Health promotion for the unemployed: the evaluation of the JOBS Program Germany from the trainers' perspective

BACKGROUND

The JOBS Program Germany is a labor market integrative and health promotion intervention for unemployed people. This study examines JOBS Program Germany trainers' view of (1) the theoretical concept of the JOBS Program, (2) its practical implementation in Germany on-site, (3) its acceptance by participants, and (4) the training effects. The study aimed at identifying potential for adaption allowing adjustments to improve the practical implementation and the training effectiveness.

METHODS

JOBS Program Germany trainers (two for each training) were interviewed via voluntary survey (computer-assisted web interviews) after each training.

RESULTS

Fourteen JOBS Program trainings have been conducted and all trainers responded resulting in 28 interviews. 78.5% and 85.7% of the respondents were rather or very satisfied with the theoretical contents and its practical implementation, respectively. Almost all trainers (96.4-100.0%) were satisfied with the on-site coordination, the cooperation with the organizer's employees, the room equipment, the training room size, and the environmental conditions in the training rooms. In 89.3% of all responses the trainers rated the last training a success. However, the trainers also provided valuable suggestions for further improvement in Germany. This concerns the revision of the training manual, the adjustment of the trainer training and the preparation of participants.

CONCLUSION

Besides the trainers' positive view on the different dimensions of the training content and implementation, their suggestions can help ensure that many unemployed people in Germany could benefit from a continued regular implementation of the JOBS Program Germany in the future.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS00022388. Registered on 20 July, 2020.

Results from a Nationwide Evaluation Study of Labor Market-Integrative Health Promotion for the Unemployed: Impact of the JOBS Program Germany

Compared to the employed, the unemployed suffer from poorer health, especially in terms of mental health. At the same time, health promotion rarely reaches unemployed people. The "JOBS Program" is an intervention to promote health and labor market integration and has shown positive effects in the USA and Finland. In this confirmatory study, we investigated whether the JOBS Program achieves similar effects in Germany. We applied a randomized controlled trial to compare an intervention group (IVG) with a waiting control group (WCG) before (T0; N = 94) and shortly after (T1; n = 65) the intervention. Concerning our primary outcomes, the JOBS Program Germany was beneficial: Compared to the WCG, the regression estimated that the IVG had (1) a 2.736 scale point higher level of life satisfaction (p = 0.049), (2) a 0.337 scale point higher level of general health (p = 0.025), and (3) a 14.524 scale point higher level of mental well-being (p = 0.004). Although not statistically significant, job search-specific self-efficacy also appeared to be positively associated with the intervention. This study provides evidence of the effectiveness of JOBS Program on the abovementioned outcomes, including for older and long-term unemployed people, supporting the benefits of regular implementation of this program for a wide range of unemployed people in Germany.

The Effectiveness of Health-Oriented Interventions and Health Promotion for Unemployed People-A Meta-Analysis

Background: Unemployment is known to have negative effects on mental and physical health. Yet, the effectiveness of interventions aimed at improving the health of unemployed people is unclear. Methods: We conducted a random-effects meta-analysis of extant intervention studies with at least two measurement points and a control group. A literature search in PubMed, Scopus, and PsycINFO in December 2021 identified 34 eligible primary studies with 36 independent samples. Results: For mental health, the average meta-analytic effect sizes for the comparison of the intervention group and the control group were significant and of small size after the intervention, d = 0.22; 95% CI [0.08, 0.36], as well as at follow-up, d = 0.11; 95% CI [0.07, 0.16]. Effects on self-assessed physical health status were small and marginally significant (p = 0.10) after the intervention: d = 0.09; 95% CI [-0.02, 0.20], and insignificant at follow-up. However, when job search training was not part of the intervention program (i.e., all available resources were used solely for health promotion), the average effect size for physical health was significant after the intervention, d = 0.17; 95% CI [0.07, 0.27]. Furthermore, the effects of physical activity promotion were significant and of small-to-medium size after the intervention, leading to increased levels of activity, d = 0.30; 95% CI [0.13, 0.47]. Conclusions: Population-based health promotion programs are recommended because even measures with small effect sizes can actually improve the health of a large group of unemployed people.

Mental health and unemployment: A systematic review and meta-analysis of interventions to improve depression and anxiety outcomes

BACKGROUND

Unemployment is associated with substantially greater depression and anxiety, constituting a considerable public health concern. The current review provides the most comprehensive synthesis to date, and first meta-analysis, of controlled intervention trials aimed at improving depression and anxiety outcomes during unemployment.

