Key stakeholder perspectives on the use of research about supported employment for racially and ethnically diverse patients with mental illness in the United States

Abstract

Objective

To explore how stakeholders responded to research evidence regarding supported employment (e.g., vocational rehabilitation), and ways evidence could be incorporated into policy and action.

Data sources

Qualitative data were collected from three stakeholder groups—people with lived experience of mental health challenges, community health advocates, and state health policy makers.

Study design

This study consisted of two sequential steps. First, three focus groups were conducted after presenting stakeholder groups (inclusive of 22 participants) with simulation data showing that improvement in employment status had a stronger impact on mental health than improvement in education or income for racially/ethnically diverse groups. Second, with guidance from focus group findings, researchers conducted additional in‐depth interviews (n = 19) to gain a deeper understanding of the opportunities and challenges related to incorporating these findings into policy and practice.

Data collection/extraction methods

Focus groups and in‐depth interviews were conducted, audio recorded, transcribed, and analyzed using a thematic analysis approach.

Principal findings

People with lived experience described the positive effect of employment in their own life while highlighting the need to increase workplace accommodations and social supports for those with mental health challenges. Across stakeholder groups, participants emphasized the need for linguistic and cultural competence to promote equity in delivery of supported employment programs. Stakeholders also underscored that centralizing existing resources and using evidence‐based approaches are crucial for successful implementation.

Conclusion

Implementing effective supported employment programs should focus on meeting the specific needs of target individuals, as many of those needs are not considered in current employment‐related programming. Collecting information from diverse users of research demonstrates what other aspects of supported employment are required for the likelihood of successful uptake. Implementation and dissemination efforts need to fortify collaborations and knowledge transfer between stakeholders to optimize supported employment and mental health resources.

What is known on this topic

• Social determinants of health, such as education, employment, and income, are important predictors of mental health outcomes and quality of life for people living with mental illness.

• Even though evidence‐based supported employment programs, such as the Individual Placement and Support program, are effective for sustaining competitive employment among people with serious mental illness, these are often unavailable.

• Important stakeholders have little opportunity to weigh in on ways research evidence—such as those related to supported employment—could be translated into policy and practice.

What this study adds

• Insights about why this supported employment model might need additional revisions (e.g., workplace accommodations, culturally responsive training) to make it feasible for different stakeholders.

• Support for the importance of gathering input from many types of stakeholders: three different stakeholder groups had systematically different ways of interpreting the same research evidence, and each group contributes unique insights for improving dissemination.

• Concrete examples of structural components that can support Individual Placement and Support services, including fidelity measurement and regular supervision throughout implementation.

1. INTRODUCTION

Scientists have long established how social determinants of health (e.g., education, employment, income, and housing) relate to outcomes and quality of life among people with mental health disorders. ¹ People of color in the United States face a disproportionate burden of social and economic challenges that accompany mental health disorders. ² , ³ Mental health disorders impede individuals' efforts to work consistently, contributing to low employment rates among people with common and severe mental illness. ⁴ , ⁵ Supported employment (SE) initiatives for individuals with mental health disorders aim to teach job skills, promote vocational rehabilitation, and help clients secure work, both at organizations that hire individuals with disabilities and in competitive, mainstream jobs. ⁶ , ⁷ , ⁸ , ⁹ These evidence‐based programs both promote mental health and allow people to work consistently. ⁶ , ¹⁰ Supported employment may be particularly helpful for people of color and minoritized groups. ³ , ⁸ , ¹¹ , ¹² Despite the research evidence supporting the effectiveness of SE initiatives, less than 20% of specialty mental health treatment facilities in the United States offer SE programs. ¹³

The Biden Administration published a Presidential Memorandum ¹⁴ promoting the use of research and best available data to craft policy and programs. However, research evidence rarely gets translated into policy, and people who are most affected by these policies rarely have the opportunity to participate in decision‐making. ¹⁵ As a result, there continues to be a significant evidence‐to‐policy gap, ¹⁶ partly because of a limited understanding of how policy makers and practitioners receive and interpret research evidence and incorporate it into policy and practice. ¹⁷ Given that people of color experience more negative consequences from mental health disorders than their White peers, ¹¹ creating and ensuring access to evidence‐based supportive initiatives—like SE—for these communities are particularly important. Thus, this study was designed to consider how disseminating relevant research evidence might increase the number of SE programs. We examined how key stakeholders would respond to, and possibly apply, research linking SE initiatives to positive mental health outcomes among individuals from racial/ethnic diverse groups.

