Promoting mental health equality by investing in organizations: lessons from implementation science Open Access

Despite increasing efforts to address mental health inequalities, the disproportionate impact of the COVID-19 epidemic on the mental health of marginalized populations highlighted the alarming disparities in mental health because of race and ethnicity in the USA. COVID-19 accentuated broader social inequalities arising from structural racism and the pervasive discrimination that Black, Indigenous and people of color (BIPOC) people confront in US society (Armstrong-Mensah et al., 2020; McGuire and Miranda, 2008; Office of the Surgeon General, 2016; Parenteau et al., 2023). People racialized as BIPOC suffered high levels of psychological distress, anxiety, depression and other mental health problems during the COVID pandemic (Huang, 2024; Saltzman et al., 2021). Despite reporting higher rates of depression and anxiety than white people, Black and Hispanic people received less medication and counseling (Sneed et al., 2020). Overall, Hispanic, Black and Asian people receive less mental health treatment than white people, with 11–17% being treated versus 30% of white people (Terlizzi and Schiller, 2022). With regard to outpatient care, a nationally representative study found that white people were twice as likely to receive outpatient services than Black and Hispanic people across gender and age groups (Olfson et al., 2023). One study found Hispanic individuals (22%) reported the most severe distress, followed by Asian individuals (18%) and Black individuals (16%) compared to white individuals (14%) (Wen et al., 2023), indicating there is a greater need than ever for the mental health system to engage BIPOC people in effective care.

Structural racism has been fueled by policies that disproportionately advantage white communities leading to differences in the social determinants of health, such as education, employment and income (Williams and Mohammed, 2013). While this results in higher health-care needs among BIPOC communities, often people living in these communities are less likely to have health insurance and access to mental health providers (Saltzman et al., 2021). However, increasing access alone is not sufficient to address mental health inequalities if the services and organizations reinforce disparities through racialized policies, procedures and biases. Providing care that is anti-racist, de-colonizing and anti-oppressive is also key to engaging people racialized as BIPOC in high-quality care. Many providers have both conscious and unconscious racial biases that negatively impact all aspects of mental health care including diagnosis, prescription of medication, choice of treatment and referrals (Department of Health and Human Services, 1999). The predominance of white mental health providers in outpatient mental health centers reinforces Western Euro-centric assumptions and norms around what constitutes mental well-being and illness (Desai et al., 2020). The result being that BIPOC people experience interpersonal and institutional racism during clinical encounters leading to high rates of disengagement (Hamed et al., 2024). While there is a pressing need to improve the treatment experience for marginalized populations throughout all outpatient care settings, organizations that are embedded in BIPOC communities play a particularly important role in addressing mental health inequalities.

Investment in organizations that target mental health inequalities from government and charities is often insufficient and only reimburses programmatic costs. Organizational overhead and administrative costs that may include infrastructure (e.g. health information technology), staff time to oversee, coordinate, communicate and provide support for service quality and workforce development are not prioritized within the limited funding available. Globally, levels of expenditure on mental health care are low and although there has been progress in the last decade, there is still a need for countries to invest in multisectoral infrastructure that improves access, quality of care, mental health promotion and prevention (World Health Organization, 2021). In the USA, private profit and nonprofit organizations deliver the large majority of mental health (88%) and substance use (93%) care and most of the care is delivered in the community (Substance Abuse and Mental Health Services Administration, 2024). While these organizations are funded by their participation in Medicaid, Medicare and private insurance plans, they also receive support from federal, state and local governmental entities in the form of block grants and from philanthropic sources (Everett et al., 2012). In addition to the traditional mental health settings, there are now efforts to increase access to mental health care for BIPOC communities, by leveraging community-based organizations (CBOs) to help identify and meet their mental health concerns (Rusch et al., 2015). These organizations can either provide services directly or facilitate cultural adaptation and access to culturally and linguistically focused clinics. The mission of these nonprofit CBOs focuses on social determinants by improving social, physical and economic well-being at the community level. Through linkage with mental health care providers, these organizations have been effective in engaging marginalized communities, such as Asian and Spanish-speaking, into care (Kim and Li, 2023; Snowden and McClellan, 2013).

