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Abstract
Objectives Stigma may negatively affect line managers’ intention to hire people with mental health problems (MHP). This study aims to evaluate line managers’ knowledge and attitudes concerning job applicants with MHP, and to assess which factors are associated with the intention (not) to hire an applicant with MHP.
Methods A sample of Dutch line managers (N=670) filled out a questionnaire on their knowledge, attitudes and experiences concerning applicants/employees with MHP. Descriptive analyses and multiple regression analyses were used.
Results The majority (64%) was reluctant to hire a job applicant with MHP, despite the fact that only 7% had negative and 52% had positive personal experiences with such employees. Thirty per cent were reluctant to hire an applicant if they knew the applicant had past MHP. Associated with higher reluctance to hire an applicant with MHP were the concerns that it will lead to long-term sickness absence (β (95% CI)=0.39 (0.23 to 0.55)), that the employee cannot handle the work (β (95% CI)=0.16 (0.00 to 0.33)) that one cannot count on the employee (β (95% CI)=0.41 (0.23 to 0.58)) and higher manager education level (β (95% CI)=0.25 (0.05 to 0.44)). Conversely, associated with positive hiring intentions was being in favour of diversity and/or inclusive enterprise (β(95% CI)=−0.64 (−0.87 to −0.41)).
Conclusions As the majority of managers were reluctant to hire applicants with MHP, and even 30% were reluctant to hire applicants who had past MHP, these findings have major implications for social inclusion in the Netherlands, where about 75% of employees would disclose MHP at work.
- mental health
- cross sectional studies
- psychiatry
Data availability statement
Data are available on reasonable request. The data sets used and analysed during the study are available from the corresponding author on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Key messages
What is already known about this subject?
Unemployment rates are 3–7 times higher among people with mental health problems (MHP).
Workplace stakeholders are less willing to hire people with health issues such as MHP.
What are the new findings?
The majority of a representative group of Dutch managers (64%) were reluctant to hire a job applicant with MHP, despite the fact that only 7% had negative and 52% had positive personal experiences with such employees.
The finding that 30% of Dutch managers are still reluctant to hire an applicant with past MHP suggests that even after recovery stigma persists and is an important barrier to social inclusion.
As 91% of Dutch managers had one or more concerns regarding hiring employees with MHP, future interventions and education should address these concerns. Prevalent ones included reports of not knowing how to help (39%) or deal with (19%) the employee and the concern that it will negatively affect the workplace atmosphere (40%).
How might this impact on policy or clinical practice in the foreseeable future?
This study illustrates that workplace stigma is a problem for social inclusion. Interventions to reduce prejudice and to improve managers’ knowledge on to support rather than exclude employees with MHP are needed.
Introduction
Several studies investigating social inclusion and employer behaviour have shown that people with mental health problems (MHP) are less often invited for job interviews or offered a job.1 2 This occurs despite the fact that there are (international) policy goals such as the Convention on the Rights of Persons with Disabilities (CRPD) of the United Nations3 and interventions such as the international programme Mental Health First Aid4 to reduce (workplace) stigma and improve inclusion of people with MHP. Because unemployment rates are 3–7 times higher among people with MHP5 and line managers (ie, those responsible for managing employees and operations to achieve specific organisational goals, hereafter ‘manager’) have an important role in their employment opportunities,6 managers’ negative attitudes may be barriers to employment for job applicants with MHP.
One of the factors that can hamper integration of people with MHP into the labour market is workplace stigma and discrimination.7 Stigma can be considered as comprising problems of knowledge (such as lack of knowledge and misinformation) and attitudes that can lead to negative discrimination,8 and has various forms. Interpersonal stigma, that is, the interaction between the non-stigmatised and the stigmatised,9 can manifest itself in managers having concerns about employees with MHP, notably about reduced productivity, strange and dangerous behaviour, symptom severity, the risk of relapse and the need for work adjustments.10–12 Structural stigma may be present in institutional policies and practices.13 Several studies have found that stigma in the workplace is greater towards people with MHP than the stigma attached to people with physical disabilities14 15 and that managers are least willing to hire job applicants with MHP compared with people without disabilities or with physical disabilities.16
In the Netherlands, legislation is in place to protect employees with disabilities (ie, the Gatekeeper Improvement Act introduced in 2002 and Extended Payment of Income Act introduced in 2004). Employers, employees and occupational physicians became jointly responsible for disability benefits and reintegration to work when an employee drops out due to sickness.17 Through this act, Dutch employers have a significant responsibility for funding sick pay, in that they must pay at least 70% of the salary during the first 2 years of sickness absence, regardless of the cause of sickness.17 18 Furthermore, employers are not allowed to ask about health problems (eg, diagnosis) of a job applicant or employee and need to ensure that employees with disabilities have access to reasonable accommodations at work, as stated in the CRPD. 3 The responsibilities and risks (including financial risks) associated with the legislation may cause higher reluctance of managers towards hiring job applicants with health problems such as MHP.