2. METHODS

2.1. Procedures

The research team partnered with leaders from regional and national organizations representing three stakeholder groups: (1) people with lived experiences (PLEs) from diverse racial/ethnic backgrounds, (2) community health advocates (CHAs) serving people of color with mental health needs, and (3) state health policy makers. This qualitative study was comprised of two sequential phases. First, three focus groups were conducted to present stakeholder group with simulation data (described below). Second, data obtained from the focus groups were used to develop a semi‐structured interview guide that facilitated in‐depth interviews. Informed consent was obtained for participation and audio recording of focus groups and interviews. All study procedures were approved by the Institutional Review Board. PLE and CHA participants received $25 gift cards for focus group participation and $30 gift cards for interview participation; policy makers declined compensation because of payment restrictions within their agencies.

2.1.1. Focus groups and interviews

Site leader partners recruited PLEs, CHAs, and policy makers through their respective agencies for focus groups, which were conducted by research team members. Focus groups with CHA and policy makers were completed remotely, while PLE groups were completed in‐person. One focus group was conducted for each stakeholder group, and a total of 22 individuals participated. At each focus group, simulation findings were presented. In an ideal world, we would compare outcomes for those who received social services to those who received none, but these experiments are often time‐consuming and costly. Thus, simulation studies allow us to use existing data and identify the impacts of many programs simultaneously. In our focus groups, we simulated improvements in three social determinants areas—education, income, and employment—and examined each determinant's effect (while holding the other two constant) on mental health outcomes using nationally representative datasets from the National Institute of Mental Health and the Social Security Administration. Compared to education or income, improved employment status produced a significant positive impact on mental health and overall functioning for Black, Latino, Asian, and non‐Latino White adults. ¹¹ Researchers then asked participants to react to the study and discuss recommendations for increasing SE program in their contexts.

Focus groups' recommendations were summarized and then used to develop semi‐structured interview guides that targeted stakeholders' perspectives on ways to translate these recommendations into real‐world policy and practice. Five CHAs who participated in the focus groups agreed to an interview, whereas PLE and policy maker focus group participants declined because of lack of interest or time. Thus, site leader partners recruited additional participants from their respective stakeholder groups. Recruitment continued until sufficient data were collected for saturation within and across groups. During these interviews, trained researchers described the simulation study results and recommendations identified during the focus groups. Next, the researchers asked participants to react to the study results and engage in subsequent discussion of strategies for reducing racial/ethnic disparities in mental health services and outcomes (see Appendix A for interview guide). Like the focus groups, the interviews with policy makers and CHAs were conducted remotely via phone, whereas PLE interviews were held in‐person.

2.1.2. Participants

A total of 19 participants completed semi‐structured in‐depth interviews: 5 CHAs, 5 PLEs, and 9 policy makers (see Table 1). PLE participants were living in Massachusetts and connected to a local recovery learning center serving individuals with mental health disorders; CHA participants were based in advocacy organizations focused on minority mental health; and policy maker participants were employed by state health agencies experienced in employment policy making across five states.

TABLE 1.

Participant information for focus groups and individual interviews

	# of participants	Completed survey	% Female	Race	Ethnicity
Focus groups
Community health advocate group	5	5	60.0	1 Asian; 1 Black; 2 White; 1 multiracial	2 Hispanic or Latino; 3 non‐Hispanic
People with lived experience of mental health disorders group	8	8	75.0	1 Black; 5 White; 1 multiracial; 1 not reported	3 Hispanic or Latino; 4 non‐Hispanic; 1 not reported
Policy maker group	9	6	66.6	2 Black; 3 White; 4 not reported	1 Hispanic or Latino; 4 non‐Hispanic; 4 not reported
In‐depth interviews
Community health advocates	5	5	60.0	1 Asian; 1 Black; 2 White; 1 multiracial	2 Hispanic or Latino; 3 non‐Hispanic
People with lived experience of mental health disorders	5	5	80.0	1 Black; 1 White; 3 not reported	3 Hispanic or Latino; 2 non‐Hispanic
Policy makers a	9	7	66.6	6 White; 1 not reported	1 Hispanic or Latino; 5 non‐Hispanic; 1 not reported

^a The nine policy maker interviewees represented five different states and completed interviews in five separate conference calls with site leaders. Each in‐depth policy maker interview included between one and three participants. Represented states reflected geographic and political diversity.

