- Open Access
Interventions to reduce the stigma of mental health at work: a narrative review
Psicologia: Reflexão e Crítica volume 36, Article number: 14 (2023)
While there are reviews of the literature on mental health stigma reduction programs, very few have focused on the workplace. Objective: We sought to identify, describe and compare the main characteristics of the interventions to reduce the stigma towards mental health at work.
The search of original articles (2007 to 2022) was carried out in the Web of Science Core Collection and Scopus databases, selecting 25 articles from the key terms: 1. Stigma, 2. Workplace, 3. Anti-stigma intervention/program, 4. Mental health. Results: These interventions can be effective in changing the knowledge, attitudes, and behaviors of workers towards people with mental health problems, although further verification of these results is needed as they are limited to date.
Discussion and conclusion
Interventions to reduce stigma in the workplace could create more supportive work environments by reducing negative attitudes and discrimination and improving awareness of mental disorders.
Stigma towards people with mental health problems
Stigma and discrimination related to mental health are global and multifaceted problems. The impact of experienced and anticipated discrimination is severe, impacting different aspects, such as poor access to health services, reduced life expectancy, exclusion from higher education and employment, and victimization, among others (Clement et al., 2015; Fox et al., 2018; Lawrence & Kisely, 2010; Sharac et al., 2010). For most people, these consequences are worse than the experience of the mental disorder itself (Gronholm et al., 2017). In addition, stigma and discrimination can lead to social isolation, low self-esteem, reluctance to seek treatment, and social rejection (Aakre et al., 2015; Corrigan et al., 2011; Knifton et al., 2009). These consequences are interrelated, increasing mental health difficulties for individuals who may experience high-stress levels while living with the constant threat of being stigmatized (Link & Phelan, 2006). It is estimated that stigmatizing attitudes and behaviors are present in 40% to 70% of people in Latin America (Mascayano et al., 2016).
As defined initially by Goffman (1963), stigma is a profoundly discrediting and isolating process of differentiation, othering, and discrimination toward a person who receives a socially devalued label. In the case of people who stigmatize, it can be understood as a combination of problems of knowledge (ignorance), attitudes (prejudice), and behavior (discrimination) (Thornicroft et al., 2008).
Stigma is a multi-component construct that involves processes of labeling, stereotyping, prejudice, social exclusion, loss of status, and discrimination, all within a context of differential power between the stigmatized and stigmatized groups (Link & Phelan, 2001). Stigma is also far-reaching and can be proximal to the person experiencing a problem, such as prejudice in intimate relationships, or it can take a more distal form, such as structural discriminatory laws and practices that exist in organizations and governments (Bos et al., 2013; Cook et al., 2014; Thornicroft, 2006).
Stigma is experienced in various contexts, including the workplace, and includes public and self-stigma elements (Malachowski & Kirsch, 2013).
Actions to reduce stigma towards people with mental health problems
Considering its effects, stigma reduction appears to be an imperative and priority public health need that requires mitigation. According to Gronholm et al. (2017), public health programs to reduce discrimination and stigma should be based on a series of decisions: the scope of mental disorders to include, explicitly or implicitly; the level of intervention, whether structural, interpersonal, or self-stigma; the group to intervene, whole population versus choosing target groups, and if opting for the latter, which groups are priority targets in terms of frequency and/or severity of the mental health problem; what focus an intervention should have for a given group and level; and how to evaluate impact.
Strategies to reduce stigma have been categorized in terms of education (replacing myths about mental disorders with accurate knowledge), contact (using direct or indirect interactions with people who have a diagnosis of mental disorder), and protest (organized groups demand changes in stigmatizing attitudes and representations of mental disorder) (Corrigan & O'Shaughnessy, 2007; Stuart et al., 2012).
