as secondary outcome), pain intensity in the low-back, work-related back injuries during patient transfer, and communication and guidance in the use of AD were measured at baseline, 6 and 12 months. RESULTS: Use of necessary AD (primary outcome), low-back pain, and back injuries did not change in the intervention compared with control group at 12-month follow-up. However, general use of AD measured with accelerometers as well as communication and guidance improved significantly in the intervention versus control group. CONCLUSION: The intervention did not result in more frequent use of the necessary AD but led to more general use of AD, as well as increased communication and guidance.

The aim of this study was to investigate which contextual aspects and mechanisms are decisive in the implementation of an integrated, tailored intervention to prevent violence and threats of violence from patients or inmates towards employees in psychiatric units and in prisons and detention centers. Based on a standardized implementation degree assessment of fidelity, reach and dose delivered, we selected two workplace cases from each sector, one with a high and one with a low implementation degree. Using a realist evaluation framework, we conducted a thematic analysis of the four selected workplace cases to identify prevalent contextual aspects and mechanisms underlying the implementation degree. We found that prioritization, synergy with parallel change processes, and intervention fit, were decisive mechanisms for the successful implementation of the intervention. We also found that lack of resources (staff instability, insufficient time, poor mental resources) and resource-demanding parallel change processes, were contextual aspects that “blocked” all mechanisms. That is, when resources were not available, none of the mechanisms for implementing the intervention was activated. Our findings point to the importance of investigating the role of contextual aspects when assessing the effectiveness of organizational interventions.

OBJECTIVE: The aim of this review was to determine whether employees exposed to effort–reward imbalance (ERI) at work have a higher risk of depressive disorders than non-exposed employees. METHODS: We conducted a systematic review and meta-analysis of published prospective cohort studies examining the association of ERI at baseline with onset of depressive disorders at follow-up. The work was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and a detailed study protocol was registered before literature search commenced (Registration number: CRD42016047581). We obtained a summary estimate for the association of ERI with risk of depressive disorders by pooling the study-specific estimates in a meta-analysis. We further conducted pre-defined sensitivity analyses. RESULTS: We identified eight eligible cohort studies, encompassing 84 963 employees and 2897 (3.4%) new cases of depressive disorders. Seven of the eight studies suggested an increased risk of depressive disorders among employees exposed to ERI. The pooled random-effects estimate was 1.49 [95% confidence interval (95% CI) 1.23–1.80, P

Abstract Background The aim of this study was to investigate whether a multidimensional public-private partnership intervention, focussing on improving the quality and efficiency of sickness benefit case management, reduced the sickness benefit duration and the duration until self-support. Methods We used a difference-in-difference (DID) design with six intervention municipalities and 12 matched control municipalities in Denmark. The study sample comprised 282,103 sickness benefit spells exceeding four weeks. The intervention group with 110,291 spells received the intervention, and the control group with 171,812 spells received ordinary sickness benefit case management. Using register data, we fitted Cox proportional hazard ratio models, estimating hazard ratios (HR) and confidence intervals (CI). Results We found no joint effect of the intervention on the sickness benefit duration (HR 1.02, CI 0.97–1.07) or the duration until self-support (HR 0.99, CI 0.96–1.02). The effect varied among the six municipalities, with sickness benefit HRs ranging from 0.96 (CI 0.93–1.00) to 1.13 (CI 1.08–1.18) and self-support HRs ranging from 0.91 (CI 0.82–1.00) to 1.11 (CI 1.06–1.17). Conclusions Compared to receiving ordinary sickness benefit management the intervention had on average no effect on the sickness benefit duration or duration until self-support. However, the effect varied considerably among the six municipalities possibly due to differences in the implementation or the complexity of the intervention.

