The effects of different types of organisational workplace mental health interventions on mental health and wellbeing in healthcare workers: a systematic review.

OBJECTIVE: To determine if and which types of organisational interventions conducted in small and medium size enterprises (SMEs) in healthcare are effective on mental health and wellbeing. METHODS: Following PRISMA guidelines, we searched six scientific databases, assessed the methodological quality of eligible studies using QATQS and grouped them into six organisational intervention types for narrative synthesis. Only controlled studies with at least one follow-up were eligible. RESULTS: We identified 22 studies (23 articles) mainly conducted in hospitals with 16 studies rated of strong or moderate methodological quality. More than two thirds (68%) of the studies reported improvements in at least one primary outcome (mental wellbeing, burnout, stress, symptoms of depression or anxiety), most consistently in burnout with eleven out of thirteen studies. We found a strong level of evidence for the intervention type "Job and task modifications" and a moderate level of evidence for the types "Flexible work and scheduling" and "Changes in the physical work environment". For all other types, the level of evidence was insufficient. We found no studies conducted with an independent SME, however five studies with SMEs attached to a larger organisational structure. The effectiveness of workplace mental health interventions in these SMEs was mixed. CONCLUSION: Organisational interventions in healthcare workers can be effective in improving mental health, especially in reducing burnout. Intervention types where the change in the work environment constitutes the intervention had the highest level of evidence. More research is needed for SMEs and for healthcare workers other than hospital-based physicians and nurses.

Barriers to and Facilitators for Finding and Keeping Competitive Employment: A Focus Group Study on Autistic Adults With and Without Paid Employment.

PURPOSE: The aim of the study was to gain more insight into barriers to and facilitators for finding and keeping competitive employment for autistic adults. Research questions were: (1) What barriers and facilitators do autistic adults report in finding and keeping competitive employment?; and (2) What are differences and similarities between autistic adults with and without paid employment regarding barriers and facilitators for sustainable employment? METHODS: Eight focus groups were conducted (N = 64 autistic adults). Four groups included only participants without paid employment (N = 24), and four groups consisted exclusively of participants with current paid employment (including part-time, N = 40). All discussions were audiotaped and transcribed verbatim to enable inductive thematic content analysis. Data were analyzed using ATLAS.ti 9. RESULTS: Ten themes and thirty-four subthemes were found. Many were interconnected. Themes facilitating sustainable employment included a positive workplace atmosphere, a supportive supervisor, being able to do work that aligns with interests and talents, favorable physical working conditions, coaching, higher self-insight, higher self-esteem, and proactivity. Most themes and subthemes emerged from both groups. Differences between the groups were that those with paid employment seemed to have experienced more friendly workplaces and supervisors, had received better coaching in finding and keeping employment, had higher self-insight and higher self-esteem, were more assertive and proactive. CONCLUSIONS: As many (sub-)themes were interrelated, the results suggest that to improve work participation, particularly two key areas are promising: (1) to realize more friendly, well-being oriented and inclusive workplaces, and (2) to increase autistic adults' self-insight into personal needs for positive wellbeing and self-knowledge regarding talents, wishes and well-being boundaries.

Recovery-oriented care in Teams Working with the ART Model in long-term Mental Health care: A Qualitative Study on the Experiences of Service Users and Their Significant Others.

The Active Recovery Triad (ART) model provides a framework for recovery-oriented care in long-term mental health settings. The aim of this study is to gain insight into the experiences and views of service users and their significant others regarding care and support they receive from teams working with the ART model. Semi-structured interviews were performed with nineteen service users and five significant others of teams operating in Dutch long-term mental health care. Data were analyzed using thematic analysis. The three core principles of the ART model formed the deductive basis of the analysis and for every principle themes were identified inductively. Under the principle 'Active', service users mentioned that they feel motivated, work actively on personal recovery goals and have dreams for the future. Service users valued the service as a safe environment, but several service users also preferred to live more independently. Under the principle 'Recovery', participants reported how the dimensions of recovery (health, personal identity, daily life and community functioning) were addressed in care and support. Also, specific conditions for recovery-oriented care were identified, for example regarding specific expertise of care providers. Under the principle 'Triad' the support from significant others, contact with care workers and with other service users were identified as important. The insights regarding what is important for service users and their significant others may contribute to the improvement of care and support in long-term mental health care. In addition, the findings of this study provide directions for the further development of the ART model.

