Health protection in times of recession The role of Active Labour Market Programmes Dr Adam Coutts

Policy importance  ALMPs form a core component in the delivery of social protection, welfare-to-work policy and broader policies of social mobility and poverty alleviation.  ALMPs and labour market training interventions are used to increase employability and reduce the risk of unemployment. Include job search assistance, basic skills training.  Becoming ever more important given increasing unemployment across Europe and US.  Some recent evidence by Stuckler, Coutts et al that they may protect the health of the unemployed during unemployment surge and recession.

Unemployment-Mortality 1% rise in unemployment associated with: - 0.8% ↑Suicide - 0.8% ↑Homicide - 1.4% ↓Traffic death No effect on all- cause mortality Source: From Stuckler et al 2009 Lancet

Some populations more vulnerable Source: From Stuckler et al 2009 Lancet

Social Protections Help… Each 100 USD greater social spending reduced the effect on suicides by: %, active labour market programmes %, family support %, healthcare %,unemployment benefits Spending> 190 USD no effect of unemployment on suicide Source: From Stuckler et al 2009 Lancet

But lack of evidence on ALMPs and health and causal mechanisms  Evidence on the effects of ALMPs and training programmes deal almost exclusively with labour market outcomes such as earnings, job outcomes and the cost-effectiveness of programmes  Evidence on labour market status and health has focussed on the health damaging effects of working conditions or of unemployment.  Less evidence available on what happens to health when there is an apparent amelioration in aspects of labour market deprivation, such as reemployment and especially that embodied within quasi-employment condition of ALMPs and return-to-work schemes.  Policy makers have assumed that mechanisms designed to move people from unemployment to employment are the key factors in tackling poverty and improving health.

ALMPs and health Evidence which exists from such studies - Työhön job search training Programme, Finland) and the Institute of Social Research (Michigan) shows Reductions in psychological distress and depression (Coutts 2005, 2009; Juvonen-Posti et al 2002; Melin and Fugl-Meyer 2003; Vuori et al 2002; Vuori and Silvonen, 2005; Vuori and Versalainen 1999, Vinokur et al 2000; Westerlund et al 2001) Increased subjective well-being (Andersen 2008); Higher levels of control/mastery (Creed et al 1999); Improvements in motivation and self-esteem through feeling needed (Coutts forthcoming, 2005; Donavan et al 1986; Hagquist and Starrin 1996; Harry and Tiggemann 1992)

Causal mechanisms Models of Jahoda (1982), Warr (1987), Fryer (1986) and Bandura’s (1997) self-efficacy model, Suggested that ALMPs and the training programmes used to deliver them have the potential to improve health, in particular that of psychological health and psychosocial functioning, through the provision of the latent functions/vitamins.

Latent and Manifest Benefits model (Muller, Creed, Waters and Machin 2005) The LAMB scale has arisen from the lack of consistency and questionable psychometric properties in the scales (Access to Categories of Work Experience and Significance of Work Scale) used to measure the latent and manifest benefits using the theories of Jahoda and Fryer, making comparative studies difficult. LAMB measures: collective purpose, social contact, social support, status, time structure, activity and financial strain.

LAMB The LAMB subscales have strong internal reliability, ranging from.74 (time structure) to.93 (financial strain) (Muller et al 2003). Only been tested amongst unemployed groups in Australia (Creed et al 2005; Hoare and Machin 2010).

New Deal for Lone Parents - UK Coutts examined the health impacts of two training programmes on lone parents and whether the change in their psychosocial environment as measured by the scale of the latent and manifest benefits of employment explain health impacts. Data: 62 lone parents participating in the programmes who were followed longitudinally for five months. Structured questionnaires comprising scales of psychological health, self- esteem, mastery, positive and negative affect, self-efficacy, were administered to the programme participants at three time intervals - at the beginning (0 months), during (2.5 months) and end of the training programmes (5 months). Results: entry into the training programmes improved the psychological health and well-being of the training participants. A clear and significant relationship was found between psychosocial environment variables such as social contact (p<.001), collective purpose (p=.047) and social identity (p=.043) and psychological health. Material economic variables (financial strain) did not to contribute significantly to health measures.

Improved psychological health (GHQ)

Next steps (1) Need for systematic review of ALMPs and health (Coutts 2009) NOT A COCHRANE REVIEW! Need to generate rigorous evidence on ALMPs as natural experiments using European Union Statistics on Income and Living Conditions (EU-SILC). Provides European wide picture of their impact pre-post recession. Replicate LAMB in different labour market contexts.

Next steps (2) Policy importance Demonstrate cost-benefit and savings to health services and treasury generated by ALMPs – what is the social value of ALMPs to government and individual? HMT Green Book Link to WHO Social Determinants of Health agenda – demonstrate what works, why and for who? Link to well being / happiness agendas of various EU govs – Stiglitz-Sen Commission on the Measurement of Economic Performance and Social Progress

Governments must invest in ALMPs and social protection not scale back! ALMPs will are vital in labour markets where there are no jobs. Provide a mechanism by which to inoculate unemployed against health damaging effects of unemployment. As governments across Europe seek to generate maximum value and economic effectiveness from their public services, there will be increased pressure to identify the broader personal and social value of non- health sector government interventions. Can governments reward ALMPs for their health / well being impacts in addition to job entry rates?

Useful references Coutts A P (2009) Active Labour Market Programmes and health: an evidence base. Marmot Review. Available at: mic%20active%20labour%20market%20full%20report.pdf. mic%20active%20labour%20market%20full%20report.pdf Fujiwara D and Campbell R (2011) Valuation Techniques for Social Cost Benefit Analysis: Stated Preference, Revealed Preference and Subjective Well-Being Approaches treasury.gov.uk/data_greenbook_news.htmhttp:// treasury.gov.uk/data_greenbook_news.htm Fujiwara D (2010) Methodologies for estimating and incorporating the wider social and economic impacts of work in Cost Benefit Analysis of employment programmes. Available at : Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M (2011) Effects of the 2008 recession on health: a first look at European data. Lancet 378, pp. 124–125. Stuckler, D, Basu S, Suhrcke M, Coutts A, McKee M (2009) ‘The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis’. Lancet.