METHODS

Searches were conducted within PsycInfo, Cochrane Central, PubMed and Embase from their inception to September 2022. Included studies conducted controlled trials of interventions focused on improving mental health within unemployed samples, and reported on validated measures of depression, anxiety, or distress (mixed depression and anxiety). Narrative syntheses and random effects meta-analyses were conducted among prevention- and treatment-level interventions for each outcome.

RESULTS

A total of 39 articles reporting on 33 studies were included for review (sample sizes ranging from 21 to 1801). Both prevention and treatment interventions tended to be effective overall, with treatment interventions producing larger effect sizes than prevention interventions. The clearest evidence for particular intervention approaches emerged for prevention-level Cognitive Therapy/CBT, followed by prevention-level work-related interventions, although neither produced entirely consistent effects.

LIMITATIONS

Risk of bias was generally high across studies. Low numbers of studies within subgroups precluded any comparisons between long-term and short-term unemployment, limited comparisons among treatment studies, and reduced the power of meta-analyses.

CONCLUSIONS

Both prevention- and treatment-level mental health-focused interventions have merit for reducing symptoms of anxiety and depression among those experiencing unemployment. Cognitive Therapy/CBT and work-related interventions hold the most robust evidence base, which can inform both prevention and treatment strategies implemented by clinicians, employment services providers, and governments.

Systematic realist synthesis of health-related and lifestyle interventions designed to decrease overweight, obesity and unemployment in adults

Background

Obesity and unemployment are complex social and health issues with underlying causes that are interconnected. While a clear link has been established, there is lack of evidence on the underlying causal pathways and how health-related interventions could reduce obesity and unemployment using a holistic approach.

Objectives

The aim of this realist synthesis was to identify the common strategies used by health-related interventions to reduce obesity, overweight and unemployment and to determine for whom and under what circumstances these interventions were successful or unsuccessful and why.

Methods

A realist synthesis approach was used. Systematic literature searches were conducted in Cochrane library, Medline, SocIndex, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and PsychInfo. The evidence from included studies were synthesised into Context-Mechanism-Outcome configurations (CMOcs) to better understand when and how programmes work, for which participants and to refine the final programme theory.

Results

A total of 83 articles met the inclusion criteria. 8 CMOcs elucidating the contexts of the health-related interventions, underlying mechanisms and outcomes were identified. Interventions that were tailored to the target population using multiple strategies, addressing different aspects of individual and external environments led to positive outcomes for reemployment and reduction of obesity.

Conclusion

This realist synthesis presents a broad array of contexts, mechanisms underlying the success of health-related interventions to reduce obesity and unemployment. It provides novel insights and key factors that influence the success of such interventions and highlights a need for participatory and holistic approaches to maximise the effectiveness of programmes designed to reduce obesity and unemployment.

Trial registration

PROSPERO 2020 CRD42020219897.

Do Start-Up Subsidies for the Unemployed Affect Participants' Well-Being? A Rigorous Look at (Un-)Intended Consequences of Labor Market Policies

BACKGROUND

The literature on start-up subsidies (SUS) for the unemployed finds positive effects on objective outcome measures such as employment or income. However, little is known about effects on subjective well-being of participants. Knowledge about this is especially important because subsidizing the transition into self-employment may have unintended adverse effects on participants' well-being due to its risky nature and lower social security protection, especially in the long run.

OBJECTIVE

We study the long-term effects of SUS on subjective outcome indicators of well-being, as measured by the participants' satisfaction in different domains. This extends previous analyses of the current German SUS program ("Gründungszuschuss") that focused on objective outcomes-such as employment and income-and allows us to make a more complete judgment about the overall effects of SUS at the individual level.

RESEARCH DESIGN

Having access to linked administrative-survey data providing us with rich information on pretreatment characteristics, we base our analysis on the conditional independence assumption and use propensity score matching to estimate causal effects within the potential outcomes framework. We perform several sensitivity analyses to inspect the robustness of our findings.

RESULTS

We find long-term positive effects on job satisfaction but negative effects on individuals' satisfaction with their social security situation. Supplementary findings suggest that the negative effect on satisfaction with social security may be driven by negative effects on unemployment and retirement insurance coverage. Our heterogeneity analysis reveals substantial variation in effects across gender, age groups, and skill levels. Estimates are highly robust.

