Effectiveness of a Stigma Awareness Intervention on Reemployment of People with Mental Health Issues/Mental Illness: A Cluster Randomised Controlled Trial.

PURPOSE: A barrier for reemployment of people with mental health issues/mental illness (MHI) is workplace stigma and discrimination. In this RCT the effectiveness of a stigma-awareness intervention addressing finding work, retaining work and decisional stress were evaluated. METHODS: A cluster RCT was conducted in 8 Dutch municipal practices. Randomisation took place at practice level. Participants were unemployed people with MHI, receiving social benefits. The intervention consisted of a decision aid for workplace disclosure for participants and a 2 × 3 h stigma-awareness training for their employment specialists. Primary outcomes were measured at baseline, 3-, 6- and 12-months. Multilevel analyses, containing random intercepts of participants nested in organizations, were conducted to analyse the effects of the intervention. RESULTS: Participants (N = 153) were randomized to an experimental (n = 76) or control group (n = 77). At six months, significantly more participants of the experimental group (51%) had found work compared to the control group (26%). At twelve months, significantly more participants of the experimental group (49%) had retained work compared to the control group (23%). Intention-to-treat analyses showed that randomization to the experimental group was associated with finding (OR(95%CI) = 7.78(1.33-45.53), p = 0.02) and retaining (OR(95%CI) = 12.15(2.81-52.63), p < 0.01) work more often at twelve months. Analyses showed that the experimental and control group did not differ in decisional stress. CONCLUSIONS: Our stigma awareness intervention was effective for finding and retaining work. As the percentage of people who found and retained work almost doubled, this suggests that on a societal level, a vast number of unemployed people could be reemployed with a relatively simple intervention. TRIAL REGISTRATION: The study was retrospectively registered at the Dutch Trial Register (TRN: NL7798, date: 04-06-2019).

Improving Work Participation Outcomes Among Unemployed People with Mental Health Issues/Mental Illness: Feasibility of a Stigma Awareness Intervention.

PURPOSE: As stigma is a barrier to work participation of unemployed people with mental health issues/mental illness (MHI), a stigma awareness intervention can be helpful to make informed decisions about disclosing MHI. The aim of this process evaluation was to investigate the feasibility of a stigma awareness intervention, to explore experiences of clients and their employment specialists; and to give recommendations for further implementation. METHODS: The intervention consisted of a stigma awareness training for employment specialists and a decision aid tool for their clients with (a history of) MHI. For the process evaluation, six process components of the Linnan & Stecklar framework were examined: recruitment, reach, dose delivered, dose received, fidelity and context. Using a mixed-methods design, quantitative and qualitative data were collected and analyzed. RESULTS: The six components showed the intervention was largely implemented as planned. Questionnaire data showed that 94% of the clients found the tool useful and 87% would recommend it to others. In addition, more than half (54%) indicated the tool had been helpful in their disclosure decision. Qualitative data showed that participants were mainly positive about the intervention. Nevertheless, only a minority of clients and employment specialists had actually discussed the tool together. According to both, the intervention had increased their awareness of workplace stigma and the disclosure dilemma. CONCLUSION: The implementation of a stigma awareness intervention was feasible and did increase stigma awareness. Experiences with the intervention were mainly positive. When implementing the tool, it is recommended to embed it in the vocational rehabilitation system, so that discussing the disclosure dilemma becomes a routine. TRAIL REGISTER: The study was retrospectively registered at the Dutch Trial Register (TRN: NL7798, date: 04-06-2019).

Psychometric properties of the Internalized Stigma of Mental Illness (ISMI-10) scale in a Dutch sample of employees with mental illness.

BACKGROUND: Internalized stigma can have numerous negative effects on the well-being and employment of people with mental illness. Brief, valid, and reliable measures are needed to get a better understanding of self-stigmatization. The aim of this study is to translate the brief version of the Internalized Stigma of Mental Illness (ISMI-10) scale into a Dutch version and to assess the reliability and validity of this Dutch version in a sample of employees with mental illness. METHODS: The ISMI-10 was translated into Dutch using the forward-backward translation procedure. The sample consisted of 161 employees with mental illness. Internal consistency was evaluated and the retest reliability was tested with 68 respondents. The construct validity was evaluated by testing convergent and divergent validity. RESULTS: The Dutch ISMI-10 showed good internal consistency (α = 0.83) and good test-retest reliability (r = 0.73). The Dutch ISMI-10 demonstrated excellent convergent validity; high correlations were found between the Dutch ISMI-10 and hope (r = -0.54), anxiety and depression (r = 0.59), self-esteem (r = -0.56), and empowerment (r = - 0.59). Acceptable divergent validity was indicated; small correlations were found between the Dutch ISMI-10 and the physical functioning subscale (r = -0.27) and the role limitation due to physical problems subscale (r = -0.21), and medium correlations were found between the Dutch ISMI-10 and the general health subscale (r = -0.36). CONCLUSION: The Dutch ISMI-10 demonstrated adequate psychometric properties for assessing internalized stigma and can be used by researchers in Dutch speaking countries to get a better understanding of self-stigmatization among people with mental illness.

