The final version of the MENTUPP ToC that was developed consists of seven key components, including: 1) proximate outcomes, 2) intermediate outcomes, 3) long-term outcomes, 4) ceiling of accountability, 5) impact, 6) intervention components, and 7) assumptions. The first six components are graphically presented in the ToC map (see Fig. 1) and the seventh is elaborated further in the “Assumptions” section.
In general, the arrows between the boxes represent the way one outcome is expected to lead to another and finally to the long-term outcomes. However, ToC goes beyond linearity including bidirectional and circular causal pathways between the outcomes as indicated by the double-pointed arrows in the ToC map.
Furthermore, the red arrows represent links between outcomes that are expected to occur directly when certain intervention components are applied, whereas the black arrows show the expected indirect effects of the intervention. Each intervention component is connected to a different outcome on the map.
Proximate and intermediate outcomes
The achievement of the intermediate outcomes must precede the long-term outcomes, so we expect that they will be achieved on an earlier stage (during the second and the fourth month), whereas the long-term outcomes are expected to be visible after the six-month MENTUPP implementation. As it concerns the proximate outcomes, they are expected to occur during the first months of the implementation period. The proximate and the intermediate outcomes are expected to occur at four levels: 1) at the individual level of all employees at all grades in the participating SMEs including leaders, as individuals who also are affected by their work environment and who also can have mental health problems, 2) at the group or team level of the interactive peers, 3) at the leader level referring to the role of supervisors and managers and their responsibility for the mental health of their employees, and 4) at the organizational level. This division corresponds to the four levels of: Individuals, Groups, Leaders, and Organization (IGLO) of the Context-Process-Outcomes (CPO) evaluation model of Fridrich and colleagues [31]. Based on the results of the reviews, the expert consultation, and the four ToC workshops, we identified six proximate and four intermediate outcomes (POs and IOs) which are located on the left side of the map (Fig. 1).
The first proximate outcome that we identified is “the implementation requirements of MENTUPP are fulfilled” (PO1). We expect that this outcome will occur at the organizational level of the SME and is necessary for the other five proximate outcomes to occur. Moreover, we foresee that this outcome will be achieved via activities from the project group to introduce the intervention to future participants and to facilitate engagement during the implementation of the intervention [13].
The next proximate outcome is “employees and leaders build knowledge on mental wellbeing, mental illness and stigma” (PO2). Enhanced knowledge can promote a person’s actual ability to perform a behavior. According to the Social Cognitive Theory developed by Bandura [32], health promotion and illness prevention can be achieved by teaching health promotional actions. Moreover, in the context of mental health, there is evidence indicating that enhancing mental health literacy, defined as “increasing knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [33] is closely related to taking action to promote one’s own mental health or that of others [34]. There is also extensive literature to show that interventions exploiting CBT-based and/or psychoeducational materials are able to reduce symptoms of depression and anxiety [23, 35,36,37]. More specifically, Martin and colleagues [23] managed to decrease psychological distress of SME managers using psychoeducational and CBT-based materials after implementing their intervention for four months. Saraf and colleagues [38] achieved an improvement on depressive and anxiety symptoms of SME entrepreneurs through their three-month intervention. Moreover, the CBT-based intervention of Sorensen and colleagues [35] which was applied in Danish workplaces achieved significant positive changes in psychological distress symptoms and symptoms of anxiety over a period of 12 months.
The third proximate outcome (PO3) is “employees and leaders enhance skills to promote mental health, deal with mental illness and prevent stigma”. This outcome is supported by the Theory of Planned Behavior which considers skills as a motivational factor for one’s perception of control over a behavior. This means that when a person intends to perform a behavior (e.g. pay more attention to one’s own wellbeing), enhanced skills will help the person to successfully achieve it [39].
“Employees and leaders adopt more positive attitudes towards mental illness and help-seeking” is the fourth proximate outcome we identified (PO4). Stigmatizing attitudes towards mental illness reduces help-seeking and are a major barrier to receiving treatment [40, 41]. Undoubtedly, adopting supportive attitudes toward the potential for treating mental illness should be a key factor in mental health interventions, enabling people to express mental health difficulties and search for appropriate support when needed.