Overall mental health organizations are underfunded and under-resourced in the USA, but it is particularly acute for smaller CBOs who rely predominately on government grants and philanthropic contributions. In this paper, we will consider how we can better support organizations that address mental health inequalities using insights from the burgeoning field of implementation science. We will describe the impact of restricted funding on nonprofit organizations and the increasing need for organizations to deliver evidence-based practices (EBPs) within mental health care. Using evidence and frameworks from implementation science research as our guide, this paper seeks to demonstrate that to implement programs including evidence-based practices effectively we must pay attention to organizational factors and implementation strategies, particularly when supporting smaller organizations serving marginalized communities.

Despite the growing need, nonprofit organizations providing mental health services continue to be underfunded not only due to reduced budgets but also because of the way funds are distributed. Overall, there has been a steady disinvestment in public services since the 1970s in the USA, with federal, state and local governments increasingly contracting out to private and nonprofit providers for greater cost efficiencies. This has led to intense competition among organizations to secure government contracts which usually restrict available funding to programmatic costs and even then may fail to cover the direct costs of service delivery (Labonté and Stuckler, 2016; Bunger et al., 2018). Funding is not only earmarked for specific programmatic costs, but funders are also less likely to invest in organizations with high administrative costs (Krawczyk et al., 2017). The rationale for restricted funding comes from a belief that the key mechanism that generates positive client outcomes is the program or service, itself and that providing unrestricted funds will lead to “bloated” expenses that benefit the institution but not its clients.

Within mental health care, government and private funders have increasingly focused on funding EBPs because of the growing body of research supporting specific programs and modalities. An EBP is defined as “an intervention for which there is strong research demonstrating effectiveness in assisting consumers to achieve outcomes” (Mueser et al., 2003, p.389). In the USA, there is a core set of practices, such as family psychoeducation, supported employment and illness management and recovery, which have been designated as EBPs (Drake et al., 2001) and widely disseminated (www.samhsa.gov/libraries/evidence-based-practices-resource-center). One example of funding being directly tied to the delivery of evidence-based practices is when the Los Angeles County Department of Mental Health experienced a time of severe budget shortfall and restricted funding for its prevention and early intervention initiative to organizations that provided EBPs (Lui et al., 2021). This use of reimbursement to incentivize EBPs is common within the USA, including offering conditional contracts or grants, providing higher reimbursement rates or tying funding to demonstration of achieved outcomes from delivering EBPs (Dopp et al., 2020). However, these mechanisms exclude investment in the organization despite the fact that organizational factors play a central role in the delivery of interventions. Implementation science has built an extensive evidence base delineating organizational barriers and facilitators to service delivery and testing implementation strategies to ensure that the effectiveness of an intervention translates to real-world settings (Weiner et al., 2022). Addressing mental health inequalities, therefore, requires effective practices and programs but also needs these practices and programs to be delivered by effective organizations.

While investing in organizations is key for all nonprofits, it is particularly important for organizations that serve communities experiencing inequalities (Brownson et al., 2021). We know that many of the smaller organizations that disproportionately suffer from a lack of general operating funds are often the same organizations that have strong ties with marginalized communities and provide “niche” services that are tailored to their needs (Despard, 2016). Smaller organizations were disproportionately impacted by COVID-19, with 48% of organizations with budgets of less than $5m experiencing cutbacks compared to 37% of organizations with budgets of over $5m (The NonProfit Times, 2021). Organizations led by BIPOC people or cultural insiders have experienced declining donations at a greater rate than those that are white-led, and organizations that are located within marginalized communities often have constrained networks within funding sources due to historical and current structural oppression leading to less grant funding (Faulk et al., 2016). Without the economies of scale afforded to larger organizations, small organizations lack the infrastructure necessary to support service provision and this in turn, undermines their ability to be competitive in securing and administering grants (Wing, 2004). The lack of funding for organizations serving marginalized communities is one more example of structural racism that drives disparities in service access and quality.