What are important ingredients for Intensive Home Support for people with severe mental illness according to experts? A concept mapping approach.

BACKGROUND: Deinstitutionalization in mental health care has been an ongoing process for decades. More and more people with severe mental illness (SMI), who previously lived in residential supported housing settings and were formerly homeless, are now living independently in the community but need intensive support to enable independent living. The support provided by regular outpatient teams is inadequate for this target group. This study explored the ingredients for an alternative form of outpatient support: intensive home support (IHS). METHODS: Concept mapping was used, following five steps: (1) brainstorming, (2) sorting, (3) rating, (4) statistical analysis & visual representation, and (5) interpretation. Purposive sampling was used to represent several perspectives, including researchers, professionals, peer workers, and policy makers. RESULTS: Experts (n = 17) participated in the brainstorming step and the sorting and rating steps (n = 14). The 84 generated statements were grouped into 10 clusters:. (1) housing rights; (2) informal collaboration; (3) reciprocity in the community; (4) normalization and citizenship; (5) recovery; (6) sustainable funding; (7) equivalence; (8) flexible, proactive 24/7 support; (9) public health and positive health; and (10) integrated cooperation in support at home. CONCLUSIONS: Given the diversity of the ingredients contained in the clusters, it seems that IHS should be designed according to a holistic approach in collaboration with several sectors. Additionally, IHS is not only the responsibility of care organizations but also the responsibility of national and local governments. Further research about collaboration and integrated care is needed to determine how to implement all of the ingredients in practice.

Developing a framework for evaluation: a Theory of Change for complex workplace mental health interventions.

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.

Experiences and needs of welfare benefit recipients regarding their welfare-to-work services and case workers.

BACKGROUND: This study aimed to explore the experiences and needs of (ex-)welfare benefit recipients from a large urban municipality in the Netherlands regarding their welfare-to-work services and their case workers. METHODS: Quantitative data from a client satisfaction survey that was filled out by 213 people (response rate 11%) who received welfare-to-work services was combined with results from four group interviews with a total of 15 people receiving welfare-to-work services. Verbatim transcripts from the interviews were analysed using inductive thematic analysis. RESULTS: The survey results showed that most clients were reasonably satisfied with the welfare-to-work services they received. Four main themes emerged from the interviews: (1) experiences and needs related to the interactions between case workers and benefit recipients; (2) the need for tailored services; (3) the complicating role of the system the case workers operate within; and (4) the existence of differences between case workers regarding how strict they followed the rules and to what extent they connected with their clients on a personal level. CONCLUSIONS: Our findings show that clients were reasonably satisfied with the welfare-to-work services provided by their municipality but that there is still room for improvement. Case workers should have good social skills to build a trusting relationship with the client, welfare-to-work services should be tailored to the individual, and clear concise information should be given to welfare benefit recipients, especially with regard to what benefit recipients can expect of the municipality and the case workers, given their dual role in supporting (re-)integration to work and monitoring benefit eligibility.

What is the Meaning of Paid Employment for Well-Being? A Focus Group Study on Differences and Similarities Between Autistic Adults With and Without Employment.

PURPOSE: The aim of the present study was to explore the meaning of work for the subjective well-being of autistic adults with and without paid (competitive) employment and to evaluate the differences and similarities between these groups. METHODS: Eight focus groups were conducted, including a total of 64 autistic adults. Four groups entailed participants with current paid employment (including part-time) and four groups entailed participants without paid employment. All discussions were audiotaped and transcribed verbatim to enable inductive thematic content analysis. Data were analyzed using ATLAS.ti 9. RESULTS: Generally, both groups viewed paid employment as very important for well-being, albeit for different reasons. Three themes were found: (1) Not having paid employment was associated with lacking societal recognition, and subsequent low self-esteem, which was a dominant theme in those without work; (2) Work can seriously damage (mental) health and well-being, found in both groups; and (3) Paid employment provides many benefits for well-being, with subthemes: 'purpose,' 'social contacts,' 'growth and use of talents,' 'structure and calmness,' and 'income and freedom', which was a dominant theme in those with paid employment. CONCLUSIONS: Both groups found paid employment highly important for their well-being, albeit for different reasons. However, both also agreed that paid employment can be very harmful to (mental) health and well-being. Suitable, well-supported jobs are important for well-being, may help to buffer stress in other life areas, and may even prevent autistic burnout. More studies are needed on how healthy jobs can be created where autistic individuals get positive energy and experience high well-being. This will also help to reduce socio-economic inequality.