Abstract Background The aim of the RCT study was to investigate if the effect of a multidisciplinary intervention on return to work (RTW) and health care utilization differed by participants’ self-reported health status at baseline, defined by a) level of somatic symptoms, b) health anxiety and c) self-reported general health. Methods A total of 443 individuals were randomized to the intervention (n = 301) or the control group (n = 142) and responded to a questionnaire measuring health status at baseline. Participants were followed in registries measuring RTW and health care utilization. Relative risk (RR) and odds ratio (OR) were used as measures of associations. Results were adjusted for gender, age, educational level, work ability and previous sick leave. Results Among all responders we found no effect of the intervention on RTW. Among participants with low health anxiety, the one-year probability of RTW was lower in the intervention than in the control group (RR = 0.79 95 % CI 0.68-0.93), but for those with high health anxiety there was no difference between the groups (RR = 1.15 95 % CI 0.84-1.57). Neither general health nor somatic symptoms modified the effect of the intervention on RTW. The intervention had no effect on health care utilization. Conclusions The multidisciplinary intervention did not facilitate RTW or decrease health care utilization compared to ordinary case management in subgroups with multiple somatic symptoms, health anxiety or low self-rated health. However, the intervention resulted in a reduced chance of RTW among participants with low health anxiety levels. Trial registration ISRCTN43004323 , and ISRCTN51445682

