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Examples of Holistic Good Practices in Promoting and Protecting Mental Health in the Workplace: Current and future challenges
Kelly Calliope Sivris, MSc, Stavroula Leka, PhD
PII: S2093-7911(15)00058-X
DOI: 10.1016/j.shaw.2015.07.002
Reference: SHAW 107
To appear in: Safety and Health at Work
Received Date: 16 March 2015 Revised Date: 10 July 2015 Accepted Date: 12 July 2015
Please cite this article as: Sivris KC, Leka S, Examples of Holistic Good Practices in Promoting and Protecting Mental Health in the Workplace: Current and future challenges, Safety and Health at Work (2015), doi: 10.1016/j.shaw.2015.07.002.
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Title Page
Examples of Holistic Good Practices in Promoting and Protecting Mental Health in the Workplace: Current and future challenges
Running title: Workplace mental health promotion
Kelly Calliope SIVRIS, MSc Email: kelly. sivris@nottingham. ac. uk
Stavroula LEKA, PhD
Centre for Organizational Health & Development (COHD) A World Health Organization Collaborating Centre in Occupational Health Faculty of Medicine & Health Sciences Yang Fujia Building Jubilee Campus University of Nottingham Wollaton Road, Nottingham NG8 1BB UK
Original Article
Examples of Holistic Good Practices in Promoting and Protecting Mental Health in the Workplace: Current and future challenges
Kelly Calliope Sivris, Stavroula Leka
Centre for Organizational Health & Development - A World Health Organization Collaborating Centre in Occupational Health School of Medicine, University of Nottingham
A B S T R A C T
Background: While attention has been paid to physical risks in the work environment and the promotion of individual employee health, mental health protection and promotion have received much less focus. Psychosocial risk management has not yet been fully incorporated in such efforts. This paper presents good practices in promoting mental health in the workplace in line with World Health Organization (WHO) guidance by identifying barriers, opportunities and the way forward in this area.
Methods: Semi-structured interviews were conducted with seventeen experts who were selected on the basis of their knowledge and expertise in relation to good practice identified tools. Interviewees were asked to evaluate the approaches on the basis of the WHO model for healthy workplaces.
Results: The examples of good practice for Workplace Mental Health Promotion (WMHP) are in line with the principles and the five keys of the WHO model. They support the third objective of the WHO comprehensive mental health action plan (CMHAP) 2013-2020 for multi-sectoral implementation of WMHP strategies. Examples of good practice include the engagement of all stakeholders and representatives, science-driven practice, dissemination of good practice, continual improvement, and evaluation. Actions to inform policies/legislation, promote education on psychosocial risks, and provide better evidence were suggested for higher WMHP success.
Conclusion: The study identified commonalities in good practice approaches in different countries and stressed the importance of a strong policy and enforcement framework as well as organisational responsibility for WMHP. For progress to be achieved in this area, a holistic and multidisciplinary approach was unanimously suggested as a way to successful implementation.
Keywords: mental health promotion, WHO model for healthy workplaces, WHO mental health action plan, good practices, national level
1. Introduction
Mental health is incorporated as an important element in the definition of health provided by the World Health Organization (WHO, 1948): "A state of complete physical, mental and social wellbeing and not merely the absence of disease". This definition focuses on a holistic approach, which brings together physical, mental and social health. It pertains to two main ideas: there is no health without mental health, and health is not just the absence of illness. Mental health has been conceptualised as 'a state of wellbeing' where the individual realises personal abilities, is able to cope with life's stressors, can be productive and contributes to the community [1-5]. Work-related determinants of mental health are
embedded in the physical and psychosocial work environment [6]. Psychosocial hazards in the workplace include aspects of work organization, design and management such as a heavy workload, lack of control, unsuitable job roles, poor interpersonal relationships, and lack of career prospects and development [7]. Quality of life, optimal health, mental health and wellbeing in the workplace are critical issues, considering the fact that people spend 15.7% to 25.4% of their time per year at work (OECD statistical facts on working hours with minimum 1381 working hours in a year for the Netherlands, and maximum 2226 working hours in a year for Mexico) [8].
As a result, WHO has stressed the urgency to advance mental health [9-11] due to the impact of mental ill health on individuals of any age [12,13], organisations and society overall. However, addressing mental health in the workplace has not received enough prioritization and it has been concluded that there is a gap between knowledge and policies (where available) and real-life practice, which needs to be analysed and managed [14,15]. Mental health in the workplace has been a 'Cinderella subject' for a long time; phenomenally accepted but practically neglected [16]. In recent decades initiatives to address this gap have been implemented either through workplace health promotion programmes or psychosocial risk management [15]. The WHO Comprehensive Mental Health Action Plan (CMHAP) 2013 states as implementation options to "Promote work participation and return-to-work programmes for those affected by mental and psychosocial disorders". And to "Promote safe and supportive working conditions, with attention to work organizational improvements, training on mental health for managers, the provision of stress management courses and workplace wellness programmes and tackling stigmatization and discrimination." [5].
