The Faculty of Medicine of the University of Lisbon [FMUL] is the promoter of the Healthy Employment Project, which is coordinated by Professor Maria João Heitor*, psychiatrist. The Newsletter Editorial Team interviewed the Professor to learn more about this project.
*Psychiatrist; Coordinator of the Healthy Employment Project taking place at the Faculty of Medicine of Lisbon and financed through the EEA grants.
Director of the Department of Psychiatry and Mental Health and the Psychiatry Service of Hospital Beatriz Ângelo (HBA), Loures; President of the Ethics Committee for Health, HBA; Psychiatrist at the Idanha Health Centre, IIHSCJ; President Elect of the Portuguese Society of Psychiatry and Mental Health.
Newsletter: Can you tell us a little about the origin of this project?
Professor Maria João Heitor: The Healthy Employment project comes at a time when Portugal is facing a period of economic crisis. With the advent of the crisis, there is a deterioration in the socioeconomic conditions of a part of the population, particularly those experiencing unemployment, and an increase in social inequalities. This can lead to poorer mental health and poorer well-being. There is a cascade and vicious circle effect: people with common mental health problems (depression and anxiety) are twice as likely to be unemployed, and individuals with severe mental illness (such as psychotic disorders) are four to five times more unemployed than the general population. In turn, unemployment can lead to worse mental health and so on. So, it has become urgent to intervene with the most fragile groups to minimize the negative effects of the crisis on people's health.
A small group of the Institute of Preventive Medicine and Public Health (IMP&SP) of the Faculty of Medicine of the University of Lisbon (FMUL) made an application in 2014 under the Public Health Initiatives Programme (operator: Central Administration of the Health System/ACSS, Ministry of Health), which was part of the sub-area for the promotion of mental health in the workplace and in the groups most affected by the economic crisis, funded by the EEA grants.
The project was approved and then developed by a multidisciplinary technical and scientific team (initially composed of Maria João Heitor, Ana Virgolino, Joana Carreiras, Joana Carvalho, Osvaldo Santos, Sérgio Moreira, Tânia Fernandes, Alexandra Dinis, David Cruz, Elisa Lopes, Inês Almeida, Rosário Rosa, Sara Ambrósio, and Tatiana Marques) at the IMP&SP and the Institute of Environmental Health (ISAMB), with the support of the FMUL (project promoter) and some collaborators for specific areas (António Vaz Carneiro and Leonor Nicolau, among others). We have established 30 partnerships, three international (with Norway and Iceland) and 27 national encompassing several sectors (health, employment, social security, municipalities, non-governmental organizations and IPSS, scientific societies, and universities).
Healthy Employment project Team
What are your goals?
With this project, we intend to contribute to: reduce inequalities associated with the impact of the crisis; promote mental health and prevent mental illness of the unemployed and of professionals dealing with vulnerable populations (unemployed and temporary workers); inform political decisions on how to act to minimize damages in this and in eventual future economic crises; develop, share and disseminate best practice; contribute to the integration of multiple sector data; improve the links between different sectors and strength bilateral relations between Portugal and Donor States (Norway, Iceland and Liechtenstein).
In short, we consider that the project is an extremely important and innovative contribution to the development of healthy public policies aimed at two target groups, the unemployed and professionals, which favour integration and full participation in the labour market, health and well-being.
What did you intend to study and know?
We intend to study and respond to the effects of the economic crisis and labour instability on mental health, to effectively intervene with unemployed people registered for less than a year in employment centres (92% were looking for reemployment) and with professionals from different sectors who deal with the unemployed and temporary workers.
How? Through training in the promotion of mental health and well-being, aiming, in the case of the unemployed, at functional literacy for mental health, social and cognitive competences and interpersonal communication, self-regulatory emotional capacity, coping strategies, and resilience. In the case of the professionals, there is also the promotion of engagement in the workplace and the prevention and treatment of burnout.
In addition, we surveyed data sources, particularly health, employment, social security, and local authorities, identified a set of relevant indicators and developed a model for an inter-sector monitoring system from a mental health perspective in all policies. This can be very useful for assessing needs, planning and informing policy decision-making.