Organizations that specifically serve people racialized as BIPOC are often located in the communities they serve and staffed by people who bring critical insider knowledge (Roth et al., 2015). This enables them to have a greater understanding of the challenges people face including those related to the social determinants of health and to address them in ways that are appropriate and engender trust (Gooden et al., 2018). These organizations, while not always providing direct mental health services, can also act as a bridge to mainstream mental health services. A recent mental health initiative in New York City, implemented a task-sharing model in senior centers serving Chinese elders, training staff in identifying mental health needs and referring them to mental health services (Ayer et al., 2018). Similarly, faith-based organizations have been able to engage marginalized immigrant populations by training lay Church members as mental health providers (Annie Casey Foundation, 2021). When providing services directly, they are more able to identify “community-defined evidence” which factors in community needs, assets and history when thinking about what would be most effective.

One strategy that allows organizations to be truly responsive to community needs, particularly in times of crisis or upheaval, is to provide unrestricted funding to give them the flexibility they need to respond effectively. During COVID-19, many Asian organizations organized around the emergence of anti-Asian hate, which not only mobilized a collective effort but also served to address the negative mental health impacts of anti-Asian racism (Chang et al., 2023). The Vera Institute, which seeks to end mass incarceration, credited unrestricted foundation funding directly with being able to nimbly “chart their own course” to support the Black Lives Matter movement (Turner, 2021). Given the vital role that these organizations play in addressing mental health inequalities, there needs to be a change in how they are funded and supported.

Until recently, mental health researchers have primarily focused on studying individual programs and practices, but now implementation science has shifted this focus to systematically evaluating the role of organizational factors in service delivery and service user outcomes. The field has built an extensive evidence base evaluating the contribution of these factors to the implementation of novel practice innovations within routine mental health care. Novel practice interventions have included evidence-based psychosocial interventions and guidelines and now include systematic intervention adaptation for marginalized communities and prevention interventions focusing on social determinants (Cabassa and Baumann, 2013). Implementation research advances the development and testing of strategies that target organizational capacity to integrate new practices. This new knowledge, which has far-reaching implications across health care and human services, helps build the case for organizational investment and informs what we should target and fund at the organizational level. Funders would benefit from a roadmap for evidence-based investments that are synergistic with programmatic funding but tailored to the organizational context. Building on the extensive critiques of evidence-based practice for failing to take account of complex and often stressed human service settings (Briggs and McBeath, 2009; Despard, 2016; Mosley et al., 2019), we seek to demonstrate how to support organizational infrastructure and help all organizations and particularly those serving marginalized communities to thrive.

Since the 1990s, EBPs have become the mantra for health-care and human services organizations (Okpych and Yu, 2014) and persuaded many funders to target investment toward specific programs and practices that are deemed to be effective. Yet, these EBPs have often been either inaccessible or ineffective for people in need, due to a failure to consider how to implement and sustain these practices in real world and diverse settings (Institute of Medicine, 2001). In addition, these more top-down approaches have not been based on community-engaged research and have neglected smaller niche programs that may be effective for specific communities (Mosley et al., 2019). When interventions are delivered in real-world settings, there is what has been termed the “voltage drop” which refers to the well-documented decrease in positive outcomes from those achieved in efficacy trials (Chambers et al., 2013). This is because of organizational factors no longer being controlled for and influencing service delivery which leads to program drift and the subsequent decrease in effectiveness. Chambers et al. (2013) argue that the voltage drop is not inevitable but can be remedied by paying careful attention to the optimal fit between an intervention and the organizational setting.