Expectations of Mental Illness Disclosure Outcomes in the Work Context: A Cross-Sectional Study Among Dutch Workers.

Purpose The decision whether to disclose mental illness at work can have important positive and negative consequences for sustainable employment and well-being. The aim of the study is (1) to examine workers' expectations of outcomes of mental illness disclosure in the workplace and to evaluate their expectations regarding which factors are of influence on these outcomes, (2) to identify distinct subgroups of workers, and (3) to characterize these subgroups in terms of personal, sociodemographic, and work-related characteristics. Methods In this cross-sectional survey study, a sample of 1224 Dutch workers was used. Latent Class Analysis (LCA) was used to identify classes of workers based on expected workplace mental illness outcomes. A three-step approach LCA was chosen to investigate whether the classes differed in characteristics. Results The majority of workers expected predominantly positive outcomes of workplace mental illness disclosure (e.g., being able to be one's authentic self; 82.4%), even though they simultaneously expected disclosure to lead to advancement-related discrimination (e.g., lower chances of contract renewal; or getting a promotion; 68.4% and 57%, respectively). Six distinct subgroups of workers were identified based on expected workplace mental illness disclosure outcomes: two positive classes (50.1%), two negative classes (33.3%), and two classes who indicated not to know what the outcomes would be (16.7%). Significant differences between the classes were found on personal experience, work-related association with mental illness, gender, educational level, and workplace atmosphere. Conclusion The disclosure process is complex, as most workers were optimistic (i.e., expected generally positive outcomes) whilst simultaneously expecting workplace discrimination. Subgroup differences in expectations regarding workplace mental illness disclosure outcomes were found.

In What Ways Does Health Related Stigma Affect Sustainable Employment and Well-Being at Work? A Systematic Review.

PURPOSE: Studies are increasingly showing that health related stigma is a barrier to employment, but it is not known how. The aim of this systematic review is to identify, appraise and analyse studies that have directly or indirectly addressed ways in which stigma affects sustainable employment and well-being at work of people with disabilities. METHODS: Using a multiphase screening process, this review is based on a comprehensive literature search (2000-2019) carried out in six electronic databases: Embase, Web of Science, Medline Ovid, Cochrane CENTRAL, PsycINFO and Google Scholar. RESULTS: 7.263 publications were identified; 96 studies were found eligible to be included in the review. 72% of the studies were conducted in North America or Europe. Few studies directly assessed how stigma affects the employment of people with disabilities. Most studies highlighted that attitudes and behaviour of employers formed a barrier to employment, as well as anticipated stigma and self-stigma in people with health problems. However, the findings also showed that the attitudes and behaviour of co-workers, health care professionals, reintegration professionals, customers, and family and friends could act as a barrier to employment although these influences are under-researched. Although many similarities were seen in the relevant findings of studies about both physical and mental disabilities, several nuances were found. CONCLUSION: Stigma hampers sustainable employment and well-being in multiple ways. Whereas the number of publications on this topic is rapidly increasing, the roles of health care professionals, reintegration professionals, co-workers, customers, and family and friends particularly warrant more attention.

Evaluation of an intervention to support decisions on disclosure in the employment setting (DECIDES): study protocol of a longitudinal cluster-randomized controlled trial.

BACKGROUND: Unemployment rates are higher among people with mental health issues/illness (MHI) than in the general working population, and many of them face the dilemma of whether or not to disclose their MHI when searching for employment. Disclosure can lead to rejection and discrimination, but alternatively can also have important advantages that may be necessary to retain employment. Whether disclosure decisions lead to sustainable employment depends on many factors, of which unemployed people themselves can only influence their decision to disclose or not and the way in which they communicate. This study evaluates the cost-effectiveness of an intervention to support unemployed people with MHI in their disclosure decision and communication. METHODS: This is a two-armed, clustered, randomized controlled trial with longitudinal design and randomization at organization level. An intervention will be examined, which consists of a disclosure decision aid tool (CORAL.NL) for unemployed people and workplace stigma-awareness training especially designed for employment specialists, which focusses on how to support unemployed people in their disclosure decisions. Participants in the intervention group are unemployed people who receive support from trained employment specialists from organizations allocated to the intervention group, and receive the CORAL.NL decision aid after baseline. The control group consists of unemployed people who receive support as usual from employment specialists from different organizations allocated to the control group. Primary outcomes are: cost-effectiveness of the intervention, e.g. healthcare costs, having employment, days until start of employment, independency of social security, having other forms of employment and decision making about disclosing MHI. Secondary outcomes are mental health and wellbeing, stigma and discrimination and work-related factors. Financial income data are collected via the registration systems of Dutch municipalities and Statistics Netherlands, and by questionnaires at baseline, and at 3, 6 and 12 months. DISCUSSION: If using a decision aid to decide about disclosure of MHI leads to people finding and retaining employment more often, this study will contribute to lowering healthcare and societal costs. TRIAL REGISTRATION: Netherlands Trial Register: NL7798. Registered on 4 June 2019.