JOBS Program Germany for health promotion among the unemployed in the community setting with institutions for employment promotion (JobsProgramDtl): study protocol for a randomized controlled trial

Background

Compared to the employed, the unemployed are characterized by a substantially worse health status, particularly with regards to mental health. At the same time, conventional offers of prevention and health promotion rarely reach the unemployed. The JOBS Program is a health promotion program that combines job application training with elements of social learning theory and self-efficacy. Randomized field studies in the USA and Finland found significant positive effects on reintegration into the labor market and health amongst the unemployed. In this confirmatory study, we analyze whether the JOBS Program produces similar positive effects for the unemployed in Germany.

Methods

This study is designed as a country-wide, multi-center, non-blinded, two-armed, parallel-group, randomized controlled trial over 6 months. A total of approximately 1500 unemployed, who are willing to participate, are randomly assigned either to an intervention group or a waiting control group with an allocation ratio of 1:1. Guided by a team of two trainers, the intervention group completes JOBS Program Germany in small groups of 8 to 15 unemployed for a period of 1 week in units of 5 h a day. Primary outcome measures are the reintegration into the labor market, self-efficacy, life satisfaction, subjective state of health, depressive symptoms, and psychological distress. Of secondary interest are moderating variables such as socio-demographic characteristics, the duration of unemployment, and the job-search intensity. Outcomes will be repeatedly assessed via computer-assisted telephone interviews at three points in time: immediately before the intervention (pre-test), immediately after the intervention (post-test), and 6 months after the intervention has ended (6-months follow-up).

Discussion

This confirmatory study will provide empirical evidence on the effectiveness of the JOBS Program on the reintegration and (mental) health of the unemployed in Germany. If our results from the randomized controlled trail in a country-wide field experiment confirm its effectiveness, the JOBS Program Germany could, perspectively, be implemented into the German employment promotion and social security system on a long-term basis.

Trial registration

German Clinical Trials Register (DRKS), DRKS00022388. Registered on 20 July, 2020.

Effects of spouse's employment status on depression

OBJECTIVES

Whether the spouse's employment status would be associated with individual's mental health condition is uncertain. Therefore, the aim of this study was to investigate the effects of spouse's employment status on depression.

METHODS

Data included the second to sixth wave of the Korean Longitudinal Study of Ageing (KLoSA). Depression was measured based on the CES-D10. Spouse's employment status was divided into 4 categories based on their employment changes.

RESULTS

Participants with still unemployed spouse were more likely to have high scores of depression (male: β = 0.32, female: β = 0.42). Participants who are employed and have unemployed spouse have higher depression scores (male: β = 0.45, female: β = 0.77).

CONCLUSION

This study identified the effect of spouse's employment status on depression by gender, and the results were significant. We should consider the possibility of conducting interventions with people who are remained unemployed.

The Implementation and Evaluation of the South African Adaptation of the JOBS Program

No validated intervention that specifically addresses the psychosocial needs of unemployed people exists in the South African context. This study intends to evaluate an evidence-based job-search program, called the JOBS intervention, that is aimed at the self-efficacy, amotivation, and self-esteem related to participants searching for jobs. A quasi-experimental research design was used. Convenient samples were taken of unemployed individuals from two low-income communities (N = 130; experimental group = 69; control group = 61). The Qhubekela Phambili program, which is based on the JOBS program, was adapted for the South African context and was implemented over six 4-h sessions. Data collection took place pre- and post-intervention. One-way repeated measures multivariate analysis of variance was used to analyze the data. Those who had undergone the intervention showed statistically significantly higher levels of job-search self-efficacy and self-esteem. This study makes a novel contribution to the literature on the JOBS program, particularly regarding developing countries. This study showed that in a context characterized by poverty and a lack of support for the unemployed, the program also delivered promising results. It confirms previous findings that the JOBS program is suitable in a variety of labor market and economic conditions.

Health promotion and prevention among the unemployed: a systematic review

The interactions between unemployment and health create a need for specific interventions for health promotion and prevention. This overview provides information on how health promotion for the unemployed has been approached with an analysis of controlled intervention studies between 1996 and 2016. The literature search consulted 11 international databases in medicine, social sciences and psychology. A total of 30 health interventions for the unemployed were identified, with 43 articles that included the effects of intervention. A controlled-study design was used in 14 studies. The health promotion measures were generally based on individual counselling, case management, training or group services. The overview demonstrates the breadth of variation in target groups and types of measures. Their result indicators for health and integration into the labor market vary substantially, as do the employment promotion effects. There is evidence of improved health and labor market integration for established approaches like the JOBS Program and JobFit. Effects are rather moderate or low in magnitude and the effect mechanisms often remain unclear. Effects weaken over time. While success is more common in the areas of health, physical activity, nutrition and stress relief, there was no impact on smoking behavior. A significant evolution can be observed in the quality and quantity of health promotion for the unemployed over time. There is a need for further research on the effectiveness and sustainability of interventions. Intervention strategies should be developed that take account of the diversity of the unemployed and their different needs.