Defined as “the study of processes and strategies that move, or integrate, evidence-based effective treatments into routine use, in usual care settings” (Proctor et al., 2009, p. 27) implementation science has emerged over the past two decades. A recent editorial in Science, reflecting on the challenges encountered with the distribution of COVID-19 vaccines, called for science to “add an additional lane” to study the uptake of effective practices (Proctor and Geng, 2021). There are many factors that influence uptake and as a result, implementation research is multi-level and complex, using knowledge from a diverse array of fields, including social marketing, health communication, behavioral approaches, patient–provider communication, risk and decision analysis, health economics and health policy (Glasgow, 2008). The complexity of the organizational environment has necessitated conceptual mapping, which has generated more than 60 implementation frameworks that have identified and organized salient factors involved in practice innovation (Birken et al., 2017). Some of the most used are the Consolidated Framework for Implementation Research (Damschroder et al., 2009), Exploration, Preparation, Implementation and Sustainment (Moullin et al., 2019), Promoting Action on Research Implementation in Health Services (Kitson et al., 1998), Reach, Effectiveness, Adoption, Implementation and Maintenance (Glasgow et al., 2019) and Diffusion of Innovation (Greenhalgh et al., 2004). Informed by these frameworks, we now better understand how organizational factors predict and sustain implementation, which in turn predicts service outcomes and client outcomes. There is now extensive evidence based on the role of key organizational factors including leadership (Reichenpfader et al., 2015), supervision (Choy-Brown et al., 2022) and organizational culture and climate (Braithwaite et al., 2017). Strengthening these factors are vital to creating healthy organizations that have the capacity to deliver high-quality mental health services. Furthermore, Baumann and Cabassa (2020) make the argument that paying attention to building capacity, supporting leaders and leveraging staff buy-in are of particular importance when implementing EBPs in diverse community-based settings.

Identifying organizational factors for investment is a critical lever toward achieving programmatic success. Leadership is one such lever that not only includes management and administrative competency but also requires the qualities needed to implement programs and practices (Choy-Brown et al., 2020b). Leaders, particularly, play a critical role in facilitating the uptake and adoption of innovation (Brimhall et al., 2016; Moullin et al., 2018; Williams et al., 2024). Staff look to the leadership to determine whether the innovation is an organizational priority and whether they are going to be supported, and even rewarded, for investing their time in this effort (Schein, 2010). Leadership behaviors that promote the uptake of a new practice include being hands-on and demonstrating personal investment in EBP activities (Stetler et al., 2014). To promote racial equity, leadership commitment along with supporting the BIPOC workforce to attain and sustain leadership roles have been found to be critical components for change (Choo, 2020; Priest et al., 2015). Organizational theory has identified four dimensions of leadership that promote implementation: proactivity (anticipating and addressing implementation challenges), perseverance (commitment to EBP implementation regardless of the magnitude of challenges), knowledge (understanding EBP and implementation issues) and supportiveness (capacity and resources to support the use of EBPs by clinicians who are tasked with delivering them) (Aarons et al., 2014). These behaviors have a positive impact on implementation climate which in turn leads to greater uptake of innovation by providers (Williams et al., 2024). Although leadership skills can be propagated as intuitive, there is evidence to support that such skills can be learned, cultivated and mastered with the proper resources and commitment (Brown and May, 2012).

For organizational learning, training is the most used tool and restricted programmatic funding often includes funds for targeted training. However, another important resource that is rarely directly funded and mostly an organizational cost is supervision, an embedded clinical resource that can support a climate of organizational learning. Supervision has been shown to increase fidelity to EBPs and has the potential to contribute to the sustained utilization of practices (Beidas et al., 2012; Motamedi et al., 2021). In addition, it is an established component of routine practice for clinicians in training and is mandated for licensure (American Psychological Association [APA], 2014; Council on Social Work Education [CSWE], 2014). The lack of direct funding for supervision often limits its scope to the completion of administrative tasks and lessens the use of evidence-based clinical supervision techniques such as direct observation and supervisor feedback (Choy-Brown and Stanhope, 2018; Rothwell et al., 2021). However, when supported, supervision can foster clinician skill development (Choy-Brown et al., 2022), shape implementation climate (Bunger et al., 2019) and advance anti-racism efforts. Increasingly, supervision is also being used as an important tool in efforts to shift provider attitudes and disrupt racial bias and discrimination in clinical practice (Bussey and Jemal, 2023).

