Re-employment & Health Rogier van Rijn Erasmus MC, department of Public Health

Unemployment: Europe Unemployment rates ,4% 4,1%

Unemployment: The Netherlands 12,6% 10,9% 7,9% 6,4% Unemployment rates 2012

Unemployment and Health Lower scores on all health dimensions for the unemployed Health survey 2003 GGD Rotterdam

Unemployment and Health Schuring et al. The effect of re-employment on perceived health. J Epidemiol Community Health. 2011;65(7): All dimensions of health improved among re-employed subjects Health at baseline was better among subjects who returned to paid employment Re-entered paid employment (n=47)Continue to be unemployed (n=918) Self-rated health (scale 0-100)

What works and what does not? Isolated health promotion programme no effect on health and work resumption

What works and what does not? -Personal advisors and individual case management helped some people -Many studies suffer from selection bias; more work-ready claimants -Financial incentives; too low or too short

What works and what does not?

Summary  Poor perceived health among the unemployed  Re-employment  health  Isolated health promotion programme not effective  Supported employment effective (USA, UK) Integrating health promotion programmes with re-employment activities

Fit4Work (F4W)  Unique collaboration between Municipal Health Services, Social Security Services and UWV in 4 largest cities of the Netherlands  Objectives:  Gain quick and sustainable work in the labour force  Increase perceived health (mental, physical)  Fit4Work stands for:  Rapid job search and job placement  Treatment of mental problems  Support and guidance to participants

Fit4Work initiatives  Cost-benefit analysis (in advance) of Fit4Work  Evaluation study of Fit4Work  Process evaluation Fit4Work

Cost-benefit analysis in advance of a new intervention - Insight into where returns can be expected - Social justification of the focus on the target population - Insight in the information gathering for the cost benefit analysis afterwards

Cost-benefit analysis  Comprehensive understanding of costs and benefits  perspective of actors (e.g. clients, municipality)  the society as a whole (taxpayer) Intervention Intermediate effects Costs & benefits

Literature study  Interventions aimed at re-employment of the unemployed  Randomised controlled trials

Effects: re-employment, hours worked Mueser KT. The Hartford study of supported employment for persons with severe mental illness. J Consult Clin Psychol. 2004;72(3): Re-employment; mean difference of 16% (IPS vs. control) Hours worked; mean 23 hrs/ week in both groups

Effects: type of work More regular work, less subsidized work and voluntary work Michion HJ. Effectiviteit van individuele plaatsing en steun in Nederland: Verslag van een gerandomiseerd gecontroleerde effectstudie UMCG/Trimbos instituut Voluntary work Subsidized work Regular work Percentage that worked at least one day Control at 6 months at 18 months IPS

Effects: other  Income and unemployment benefit  Increase of regular work  income, benefits  Quality of life  Effects are not well known  Use of healthcare  Effects are not well known  Use of informal care  Effects are not well known

Total costs and benefits Costs (-) and benefits (+) Compared to regular re-employment programme Costs Fit4Work Production paid employment7.010 Work related costs-220 Operating costs providing benefits230 Expenditure health care & municipal facilities+PM Criminality and disturbance+PM Informal care+PM Leisure time-PM Quality of life+PM Distortionary taxation350 Total PM

Fit4Work initiatives  Cost-benefit analysis (in advance) of Fit4Work  Evaluation study of Fit4Work  Process evaluation Fit4Work

Evaluation study Fit4Work Research questions  Which factors determine the reach and uptake of Fit4Work?  What are the effects of Fit4Work on perceived mental health, work resumption, and social participation?  What are costs and benefits relative to estimated effects of Fit4Work?

Pragmatic Randomised Controlled Trial Target population (n=1000) Questionnaire (12 months) Questionnaire (24 months) Randomisation Fit4Work (n=500) Control (n=500) Questionnaire (baseline)  Long-term unemployed subjects (age < 50yr) with mental health problems  Sufficient labour market skills  Sufficient skills to be able to provide answers in an interview  No severe acute psychiatric illness  No drug addiction or being homeless  Primary outcomes;  perceived mental & physical health  work resumption  social participation  Secondary outcomes;  self-esteem  resilience  social problems  medical consumption  intersectoral integrated approach  improving mental health  addressing barriers in social- and labour force participation  regular re-employment programme and medical care

Fit4Work initiatives  Cost-benefit analysis (in advance) of Fit4Work  Evaluation study of Fit4Work  Process evaluation Fit4Work

Process evaluation Fit4Work  Process evaluation consists of:  Formative evaluation – implementation research  Summative evaluation - crucial element analysis Research & Business Intelligence

Formative evaluation  Research questions:  How well is the intervention adopted by the participating institutions and are the essential elements delivered as intended ?  Is the reach of the target population sufficient?  Methods:  Interviews; participants of multidisciplinary teams  Document analysis; selection of intervention plans  Observation; attend multidisciplinary meeting  File analysis; analyse participant files

Summative evaluation  Research question:  Which components are considered to contribute most to the primary and secondary outcome measures?  Which subgroups seem to respond best to the Fit4Work intervention  Methods:  Data analysis of questionnaires  Casuistic analysis of participants, drop-outs, re-employed persons  File analysis

 Thanks for your attention 