Changes in rehabilitation actors’ mental health literacy and support to employers: An evaluation of the SEAM intervention

Abstract

BACKGROUND:

Lack of mental health literacy among rehabilitation professionals and employers in the return-to-work of persons with mental health problems resulted in the development of a three-day group training program, the Support to Employers from rehabilitation Actors about Mental health (SEAM) intervention.

OBJECTIVE:

To evaluate the impact of SEAM on rehabilitation professionals’ knowledge and beliefs, attitudes, and supporting behaviors towards people with mental health problems and employers as part of the return-to-work process.

METHODS:

In this longitudinal study, 94 rehabilitation professionals were included. Data were collected prior to (T1), immediately after (T2) and 6 months after SEAM training (T3) using knowledge and attitude scales and a questionnaire on supporting behaviors. SEAM includes training in Mental Health First Aid, presentations and discussions on current research on work and mental health, and strategies and communication guidelines to use when meeting service users and employers as part of the return-to-work of persons with mental health problems. SEAM also includes a homepage with targeted employer information. Data were analyzed using non-parametric statistics.

RESULTS:

SEAM significantly increased rehabilitation professionals’ knowledge of mental health (T1-T2: z = –2.037, p = 0.042; T2-T3: z = –5.093, p = 0.001), and improved their attitudes towards persons with mental health problems (T1-T2: z = 4.984, p = 0.001). Professionals (50–60%) also estimated that they had increased their use of supporting strategies towards service users and employers.

CONCLUSIONS:

The study suggests that SEAM can increase mental health literacy among rehabilitation professionals and lead to a greater focus on service users’ resources and work ability, as well as on employers’ support needs.

Keywords

Vocational rehabilitation occupational health mental illness occupational therapy Mental Health First Aid

1 Introduction

In Sweden today, mental health (MH) problems are primary reasons for people of working age being excluded from the labor market [1]. Previous research shows that rehabilitation professionals’ and employers’ support has a significant role in successful return-to-work (RTW) for this group of people [2 –5]. Adequate support provided by rehabilitation professionals to employers also influences employers’ willingness to hire and support employees with MH problems [3]. However, both rehabilitation professionals and employers are known to have limited belief in persons with MH problems work ability as well as lack of mental health literacy. This may make successful RTW less likely for persons experiencing these problems [6, 7]. In this article, mental health literacy is defined as knowledge and beliefs about MH problems. Mental health literacy affects a person’s identification, management and prevention of MH problems [8]. Mental health literacy includes how to prevent and recognize signs of MH problems, having knowledge of available treatments, help-seeking options, self-help strategies, and how to support someone showing signs of MH problems [9, 10]. Research is needed on how to improve employers’ and rehabilitation professionals’ mental health literacy related to the RTW process of persons with MH problems [6].

Employers’ lack of mental health literacy is described as one of the biggest obstacles for prevention of sick leave and RTW for persons who experience MH problems [3 , 11–13]. Many employers are uncertain of how to provide adequate support for their employees with these issues and how to prevent MH problems at work [3 , 14]. Additionally, employers with low mental health literacy are found to have negative attitudes towards workers with MH problems and concerns about their ability to work and be productive [6 , 14–19]. Employers are also uncertain of how to provide reasonable work accommodations [12]. According to our previous interview studies [3, 6], employers describe themselves as feeling isolated in handling and coordinating RTW for employees with MH problems. Employers are explicit about their need for increased support and information from rehabilitation professionals [14]. In particular, employers described themselves as feeling uncertain about work ability of job seekers with MH problems, and therefore desired to “screen for MH problems” [6]. Appropriate support for employers from rehabilitation professionals may increase employers’ self-confidence in meeting and supporting employees with MH problems and decrease the stigma related to having these problems.