Good reasons exist for combating stress at work. It is a burden for individual employees and their families and costly to companies and society. Moreover preventing stress at work is a sign of good corporate citizenship as it respects modern legislation that stimulates the provision of a good quality of working life. In order to recommend good interventions, we need to know which interventions work. Outcome evaluation research is, therefore, important but not enough. We not only need to know “what works”, but also “when, how, and why” this may be the case. This means that we need to combine classical effect evaluation research with process evaluation. Combining these two approaches fits in a young scientific discipline: implementation research. Implementation refers to “the way a program is put into practice and delivered to participants” (1). Implementation research crosses traditional disciplinary boundaries, with contributions being made from both occupational and public health domains but also from psychological theories on motivation, behavioral change, and social influence. In a recent commentary, Durlak (1) has highlighted major findings in implementation research. He concludes: “We now know that it is not evidence-based programs that are effective, but it is well-implemented evidence-based programs that are effective” (p1124). He also explains: “If we do not assess implementation, we do not know if a program has been put to an adequate test. It may fail not because the intervention lacks value, but because the intervention was not implemented at a sufficiently high level to produce its effects” (p1124). Effect-only evaluation data may thus mask intervention effects that are sensitive to variations in intervention processes (2). This all means that checking effects is not enough to determine whether a program works or not. To answer this question properly, we need to open up the black box because we also must know how it was implemented. Ten years earlier – in an occupational health intervention context – Tage Kristensen made comparable arguments (3). Kristensen explained the difference between implementation and theory failure by describing the case of a patient (employee) and a pill (stress intervention): “It does not help that the pill has effect if the patient does not take it, and it does not help that the patient takes the pill if it has no effect” (p207). In both cases, process evaluation is needed to find out what actually happened and make the right decisions to proceed. In the first case (pill not taken), the implementation failed and it is therefore not possible to determine if the program works. The underlying theory still may be right. Had the implementation not been studied, the erroneous conclusion might have been that “the theory was wrong”. In this first case, the next step should hence be to work on better implementation. In the second case (the patient took the pill), there were no problems with implementation, but there was no effect. This means that the theory behind the intervention seems to be wrong and needs to be reconsidered. Process evaluation is thus needed to evaluate the generalizability of an intervention (to answer questions such as “under which circumstances will an intervention work?” and “which were the factors that hindered or stimulated the change?”), so that it can be implemented successfully in a variety of settings (2, 4). Studying implementation and process factors is both complicated and challenging. One of the problems is that there are many factors that may codetermine whether a certain intervention does or does not bring about the desired change in health or health behavior. To overcome the problem of long ad hoc lists and enumerations, more systematic taxonomies are needed. Such conceptual frameworks have yet been suggested, for example by Steckler and Linnan (5), Saunders and colleagues (6), and Nielsen & Randall (2). The first two examples merely focus on intervention delivery and participation. They distinguish between fidelity, dose delivered, dose received (exposure and satisfaction), reach, recruitment procedures and context aspects. The broader framework of Nielsen & Randall makes a distinction between (i) the intervention design and implementation, (ii) the context, and (iii) participants’ mental models, such as readiness for change. These latter authors have developed a checklist in order to systematically check these three clusters. Checkpoints in the first cluster are: Who initiated the intervention and for what purpose?; Did the intervention activities target the problems of the workplace?; Did it reach the target group?; Who were the drivers of change?; and What kind of information was provided to participants during the study? The main checkpoint in the context cluster is “which hindering and facilitating factors in the context influenced intervention outcomes?”, whereas the third cluster checks the role of participants’ mental models, such as resistance. Kompier made an earlier comparable attempt (7), arguing that high quality intervention research needs to study three clusters of questions, ie, with respect to the content of the interventions, the context of the study and its interventions, and the design of the study at hand. Also in the organizational health intervention domain, another promising “context, process and outcome evaluation model” has recently been published (8). When it comes to interventions to reduce occupational stress, there certainly is a need for the development, refinement, and utilization of such taxonomies. Various reviews of organizational level intervention studies have been published since 2000 (for example 9–13). The focus of such studies is on the methodological quality of the included studies, which of course is a good thing, and on the effects of interventions (outcome evaluation), but not so much on the intervention itself and how it is implemented. This means that the link between process evaluation and outcome has not yet been systematically addressed (14). Therefore it is hard to understand what actually happened in these intervention studies, and as a consequence is it hard to answer questions such as “How, when and why interventions have or have no effects” (see also 15). In search of better answers to these questions process evaluation is a conditio sine qua non. In this issue of the Scandinavian Journal of Work, Environment and Health, Havermans et al (16) present an interesting overview of process variables in organizational stress management interventions. In a thorough search process, they selected 44 articles that each report on process evaluations. Process variables were defined as “any measure included in the evaluation study that is hypothesized to be associated with the process of implementation of the stress management intervention” (p2). Each article was assessed with a clear template that, as proposed by Nielsen & Randall (2), classified process variables into three major categories: context, intervention, and mental models. Each of these three clusters was itself divided in a number of sub-clusters. The context cluster was made up of context, and barriers and facilitators. The intervention cluster constituted initiation, intervention activities, implementation, and implementation strategy. The mental model comprised readiness for change, perceptions, and changes in mental models. All in all, in 44 articles, 47 process factors were identified. In the majority of these articles, these process factors were collected at one point in time. Process factors were mostly measured at the level of the individual employee and post intervention. Together these authors provide a broad overview of the wealth of factors that may influence the outcomes of an intervention. Interestingly half of the 44 articles did not refer to the process evaluation literature. This suggests that, until now, process factors often are investigated in a merely explorative manner. Furthermore, as Havermans et al point out, many studies do not seem to include a program theory for the intervention under study, ie, explaining how the authors assume the intervention to work and which proximate, intermediate and distal changes (8) they expected. Without predictions stated in a program theory, however, it remains unclear when a certain implementation process is good enough or if intermediate goals were reached. This makes it more difficult to integrate process and effects evaluation. Also, more than half of the studies had a participatory format, which means cooperation of different stakeholders in the assessment, targeting and prevention of work stress. This is an interesting observation that raises the question why employee participation may be essential. We believe that there are several assets to such an approach. First, it may support an accurate problem identification and analysis, and may optimize the fit of the intervention to the organizational culture and context. This simply acknowledges the fact that employees “have agency” and are experts as to their own work situation. Employee participation may also mean improved communication and less resistance to change. It may increase responsibility for dealing with the problems identified and increase commitment to change strategies. And, finally, it may constitute an intervention in its own right as it reflects the concrete enactment of job control (17). The formulation of a program theory and process evaluation, for example through the repeated measurement of commitment and quality of communication, may contribute to the further testing of such assumptions. So far organizational stress interventions reveal mixed results and this makes it difficult to find the best ways for reducing stress at work and to convince businesses to engage in these activities. Outcome research is essential, but only measuring effects without taking the implementation into account may lead to erroneous conclusions. We thereby risk discarding potentially powerful interventions concepts without having tested them properly. The “does it work?” question is a simplification. More informative questions are “under which circumstances will this intervention work?” and “what are hindering and stimulating factors?”. In organizational stress intervention research, process evaluation is thus needed as “an add-on” to – and not substitute for – effect evaluation. The Havermans et al paper can be interpreted as a plea for the integration of process evaluation in all studies of organizational stress interventions, in a way that enables the relation of process aspects to outcomes. We believe that future research may aim at a further standardization of a taxonomy that is rich but not overly detailed. It seems that the Nielsen & Randall classification scheme provides a good starting point. We also believe that such organizational stress management intervention research will falsify an “implementation research hypothesis” formulated by Mick Jagger and Keith Richards in 1965. They assumed that “It’s the singer, not the song”, whereas we argue that it is both the intervention (the song) and the implementation (the singer) that make a difference when it comes to organizational stress management interventions.