Health-improving interventions for obtaining employment in unemployed job seekers

BACKGROUND

Unemployment is associated with decreased health which may be a reason or a consequence of becoming unemployed. Decreased health can inhibit re-employment.

OBJECTIVES

To assess the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers.

SEARCH METHODS

We searched (3 May 2018, updated 13 August 2019) the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, PsycINFO, CINAHL, SocINDEX, OSH Update, ClinicalTrials.gov, the WHO trials portal, and also reference lists of included studies and selected reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers. The primary outcome was re-employment reported as the number or percentage of participants who obtained employment. Our secondary outcomes were health and work ability.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted outcome data, and assessed risk of bias. We pooled study results with random-effect models and reported risk ratios (RRs) with 95% confidence intervals (CIs) and assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 15 randomised controlled trials (16 interventions) with a total of 6397 unemployed participants. Eight studies evaluated therapeutic interventions such as cognitive behavioural therapy, physical exercise, and health-related advice and counselling and, in seven studies, interventions were combined using therapeutic methods and job-search training. Therapeutic interventions Therapeutic interventions compared to no intervention may increase employment at an average of 11 months follow-up but the evidence is very uncertain (RR = 1.41, 95% CI 1.07 to 1.87, n = 1142, 8 studies with 9 interventions, I² = 52%, very low-quality evidence). There is probably no difference in the effects of therapeutic interventions compared to no intervention on mental health (SMD 0.12, 95% CI -0.06 to 0.29, n = 530, 2 studies, low-quality evidence) and on general health (SMD 0.19, 95% CI -0.04 to 0.41, n = 318, 1 study, moderate-quality evidence). Combined interventions Combined interventions probably increase employment slightly compared to no intervention at an average of 10 months follow-up (RR 1.12, 95% CI 1.06 to 1.20, n = 4101, 6 studies, I² = 7%). There were no studies that measured work-ability, adverse events, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Interventions combining therapeutic methods and job-search training probably have a small beneficial effect in increasing employment. Therapeutic interventions may have an effect on re-employment, but we are very uncertain. Therapeutic interventions may not improve health in unemployed job seekers. Large high-quality RCTs targeting short-term or long-term unemployed people are needed to increase the quality of the evidence. A cost-effectiveness assessment is needed of the small beneficial effects.

[Impact of Great Recession on mental health in Spain. SESPAS Report 2020]

The objective of this article is to identify the effects of the Great Recession on the mental health of people residing in Spain. After presenting a conceptual framework on the mechanisms through which economic crises affect mental health, we describe the main results of 45 papers identified in our search. Studies indicate a worsening of mental health in Spain in the years of economic crisis, especially in men. Working conditions (unemployment, low wages, instability, precariousness) emerge as one of the main channels through which mental health is put at risk or deteriorates. This deterioration occurs with intensity in particularly vulnerable groups, such as immigrant population and families with economic burdens. In the case of suicides, the results were inconclusive. Regarding the use of health care services, an increase in the consumption of certain drugs seems to be identified, although the conclusions of all the studies are not coincidental. Social inequalities in mental health do not seem to have remitted. We conclude that Spain needs to improve information systems to a better understanding of the health effects of economic crises. In terms of public policies, together with the reinforcement of health services aimed at addressing mental health problems, an income guarantee network for people in vulnerable situations should be promoted, as well as the development of policies aimed at the labour market.

Employment relations and dismissal regulations: Does employment legislation protect the health of workers?

Sociologists have long acknowledged that being in a precarious labour market position, whether employed or unemployed, can harm peoples' health. However, scholars have yet to fully investigate the possible contextual, institutional determinants of this relationship. Two institutions that were overlooked in previous empirical studies are the regulations that set minimum compensation for dismissal, severance payments, and entitlements to a period of notice before dismissal, notice periods. These institutions may be important for workers' health as they influence the degree of insecurity that workers are exposed to. Here, we test this hypothesis by examining whether longer notice periods and greater severance payments protect the health of labour market participants, both employed and unemployed. We constructed two cohorts of panel data before and during the European recession using data from 22 countries in the European Union Statistics on Income and Living Conditions (person years = 338,000). We find more generous severance payments significantly reduce the probability that labour market participants, especially the unemployed, will experience declines in self-reported health, with a slightly weaker relationship for longer notice periods.