Assuming that the implementation requirements are fulfilled (PO1), then the enhancement of knowledge and skills and the adoption of more positive attitudes towards mental illness (PO2, PO3, PO4) are assumed to be achievable. We consider that the proximate outcomes within the blue boxes in Fig. 1 to be fundamental, in that they have to be achieved at the individual level by employees of all grades. The proximate outcomes are assumed to lead to long-term outcomes, and they can contribute to the improvement of psychosocial factors in the workplace(IO1). The intervention is available on a universal basis in the workplace i.e., the individual level should include all employees in the organization following the assumption that even people who do not suffer from mental illness are expected to benefit from mental health promotion in the workplace [21, 42]. It also means that all individual employees at all levels can benefit from mental health promotion in the workplace as they all have personal mental health needs [43].
The proximate outcomes at the leader level are illustrated by two yellow-colored boxes in Fig. 1 (PO5, PO6). These outcomes describe the changes that are expected from the leaders with regard to their role as leaders and refer to their skills and activities in relation to employees’ mental health in the workplace.
The fifth proximate outcome expected at the level of the leaders is that “leaders enhance skills to address mental illness and prevent mental harm” (PO5). Addressing employees’ mental health needs in the workplace context is considered to be a crucial component of a genuinely integrated approach [21]. Psychoeducation for people in a leading role within an organization may provide increased understanding and practical solutions to offer to employees [21].
The final proximate outcome we identified is that “leaders build knowledge on understanding and identifying psychosocial stressors in the workplace” (PO6). There is evidence to suggest that mental wellbeing can be promoted by enhancing positive aspects of work and reducing work-related risk factors [21, 36]. To this end, leaders need to increase their knowledge and skills as they are key persons to implement change at the organizational level.
Column 3 of the boxes on the map in Fig. 1 depicts the intermediate outcomes. All proximate outcomes that were described above are perceived as key elements to achieve “improved psychosocial factors in the workplace” (IO1). We expect this outcome at the organizational level (green color), but it will be achieved through proximate outcomes at the individual level of all employees (blue color), at the level of leaders (yellow color), and through the interaction between peers (purple color). The psychosocial factors that are targeted through the MENTUPP intervention and that are linked to this outcome, are the influence that employees have on their work, the quality of leadership they experience, the social support that they receive from colleagues and supervisors, the existence of mutual trust between employees and of trust regarding the management and the justice experienced in the workplace.
The intermediate outcomes also include two assumed outcomes at group or team level (purple boxes). One of the intermediate outcomes on the map expected to occur at the team level is that “employees and leaders facing mental health difficulties (meaning mental health distress and/or illness) are supported by the team” (IO2). The assumption here is that the promotion of self-organized peer support in the workplace is believed to help prevent and deal with mental health difficulties through the promotion of help-seeking and providing help behaviors [44].
The next intermediate outcome (IO3) which we expect to derive from the team level is that “the team experiences an inclusive atmosphere within the working environment where positive psychosocial factors are promoted”. This outcome is based on the assumptions that peers have to (a) experience that changes occurred at the organizational and the team level, and (b) perceive these changes as helpful (c)in order to disclose their mental health difficulties and receive support within the working environment [45, 46]. IO2 and IO3 are expected to derive from and add to “improved psychosocial factors in the workplace” (IO1) and are also linked to the long-term outcomes of the intervention.
The last intermediate outcome we expect is “employees and leaders facing symptoms of mental illness improve attitudes towards seeking professional support” (IO4). This outcome is linked to the proximate outcome of building knowledge (PO2). This outcome is based on the assumption that if people experiencing mental health difficulties are able to recognize a need for support and know where to find it, they will be more likely to seek professional help. All intermediate outcomes (IO1—IO4) are expected to lead to the long-term outcomes.
Long-term outcomes
We expect that four long-term outcomes (LOs) will arise from the MENTUPP intervention in the workplace: (LO1) “improved mental wellbeing and reduced burnout”, (LO2) “reduced mental illness”, (LO3) “reduced mental illness related stigma”, and (LO4) “reduced productivity losses”. Even though the long-term outcomes are expected to occur after the six months, we speculate that outcomes on productivity losses may need more time as they are dependent to the mental health-related long-term outcomes of our intervention.