OBJECTIVES: The aim of this study was to evaluate the implementation of the Danish national return-to-work (RTW) program in 21 Danish municipalities. METHODS: We conducted a structured process evaluation on (i) reach and recruitment, (ii) fidelity, (iii) dose-delivered, (iv) dose-received, and (v) context by formulating 29 implementation criteria and analyzing qualitative and quantitative data from administrative records, interviews, field notes, and questionnaires. RESULTS: All municipalities integrated the basic features of the RTW program into the existing framework of the sickness benefit management system to an acceptable degree, ie, establishment of RTW teams, participation of RTW team members in the training courses, and following the general procedures of the program. However, the level of implementation varied considerably between the municipalities, particularly with respect to fidelity (defined as implementation consistent with the principles of the interdisciplinary RTW process). Five municipalities had high and eight had low fidelity scores. Similar large differences were found with regard to dose-delivered, particularly in the quality of cooperation with beneficiaries, employers, and general practitioners. Only 50% of the first consultations with the RTW coordinator were conducted in time. Among participants who were employed when their sickness absence period started, only 9% had at least one meeting with their workplace. CONCLUSION: It was feasible to implement the basic features of the Danish RTW program, however, large variations existed between municipalities. Establishment of well-functioning interdisciplinary RTW teams might require more time and resources, while ensuring early assessment and more frequent cooperation with employers might need more general adjustments in the Danish sickness benefit system.

OBJECTIVES: The aim of this study was to evaluate the effect of the Danish return-to-work (RTW) program on long-term sickness absence in a randomized controlled trial in three municipalities. METHODS: The intervention group comprised 1948 participants while the control group comprised 1157 participant receiving ordinary sickness benefit management (OSM). Study participants were working-age adults receiving long-term (≥8 weeks or more) benefits, included regardless of reason for sickness absence or employment status. Each beneficiary was followed-up for a maximum period of 52 weeks. Cox proportional hazards model was used to estimate hazard ratios (HR) for return to work (RTW) with 95% confidence intervals (95% CI). RESULTS: The intervention effect differed significantly between the municipalities (P=0.00005). In one municipality (M2) the intervention resulted in a statistically significant increased rate of recovery from long-term sickness absence (HR 1.51, 95% CI 1.31–1.74). In the other two municipalities, the intervention did not show a statistically significant effect (HR_M1 1.12, 95% CI 0.97–1.29, and HR_M3 0.80, 95% CI 0.63–1.03, respectively). Adjustment for a series of possible confounders only marginally altered the estimated HR. CONCLUSION: The effect of the intervention differed substantially between the three municipalities, indicating that that contextual factors are of major importance for success or failure of this complex intervention.