Has the project has been carried out as intended?
Initially, the project was expected to last longer but we were informed that we would have less time to complete it. Thus, it was necessary to condense the planned activities in a period of only about 18 months (April 2015 to November 2016). Also, over time, we were becoming a progressively smaller team and in the final stage we were very few ... The challenge was therefore even more complex but we managed to carry out all activities and get the products we had planned, which is very rewarding.
For its implementation, we had three international partners, two Norwegians and one Icelandic, respectively, the Faculty of Health Science Buskerud and Vestfold University College, the Norwegian Institute of Public Health and the Directorate of Health, Department of Health Promotion, Determinants of Health and Well-being (Reykjavík, Iceland) and 27 national partners: the Institute of Employment and Vocational Training, IP (IEFP, IP); the Institute of Social Security, IP (ISS); the Doutor Ricardo Jorge National Institute, IP (INSA, IP); Nova School of Business and Economics (SBE); Regional Health Administration (ARS) North; ARS LVT; ARS Alentejo; ARS Algarve; Tâmega e Sousa Hospital Centre (CH); CH University of Coimbra; CH Lisbon North; CH Psychiatry of Lisbon; CH of Setúbal; CH of the Algarve; Beatriz Angelo Hospital, Loures (HBA); Sisters Hospitallers of the Sacred Heart of Jesus Institute (IIHSCJ); ALTERSTATUS; CEMBE; EUTIMIA; City Hall (CM) Amarante; CM Figueira da Foz; CM Odivelas; CM Loures; CM Sines; CM Vila Real de Santo António; Portuguese Society of Psychiatry and Mental Health (SPPSM) and Commercial and Industrial Association of Figueira da Foz (ACCIF).
The experience of working with our partners and the innovative features of the project have positively exceeded our expectations.
As for the results and conclusions of your studies, what can you highlight? Are there significant gender differences?
Is there any data you might consider new? Something that surprised you?
One of the main components of this project was the implementation of a mental health training and promotion programme. In this sense, between March and April 2016 we went to the community and there were training sessions held in the municipalities of Sines and Loures aimed at unemployed people between 18 and 65 years of age and schooling between years 9 and 12, and also at persons with higher education enrolled in employment centres.
In order to carry out this training, the project team also had the support and collaboration of our partners from the IEFP, Loures Employment Centre and Sines Employment Service, Sines City Council, Loures City Council, Alterstatus, and Eutimia.
The topics addressed in each session initially focused on a more general and contextual view of work, employment and unemployment and their relation to well-being, and later narrowed towards issues more focused on health and mental illness, particularly common mental disorders - depressive disorders and anxiety disorders.
The intervention with the unemployed involved 140 individuals and if we compare the data collected before and one month after the intervention, we find that when compared with a control group, half of the participants improved their psychological well-being, more than a third increased their literacy regarding anxiety and about half increased their literacy regarding depression. Unemployed who have children have a better understanding of their overall health and better literacy about anxiety. Women have more literacy about depression than men. However, unemployed women have less psychological well-being than men, they are in greater distress.
With regard to professionals, our intervention included 175 workers from multiple sectors. Although 35% have felt sad or depressed recently and consider that working all day with people is a pressure, most feel very involved and committed to their work.
Are we well aware today of the mechanisms, how unemployment (and employment) affects individuals' mental health?
According to the scientific literature, it is known that both unemployment and precarious working conditions are related to a degradation of mental health and overall well-being of individuals. Economic problems and poverty are powerful social determinants with an impact on mental health. On the other hand, good mental health is a basic condition for the socioeconomic development of a country.
Having or not having work makes all the difference. It will have implications on each person’s identity, on the family, friends, leisure, time management, money, life’s project, and on health.
If, on the one hand, being unemployed or having a precarious job impacts on health and mental health, on the other hand it is known that stress in the workplace contributes to about 50% of lost workdays and increases up to 40% the risk of cardiovascular disease.
In your opinion, what should our society do to prevent the mental health problems associated with unemployment and employment?
Measure, evaluate, intervene and communicate.