As stigma in the work context is an understudied and underestimated factor contributing to unemployment,7 the aim of this study was to examine managers’ hiring intentions towards employees with past or current MHP, using a cross-sectional design. As previous research has emphasised that stigma is processed in three steps (ie, inadequate knowledge, subsequent negative attitudes and discrimination8), the research questions are as follows: (1) What is managers’ knowledge of MHP?, (2). What are their attitudes, including intentions, concerns and reasons to hire a job applicant with past or current MHP? and (3) Which factors are associated with the intention (not) to hire a job applicant with past or current MHP?.
Method
Data were collected in February 2018 using the Longitudinal Internet Studies for the Social Sciences (LISS) panel19 that was administered by CentERdata. The LISS panel is a Dutch representative, random sample of 5000 households and 8280 panel members who participate in monthly internet surveys, covering a large variety of domains including work, education, income, housing, time use, political views, values and personalities. The panel is based on a true probability sample of households in the Netherlands drawn from the population register. Households are provided with a computer and internet connection if needed to participate. LISS panel members have given informed consent to participate in monthly questionnaires. More information about the LISS panel can be found at http://lissdata.nl.
For the present cross-sectional study, an online questionnaire was sent to all members of the LISS panel who held a position of manager in February 2018 (N=976). After 1 month, a reminder was sent to members who had not filled out the questionnaire. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were followed during reporting of this cross-sectional study.20
Measures
Because of the explorative design of this study, a new questionnaire was developed fitting the purpose of this study, using several steps. First, scientific literature about stigma, discrimination and mental health in the workplace was explored. Second, the main topics in the questionnaire were identified, that is, knowledge about MHP, attitudes towards MHP including potential concerns and positive reasons and hiring intentions based on the theoretical stigma model proposed by Thornicroft et al.8 Third, consultation and discussion took place with senior researchers and international experts in the field of stigma and mental health. Finally, the questionnaire was pilot tested within the researchers’ network (N=18) and adjustments such as on the clarity of questions were based on feedback. The final version of the questionnaire addressed the following topics:
Questions on knowledge and attitudes regarding employees and job applicants with past or current MHP, including personal experiences, for example, ‘What are your overall personal experiences with coworkers with MHP in the workplace?’ (1=very negative to 5=very positive). These questions were based on the literature of workplace stakeholders’ knowledge and attitudes.12 15 Because addiction problems are a highly prevalent common mental disorder21 and one of the most stigmatised MHP,22 participants were asked in two statements: ‘I would be reluctant to hire a job applicant, if I were to know that (s)he currently has alcohol addiction problems’ and ‘I would be reluctant to hire a job applicant, if I were to know that (s)he has had alcohol addiction problems’ (1=strongly disagree to 5=strongly agree).
Potential concerns about having an employee with MHP for managers were asked using 17 statements, for example, ‘it will have a negative impact on workplace atmosphere’ (including the statements ’something else, namely…' and ‘I have no concerns about this’). Managers could indicate per statement with yes/no whether this was a concern for them. The statements were based on literature11 23 and feedback received in the pilot version.
Positive reasons to hire a job applicant while knowing that he/she has MHP, for example ‘if I think that the applicant will do a good job’, were asked using seven statements, to be answered with ‘yes’ or ‘no’. Statements were based on findings of a qualitative study on disclosure.24
Sociodemographics (ie, sex, age, number of household members, marital status, domestic situation and education) and work characteristics (ie, company size, sector and personal net monthly income in euros), were collected by CentERdata.
Statistical analyses
Descriptive analyses were carried out to illustrate the socio-demographics and work characteristics of managers and to explore managers’ knowledge and attitudes about employees or job applicants with MHP. For the descriptive analyses of personal experiences with coworkers with MHP the response categories ‘very negative/positive’ and ‘fairly negative/positive’ were merged into ‘very to fairly negative/positive’. Furthermore, for the descriptive analyses of the intention (not) to hire someone with past or current MHP, the response categories ‘strongly disagree/agree’ and ‘slightly disagree/agree’ were merged into ‘strongly to slightly disagree/agree’. Separate descriptive analyses were conducted about the intention towards hiring someone who has (had) alcohol addiction problems.