The long-term outcomes LO1, LO2, LO3, are expected to affect all employees at the individual level (indicated by blue colored boxes in Fig. 1), whereas the fourth long-term outcome LO4 relates to the organizational level (green color). We assume that the relationship between the long-term outcomes and the improvement of psychosocial factors (IO1) is bidirectional as there can be mutual benefits.
Finally, the long-term outcomes (LO1-LO3) are linked to the achievement of the fourth long-term outcome (LO4) concerning the reduction of productivity losses which is a desired change located at the organizational level.
Impact
The real-world change that is endeavoured through the long-term outcomes of the MENTUPP intervention is defined as “improved mental health in the working population and positive impact on productivity results”.
Ceiling of accountability
The ceiling of accountability is located between the impact of MENTUPP and its long-term outcomes. This indicates that MENTUPP can be credited for promoting mental health in the workplace, although it cannot account for factors that lie outside the project’s sphere of influence. Hence, this is the threshold beyond which the outcomes of the intervention will not be measured anymore by the researchers.
Intervention components
The MENTUPP intervention consists of 23 intervention components embedded within an online platform designed to achieve the proximate, intermediate, and long-term outcomes. The 23 components relate to six overarching domains. They can be further divided into seven activities in domain 1 that need to take place within the organization and 16 informative and psychoeducational components in domains 2–6 that are embedded in the online platform, so that they can be used by the participants of the intervention.
Domain 1: Implementation requirements
This domain includes seven activities that the project group is planning to conduct to assure that the intervention is initiated appropriately. The first activity involves communicating with the SME leaders and successful recruitment to the MENTUPP research project. The second activity requires commitment from management and willingness from their side to support and promote the intervention. The third activity is to conduct a pre-implementation assessment establishing a project planning group to promote implementation, outlining data confidentiality, and ensuring participants can engage with the intervention during paid working hours. The fourth activity is to conduct an introductory session with the leaders of the SME to introduce them to the informed consent, the purpose of the intervention, the evaluation measures, and the focus groups. The fifth activity is to inform the SME employees about participation and how it can be achieved through their access to the MENTUPP Hub. The sixth activity is an invitation to the participants to access the Hub. The seventh activity involves establishing a planning group including workplace management in the implementation process and facilitating engagement.
Domain 2: Building knowledge
Four psychoeducational components are sought to build participants’ knowledge base about mental health in the workplace. The first and the second components focus on a better understanding of depression and anxiety, their impact on work, and treatment options. The third component provides a test to assess attitudes and behavioral intentions toward people with mental illness. The fourth component in this domain is to better understand mental wellbeing, stress, and burnout emphasizing what everyone in the organization can do to support mental health and wellbeing.
Domain 3: Enhancing skills
Five psychoeducational components representing this domain aim to enhance the mental health skills of employers and employees. The first component in this domain is targeted at laying the knowledge foundations for understanding how mental health and wellbeing at work can be strengthened by everybody in the organization providing practical exercises based on a Cognitive Behavioral Therapy (CBT) approach to deal with unhelpful thoughts, introducing emotions arising under stress, and presenting practical exercises for managing stress, such as breathing and mindfulness techniques. The second component teaches participants to identify symptoms of depression and anxiety, as well as to develop help-seeking skills. Employees can use the third component to better understand how stigmatization associated with mental illness can be expressed in their work sector and adopt sector-specific coping strategies that are provided. The fourth component serves to learn how to react when being stigmatized and to build communicational skills to properly talk about mental health problems. The fifth component only applies to leaders of the organization and supports their understanding of the business impact of depression and anxiety, providing guidance on how to talk about mental health and support to employees who they suspect are depressed, anxious, have suicidal thoughts, or those who are returning to work having been on mental health-related sick leave.
Domain 4: Adopting more positive attitudes
There are two components in this domain, the first aims to improve participants’ understanding of mental illness-related stigma and its connection to social stereotypes and the second relates to recommendations for how to reduce stigma at work and how to improve communication about mental health.