Contact as education is a widely used intervention strategy (Gronholm et al., 2017; Knifton et al., 2009); however, the most successful programs are multi-component; although they employ educational strategies, they are not limited to them but favor daily contact with people with severe mental disorders and, some, also consider the development of social interaction skills (Knaak et al., 2014; Thornicroft et al., 2016). On the other hand, leading approaches to reduce self-stigma use interventions that increase coping skills, self-esteem, empowerment, hope, subjective perception of recovery, and help-seeking behavior in those affected (Alonso et al., 2019; Mittal et al., 2012). Stangl et al. (2013) have suggested that these strategies address multiple domains and levels of stigma, from an ecological model, to enrich the perspective of analysis on interventions.
One context of intervention to reduce stigma is the workplace, which, in line with what the ecological model posits, implies recognizing that for its reduction, work must be done at the individual levels -microsystem- as well as the group and interactive context -mesosystem-. Following this line of argument, Stuart (2004) highlights as a strategic guideline for addressing stigma the identification of the employment and workplace experiences of people with mental health problems to describe the extent and nature of stigma, as well as the social and organizational characteristics (such as policies, procedures, management structures or programs) that promote or prevent its occurrence in the workplace.
The impact of weak mental health at work is widely recognized and involves work losses associated with absenteeism, presenteeism, and turnover, with a high economic cost to organizational systems (Czabała et al., 2011; Hanisch et al., 2016). For the same reason and given the high prevalence of mental health problems in both the general and working population, the workplace is increasingly being recognized as an important target for mental health promotion, prevention, and intervention (Malachowski & Kirsh, 2013), something that implies necessarily considering interventions with workers.
Unfortunately, research on the effectiveness of interventions to reduce stigma at work is limited; mainly, educational strategies and direct contact with people who have experienced a mental disorder are used, and some of these have been found to reduce stigma, although the evidence presented is not entirely conclusive (Corbière et al., 2009; Malachowski & Kirsh, 2013; Szeto & Dobson, 2010). Because of this, there is a need to understand better the strategies and their effectiveness in combating stigma in the workplace (Corrigan & Fong, 2014).
Relevance of interventions to reduce stigma in the workplace
Szeto and Dobson (2010) provide two arguments for the importance of studying interventions to reduce mental health stigma in the workplace. The first is the low awareness rate of stigma in these contexts, considering that awareness or recognition does not necessarily equate to understanding or comprehension. Interventions could complement broader efforts to reduce stereotypes, prejudice, and discrimination toward those experiencing a mental disorder by increasing awareness and providing more information on a sustained basis. A second argument comes from research in Social Psychology; a subject's appraisal varies as a function of context (Barden et al., 2004; Rudman & Lee, 2002). The literature suggests that the knowledge and information learned as part of public anti-stigma campaigns are related to the context in which they were learned. Positive, counter-stereotypical representations of those experiencing a mental disorder may not be activated in the workplace, as this was not the context in which this information was acquired (Szeto & Dobson, 2010).
In the same vein, Gawronski et al. (2010) have suggested that counter-attitudinal information delivered as part of an intervention should be given in multiple contexts, thus eliminating the contextual dependence on this information. Similarly, Krupa et al. (2009) have argued that stigma processes are sensitive to and derived from the context and the social relationships embedded within them. These authors have also found that assumptions made in the literature about general stigma may not be operative within the work context.
Thus, the development and implementation of effective stigma reduction programs specifically designed for the workplace are of great importance. While public efforts to reduce stigma have yielded mixed results (Corrigan & Shapiro, 2010; Szeto & Dobson, 2010), developing strategies tailored to particular contexts, such as the workplace, may be a more promising route to stigma reduction. On the other hand, participation in stigma reduction programs, for example, in human resource development, could be mandatory in an organizational setting, making it more time- and information-intensive (Hanisch et al., 2016).
This review is justified by some of the arguments presented, particularly the importance of the context in which stigma arises and can be changed, the limited knowledge of stigma and its nature in the workplace, as well as the author’s recognition of the promising feasibility of stigma-reducing interventions tailored to specific contexts such as work and organizations.
