Introduction

Mental illness affects approximately 1 in 4 youth ages 15–24 in Canada [1] ,the highest incidence of mental disorders of any age group [2,3,4]. Approximately 70–90% of people with serious mental illness are unemployed in Canada, and this trend begins early in life [2, 4]. The proportion with mental illness in school or employed among youths aged 15 to 18 years is about the same as their peers without a mental illness [2]. However, this proportion drastically changes among 19–24 year-olds, with only 48% of those with mental illness reporting being employed or in school, compared to 87% without a mental illness [2, 5].

Obtaining work or attending school are important to youth and young adults and are associated with positive health outcomes, social well-being, long-term recovery, and quality of life [6,7,8]. Like most of their peers, young adults with mental illness want to work, yet they face enormous stigma in getting and keeping jobs [9]. Challenges are even greater for those who have not completed their education and/or developed effective work habits and skills to cope with their illness [2, 10]. Thus, effective services are needed early after diagnosis to enable young adults with mental health conditions to successfully transition to early adulthood and employment.

A recent Cochrane review looking at the effectiveness of interventions for obtaining and maintaining employment for adults with severe mental illness found that supported and augmented supported programs were more effective than other interventions, with augmented supported employment programs (SEP) showing slightly better results than supported employment [11]. Augmented employment programs refer to SEP which include other interventions, such as integrated mental health support [11]. These SEP and augmented SEP were primarily based on the Individual Placement and Support (IPS) model of supported employment which is designed to achieve mainstream competitive employment [12]. In Canada, IPS has been primarily used for the past decade to support adults with mental illness in obtaining employment and has been promoted as an evidence-based intervention that should be prioritized in psychiatric rehabilitation across the country [13,14,15,16].

Description of Intervention

Using this IPS model, we developed a novel intervention called Youth Breakthrough to Employment And Training (YBEAT) for young adults aged 19 to 29 with mental health conditions. The intervention was co-created by professionals in health and social services, young adults, and their families. YBEAT is an integrated SEP and education intervention program that provides health, social, and employment skills education in small groups, plus supported job placement tailored to the individual’s goals. Goal setting was incorporated in the YBEAT program, and participants’ work-related goals were measured and evaluated over time. The unique feature of the YBEAT program is that the courses in this program were tailored to these work-related goals. This program was housed in a facility that provides community mental health services, in Vancouver, an urban city in the province of British Columbia (BC), Canada. Participants of this program would also be able to access other mental health services like counselling, and cognitive behavioural therapy. The team comprised of two supported employment specialists, and an occupational therapist and a peer support worker.

Youths were eligible for the YBEAT program if they were interested in seeking or maintaining employment, aged 19 to 29 years receiving mental health services and self-reported a mental illness (defined as one or more of the following: major depressive disorder, bipolar disorder I, II, anxiety disorder, schizophrenia spectrum disorder, schizoaffective disorder, delusional disorder; and psychotic disorder; not otherwise specified).

There were three phases in this 16-week program:

  1. (i)

    Phase I: Five weeks of scheduled group education sessions on basic topics like career exploration, resumes, and interview skills, supplemented by individualized sessions with program staff. Certification workshops were also offered (e.g., First Aid, FOODSAFE Level 1).

  2. (ii)

    Phase II: Four weeks work experience in settings that matched participants’ career goals. Program staff supported participants and employers to develop a workplace Action Plan outlining training, support and work expectations.

  3. (iii)

    Phase III: Participants were placed in jobs (or appropriate school/training). Staff provided targeted support for seven weeks to ensure a successful transition into employment. Based on the funding model, the program could not extend beyond this phase.

To explore participants’ experience of this novel program, qualitative research was conducted. The objectives of this study were to gain an understanding of participants’ experiences of the YBEAT program. The central question of this study was “What is the experience of going through the YBEAT program?” Results of this study will help us understand the young adult’s perspective about the relevance and applicability of this intervention and provide insight to the realities that youths with mental health conditions face in Canada.