Studies have shown that professionals in RTW services also lack knowledge of MH problems, have negative attitudes towards service users with these problems, and doubt their work ability [6 , 12–19]. Additionally, their attitudes have been shown to impact employers’ attitudes and willingness to open their workplaces to workers with MH problems [2 , 6]. According to Lexén et al. [6] and Porter et al. [14], lack of mental health literacy among rehabilitation professionals results in some professionals pushing service users into unsuitable workplaces without making proper job-person matches. This has negative consequences for the service user, the employer, and the business. The employers describe meeting with rehabilitation professionals as part of the RTW of employees and/or recruitment of persons with MH problems as lacking an understanding of their situation and the specific job requirements [14]. Accordingly, there is a need to increase rehabilitation professionals’ mental health literacy and to develop strategies that focus on employers’ needs and can be used by rehabilitation professionals when approaching employers [7].

Rehabilitation professionals’ lack of mental health literacy and uncertainty in the RTW process for persons with MH problems may make a successful RTW less likely for persons experiencing these problems [6, 7]. It may result in misunderstandings and discrimination of persons with MH problems in the RTW process [20]. Rehabilitation professionals’ uncertainty may also further increase employers’ uncertainty and feelings of being alone in handling the RTW process. The Support to Employers from rehabilitation Actors about Mental health (SEAM) intervention was developed in response to the identified lack of mental health literacy among rehabilitation professionals and employers, in order to enable rehabilitation professionals to provide adequate knowledge and support to service users with MH problems and their employers. The intervention design was based on findings from previous interview studies [6 , 21] and inspired by strategies used in supported employment [3, 22], cognitive behavior therapy [23, 24], and motivational interviewing [25]. When developing the SEAM intervention, an iterative participatory design [26] was used that involved an expert group of employers with experience of supporting employees with MH problems, representatives from the Swedish Social Insurance Agency, the Public Employment Service (PES), Human Resources, persons with experience of MH problems, and researchers. The aim of this study was to evaluate the impact of the SEAM intervention on rehabilitation professionals’ mental health literacy (knowledge, beliefs, attitudes, and supporting behaviors) towards people with MH problems as well as their supporting behaviors towards employers as part of the RTW process.

2 Methods

2.1 Research design

The study used a longitudinal observational design [27] and was conducted in Scania, in southern Sweden, during 2015–2017. The impact of SEAM was evaluated on three occasions: immediately before the rehabilitation professionals received the SEAM training (T1), immediately after training (T2), and 6 months after training completion (T3).

2.2 The SEAM intervention

SEAM focuses on increasing rehabilitation professionals’ knowledge in mental health, as well as their self-confidence and willingness to support a client with MH problems and their employer. SEAM also aims to decrease stigma related to having a MH problem and increase the belief in work ability of persons experiencing this problem. SEAM is a three-day group training with a maximum of 20 rehabilitation professionals in each group. The training includes Mental Health First Aid (MHFA) [28], complemented with presentations and discussions on current research on work and mental health, and strategies and communication guidelines to use when meeting service users and employers as part of the RTW of persons with MH problems. SEAM also includes a homepage with targeted employer information.

2.2.1 The three parts of the SEAM training

Part 1 (12 hours), Mental Health First Aid: MHFA is an evidence-based course developed in Australia in 2002 [28] and has been adopted in 21 countries [29], including Sweden [30]. MHFA [28] provides knowledge of the most common mental illnesses, risk factors and warning signs for mental health and addiction concerns, strategies for how to help someone in both crisis and non-crisis situations, and where to turn for help. Action planning for different mental crises conditions is taught. Examples include how to support someone who has a panic attack, or shows signs of suicide, self-harm, intoxication, psychosis or violent behavior. The training includes group exercises and illustrative films. The effects of MFHA have been investigated in several randomized controlled trials [30 –33]. A systematic review and meta-analysis demonstrated that MHFA increases mental health literacy, decreases negative attitudes, and increases supportive behaviors towards individuals with MH problems among the general public and professionals in RTW services [29].

Part 2 (3 hours), Work and mental health: This part of the SEAM training includes information on current research on work and mental health, the importance of work for recovery, and evidence-based support to facilitate RTW for persons with MH problems.

Part 3 (3 hours), SEAM strategies and communication guidelines: This part includes education in strategies and communication guidelines for rehabilitation professionals to use when meeting service users and employers as part of the RTW of persons with MH problems. These are based on previous research within the field and the results of the expert group’s work.