Implementation science has also focused on the so-called warmer elements of organizational context, namely, culture and climate, as opposed to the colder elements which are structure and processes (King et al., 2018). They are a key part of the social context of organizations that focus on shared workforce perceptions, which have been found to influence innovation both positively and negatively across sectors (Glisson and Williams, 2015). Organizational climates and cultures within mental health organizations that are rooted deeply in Western Eurocentric values can also be significant barriers to engaging with racialized and marginalized groups (Desai et al., 2020). Shifting these climates and cultures entails not only hiring more employees who bring rich cultural insider knowledge but also creating psychologically safe, supportive and inclusive workplaces (Priest et al., 2015). While often used interchangeably, they are distinct constructs with culture referring to shared employee perceptions around “the behavioral expectations and norms that characterize the way work is done in an organization” (Glisson et al., 2006, p. 85). These shared perceptions shape how workers carry out their work, from prioritizing to completing tasks and are communicated by social processes such as modeling and reinforcement. Organizational climate refers to shared employee perceptions around “the psychological impact of their work environment on their own personal wellbeing” (Williams and Glisson, 2014, p. 64), determining their perceptions about the meaning and significance of their work. Culture and climate, although made up of the sum of individual perceptions, exist at the organizational level and are measured in aggregate (Beidas et al., 2014). Positive culture and climate have been found to improve adoption of new practices and the quality of services, reduce staff turnover and increase positive service user outcomes (Glisson and Williams, 2015).

In addition to understanding the effects of general culture and climate, implementation science research has also sought to specify and examine the specific strategic climate needed for a given implementation. A key part of implementation climate is the extent to which providers perceive that implementing a new practice is expected, supported and rewarded by an organization (Aarons et al., 2014). Providers need to have a shared buy-in to a new practice and feel they have the capacity to implement the change (Damschroder et al., 2022). By engaging providers in the innovation during the planning stages and having leaders actively involved in the implementation not only ensures adoption of the practice but can also improve the efficiency of training efforts (Stanhope et al., 2019). Overall, positive implementation climates are associated with higher employee satisfaction and service user perception of service effectiveness (Jacobs et al., 2015).

Implementation strategies, which are defined as “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice” (Proctor et al., 2013, pg. 3), are the practical application of implementation science. Supported by research (Ashcraft et al., 2024), these strategies cover a broad array of activities that target organizational factors including leadership, supervision, organizational culture and climate and organizational readiness. One example is the Leadership and Organizational Change for Implementation (LOCI) strategy that aims to improve general leadership, implementation leadership and climate for the implementation of EBPs (Aarons et al., 2015). Grounded in theory, LOCI is a multilevel intervention targeting leadership alignment, behavior and strategic planning and uses an audit of employee perceptions of strategic climate and leadership and facilitated feedback to leaders, ongoing expert consultation and educational materials and meetings (Williams et al., 2020; Williams et al., 2024), Effectiveness trials have tested LOCI across multiple settings in the USA and abroad (Aarons et al., 2015; Aarons et al., 2017; Skar et al., 2022) and found it can strengthen key organizational factors such as strategic leadership and organizational climate (Williams et al., 2024).

While supervision is an embedded resource in most mental health organizations, it is often under-utilized as an implementation strategy. To be more intentional, supervision strategies have been paired with practice innovation efforts to reinforce provider learning and uptake of new behaviors. One example is the R³ Model, which was developed to support child welfare workers in adopting two new EBPs (Saldana et al., 2016). Based on social learning theory, the supervisors were trained to use parallel reinforcement strategies with caseworkers, as they were using with their own clients. In this case, they focused on reinforcement of effort, reinforcement of roles and relationships and reinforcement of small steps. Results of a pilot study of the R³ Model demonstrated that supervisors improved in providing reinforcement over time and that leadership perceived an overall improvement in organizational climate (Saldana et al., 2016).

