A study led by the WHO estimates that mental health difficulties cost the global economy US$ 1 trillion every year in lost productivity [53]. These costs are expected to rise as the COVID-19 pandemic has aggravated financial instability, prompted restructuring, and accelerated the pace of change in enterprises, which may create new psychosocial risks or exacerbated existing ones [53]. Workplaces that promote mental health and support people with mental disorders are according to the WHO more likely to reduce absenteeism, increase productivity and benefit from associated economic gains, but there is a need to support SMEs more thoroughly in implementing such measures [24, 36]. The current survey assessed key informants’ opinion about the use and acceptability of interventions to promote wellbeing and prevent mental health issues in SMEs, reasons for not using such interventions by SMEs, and gender specific needs to watch out for. Our study included a diverse set of key informants from a wide range of countries, and a key finding was the strong level of agreement regarding the need for psychosocial interventions in an SME context. This data supports the feasibility and utility of developing an intervention such as the MENTUPP intervention to be used across a wide range of contexts, as a universal intervention for SME employees from the sectors of construction, healthcare and ICT.

Measures to create mentally healthy workplaces are according to our results the most commonly used mental health intervention in SMEs. Such measures include providing flexible and supportive working conditions and/or acting to avoid stressful working conditions, such as long working hours, excessive workload or poor supervisory support. More specific mental health interventions such as training managers or human resources staff on how to promote wellbeing, providing psychological support services to employees, conducting a needs assessment to inform an organizational approach, developing and implementing a strategic and coordinated approach to promote employees' mental wellbeing, and developing and implementing a strategic and coordinated approach to reduce stigma are according to the informants in our study used little or not at all in SMEs. The ESENER survey, a cross-national survey that examines how European SMEs manage safety and health risks in practice (EU-OHS 2020), similarly reports that roughly half of the participating SMEs are putting in place measures to address psychosocial risks and create a healthier workplace. Examples of these measures are allowing employees to take more decisions on how to do their job, arranging confidential counselling for employees, organizing training on conflict resolution, and reorganizing work to reduce job demands and work pressure (EU-OHS 2020). Benning et al. [3] also report that in Dutch SMEs the most frequently used preventive health measures focus on improving working conditions, whereas interventions that aim to promote healthier lifestyles (e.g. sports/fitness subscriptions, lifestyle counselling, stress-management courses) are hardly used.

Our results show that there are several barriers at the level of the organisation that prevent SMEs from implementing interventions to promote employee wellbeing. According to nearly a third of our informants, investing in employees’ mental health is not a priority and therefore usually not part of the organization’s culture. Financial or budgetary issues as well as time management problems are also frequently mentioned as barriers by the informants. Furthermore, several informants pointed out that SMEs lack knowledge about mental health policies and interventions, and lack structures and competency to implement such interventions within the organisation, which may affect supervisors’ commitment to put their shoulders to the wheel. A literature review conducted by McCoy et al. [30] examined evidence regarding the adoption and efficacy of worksite health promotion programs in small businesses and identified comparable barriers. The direct and indirect costs of adopting a program was perceived as a major hindrance for small businesses, as they have fewer resources to invest in health programs that may or may not pay off and cannot afford to hire a staff person who is responsible for implementing such programs. McCoy et al. [30] reported two additional barriers that were not mentioned in our study: first, especially in small businesses it can be hard to justify targeted interventions that may only reach a small number of employees; second, companies do not have time and expertise to evaluate the efficacy of such interventions which is important to decide about its sustainability. The barriers mentioned by our informants are also similar to the findings reported by Benning et al. [3], who recently investigated determinants for implementing measures to prevent musculoskeletal and mental disorders in Dutch SMEs. The identified determinants relate to 10 distinct themes: (1) available resources (both finances and staff) (2) complexity of implementation of measures, (3) awareness, (4) knowledge and expertise, (5) availability of time, (6) employer and worker commitment, (7) workers’ openness for measures, (8) communication, (9) workers’ trust and autonomy, and (10) integration in organizational policy.

Except for barriers at the level of the organisation, our informants mentioned several concerns at the individual level that may prevent employees in SMEs from participating in mental health interventions at work. In particular, worries about confidentiality, discretion and mistrust, fear of stigma, discrimination and prejudices, as well as concerns about career progression and job security (e.g., job loss, loss of status, etc.) may be a deterrent [5]. Also, employees not being interested in mental health interventions is a reported barrier. The review of McCoy et al. [30] also reported privacy concerns such as stigmatisation of high-risk groups and discriminatory job dismissal. Benning et al. [3] similarly refer to the fear that employees are not taken seriously or will be stigmatized when it comes to psychosocial risks.

Our informants highlighted methods that could be used to overcome these barriers. Promising strategies to get the buy-in from managers for mental health interventions are providing information about the economic and social benefits of workplace mental health promotion, sharing positive testimonials from other managers, and promoting the use of interventions requiring minimal time investment for managers as well as employees. Once there is buy-in of employers, information, tools and advice on how to create mentally healthy working conditions, how to establish policies about creating mentally healthy workplaces, how to deal with work stress and burnout, and how to detect and handle mental health problems among employees are, according to our informants, highly needed. The informants also highlighted the importance of putting effort into strengthening the commitment of supervisors and managers along the way by arranging regular communications about mental health. A study of Dawkins and colleagues [13] similarly emphasized the need to strengthen SME managers’ interest in engaging in mental health programs by presenting a strong business case focusing on the benefits of the program for managers, employees, and the overall business and by stipulating that such interventions are effective and worth their time and money. Although numerous studies are available on the positive effects of mental health interventions in large companies, such studies are almost non-existent in SMEs despite SMEs employing a large proportion of working populations [17, 30, 44].