2.2.2 SEAM information homepage

The homepage for employers includes information on how an employer can approach and support an employee showing signs of MH problems, and guidelines on how MH problems can be prevented at the workplace.

2.3 Participants

Participants were recruited through informational meetings at the Swedish Public PES and by contact persons or employers at the PES who provided information about the study to their employees. Information about the study was given verbally and in written form. The name and contact details of potential participants were then forwarded to the researchers. Ninety-four PES rehabilitation professionals (n = 94) were included in the evaluation. Most participants were women (70%), had 11 to 25 years of work experience and some experience of MH problems (e.g., own experience of having MH problems, next of kin or a close friend with MH problems, or education in MH problems). Most participants (91%) had previous experience of working within the mental healthcare and support systems. For more information on sociodemographic factors see Table 1.

Table 1
Description of sociodemographic factors and personal experience for Public Employment Service (PES) rehabilitation professionals (n = 94)

N %

Sex

Male 28 30

Female 66 70

Age (mean, range) 46 (25–64)

Education level in years

Upper secondary > 16 14 15

University/college < 18 80 85

Work experience (number of years, range) 25 (3–40)

Personal experience of MH problems ^*

No experience 20 21

Experience through own MH problems 19 20

Experience through next of kin MH problems 41 43

Experience through close friend with MH problem 36 38

Experience through education in mental health 30 32

	N	%
Sex
Male	28	30
Female	66	70
Age (mean, range)	46 (25–64)
Education level in years
Upper secondary > 16	14	15
University/college < 18	80	85
Work experience (number of years, range)	25 (3–40)
Personal experience of MH problems ^*
No experience	20	21
Experience through own MH problems	19	20
Experience through next of kin MH problems	41	43
Experience through close friend with MH problem	36	38
Experience through education in mental health	30	32

Note. PES = Public Employment Service; MH problems = mental health problems ^*Several response options are possible.

2.4 Sample size and effect size

The sample size was based on a power analysis with an expected effect size of 0.3 in the attitude outcome, a significance level of 0.05, power of 0.8, and an expected dropout rate of 10 percent. At the second follow-up (T2), immediately after SEAM training completion, 74 participants remained and 20 had dropped out. At the third evaluation time point (T3), 6 months after completion of training, 45 participants remained and 29 had dropped out. The primary reason for dropout was not having time to fill out the follow-up web survey because of a heavy workload, changing jobs, or changing e-mail address because of a national reorganization at the PES. No significant differences were found between baseline (T1) and 6 months after training completion (T3) with regard to gender (z = –0.435, p = 0.664), age (z = –0.126, p = 0.900), education level in years (z = –1.767, p = 0.077), or work experience in years (z = –141, p = 0.888).

2.5 Data collection

A web survey was used and contained questions on sociodemographic characteristics (age, gender, educational level, and work history), experience and knowledge of MH problems, and attitudes towards people with MH problems. Questions on rehabilitation professional use of supporting strategies towards job seekers with MH problems and employers were also included in the third survey (T3). Research Electronic Data Capture (REDCap) was used to collect data. REDCap is a secure web application for building and distributing web surveys [34]. A link to the web survey was sent to the participants e-mail addresses. A reminder was sent up to two times.

2.5.1 Instruments included in the web survey

2.5.1. 1 Reported and intended behaviour scale: Reported and Intended Behaviour Scale (RIBS) [35] concerns past and present experiences of meeting people with MH problems. Previous and current experience is estimated in four areas: 1) accommodation, 2) work, 3) neighborhood, and 4) friendship with a person with MH problems. These questions are answered with “yes”, “no”, or “do not know”. Several response options are possible. RIBS is a psychometrically robust measure with substantial/moderate internal consistency, Cronbach’s alpha 0.85, and test-retest reliability with a kappa value of 0.75 and weighted kappa ranging from 0.62 to 1.0 [46]. Additionally, service users and international stigma researchers have confirmed RIBS validity.