The current study
Based on the above background, an important challenge still pending is to determine the characteristics of interventions aimed at reducing the stigma towards mental health problems in the work context. Therefore, this review seeks to identify, describe and compare the primary interventions to reduce mental health stigma in the workplace, at the micro and meso level. It is also expected to detect some research gaps and provide some recommendations for improvement. We searched for articles between 2007 and 2022 and the geographical scope of these articles was only conditioned by the search languages English and Spanish. The aim of the study fits a narrative review model as we aim to approach a broad range of issues within a given topic (Onwuegbuzie & Frels, 2016), which in this case are interventions to reduce mental health stigma at work. Furthermore, our study corresponds to the narrative review subcategory "general literature review" which provides a review of the most important and critical aspects of current knowledge on the topic (Onwuegbuzie & Frels, 2016).
A narrative review of the literature was conducted, which is defined as a “written document that critically reviews the relevant literature on a research topic, presenting a logical case that establishes a thesis delineating what is currently known about the subject” (Machi & McEvoy, 2022, p. 1). Corresponding to the subcategory "general literature review", this narrative review was conducted following the quality guidelines established by Baethge et al. (2019). The search for original articles from January 2007 to August 2022 was carried out in the Web of Science Core Collection and Scopus databases. It was decided to work with these databases because they ensure a wide variety of articles of scientific impact. The approximate starting period of the search was defined by reference to Szeto and Dobson (2010), who formulated one of the first reviews on the topic with an emphasis on the pioneering Mental Health First Aid Programme (2007) as a joint international effort to reduce stigma towards mental health problems including the workplace context. As stated above, the geographical scope of the search was only conditioned by the search languages, which were English and Spanish. The key terms used in the title, abstract, and keywords sections were: 1.- Stigma; 2.- Workplace; 3.- Anti-stigma intervention/program; 4.- Mental health. These terms were combined with logical functions and operators using the “OR, AND & NOT”, specific for each search engine, to reduce and specify the resulting articles. Thus, 154 articles were found in both databases, 74 in Web of Science Core Collection and 80 in Scopus. By discarding duplicates, this number was reduced to 130, and 22 articles were selected for this narrative review. Three articles that met the inclusion criteria were added and cited in the studies by Malachowski and Kirsh (2013) and Hanisch et al. (2016). Figure 1 is the flow chart of the search performed.
The following process was carried out to select the studies: reading the title and abstract, reading the full text, and selecting the articles to be included. Regarding the inclusion criteria, the main parameter followed was the type of interventions to reduce mental health stigma in workers, specifically the selection of empirical studies referring to workplace interventions to reduce mental health stigma in workers. Regarding exclusion criteria, case studies, dissertations, letters to the editor, and duplicate records were eliminated from the analysis. All these steps were followed to safeguard the quality of the literature search for the narrative review (Baethge et al., 2019). Finally, articles in a language other than English or Spanish were not considered.
Twenty-five empirical studies were included, which were characterized and are presented in the following section (Dimoff et al., 2016; Dobson et al., 2021; Gould et al., 2007; Griffiths et al., 2016; Hamann et al., 2016; Hanisch et al., 2017; Hossain et al., 2009; Jensen et al., 2016; Jorm et al., 2010; Knifton et al., 2009; Krameddine et al., 2013; Kubo et al., 2018; Lunasco et al., 2010; Moffitt et al., 2014; Moll et al., 2015; Moll et al., 2018a, 2018b; Moll et al., 2018a, 2018b; Nishiuchi et al., 2007; Oakie et al., 2018; Quinn et al., 2011; Reavley et al., 2018; Shann et al., 2019; Svensson & Hansson, 2014; Szeto et al., 2019; Tynan et al., 2018). The analysis plan was underpinned by selecting, reading, synthesizing, and exposing these studies on interventions to reduce mental health stigma in the workplace.
From the selected articles, it was possible to establish a series of categories of analysis that allowed the characterization of the interventions. These categories are 1) Scope of application; 2) Design proposal and intervention modality; 3) Objective of the intervention; 4) Impact of the intervention. The analysis of each dimension is presented below; the specific results are included in Table 1.
Scope of application
This category groups the target population or participants and the private or public sector in which the intervention is applied. It also refers to the work and/or organizational setting in which it is implemented. The setting is the sector of activity or organizational environment (in terms of processes or structures) where the intervention occurs. Finally, the category includes the country where the intervention takes place.