2.2. Data analysis

Findings from this manuscript focus on data yielded during in‐depth interviews and not the earlier focus groups. Interview transcripts were analyzed using an inductive thematic analysis approach. ¹⁸ A codebook was generated based on review of all transcripts and revised by the team in three rounds. Interviews were coded by two PhD researchers (L.Z., L.F.) using Dedoose, ¹⁹ a web‐based application to support qualitative analysis, and coding disputes were identified and resolved by a third researcher (A.C.). After codes were applied to the interview data, codes were grouped into related categories to develop themes. Final themes represented salient categories that included multiple codes across interview data. To increase validity, site leaders reviewed a summary of the findings, and an external qualitative methodologist reviewed the methodology and resulting themes to provide feedback on the research team's interpretations.

3. RESULTS

Three main themes emerged from the qualitative analysis of interviews: (1) perceived impact of SE initiatives, (2) gaps and barriers to SE program implementation, and (3) facilitators of successful SE program implementation. Below, we elaborate on several subthemes and highlight subthemes that only resonated for one or two groups.

3.1. Theme 1: Perceived impact of SE initiatives

Participants across all groups reacted to the simulation study findings by describing their personal perceived impact of SE programs. PLEs described the positive effect of employment in their lives, expressing pride in their work and noting that they derived a sense of meaning from holding part‐time jobs. Policy makers, some whose states were actively implementing SE programs, described the efficacy of these programs in engaging individuals across a spectrum of behavioral health disorders. Policy makers emphasized that employment should not be considered an “adjunct service” of recovery, but rather a crucial and effective strategy to promote recovery and wellness. Though CHAs shared perspectives about integrated models of care, they had less direct experience implementing SE programs. Thus, they tended to speak more generally about important considerations for supportive services. Nonetheless, there was broad recognition across groups that SE cannot operate as a lone strategy. Rather, programming must simultaneously address employment needs, medical comorbidities, and socioeconomic precarity.

PLEs and policy makers also highlighted the model of Individual Placement and Support ⁶ as a recommended employment program. PLEs noted that this model distinguishes itself from other programs by allowing participants to decide their own career path rather than push them to take any available job opportunity. For example, one participant reported that they are sometimes “pushed down certain career paths that we don't necessarily want to go down, but almost feel like we have to go down because we don't have any other choices” (PLE01). This participant, having been advised to pursue training in pharmacy technician and medical secretary skills, stated, “Nothing's wrong with those careers, [but] who's to say I want to be a secretary or a pharmacy technician?” (PLE01). Policy makers also spoke about shifting SE approaches to be more in line with the Individualized Placement and Support model in their region:

… our tagline is ‘Work is Recovery’ … I've been really excited and quite proud to see that cultural paradigm shift. We still have some work to do, you know there's still some clinicians who have that mentality that ‘we have to wait until they're stable,’ whatever that means. Or ‘clean and sober for decades before they can work,’ so I think we're making great progress as far as changing that cultural norm. (P147)

Aside from this model, no other employment program was mentioned by name. However, policy makers described some different funding streams that could potentially be tapped to help states pilot new programs, such as the use of 1115 Medicaid waivers or the braiding of SAMHSA block grants with foundation grants to fund SE services.

3.2. Theme 2: Gaps in and barriers to SE implementation

Stakeholders also reacted to simulation results by highlighting gaps in current SE programming. A lack of both workplace accommodations and social supports was described as challenges, particularly by PLEs, and economic stressors and the need for more linguistic and cultural competence were identified as important issues across all stakeholder groups.