Two multiple regression analyses were conducted to examine which factors were associated with the dependent variables intention to hire someone with past/current MHP, on the 5-point Likert scale. Included were background characteristics, workplace characteristics, (personal) experiences with people with MHP, concerns about having an employee with MHP and positive reasons to hire a job applicant with MHP. For the multiple regression analyses, marital status was merged into the categories ‘married’ and ‘unmarried’, and education was merged into ‘high school or less’ and ‘more than high school’. Concerning potential concerns and positive reasons, ‘Something else’ was left out the analyses because this item covers a variety of self-invented concerns/reasons. Because workplace characteristics ‘company size’ and ‘personal net monthly income in euros’ had many missing values, (31% and 7%, respectively), these missing data were imputed in the model via multiple imputation. In both models, five imputations were conducted and pooled regression coefficients were reported.
Data analyses were performed with IBM SPSS Statistics for Windows, V.22.0. All p values were two tailed with an accepted significance level of 0.05.
Results
The questionnaire was filled out by 670 managers (response rate=68.8%). Responders and non-responders did not differ significantly in gender, education and personal net monthly income in euros. Responders had a significantly higher age (respectively M(SD)=46.10 (11.92) and 41.27 (11.00); t(637)=-6.20, 95% CI −6.36 to −3.30) and were more often married (respectively N(%)=374 (55.8%) and 135 (44.1%); t(974)=3.41, 95% CI 0.05 to 0.18) than non-responders. Fifty managers (7.5%) were excluded from the sample because they did not hold a position of manager at that moment. Therefore, N=620 managers were included in the analyses. Most managers were men (67.6%, N=419), married (56.0%, N=347) and working in a small company (55.0%, N=234). Concerning personal MHP, 15.4% of managers (N=94) had current or previous experience of a MHP themselves (see table 1).
Characteristics of the sample
Research question 1: what is managers’ knowledge of employees with MHP?
Most managers knew someone with MHP in either their work environment (58.3%, N=356) or outside the work environment (57.9%, N=354). The majority of managers had very to fairly positive personal experiences with coworkers with MHP in the workplace (52.1%, N=323), whereas 7.4% (N=46) of managers had very to fairly negative personal experiences with coworkers with MHP. Managers estimated that 20.9% (Min=0%, Max=100%) of employees in their organisation would be affected by MHP during their working life. Finally, managers were asked what MHP they thought of when they heard or read about ‘an employee with MHP’. The majority of managers mentioned depression, burnout, stress, and mental/emotional exhaustion (see table 2).
Knowledge and attitudes regarding (future) employees with MHP
Research question 2: what are managers’ attitudes, including intentions, concerns and reasons to hire a job applicant with past or current MHP?
Concerning attitudes, 64.4% (N=398) of managers were reluctant to hire a job applicant who currently has MHP. Moreover, 29.5% (N=182) were reluctant to hire a job applicant if they knew the applicant had past MHP. Regarding alcohol addiction problems, respectively, 84.0% (N=519) and 31.9% (N=197) of managers were reluctant to hire a job applicant with a current or past alcohol addiction (see figure 1).
Intention to hire someone with past or current MHP. *The response categories ‘strongly disagree’ and ‘slightly disagree’ were merged into ‘strongly to slightly disagree’ and the response categories ‘strongly agree’ and ‘slightly agree’ were merged into ‘strongly to slightly agree’. MHP, mental health problem.
No concerns were reported by 8.8% of managers; the great majority of managers (91.2%) did have one or more concerns regarding hiring employees with MHP. As can be seen from table 3, the most frequently reported concerns were that the employee could not handle the work (55.4%, N=343), that the MHP will lead to long-term sickness absence (43.1%, N=267), that one cannot count on the employee (41.3%, N=256), employees with MHP will have a negative impact on the workplace atmosphere (39.8%, N=247) and not being sure how to help the employee (39.3%, N=244). The most frequently reported positive reason to hire a job applicant with MHP was thinking that the applicant will do a good job (75.1%, N=466, see table 3).
Percentages of potential concerns and positive reasons for hiring, and multiple regression analyses between demographics, workplace characteristics, experiences with people with MHP, potential concerns regarding employees with MHP and dependent variables intention not to hire someone with current/past MHP
Research question 3: which factors are associated with the intention (not) to hire job applicants with past or current MHP?
Two multiple regression analyses were conducted with socio-demographic and workplace characteristics, (personal) experiences with people with MHP, concerns and positive reasons as independent variables and the dependent variables intention to hire someone with current MHP and intention to hire someone with past MHP.