A well developed and tested implementation strategy designed to improve organizational culture and climate is the Availability, Responsiveness and Continuity (ARC) Model of Organizational Effectiveness. A multi-component approach, first, ARC embeds five principles of organizational effectiveness to guide the practice innovation which are: mission-driven not rule-driven; results-oriented not process-oriented; improvement-directed not status quo–directed; relationship-centered not individual-centered; and participation-based not authority-based (Glisson and Schoenwald, 2005). Second, ARC provides tools and training for providers to be able to identify the barriers and facilitators to uptake of the new practice and, third, the strategy targets provider attitudes such as openness to change. This comprehensive strategy also provides structure as well as process for an innovation effort by creating an ARC specialist and an ARC liaison to leadership and front-line teams. The ARC developers created an organizational social context measure that can assess an agency’s culture and climate based on engagement, functionality and stress (Glisson and Williams, 2015). In a randomized trial testing the impact of ARC, the strategy improved organizational climate and decreased provider turnover rates (Glisson et al., 2010).

Strategies, such as LOCI and ARC, are multi-component and integrate multiple discrete implementation strategies that target organizational factors and require considerable time and investment. Powell et al. (2015) polled stakeholders and identified 73 discrete practical strategies that can be used separately or in combination to support practice innovation. While these strategies have evidence of effectiveness, they may not be cost-effective or feasible for all organizations. By conducting economic evaluations of these strategies and comparing effectiveness with less intensive strategies, we can better align them with the resources available to CBOs and also identify opportunities for cost savings to promote their sustainment (Dopp et al., 2023).

Using an equity lens expands our notion of what constitutes successful implementation of EBPs. Starting with the selection of a practice, organizations should consider whether an EBP is proven to be effective within specific racial and ethnic minority communities and the extent to which it aligns with the larger community culture. Also, by using the science of adaptation, we can explore if there are ways to adapt a practice to make it congruent with cultural values and norms while maintaining its effectiveness (Cabassa and Baumann, 2013). The equity lens also challenges us to think more broadly about outcomes, namely how EBPs promote equitable population impact and not just individual-level change (Damschroder et al., 2022). For funders, that means rather than just focusing on individual programs and practices, they should consider how their funding can level the organizational playing field and meet community-level needs. This entails understanding how larger historical, economic and political forces impact low-resourced settings and their capacity to deliver services (Yapa and Bärnighausen, 2018). A recent Lancet Commission on transforming mental health implementation research recommended adopting equity-informed interventions and strategies that address structural and social barriers (McGinty et al., 2024). Similarly, Woodward et al. (2021) developed the Health Equity Implementation Framework, which embeds the relevance of race and ethnicity in the clinical encounter and the organizational setting, but also includes the influence of sociopolitical forces, economies and physical structures on health-care delivery.

While community-engaged organizations have great potential to meet the mental health needs of marginalized communities and address mental health inequalities, they are often under resourced. Implementation science has created frameworks, measures and methodologies to help us understand how to strengthen these organizations and improve service delivery. Its burgeoning evidence base demonstrates how factors such as leadership, organizational learning and culture and climate influence the implementation of new practices and improve client outcomes. Informed by these findings, there is a strong argument to be made for funding general operating expenses to fortify organizations to continue their mission-driven work to promote health equity. Moreover, the work to address mental health inequalities demands that we address structural factors, which requires robust organizations that have both the will and the capacity to take on larger social, political and economic factors. Already, we are seeing within health care a recognition that the demand for high-quality, anti-racist services must be accompanied by significant infrastructure support (Burwell, 2016; Choy-Brown et al., 2020a; Powell et al., 2016). Enhancing organizational settings not only strengthens an organization’s ability to deliver and sustain practices but also allows them to respond nimbly to fast-changing environments such as the challenges of COVID-19 and the movement for racial justice. It also gives smaller organizations, which often serve marginalized communities, a more secure operational base. Drawing on Maslow’s hierarchy of needs, implementation researchers have made the argument that EBPs will never be the “panacea” without increased funding to meet the basic needs of organizations (Stewart et al., 2021). Whether funding sources are general to give organizations flexibility or specifically targeted to increasing key organizational factors, both strategies have the potential to improve individual and population mental health well-being.

Disclosure statement: The authors report there are no competing interests to declare.