3.2.1. Workplace accommodations

PLE participants emphasized a need for workplace accommodations, noting that employers in current SE programs often do not provide allowances for medical absences, whether for physical or mental health needs. As one PLE reported:

They have fired me out of a job because I was not giving a good performance and in another one, they did not want me anymore because I had too many absences … because of [medical] appointments, and they didn't understand. If you miss one or two times, they fire you. (PLE02)

Another participant remarked: “People become unwell at some point during their employment, and unfortunately, companies and organizations and jobs don't have certain protocols for [them]. So, when they become unwell, they're just being released from their jobs, and it's not fair” (PLE03). This participant advocated for educating employers about common behavioral health conditions to encourage more accommodating absence policies, such as paid medical leave.

3.2.2. Social support

PLEs described the need for peer supports (e.g., other PLEs providing knowledge, emotional comfort, and practical guidance) and volunteer support groups in conjunction with SE, particularly considering their frequently fragmented social networks. For example, one participant related having little contact with family members because of substance use concerns:

I've got my father who's an alcoholic, my brother who uses crack—whatever, he's my brother, but I'm sad when I see stuff that I don't like … and he's your own blood, and he's poisoning your life, you have to like, move on and say, ‘I'm sorry, you're my family, but you're not going to interrupt my bubble. My own world that I have now.’ (PLE05)

This individual described participating in peer support programs after an eight‐month hospitalization, thereby allowing her to establish a new social network, find meaning, and become motivated toward recovery.

Another PLE participant shared that after an exacerbation of mental illness, her husband and children considered her “dangerous” and left her. Although she struggled with social isolation for many years, she later found peer and group support uplifting: “Everyone has the same opportunity to talk, to share your experiences. So, when you see someone the same as you, that person also gives you support, they hug you, they console you. It is very nice. It feels good, it feels like a family here” (PLE02).

When discussing peer support programs, policy makers and CHAs highlighted the potential for peer specialists to further SE goals, for example, by connecting peers to employment services and skills workshops. Policy makers also suggested that peer specialists could serve as benefits counselors, teaching from personal experience about obtaining benefits such as social security and Medicaid.

3.2.3. Economic stressors

Policy makers and CHAs, more than PLEs, reacted to the research evidence presented by asserting that individuals with behavioral health needs should receive additional support to avoid financial precarity. They highlighted a need to adjust social safety nets. For example, although social security, disability insurance, and Medicaid supports may be available, participants identified concerns about losing benefits as a major barrier to engagement with SE programs. As one policy maker noted:

One of the biggest fears that people have is that, you know, when it takes you an average [of] 3 to 5 years to get on to SSI [Supplemental Security Income] and SSDI [Social Security Disability Insurance], the fear of going off of that oftentimes dissuades people from trying work. (P01)

Importantly, PLEs reported that, even while employed and receiving benefits, they often experienced financial insecurity given the limitations of social welfare mechanisms:

What do I do if I'm able to work, but then I lose my job, and my bills still need to be paid? So, what I would do, or still do is, because of that fear … is try to save enough to live on for a month or two. And I mean, that is a good skill to have, but it is in essence being my own safety net. (PLE04)

Housing insecurity was another social stressor that policy makers identified as a potential area in which to expand safety nets, as housing serves as a “huge need for recovery” (P01). All policy makers reported ongoing supported housing interventions under evaluation in their states. They highlighted links between housing insecurity, behavioral health, and the ability to maintain employment: “If we're really going to pay attention to whole‐person care, then employment and housing have to be a part of the conversation” (P01). This participant went on to state that holistic models of care also promote better personal management of complex health conditions and less frequent use of emergency health services. Such underscoring of the need for whole‐person care was echoed by CHAs. For example, a CHA explains the need to reduce socioeconomic burdens to better implementing employment programming:

I think the policy area that needs to be looked at is how do you span and reduce the barriers for people who are trying to continue to work more extensively for longer hours, for longer periods of times without being punished in terms of the benefits? (P107)

This concern was echoed by a PLE describing the difficulty of balancing the desire to work and the need for safety nets:

I don't really know if I can work full time because … can I do that? Physically, emotionally. So there has to be some safety net there, not just in getting on and off [of disability] but being able to be on for a little while, while you test yourself working towards full time. Because I don't know anybody who can just drop disability and just go to work full time. That to me would be very difficult for a lot of people, a lot of us. (PLE156)