1.1. Approaches to promoting mental health in the workplace
Workplace health promotion (WHP) and psychosocial risk management are two overarching approaches to improve employees' health, safety and wellbeing, which incorporate mental health promotion and mental ill health prevention [15,17]. WHP is a combination of various efforts from employers, employees, and the community in favour of maintaining wellbeing. These efforts include empowerment of individuals and resilience building, the development of personal health resources and the implementation of wellness programmes [18]. Mental health promotion is a basic part of WHP, which needs to be addressed in order to ensure employee wellbeing [4,19,20].
On the other hand, psychosocial risk assessment and management are vital ways to identify and control psychosocial risks in order to protect employees' physical and mental health. Psychosocial risk management in the workplace is underpinned by legislation in many countries [21]. Appropriate and adequate policy formulation for mental health protection and promotion considerably enhances the level of success for initiatives that include psychosocial risk management [15].
1.2. WHO initiatives
The WHO Healthy Workplaces Model (MHW) has been developed on the basis of the WHO global plan of action on workers' health (GPA) and is in line with the WHO CMHAP [2,5]. Specifically, the MHW stresses the importance of effective leadership, workplace mental health promotion (WMHP)/mental ill health prevention, strengthening evidence and research (evaluation and assessment). The model additionally stresses the importance of tackling psychosocial risks as they are highly linked to poor workplace mental health (WMH) [22], the provision of personal health resources in support of mental health, and enterprise community involvement, with a view to promote employee wellbeing and work-life balance from a wider perspective [2,20].
The MHW is based on five keys: leadership engagement, workers' involvement, ethics, continual improvement and integration. It proposes that the development of a healthy workplace should be underpinned by the engagement of key stakeholders including leaders, employees and their representatives [2,23,24]. Attention is paid to the importance of ethics and compliance with legislation as the first step of good practice [25]. The importance of evaluation and continual improvement is highlighted since adaptation in relation to new needs increases effectiveness [26]. The last key element is coherent and comprehensive integration as a vital part of an effective implementation [27].
1.3. Aims
The current study is guided by the key objectives of the WHO model for healthy workplaces/ the GPA for workers' health and the CMHAP. The aim of the study was to identify initiatives/tools, which are aligned with the five keys and process of the MHW, and gather knowledge and expertise on good practices on WMHP. The aim was to summarise commonalities across countries, highlight barriers that need to be tackled, and conclude on opportunities for future improvement. 2. Methodology
The study was structured in two parts and lasted 5 months in total. The first part included scientific and grey literature reviews to identify the initiatives. The second part was based on semi-structured interviews with experts with good knowledge of the identified initiatives.
2.1. Selection of initiatives
The current study aimed to support the development and establishment of the MHW audit tool for the WHO in order to assess progression towards healthy workplaces following the GPA and CMHAP objectives. Only initiatives/tools in line with the MHW have been included. Eleven good practice initiatives/tools for WMHP were selected. The authors attempted to provide a balanced perspective across countries and WHO regions; however, that was not always feasible due to lack of tools in some countries and/or WHO regions. The selection process was not exhaustive as tools at organisational level (single cases) were excluded. The aim was to gather a sufficiently representative number of initiatives, and identify good practices and commonalities amongst different countries in the WHO regions; investigate the way of promoting and protecting workplace mental health [28,29]. The results of the scientific and grey literature review were cross-checked with those of another study [28]. The final choice of initiatives was made according to the predefined criteria of inclusion. A literature search protocol was used, based on selection criteria for addressing WMH [30,31] including:
• Initiatives in line with the MHW
• Initiatives at national level
• Initiatives at sectoral and inter-organisational level (implemented by many organisations in the country)
• Focus on mental health promotion and mental ill health prevention
• Workplace focus
• No single interventions but holistic initiatives
• Already implemented
2.1.1. Search strategy
The search was conducted in two parts. The first part included electronic and library searches for the academic literature and both electronic and hard copies of the available material. The second part was the grey literature search, which was mainly performed by using online databases, search engines and websites (see below). After gathering all the required sources and information, a data synthesis was conducted in order to identify initiatives across WHO regions based on the protocol. Initiatives were identified in the Americas, the European region, the African region, the Western Pacific region, and South-East Asia, but none in the Eastern Mediterranean region. In addition, we tried to reduce reporting biases by avoiding duplicating studies while searching through multiple databases. We also tried to prevent biases stemming from the language barrier by trying not to exclude information in languages other than English [30].
2.1.2. Academic literature
The academic literature search was conducted in two parts. The first part included electronic searches, which were performed by using the following online databases for relevant articles (including internet based searches): Pubmed, Medline, Global Information Full Text (provided by the WHO), EBSCO, ApaPsyNET, ApaPsyInfo (OVID), Nexis, Applied Social Sciences Index and Abstracts (ASSIA), the Cochrane Library, the World Bank online Library, the Campbell Collaboration, Web of
Knowledge (Web of Science), African Index Medicus, Health and Safety Science Abstracts, EMBASE, National Electronic Library for Health, BMJ Group. The second part included electronic searches of the WHO's library, the University of Nottingham's library catalogue, and Google Scholar.
