Implementation of WHO's Doing What Matters in Times of Stress in Dutch Small and Medium-sized Enterprises (SMEs)

Rationale: Small and medium-sized enterprises (SMEs) often lack the resources to combat the negative consequences of work stressors (e.g., high workplace digitalization). This puts their employees at risk of developing mental health problems. Literature on effective interventions at work for SME employees' mental health is scarce and inconclusive. This project focuses on the implementation of Doing What Matters in Times of Stress (DWM), a scalable, low-intensity, online psychological intervention developed by the World Health Organization (WHO) and adapted for use in Dutch SMEs. This study is part of the larger EU H2022-ADVANCE project, which aims to improve the mental health of vulnerable populations in Europe.

Objective: The main objective is to assess the (cost-)effectiveness of DWM in improving the mental health and work outcomes in employees of Dutch SMEs. Another objective is to identify a) barriers and facilitators to intervention engagement and adherence and b) opportunities and budget impact for scaling up the implementation of the interventions within the context of working adults in Dutch SMEs.

Study design: The first phase of this study concerns a cluster randomized controlled trial (cRCT) comparing DWM and care-as-usual (CAU) to CAU only. Main and secondary outcomes will be assessed at baseline (week 1), 1 week after completion of the 5-week intervention (week 7), and at 3-month follow-up (week 18) which is approximately 12 weeks after the end of the intervention. The second phase consists in the qualitative process evaluation that pertains individual interviews and/or focus group discussions.

Study population: In the first phase, the population is working adults in Dutch SMEs with self-reported elevated psychological distress. The aim is to include in the trial a total of 74 SMEs (37 per study arm) and to include five to 10 employees per SME (on average of seven employees; 259 per study arm, total N = 518), to detect a significant reduction in symptoms of depression and anxiety of Cohen's d of 0.34 at 1-week post-intervention (power=0.80, two-sided alpha=0.05, ICC=0.01, 30% attrition).

In the qualitative process evaluation, the population is: participants who completed DWM and improved (n=10), who did not improve (n=10), and who dropped-out during DWM (n=10); facilitators of DWM (n=5-10); representatives of SMEs, occupational health advocacy umbrella organisations and SME umbrella organisations (n=10).

Intervention: DWM is an online intervention based on an illustrated stress management book developed by WHO. It is delivered in 5 sessions over 5 consecutive weeks, with a weekly supporting 15 minutes telephone call from a trained non-specialist facilitator (i.e., helper). DWM teaches strategies to help reduce stress such as mindfulness exercises (e.g., grounding).

Main study parameters/endpoints: The primary outcome of the cRCT will be the reduction in symptoms of depression and anxiety from baseline to 1-week post-treatment. A decrease is anticipated in the intervention group compared to the control group, with a Cohen's d effect size of 0.34. A decrease is also anticipated in the intervention group compared to the control group in the secondary outcomes: anxiety, depression, burnout, absenteeism, presenteeism, self-stigma; and an increase in work-engagement. Effectiveness will be assessed using linear mixed models, which account for repeated measures and clustering at the organizational level.

Through interviews and/or focus group discussions, the feasibility of scaling-up the implementation of the DWM intervention within the Netherlands will be examined.

Inclusion criteria

(SMEs):

• Having 10 to 250 employees
• Being located in the Netherlands

In case of insufficient recruitment among SMEs, a mitigation strategy is to recruit public and non-profit organizations, and units of larger organizations, all employing between 10 and 250 employees.

Inclusion criteria

(Individual participants):

• 18 years or older
• Having elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 scores > 15.9)
• Sufficient literacy and mastery (written and spoken) of one of the languages the DWM intervention is being delivered in (i.e., Dutch or English)
• Having access to an electronic device with internet access to follow the intervention
• Written informed consent before entering the study

Exclusion criteria

(Individual participants):

• Imminent suicide risk, or expressed acute needs or protection risks that require immediate follow-up
• Currently receiving specialized psychological treatment (e.g., EMDR or CBT) at the time of screening
• In case of current psychotropic medication use: being on an unstable dose for at least 2 months or a change in dosage over the past 2 months.
• Having participated in the preceding ASCEND trial as supervisor (see NCT ID: NCT06989398)