3.2.4. Linguistic and cultural competence

Across groups, participants emphasized that providers with relevant linguistic and cultural competence are crucial for SE and social service programs to serve people of color and minoritized groups effectively. Interviewees described a lack of providers offering services in patients' native languages, including Spanish, Vietnamese, Hmong, Tagalog, Mandarin, and indigenous languages. One PLE whose first language is Spanish reported difficulty participating in support programs due to language barriers, saying “… a friend took me to—but I did not like it, there was nobody in Spanish and it did not grab [my attention], I like it more here [at the recovery learning center where Spanish is spoken]” (PLE151). CHA and policy makers also described messages as frequently being lost in translation. Another policy maker echoed this concern: “[There are] certainly not equitable services in terms of providing services to Latino populations … just because we do not have enough staff on either side of the house in terms of being bilingual” (P02). Indeed, CHA and policy makers highlighted language barriers as a continuously more urgent issue for the growing Latino population in their respective service locations. Overall, CHAs and policy makers reported setting goals to increase the number of bilingual providers, interpreter availability, and English as a second‐language course offerings to support both treatment and SE initiatives.

Participants emphasized a need to train SE providers in cultural sensitivity and cross‐cultural engagement and described a dearth of professionals from diverse backgrounds. For example, one CHA depicted how providers without any cultural training may not know to convey the importance of self‐confidence and self‐promotion during employment‐related skills training. These skills may not be prioritized within certain cultures that value humility. Another advocate felt that basic training about cultural values could help providers understand how to better retain clients in SE programs. “Most providers are not trained to understand how culture and language is the primary influencer of help‐getting behaviors by their clients” (CHA02). As this advocate stated further, when providers are not trained in “how to be effective in communicating and informing and educating” (CHA02), minority populations are not effectively engaged in SE, may be unaware of treatment options, and are ultimately lost to follow‐up.

3.3. Theme 3: Facilitators of successful implementation

After reviewing presented research evidence, interviewees recognized three specific types of partnerships and collaborations as crucial to the general success of SE and mental health interventions. Those included: (1) mapping out and centralizing community resources, (2) applying evidence‐based models of SE programs, and (3) convening and facilitating collaboration among diverse stakeholders to implement SE efforts.

3.3.1. Mapping out and centralizing community resources

Interviewees noted that community organizations tend to offer just one type of service and that state resources are often siloed. Thus, PLEs must often navigate multiple organizations to obtain necessary services. For example:

If we used all our resources and merged them, we would be able to do explosive work. … Each organization can't do everything on their own, and they don't provide each and every service. So, let's say I work in an organization that doesn't specialize in housing or crisis prevention, but there [are] other organizations that do. I would be able to be the forefront person to say, ‘Actually, we work with an organization that does specialize in housing or crisis intervention. Let me connect you with that person.’ Instead of saying, ‘Oh, well that's another organization. Yeah, let me get back to you.’ Now we're becoming part of the problem. The person might become immediately homeless, or we're not addressing their needs at that point in time. (CHA04)

PLEs also recognized this problem: “I think sometimes providers, they don't know what's out there a lot of times, so they don't know how to refer people to other supports or resources” (PLE01). Other PLEs and CHAs believed that creating directories and maps of community‐level resources would facilitate referrals, and one policy maker noted state efforts to support community service integration. Although some interviewees cited lack of time as a potential barrier to properly establishing these resource maps and directories, they overall expressed enthusiasm about developing networks of organizations to better “connect people immediately to the type of services that they need” (CHA04).

3.3.2. Applying evidence‐based models of SE

Advocates reported wanting to learn from other experts' experiences on application of SE models “instead of reinventing the wheel” (CHA05). Policy makers advocated promoting evidence‐based models of employment support, especially Individual Placement and Support. ⁶ They reported creating committees and participating in learning collaboratives across states to better share information about SE program implementation. Furthermore, policy makers described developing fidelity monitoring programs and scoring systems to track adherence to evidence‐based models. One policy maker, however, stated that even when committees and collaboratives generate formal “dissemination plans,” or a set of recommendations about how to implement a successful program, these plans can “sit on the shelf” if not accompanied by resources or cooperative agreements between partners (P03).