Domain 5: Improving psychosocial factors in the workplace
The intervention components that are categorized in domains 2, 3, and 4 are related to outcomes at the individual level of all the employees and of the leaders only. However, two further practically oriented toolbox components in this domain are connected to outcomes at the organizational and team level. The first component aims to deepen the understanding of peer support and establish a culture of supporting each other at work. The second component is designed to help leaders achieve a better understanding of mental wellbeing, stress, and burnout in the context of the workplace. It also includes the identification of psychosocial work environment factors that may influence mental wellbeing, stress, and burnout. Furthermore, it includes suggestions to improve communication with staff about psychosocial work environment factors and to address these factors engaging employees in the development of these processes and initiation of related action plans.
Domain 6: Arranging additional support
It is anticipated that some of the participants will discover a need for additional support to overcome mental illness. To address this possibility and help prevent suicidal behavior, the iFightDepression tool—an internet-based self-management program for people with milder forms of depression (https://ifightdepression.com/en/self-management-resources/ifightdepression-tool) was introduced in some partner countries if it became apparent that a participant may is in need of additional support. However, this component is not available to all the implementation countries via MENTUPP although it is partially available for general use via the iFightDepression website. Through this online platform key information about depression, self-help resources, and contact details of help services are provided. Additionally, participants are provided with a third component which is the contact details of the national mental health helplines of the countries involved in the intervention. The intervention components arranging additional support for employees and leaders have been designed to support them during the implementation period if needed, but they can also be exploited as resources of additional help in the long-term.
Assumptions
The outcomes of the MENTUPP ToC can be influenced by the intervention components, but also by the assumptions outlined in Table 3 below. Whereas the intervention components are part of the intervention and thus, can be managed within the context of the project, assumptions are not part of the intervention and lie beyond the control of the project. Nevertheless, assumptions need to be met for the outcomes to occur.
The assumptions in a ToC are to some degree comparable to the omnibus context that is referred to by Fridrich and colleagues [31]. The omnibus context refers to aspects related to the general intervention and the implementation setting and are hardly or not at all manipulable by implementers (e.g. economic situation), but may have an influence on the implementation [31]. Based on consultation with the participants of the ToC workshops, we identified ten assumptions that need to be true for our results to be achieved which are presented in Table 3.
Indicators
An important advantage of Theory of Change is that it improves the evaluation of complex interventions by identifying meaningful evaluation indicators linking them to the expected long-term, intermediate and proximate outcomes. The evaluation strategy of the pilot study relies on a comprehensive mixed method design which consists of a combination of quantitative and qualitative measures [13] which were connected to the indicators identified by the ToC. This allows us to examine whether MENTUPP generates the expected outcomes as prescribed in the ToC and to test more specific hypotheses.
Furthermore, the developed program theory will be used in conjunction with a comprehensive process evaluation including the ToC assumptions (Sect. 3.6). The diversity between the involved countries, work sectors, size of enterprises and participant characteristics is expected to have an impact on implementation. Therefore, indicators have also been developed to assess the ToC assumptions. This way, contextual factors external to the intervention and their impact on the outcomes and the implementation can be evaluated. The differences between intervention contexts will be used as moderators to indicate barriers and facilitators to implementation.
We will thoroughly report on the MENTUPP outcome and process strategy and results in upcoming publications, but we shortly present here an example of how the indicators developed through the ToC will facilitate the evaluation of this complex intervention.
The ToC map describes the assumed associative relationship between PO4 (employees and leaders adopt more positive attitudes towards mental illness and help seeking) and IO2 (employees and leaders facing mental health difficulties are supported by the team) which in turn causes LO3 (reduced mental illness related stigma). In order to examine this relationship, we have developed three indicators which can be measured with validated scales: 1) attitudes towards mental illness and help seeking, 2) social support by colleagues, and 3) personal stigma towards mental illness respectively. Then, linear mixed models can be used to take two levels of clustering in the data into account. The two levels would be employees and leaders within the participating SMEs. Baseline and post-intervention data will be used to identify the differences in: 1) attitudes towards mental illness and help seeking, 2) social support by colleagues, and 3) personal stigma towards mental illness between the groups. The causal relationship between proximate, intermediate, and long-term outcomes will be examined using regression analysis techniques.
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