Methods

The YBEAT study was a one-year longitudinal study, designed to evaluate the effectiveness of the YBEAT program. The YBEAT study consists of both a quantitative study and a qualitative study. This present study describes the qualitative component of the YBEAT study.

Study Design and Settings

Focus groups and individual semi-structured interviews were used to capture the experience of youths who had completed the YBEAT program. The interview questions were designed using a program evaluation approach (see supplementary material) [17]. Focus group interviews were conducted by two team members (SB & AL) at the same facility where the YBEAT program was held. Individual interviews were conducted by a trained research coordinator and two graduate students at a hospital in downtown Vancouver, at a time chosen by the participants. One individual interview was conducted over the phone due to the COVID-19 pandemic. Prior to the interviews, written consent was sought. Participants were also provided a modest honorarium to cover travel and time costs.

Selection of Participants

Recruitment for this study occurred between October 2019 to May 2020. Purposeful sampling was used to identify and recruit participants for this study. All participants who joined the program in were also invited to enroll into the YBEAT study. Participants were approached by the study Research Coordinator (AL) after completing the 16-week YBEAT program and asked if they would be willing to participate in this qualitative study about their experience in YBEAT. The study was approved by the University of British Columbia’s Behavioral Research Ethics Board (H15-00,368).

Data Analysis

Interviews were audio-recorded and transcribed verbatim. All identifiers were removed before transcription. All interview transcripts were verified prior to coding to ensure accuracy. Data were analysed using qualitative thematic analysis and our team followed the guidelines as outlined by Braun and Clarke (2006). Transcripts were read once through to get a better understanding of the text before coding. Initial coding was conducted independently by team members (NO, SB & AL) using NVivo software and supported by Excel. As the primary aim of this study was to describe the experience of a program, a program evaluation framework was adopted. Using a deductive approach, primary codes were organized and mapped onto Donebedian’s Structure-Process-Outcome Model [17]. Donebedian’s healthcare quality model, as shown in Fig. 1, depicts a model which consists of structure, process and outcomes and provides a framework for evaluating and monitoring healthcare services and quality of care. Structure refers to the conditions under which the program is provided and the way the program is set up; Process refers to the components of program that contributes to a person’s health and well-being and Outcome refers to changes in participants that are attributed to the program [17,18,19]. In this model, measures of structure will affect the processes, which in turn affects the outcome measures [17, 19]. Using this framework, codes were merged into themes and categorized according to the model by the research team. When needed, new codes from subsequent interviews were added. Once all the data were analysed, themes were compared and further refined to increase the dependability of our findings. Further synthesis of the themes and the relationships between them resulted into a modified model of the YBEAT program (Fig. 2). Disagreements were resolved through discussion with the whole research team. Confirmability was established with an audit trail. Data triangulation was conducted with reflections and observations notes from interviewers.

Fig. 1
figure 1

 Donebedian's structure-process-outcome framework

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Fig. 2
figure 2

 Experience of YBEAT program using Donebedian’s structure-process-outcome model

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Results

Participant Characteristics

In total, 34 youths agreed to participate. All participants lived in or near the Greater Vancouver area in B.C., Canada. Three focus groups and eight individual interviews were conducted. The participants were youths aged 17 to 30 years old, with a mean age of 24.7 years (SD:3.1; median age = 25) (Table 1). At the time of the interview, no participants were enrolled in school. More than half of participants were white, and 50% of them identified as women. In terms of primary diagnosis, 61.7% of the participants reported depression as their primary health condition. At the time of the interviews, 64.7% of participants had part time or full-time employment.

Table 1 Characteristics of study participants (n = 34)
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Experience of the YBEAT Program

The experience of the YBEAT program was described through Donabedian’s framework of program evaluation. Figure 2 illustrates the model and the themes associated with each component of the model. This model lays out the important elements to evaluate in a SEP.

Structure

Structure according to Donabedian’s framework, refers the settings and systems of how care is provided [17, 18]. The themes under this component reflect the attributes of the program such as staff and the physical and social environmental structures of the program (Table 2).