Facing unemployment: study protocol for the implementation and evaluation of a community-based intervention for psychological well-being promotion

BACKGROUND

Economic crises and unemployment have profound impact on mental health and well-being. Main goal of the Healthy Employment (HE) project is to enhance intersectoral actions promoting mental health among unemployed, namely through the implementation and effectiveness-evaluation of short-term and sustainable group interventions.

METHODS

The project follows a RE-AIM-based (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework for assessing a cognitive-behavioural and psychoeducational intervention that has been developed for promoting mental health among unemployed people. It is a short-term group intervention (five sessions, four hours each, 20 unemployed persons per group) focused on mental health literacy, interpersonal communication and of emotional regulation. Implementation of the intervention will be carried out by clinical psychologists, following a standardized procedure manual. Effectiveness will be assessed through a randomized field study with two arms (intervention and control). Participants are unemployed people (18-65 years old, both genders, having at least nine years of formal education) registered at public employment centres from different geographical regions for less than 12 months (including first-job seekers). Allocation to arms of the study will follow a random match-to-case process, considering gender, age groups and educational level. Three moments of evaluation will occur: before intervention (baseline), immediately after its ending and three months later. Main outcomes are mental health literacy, mental health related personal and perceived stigma, psychological well-being, satisfaction with life and resilience. Intention-to-treat and per-protocol analyses will be conducted. Cohen's d coefficient and odds ratio will be used for assessing the size of the intervention effect, when significant.

DISCUSSION

Scientific and clinical knowledge will be applied to promote/protect psychological well-being of unemployed people. While the first phases of the project are funded by the European Economic Area Grants, long-term assessments of the intervention require a larger timeframe. Further funding and institutional support will be sought for this purpose. Already established intersectoral collaborations are key-assets to reach long-term sustainability of this project.

TRIAL REGISTRATION

The study was registered with the Australian New Zealand Clinical Trials Registry; Prospectively registered number: ACTRN12616001432404 ; date of registration: 13 October 2016.

Interventions to mitigate the effects of poverty and inequality on mental health

PURPOSE

To review psychosocial and policy interventions which mitigate the effects of poverty and inequality on mental health.

METHODS

Systematic reviews, controlled trials and realist evaluations of the last 10 years are reviewed, without age or geographical restrictions.

RESULTS

Effective psychosocial interventions on individual and family level, such as parenting support programmes, exist. The evidence for mental health impact of broader community-based interventions, e.g. community outreach workers, or service-based interventions, e.g. social prescribing and debt advice is scarce. Likewise, the availability of evidence for the mental health impact of policy level interventions, such as poverty alleviation or youth guarantee, is quite restricted.

CONCLUSIONS

The social, economic, and physical environments in which people live shape mental health and many common mental disorders. There are effective early interventions to promote mental health in vulnerable groups, but it is necessary to both initiate and facilitate a cross-sectoral approach, and to form partnerships between different government departments, civic society organisations and other stakeholders. This approach is referred to as Mental Health in All Policies and it can be applied to all public policy levels from local policies to supranational.

Interventions to reduce the impact of unemployment and economic hardship on mental health in the general population: a systematic review

BACKGROUND

Job loss, debt and financial difficulties are associated with increased risk of mental illness and suicide in the general population. Interventions targeting people in debt or unemployed might help reduce these effects.

METHOD

We searched MEDLINE, Embase, The Cochrane Library, Web of Science, and PsycINFO (January 2016) for randomized controlled trials (RCTs) of interventions to reduce the effects of unemployment and debt on mental health in general population samples. We assessed papers for inclusion, extracted data and assessed risk of bias.

RESULTS

Eleven RCTs (n = 5303 participants) met the inclusion criteria. All recruited participants were unemployed. Five RCTs assessed 'job-club' interventions, two cognitive behaviour therapy (CBT) and a single RCT assessed each of emotional competency training, expressive writing, guided imagery and debt advice. All studies were at high risk of bias. 'Job club' interventions led to improvements in levels of depression up to 2 years post-intervention; effects were strongest among those at increased risk of depression (improvements of up to 0.2-0.3 s.d. in depression scores). There was mixed evidence for effectiveness of group CBT on symptoms of depression. An RCT of debt advice found no effect but had poor uptake. Single trials of three other interventions showed no evidence of benefit.