Workplace Mental Health Disclosure, Sustainable Employability and Well-Being at Work: A Cross-Sectional Study Among Military Personnel with Mental Illness.

Purpose Disclosure of mental illness to a supervisor can have positive (e.g. supervisor support) and negative consequences (e.g. stigma). However, research on the association between disclosure and sustainable employability and well-being at work is scarce. The aim of this study was to investigate the association between the disclosure decision (yes/no), experiences with the decision (positive/negative) and sustainable employment and well-being at work among military personnel with mental illness (N = 323). Methods A cross-sectional questionnaire study was conducted. Descriptive and regression (linear and ordinal) analyses were performed. Comparisons were made between those with positive and negative disclosure experiences. Results Disclosure decision (yes/no) was not significantly associated with any of the measures of sustainable employability and well-being at work. However, positive disclosure experiences were significantly associated with higher scores on almost all measures of sustainable employability and well-being at work. Those with negative disclosure experiences reported significantly more shame (Mpos = 2.42, Mneg = 2.78, p < .05) and discrimination (Mpos = 1.70, Mneg = 2.84, p < .001). Those with a positive disclosure experience, reported significantly more supervisor support (Mpos = 3.20, Mneg = 1.94, p < .001). Conclusion We did not find evidence that the disclosure decision itself is related to measures of sustainable employment and well-being at work. In contrast, how participants had experienced their (non-)disclosure decision was significantly related to almost all measures. This emphasizes the importance of the work environments reactions to disclosure and mental illness in the workplace. Future research and interventions should focus on increasing the likelihood of positive disclosure experiences through creating a more inclusive work environment, with more supervisor support and less stigma.

Fidelity and Clinical Competence in Providing Illness Management and Recovery: An Explorative Study.

Illness Management and Recovery (IMR) is a psychosocial intervention supporting people with serious mental illnesses. In this study, 15 IMR groups were assessed for fidelity and clinician competency to establish the implementation level of all IMR elements and explore complementarity of the IMR Treatment Integrity Scale (IT-IS) to the standard IMR Fidelity Scale. Use of the IT-IS was adapted, similar to the IMR Fidelity Scale. Descriptive statistics were applied. Implementation success of IMR elements varied widely on the IMR Fidelity Scale and IT-IS (M = 3.94, SD = 1.13, and M = 3.29, SD = 1.05, respectively). Twelve IMR elements (60%) were well-implemented, whereas eight (40%) were implemented insufficiently, including some critical cognitive-behavioral techniques (e.g., role-playing). The scales appeared largely complementary, though strongly correlated (r (13) = 0.74, p = 0.002). Providing all IMR elements adequately requires a variety of clinical skills. Specific additional training and supervision may be necessary.

The Active Recovery Triad monitor: evaluation of a model fidelity scale for recovery-oriented care in long-term mental health care settings.

OBJECTIVE: The Active Recovery Triad (ART) model is a recently developed care model for people who are admitted to an institutional setting for several years and receive 24-h mental health care and support. This study focuses on the ART monitor, a model fidelity scale that measures the degree of compliance with the ART model. Our aim is to evaluate the psychometric properties of the ART monitor and to further improve the instrument. METHODS: Fifteen teams at the start (n = 7, group 1) or in the process (6 months to three years) of implementing care according to the ART model (n = 8, group 2) were audited using the ART monitor. Auditors were trained care workers, peer workers, and family peer workers. Auditors and team members provided feedback on the instrument. The content validity, construct validity and inter-rater reliability of the ART monitor were investigated. Based on the outcomes of these psychometric properties, the ART monitor was finalized. RESULTS: Regarding content validity, auditors and teams indicated that they perceived the ART monitor to be a useful instrument. In terms of construct validity, a significant difference (t(13) = 2.53, p < 0.05) was found between teams at the start of the implementation process (group 1, average score of 2.42 (SD = 0.44)) and teams with a longer duration of implementation (group 2, average score of 2.95 (SD = 0.37)). When allowing for a one-point difference in scores, 88% of the items had an inter-rater agreement over 65%. Items with a relatively low inter-rater reliability, in combination with feedback from auditors and teams regarding content validity, provided direction for further improvement and revision of the instrument. CONCLUSIONS: We concluded that the revised ART monitor is feasible and useful in mental health care practice. However, further evaluation of its psychometric properties will be needed.