2.5.1. 2 Mental health knowledge scale: Mental Health Knowledge Scale (MAKS) [36] measures knowledge of mental illness. The instrument has been developed in England and has good psychometric properties. MAKS contains 12 statements; 6 are about knowledge of treatment and rehabilitation of persons with MH problems. The statements are estimated on a 5-point scale ranging from “totally agree” (5) to “strongly disagree” (1). There is also the ability to enter “do not know”. The total score for each participant is calculated by adding the response value of each item. For this analysis, negatively worded items were reversed as follows: (5 = 1) (4 = 2) (3 = 3) (2 = 4) (1 = 5). “Do not know” was coded as neutral (= 3). MAKS internal reliability, Cronbach’s alpha 0.65, and test-retest reliability using Lin’s concordance statistic (0.71), is moderate to substantial, and test validity is supported in a review performed by experts in stigma research and service users. Cronbach’s alpha for the MAKS was 0.66 in the present study.

2.5.1. 3 Community attitudes towards mental illness scale-swedish version: Community Attitudes towards Mental Illness scale-Swedish version (CAMI-S) [37] aims at estimating knowledge of mental illness. CAMI-S contains 20 statements relating to three attitude factors: 1) open-minded and pro-integration 2) fear and avoidance, and 3) community mental health ideology. Each statement is estimated on a 6-point scale ranging from “not at all” (1) to “totally agree” (6). The total score for each participant is calculated by summing the response value of each item. For this analysis, negatively worded items were reversed as follows: (1 = 6) (2 = 5) (3 = 4) (4 = 3) (5 = 2) (6 = 1). The development of the Swedish version of CAMI-S suggests very good internal consistency for the scale, with a Cronbach’s alpha value of 0.90 [48]. Cronbach’s alpha was 0.90 in the present study.

2.5.1. 4 Supporting behavior questionnaire: The supporting behavior questionnaire was developed based on the strategies taught in the SEAM training. As part of the questionnaire the participants are asked whether they have had contact with a service user who expressed that he or she had a MH problem in the last six months, or if they had contact with an employer as part of the RTW of a service user with MH problems. If yes, the participant is asked to rate the extent to which they used the different SEAM support strategies when meeting with a service user/employer on a 5-point scale (ranging from 1 = “not at all” to 5 = “to a much greater extent/on many more occasions”).

2.6 Statistical analysis

All analyses were performed using IBM SPSS Statistics 22. Kolmogorov-Smirnov tests were used to assess normality of data. Since most data were non-normally distributed, non-parametric statistics were used. The Wilcoxon signed rank test was applied to evaluate changes between baseline (before training, T1), immediately after the training (T2), and 6 months after the training (T3). Mann-Whitney U tests were used to analyze differences in gender, age, education level and work experience between participants at baseline (T1) and participants remaining at 6 months after training completion (T3). Cronbach’s alpha was calculated to assess reliability, or internal consistency, for the MAKS and CAMI-S instruments.

3 Results

3.1 Impact of SEAM on knowledge of mental illness

SEAM significantly increased rehabilitation professionals’ knowledge about MH problems from prior to (T1) to immediately after completion of the SEAM training (T2) (z = –2.037, p = 0.042). This increase in knowledge persisted at the 6-month follow-up (T3) (z = –5.093, p = 0.001). For example, after training completion (T1 to T2), significantly more rehabilitation professionals thought that persons with MH problems wanted to have paid employment (z = –2.092, p = 0.036). Furthermore, significantly more professionals knew what advice to give to a friend with MH problems (z = –3.041, p = 0.002), that people with MH problems can recover from their mental illnesses (z = –2.201, p = 0.028), and that schizophrenia is a mental illness (z = –1.983, p = 0.047). Significantly more professionals knew that stress and grief are not mental illnesses (z = –2.074, p = 0.038).

3.2 Impact of SEAM on rehabilitation professionals’ attitudes towards service users with mental health problems

Rehabilitation professionals’ attitudes towards service users with MH problems improved significantly according to the CAMI-S scale from prior to SEAM training (T1) to after training completion (T2) (z = –4.984, p = 0.001). No further change was seen from training completion (T2) to 6-month follow up (T3) (z = –1.088, p = 0.276).