A review of the shared characteristics of this category reveals at least three attributes or dimensions that cut across these studies. On the one hand, there is a greater application of these interventions in the public sector compared to the private sector or the application in both sectors. In this line, of the 21 studies in which the sector to which the organizations belong is identified, 52% (N = 11) correspond to the public sector, while 29% (N = 6) to the private sector and 19% (N = 4) to studies applied in both. The participants in the interventions are diverse in terms of occupations and the workforce to which they belong. This ranges from workers performing operational or functional tasks in various sectors of activity to people in managerial or supervisory roles. Detailing these data in descending order, of the 25 studies analyzed, 20% (N = 5) considered workers in managerial or supervisory positions, 20% (N = 5) corresponded to health professionals, another 16% (N = 4) were identified broadly as workers in different organizations, and 12% (N = 3) were identified as workers in various organizations, 12% (N = 3) were civil servants, 8% (N = 2) were military, another 8% (N = 2) included workers in the industrial manufacturing sector. In smaller proportions, studies were found with police officers (4%, N = 1), firefighters (4%, N = 1), first responders (4%, N = 1), and school teachers (4%, N = 1).
Concerning work settings, there is a greater presence of focused interventions in public government (16%, N = 4), health (16%, N = 4), industrial manufacturing (12%, N = 3), business in different sectors of activity (12%, N = 3) and police and public protection services (12%, N = 3). This is followed by studies in education and telecommunications (8%, N = 2) and military (8%, N = 2). The lowest presence of studies is in the agriculture sector (4%, N = 1), construction sector (4%, N = 1), non-governmental organizations (4%, N = 1), and unidentified organizational settings (4%, N = 1). Finally, Anglo-Saxon countries show greater development and implementation of these interventions, especially Canada (32%, N = 8), Australia (20%, N = 5), and the United Kingdom (20%, N = 5). Other developed countries such as Japan (8%, N = 2), Germany (4%, N = 1), Denmark (4%, N = 1), Sweden (4%, N = 1), and developing countries such as South Africa (4%, N = 1) also have actions along these lines. It is noteworthy that, of the Anglo-Saxon countries, the United States of America has the lowest number of studies (4%, N = 1).
Design proposal and intervention modality
The category refers to the type of methodological design, the modality or type of intervention most used, as well as the duration and frequency of the intervention.
Regarding methodological design, 52% of the studies analyzed (N = 13) are randomized controlled clinical trials. They are followed by studies of pre-experimental design (pre-post-test in one group) (40%, N = 10) and quasi-experimental design (one experimental and one control group, non-randomized, with pretest and posttest evaluation) (8%, N = 2). Another relevant aspect is that most of them are training programs that include a wide diversity of characteristics, which can be systematized into some common categories: (a) They are interventions that include mental health literacy, and their format is usually standardized and manualized; (b) The interventions encourage the recognition of mental health risk behaviors, which in some cases takes the form of job induction; c) The importance of taking responsibility for mental health problems and possible discrimination or stigma is emphasized; d) Direct contact strategies are used to a lesser extent (such as narratives of service users), experiential group learning, peer support, didactic teaching approaches and the use of interactive resources; e) In line with the above, there is a growing trend in the incorporation of new technologies in the training actions implemented, whether in e-learning format, training based on digital games, among other innovations.
There is also a marked predominance of the intervention known as MHFA (Mental Health First Aid) as part of the change initiatives implemented, which is present in 43.4% of the studies analyzed (N = 10). This intervention consists of a protocolized international training program based on standardized mental health literacy, with a knowledge and skills training modality that fosters recognizing mental health risk behaviors in others.
Finally, it was noted that stigma reduction training in the different studies ranged from two hours to multiple sessions that may extend over several weeks.
Objective of the intervention
Describes the goal that the intervention is intended to achieve and therefore involves establishing the focus(s) of the intervention in terms of the type of disorder and expected change (e.g., outcome measures such as attitudinal change, behavioral change, etc.).
