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Meta-Analysis
. 2017 Aug 20;8(8):CD009820.
doi: 10.1002/14651858.CD009820.pub2.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children

Marcia Gibson  1 , Hilary Thomson, Kasia Banas, Vittoria Lutje, Martin J McKee, Susan P Martin, Candida Fenton, Clare Bambra, Lyndal Bond
Affiliations
Meta-Analysis

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children

Marcia Gibson et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Lone parents in high-income countries have high rates of poverty (including in-work poverty) and poor health. Employment requirements for these parents are increasingly common. 'Welfare-to-work' (WtW) interventions involving financial sanctions and incentives, training, childcare subsidies and lifetime limits on benefit receipt have been used to support or mandate employment among lone parents. These and other interventions that affect employment and income may also affect people's health, and it is important to understand the available evidence on these effects in lone parents.

Objectives: To assess the effects of WtW interventions on mental and physical health in lone parents and their children living in high-income countries. The secondary objective is to assess the effects of welfare-to-work interventions on employment and income.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, PsycINFO EBSCO, ERIC EBSCO, SocINDEX EBSCO, CINAHL EBSCO, Econlit EBSCO, Web of Science ISI, Applied Social Sciences Index and Abstracts (ASSIA) via Proquest, International Bibliography of the Social Sciences (IBSS) via ProQuest, Social Services Abstracts via Proquest, Sociological Abstracts via Proquest, Campbell Library, NHS Economic Evaluation Database (NHS EED) (CRD York), Turning Research into Practice (TRIP), OpenGrey and Planex. We also searched bibliographies of included publications and relevant reviews, in addition to many relevant websites. We identified many included publications by handsearching. We performed the searches in 2011, 2013 and April 2016.

Selection criteria: Randomised controlled trials (RCTs) of mandatory or voluntary WtW interventions for lone parents in high-income countries, reporting impacts on parental mental health, parental physical health, child mental health or child physical health.

Data collection and analysis: One review author extracted data using a standardised extraction form, and another checked them. Two authors independently assessed risk of bias and the quality of the evidence. We contacted study authors to obtain measures of variance and conducted meta-analyses where possible. We synthesised data at three time points: 18 to 24 months (T1), 25 to 48 months (T2) and 49 to 72 months (T3).

Main results: Twelve studies involving 27,482 participants met the inclusion criteria. Interventions were either mandatory or voluntary and included up to 10 discrete components in varying combinations. All but one study took place in North America. Although we searched for parental health outcomes, the vast majority of the sample in all included studies were female. Therefore, we describe adult health outcomes as 'maternal' throughout the results section. We downgraded the quality of all evidence at least one level because outcome assessors were not blinded. Follow-up ranged from 18 months to six years. The effects of welfare-to-work interventions on health were generally positive but of a magnitude unlikely to have any tangible effects.At T1 there was moderate-quality evidence of a very small negative impact on maternal mental health (standardised mean difference (SMD) 0.07, 95% Confidence Interval (CI) 0.00 to 0.14; N = 3352; studies = 2)); at T2, moderate-quality evidence of no effect (SMD 0.00, 95% CI 0.05 to 0.05; N = 7091; studies = 3); and at T3, low-quality evidence of a very small positive effect (SMD -0.07, 95% CI -0.15 to 0.00; N = 8873; studies = 4). There was evidence of very small positive effects on maternal physical health at T1 (risk ratio (RR) 0.85, 95% CI 0.54 to 1.36; N = 311; 1 study, low quality) and T2 (RR 1.06, 95% CI 0.95 to 1.18; N = 2551; 2 studies, moderate quality), and of a very small negative effect at T3 (RR 0.97, 95% CI 0.91 to 1.04; N = 1854; 1 study, low quality).At T1, there was moderate-quality evidence of a very small negative impact on child mental health (SMD 0.01, 95% CI -0.06 to 0.09; N = 2762; studies = 1); at T2, of a very small positive effect (SMD -0.04, 95% CI -0.08 to 0.01; N = 7560; studies = 5), and at T3, there was low-quality evidence of a very small positive effect (SMD -0.05, 95% CI -0.16 to 0.05; N = 3643; studies = 3). Moderate-quality evidence for effects on child physical health showed a very small negative effect at T1 (SMD -0.05, 95% CI -0.12 to 0.03; N = 2762; studies = 1), a very small positive effect at T2 (SMD 0.07, 95% CI 0.01 to 0.12; N = 7195; studies = 3), and a very small positive effect at T3 (SMD 0.01, 95% CI -0.04 to 0.06; N = 8083; studies = 5). There was some evidence of larger negative effects on health, but this was of low or very low quality.There were small positive effects on employment and income at 18 to 48 months (moderate-quality evidence), but these were largely absent at 49 to 72 months (very low to moderate-quality evidence), often due to control group members moving into work independently. Since the majority of the studies were conducted in North America before the year 2000, generalisabilty may be limited. However, all study sites were similar in that they were high-income countries with developed social welfare systems.