On the CAMI-S scale, there was a significant change between T1 to T2 in all three subscales (Table 2). No significant changes on the subscales ‘fear and avoidance’ or ‘community ideology’ were found from training completion to 6 months after completion (T3). However, there was a significant change in the attitude factor being ‘open-minded and pro-integration’ from T2 to T3 (Table 2).

Table 2
Changes in Community Attitudes towards Mental Illness scale Swedish version (CAMI-S) attitude subscales among rehabilitation professionals from baseline, immediately after training, and 6 months after training completion

Measurements points

Median (range) T1 to T2 T2 to T3

T1 (n = 86) T2 (n = 68) T3 (n = 38) z-value p-value z-value p-value

1. Open-minded and pro-integration 4.33 (2–5) 5.11 (2–6) 5.00 (3–6) –5.680 0.001^* –2.030 0.042^*

2. Fear and avoidance 5.17 (4–6) 5.67 (4–6) 5.25 (3–6) –3.240 0.001^* –4.220 0.673

3. Community ideology 5.20 (3–6) 5.60 (3–6) 5.40 (3–6) –3.386 0.001^* –0.470 0.638

	Measurements points
1. Open-minded and pro-integration	4.33 (2–5)	5.11 (2–6)	5.00 (3–6)	–5.680	0.001^*	–2.030	0.042^*
2. Fear and avoidance	5.17 (4–6)	5.67 (4–6)	5.25 (3–6)	–3.240	0.001^*	–4.220	0.673
3. Community ideology	5.20 (3–6)	5.60 (3–6)	5.40 (3–6)	–3.386	0.001^*	–0.470	0.638

Note. CAMI-S = Community Attitudes towards Mental Illness Swedish version (33); T1, baseline, immediately before intervention; T2, immediately after training; T3, 6 months after intervention ^*Significant at p≤0.05 level.

3.3 Impact of SEAM on rehabilitation professionals’ supporting behaviors towards service users with mental health problems

More than 50%of those who completed the 6-month survey estimated that they had used six of the nine SEAM strategies when supporting a service user in RTW on “quite a lot” or “many” more occasions than before training (Table 3). More than 50%felt more safe in contact with a service user with MH problems, had taken time and listened non-judgmentally to a service user telling about his or her MH problems, recognized signs and symptoms of MH problems, given information about effective help, and assessed the risk of a mental health crisis on “quite a lot” or “many” more occasions.

Table 3
Percentage of study participants who often used SEAM (Support to Employers from rehabilitation Actors about Mental health) strategies when meeting with the service user/employer as part of the return-to-work process 6 months after training completion

SEAM /MHFA strategies used during contact with a service user with MH problems (n = 44) n %

I have on quite a lot, more occasions, or on many more occasions:

Made contact with a person with MH problems (n = 41) 20 49

Felt safe in contact (n = 40) 21 52

Taken time and listen nonjudgmentally (n = 41) 21 51

Recognized signs of mental illness (n = 41) 24 59

Asked about suicidal thoughts (n = 41) 12 29

Given information about effective help (n = 41) 21 51

Recognized symptoms of mental illness (n = 41) 24 59

Assessed risk of mental health crises (n = 41) 22 54

Suggested self-help strategies (n = 39) 17 44

SEAM strategies used during contact with the employer as part of the RTW of service users with MH problems (n = 44) n %

I have to a greater or a much greater extent:

Developed good relationships with employers (n = 39) 4 10

Engaged employers in rehabilitation and occupational health and safety issues (n = 38) 24 63

Conveyed employer knowledge of MH problems (n = 38) 28 74

Paid attention to the employer situation and considered the employer as expert on their business/organization (n = 38) 23 61

Met employers with experience of MH problems (n = 38) 20 53

Highlighted job seeker or employee abilities and resources when meeting with employer (n = 38) 30 79

Provided employers with the opportunity to meet with job seekers/service users (n = 38) 27 71

