One in eight people across the globe struggle with a mental health disorder, with depression and anxiety being the most prevalent (World Health Organization, 2022). On top of the negative impact on wellbeing, depression and anxiety have also been associated with sickness absence, delayed return to work, loss of productivity, and overall economic burden (Stansfeld et al., 2011). Despite increased awareness regarding the impact of mental health disorders on people’s lives, there is still stigma associated with seeking help (Henderson et al., 2013), including within the workplace environment.
These outcomes, particularly those regarding the economy, have led researchers and employers to develop interventions focused not only on reducing mental health stigma, but also on reducing sickness absence and improving wellbeing and productivity. However, most interventions focus on individuals already diagnosed with a mental illness or at risk of developing one, rather than the general population (Dewa et al., 2015). Similarly, most interventions have included the implementation of standardised treatments for depression and anxiety, like psychotherapy or medication (Nigatu et al, 2016). However, these interventions seem to have had limited effects on preventing sick leave associated with mental illness.
To address this, Gray et al. (2023) developed an intervention to reduce sickness absence and stigma by improving mental health literacy and help-seeking through a low-level psychological intervention.
The intervention, named Prevail, was divided into two parts based on their target population:
- Prevail Staff Intervention: For general staff, focused on improving knowledge about mental health issues, normalising common mental health disorders, reducing mental health stigma (including self-stigma), and helping staff developing a plan they can use to manage common mental disorders within their workplace, to reduce stress and functional impairment.
- Prevail Managers Intervention: For managers, adopting a formulation-based approach so they can work with employees and co-produce plans to solve identified problems, improve wellbeing and, consequently, reduce sickness absence and improve productivity.
To test Prevail, the authors conducted a clustered randomised controlled trial (RCT), where they randomised their target population (Driver and Vehicle Licencing Agency [DVLA] staff) based on manager allocation to teams. Based on power calculations, 1,051 individuals (including 67 managers and their teams) were randomised.
Data was collected at baseline (1-2 weeks pre-intervention) and 4 weeks post-intervention, with changes in attitude towards mental health assessed using the Stigma and Self Stigma Scale (SASS), and satisfaction assessed with an evaluation questionnaire. Data was also collected from the DVLA regarding the number of sick days over the 3-month period following the intervention, which was compared to 1-year prior.
Univariate analysis of variance (ANOVA), Chi Square analyses and Cochran-Mantel-Haenszel tests were used to analyse data. As the study was conducted during COVID-19, parts of the original data analysis plan had to be adapted.
Although 1,051 participants were randomised, a total of 735 members of staff participated in the study, with 467 (64.6% females) allocated to Prevail and 268 (55.6% females) allocated to the control group. Only 306 participants completed the post-intervention questionnaires, with 268 from the Prevail group and 106 from the control group.
Effectiveness of Prevail
- Stigma towards others: In comparison to the control group, scores in the Prevail group showed a reduction in negative beliefs about mental health disorders from baseline to post-intervention, but this was non-significant (p = .52).
- Social distance: There was a reduction on the scores of both groups on the social distance domain; however, reduction was significant only for Prevail (p = .03).
- Self-stigma and anticipated stigma: There were significative reductions (p < .001) in the scores for the self-stigma and anticipated stigma domains in Prevail, with no reductions in the control group.
- Lack of disclosure/help-seeking: There was a reduction in the scores of both groups at post-intervention; however, the reduction was significant only for Prevail (p = .006), suggesting they were more likely to disclose a mental illness or seek help as a result of the intervention.
Evaluation of Prevail
492 participants completed the evaluation questionnaire, identifying that the majority found the intervention easy to understand, believed it was delivered at a good pace, was of an appropriate duration, and felt able to apply what they learnt to themselves and others. Interestingly, there were several participants who had a history of mental health difficulties and were already receiving psychological interventions; for them, Prevail was not as useful as it did not introduce new content.
49 managers completed the evaluation questionnaire, with similar results. Action problem solving was identified as the most useful element of the intervention.
Impact on sickness absence
By comparing the number of sick days taken before and after the intervention, authors found a significantly higher number of sick days (for all sicknesses and mental health disorders) post-intervention in the control group compared to the Prevail group (p < .001). There were also significant differences between male and females, as there were more days of sickness absence post-intervention in the control group (p < .001)
The authors concluded that Prevail is a novel workplace-based programme which is easily deliverable, well received by staff, and potentially effective in increasing mental health literacy, wellbeing and help-seeking, and in reducing self-stigma and sickness absence. Subsequently, they suggested that Prevail could also increase companies’ productivity by reducing absenteeism and workforce losses.
However, the authors acknowledged that their results only showed short-term changes, as due to the COVID-19 pandemic they were unable to assess the impact of Prevail in the longer-term.
Strengths and limitations
- The authors were able to successfully design, deliver and assess a work-based anti-stigma intervention, showing that this type of intervention can be easily delivered, be well received by the target population, and be potentially effective in improving staff’s wellbeing and reducing sickness absence.