CONCLUSIONS

'Job-club' interventions may be effective in reducing depressive symptoms in unemployed people, particularly those at high risk of depression. Evidence for CBT-type interventions is mixed; further trials are needed. However the studies are old and at high risk of bias. Future intervention studies should follow CONSORT guidelines and address issues of poor uptake.

The effects of unemployment and perceived job insecurity: a comparison of their association with psychological and somatic complaints, self-rated health and life satisfaction

PURPOSE

Research has provided convincing evidence for the adverse effects of both short- and long-term unemployment, and perceived job insecurity on individuals' health and well-being. This study aims to go one critical step further by comparing the association between short- and long-term unemployment, and perceived job insecurity with a diverse set of health and well-being indicators.

METHODS

We compare four groups: (1) secure permanent employees (N = 2257), (2) insecure permanent employees (N = 713), (3) short-term unemployed (N = 662), and (4) long-term unemployed (N = 345) using cross-sectional data from the nationally representative Living Conditions Survey in Finland.

RESULTS

Covariance analyses adjusted for background variables support findings from earlier studies that long-term unemployment and perceived job insecurity are detrimental: short-term unemployed and secure permanent employees experienced fewer psychological complaints and lower subjective complaints load, reported a higher self-rated health, and were more satisfied with their life compared to long-term unemployed and insecure permanent employees. Second, whereas unemployment was found to be more detrimental than insecure employment in terms of life satisfaction, insecure employment was found to be more detrimental than unemployment in terms of psychological complaints. No differences were found regarding subjective complaints load and self-rated health.

CONCLUSIONS

Our findings suggest that (1) insecure employment relates to more psychological complaints than short-term unemployment and secure permanent employment, (2) insecure employment and long-term unemployment relate to more subjective complaints load and poorer health when compared to secure permanent employment, and (3) insecure employment relates to higher life satisfaction than both short- and long-term unemployment.

Economic recession and suicidal behaviour: Possible mechanisms and ameliorating factors

BACKGROUND

A growing body of research evidence from countries around the world indicates that economic recession is associated with increases in suicide, particularly in males of working age.

AIMS

To explore contributory and ameliorating factors associated with economic recession and suicide and thereby stimulate further research in this area and encourage policy makers to consider how best to reduce the impact of recession on mental health and suicidal behaviour.

METHOD

We conducted a selective review of the worldwide literature focusing on possible risk factors, mechanisms and preventative strategies for suicidal behaviour linked to economic recession.

RESULTS

A model of how recession might affect suicide rates is presented. A major and often prolonged effect of recession is on unemployment and job insecurity. Other important effects include those exerted by financial loss, bankruptcy and home repossession. It is proposed these factors may lead directly or indirectly to mental health problems such as depression, anxiety and binge drinking and then to suicidal behaviour. Countries with active labour market programmes and sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job-search initiatives for the unemployed. Other measures likely to help include targeted interventions for unemployed people, membership of social organisations and responsible media reporting. Good primary care and mental health services are needed to cope with increased demand in times of economic recession but some governments have in fact reduced healthcare spending as an austerity measure.

CONCLUSION

The research evidence linking recession, unemployment and suicide is substantial, but the evidence for the other mechanisms we have investigated is much more tentative. We describe the limitations of the existing body of research as well as make suggestions for future research into the effects of economic recession on suicidal behaviour.

Health-related quality of life and cognitive emotion regulation strategies in the unemployed: a cross-sectional survey

Background

The loss of one’s job has been conceptualized as a major stressful life event in an adult’s life and has consistently been associated with lower health-related quality of life (HRQoL). The role of cognitive emotion regulation strategies after the experience of stressful events has emerged as an important predictor of adverse psychological and health outcomes. However, the effect of these coping strategies on the HRQoL of unemployed people has not been examined until now. We aimed to study the associations of these cognitive emotion regulation strategies on HRQoL of unemployed people.

Methods

Using cross-sectional data, 1,125 unemployed adults were assessed using a Cognitive Emotion Regulation Questionnaire for cognitive coping and SF-12 to assess HRQoL. We studied the effect of cognitive emotion regulation strategies on mental and physical health composite separately, adjusting for gender, age, educational level and length of unemployment, using hierarchical regression analyses.