MESURE – Quoting Joseph Stiglitz, “What you measure affects what you do. If you don’t measure the right thing, you don’t do the right thing”. Accordingly, it is paramount to have an accurate notion of reality, and for that we need excellent information systems, with adequate instruments and data collection, analysis and monitoring mechanisms, and multi-sector indicators.
EVALUATE – Before we replicate and disseminate the interventions that have been tested in the community under the Healthy Employment project, we conducted a mental health and well-being impact assessment (MHWIA) to a priori evaluate the potential positive and negative impacts of such interventions on mental health and well-being, and to identify how future interventions can contribute to maximize the well-being of both the professionals and the people they support (unemployed and temporary workers). Therefore, impact evaluations are indispensable.
INTERVENE - Interventions aimed, among other things, at promoting literacy for mental health are crucial. A key point in promoting mental health is information. If an individual is adequately informed about depression, anxiety, and stigma, about how to detect early signs and symptoms, and where to seek help, he is half way not to let psychiatric morbidity set in, or if it does, it can be identified, addressed, and treated as early as possible.
COMMUNICATE - the communication strategy, be it interpersonal (in serving vulnerable audiences, in companies, within families), between and for professionals from different sectors or for the general public, is a central component of the project.
Will the project be continued in other similar projects or initiatives?
For the time being, we have sought to ensure the sustainability of the project through essentially four aspects: we have developed two APPs for mobile phones to promote healthy lifestyles; we established a partnership with the Portuguese Society of Psychiatry and Mental Health to continue a mental health monitoring and epidemiological surveillance system, liaising with competent entities in these areas (Directorate General of Health, Institute of Employment and Professional Training, IP/IEFP, Social Security Institute, IP/ISS, and local authorities, among others); we are completing an information tool for policy briefing with recommendations on what actions need to be taken vis-à-vis the most vulnerable persons; certain outputs of the project, such as intervention and best practices textbooks for the unemployed and professionals, will be shared with national, regional and local bodies from various sectors, hoping that they can be integrated into regular procedures and practice among populations.
The project foresees the creation of a network for mental health promotion and prevention of mental illness that is sustainable, intersectoral and that guarantees positive impacts and a return on investment on health, well-being and economy.
Project’s website: www.empregosaudavel.org
*Psychiatrist; Coordinator of the Healthy Employment Project taking place at the Faculty of Medicine of Lisbon and financed through the EEA grants.
Director of the Department of Psychiatry and Mental Health and the Psychiatry Service of Hospital Beatriz Ângelo (HBA), Loures; President of the Ethics Committee for Health, HBA; Psychiatrist at the Idanha Health Centre, IIHSCJ; President Elect of the Portuguese Society of Psychiatry and Mental Health.
Newsletter: Can you tell us a little about the origin of this project?
Professor Maria João Heitor: The Healthy Employment project comes at a time when Portugal is facing a period of economic crisis. With the advent of the crisis, there is a deterioration in the socioeconomic conditions of a part of the population, particularly those experiencing unemployment, and an increase in social inequalities. This can lead to poorer mental health and poorer well-being. There is a cascade and vicious circle effect: people with common mental health problems (depression and anxiety) are twice as likely to be unemployed, and individuals with severe mental illness (such as psychotic disorders) are four to five times more unemployed than the general population. In turn, unemployment can lead to worse mental health and so on. So, it has become urgent to intervene with the most fragile groups to minimize the negative effects of the crisis on people's health.
A small group of the Institute of Preventive Medicine and Public Health (IMP&SP) of the Faculty of Medicine of the University of Lisbon (FMUL) made an application in 2014 under the Public Health Initiatives Programme (operator: Central Administration of the Health System/ACSS, Ministry of Health), which was part of the sub-area for the promotion of mental health in the workplace and in the groups most affected by the economic crisis, funded by the EEA grants.