At least two common core aspects characterize this category. First, it focuses on different disorders towards which to reduce stigma: a) Interventions with a focus on general mental health, these are the most numerous and reach 64% of the studies analyzed (N = 16); b) Interventions directed toward depressive and anxiety disorders, with 28% of the studies (N = 7); c) Interventions with a focus on post-traumatic stress disorder and stress, with 8% (N = 2). Secondly, although all the studies analyzed aim to reduce stigma towards mental health problems in work contexts, the specific objectives, and expected changes are mixed in the studies, making it difficult to classify them. In general terms, the researches aim to: a) Increase mental health literacy, either in general or in specific disorders, increasing the level of knowledge in this regard; b) Increase positive attitudes and decrease prejudices and stigmatizing attitudes; c) Increase orientation and support behaviors towards those who present mental health problems (positive behavioral intention, confidence, and self-efficacy); d) Increase communication skills and recognition of mental health problems; e) Increase help-seeking behaviors in those who have mental health problems. In addition, some studies point out a general objective to promote mental health at work to increase the well-being of workers.
Impact of the intervention
Finally, this category refers to the evaluation of the impact of the intervention in terms of the results obtained through indicators that assess its effectiveness in reducing stigma. It also includes an assessment of their potential limitations.
In this category, the research results were classified into five subcategories: 1) A total of 20 studies (80%) show an increase in positive attitudes and a reduction in stigmatizing attitudes (prejudice) towards mental health problems, in some cases general and others specific. Only two reports mixed results, i.e., a combination of expected and unexpected changes in the variables evaluated; 2) 69.56% (N = 16) indicate that participants increased their knowledge in mental health (in general and in particular disorders); 3) 10 studies (43. 47%) report changes in confidence and self-efficacy in actions to help people with mental health problems; 4) 36% (N = 9) showed increased help-seeking behaviors, as well as mental health promotion, of which only one reports unexpected changes, in one of the outcome measures used; 5) Only two investigations (8.69%) report changes in intention and attitude to support, and support-seeking, one in positive terms and another with mixed results.
Two of the 25 studies analyzed report changes maintained at six months (changes in knowledge, reduction of stigma, and increase in self-confidence in helping) and two years (improvement in knowledge and self-confidence in helping), respectively. From this, it can be deduced that the changes maintained are more attitudinal and knowledge nature but not of a behavioral nature.
In terms of limitations, the main ones are the study design in terms of the non-inclusion of the control group in the case of pre-experimental designs (pre-post-test in one group) (40% of the studies analyzed, N = 10) and the short longitudinal nature and lack of control in the case of quasi-experimental designs (one experimental and one control group, non-randomized, with pretest and posttest evaluation) (8%, N = 2), this is not the case for studies based on the randomized controlled clinical trials design (52%, N = 13), which is more like a strength. Other limitations identified were relatively small sample size (20%, N = 5), the studies was restricted to one type of organization (40%, N = 10), the studies attrition (24%; N = 6), evaluation using self-rated questionnaires (32%; N = 8), the short-term follow up period (20%; N = 5), the fact that intentions may not translate into actual behaviors (8%; N = 2), ability to identify the use and impact of training (8%; N = 2), lack of qualitative data to understand the changes (8%; N = 2), and participants might have been presensitized in public stigma reduction efforts (4%; N = 1).
This is one of the few reviews on stigma in the workplace. The objective was to identify and describe the main characteristics of interventions to reduce mental health stigma in the workplace.
It highlights the scarcity of interventions aimed at these purposes; only 25 investigations were included. This result reaffirms the need for studies in this line of work. Organizational context is an environment where interventions for stigma reduction can be successful considering its nature, duration, intensity, and contextual specificity, among other factors, pointed out by different authors (Hanisch et al., 2016; Krupa et al., 2009; Szeto & Dobson, 2010).
Regarding the characteristics of the interventions, the military, government, healthcare, and manufacturing contexts, with greater representation of the public sector, are where a greater number of these programs have been developed. This shows the concern and investment of resources in improving the mental health of public servants, as well as the need to include these interventions in other workplaces beyond public services.