Barriers and Facilitators for Return to Work from the Perspective of Workers with Common Mental Disorders with Short, Medium and Long-Term Sickness Absence: A Longitudinal Qualitative Study.

Purpose Although common mental disorders (CMDs) highly impact individuals and society, a knowledge gap exists on how sickness absence can be prevented in workers with CMDs. This study explores: (1) workers' perceived causes of sickness absence; (2) perceived return to work (RTW) barriers and facilitators; and (3) differences between workers with short, medium and long-term sickness absence. Methods A longitudinal qualitative study was conducted involving 34 workers with CMDs. Semi-structured interviews were held at two time-points during their RTW process. The 68 interviews were audio-taped, transcribed and thematically analyzed to explore workers' perspective on sickness absence causes, RTW barriers and facilitators, and compare data across the three sub-groups of workers. Results Workers reported various causes for their absence, including: (1) high work pressure; (2) poor work relationships; (3) unhelpful thoughts and feelings, e.g. lacking self-insight; and (4) ineffective coping behaviors. According to workers, RTW was facilitated by work adjustments, fulfilling relationships with supervisors, and adequate occupational health guidance. Workers with short-term leave more often reported favorable work conditions, and proactive coping behavior. In contrast, the long-term group reported reactive coping behavior and dissatisfaction with their work. Conclusion Supporting workers with CMDs in gaining self-awareness and regaining control, discussing the value of their work, and creating work conditions that enable workers to do valuable work, seem central for successful RTW and might prevent sickness absence. Supervisors play a key role in enabling workers to do valuable work and further research should focus on how supervisors can be supported in this task.

Line managers' hiring intentions regarding people with mental health problems: a cross-sectional study on workplace stigma.

OBJECTIVES: Stigma may negatively affect line managers' intention to hire people with mental health problems (MHP). This study aims to evaluate line managers' knowledge and attitudes concerning job applicants with MHP, and to assess which factors are associated with the intention (not) to hire an applicant with MHP. METHODS: A sample of Dutch line managers (N=670) filled out a questionnaire on their knowledge, attitudes and experiences concerning applicants/employees with MHP. Descriptive analyses and multiple regression analyses were used. RESULTS: The majority (64%) was reluctant to hire a job applicant with MHP, despite the fact that only 7% had negative and 52% had positive personal experiences with such employees. Thirty per cent were reluctant to hire an applicant if they knew the applicant had past MHP. Associated with higher reluctance to hire an applicant with MHP were the concerns that it will lead to long-term sickness absence (ß (95% CI)=0.39 (0.23 to 0.55)), that the employee cannot handle the work (ß (95% CI)=0.16 (0.00 to 0.33)) that one cannot count on the employee (ß (95% CI)=0.41 (0.23 to 0.58)) and higher manager education level (ß (95% CI)=0.25 (0.05 to 0.44)). Conversely, associated with positive hiring intentions was being in favour of diversity and/or inclusive enterprise (ß(95% CI)=-0.64 (-0.87 to -0.41)). CONCLUSIONS: As the majority of managers were reluctant to hire applicants with MHP, and even 30% were reluctant to hire applicants who had past MHP, these findings have major implications for social inclusion in the Netherlands, where about 75% of employees would disclose MHP at work.

Development of an Intervention Aimed at Increasing Awareness and Acknowledgement of Victimisation and Its Consequences Among People with Severe Mental Illness.