The project was approved and then developed by a multidisciplinary technical and scientific team (initially composed of Maria João Heitor, Ana Virgolino, Joana Carreiras, Joana Carvalho, Osvaldo Santos, Sérgio Moreira, Tânia Fernandes, Alexandra Dinis, David Cruz, Elisa Lopes, Inês Almeida, Rosário Rosa, Sara Ambrósio, and Tatiana Marques) at the IMP&SP and the Institute of Environmental Health (ISAMB), with the support of the FMUL (project promoter) and some collaborators for specific areas (António Vaz Carneiro and Leonor Nicolau, among others). We have established 30 partnerships, three international (with Norway and Iceland) and 27 national encompassing several sectors (health, employment, social security, municipalities, non-governmental organizations and IPSS, scientific societies, and universities).
Healthy Employment project Team
What are your goals?
With this project, we intend to contribute to: reduce inequalities associated with the impact of the crisis; promote mental health and prevent mental illness of the unemployed and of professionals dealing with vulnerable populations (unemployed and temporary workers); inform political decisions on how to act to minimize damages in this and in eventual future economic crises; develop, share and disseminate best practice; contribute to the integration of multiple sector data; improve the links between different sectors and strength bilateral relations between Portugal and Donor States (Norway, Iceland and Liechtenstein).
In short, we consider that the project is an extremely important and innovative contribution to the development of healthy public policies aimed at two target groups, the unemployed and professionals, which favour integration and full participation in the labour market, health and well-being.
What did you intend to study and know?
We intend to study and respond to the effects of the economic crisis and labour instability on mental health, to effectively intervene with unemployed people registered for less than a year in employment centres (92% were looking for reemployment) and with professionals from different sectors who deal with the unemployed and temporary workers.
How? Through training in the promotion of mental health and well-being, aiming, in the case of the unemployed, at functional literacy for mental health, social and cognitive competences and interpersonal communication, self-regulatory emotional capacity, coping strategies, and resilience. In the case of the professionals, there is also the promotion of engagement in the workplace and the prevention and treatment of burnout.
In addition, we surveyed data sources, particularly health, employment, social security, and local authorities, identified a set of relevant indicators and developed a model for an inter-sector monitoring system from a mental health perspective in all policies. This can be very useful for assessing needs, planning and informing policy decision-making.
Has the project has been carried out as intended?
Initially, the project was expected to last longer but we were informed that we would have less time to complete it. Thus, it was necessary to condense the planned activities in a period of only about 18 months (April 2015 to November 2016). Also, over time, we were becoming a progressively smaller team and in the final stage we were very few ... The challenge was therefore even more complex but we managed to carry out all activities and get the products we had planned, which is very rewarding.
For its implementation, we had three international partners, two Norwegians and one Icelandic, respectively, the Faculty of Health Science Buskerud and Vestfold University College, the Norwegian Institute of Public Health and the Directorate of Health, Department of Health Promotion, Determinants of Health and Well-being (Reykjavík, Iceland) and 27 national partners: the Institute of Employment and Vocational Training, IP (IEFP, IP); the Institute of Social Security, IP (ISS); the Doutor Ricardo Jorge National Institute, IP (INSA, IP); Nova School of Business and Economics (SBE); Regional Health Administration (ARS) North; ARS LVT; ARS Alentejo; ARS Algarve; Tâmega e Sousa Hospital Centre (CH); CH University of Coimbra; CH Lisbon North; CH Psychiatry of Lisbon; CH of Setúbal; CH of the Algarve; Beatriz Angelo Hospital, Loures (HBA); Sisters Hospitallers of the Sacred Heart of Jesus Institute (IIHSCJ); ALTERSTATUS; CEMBE; EUTIMIA; City Hall (CM) Amarante; CM Figueira da Foz; CM Odivelas; CM Loures; CM Sines; CM Vila Real de Santo António; Portuguese Society of Psychiatry and Mental Health (SPPSM) and Commercial and Industrial Association of Figueira da Foz (ACCIF).
The experience of working with our partners and the innovative features of the project have positively exceeded our expectations.
As for the results and conclusions of your studies, what can you highlight? Are there significant gender differences?
Is there any data you might consider new? Something that surprised you?
One of the main components of this project was the implementation of a mental health training and promotion programme. In this sense, between March and April 2016 we went to the community and there were training sessions held in the municipalities of Sines and Loures aimed at unemployed people between 18 and 65 years of age and schooling between years 9 and 12, and also at persons with higher education enrolled in employment centres.
