To our knowledge, this is the first systematic review to examine the effectiveness of interventions targeting stigma towards mental illness at the workplace. The majority of the included studies were published since 2010, reflecting a growing interest in evaluations of stigma-reduction programs at the workplace. Our review illustrates that workplace anti-stigma interventions may be effective in changing employees’ knowledge, attitudes, and behavior towards people with mental-health problems. However, due to methodological shortcomings in the majority of the included studies, the lack of follow-ups beyond post-intervention assessments, as well as heterogeneity in terms of intervention content, duration, and outcome measures, the evidence for the effectiveness of workplace anti-stigma interventions is inconclusive and must be interpreted with caution.
While prior systematic reviews of general population interventions corroborate our findings of poor evaluation study design, they also found stigma-reduction efforts to be effective in changing people’s knowledge, attitudes, and behaviors towards people with mental-health problems [25–29]. The development and implementation of effective anti-stigma programs specifically designed for the workplace is, however, of high importance. First, while public efforts have returned mixed results, the development of tailored strategies targeting the workplace might prove a more promising route to stigma change, as awareness of public campaigns has often been found to be quite low [24, 52]. Thus, while public anti-stigma efforts target a greater part of the population, more people might be reached effectively via more targeted interventions (e.g. at work). Second, participation in anti-stigma programs, for example in the scope of personnel development, could be made mandatory in an organizational setting, whereas public stigma campaigns require people to participate voluntarily. Third, by nature, exposure to mass-media approaches to stigma change can be short in time, whereas workplace interventions can be more intensive in terms of length and information.
Our review shows that workplace anti-stigma interventions can be particularly effective in changing employees’ knowledge of mental disorders, as well as helping behavior, while results related to attitudinal change were mixed, but positive overall. In two studies [41, 48], a spillover effect was identified, meaning that a change in one outcome measure (e.g. behavior) occurred even though the intervention exclusively targeted other outcomes (e.g. knowledge or attitudes). This implies that the three dimensions of stigma (knowledge, attitude, and behavior) might be interrelated, as has been suggested before [53]. The theory of health education [54] postulates that attitude mediates the relationship between knowledge and behavior. In contrast, the current review showed that attitudinal change is not required to achieve behavioral change. In line with prior research [47, 55], three studies found that knowledge might directly trigger a behavior under certain conditions, even without any attitudinal change [40, 43, 45]. However, further research into how anti-stigma interventions change or affect each of the three dimensions of stigma is required to fully understand the stigmatization process.
The debilitating impact of mental illness at work is widely recognized, and organizations are increasingly investing in workplace mental-health interventions. However, emerging evidence indicates that stigma towards mental illness, in part, contributes to the underutilization of costly mental-health services (e.g. EAP, workplace counseling) that are already offered by organizations [16, 18]. It is, therefore, important to address and remove stigma as a barrier to increase the effectiveness and ‘value-for-money’ of these interventions.
This review addresses the research gap regarding the behavioral dimension of stigma as an outcome and, more importantly, highlights that workplace anti-stigma interventions have the potential to change employee behavior [3]. In contrast, anti-stigma campaigns targeting the general public have often failed to change behavior [56]. Perhaps in an organizational context as compared to the public context, behavioral change (e.g. in supportive or help-seeking behavior) could be achieved more readily by giving clear calls for action in specific situations at work. This has important practical implications for organizations and employers alike, as behavioral change is considered the ultimate goal of efforts to reduce stigma and is likely to result in a more supportive work environment, which, in turn, is a necessary prerequisite for the success of any mental-health intervention (e.g. workplace counseling, EAP) [53, 57].
In light of the impact of stigma on seeking help and accounting for the fact that a large proportion of people experiencing mental-health problems do not seek help, it is essential to measure the impact of anti-stigma interventions on help-seeking behavior [58]. Despite the heterogeneity in the operationalization of behavior, however, none of the included studies examined help-seeking behavior as an outcome, focusing instead on potential intervention effects on participants’ supportive behavior towards afflicted individuals. Future evaluations of workplace anti-stigma interventions should place stronger emphasis on assessing a potential impact on employees’ help-seeking behavior (e.g. health-service utilization), as well as on their mental health (e.g. sick leave, presenteeism). This would help assess the cost-effectiveness of workplace anti-stigma interventions and strengthen the economic incentive for organizations to invest in stigma-reduction efforts.