Table 2 Additional quotes in each theme
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Program Environment

With regards to the program environment, participants commented on the physical aspects of the space where the program was held and the social atmosphere throughout the program. In general, participants felt that the location was an “accessible location”, and the building was accessible. Some participants had to commute for a long time (> 1 h) to attend the program and finding parking was an issue.

Participants spoke more positively about the social environment. Some felt that it was a safe space where they could discuss their mental health issues and concerns without the fear of being judged. This open discussion format allowed them to be heard and also hear the opinions of others. One participant described it as “overall comfortable and non-judgemental” while another felt that environment created “the opportunity [for her] to speak and gain confidence”. The feeling about the social environment was perhaps best summarized by this participant in FG1:

“…what I love most about is that I beat my anxiety of coming here because really, when I come here, there is a lot of positive, but basically it’s a positive environment. So, the people, not just the staff, but also my classmates, it’s very helpful, very encouraging and stuff.”

The physical environment was described as less youth friendly. Participants suggested having larger rooms with more space to work independently or more windows.

Staff

Staff were an integral part of the YBEAT program. Participants generally felt very supported and comfortable around the YBEAT interdisciplinary staff. One participant commented that, “I really liked it because the teachers [staff] are really supportive and you can ask them anything and you can be like, 'I’m having a bad day', and they would like to understand, because that was, like, kind of, like, the whole point.” Staff who have a positive outlook also infected the participants with their positivity. The extra care and support given by the staff throughout the program also made it easy for participants to engage and attend the classes. Participants appreciated that staff regularly checked in on their health and employment goals throughout the program, as illustrated by this comment about the peer support worker who “always checked in to see if we were okay and if the topics were a little bit too heavy in the conversation…she was always there to help me or our whole cohort if we ever needed one-on-ones.”

Participants also raised the importance of guest speakers, undergoing training in mental health and cultural safety to understand how the program is unique. Many suggested that new members to the group, including guest speakers and potential employers, can have a significant impact on the overall group dynamics and feeling of safety. Screening and prepping inclusive quality guest speakers were viewed as more important than having many speakers in the program.

Process

This component refers to the processes of care delivered [17]. In this program, care was delivered through a series of workshops, work internships and providing mental health support for 16 weeks. The themes here captured the participants’ experiences and thoughts on the format of the YBEAT program and the elements of the YBEAT program.

Program Format

There were different responses to the duration of the program. On one end, many participants echoed the sentiment that the program was “too short”, “too rushed”, and “[the first weeks] went by very fast”, one participant suggested that extending the program but making the days shorter. Some participants suggested the time was ideal. While a couple of participants felt that they received enough out of the program within the timeframe, the general consensus among participants was that they needed more time for the modules they found useful (i.e., mental health, mindfulness, interview preparation). Participants also discussed the importance of staff being available the 16-weeks, for career mentorship if needed.

Elements of the Program

The YBEAT program consisted of different in class sub-curriculums covering three areas: career exploration skills, job training, and mental health support. All participants appreciated the career exploration courses and the different certification courses that they could take as they felt that these courses “can help steer you to the career you want or what’s available for work”. Learning to write resumes, cover letters and having mock interviews were really helpful elements of the program as one participant put it, “resumes and cover letters, before here I had no clue”. This was echoed by another participant in FG3 who liken the whole process as “practice for a real job” which really helped people like him who had been out of a job for a while. Additionally, these courses also helped them gain skills on how to improve their interpersonal skills at work.

Another element of the whole program that participants welcomed was the networking opportunities in the program which exposed them to a “good variety of jobs” and made them consider different career paths.

Participants also identified the unique aspect of the program which was the specialized mental health supports. They vocalized appreciation for the focus on mental health challenges and developing different strategies to manage symptoms when obtaining and maintaining employment. One participant described why they decided to participate in the program:

“I was kind of interested in the fact that it was not just about job searching skills per-se, it was more mental health, and it was everything all together. I felt like it just, there was things that I needed work on, and I just didn’t know how to do it on my own.” – individual interview

The importance of having a counsellor onsite and other programs like mindfulness and yoga were also highlighted as many participants felt that these were beneficial for their work and mental health. Other elements of the program that participants really enjoyed were the physical activities in the morning and the food. Some participants had to commute to attend the program and hence, food was an incentive and allowed them to focus throughout the program without worrying about food security.