Indeed, cooperative agreements between government and policy making agencies were commonly discussed. Participants reported that supportive leaders, legislation, memoranda of understanding, and cooperative agreements were crucial to acquiring resources and successfully implementing SE programming. For example, two policy makers reported that their governor had signed an executive order to be an “Employment First” state, which allowed for the expansion of job opportunities for people with disabilities. Another policy maker mentioned that new leaders in the behavioral health division, who valued addressing social determinants, helped create a strategic plan that raised awareness and created resources for housing instability and unemployment among PLEs. The same policy maker also reported that key legislation allowed the state to develop a robust data collection system to measure outcomes related to housing and employment among PLEs. Policy makers reported other examples of productive government collaborations, including interagency work on dual diagnoses, data‐sharing agreements between agencies serving the same populations, and state‐sanctioned behavioral health task forces that created opportunities for mentoring and employment programs for PLEs. Policy makers also asserted the importance of these programs for individual recovery and health:

We have a zero‐exclusion policy, which means anyone who's interested in working, whether they use substances or not, whether people feel that their symptoms are very active, it doesn't really matter … that work is really a big, huge piece of recovery (P159)

Notably, participants from all stakeholder groups stressed the importance of having a diverse representation of PLEs, community members, and program representatives on advisory committees, task forces, and policy groups when implementing SE initiatives and other supportive programming. One policy maker stated that not including PLEs and organizations from varying levels in collaborative efforts would mean that programs and action plans would “be created in a vortex” (P05). This participant also emphasized inclusion “so that you really hear what the constituents as a whole would need as a solution.” Similarly, one PLE emphasized: “If we're not sharing what we need, then everybody else is speaking for us. So, we definitely don't need anybody speaking for us” (PLE01).

4. DISCUSSION

Despite the widely identified need to engage relevant stakeholders in evidence‐based policy making, ¹⁶ little is known about ways stakeholders respond to and use research evidence. ¹⁷ After reviewing the research evidence, participants from all three stakeholder groups prioritized increasing the availability of SE programs and the use of the Individual Placement and Support model. This model involves placing individuals in competitive jobs without extended training and remains the SE model with the strongest evidence base for improving employment outcomes among those with mental health disorders. ⁹ , ²⁰ However, as the PLEs in our study reported, SE programs should also incorporate workplace accommodations and other adaptations to help address individuals' medical co‐morbidities, economic precarity, and many social stressors. ²⁰ For example, when traditional SE approaches cannot meet individuals' needs, some states like Utah offer a “Customized Employment” approach, which includes an additional lengthy exploratory phase to anticipate accommodations and adaptations needed during job placements. ²¹

Participants identified a need for housing assistance, peer support, and support groups as important adjuncts to SE; consistent with other studies suggesting that these resources have lasting impact on mental health outcomes. ²² , ²³ , ²⁴ , ²⁵ , ²⁶ Policy makers and CHAs are well‐positioned to implement policies aimed at reducing financial precarity; such efforts could include expanding existing social welfare programs and community‐based social services ²⁷ that could complement existing SE programs. Policy makers might expand Medicaid income eligibility criteria to ensure that, even when pursuing employment, people with mental health disorders can continue to access care. ⁵ Although numerous studies highlight cultural and language barriers to mental health services for minority populations, ²⁸ , ²⁹ , ³⁰ , ³¹ there is limited literature about how these concerns relate specifically to SE. In a study of Latino adults with disabilities, researchers found that less acculturated individuals struggled with employment and vocational rehabilitation, which researchers attributed to the mistrust toward providers. ³² Thus, training diverse personnel able to employ SE initiatives in linguistically and culturally responsive ways is critical and for SE program implementation with underserved communities. ³³ , ³⁴

Interviewees also highlighted the need for collaborations between diverse stakeholders in SE dissemination plans, in line with studies hypothesizing the value of outreach components of the Individual Placement and Support model. ³⁵ , ³⁶ Notably, participants suggested offering cultural competence trainings for SE providers, teaching not only the ways in which culture can impact help‐seeking behaviors and employment‐related values but also concrete skills about self‐promotion during job interviews and advocacy for workplace accommodations. Employment specialists are well‐positioned to help clients understand how their cultural values shape vocation, to negotiate accommodations for cultural customs and holidays, and to recognize cultural discrimination in the workplace. ³⁷ Although participants did not explicitly mention experiencing racism, researchers have found that African Americans are more likely to report workplace discrimination, and that workplace discrimination relates to greater depressive symptoms across all racial/ethnic groups. ³⁸ Given that individuals experiencing multiple types of discrimination are at risk for poorer mental health outcomes, ³⁹ more research is needed in how intersecting discriminations—such as racism or unfair treatment due to mental illness—can further impact people of color.

