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

2. Unemployment: Europe Unemployment rates 2012 6,4% 4,1%

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

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

5. Unemployment and Health Schuring et al. The effect of re-employment on perceived health. J Epidemiol Community Health. 2011;65(7):639-44 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)

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

7. 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

8. What works and what does not?

9. 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

10. 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

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

12. 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

13. 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

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

15. 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):479-90. Re-employment; mean difference of 16% (IPS vs. control) Hours worked; mean 23 hrs/ week in both groups

16. 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. 2011. UMCG/Trimbos instituut Voluntary work Subsidized work Regular work Percentage that worked at least one day Control at 6 months at 18 months IPS

17. 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

18. Total costs and benefits Costs (-) and benefits (+) Compared to regular re-employment programme Costs Fit4Work-2.840 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 Total4.530 +PM

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

20. 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?

21. 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

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

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

24. 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

25. 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

26.  Thanks for your attention  r.vanrijn@erasmusmc.nl