- The above was achieved through a clear design, in which authors used evidence-based information to develop their intervention; a largely appropriate methodological approach, which included power calculations and a clustered RCT design; and measures focused on assessing changes in attitudes, acceptability of the intervention, and actual changes in sickness absence behaviour.
- Another strength was the inclusion of managers, as authors recognised managers play an important role in the work experience of most employees; therefore, including them could have helped them improve their own attitudes towards employees struggling with a mental illness, increasing their empathy and providing them with basic tools to support staff wellbeing.
- Due to the nature of its design, there might have been some leakage and contamination from the intervention group to the control group. Therefore, participants from the control group might have become aware of the content of the intervention, which could have influenced their own attitudes.
- Attrition at follow-up was significant, as the authors lost 57% participants from the intervention group and 39.5% from the control group. This might be due to the onset of the Covid-19 pandemic; however, it is not clear whether the authors considered attrition in their power calculation, which would suggest the study was underpowered. An intention to treat analysis would have helped here.
- Although the authors tried to assess participants’ satisfaction with the intervention, they missed the opportunity to identify key mechanisms of change associated with the identified stigma reduction, and more importantly with the reduction of sickness absence observed in the intervention group.
- Similarly, the authors did not look for potential barriers to implement the intervention elsewhere, or other elements which could cause issues when adapting it to different settings. These elements could have been identified by conducting a process evaluation.
- Finally, the onset of the COVID-19 pandemic prevented authors from assessing the effects of the intervention in the longer-term, so, it is unclear if the changes identified were maintained.
Implications for practice
Overall, this study has important implications for practice, as it is a novel anti-sigma intervention that has been tested on members of the public in a real workplace setting, with initial results showing potential benefits for both companies and their employees. In comparison to existing workplace interventions, which often target individuals already struggling with mental illness, this intervention was developed with universal implementation in mind. Whilst further research is the obvious next step, as it still needs to be determined whether these gains can be maintained over the long term, policymakers and other government organisations could begin to consider whether trialling similar interventions in other workplace environments would be feasible.
As this intervention was focused on DVLA staff, trialling the intervention within other government organisations or companies with a similar management system may be appropriate. From questionnaire feedback, the current study suggests that employees may welcome this type of intervention, as it has the potential to improve their mental health literacy, wellbeing, and help-seeking behaviour, an element which has not been considered in previous workplace interventions (Hanisch et al., 2016). Employers might also be willing to implement similar interventions if they know that workforce losses can be reduced, and productivity increased. Therefore, this intervention might be acceptable and transferrable to other workplace settings, like privately owned companies, and could make a real-world difference. However, due to the considerable limitations within this study, much more research is needed to become confident in the effectiveness of Prevail.
Finally, from a personal perspective, although many organisations, including the NHS, frequently mention their plans to support staff wellbeing, these are often not reflected in outcomes from staff satisfaction surveys. It makes me concerned that staff wellbeing could be seen as a tick-box exercise rather than a priority for employers. As Prevail was successfully conducted within a government organisation, I think it could be possible to implement a similar intervention with NHS staff, who would not only benefit from reduced self-stigma, but also increased support to seek help when needed.
Statement of interests
Gray, N.S., Davies, H., Brad, R. et al. (2023) Reducing sickness absence and stigma due to mental health difficulties: a randomised control treatment trial (RCT) of a low intensity psychological intervention and stigma reduction programme for common mental disorder (Prevail). BMC Public Health 23, 1324. https://doi.org/10.1186/s12889-023-16200-x
Dewa, C. S., Loong, D., Bonato, S., & Joosen, M. C. (2015). The effectiveness of return-to-work interventions that incorporate work-focused problem-solving skills for workers with sickness absences related to mental disorders: a systematic literature review. BMJ Open, 5(6), e007122.
Hanisch, S. E., Twomey, C. D., Szeto, A. C., Birner, U. W., Nowak, D., & Sabariego, C. (2016). The effectiveness of interventions targeting the stigma of mental illness at the workplace: a systematic review. BMC Psychiatry, 16(1), 1-11.
Henderson, C., Evans-Lacko, S., & Thornicroft, G. (2013). Mental illness stigma, help seeking, and public health programs. American Journal of Public Health, 103(5), 777-780.
Nigatu, Y. T., Liu, Y., Uppal, M., McKinney, S., Rao, S., Gillis, K., & Wang, J. (2016). Interventions for enhancing return to work in individuals with a common mental illness: systematic review and meta-analysis of randomized controlled trials. Psychological Medicine, 46(16), 3263-3274.
Stansfeld, S. A., Fuhrer, R., & Head, J. (2011). Impact of common mental disorders on sickness absence in an occupational cohort study. Occupational and Environmental Medicine, 68(6), 408-413.
World Health Organization (2022, June). Mental disorders. Retrieved September 2023.