Outcome

In Donabedian’s framework, outcomes must be relevant to the objective of the program and means to achieve the outcome must also be considered [17]. The main outcome for this program was employment, however despite the benefits of the program and the connections that they made during the program, there were still many obstacles that exist for people with mental health issues when it comes to attaining and maintaining employment. In this theme, the benefits of the program, the barriers and facilitators to finding a job and maintaining a job were discussed.

Benefits of the Program

Participants outlined unintended benefits from attending the YBEAT program. One benefit was establishing a routine. Participants described that attending YBEAT was helpful to developing a routine, getting up early in the morning and leaving the house. Following this routine made some participants realize that they could do more hours of work than they thought, and this motivated them to seek full time employment. This development of a routine was especially useful for participants who had been unemployed for a while. Learning and maintaining a routine was identified by some as being more important than being employed as this participant from our individual interviews described, “it was really good, I really liked it. I liked how it was really structured, because they kind of make you go there every day for like the weekdays, so that you’re getting up earlier, going there; almost like a job, you have to be there for your activities.” Some participants saw this as an opportunity for adjustment and growth related to maintaining a schedule and highlighted that this was very much key to their success in the long run.

Another benefit of the program was the friendships formed between participants and the support they received from their peers, which lasted beyond the 16 weeks of intervention, as described by this participant in FG2:“I felt supported by the peers in my groups, because like we were really a tight knit group, so we could plan hangouts to go to like the fair.”

“I felt supported by the peers in my groups, because like we were really a tight knit group, so we could plan hangouts to go to like the fair.”

Barriers and facilitators

The theme of barriers and facilitators was divided into two subthemes: barriers to finding employment and barriers to maintaining employment.

Barriers and facilitators to finding employment

In this subtheme, participants spoke mainly of barriers to finding a job and why they were still unemployed since the end of the YBEAT program. One such barrier was the daunting task of applying for a job. Even though participants learn skills like writing resumes in the YBEAT program, it was frustrating having to navigate the job application process because it differed from job to job. One participant described online job application as jumping through “all these hoops” while another spoke about the time it took just to find the application site.

Participants also recounted experiences where they did not have particular items, such as a phone or a uniform, and those were essential items for the jobs they applied. Not having these resources, or the money to purchase them, were recognized as significant stressors in the job searching process. For participants who were not in an ideal housing situation or who lived far away from their employment, another barrier was the need for accommodation. This was a difficult topic to breach during the interview. One participant “felt like [he] didn’t get the job because [he] mentioned it (accommodation)” as employers were generally not open to providing accommodation. Other barriers mentioned related to time management and financial management which added to the pressure and stress because “finding a job was a job itself”.

Another barrier that was consistently mentioned by our participants was the subject of disclosure of mental illness. Even though all participants were taught skills related to disclosure of their mental health condition in the workplace, nearly all participants recalled a negative incident regarding disclosure. While many participants felt that they should disclose their health condition, they also noted how acutely aware they were of the stigma and the possibility of being rejected with self-disclosure of a mental health condition. Some participants reported giving their employers a “vague idea” without giving too many details while others chose to be more forthcoming with their issues as described by this participant in FG2:

“Pretty much like you just have to tell for the most part I’ve had issues in the past and I’ve worked through most of them and I’m ready to move on.”

There were also those who chose not to disclose and those who disclosed only after getting an offer, as this participant in FG1 advised, “…along with the reasonable accommodations you would reasonably expect them to make, only after you have been made an offer.”

The facilitators to finding employment were mainly the accommodations to the barriers they faced. Some facilitators mentioned, were having transportation provided, a workplace that was easily accessible by public transit, a job with accommodation or a job that pays enough to cover rent. Jobs that had these extra perks were much appreciated by our participants.