2.1.3. Grey literature
Regarding the grey literature, electronic searches were performed through the National Technical Information Service (NTIS), the OpenSIGLE, website, and Google Search Engine in order to identify available websites of promoted initiatives/tools. Relevant websites and databases including publications available within these sources were reviewed. In particular, websites from the WHO, the International Labour Organization (ILO), the International Commission on Occupational Health (ICOH), the UK Health and Safety Executive (HSE), Centres for Disease Control and Protection (CDC), the US National Institute for Occupational Safety and Health (NIOSH), the European Agency for Safety and Health at Work (EU-OSHA), and the European Trade Union Institute (ETUI) were reviewed. Searches also included the European Commission MISSOC Comparative Tables on Social Protection, materials from conference proceedings and internet pages of any additional relevant organisations identified through these searches.
2.1.4. Keywords
Specific keywords and terms were used throughout the search strategy which included: mental health, mental ill health, promotion, prevention, work-related stress, occupational stress, wellbeing, promotion, good practice, workplace, worksite, wellness, national, sectoral, level, social determinants of health, psychosocial, risk factors, hazards, risk assessment, risk management, community involvement, stress management, interventions, psychological, health, healthy, problems, burden, demands, working hours, work-life balance, conflicts, uncertainty, job insecurity, change, restructuring, working environment, working conditions, impact, (widely applied) organisational, emotional exhaustion, common mental disorders (CMDs), preventive tools, WHO, regions, member states, global, country.
All the keywords were flexibly combined, altered and/or truncated in order to serve the search needs. All the sources that came up due to these key terms were reviewed on the basis of their summary and/or abstract to check for relevance and compliance with the protocol. Additionally, reference lists were reviewed in order to identify any possible relevant citations and sources in support of the search strategy. The results of the scientific and grey literature review were cross-checked with those of another study conducted by members of the research team for the ILO [28]. This study involved a review and global survey with key stakeholders to identify initiatives of good practice in the area of WMHP at national level. It was encouraging to see that the findings of both studies showed considerable convergence. After carefully reviewing all results, the final choice of initiatives was made according to the predefined criteria of inclusion.
2.2. Semi-structured expert interviews 2.2.1. Participants
Seventeen semi-structured interviews were conducted with occupational safety and health (OSH) experts across WHO regions that have good knowledge of the selected eleven initiatives by having been involved in their development, implementation and evaluation. Purposive sampling was used, combined with snowball sampling at times, in order to ensure that the authors were able to interview people with the most suitable experience [30]. Due to limitations with respect to tools' availability, as mentioned above, the number of experts for each WHO region was not equal (e.g. there are many more initiatives in Europe contrary to Africa region). There was a fair balance between genders as there were nine male and eight female participants. The participants came from the United Kingdom, Italy, Belgium, Spain, the Netherlands, Finland, Poland, Canada, USA, Australia, Thailand, Japan, and Ghana. They had between 538 years of relevant work experience. The participants were highly knowledgeable experts with many years of experience in OSH and mental health in the workplace in the public and private sector. All experts were involved in the development, implementation and assessment stages of the tools.
2.2.2. Procedure
All the participants were recruited through an online process including an official contact letter/invitation. A standardised process was applied to minimise biases and ensure accuracy and consistency. All interviews were audio recorded and transcribed to avoid misinterpretations or missing data [30]. Ethics approval was seen before the commencement of data collection. All the participants were informed and debriefed about the purpose of the study, confidentiality and data storage based on the Data Protection Act (1998) [32].
2.2.3. Data analysis
Thematic analysis helped to identify themes amongst collected data. An inductive or bottom-up approach was employed in order to explore and understand the data [33]. The transcription process was based on conventions for convenience and accuracy. Analysis was conducted in depth with a latent-constructivistic approach, which ensured authenticity, transparency and trustworthiness [30,33,34]. After summarising the key points of all the transcripts, the creation of main codes was initiated [35,36].The codes were clustered under primarily coherent themes [37,38].
For the readers' convenience, the groups of experts have been abbreviated as follows: experts with OHS experience of 5-10 years (female/male) = F/M1, experts with OHS experience of 10-20 years (female/male) = F/M2, experts with OHS experience of 20-30 years (female/male) = F/M3, and experts with OHS experience of more than 30 years (female/male) = F/M4. 3. Results
3.1. Literature review
The search strategy included twenty databases, and concluded to a selection of eleven tools. Table 1 represents the list of the identified tools per country and WHO region while further details on each initiative are presented at Table 2.
3.2. Interviews
The thematic analysis highlighted four basic themes: a) good practices for WMHP at national level, b) responsibility for WMHP, c) barriers, and d) potentials for successful implementation. The themes consisting of sub-themes and including their descriptors are presented in Tables 3, 4, 5, and 6. 3.2.1. Good practices
Good practices were indicated as the first theme with five subthemes: participation and social dialogue, science/research into practice, a clear action plan, shared knowledge, and evaluation (Table 3). All the responses, which indicated a level of success with respect to implementation, were coded as positive for this theme.
The first subtheme, which is about participation and social dialogue for all the stakeholders, was prevalent among all participants. These actions incorporate the full engagement of all, "safety and health [experts], labour [employees] and representatives of labour, management of all level... put them all together in the same room and say we are all after the same main point" (M3, USA), "a cross-sectional engagement" (M4, Canada). Employees' empowerment has been agreed as a vital element for success, "take their role in the company" (F4, the Netherlands); "top management [has to] give feedback... and [people need] to show empathy to each other" (M1, Japan).