Concerning hiring intentions towards an applicant with current MHP, significantly related to higher reluctance to hire an applicant with MHP were concerns that it would lead to long-term sickness absence (β (95% CI)=0.39 (0.23 to 0.55)), that the employee would not be able to handle the work (β (95% CI)=0.16 (0.00 to 0.33)), that one would not be able to count on the employee (β (95% CI)=0.41 (0.23 to 0.58)) and higher manager education level (β (95% CI)=0.25 (0.05 to 0.44)). In contrast, being in favour of diversity and/or inclusive enterprise (β(95% CI)=−0.64 (−0.87 to −0.41)) was associated with a significantly higher intention to hire someone with MHP. The overall fit of the model was adjusted R2=0.187 (see table 3).
Regarding the hiring intentions towards an applicant with past MHP, significantly associated with higher reluctance to hire someone with past MHP were male gender (β(95% CI)=−0.20 (−0.39 to −0.01)) concerns that it would lead to long-term sickness absence (β(95% CI)=0.19 (0.01 to 0.37)), that one would not be able to count on the employee (β(95% CI)=0.21 (0.02 to 0.41)), and having had no MHPs themselves (β(95% CI)=−0.41 (−0.65 to −0.18)). Believing that the applicant will do a good job (β(95% CI)=−0.36 (−0.56 to −0.16)) and being in favour of diversity and/or inclusive enterprise (β(955% CI)=−0.29 (−0.54 to −0.04)) was associated with a significant higher intention to hire someone with past MHP. The overall fit of the model was adjusted R2=0.103 (see table 3).
Discussion
This study examined managers’ knowledge, concerns and positive reasons to hire a job applicant with past or current MHP, and examined factors associated with the intention (not) to hire a job applicant with past or current MHP. Whereas only 7% of managers had negative personal experiences with employees with MHP, the majority of managers were reluctant to hire someone with current MHP or alcohol addiction problems (respectively, 64% and 82%). Moreover, about one-third of managers were reluctant to hire someone with past MHP or alcohol addiction problems (respectively, 30% and 32%). The great majority (91%) of managers had one or more concerns regarding hiring employees with MHP. Strongest predictors for being reluctant to hire an applicant with current MHP were concerns about long-term sickness absence, concerns that the employee would not be able to handle the work, the concern of not being able to count on the employee and higher manager education level. In contrast, significant predictors for positive hiring intentions was managers’ being in favour of social inclusion out of principle.
Despite the fact that managers had an accurate understanding of prevalence of MHP in the work environment and that most managers had positive personal experiences with people with MHP in private or at work, the majority was reluctant to hire an applicant with MHP. Previous studies have also found many managers to have concerns about e.g. absenteeism and the reliability of employees with MHP.10–12 However, managers’ views may be too pessimistic due to a well-known phenomenon in social psychology called the negativity bias.25 This phenomenon refers to the fact that negative instances tend to be more influential than comparably positive ones. For instance, it could well be that employees with MHP who display ‘negative behaviour’ in the workplace (eg, conflict, crying, absenteeism) are perceived more often than those who display ‘positive behaviour’, tthat is, continue doing their work despite their health problems. Moreover, as a substantial part of employees with MHP does not disclose, managers may not even be aware of their health problems and be blind to those ‘positive examples’. The point prevalence of MHP in the working age population about 20%,5 which implies that many employees with MHP must do their work well despite their health problems, and remain unnoticed. Furthermore, concerns may be a result of limited or biased knowledge of mental illness26 because managers are—like everyone else—exposed to the typically negative societal stereotypes created by, for example, entertainment and news media, often emphasising unreliability and dangerousness.27 28 Providing more accurate knowledge and a representative presentation of people with MHP, for example, through intergroup contact with an unbiased group of employees with MHP can have destigmatising effects.29 However, currently non-disclosing employees will need to feel safe enough to share their MHP with their supervisor to do so.30
According to Dutch legislation employers cannot fire a sick listed employee for 2 years, during which they need to pay for at least 70% of the sick employee’s salary.17 This may explain managers’ fears for long-term absenteeism when hiring an employee with MHP found in the present study. In the Netherlands, absenteeism costs are annually more than 11 billion euros for employers in continued payment of wages, and 22% of absenteeism is associated with MHP, with an average absence duration of 56 days in a year.31 Therefore, managers’ worries about long-term sick leave is understandable. However, we found that being protected against financial risk, for instance by wage subsidy, was not a significant predictor of positive hiring intentions, which suggests the influence of costs on managers’ reluctance should not be overestimated. Moreover, MHP are highly prevalent in our society (the lifetime prevalence of mental disorders in the global population is 29%32) and we should not exclude these employees from the labour market. Improving a realistic view, that is, that MHPs do not always lead to adverse occupational outcomes, promoting positive attitudes about, for example, social inclusion in the work environment and improving manager skills in how to guide employees with MHP may have a positive influence on the hiring intentions of managers.