As has been found in several reviews on stigma, not only in the workplace, Anglo-Saxon and developed countries are the ones leading interventions to reduce it (Mehta et al., 2015), while research is needed in developing countries because considering the cultural aspects of the phenomenon (Mascayano et al., 2016; Yang et al., 2007). Stigma is a social phenomenon and cultural aspects shape it. For example, in Latin American countries, stigma is related to gender roles; women who cannot exercise the role of caregiver and men the role of provider, linked to a patriarchal culture, tend to be more stigmatized (Mascayano et al., 2016; Yang et al., 2014). In general, stigma reduction programs are developed in Western countries, as was seen in this review, which cannot always be introduced in places with other values and material resources (Mascayano et al., 2020). The study by Jorm et al. (2010) was the only one conducted in a middle-income country such as South Africa. In this study, the content of the Mental Health First Aid training course was adapted to the particular context, detecting the most frequent mental health problems in young people in schools, establishing contextualized approach plans and using the Department of Education and local children's services as a strategic partner. It is, therefore necessary to conduct research in developing countries and determine which components need to be modified to take into account the context and which can be used without major changes.
Intervention formats are diverse in the number of hours and strategies used. Regarding duration, interventions to reduce stigma in other populations (university students, health professionals, and patients) have found the same, i.e., the extension is variable and the minimum amount of time required to achieve effectiveness is unclear (Gronholm et al., 2017; Morgan et al., 2018). Therefore, it is important to make progress in determining the number of hours that an intervention should take to obtain positive results. This time is related to the strategies used and their modality of implementation. In terms of strategies, the Mental Health First Aid program, which has as one of its focuses on the reduction of stigma, but focuses on providing support to co-workers who have a mental disorder, stands out. From this perspective, programs to reduce stigma in the workplace focus primarily on improving workers' mental health rather than on other components of the organizational system, such as users. In the health care setting, interventions to reduce stigma have among their main target populations workers; however, their focus is on how they care for consultants (Henderson et al., 2014; Knaak & Patten, 2016). Interestingly, these two types of interventions, directed towards staff and users, establish a common ground to enhance, in workplaces where people with mental health problems are frequently attended, an intervention that serves both purposes, i.e., to reduce stigma towards both workers and users.
As workplace interventions are oriented toward workers, they have an important educational component that facilitates the participant to recognize mental health problems to seek and provide help. Although interventions to reduce stigma in other groups also use mental health literacy as a strategy (Bingham & O'Brien, 2018; Stuart et al., 2012), they often use contact because of the positive effects it has on reducing stigma (Henderson & Gronholm, 2018; Mascayano et al., 2015; Thornicroft et al., 2016). Their lesser use in workplace interventions, on the one hand, reaffirms that stigma reduction is not the central focus of interventions and, on the other hand, shows that other strategies, such as skills development, can be effective. Programs in the work context include skills training to recognize and support co-workers with mental health problems. The emphasis given to skills development could be an important contribution to programs to reduce stigma among healthcare workers who, as they are user-facing, primarily use education and contact as strategies (Fokuo et al., 2017; Knaak & Patten, 2016).
Most interventions focus on a specific disorder rather than mental disorders. Targeting allows for the delivery of information atingent to a condition, which increases the effectiveness of education (Stuart et al., 2012), and in this particular case, increases strategies for providing support to a co-worker.
The design of the interventions includes pre- and quasi-experimental, and most occupy a randomized clinical trial (RCT) design. However, pre- and quasi-experimental designs together are almost as numerous as experimental designs. This is relevant as an RCT maximizes the control of variables that could interfere with the results (Gronholm et al., 2017); therefore, it is important to continue advancing in the use of more rigorous methodological designs such as this one.