The current review found some evidence indicating the positive impact of anti-stigma interventions on participants’ general mental health [36, 37]. Improved knowledge of signs of mental illness and treatment options may lead employees to seek help earlier. This is supported by findings of a prior meta-analysis, which found that MHFA training helped improve participant mental health by improving self-recognition, increasing insight into one’s own and others’ mental well-being, and by increasing coping skills [30]. Workplace anti-stigma interventions might not only create a more supportive work environment by reducing stigmatizing attitudes and discrimination, but also lead to improved knowledge and awareness of mental illness and to improved employee mental health via increased and potentially earlier help-seeking. So far, economic evaluations of anti-stigma interventions are generally lacking; however, preliminary evidence indicates a potential return on investment for employers [59].
While the evaluated anti-stigma interventions themselves seem to be scientifically sound in terms of their theoretical background and content, the evaluation methods used need to be improved substantially. A prominent finding of this review was the large number of studies with methodological shortcomings, high risk of bias, no control groups, and small sample sizes. Studies frequently also reported high levels of dropouts and varied in terms of program completion. A potential reason for this might be the challenge of evaluating interventions in a scientifically sound manner in companies which might be unwilling to engage in such research or pose restrictions due to data-protection rights.
The current review further highlights a misfit between what some intervention studies claimed to target and what they actually assessed in terms of outcomes [41, 48]. If studies fail to assess the impact on outcomes they claim to target in their intervention, important evaluation data gets lost. Studies targeting and assessing a change in only one dimension of stigma (e.g. attitude) might fail to detect a spillover effect on other dimensions of stigma (e.g. knowledge or behavior).
Previous research has questioned the retention of intervention effects over time, especially with regards to attitudinal and behavioral change [28, 29]. The majority of studies in this review did not conduct a follow-up assessment of intervention effects. However, where reported, improvements in knowledge, attitudes, and behavior were maintained over time [39, 40, 47, 49, 51]. Future research needs to place greater emphasis on conducting follow-up evaluations that go beyond pre-post measurements.
Limitations
Although this review generated important findings, there are several limitations that should be mentioned. First, only three electronic databases were used to gather articles for this review, and a search in languages other than English, German, Portuguese, and Spanish was not undertaken. Despite the lack of breadth, the searches were supplemented by searching Google Scholar, checking references, and communication with experts, which yielded 14 further studies, three of which were unpublished. The possibility of publication bias needs to be considered, as there may have been relevant studies that did not produce positive results and, consequently, were not published.
A second limitation of the current review involves generalizability of the current findings. The majority of participants in the reviewed studies were well-educated employees, such as managers. This limits the generalizability of the findings to other occupations or sectors that employ less-educated workers (e.g. service industries). While it makes sense to address managers due to their supervisory role and their importance in recognizing and dealing with signs of mental illness in subordinates, it may be just as important to target less-educated workers because there is some evidence indicating that less-educated compared to more-educated people are more likely to hold stigmatizing attitudes towards people with mental illnesses [60]. It is also important to note that all of the studies included in this review were carried out in high-income countries and, therefore, the findings may not apply to low- and middle-income countries, where stigma towards mental illness might be particularly strong or prevailing.
This review provides a narrative synthesis of the evidence of anti-stigma intervention effectiveness rather than a meta-analysis of results, which limits the strength of the conclusions that can be drawn. Given the heterogeneity of the methodology and outcome data across studies, it was not possible to conduct a meta-analysis at this time.
Implications for future research
It was beyond the scope of the current review to identify which types or components of anti-stigma interventions are particularly effective in improving employees’ knowledge, attitudes, and behavior. Future research should compare and contrast different types of anti-stigma interventions to determine the optimal program content and duration for the workplace context. Although a positive impact was found in all types of anti-stigma interventions studied, it is crucial to emphasize a stronger evaluation methodology as much as improving anti-stigma content.
Future research in this field should engage in more standardized, high-quality evaluations which measure all dimensions of stigma towards mental illness to better understand the potential impact of anti-stigma interventions at the workplace. This would allow researchers to compare quantitative measures of stigma across studies more easily and to conduct a meta-analysis which would help build a stronger evidence base for the effectiveness of workplace anti-stigma interventions.
To increase the generalizability of the current findings, anti-stigma interventions with larger, more diverse samples in terms of gender, race, socioeconomic status, education/hierarchy, geographic location, and type of workplace should be tested.