Barriers and facilitators to maintaining employment

For many participants, obtaining a job was crossing the first big hurdle and maintaining employment was the second big hurdle they had to cross. Barriers to maintaining a job included the pay, work conditions and relationships with co-workers. A hostile work environment like one with co-workers and employers who did not understand their health condition, made it difficult for participants to continue working, as illustrated by this participant in FG1:

“I was I was working at a warehouse…it was like a food grader and I didn't like that job cause first of all, the workers spoke a different language than me and it was very cold in the freezer. You had to wear a lot of heavy clothing.”

Low wages and not being promised the actual wages were one of the reasons why participants quit their previous jobs. This was especially common for overtime pay, many participants talked about being overworked and not being paid overtime. However, it was not always about the pay but this balance between managing their mental health and the financial needs. Participants clarified that for them, working longer shifts for only a couple days a week, was better for their mental health than working full time hours as they could spend the rest of the time doing something else.

In terms of facilitators, many participants echoed that finding a job that meets their expectations gave them satisfaction and meaning. This sentiment was summarized by this quote from our individual interview:

“… working with children it feels more fulfilling because I’m helping to raise, like a child, and helping them become people and teaching them about the world. And there is more love and nurturing involved and it’s a lot more fulfilling than working in customer service. It seems like I’m actually doing something good for the world and not just making my boss richer. [laughs]”

Other factors that kept participants motivated to work and allowed them to thrive at work were things like a flexible work environment, good support from co-workers and understanding bosses.

Improvements

Improvements to the quality of care refer to the solutions to improve quality of care provided [17]. In our model, this is a feedback loop. Constant feedback allows for increased success of program. This theme described participants’ suggestions to improve the YBEAT program. It consists of things that can be done to improve the effectiveness of the program and the care of the clients in this program. One common suggestion was to have a more tailored program according to participants’ needs, these needs varied from food options, to “just one-on-one with a staff and just to discuss how the search is going and other things” to having the option to take specific courses related to their interests. Participants also expressed their wish to have more leisure courses like expressive arts or creative arts courses, therapy animals and teambuilding events. In general, participants wanted some freedom to be able to choose their own programming within the 16-weeks.

Another suggestion that was repeatedly brought up was the need to provide financial support as one participant in FG2 pointed out,

“I was actually going to say more financial support through the course, like some of the other courses you actually get paid by the hour to go to them which is a pretty big pro when you don’t have a job currently right cause that can really help you make ends meet and get everything in order, cause like I was talking to one of my friends and she’s in a job she’s not liking right, and umm, the thing is though she can’t quit it to do this when she would have to go through the full YBEAT because then she doesn’t have any income and that’s kind of a problem there”.

Another issue was the longer follow-up period and access to the YBEAT program staff after the 16 weeks. This also included extension of some of the benefits they had during the program like gym passes and bus passes. Many participants talked about additional support from staff to help navigate legal issues and social welfare systems. They felt that having these support systems throughout the process was necessary for their success.

Discussion

The main objective of this study was to gain an understanding of participants’ experiences of the YBEAT program. In this study, a total of 34 young adults described their experiences participating in the 16-week YBEAT program and with finding and maintaining employment. The Donabedian’s model allowed us to view the participants’ experiences using a program evaluation lens. Better understanding of participants’ experiences help us to evaluate and improve the current program. Based on our results, we proposed a modified structure-process-outcome model for evaluating SEP for young adults with mental health conditions. This model lays down the important components to evaluate in any SEP The feedback loop in the model highlights the need for constant feedback of program.

Under structure, there were two main components, program environment and staff. While the physical environment is important when conducting any program or workshop, establishing a safe, inclusive, and positive environment was viewed by participants as crucial to the success of the program when working with young people with mental health challenges. Our results also showed that staff, whether permanent or guest instructors, were an integral part of this program. Experiences with core staff were positive, with negative experiences often resulting from guest speakers or staff who had less experience with working with people with mental illness. These results were in line with other research which showed that attitudes, experiences, and leadership qualities of program staff are vital to the success of SEP [20, 21]. Hence, the training of staff, especially for guest speakers or sessional instructors, is crucial in building a positive environment.

