Welfare to work interventions and their effects on health and well-being of lone parents and their children

Lone parents, health, wellbeing and welfare to work: a systematic review of qualitative studies

BACKGROUND

Lone parents and their children experience higher than average levels of adverse health and social outcomes, much of which are explained by high rates of poverty. Many high income countries have attempted to address high poverty rates by introducing employment requirements for lone parents in receipt of welfare benefits. However, there is evidence that employment may not reduce poverty or improve the health of lone parents and their children.

METHODS

We conducted a systematic review of qualitative studies reporting lone parents' accounts of participation in welfare to work (WtW), to identify explanations and possible mechanisms for the impacts of WtW on health and wellbeing. Twenty one bibliographic databases were searched. Two reviewers independently screened references and assessed study quality. Studies from any high income country that met the criteria of focussing on lone parents, mandatory WtW interventions, and health or wellbeing were included. Thematic synthesis was used to investigate analytic themes between studies.

RESULTS

Screening of the 4703 identified papers and quality assessment resulted in the inclusion of 16 qualitative studies of WtW in five high income countries, USA, Canada, UK, Australia, and New Zealand, covering a variety of welfare regimes. Our synthesis found that WtW requirements often conflicted with child care responsibilities. Available employment was often poorly paid and precarious. Adverse health impacts, such as increased stress, fatigue, and depression were commonly reported, though employment and appropriate training was linked to increased self-worth for some. WtW appeared to influence health through the pathways of conflict and control, analytical themes which emerged during synthesis. WtW reduced control over the nature of employment and care of children. Access to social support allowed some lone parents to manage the conflict associated with employment, and to increase control over their circumstances, with potentially beneficial health impacts.

CONCLUSION

WtW can result in increased conflict and reduced control, which may lead to negative impacts on mental health. Availability of social support may mediate the negative health impacts of WtW.

The protocol for the Families First Edmonton trial (FFE): a randomized community-based trial to compare four service integration approaches for families with low-income

BACKGROUND

Families with low incomes experience an array of health and social challenges that compromise their resilience and lead to negative family outcomes. Along with financial constraints, there are barriers associated with mental and physical health, poorer education and language. In addition, vulnerable populations experience many services as markedly unhelpful. This combination of family and service barriers results in reduced opportunities for effective, primary-level services and an increased use of more expensive secondary-level services (e.g., emergency room visits, child apprehensions, police involvement). A systematic review of effective interventions demonstrated that promotion of physical and mental health using existing service was critically important.

METHODS/DESIGN

The Families First Edmonton Trial (FFE) tests four service integration approaches to increase use of available health and social services for families with low-income. It is a randomized, two-factor, single-blind, longitudinal effectiveness trial where low-income families (1168) were randomly assigned to receive either (1) Family Healthy Lifestyle plus Family Recreation service integration (Comprehensive), (2) Family Healthy Lifestyle service integration, (3) Family Recreation service integration, or (4) existing services. To be eligible families needed to be receiving one of five government income assistance programs. The trial was conducted in the City of Edmonton between January 2006 and August 2011. The families were followed for a total of three years of which interventional services were received for between 18 and 24 months. The primary outcome is the number of family linkages to health and social services as measured by a customized survey tool "Family Services Inventory". Secondary outcomes include type and satisfaction with services, cost of services, family member health, and family functioning. Where possible, the measures for secondary outcomes were selected because of their standardization, the presence of published norming data, and their utility as comparators to other studies of low-income families. As an effectiveness trial, community and government partners participated in all committees through a mutually agreed upon governance model and helped manage and problem solve with researchers.

DISCUSSION

Modifications were made to the FFE trial based on the pragmatics of community-based trials.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT00705328.

In-work tax credits for families and their impact on health status in adults

BACKGROUND

By improving two social determinants of health (poverty and unemployment) in low- and middle-income families on or at risk of welfare, in-work tax credit for families (IWTC) interventions could impact health status and outcomes in adults.

OBJECTIVES

To assess the effects of IWTCs on health outcomes in working-age adults (18 to 64 years).

SEARCH METHODS

We searched 16 electronic academic databases, including the Cochrane Public Health Group Specialised Register, Cochrane Database of Systematic Reviews (The Cochrane Library 2012, Issue 7), MEDLINE and EMBASE, as well as six grey literature databases between July and September 2012 for records published between January 1980 and July 2012. We also searched key organisational websites, handsearched reference lists of included records and relevant journals, and contacted academic experts.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials and cohort, controlled before-and-after (CBA) and interrupted time series (ITS) studies of IWTCs in working-age adults. Included primary outcomes were: self rated general health; mental health/psychological distress; mental illness; overweight/obesity; alcohol use and tobacco use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in included studies. We contacted study authors to obtain missing information.

MAIN RESULTS

Five studies (one CBA and four ITS) comprising a total of 5,677,383 participants (all women) fulfilled the inclusion criteria and were synthesised narratively. The in-work tax credit intervention assessed in all included studies is the permanent Earned Income Tax Credit in the United States, established in 1975. This intervention distributed nearly USD 62 billion to over 27 million individuals in 2011, and its administration costs were less than one per cent of its total costs. All included studies carried a high risk of bias (especially from confounding and insufficient control for underlying time trends). Due to the small number of (observational) studies and their high risk of bias, we judged this body of evidence to have very low overall quality.One study found that IWTC had no detectable effect on self rated general health and mental health/psychological distress five years after its implementation (i.e. a considerable change in the generosity of the permanent IWTC) and on overweight/obesity eight years after implementation. One study found no effect of IWTC on tobacco use five years after implementation, one a moderate reduction in tobacco use one year after implementation (odds ratio 0.95, 95% confidence interval (CI) 0.94 to 0.96), and one differential effects, with no effect in African-Americans and a large reduction in European-Americans two years after implementation (risk difference -11.1%, 95% CI -20.9% to -1.3%). No evidence was available for the effect of IWTC on mental illness and alcohol use. No adverse effects of IWTC were identified.One study also found no detectable effect of IWTC on the number of bad physical health days and of risky biomarkers for inflammation, cardiovascular disease and metabolic conditions eight years after implementation. One study found that IWTC had a large, positive effect on income from wages or salaries one year after implementation. Two studies found no effect on employment two and five years after implementation, whereas two found a moderate increase five and eight years after implementation and one a large increase in employment due to IWTC one year after implementation.No differences in outcomes between groups with different educational status were found for self rated health and mental health/psychological distress. In one study European-American women with lower levels of education were more likely to reduce tobacco use, while tobacco use did not change among African-American women with lower levels of education. However, no differences in tobacco use by educational status were observed in a second study. Two studies found that the intervention may have reduced inequity with respect to employment, where women with less education were more likely to move into employment (although one did not establish whether this difference was statistically significant), while two studies found no such difference and no studies found differences by ethnic group on employment rates.

AUTHORS' CONCLUSIONS

In summary, the small and methodologically limited existing body of evidence with a high risk of bias provides no evidence for an effect of in-work tax credit for families interventions on health status (except for mixed evidence for tobacco smoking) in adults.