Line manager training and organizational approaches to supporting well-being

Abstract Background Employee mental health and well-being (MH&WB) is critical to the productivity and success of organizations. Training line managers (LMs) in mental health plays an important role in protecting and enhancing employee well-being, but its relationship with other MH&WB practices is under-researched. Aims To determine whether organizations offering LM training in mental health differ in the adoption of workplace- (i.e. primary/prevention-focused) and worker-directed (including both secondary/resiliency-focused and tertiary/remedial-focused) interventions to those organizations not offering LM training and to explore changes in the proportions of activities offered over time. Methods Secondary analysis of enterprise data from computer-assisted telephone interview surveys. The analysis included data from organizations in England across 4 years (2020: n = 1900; 2021: n = 1551; 2022: n = 1904; 2023: n = 1902). Results Offering LM training in mental health was associated with organizations’ uptake of primary-, secondary-, and tertiary-level MH&WB activities across all 4 years. The proportion of organizations offering primary-, secondary- and tertiary-level interventions increased over time. On average, tertiary-level activities were most adopted (2020: 80%; 2021: 81%; 2022: 84%; 2023: 84%), followed by primary-level activities (2020: 66%; 2021: 72%; 2022: 72%; 2023: 73%) and secondary-level activities (2020: 62%; 2021: 60%; 2022: 61%; 2023: 67%). Conclusions Offering LM training in mental health is associated with the adoption of other MH&WB practices by organizations. Suggesting that organizations that are committed to the mental health agenda are more likely to take a holistic approach (including both worker and workplace strategies) to promoting workforce mental health, rather than providing LM training in isolation.


INTRODUCTION
National surveys show population declines in personal well-being across the UK [1].Over the past few years, there has been an increase in mental health challenges among working adults during and after the coronavirus disease 2019 (COVID-19) pandemic [2].From a public health perspective, the prevention and management of mental ill health through the workplace setting is an important strategy for improving population health [3].From an economic perspective, for those who are vocationally active, mental ill health is now a leading cause of workplace sickness absence, accounting for around 17 million working days lost each year [4], costing around £56 billion annually [5].This has implications for the productivity of employees and a high economic impact on organizations [6,7].Therefore, there are clear public health and economic arguments for promoting mental health and well-being (MH&WB) at work.Despite the rising prevalence of mental ill health, many employers are still unaware of their critical role in supporting the mental health of their employees [5,8], with many employers having limited provisions or policies in place to promote employee psychological well-being [9].We hypothesize that organizations that offer training to their line managers (LMs) in MH&WB may offer more, or a different profile of, MH&WB policies and practices compared to organizations that do not offer training.Potentially due to an increased awareness and knowledge about workforce well-being amongst their managers who may subsequently implement them.However, there is currently no evidence to demonstrate this.
Workplace mental health interventions are typically categorized as primary (prevention-focused activities focused on reducing or better-managing work stressors through job design and management practices), secondary (employee-focused activities focused on bolstering their resilience and coping strategies), or tertiary (remedial-and curative-focused activities) [10].A holistic approach integrating all three levels of intervention, which targets both workplace-(e.g.primary) and worker-directed strategies (e.g.secondary and tertiary interventions), is advocated as the best practice [11,12].However, primary prevention is of particular importance to maximize employee health and productivity [12,13].The importance of prevention-orientated approaches is strongly emphasized in both national guidance (e.g.National Institute for Health and Care Guidance [11]) and international standards (e.g.ISO 45003 standards on psychological health and safety at work [14]), with reference to the central and ongoing role played by LMs throughout the process.
LMs' behaviours and wider management practices are a determinant of employee well-being [15][16][17].It is, therefore, crucial to equip LMs with the knowledge, skills and abilities to (i) effectively support, guide and promote the MH&WB of their direct reports (people they manage); (ii) ensure they can design and manage people's work to minimize work-related stress and (iii) cultivate a supportive and psychologically safe work environment.There is growing evidence that the necessary knowledge, skills and behavioural competencies needed to execute these tasks and roles by LMs can be learned and enhanced through targeted training programmes [18][19][20].However, a survey conducted by the Institution of Occupational Safety and Healthprior to the COVID-19 pandemic-found that only 43% of organizations offered mental health training for their managers [21].From 2020, the onset of the COVID-19 pandemic amplified workforce mental health risks [22].While there are interventions being developed to support workforce mental health [23][24][25][26], the provision of LM training in mental health remains sub-optimal.Although data from large-scale employer surveys demonstrate that the proportion of organizations offering LM training has increased over time (to 59% in 2023), 41% of organizations still do not provide LM training in mental health [27].
There is little information available on the context in which LM training in mental health is delivered in organizations that provide it.The aim of this study, therefore, is to explore whether (or not) LM training initiatives contribute to a wider organizational strategy targeting employee well-being, which draws on a variety of workplace health promotion approaches and initiatives.To address this aim, the research question is: 'Do organizations offering LM training differ in their adoption of primary-, secondary-and tertiary-level MH&WB practices, compared to those that do not?' .