The science/research into practice subtheme was agreed as a matter that raises difficulties, but as the only pathway to successful implementation. "Yes [organisations] may expect your [approach] to be based on a good psychological theory, but it is the application of that theory in the real world... and you have to be careful with terminology as stress is not [easily] recognizable [and understood]" (M1, UK). Correct understanding of science can be a challenge for organisations; misunderstanding leads to "missing information" (M3, Belgium). Scientific knowlegde needs to be presented in an apt way without losing value; "have one 'leg' in science/knowledge and the other one in practice... knowledge activism" (M3, Spain).
A clear action plan includes elements such as "a development circle" (M1, UK), "careful planning" (F2, Australia) to avoid wasting money and the need for full awareness of the problem in order to choose
actions that "meet the identified needs" (M4, Canada). It is helpful to focus on "a general methodology to be able to meet the majority of population" (M3, Spain), but "being specific" to solutions and "never transfering" solutions is dramatically significant (F4, the Netherlands). Tools need to be "tailored by sector" (M3, Italy).
"Continual improvement" and adaptation through evaluation have been outlined as important elements. When "a rational plan" does not work (F4, the Netherlands), adaptation is the way to solutions (M3, USA). All of the tools incorporate plans and actions of evaluation aiming at sustainability. Three out of eleven tools are going to be evaluated with all the rest having been already fully or partially evaluated including either formal or informal evaluations.
3.2.2. Responsibility
This theme was supported by three subthemes: current trends, drivers, and impact (Table 4). With respect to current trends, there was an agreement that "the emphasis has changed from organisational responsibility to individual responsibility" (M1, UK). The message currently coming out from many governments and organisations is that "individuals have the responsibility for their own mental health and they need to be more resilient" (M3, USA). Moreover, there is also the issue of "MH seen as a peripheral issue" (F3, the Netherlands) for organisations that "do not see why they should be doing it" (M1, UK) and do not understand the high impact of primary prevention.
Drivers for WMHP mainly included the need of organisations to find ways to comply with the law as part of their social responsibility, but also tackle the persistent numbers of work-related injuries and illness. "Legal obligation... led companies to invest more in the prevention of workers' mental health" (M3, Italy). Organisations will seek tools in order to "meet the needs" for a particular sector rather than doing "philanthropy" (M1, Ghana); "decline in productivity" (M3, Italy) creates a need for actions that will decrease the number of work-related illness and injuries.
The impact of organisational responsibility for WMHP has been stressed as more important concerning prevention and the level of success than individual responsibility; "it is ok to think about health risk assessment and what are the individual challenges", but the responsibility should "not start from there" (M3, Belgium). The organisational environment will affect "every single employee, whether they know it or not, whether they have a health condition or not, and it is those organisational changes that have the greatest opportunity for primary prevention" (M3, USA).
3.2.3. Barriers
The theme of barriers was based on responses in relation to difficulties in developing and implementing WMHP tools. Therefore, all the asnwers referring to obstacles, resistance, difficulties, and constraints were coded positive for this theme (Table 5). The subthemes, which support this theme, are: knowledge deficiency, financial constraints, cultural gaps, time pressure, and fear.
Knowledge deficiency was supported by the fact that many middle managers have a lot of responsibilities, but they are not "best qualified to deliver" and this "blocks good practice" (M1, UK) because "low level of awareness of the impact of employees' mental illness is the main barrier" (M3, Italy). People finish their education, but they "have never heard about OSH prevention" (M3, Belgium).
Financial constraints were illustrated through the burden of "upfront investments" (M3, USA), the financial prerequisite of continual improvement and the shift towards constant cost reduction without any added productivity value. There was a consensus on the fact that "insufficient investment" has an impact on processes and makes implementation "less successful" (F4, the Netherlands). In particular, when "there is not much money and the [financial] crisis is present", organisations will "not put money [on evaluation]" (F2, Finland) and "every time there is a financial crisis... [WMHP] is the first to be cut, because organisations are not [obliged] to do it" (M1, Ghana).
Cultural gaps include barriers such as immature organisational cultures that lack the right mentality and background to engage in WMHP. For example, in some organisations "there is some form of hierarchy in getting things done" (M1, UK), and "workers do not talk free... there is an imbalance of power...so tailoristic and authoritarian [organisational culture]" (M3, Spain).
Time pressure and fear were reported to impact on WMHP implementation. With respect to time, benefits for mental health may take years to be seen in an organisation and this is very "challenging" for
them (M1, Japan) because OSH specialists cannot "solve all the problems in 1-2 days" (M3, Belgium). Changes need time and organisations often want overnight solutions to their problems. Despite of companies' preference for "quick fixes" (M1, UK), successful outcomes come only with consistent "repetition" and work in the long term (F4, the Netherlands).
Fear of "unemployment and precariousness" makes people afraid of talking about work and MH related issues and leads employees to accept bad working conditions and employers not to take care of WMH (M3, Spain). "A lot of people, including employers, are a bit afraid of it [mental illness and its consequences]... that they prefer to get rid of those people instead of doing something to make them better" (F2, the Netherlands). Employers are scared that if they start with risk assessment and management, this might "open a can of worms" (F2, Australia), which will lead to time and money loss. 3.2.4. Potentials for future success
The theme of potentials for future success includes informing policies/legislation, working for better evidence, educating people on psychosocial risk identification, and applying a holistic approach (Table 6).
