Improving Vocational Rehabilitation for people with Mental Health Problems through Intersectoral Collaboration: A Mixed-Method Implementation Study

Abstract Rationale: Work participation is associated with improved health and wellbeing. Vocational rehabilitation (VR) programs support individuals, including those with mental health problems, in obtaining and maintaining employment. Integrating mental health and work support in VR is considered more effective but requires cross-sector collaboration. In a Dutch region, multiple stakeholders jointly implemented a collaborative initiative, covering the access route to and the delivery of three VR interventions. This study evaluated the implementation process, outcomes, and working mechanisms of this collaborative initiative. Method: We conducted a mixed-methods process evaluation, including 37 interviews with 12 clients, 14 professionals, and 11 managers/directors, supplemented by field notes and documents over a 3-year period. Monitoring data included intervention start and end dates, participation ladder (PL) level, and registered outcomes (i.e., paid employment or voluntary work). Data were analysed using the UK MRC guidelines for process evaluations, covering implementation outcomes (according to Proctor), mechanisms of impact, context, and both intended and unintended outcomes. Results: Between January 2021 and December 2023, 129 clients were reached. Recruitment was challenging. Referral was hindered by external professionals’ limited awareness, knowledge, and belief in clients’ potential. Mean duration (dose) of the intervention lasted or exceeded the original setup, aligning with client perceived needs. Monitoring fidelity ranged from 100% at the start to 89% at 12 months, indicating fair to good fidelity. Clients valued informal conversations equally or more than the structured monitoring conversations. Trust between clients and professionals enhanced the intervention experience and perceived effectiveness. From 111 out of 129 participants their outcomes were monitored: 62 (56%) entered voluntary or paid work, after participation in the intervention. Key collaborative mechanisms were mutual trust among professionals and belief in the added value of collaboration. Contextual factors included economic-financial, political-financial, and socio-psychological factors: Governmental support and the meaningfulness of work were facilitating factors, whereas barriers included legislation and stigma, including low expectations regarding the capabilities of individuals with mental health problems. Conclusion: Professionals’ knowledge and awareness of VR interventions, alongside stigma and existing legislation influenced whether individuals with mental health issues were reached for an intervention that best fits their needs. This may lead to practice variation and unequal opportunities. Clients appreciated the multifaceted support and felt they had more choices although intervention choice was usually directed by professionals. During interventions delivery both clients and professionals valued cross-sector collaboration. Trust between client and professional and among professionals was found to be a crucial mechanism for the collaborative initiative, clients progress and VR intervention success.