Methods for encouraging employees to participate in mental health interventions, according to our informants, are: sparking their interest through campaigns, strengthening personal relationships between employees which may help to reduce stigmatizing attitudes, and increasing employees’ knowledge on mental health. Public Health England [40] additionally highlighted the importance of good relationships between leaders and their employees to improve health and wellbeing in the workplace.

One important concern was raised regarding the acceptability of online mental health tools. Despite the practical benefits of accessing such interventions via work computer equipment, two-thirds of the informants believed that employees may feel uncomfortable to do so in the workplace setting. Our results also show that employees have easier access to online interventions via their personal smartphone than via a computer [8] also report that for people working in open-plan offices, access to such interventions during work-hours is considered less feasible. Moreover, although online interventions are considered convenient and flexible to use, many employees do not have time to engage in such interventions during working hours and favour a temporary and spatial separation of work and individual web-based psychological interventions [8].

Finally, as stated [28, 32], gender is an important determinant of both mental health and employment and this consideration is also reflected in our findings as many of the informants concurred that there is a significant difference between men and women in terms of seeking help for mental health problems, with women being more likely to seek help. Women are at greater risk of suffering from depressive and anxiety disorders than men [18], which may partially be due to women being at increased risk of trauma and exposure to psychosocial risks such as sexual harassment in the workplace [7], which has been shown to nearly triple the risk of depression [14]. Furthermore, women tend to have lower status job roles and female-dominated industries are characterised by low pay and lower benefits [20]. However, a study found that employed men found it more difficult to access mental health services than employed women [31], while a study of [10] reports that the reluctance of men to seek help and to disclose about vulnerability is more pronounced in rural than in urban settings. Therefore, the differences in help-seeking may reflect partially a lower prevalence of some mental health conditions in men, as well as a tendency for some males to face additional barriers to help-seeking. The aforementioned tendencies for men and women are most likely not related to differences due to biological sex but instead to differences in gender roles: for example, a recent study in psychiatric nurses found that individual gender roles were associated with sex-specific health trajectories, including the masculine gender-role having a protective effect on trauma symptoms [26]. The same study also focused on occupational gender-roles, which may vary across different workplace settings. Many of our informants mentioned that gender-specific needs should be considered when addressing male-dominated and female-dominated workplaces. Seaton et al. [45] also mention that developing mental health interventions tailored to the specific needs of men working in a masculine workplace culture (e.g. tackling masculine ideals such as self-reliance and stoicism), are preferable in male-dominated working cultures over interventions targeting the general public. However, it must be noted that women working in male-dominated industries face particular challenges and are at risk of increased depressive symptoms [49]. Indeed, a study found that working in a sector where one’s own gender was predominant was associated with better mental health for both genders [49], highlighting the importance of not overlooking the needs of women when planning interventions for male-dominated industries.

A major strength of this study is that it contributes to the limited amount of scientific knowledge that is available about the needs and barriers of SMEs across Europe to become more active in implementing mental health interventions. The findings are valuable in shaping the MENTUPP intervention [1] and in giving direction to future research. Moreover, the study is comprehensive for two reasons. First, the data relate to a variety of countries in different geographical, political, cultural and economic regions, and involve a range of experts. Despite these differences, answers were largely consistent between country and expert groups. Second, the content of the survey is extensive as it addresses various research questions and the development of the survey relied on the identification of knowledge gaps in the literature and the consensus of a large number of international researchers involved in the MENTUPP consortium.

Despite these strengths, there are also some methodological limitations that need to be acknowledged. First, the study used a combination of sampling methods (networking, snowballing, internet searches) to locate key informants with specific expertise in mental health in construction, healthcare and ICT, which resulted in an unequal number of informants per country, with Albania and Hungary both being represented by ten or more informants and Australia and Germany being represented by less than five informants each. Thus, although the data were collected in several countries and comprise three different sectors of activity, they can neither at a national level nor at a sectorial level be interpreted as representative. The data in Supplementary Table 1 shows that the countries with significantly lower response rates (Australia and Germany) are countries where less than half the workforce are employed by SMEs, meaning there is the possibility that there may be some specificities to countries where a lower proportion of the population is employed in SMEs which are not captured by this survey. Second, the response rate of 44.5% was quite low, resulting in a relatively low number of informants participating in the consultation survey, although this response rate appears to be typical of web-based expert surveys [9, 11]. The response rate and variation between countries, appeared to be related to several factors. Research officers found it especially difficult to engage with experts from outside their personal network, while experts who declined to participate cited lack of time, or that they received too many requests to take part in this type of activity. A small number of experts in Germany also complained of technical issues with the German-language version of the survey. While the response rate may have biased our responses, the general trends of our results have also been found in other studies – therefore we believe that the informants responded in line with earlier findings. Third, our data did not allow us to look more in depth to sector specific results, as most participants reported to have knowledge of more than one sector or did cross-sectoral work and thus did not relate to one specific sector, as is the case for academics or representatives of occupational health association groups. Hence, our findings need to be interpreted across the three target sectors. Finally, there is a small possibility that the quality of the qualitative data is affected by translation issues as the majority of the informants were not native English speakers. However, this was mitigated by them either being fluent enough in English to directly answer in English, or the local language answers were translated by a research officer with specialist knowledge in the field. Furthermore, the thematic analysis identified consistent themes across responses from both English-speaking and other countries, and the core findings of the qualitative data largely corroborate previous study findings.