Policies/legislation have a huge impact on how organisations act towards WMHP and there was a common view that mental health can be protected and promoted only if "policies are informed" (M1, UK). WMH needs to be supported by legislation because organisations, in their majority, take actions due to legal pressures rather than personal choice (M1, Japan) and "it is disappointing that 40-50 years after the good work agenda [in the UK], we are still trying to propagate basic messages to organisations" (M1, UK). It would be very supportive for WMHP initiatives if "the labour inspection could include psychosocial [risks], not only physical... it could influence people... because [it] has great prestige and power" (F3, Poland). If the labour inspection becomes more active and includes psychosocial risks, WMHP will be easily identified, understood and dealt with.
Constant "monitoring" (F2, Thailand) of the processes is the only way to achieve a better evidence base and convince organisations that there are practical reasons to take preventive actions. There is a need "to find the link between economic benefit for the company and prevention" (M3, Belgium) and "cost-effectiveness" (M4, Canada). If there is clear evidence and understanding about "economic internal investment and financial benefits... this will put programmes in place" (M3, Belgium). There are "missed opportunities by swinging between the responsibilities of employers and employees rather than working more holistically" (M1, UK). A holistic approach is vital because "when you try to find the problem, the causes of the psychosocial problems are not often only psychosocial aspects" (M3, Belgium).
4. Discussion
4.1. Whose responsibility?
This paper aimed to shed further light in the area of WMHP by investigating key approaches that have been introduced in several countries to promote mental health in the workplace. On the basis of interviews with experts, it aimed to provide recommendations on key elements of good practice and key challenges that need to be tackled by appropriate policies and stakeholder actions.
Many participants agreed on the fact that there is a mentality across organisations that mental health is a personal problem and individuals have to find a way out of it. Even if organisations take some actions, they are usually reactive such as counselling and training provision to make individuals 'stronger' and more resilient. This mentality is held not only by organisations, but also by governments. This creates many challenges for seeing success in the domain of WMHP. However, it was argued that since the impact of poor mental health is already known, governments and organisations would inevitably end up shifting their viewpoints towards prevention. OSH legislation can be a powerful motivator where it exists [3,20]. However, since legal frameworks are lacking in many countries, this is not enough [39]. Hard data and evidence of the impact of poor mental health are currently the only overriding reason that triggers organisations to consider their organisational responsibility in this area from the perspective of prevention. There is a need for evidence-based policy making and the promotion of a multi-level intervention framework on the basis of a strong evidence base to drive progress in this area [14,39].
4.2. In line with the WHO GPA & MHW five keys
Regarding the GPA and the five keys for healthy workplaces, four out of the five GPA objectives have been discussed through the initiatives (devise and incorporate policies, protect/promote health, provide evidence) and all five keys of MHW have been covered. The study evaluated how the eleven tools support organisations to accomplish the five keys of the MWH in order to meet GPA's objectives. The objectives were met by all initiatives. However, some initiatives illustrated a better and stronger support of the objectives contrary to others. All of them were developed in order to protect and promote employees' health, mental health and wellbeing. One of the key drivers, apart from compliance with the law, was the goal to eradicate the incidents of work-related injuries and illnesses from both a physical and mental perspective [5,40].
The objectives on devising and incorporating workers' health into other policies (the first and the fifth objective of the GPA), especially for mental health, were covered by the findings on opportunities for the identified tools. Stakeholder consensus on the need for more effective WMH policies highlights the importance to inform and reform current policies [14]. There are policies and legislation for OSH prevention, but not all countries have legislation directed to WMH. It was evident that European countries have more policies for employees' mental health [7,41]. Interestingly, even for the countries with a hitherto strong background in this area, difficulties were reported regarding the implementation of initiatives because organisations are not yet fully aware and educated on psychosocial risk assessment [42].
The GPA objective on the protection and promotion of workers' health (the second objective) through primary prevention of occupational hazards, including psychosocial hazards, was supported by the findings on good WMHP practices, which include employee participation/social dialogue. Engagement of all stakeholders is a vital part of success, which pertains to the first two keys of the MHW; the first key represents leadership commitment and engagement, the second key represents workers and their representatives' involvement. All levels in a working environment include top management, employees, employers, representatives of all stakeholders, OSH specialists, and collaboration between industries, sectors and countries [2,18,23,24]. In particular, social dialogue and communication between all stakeholders are a substantial basis for effective implementation and improvement in the workplace. Employee empowerment in order to bridge the power gap between employers and employees was reported to be a central part of success. Charismatic leadership that empowers people though appreciation, showing trust, giving responsibilities and providing feedback and support is a great strength for organisations and WMHP effectiveness [19,20,43-45].
Business ethics and legality (third key) were supported by organisations that had to comply with the law at first and then move on to the next step, which was to find ways to a successful implementation. The fact that psychosocial risks are not easily identified and measured was the main reason why organisations fail to see great results. People need to know what psychosocial risk means in order to deal with it. Lack of awareness and an appropriate policy framework allow organisations to superficially comply with OSH law but not seeing results with respect to mental health [2,46].