Individuals with severe mental illness have a significant risk of (anticipated) discrimination and (criminal) victimisation, which is not structurally and systematically addressed by mental health practitioners. The aim of this study was to develop and pilot an intervention which supports professionals to address victimisation and its consequences, in order to reinforce safe social participation and improve recovery. Following the rehabilitation and positive risk management literature, in addition to current practice, intervention components were developed in two focus groups and four subsequent expert meetings. The intervention was piloted in two outpatient teams before being finalised. The Victoria intervention includes positive risk management, focusing on clients' narratives and strengths, and awareness of unsafe (home) environments: it comprises four steps: exploring issues with social participation, analysing victimisation experiences, clarifying the context of these experiences, and determining future steps, including victimisation-sensitive rehabilitation planning and optional trauma treatment. Future research should further test this intervention.

Fidelity and IPS: does quality of implementation predict vocational outcomes over time for organizations treating persons with severe mental illness in the Netherlands?

PURPOSE: Individual placement and support (IPS) is an evidence-based supported employment intervention. Quality of IPS implementation is assessed using a validated fidelity scale. Previous studies found a positive association between fidelity and employment outcomes at a single time-point. This study examines the longitudinal associations between IPS fidelity scores and employment outcomes. METHODS: We examined fidelity and employment outcome data for 27 IPS programs in the Netherlands providing IPS. These programs received at least one fidelity assessment and reported quarterly employment outcomes for at least one year to a central registry between 2014 and 2019. We first examined changes over time for fidelity and employment outcome. Then we analyzed the longitudinal associations between the quarterly employment outcomes and the IPS fidelity assessments on multiple time-points using a mixed-model analysis for the 17 programs with at least two fidelity assessments. RESULTS: Both IPS fidelity and employment outcomes improved over time, with the largest improvement in employment outcomes achieved after 18 months of implementation. We found a significant positive longitudinal association between IPS-fidelity and employment. CONCLUSIONS: Improvement of fidelity is associated with improvement of employment outcomes over time. Future research should be focused on the improvement of specific elements of IPS implementation and their influence on employment outcomes.

Recovery in Supported Accommodations: A Scoping Review and Synthesis of Interventions for People with Severe Mental Illness.

Research on the recovery domains beside clinical recovery of people with severe mental illness in need of supported accommodations is limited. The aim of this study was (1) to investigate which recovery interventions exist for this group of people and (2) to explore the scientific evidence. We conducted a scoping review, including studies with different designs, evaluating the effectiveness the recovery interventions available. The search resulted in 53 eligible articles of which 22 focused on societal recovery, six on personal recovery, five on functional recovery, 13 on lifestyle-interventions, and seven on creative and spiritual interventions. About a quarter of these interventions showed added value and half of them initial promising results. The research in this area is still limited, but a number of recovery promoting interventions on other areas than clinical recovery have been developed and evaluated. Further innovation and research to strengthen and repeat the evidence are needed.

Fidelity Scale: From Black Box to Holy Grail.

Fidelity scales are indispensable in the pursuit of evidence-based mental healthcare. Without fidelity checks, treatment remains a mysterious black box. The aim of this article is to comment on the studies in this special section, and to discuss some general issues with regard to fidelity assessment. Despite all of their supposed benefits, resistance to fidelity scales persists among mental health practitioners. One way to overcome this resistance is to conduct fidelity assessments in the context of a well-guided learning community. The predictive validity of fidelity scales is considered the single most valuable attribute of these instruments. Research on predictive validity requires large sample sizes, which is difficult to achieve. It should nevertheless not prevent us from rigorously searching for this Holy Grail of fidelity assessment. In addition, fidelity assessment should be placed in a broader perspective. The quality of care for people with severe mental illness cannot be assessed conclusively according to the extent to which separate interventions have been applied with good fidelity. These individuals need access to high-quality treatment and support systems within the community, which can enable them to live their lives as valued citizens. In conclusion, fidelity assessment, both at the level of interventions and systems, contributes to a highly desirable transparency in practice variations within the field of mental healthcare.

The effect of rehabilitation combined with cognitive remediation on functioning in persons with severe mental illness: systematic review and meta-analysis.