Results

Results showed unemployed men tended to express greater use of self-blame, other-blame, and catastrophizing, and lower use of perspective taking strategies when confronted with unemployment. Moreover, self-blame (for mental health composite only), blaming others, rumination, and catastrophizing negatively correlated, while positive reappraisal, putting into perspective, planning, and positive refocusing positively correlated with both mental and physical health composite in unemployed people. Further hierarchical regression analyses indicate that five strategies (a lower reported use of self-blame, rumination, and catastrophizing, as well as higher scores of positive reappraisal and positive refocusing) and three strategies (lower scores of catastrophizing and rumination and high scores in planning) have significant and independent contributions, beyond gender, age, educational level and length of unemployment, to the prediction of mental health and physical health composite, respectively.

Conclusions

Cognitive emotion regulation strategies appeared to be significantly correlated with HRQoL in unemployed people. Our findings suggest the potential value of including assistance programs focused on cognitive emotion regulation strategies to complement current psychosocial and health approaches aimed at preserving or improving unemployed people’s HRQoL.

Social determinants of mental health

A person's mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality the higher the inequality in risk. The poor and disadvantaged suffer disproportionately, but those in the middle of the social gradient are also affected. It is of major importance that action is taken to improve the conditions of everyday life, beginning before birth and progressing into early childhood, older childhood and adolescence, during family building and working ages, and through to older age. Action throughout these life stages would provide opportunities for both improving population mental health, and for reducing risk of those mental disorders that are associated with social inequalities. As mental disorders are fundamentally linked to a number of other physical health conditions, these actions would also reduce inequalities in physical health and improve health overall. Action needs to be universal: across the whole of society and proportionate to need. Policy-making at all levels of governance and across sectors can make a positive difference.

Financial crisis, austerity, and health in Europe

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

Actions to alleviate the mental health impact of the economic crisis

The current global economic crisis is expected to produce adverse mental health effects that may increase suicide and alcohol-related death rates in affected countries. In nations with greater social safety nets, the health impacts of the economic downturn may be less pronounced. Research indicates that the mental health impact of the economic crisis can be offset by various policy measures. This paper aims to outline how countries can safeguard and support mental health in times of economic downturn. It indicates that good mental health cannot be achieved by the health sector alone. The determinants of mental health often lie outside of the remits of the health system, and all sectors of society have to be involved in the promotion of mental health. Accessible and responsive primary care services support people at risk and can prevent mental health consequences. Any austerity measures imposed on mental health services need to be geared to support the modernization of mental health care provision. Social welfare supports and active labour market programmes aiming at helping people retain or re-gain jobs can counteract the mental health effects of the economic crisis. Family support programmes can also make a difference. Alcohol pricing and restrictions of alcohol availability reduce alcohol harms and save lives. Support to tackle unmanageable debt will also help to reduce the mental health impact of the crisis. While the current economic crisis may have a major impact on mental health and increase mortality due to suicides and alcohol-related disorders, it is also a window of opportunity to reform mental health care and promote a mentally healthy lifestyle.

The health effects of economic decline

Political pronouncements and policy statements include much conjecture concerning the health and behavioral effects of economic decline. We both summarize empirical research concerned with those effects and suggest questions for future research priorities. We separate the studies into groups defined by questions asked, mechanisms invoked, and outcomes studied. We conclude that although much research shows that undesirable job and financial experiences increase the risk of psychological and behavioral disorder, many other suspected associations remain poorly studied or unsupported. The intuition that mortality increases when the economy declines, for example, appears wrong. We note that the research informs public health programming by identifying risk factors, such as job loss, made more frequent by economic decline. The promise that the research would identify health costs and benefits of economic policy choices, however, remains unfulfilled and will likely remain so without stronger theory and greater methodological agreement.

The individual experience of unemployment

This review describes advances over the past decade in what is known about the individual experience of unemployment, predictors of reemployment, and interventions to speed employment. Research on the impact of unemployment has increased in sophistication, strengthening the causal conclusion that unemployment leads to declines in psychological and physical health and an increased incidence of suicide. This work has elucidated the risk factors and mechanisms associated with experiencing poor psychological health during unemployment; less so for physical health and suicide. Psychologists have begun to contribute to the study of factors associated with reemployment speed and quality. The past decade has especially illuminated the role of social networks and job search intensity in facilitating reemployment. Evidence suggests some individuals, especially members of minority groups, may face discrimination during their job search. Although more work in this arena is needed, several intervention-based programs have been shown to help individuals get back to work sooner.

Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression

We assessed the role of promotoras--briefly trained community health workers--in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention's impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention's implementation, involving infrastructure at the health centers, boundaries of the promotoras' roles, and "turf" issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.