All the good practices work in a parallel way with the fourth key for healthy workplaces of the MHW. The initiatives unanimously incorporate and support the element of systematic, comprehensive process to ensure effectiveness and continual improvement through numerous actions as the only way to success for WMHP. All of the participants, regardless of the initiative's current evaluation status, have agreed on the importance of continual improvement through understanding suitable or less suitable practices and sustaining a systematic evaluation process [5,40,47]. Sustainability and integration in a multilevel way implying the application of a holistic approach is in line with the fifth key of the MHW. Multilevel integration represents proposed changes not only through single interventions in the workplace, but a broader approach to changes: integrating an appropriate mentality, with tasks, roles, approaches, and solutions [2,20]. A multidisciplinary holistic approach was identified as a robust solution for successful implementation. It has been understood that there are current efforts for a holistic approach and multilevel integration; looking at issues from many perspectives and different viewpoints does help in understanding not only economic aspects, but also cultural, personal, psychological, health, and productivity aspects and their connection [24,48]. It was common that cultures with a collectivistic mentality, such as Ghana,
Japan, and Thailand embraced a community approach, mindfulness and spirituality more heavily with respect to mental health than individualistic ones, which tend to have a business-oriented understanding. Attention to the values of family, community and spiritual self was more discernible through collectivism [49-53]. However, the implementation of a holistic approach is still in progress in all countries covered.
4.3. In line with the WHO CMHAP
The initiatives included in this study have also been explored in order to identify the extent to which they are in line with the CMHAP [5]. The initiatives mainly cover the first, the third and the fourth objective (CMHAP has four objectives in total). The first objective (1) suggests the strengthening of leadership, the increase of national policies and laws for mental health in line with international human rights standards; there is a need for more policies on WMH. The third objective (3) prompts mental health promotion through the implementation of multi-sectoral strategies at national level. All the identified initiatives are multi-sectoral workplace strategies at national level as pointed by the CMHAP. The fourth objective (4) focuses on strengthening the evidence and research for mental health, which is part of the findings on potentials of this study. This objective aims to the collection and report of mental health indicators every two years, which could potentially be facilitated by a consistent monitoring process within organisations [5].
Taking a closer look at the initiatives and their link to CMHAP, the Management Standards for work-related stress are based on psychosocial risk assessment to identify the cause and gather evidence (met 4th objective), implement prevention (met 3rd objective) and inform/engage stakeholders (met 1st objective). PSYRES was research driven and aimed to gain insight and identify effective preventive actions for psychological wellbeing during restructuring (met 4th objective) and inform/engage/empower stakeholders (met 1st objective). The OSH Covenants/Catalogues are risk management projects to identify causes, gather evidence (met 4th objective), implement prevention (met 3rd objective) and engage all stakeholders in order to improve leadership for a healthy workplace (met 1st objective). ISTAS21 is a psychological risk assessment questionnaire aiming to identify risks and prevent (3rd objective), inform and share evidence (4th objective), and motivate/engage stakeholders (1st objective). SOBANE strategy is an occupational risk management tool including psychosocial risks, which aims to identify the problem by using evidence (4th objective), suggest preventive and/or treatment actions (3rd objective), and empower stakeholders in order to improve leadership for WMH (1st objective). The Canadian Standard is a systematic process to create psychologically safe workplaces by identifying and tackling psychosocial hazards (3rd and 4th objective) and supporting the leadership by informing/motivating/engaging the people involved (1st objective). Total Worker Health focuses on psychosocial stress hazard reduction approaches (3rd objective), evidence provision (4th objective), and dissemination of knowledge in order to strengthen awareness and leadership for workplace wellbeing (1st objective). From a similar perspective, P@W and MHACL work on the basis of psychosocial risk identification and management aiming to share knowledge, inform and engage all stakeholders and leadership (1st, 3rd and 4th objectives). The Happy Workplace (met all three objectives) and the Employee Wellbeing Programme (met 1st and 3rd objective) aim to improve employees' wellbeing through various strategies, but without a clear-cut reference to psychosocial risks. In particular, the Employee Wellbeing Programme is at a very early stage regarding WMHP and psychosocial risk management [5].
4.4. Constraints and opportunities
There are some differences in terms of the life cycle of the examined tools. For example, PSYRES, OSH Covenants, and the Management Standards have now stopped the process of continual improvement contrary to Canada's Standard, SOBANE, P@W, MHACL, Total Worker Health Strategy, Promotion of Wellbeing Programme, ISTAS 21, OSH Catalogues and the Happy Workplace Concept. Even though organisations do seek advanced tools and improvement, it has been noted that the economic climate and recessions affect the continuation of actions [54,55].
Knowledge deficiency is a great problem because not only companies cannot identify the reasons behind poor mental health in their work environment, but they also cannot easily transform shared knowledge into effective practice [14,56]. Therefore, there is a great need to act in a two-way direction by educating people about mental health/psychosocial risks and making science and good practice
understandable to the wider audience [56,57]. With respect to cultural gaps, it is quite difficult to control differences between organisational cultures. Mature-larger organisations with better awareness on mental health in the workplace accept and use tools more easily, but it is more difficult to fully implement them. This is in contrast with smaller organisations that are more difficult to penetrate, but easier to fully integrate. The solution is to be as specific as possible based on the given situation and context [58].