METHODS
A secondary analysis of longitudinal, anonymized survey data from organizations in England was conducted.The data were derived from computer-assisted telephone interview surveys collected over 4 years, under a broader project 'Mental health and well-being practices, outcomes, and productivity: A causal analysis' .Data were collected from employer representatives (business managers) in 2020 (1900 firms), 2021 (1551 firms), 2022 (1904 firms) and 2023 (1902 firms).Of these, 118 organizations participated in the survey for all 4 years.Throughout this study, the predictor variable was 'LM training in mental health' , measured as a single, dichotomous variable (coded: no = 0, yes = 1).All outcome variables were measured as categorical variables.To explore the relationships between our predictor variable and outcomes, we conducted probit regression analyses to determine the probability of specific outcomes occurring based on the presence or absence of LM training in mental health.This allowed for a deeper understanding of how LM training relates to the use of other MH&WB practices by surveyed organizations.The analyses controlled for age of the organization (0-10 years, 11-20 years, more than 20 years), sector (Production, Construction, Wholesale/Retail, Hospitality, Business Services and Other Services) and size of the organization (micro/small:1-49; medium: 50-249; large: 250+ employees).The MH&WB practices offered by organizations were classified into primary,

Key learning points
What is already known about this subject: • Improving employee well-being is important for the overall performance of organizations.• Line managers play a crucial role in supporting employees' well-being and are strategically positioned to identify early signs of mental health issues.• Providing line manager training in mental health is a recommended strategy for enhancing employee mental health and well-being.

What this study adds:
• Positive mental health and well-being practices increased throughout the COVID-19 pandemic-the proportion of organizations offering primary-, secondary-and tertiary-level interventions has increased year on year.• Positive mental health and well-being practices cluster together-those organizations offering line manager training are more likely to offer a range of primary-, secondary-and tertiary-level interventions than organizations not offering this training.• Among organizations offering line manager training in mental health, tertiary-level intervention activities are the most frequently adopted, followed by primary-and then secondary-level mental health and well-being practices.
What impact this may have on practice or policy: • Organizations should invest in line manager training in mental health as part of their broader mental health strategy as a primary preventative initiative.• Organizations should aim for a comprehensive approach that comprises the implementation of primary-, secondary-and tertiary-level mental health and well-being practices.• Research is needed to quantify the specific impacts of line manager training on organizational-level outcomes, such as sickness absence and presenteeism.
secondary and tertiary 1, available as Supplementary data at Occupational Medicine Online) as conceptually defined by the public health paradigm [28,29].

RESULTS
We observed that organizations with LM training in mental health adopted more primary-level MH&WB practices compared to organizations without such training provisions (Table 1).This trend strengthened over the 4 years, evidenced by an increase in the proportions of firms offering LM training from 2020 to 2023 (2020: n = 413; 2021: n = 371; 2022: n = 497; 2023: n = 576) (Figure 1).On average, organizations that offered LM training in mental health were more likely to adopt secondary-level MH&WB practices compared to organizations without LM training provisions  2).Although the proportion of firms offering some of the secondary MH&WB practices increased from 2020 to 2023, there was an decrease in the proportion of firms offering general health promotion interventions including s1 'Support with physical activity such as gym memberships, cycle to work schemes' and s2 'Supplying healthy food and drinks' (Figure 2).
On average, organizations that offered LM training in mental health were more likely to adopt tertiary-level MH&WB practices compared to organizations without LM training provisions (Table 3).The proportion of firms offering these activities also increased from 2020 to 2023 or 2021 to 2023, where applicable (Figure 3).