Created individually adapted employer support networks (n = 38) 14 37

Given onsite work support (n = 37) 23 62

SEAM /MHFA strategies used during contact with a service user with MH problems (n = 44)	n	%
I have on quite a lot, more occasions, or on many more occasions:
Made contact with a person with MH problems (n = 41)	20	49
Felt safe in contact (n = 40)	21	52
Taken time and listen nonjudgmentally (n = 41)	21	51
Recognized signs of mental illness (n = 41)	24	59
Asked about suicidal thoughts (n = 41)	12	29
Given information about effective help (n = 41)	21	51
Recognized symptoms of mental illness (n = 41)	24	59
Assessed risk of mental health crises (n = 41)	22	54
Suggested self-help strategies (n = 39)	17	44
SEAM strategies used during contact with the employer as part of the RTW of service users with MH problems (n = 44)	n	%
I have to a greater or a much greater extent:
Developed good relationships with employers (n = 39)	4	10
Engaged employers in rehabilitation and occupational health and safety issues (n = 38)	24	63
Conveyed employer knowledge of MH problems (n = 38)	28	74
Paid attention to the employer situation and considered the employer as expert on their business/organization (n = 38)	23	61
Met employers with experience of MH problems (n = 38)	20	53
Highlighted job seeker or employee abilities and resources when meeting with employer (n = 38)	30	79
Provided employers with the opportunity to meet with job seekers/service users (n = 38)	27	71
Created individually adapted employer support networks (n = 38)	14	37
Given onsite work support (n = 37)	23	62

Note. MH problems = Mental health problems; MHFA = Mental Health First Aid; RTW = return-to-work; SEAM = Support to Employers from rehabilitation Actors about Mental health.

3.4 Impact of SEAM on rehabilitation professionals’ supporting behaviors towards employers

More than 50%of those who completed the 6-month survey estimated that they had used seven of the nine SEAM supporting strategies to a greater or a much greater extent than before training when supporting an employer of a person with MH problems in RTW (Table 3). More than 60%estimated that they “to a greater or a much great extent” had engaged the employer in rehabilitation and occupational health and safety issues, paid attention to the employer’s situation, considered the employer as an expert on their business/organization, and provided onsite work support. More than 70%had “to a greater or a much greater extent” conveyed employer knowledge of MH problems, highlighted the job seeker or employee abilities and resources in the meeting with the employer, and provided the employer with the opportunity to meet with the job seeker or service user.

4 Discussion

SEAM significantly increased rehabilitation professionals’ knowledge in mental health and positively changed their attitudes and supporting behaviors towards employers and service users with MH problems as part of the RTW process. These results are in keeping with previous research, which shows that better knowledge of mental illness is generally linked to a more positive attitude towards persons with MH problems [38]. Furthermore, international and national research in relation to MHFA [29] shows that completion of MHFA training (part of SEAM training) among the general public commonly leads to more positive attitudes, improved knowledge and an increased amount of supporting behaviors towards a person with MH problems. Based on this research, it is reasonable to assume that an intervention like SEAM may have a direct impact on rehabilitation professionals’ mental health literacy (knowledge, attitudes and supporting behaviors towards service users with MH problems).

As part of the SEAM training rehabilitation professionals were trained in mental health and work, which included discussions on the stigma related to having MH problems. The different parts of the training are likely to have contributed to the observed increase in knowledge, positive changes in attitudes and improvement in supporting behaviors towards service users with MH problems. Previous stigma research shows that lack of knowledge, negative attitudes, and discrimination are barriers that adversely affect the opportunities for RTW among people with MH problems [39]. People with MH problems are more often treated with fear and hostility rather than support, compassion and understanding [15, 39]. This can lead to isolation and depression, but also to these persons not receiving care and rehabilitation on the same conditions as others [15]. They are often misunderstood, and at increased risk of discrimination in the RTW process [20]. Rehabilitation professionals’ views of persons with MH problems as capable working individuals play an important role for successful RTW [7, 40]. In this way, professional mental health literacy is crucial for a successful RTW for these persons. This further reinforces the importance of interventions such as SEAM.