Fear was another constraint, especially in countries that are more affected by recessions. Employees are afraid of losing their job and having minimal opportunities, which make them accept any working conditions without any resistance. In this case, employers might choose not to fully integrate WMHP and avoid time and money expenditure, especially if there is no legislation forcing them to explicitly take actions [55]. There is also a grey area where OSH law exists, but evidently mental health is the missing bit. Participants interestingly suggested that this lacuna can be overcome with the use of labour inspection that includes psychosocial risk factors [20,21], although this is far from reality in most countries around the world.
4.5. Limitations and strengths of the study
The main limitation of the study is the selective, qualitative and interpretative nature of it, which does not allow further generalisations. In addition, lack of tool availability led to an unequal number of experts for each WHO region, which may have affected evaluation due to cultural differences. Nevertheless, the tools were selected based on clear inclusion criteria across WHO regions (with the exception of the Eastern Mediterranean where no suitable tools were identified). Despite cultural differences, there clearly are similarities as concerns good practices, responsibilities, barriers and opportunities, which also give credibility to the findings. Lastly, all the participants are highly knowledgeable experts with many years of experience in OSH and mental health in the workplace.
4.6. Conclusion
The findings of this study indicated that there is a lack of coordinated preventive action for WMHP. There is an urgent need for education, which will enable all stakeholders to understand the impact and cost of poor mental health. Findings suggest that a holistic approach for WMHP combined with informed legislation and active labour inspection is the best plan of action at national level for future success.
Practices, which comply with the WHO five keys for healthy workplaces, such as engagement of all stakeholders, social dialogue, proper translation of science into tangible practice, dissemination of good practices, and continual improvement are acknowledged to be effective ways to promote mental health in the workplace. Nonetheless there is a lot of space for improvement. One very significant potential for improvement is the holistic approach that fully incorporates psychosocial aspects and explores possible psychosocial risks in the workplace. Future research should identify and evaluate such holistic approaches across all WHO regions in order to globally map available expertise.
Conflicts of interest
All authors declare no conflicts of interest Acknowledgements
The authors would like to thank Dr Evelyn Kortum and Dr Taghi Yasamy (World Health Organization Headquarters) for their assistance and support during this study.
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Table 1: Tool per country and WHO region__
Tool_ Country_ WHO Region
Management Standards for work-related stress [59,60] PSYRES: Psychological health and well-being in restructuring [61,62] ISTAS 21 [63] OSH Covenants and Catalogues [64] SOBANE strategy [65] United Kingdom, Italy Finland, Poland, Denmark, the Netherlands Spain The Netherlands Belgium Europe Europe Europe Europe Europe
National Standard on Psychological Health and Safety in the Workplace [66] Total Worker Health Strategy [67,68] Canada USA The Americas The Americas
People at Work (P@W) [69] Mental Health Action Checklist (MHACL) [70] Australia Japan The Western-Pacific The Western-Pacific
The Happy Workplace Concept [71] Thailand South-East Asia
Employee Well-being Programme [72] Ghana Africa
Table 2_
Tool* Details
Europe For the European region, five initiatives were selected:
Management Standards for work-related stress The first one is the Management Standards for work-related stress by Health and Safety Executive (HSE) in the United Kingdom, which has been adapted and is now also used in Italy. The Management Standards are voluntary and incorporate six key areas of work design, which can enhance health and wellbeing protection and promotion in the workplace (demands, control, support, relationships, role, and change). The Standards provide a step-by-step risk assessment and management approach in order to help organisations easily implement the process [59,60].
PSYRES: Psychological health and well-being in restructuring The second initiative chosen is the Psychological Health and Wellbeing in Restructuring (PSYRES) project in the Netherlands, Poland, Finland and Denmark. PSYRES is a research-driven initiative at national level, which aims to disseminate knowledge and good practice about workplace mental health protection and promotion during the organisational restructuring process [61,62].
ISTAS 21 The next initiative that was selected is ISTAS21 in Spain. ISTAS21 is based on the Danish Copenhagen Psychosocial Questionnaire (CoPsoQ) for assessing psychosocial risks. It is a voluntary methodology, which is based on risk assessment and risk management [63].
OSH Covenants and Catalogues The Work and Health Covenants and OSH Catalogues in the Netherlands were also identified as relevant sectoral tools. These initiatives essentially are social partner agreements on how to protect and promote a healthy work environment at sectoral level [64].
SOBANE strategy Lastly, the SOBANE strategy in Belgium was identified as a tool at national level for the assessment and management of psychosocial risks, which strongly supports a holistic approach. It is a voluntary initiative that can be used by any organisation and sector aiming to comply with the law and protect/promote employees' wellbeing [65].
The Americas For the region of the Americas, the National Standard on Psychological Health and Safety in the Workplace in Canada, and the Total Worker Health Strategy in the United States of America were selected.
National Standard on Psychological Health and Safety in the Workplace Canada's standard is part of the Mental Health Strategy for Canada, and the first ever national standard directly targeting psychological health and safety in the workplace that is auditable. It is a voluntary standard and it is aligned with other existing standards to ensure healthy workplaces and support employees with mental ill health. It also aims to assist organisations by providing guidelines to employers in order to improve the psychological health in the workplace step-by-step. It encourages the executive leadership to set workplace mental health as a priority. Special training is provided and free monthly webinars are conducted to help people recognise, assess, manage and deal with psychological health and safety in the workplace [66].