DISCUSSION
This study explored the relationship between LM training in mental health and the adoption of primary-, secondary-and tertiary-level MH&WB practices.Our findings show that LM training was significantly associated with MH&WB practices across all three levels.For organizations that offer LM training, there was a consistent increase in the proportion of primary-(prevention-focused) and tertiary (curative/remedial)level MH&WB practices offered across the 4 years.However, there was some variation in the proportion of secondary-level MH&WB practices offered, with some increasing and others, in contrast, decreasing over time.Among the three intervention levels, tertiary interventions were adopted most frequently, followed by primary and then secondary interventions.
A strength of this study is that it provides a comprehensive analysis of how a large sample of UK organizations adapted their MH&WB practices over several years, from immediately before ( January 2020), to the end (May 2023) of a pandemic.The focus on LM training in mental health presents a valuable contribution by highlighting the overall benefits of providing this training to the wider organizational customs and practices.To the best of our knowledge, this is the first study to examine the relationship between LM training in mental health and the broader use of primary-, secondary-and tertiary-level MH&WB practices by organizations.However, the use of unbalanced panel data in the analyses limits our ability to capture the genuine 'longitudinal' effects of LM training on the organizational adoption of MH&WB practices.Due to the variations in the number of observations at each time point, there is reduced precision in capturing the temporal dynamics of the relationships being investigated.While our measures capture the presence/absence of various MH&WB practices (including LM training) and demonstrate how they are related, further research is required to determine the effectiveness of these practices on individual-and organizational-level outcomes.
Our study contributes to the growing body of literature which highlights the importance of providing mental health training for LMs in the workplace [15,18,20,29].While current intervention studies are exploring the impacts of LM training on individual employees and their LMs (e.g.Total Worker Health Intervention [25]; Managing Minds at Work [23,26]), our study explores patterns of well-being intervention at an organizational level which, to our knowledge, have not previously been documented.The establishment of a relationship between the provision of LM training in mental health and other positive MH&WB policies and practices suggests the training of LMs in mental health is associated with a broader organizational commitment to employee well-being at all three intervention levels.Essentially, we observed that positive MH&WB practices cluster together.
Further research is needed to explore the types of intervention (i.e.their content/nature, dose, duration and frequency) that are more, or less, effective for improving workforce well-being and indices of business performance.The fact that we identified increases in the adoption of MH&WB practices over recent years is promising given the rise in mental health problems working adults during and after the pandemic [30].This suggests a greater awareness of employers relating to mental health at work, which manifests in actions to mitigate or manage this growing trend.The association between the provision of LM training and other MH&WB practices perhaps indicates that raising managers' awareness, knowledge, confidence and skills relating to workforce mental health may act as a catalyst for the implementation of positive, health-focused practices across the organization.
A notable finding from this study is the increasing proportions of tertiary-level interventions used by organizations over the 4 years.Previous research suggests that organizations may opt for tertiary-level interventions due to the perceived immediate benefits and tangibility of support services [31].However, while these interventions are important in offering support to employees already suffering from mental health issues, their effects are not as long-lasting as primary and secondary interventions-as they do not address the root causes of the issue [32].Hence, scholars argue that the best approach for addressing mental health issues at work (e.g.work-related stress) is a balanced, holistic approach that combines all three intervention levels [33].Future research in this area should focus on quantifying the specific impacts of LM training on organizational-level outcomes, such as sickness absence and presenteeism.This evidence would help to inform employers' investment decisions relating to MH&WB at work, which will ultimately impact employee health and well-being.

COMPETING INTERESTS
N.P. is the CEO of the Society of Occupational Medicine.In this role, he has no editorial influence on the Journal although the

Table 1 .
Probit analysis of LM training in mental health associated with primary-level MH&WBs T. DULAL-ARTHUR ET AL.: LINE MANAGER TRAINING ORGANIZATIONAL APPROACHES • 419 (Table

Table 2 .
Probit analysis of LM training in mental health associated with secondary-level MH&WBs

Table 3 .
Probit analysis of LM training in mental health associated with tertiary-level MHWBs S.O.M. financially manages the Journal.All other authors have no competing interests to declare.FUNDINGThe data used here were originally collected as part of an Economic and Social Research Council funded project 'Workplace mental-health and well-being practices, outcomes and productivity' (grant number: ES/W010216/1).This secondary analysis project 'Mental health at work: a longitudinal exploration of line manager training provisions and impacts on productivity, individual and organizational outcomes' was supported by the Economic and Social Research Council [The Productivity Institute: grant number: ES/V002740/1].