There was a significant change in all three CAMI-S subscales 1) Open-minded and pro-integration; 2) Fear and avoidance; and 3) Community mental health ideology after training (T1 to T2). There was also a significant change in the attitude factor, “Open-minded and pro-integration”, from the second to third follow-up (T2 to T3). In general, Swedish persons have been found to be fearful of and avoidant towards persons with MH problems, especially persons with serious and enduring MH problems [37]. Health professions have not been found to be different in this regard. Previous research show limitations in their mental health literacy [6 , 12–19]. Additionally, they have been criticized for not giving service users with MH problems sufficient and adequate support in RTW [41 –43], even though such support is crucial [7 , 45]. It is therefore encouraging that an intervention like SEAM can prepare rehabilitation professionals to interact better with persons with MH problems, reduce fear and avoidance towards persons with MH problems and positively affect professional’s mental health ideology. This may increase the chances that service users with MH problems have successful RTW.

4.1 Methodological considerations

There are several methodological limitations to consider. The number of dropouts in web survey responses between the first, second, and third surveys may have negatively affected the results. The dropouts may be explained by national reorganization at the PES, which put great pressure on individual rehabilitation professionals, and many had to change jobs within the organization. However, the lack of significant differences in sociodemographic characteristics between the participants before training (T1) and those remaining six months after training completion (T3) suggests limited influence of the high dropout rate.

Some of the informants pointed out difficulties in answering the CAMI-S stigma instrument, and that may limit the validity and reliability of the results. This instrument was developed to measure community attitudes to MH problems in general, and many of the professionals in this study are used to distinguishing between different types of mental illness (6). Therefore, an instrument that measures attitudes (stigma) in a more nuanced way, more specifically in relation to the workplace, needs to be developed.

Another limitation was that the impact of SEAM on rehabilitation professionals’ supporting behaviors towards service users with MH problems and employers was only evaluated at the 6-month follow-up (T3). It was therefore not possible to analyze significant short-term changes from prior to training (T1) to after training completion (T2). Accordingly, there is a need for research on the short-term changes in supporting behaviors resulting from participation in SEAM training.

The lack of a randomized controlled study design may limit generalization of the results. Such a design would be necessary to verify whether the impact demonstrated is a result of the SEAM intervention or mainly due to other circumstances related to the participating individuals, their organizations, or work procedures. There is also a need to investigate SEAM’s effect on employers’ attitudes, knowledge, and supporting behaviors. This was not possible within the framework of this project. To evaluate SEAM using qualitative methods such as focus groups with rehabilitation professionals and employers, and to further develop SEAM based on such results is also needed. In summary, SEAM needs to be further researched before the intervention is scaled up within the framework of current RTW services.

5 Conclusions

SEAM may improve rehabilitation professional attitudes towards persons with MH problems and provide them with increased mental health literacy in relation to work that focuses on service users’ resources and work ability, as well as employers’ support needs. SEAM may also increase and improve professionals’ supporting behaviors towards service users and employers. This in turn can reduce employers’ negative attitudes, fear and uncertainty, and increase the chances of successful RTW for persons with MH problems. However, evaluating SEAM in a randomized controlled study design is necessary to verify that the demonstrated effects are a result of the SEAM intervention and not dependent on other circumstances.

Footnotes

Acknowledgments

The authors thank the rehabilitation professionals and the Swedish Public Employment Service who made this study possible. This work was supported by the Swedish Social Insurance Agency (Dnr: 057826-2014) and the Lund University Faculty of Medicine.

Conflict of interest

The authors declare no conflicts of interest.

Informed consent

Informed consent was obtained from each individual participant included in the study.

Research involving human participants and/or animals

All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1975, as revised in 2000. The Regional Ethical Board in Lund, Sweden (Dnr 2015/90) approved the study.

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	Measurements points
	Median (range)			T1 to T2		T2 to T3
	T1 (n = 86)	T2 (n = 68)	T3 (n = 38)	z-value	p-value	z-value	p-value
1. Open-minded and pro-integration	4.33 (2–5)	5.11 (2–6)	5.00 (3–6)	–5.680	0.001^*	–2.030	0.042^*
2. Fear and avoidance	5.17 (4–6)	5.67 (4–6)	5.25 (3–6)	–3.240	0.001^*	–4.220	0.673
3. Community ideology	5.20 (3–6)	5.60 (3–6)	5.40 (3–6)	–3.386	0.001^*	–0.470	0.638