Total Worker Health Strategy Regarding the USA initiative, Total Worker Health is a voluntary strategy by the National Institute for Occupational Safety and Health (NIOSH), which encompasses occupational health and safety, injury and illness prevention in order to advance employees' health and wellbeing. Mental health is allied to the strategy's pursuit of wellbeing through addressing stress and mental ill health of employees. Specific guidelines are provided to help organisations assess/manage OSH issues and promote employees' wellbeing. This initiative is heavily research driven and the Centres of Excellence, which are funded by NIOSH, conduct research on health risk factors and psychosocial stress hazard reduction in support of the Total Worker Health strategy [67,68].
The Western-Pacific For the Western Pacific region, the People at Work Project (P@W) in Australia, and the Mental Health Action Checklist in Japan (MHACL) were selected.
People at Work (P@W) The P@W is a voluntary psychosocial risk assessment process and it has been developed and managed by the University of Queensland as a collaboration between many initiators such as Safe Work Australia, the Australian National University, WorkSafe Victoria etc. The process aims to provide reliable risk assessment to organisations by measuring job demands and job resources. It is available for all type of industries and sectors [69].
Mental Health Action Checklist (MHACL) Regarding the MHACL, it is also a voluntary worker participatory approach to improve mental health in workplaces. MHACL focuses on six technical areas, which are: sharing work planning, work time and organisation, ergonomic work methods, workplace environment, mutual support in the workplace, and preparedness and care. The checklist aims to enhance workplace-level discussions on identifying various kinds of improvements in the workplace for any type of industry in order to promote workplace mental health [70].
South-East Asia The Happy Workplace Project in Thailand was selected for the South-East Asia region.
The Happy Workplace Concept It is a project funded by the Thai Health Promotion Foundation. This voluntary initiative is a highly holistic approach regarding work-life balance and addresses health promotion in various ways such as physical, mental, spiritual, social, communal and cultural. This project is heavily based on the concept of happiness and how employees experience it. Training is provided, but there is also the 'Happinometer' assessment tool, which helps organisations measure employees' happiness in order to take further action. This voluntary initiative focuses more holistically on work-life balance in comparison to the rest [71].
Africa For the African region, the Employee Wellbeing Programme in Ghana was selected.
Employee Well-being Programme It is a collaboration between the Ministry of Health in Ghana and GIZ (Deutsche Gesellschaft fur Internationale Zusammenarbeit). This voluntary initiative started with a focus on tackling HIV and further developed into a general wellbeing programme, which includes aspects such as social protection (financial wellness and counselling, preparation for retirement, insurance), and efforts to support national systems and leadership that deliver environmental management. This initiative provides tools and policies to organisations and is heavily based on the WHO model for healthy workplaces. The psychosocial work environment is part of model's health and safety aspect, however, the process of psychosocial risk assessment and management is at considerably early stage in Ghana, and hitherto the actions are limited [72].
* For the Eastern Mediterranean WHO region no initiative or tool at national level for WMHP was identified, therefore no further actions could be taken in order to explore any possible development or implementation.
Table 3: Good Practices Theme
Themes
Subthemes
Descriptors
Good practices
Participation and social dialogue
Science/research into practice
Clear action plan Shared knowledge Evaluation
Stakeholders' engagement Employees' empowerment
Collaboration between countries, and between the public and private sector
Feedback and support provision at all levels in the workplace
Effective translation of science into practical steps and approaches Availability of appropriate expertise to organisations Accessible and user-friendly language
Stepwise approach of action Well-structured implementation process Specificity and clarity
Dissemination of knowledge on good practice (workshops, internet, media)
Material provision to stakeholders (booklets, guides, brochures)
Continual improvement through assessments Adaptation to organisational changes
Table 4: Responsibility for Workplace Mental Health Theme
Themes Subthemes Descriptors
Responsibility for Current trends MH as a peripheral rather than a central issue
WMH Shift from organisational responsibility to individual responsibility
Organisational responsibility works better for easily measurable problems Drivers Legislation
Numbers of work-related injuries and illnesses
Impact Organisational responsibility has a bigger effect
Individual responsibility is not enough Higher impact when individual responsibility follows organisational
Table 5: Barriers Theme
Themes
Barriers
Subthemes
Descriptors
Knowledge deficiency
Financial constraints
Cultural gaps
Time pressure Fear
Lack of knowledge amongst managers, professionals, workers Non-scientific approaches Inaccurate use of data
Upfront investment
Continual improvement needs investment Cost reduction
More difficulties for SMEs
Difficult to communicate mental health issues
Mature vs immature cultures
The impact of unwritten rules
Organisations prefer quick fixes Results/changes need time
Afraid employers (time and money loss, business failure) Afraid employees (precariousness, lack of opportunities)
Table 6: Potentials Theme
Themes
Potentials
Subthemes
Descriptors
Policies/legislation
Better evidence Educate people
Holistic approach
Inform and update policies on WMH Need for proper legislation Active labour inspection
Preventive actions are more effective than reactive actions
Clear short-term and long-term cost-benefit relation Constant monitoring at all levels
Training for all stakeholders in the workplace Education on psychosocial risk identification National and international dissemination of good practice
Both organisational culture and community needs to promote MH Direct and indirect actions
Multidisciplinary approach and multilevel integration