Finally, this study demonstrates stakeholders' prioritization of partnerships and collaborations in promoting, disseminating, and implementing SE initiatives. Stakeholders suggested mapping mental health care sites and other resources to facilitate appropriate client referrals and create local partnerships, which is a strategy that has improved integrated care. ⁴⁰ CHA and policy makers also called for concrete measures to disseminate successful SE models, including regular supervision of projects throughout implementation as well as fidelity measures. E‐learning modules about SE programs may represent another promising technique for dissemination and collaboration. ⁴¹ Notably, interviewees raised a unique point about the power of collaborations between government agencies and policy makers in establishing resources for SE. This perspective is distinct from existing literature emphasizing partnerships between nongovernmental/community and governmental organizations ⁴² or between clinical services and employment services ⁴³ in promoting SE.

4.1. Limitations

We discuss two key limitations. First, we employed convenience sampling and recruited PLEs only from Massachusetts, whose experiences may differ from those of PLEs in other states. Importantly, however, we included CHAs and policy makers from multiple states with a diverse range of experiences in mental health care. Second, the racial/ethnic minority, and particularly Black, representation in the interviews could be greater. For example, most policy makers interviewed identified as White, which limits our ability to understand perspectives on the topic from policy makers of other racial/ethnic groups. More qualitative studies are needed to obtain a more in‐depth understanding of challenges that policy makers of color face translating research into policy and action.

5. CONCLUSIONS

To better accelerate the use of research evidence, investigators should identify innovative ways to disseminate findings to a broader audience, focusing on key stakeholders who will institute or benefit from implementation of related evidence‐based programs. As an example, SE initiatives have demonstrated promising outcomes for diverse groups of individuals with mental health disorders, but such programs have not attained widespread enactment. By sharing empirical findings with and eliciting feedback from relevant stakeholders, we obtained critical input regarding the gaps and opportunities for increased research uptake. Implementation and dissemination efforts need to fortify collaborations and knowledge transfer between stakeholders to optimize existing SE and mental health resources.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

Appendix A. SAMPLE IN‐DEPTH INTERVIEW GUIDE

• Purpose of the in‐depth interview: Participants will be informed that this is an opportunity to break new ground and that we are using research data and other complementary materials to develop recommendations of how to change or develop policy and systems interventions to reduce racial/ethnic disparities in mental health services and outcomes.

A.1. Introductions and review of simulation study on social determinants

Prioritizing recommendations:

• After reviewing these recommendations and using your expert knowledge, what recommendation would you tackle first as a way to reduce these disparities?

• Why would you choose this one (these) over others?

• Would other people with lived experience/community health advocates/policy maker have the will to address this as a priority?

• How about you?

Addressing the problem:

• What are some ways you might recommend to implement these recommendations?

• How would you go about implementing them?

• How passionate do you feel about undertaking these recommendations?

• What do you see as your main obstacles in making these changes?

• Could you elaborate a scenario of how you would address these problems?

• What steps would you follow to move your recommendation forward?

• What would you need to carry out these recommendations?

• Who would need to be involved?

Establishing an agenda: As part of this process, we would like to hear your ideas of how you would map your work on these recommendations:

• What information would you need to collect to know you are on the right track?

• With whom would you discuss this plan to get feedback and refine it?

• How would you go about getting this feedback?

• What barriers do you anticipate when putting in motion your proposal?

Sharing your recommendations:

• Imagine you got a lot of positive feedback on these recommendations; how would you go about trying to get others to adopt them?

• Which audiences would you target?

• Why?

• How would you tailor your discussions to these different audiences?

• What is the most important piece of information to convey to these audiences?

Zhen‐Duan J, Chary A, NeMoyer A, et al. Key stakeholder perspectives on the use of research about supported employment for racially and ethnically diverse patients with mental illness in the United States. Health Serv Res. 2022;57(Suppl. 1):95‐104. doi: 10.1111/1475-6773.13905