OBJECTIVE: The aim of this study was to analyze whether exposure to workplace bullying among 5701 female employees in the Danish eldercare sector increases the risk of onset of a major depressive episode (MDE). METHODS: Participants received questionnaires in 2004–2005 and again in 2006–2007. MDE was assessed with the Major Depression Inventory. We examined baseline bullying as a predictor of onset of MDE at follow-up using multiple logistic regression. We further conducted a cross-sectional analysis at the time of follow-up among participants who at baseline were free of bullying, MDE, and signs of reduced psychological health. Finally, we analyzed reciprocal effects, by using baseline bullying and baseline MDE as predictors for bullying and MDE at follow-up. RESULTS: Onset rates of MDE in the groups of no, occasional, and frequent bullying were 1.5%, 3.4%, and 11.3%, respectively. Odds ratios (OR) for onset of MDE were 2.22 [95% confidence interval (95% CI) 1.31–3.76] for occasional bullying and OR 8.45 (95% CI 4.04–17.70) for frequent bullying, after adjustment for covariates. In the cross-sectional analysis, OR were 6.29 (95% CI 2.52–15.68) for occasional bullying and 20.96 (95% CI 5.80–75.80) for frequent bullying. In the analyses on reciprocal effects, both baseline bullying [occasional: OR 2.12 (95% CI 1.29–3.48) and frequent: OR 6.39 (95% CI 3.10–13.17)] and baseline MDE [OR 7.18 (95% CI 3.60–14.30] predicted MDE at follow-up. However, only baseline bullying [occasional: OR 7.44 (95% CI 5.94–9.31) and frequent: OR 11.91 (95% CI 7.56–18.77)] but not baseline MDE [OR 0.93 (95% CI 0.47–1.84)] predicted bullying at follow-up. CONCLUSIONS: Workplace bullying increased the risk of MDE among female eldercare workers. MDE did not predict risk of bullying. Eliminating bullying at work may be an important contribution to the prevention of MDE.

The Danish national return-to-work (RTW) program aims to improve the management of municipal sickness benefit in Denmark. A study is currently ongoing to evaluate the RTW program. The purpose of this article is to describe the study protocol. The program includes 21 municipalities encompassing approximately 19 500 working-age adults on long-term sickness absence, regardless of reason for sickness absence or employment status. It consists of three core elements: (i) establishment of multidisciplinary RTW teams, (ii) introduction of standardized workability assessments and sickness absence management procedures, and (iii) a comprehensive training course for the RTW teams. The effect evaluation is based on a parallel group randomized trial and a stratified cluster controlled trial and focuses on register-based primary outcomes – duration of sickness absence and RTW – and questionnaire-based secondary outcomes such as health and workability. The process evaluation utilizes questionnaires, interviews, and municipal data. The effect evaluation tests whether participants in the intervention have a (i) shorter duration of full-time sickness absence, (ii) longer time until recurrent long-term sickness absence, (iii) faster full RTW, (iv) more positive development in health, workability, pain, and sleep; it also tests whether the program is cost-effective. The process evaluation investigates: (i) whether the expected target population is reached; (ii) if the program is implemented as intended; (iii) how the beneficiaries, the RTW teams, and the external stakeholders experience the program; and (iv) whether contextual factors influenced the implementation. The program has the potential to contribute markedly to lowering human and economic costs and increasing labor force supply. First results will be available in 2013. The trial registrations are ISRCTN43004323, and ISRCTN51445682.

Targeting occupational health and safety interventions to different groups of employees and sectors is important. The aim of this study was to explore the environment-intervention fit of a Danish psychosocial work environment intervention program for the residential and home care sector. Focus group interviews with employees and interviews with mangers were conducted at 12 selected workplaces and a questionnaire survey was conducted with managers at all 115 workplaces. The interventions enhanced the probability of employees experiencing more “good” work days, where they could make a difference to the lives of clients. The interventions may therefore be characterized as culturally compelling and having a good fit with the immediate work environment of employees. The interventions furthermore seemed to fit well with the wider organizational environment and with recent changes in the societal and economic context of workplaces. However, some workplaces had difficulties with involving all employees and adapting the interventions to the organization of work. The findings suggest that flexibility and a variety of strategies to involve all employees are important aspects, if interventions are to fit well with the care sector. The focus on employees’ conceptualization of a “good” work day may be useful for intervention research in other sectors.