Fit for Work evaluation study: the effects of a multidisciplinary re-employment programme for persons with mental health problems

Unemployment is an important factor underlying health inequalities. Unemployed persons have a higher mortality and more often experience diseases with functional limitations. Unemployment may cause deterioration of health, especially mental health, and a poor health increases the risk of becoming unemployed. A poor mental health acts as a barrier for return to paid employment. Vice versa, there are clear indications that re-employment may have a profound influence on health. Inclusion of unemployed people in the workforce is an important strategy to reduce socioeconomic inequalities in health. The recent collaboration of Municipal Health Services, Social Security Services, and UWV-Werkbedrijf in the four largest cities of the Netherlands will introduce the Fit-4-Work programme for unemployed persons with mental health problems. This programme consists of a structured diagnosis and treatment of psychiatric problems, integrated in reintegration with individual placement to work. This study will evaluate the effectiveness of Fit-4-Work with regard to mental health, return-to-work, social participation, and costs and benefits from societal perspective as well the particular position of different services. The study is a pragmatic randomised controlled trial (RCT) with two arms: intervention (500 persons) and control group (500 persons). Persons in the intervention group will receive a structured F4W intervention for up to 2 years, whereas the persons in the control group will receive the usual reintegration activities and health care when sought during the complete study duration. The target population consists of long-term unemployed subjects (social security payments through WIJ, WWB, WIA, or WAJONG), often in a low socio-economic position and belonging to ethnic groups, such as Surinamese & Antilleans, Moroccans, and Turks. The F4W intervention consists of an intersectoral integrated approach aimed at improving mental health and addressing barriers in social participation and labour force participation. The intersectoral approach is assured by a multidisciplinary team consisting of a psychologist, a nurse (wijkverpleegkundige), a social worker, a labour market expert, and a social services officer. In a structured intake mental health problems, as well co-existing social or physical problems are identified. The structured intake will guide the decision how to tailor mental health interventions and re-integration programmes to the specific needs of the unemployed person. The tailored interventions will consist of mental health interventions (offered by mental health care organisations) and labour market interventions, but may be extended with health behavioural interventions (offered through municipal health organisations), and social interventions. The purpose of the new intersectoral intervention is to bring about an acceleration in the re-integration process. In order to achieve an acceptable response in this study population, it only will be feasible to collect the necessary information by means of a structured interview. In addition, this interview must tailor its questions to the level of understanding of the prospective participant. At baseline among all subjects short interviews will be administered of approximately 30 minutes. A research assistant will be present during specific days at the four employment service departments that enrol potential participants. Given the size of the study population and the interview efforts, data collection by interview will be limited to baseline, 12 months, and 24 months follow-up. During the interviews information will be collected on (1) previous work experience, educational status, (2) age, marital status, children, (3) social problems, (4) mental health problems, (5) physical health problems, (6) motivation and attitude towards work. (7) self-esteem and general resilience, (8) general health and medical consumption, and (9) social participation. The primary outcome measures are mental health, work resumption in paid employment or supported employment (sheltered jobs), and social participation. Secondary outcome measures are self-esteem, resilience, social problems, physical health, and medical consumption. The evaluation of the intervention will consist of a formative evaluation (are the goals of the intervention achieved), an effect evaluation (what is the effectiveness and the cost-effectiveness), and a summative evaluation (which elements in the intervention most likely contribute to its effectiveness). We assume enrolment of 500 subjects in intervention and in reference group. With an initial participation of 70% and loss-to-follow-up of 30%, 245 subjects will complete the study in each group. Thus, we are able to detect a difference of at least 12% in the primary outcome measure (40% work resumption versus 29% in control group). For continuous outcome measures, such as mental health, an effect size of 0.25 can be demonstrated.