The main outcome measures focus on increasing mental health knowledge and confidence in providing help, changing attitudes toward help-seeking and people with mental disorders, and proxy measures of behavioral change such as decreasing social distance. In general terms, the interventions are effective, i.e., they generate significant changes in these variables. However, this area of stigma reduction, like others, lacks measures of direct behavioral change (Corrigan & Shapiro, 2010; Stuart et al., 2012), which is a limitation because although knowledge and attitudes contribute to determining behaviors, the relationship is not direct, so their modification does not imply a real behavioral change (Corrigan & Shapiro, 2010; Stuart et al., 2012). Perhaps, one of the main challenges of research on this topic is to incorporate behavioral change measures, considering the practical difficulties that exist for their implementation in natural contexts, such as work. On the other hand, outcome variables are individual. For some years, it has been considered that organizational aspects such as culture and structure play a role in the formation of attitudes and behaviors, so it is recommended to consider them when intervening (Cook et al., 2014; Henderson et al., 2014), especially when considering stigma from an ecological model.
Including organizational variables is a challenge for workplace interventions because although, in general, these programs are favorable and show that there is an improvement in knowledge, attitudes, and supportive behaviors towards people with a psychiatric diagnosis (Hanish et al., 2016), so far the workplace is only considered as a setting, not including a decided organizational look at it, being an important future challenge (Thomson & Grandy, 2018). Some of the studies analyzed, to give sustainability to changes in follow-up, emphasize the critical character of different factors such as the nature of the work environment, the collective and team disposition towards mental health, the organization's capacity to address these problems, the use of contextually relevant examples, support from all levels of the organization, among others (e.g., Moll et al., 2018a, 2018b; Shann et al., 2019).
It appears that the effect of the interventions is sustained over time. However, this result is very incipient due to the scarcity of studies that contemplate follow-up, so research is needed to determine the medium- and long-term effects of the programs (Gronholm et al., 2017; Thornicroft et al., 2016). On the other hand, in addition to the design limitations of the interventions highlighted in the results (particularly in pre-experimental and quasi-experimental designs), there are also others that cut across the different studies, notably the relatively small sample size, the restricted type of organization considered, the studies attrition, the evaluation using self-rated questionnaires and the short-term follow up period, among others.
In summary, it is possible to point out that the main challenges and recommendations for research on interventions to reduce mental health stigma in work settings are the following: the scarcity of research on cultural aspects specific to developing and undeveloped countries, which needs to be strengthened in order to identify key factors for replicability and effectiveness; the importance of determining the duration of an intervention to achieve positive results; the need for interventions that serve both to reduce stigma towards those who work and towards the users/clients of the organization; the emphasis on skills development in these interventions to reduce stigma towards those who work and towards the users/clients of the organization; the emphasis on skills development could be an important contribution to programmes to reduce stigma with health workers in direct contact with users; it is recommended that further progress be made in the use of more rigorous methodological designs such as randomized controlled clinical trial design; it is essential to incorporate measures of behavioral change to estimate the impact of interventions, as well as variables of an organizational nature that provide the context and psychosocial support for such changes; more research is also needed on the medium and long-term effects of programmes focused on the workplace.
One of the limitations of this review was that only articles in Spanish and English were considered, so any other contributions in the area were not included. On the other hand, there is a disparity of methodological designs, making it difficult to compare the results; also, not all studies present indicators of the changes achieved, such as effect size. For this reason, it is important that future research advances using rigorous methodological designs that show the magnitude of the results achieved.
This review established four domains of analysis of interventions to reduce stigma in the workplace. Based on these criteria, it was possible to highlight common attributes among the different interventions, which facilitated their characterization and understanding, thus contributing to the advancement of this field of knowledge.
The workplace is a privileged space to intervene in the reduction of stigma because it has a captive population with which it is possible to work from an ecological model in programs that consider intervention strategies by levels, which would favor individual changes likely to apply in the context where they were generated, and changes in the organization to make it more inclusive.
Availability of data and materials
The data that support the findings of this review are available from the corresponding author upon reasonable request.
Mental Health First Aid
Randomized clinical trial
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Ramírez-Vielma, R., Vaccari, P., Cova, F. et al. Interventions to reduce the stigma of mental health at work: a narrative review. Psicol. Refl. Crít. 36, 14 (2023). https://doi.org/10.1186/s41155-023-00255-1
- Social stigma
- Interventions to reduce stigma
- Mental health