With regards to process, the elements of YBEAT and the format were highlighted. In general, experiences of the YBEAT program were positive, reflecting the acceptability of the program among young adults with mental illness. Consistent with other qualitative literature on supported employment, the participants in this study welcomed the integration of health, psychological and social services with the SEP as it helped them build important skills to manage their symptoms and the stresses of finding a job [22]. These additional skills extend beyond performing the job and include social skills and coping skills, which helped participants build confidence and motivation to seek employment. This in turn improved job readiness, an important contributor to successful employment [23, 24]. As all participants in this study have all completed the program, results indicate that the elements of YBEAT like building an inclusive environment and the increased peer support, in additional to building competency in work and health management, are essential elements in improving retention in SEP programs and motivation for employment [25].

There were mixed responses about the format and duration of a 16-week program. Participants in our study sought more support after completing the YBEAT program, highlighting they were in a “career exploration” phase and rather than a career phase [26]. Continued support whether financial or social and regular follow-up from staff were crucial factors that contributed to their well-being. Research have shown that longer follow up and support from program staff often resulted in better outcomes for participants in a SEP [23]. Like the YBEAT program, many SEPs are often funded to be short-term as continued support for an indefinite period may not be sustainable due to funding and logistical issues [27, 28]. As the degree and type of support required by participants were very varied, a possible solution to provide continued support is to employ a more person-centred approach. The use of an individualized follow up plan, carefully integrated within a health service, may help overcome these challenges [26]. Based on our results, some recommendations include allowing participants to state how often they desire a check-in from staff, when they require support and the type of support needed like staff accompaniment or career advice.

The main outcome of the YBEAT program was obtaining employment, however, obtaining and maintaining a job were described very differently by many participants. Barriers to getting a job included being overwhelmed by the job application process, and time management while barriers to maintaining a job included stigmatizing work environments, low pay and being in a job that was perceived as boring or not meaningful [29]. Although participants highlighted that the YBEAT program did an excellent job supporting youth through many of these challenges at the individual level, some of these barriers identified were at a system-level, including obtaining employment with competitive wages, timely access to mental health care, integrating services (health and employment) that are not time limited, and implementing care based on evidence-based services such as the IPS model [30]. Hence, success of a supported employment program should not only be measured by employment alone. This is consistent with previous research on supported employment program in mental health, where focusing only on gaining employment and not the youths’ needs, led to feelings of being stuck and poor motivation [31, 32]. Our results showed that participants benefitted from the program and obtained many skills that are likely to last beyond the 16-week intervention [33]. A broader approach to the measurement of outcomes of IPS programs is needed. Processes are needed to ensure ongoing engagement of young people to understand the value of such programs and to co-design quality improvement efforts with funders and programs to ensure programs meet the needs of diverse young people.

Limitations

Our study presented the experiences of participants attending our YBEAT program and the sample was drawn from one location, thus study findings may not be reflective of the general population of all youths with mental health challenges. As the YBEAT program was unique to one Canadian urban centre, transferability of the study findings is limited to this context. As well, due to the COVID-19 pandemic, we were unable to conduct triangulation of the findings with participants. In addition, feedback from YBEAT staff members was not conducted due to the turnover of staff. However, the aim of this study was to understand the experience from the participants’ perspective. Finally, this study did not collect data on race or ethnicity and did not successfully recruit young people who identified outside the gender binary. Future efforts to sample diverse participants may help inform strategies to address differences, including policies and practice to optimize employment programming and outcomes for young Canadians.

Conclusion

Overall, the YBEAT program was valuable to the participants in this study. Many participants reported gaining skills that would last beyond the 16-weeks of intervention. Mental health education for non-core staff and shifting the focus from gaining employment to career development and quality of life were important takeaways. The value of youth voice in this evaluation also provided information about the structure, process, and outcomes of the program that were important to participants. This proposed model can be used as a structure for monitoring and evaluating IPS programs. In parallel with high-quality health care, integrating effective work services are needed to empower young adults with mental health challenges to fully participate in their communities through career exploration and meaningful employment.