The finding that the majority of managers was reluctant to hire applicants with MHP, seems to contrast with the high percentage (75%) of Dutch employees that indicated they would disclose MHP to their managers in a recent study.30 Although the latter finding comes from a study on employees who already were employed this area needs further study. A possible explanation is that Dutch employers cannot fire sick listed employees for 2 years17 which may create a false sense of security and a higher willingness in employees with MHP to disclose. This urges the importance of making disclosure decisions deliberately and to prepare them well to enhance the possibility of a positive outcome. More studies are needed on how to support job applicants with MHP in when and what to communicate. Strategic disclosure and preparing who to disclose to, how to disclose and the content of the message24 may have a positive influence on the hiring outcomes.33 34
The fact that as many as 30% of managers were reluctant to hire someone with past MHP, suggests that even after recovery of MHP, stigma remains and may form an important barrier to the employment opportunities of people with MHP. This calls for the development of destigmatising interventions and manager training,24 35 but research on workplace stigma and especially on destigmatizing interventions is still in its infancy. Work related antistigma interventions could improve managers’ knowledge, skills and supportive behaviour,36 which can be important positive facilitators for sustainable return to work for people with MHP.37 Also, studies have shown that the work context itself plays a critical role in (sustainable) employment of people with MHP.37 38 Finally, a new view on sustainable employability, based on the capability approach,39 40 may be of added value in designing future antistigma interventions for managers. This promising non-medical approach, which is becoming increasingly popular in Dutch occupational health practice, stresses diversity, and therefore, is destigmatising by nature. Here, emphasis is placed on what employee’s value in work, and how they are able and enabled to realise these values, and on employees’ well-being.39 40 Workplace stigma is an important disabler of employees’ values.
Strengths and limitations
The strengths of this study are the use of a large sample of managers from the representative LISS-panel. The LISS-panel recruits participants on a true probability sample drawn from population registers. Because the questionnaire is filled out by managers working in practice, and not as a vignette study, the study provides a reliable insight into the attitudes of managers. Managers participate monthly in this panel, online and anonymously, which may reduce the influence of social desirability. Limitations of this study are the cross-sectional design of the study, for which no causality can be presumed. Because this study is one of the first studies to examine managers’ attitudes towards people with MHP in the Netherlands, the topics in the questionnaire are broad and explorative. Finally, managers were asked about their intention to hire someone with MHP instead of their actual hiring behaviour. Future studies may want to take a longitudinal approach, investigating actual hiring behaviour of managers over time and other topics related to workplace stigma, such as structural stigma.
Conclusion
In conclusion, as almost one-third of managers were reluctant to hire job applicants with past MHP, and 64% were reluctant to hire applicants with current MHP, these findings have major implications for social inclusion in the Netherlands, where about 75% of employees would disclose MHP at work. Further research on mental health disclosure and workplace stigma is urgently needed to improve social inclusion of people with MHP. Moreover, relevant work experience should be gained, including unpaid work experience such as internships/traineeships and work experience programmes to increase job seekers’ knowledge and skills. Importantly, this work experience must be communicated and highlighted during job interviews by job applicants.
Data availability statement
Data are available on reasonable request. The data sets used and analysed during the study are available from the corresponding author on reasonable request.
Ethics statements
Ethics approval
The Ethic Review Board of Tilburg University approved the study design, protocol, and data management plan (registration number: RP193).
Acknowledgments
In this paper we make use of data of the LISS (Longitudinal Internet Studies for the Social sciences) panel administered by CentERdata (Tilburg University, The Netherlands). We want to thank the Tilburg University Alumni Fund for their financial support.
References
Footnotes
Contributors EPMB, MCWJ, JvW and KJ designed the study. EPMB was project leader. EPMB and JvW acquired funding for the study. JM assisted in the statistical analyses of the study. KJ wrote the (revised) manuscript and EPMB, MCWJ, JW, CD, CH and JM provided feedback on the (revised) manuscript. All authors named adhere to the authorship guidelines of the trials and agreed to publication. All authors read and approved the final manuscript and revised manuscript and no professional writer has been involved.
Funding This study was funded by the Tilburg University Alumni Fund.
Disclaimer The funder had no role in the design of the study, in the collection, analysis, or interpretation of data, or in the writing of the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.