The limitations of employment as a tool for social inclusion

Background

One important component of social inclusion is the improvement of well-being through encouraging participation in employment and work life. However, the ways that employment contributes to wellbeing are complex. This study investigates how poor health status might act as a barrier to gaining good quality work, and how good quality work is an important pre-requisite for positive health outcomes.

Methods

This study uses data from the PATH Through Life Project, analysing baseline and follow-up data on employment status, psychosocial job quality, and mental and physical health status from 4261 people in the Canberra and Queanbeyan region of south-eastern Australia. Longitudinal analyses conducted across the two time points investigated patterns of change in employment circumstances and associated changes in physical and mental health status.

Results

Those who were unemployed and those in poor quality jobs (characterised by insecurity, low marketability and job strain) were more likely to remain in these circumstances than to move to better working conditions. Poor quality jobs were associated with poorer physical and mental health status than better quality work, with the health of those in the poorest quality jobs comparable to that of the unemployed. For those who were unemployed at baseline, pre-existing health status predicted employment transition. Those respondents who moved from unemployment into poor quality work experienced an increase in depressive symptoms compared to those who moved into good quality work.

Conclusions

This evidence underlines the difficulty of moving from unemployment into good quality work and highlights the need for social inclusion policies to consider people's pre-existing health conditions and promote job quality.

Low mood and employment: when affective disorders are intertwined with the workplace--a UK perspective

Working is undoubtedly an important aspect of western life. As well as structuring time, it provides financial security, meaning, identity and social participation, and has a beneficial effect on long-term physical and mental well-being. Despite this, people with mental health conditions have the lowest employment rate of any disabled group, although many of them want to work and work is highly beneficial for their physical and mental health. Existing research on mental health problems and employment outcomes have tended to focus on interventions for people with severe mental illness. Little research exists on the relationship between affective disorders, mainly depression and anxiety, and employment. This review focuses on studies conducted in the UK. Its conclusion is that there is no single rigorous investigation to test the relationship between common mental disorders and vocational outcomes.

The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis

BACKGROUND

There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects.

METHODS

We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007.

FINDINGS

We noted that every 1% increase in unemployment was associated with a 0.79% rise in suicides at ages younger than 65 years (95% CI 0.16-1.42; 60-550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0.49%, -0.04 to 1.02), and with a 0.79% rise in homicides (95% CI 0.06-1.52; 3-80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1.39% (0.64-2.14; 290-980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4.45%, 95% CI 0.65-8.24; 250-3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28.0%, 12.30-43.70; 1550-5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US$10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0.038% (95% CI -0.004 to -0.071).

INTERPRETATION

Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns.

FUNDING

Centre for Crime and Justice Studies, King's College, London, UK; and Wates Foundation (UK).

Longitudinal relations between employment and depressive symptoms in low-income, suicidal African American women

Unemployment and depression are problematic at both individual and societal levels, and research suggests that the two phenomena are related. More thorough and longitudinal analyses, particularly ones within low-income minority populations, are needed to guide the development of programs to increase employment in persons with mental health problems. The current study aimed to specify the relations over time between depressive symptoms and employment status within a sample of 46 low-income African American women participating in an intervention study for intimate partner violence and suicidal behavior. Hierarchical logistic regression analysis indicated that baseline levels of depressive symptoms predicted employment status at the end of a 10-week intervention period, controlling for baseline employment status. Chi-square analysis and qualitative analyses of trends in depression scores showed that changes in employment status during the 10-week intervention period predicted 6-month and one-year follow-up levels of depressive symptoms. Results imply that, for women in the currently sampled population, depressive symptoms create vulnerability for job loss, but the ability to gain employment despite high levels of depressive symptoms is linked to lowered depression levels over the long term. Community programs assisting such women could therefore not just lower the vulnerability to job loss by treating depressive symptoms, but they could potentially lower long-term depression levels through interventions that enhance employability and motivation to pursue work.

Effective Group Training Techniques in Job-Search Training

The aim was to examine the effects of group training techniques in job-search training on later reemployment and mental health. The participants were 278 unemployed workers in Finland in 71 job-search training groups. Five group-level dimensions of training were identified. The results of hierarchical linear modeling demonstrated that preparation for setbacks at the group level significantly predicted decreased psychological distress and decreased symptoms of depression at the half-year follow-up. Trainer skills at the group level significantly predicted decreased symptoms of depression and reemployment to stable jobs. Interaction analyses showed that preparation for setbacks at the group level predicted fewer symptoms of psychological distress and depression, and shared perceptions of skilled trainers at the group level predicted fewer symptoms of depression among those who had been at risk for depression.