In order to carry out this training, the project team also had the support and collaboration of our partners from the IEFP, Loures Employment Centre and Sines Employment Service, Sines City Council, Loures City Council, Alterstatus, and Eutimia.
The topics addressed in each session initially focused on a more general and contextual view of work, employment and unemployment and their relation to well-being, and later narrowed towards issues more focused on health and mental illness, particularly common mental disorders - depressive disorders and anxiety disorders.
The intervention with the unemployed involved 140 individuals and if we compare the data collected before and one month after the intervention, we find that when compared with a control group, half of the participants improved their psychological well-being, more than a third increased their literacy regarding anxiety and about half increased their literacy regarding depression. Unemployed who have children have a better understanding of their overall health and better literacy about anxiety. Women have more literacy about depression than men. However, unemployed women have less psychological well-being than men, they are in greater distress.
With regard to professionals, our intervention included 175 workers from multiple sectors. Although 35% have felt sad or depressed recently and consider that working all day with people is a pressure, most feel very involved and committed to their work.
Are we well aware today of the mechanisms, how unemployment (and employment) affects individuals' mental health?
According to the scientific literature, it is known that both unemployment and precarious working conditions are related to a degradation of mental health and overall well-being of individuals. Economic problems and poverty are powerful social determinants with an impact on mental health. On the other hand, good mental health is a basic condition for the socioeconomic development of a country.
Having or not having work makes all the difference. It will have implications on each person’s identity, on the family, friends, leisure, time management, money, life’s project, and on health.
If, on the one hand, being unemployed or having a precarious job impacts on health and mental health, on the other hand it is known that stress in the workplace contributes to about 50% of lost workdays and increases up to 40% the risk of cardiovascular disease.
In your opinion, what should our society do to prevent the mental health problems associated with unemployment and employment?
Measure, evaluate, intervene and communicate.
MESURE – Quoting Joseph Stiglitz, “What you measure affects what you do. If you don’t measure the right thing, you don’t do the right thing”. Accordingly, it is paramount to have an accurate notion of reality, and for that we need excellent information systems, with adequate instruments and data collection, analysis and monitoring mechanisms, and multi-sector indicators.
EVALUATE – Before we replicate and disseminate the interventions that have been tested in the community under the Healthy Employment project, we conducted a mental health and well-being impact assessment (MHWIA) to a priori evaluate the potential positive and negative impacts of such interventions on mental health and well-being, and to identify how future interventions can contribute to maximize the well-being of both the professionals and the people they support (unemployed and temporary workers). Therefore, impact evaluations are indispensable.
INTERVENE - Interventions aimed, among other things, at promoting literacy for mental health are crucial. A key point in promoting mental health is information. If an individual is adequately informed about depression, anxiety, and stigma, about how to detect early signs and symptoms, and where to seek help, he is half way not to let psychiatric morbidity set in, or if it does, it can be identified, addressed, and treated as early as possible.
COMMUNICATE - the communication strategy, be it interpersonal (in serving vulnerable audiences, in companies, within families), between and for professionals from different sectors or for the general public, is a central component of the project.
Will the project be continued in other similar projects or initiatives?
For the time being, we have sought to ensure the sustainability of the project through essentially four aspects: we have developed two APPs for mobile phones to promote healthy lifestyles; we established a partnership with the Portuguese Society of Psychiatry and Mental Health to continue a mental health monitoring and epidemiological surveillance system, liaising with competent entities in these areas (Directorate General of Health, Institute of Employment and Professional Training, IP/IEFP, Social Security Institute, IP/ISS, and local authorities, among others); we are completing an information tool for policy briefing with recommendations on what actions need to be taken vis-à-vis the most vulnerable persons; certain outputs of the project, such as intervention and best practices textbooks for the unemployed and professionals, will be shared with national, regional and local bodies from various sectors, hoping that they can be integrated into regular procedures and practice among populations.
The project foresees the creation of a network for mental health promotion and prevention of mental illness that is sustainable, intersectoral and that guarantees positive impacts and a return on investment on health, well-being and economy.
Project’s website: www.empregosaudavel.org