BACKGROUND: Psychiatric rehabilitation (PR) can improve functioning in people with severe mental illness (SMI), but outcomes are still suboptimal. Cognitive impairments have severe implications for functioning and might reduce the effects of PR. It has been demonstrated that performance in cognitive tests can be improved by cognitive remediation (CR). However, there is no consistent evidence that CR as a stand-alone intervention leads to improvements in real-life functioning. The present study investigated whether a combination of PR and CR enhances the effect of a stand-alone PR or CR intervention on separate domains of functioning. METHOD: A meta-analysis of randomized controlled trials of PR combined with CR in people with SMI was conducted, reporting on functioning outcomes. A multivariate meta-regression analysis was carried out to evaluate moderator effects. RESULTS: The meta-analysis included 23 studies with 1819 patients. Enhancing PR with CR had significant beneficial effects on vocational outcomes (e.g. employment rate: SMD = 0.41), and social skills (SMD = 0.24). No significant effects were found on relationships and outcomes of community functioning. Effects on vocational outcomes were moderated by years of education, intensity of the intervention, type of CR approach and integration of treatment goals for PR and CR. Type of PR was no significant moderator. CONCLUSIONS: Augmenting PR by adding cognitive training can improve vocational and social functioning in patients with SMI more than a stand-alone PR intervention. First indications exist that a synergetic mechanism also works the other way around, with beneficial effects of the combined intervention compared with a stand-alone CR intervention.

Recovery for all in the community; position paper on principles and key elements of community-based mental health care.

BACKGROUND: Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe. MAIN TEXT: The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network. CONCLUSIONS: Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

Effectiveness of a tailored implementation strategy to improve adherence to a guideline on mental health problems in occupational health care.

BACKGROUND: As compliance to guidelines is generally low among health care providers, little is known about the impact of guidelines on the quality of delivery of care. To improve adherence to guideline recommendations on mental health problems, an implementation strategy was developed for Dutch occupational physicians (OPs). The aims were 1) to assess adherence to a mental health guideline in occupational health care and 2) to evaluate the effect of a tailored implementation strategy on guideline adherence compared to traditional guideline dissemination. METHODS: An audit of medical records was conducted as part of a larger RCT study. Participants were 66 OPs (32 intervention and 34 control) employed at one of six sites of an Occupational Health Service in southern Netherlands. OPs in the intervention group received multiple-session peer group training which focused on identifying and addressing barriers to using the guideline, using a Plan-Do-Check-Act approach. The control group did not receive training. Medical records of 114 workers sick-listed with mental health problems were assessed (56 intervention and 58 control). Guideline adherence was determined by auditing the records using 12 guideline-based performance indicators (PI), grouped into 5 PIs: process diagnosis, problem orientation, interventions/treatment, relapse prevention, and continuity of care. Differences in performance rates of the PIs between the intervention and control groups were analyzed, taking into account the cluster study design. RESULTS: OPs who received the training showed significantly greater adherence compared to the controls (p < .028) in 4 out of 5 grouped PIs, i.e. process diagnosis, problem orientation, interventions/treatment and relapse prevention. In one out of 12 PIs adherence was found adequate (53% of the medical records), in 6 PIs adherence was found minimal, and in 5 PIs the majority of the records showed no adherence. CONCLUSIONS: An implementation strategy which addressed key barriers for change and tailor-made interventions improves adherence to an occupational health guideline for mental health problems compared to traditional guideline dissemination. However, adherence to the guideline recommendations is still far from optimal. To optimize adherence, it is recommended that implementation strategies focus on the workers level, organizational level, and the professional level. TRIAL REGISTRATION: ISRCTN86605310 . Registered 30 June 2010.

Employment Rates in Flexible Assertive Community Treatment Teams in The Netherlands: An Observational Study.

We determined the proportions of clients treated in Flexible Assertive Community Treatment teams who were unemployed and gained employment and who were employed and lost employment. Secondly, we explored the demographical and clinical factors associated with employment. Data were collected during routine outcome monitoring. We calculated differences in employment rates over a year and explored differences in demographic characteristics at baseline between patient groups. Logistic regression analysis was used to estimate the role of clinical predictor variables on employment status. Over time, 10% remained employed, 5% lost their employment, 3% gained employment and 82% remained unemployed. Clients who found employment were younger, more often male, and had significantly fewer psychosocial problems and a higher subjective quality of life during follow-up than those who remained unemployed. Problems with motivation for treatment at baseline were related to losing employment or remaining unemployed. Better implementation of vocational services is very important for increasing the number of clients gaining employment.