Authors' conclusions: The effects of WtW on health are largely of a magnitude that is unlikely to have tangible impacts. Since income and employment are hypothesised to mediate effects on health, it is possible that these negligible health impacts result from the small effects on economic outcomes. Even where employment and income were higher for the lone parents in WtW, poverty was still high for the majority of the lone parents in many of the studies. Perhaps because of this, depression also remained very high for lone parents whether they were in WtW or not. There is a lack of robust evidence on the health effects of WtW for lone parents outside North America.

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Conflict of interest statement

MG: none known.

HT: none known.

KB: none known.

VL: none known.

MJM: none known.

SPM: none known.

CF: none known.

CB: none known.

LB: none known.

Figures

Figure 1
Figure 1
Study flow diagram. *An initial stage of screening reduced records from all other sources to 1609. The remaining records were then de‐duplicated against the Endnote library containing the electronic search results. Note this figure does not include publications found on websites without searchable databases.
Figure 2
Figure 2
Age of children at time of data collection by time point
Figure 3
Figure 3
Example of study logic model from NEWWS 2001 Copyright © 2001 MDRC: reproduced with permission.
Figure 4
Figure 4
Figure 5
Figure 5
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 6
Figure 6
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 7
Figure 7
Forest plot of comparison: 1 Time point 1 Maternal mental health, outcome: 1.1 Maternal mental health continuous.
Figure 8
Figure 8
Forest plot of comparison: 2 Time point 2 Maternal mental health, outcome: 2.1 Maternal mental health continuous.
Figure 9
Figure 9
Forest plot of comparison: 3 Time point 3 Maternal mental health, outcome: 3.1 Maternal mental health continuous.
Figure 10
Figure 10
Forest plot of comparison: 4 Time point 1 Maternal physical health, outcome: 4.1 In poor health (%).
Figure 11
Figure 11
Forest plot of comparison: 5 Time point 2 Maternal physical health, outcome: 5.1 In good or excellent health %. Event defined as In good or excellent health.
Figure 12
Figure 12
Forest plot of comparison: 6 Time point 3 Maternal physical health, outcome: 6.1 Self‐reported health (1‐5).
Figure 13
Figure 13
Forest plot of comparison: 7 Time point 1 Child mental health, outcome: 7.1 Child behaviour problems continuous.
Figure 14
Figure 14
Forest plot of comparison: 8 Time point 2 Child mental health, outcome: 8.1 Child behaviour problems continuous.
Figure 15
Figure 15
Forest plot of comparison: 9 Time point 3 Child mental health, outcome: 9.1 Child behaviour problems continuous.
Figure 16
Figure 16
Forest plot of comparison: 10 Time point 1 Child physical health, outcome: 10.1 General health rating (1‐5).
Figure 17
Figure 17
Forest plot of comparison: 11 Time point 2 Child physical health, outcome: 11.1 Child physical health continuous.
Figure 18
Figure 18
Forest plot of comparison: 12 Time point 3 Child physical health, outcome: 12.1 Child physical health continuous.
Analysis 1.1
Analysis 1.1
Comparison 1 Time point 1 Maternal mental health, Outcome 1 Maternal mental health continuous.
Analysis 1.2
Analysis 1.2
Comparison 1 Time point 1 Maternal mental health, Outcome 2 Maternal mental health dichotomous.
Analysis 2.1
Analysis 2.1
Comparison 2 Time point 2 Maternal mental health, Outcome 1 Maternal mental health continuous.
Analysis 2.3
Analysis 2.3
Comparison 2 Time point 2 Maternal mental health, Outcome 3 Maternal mental health dichotomous.
Analysis 3.1
Analysis 3.1
Comparison 3 Time point 3 Maternal mental health, Outcome 1 Maternal mental health continuous.
Analysis 3.2
Analysis 3.2
Comparison 3 Time point 3 Maternal mental health, Outcome 2 Maternal mental health dichotomous.
Analysis 4.1
Analysis 4.1
Comparison 4 Time point 1 Maternal physical health, Outcome 1 In poor health (%).
Analysis 5.1
Analysis 5.1
Comparison 5 Time point 2 Maternal physical health, Outcome 1 In good or excellent health (%).
Analysis 6.1
Analysis 6.1
Comparison 6 Time point 3 Maternal physical health, Outcome 1 Self‐reported health (1‐5).
Analysis 6.2
Analysis 6.2
Comparison 6 Time point 3 Maternal physical health, Outcome 2 In good or very good health (%).
Analysis 7.1
Analysis 7.1
Comparison 7 Time point 1 Child mental health, Outcome 1 Child behaviour problems continuous.
Analysis 7.2
Analysis 7.2
Comparison 7 Time point 1 Child mental health, Outcome 2 Child behaviour problems dichotomous.
Analysis 8.1
Analysis 8.1
Comparison 8 Time point 2 Child mental health, Outcome 1 Child behaviour problems continuous.
Analysis 8.2
Analysis 8.2
Comparison 8 Time point 2 Child mental health, Outcome 2 Adolescent mental health dichotomous.
Analysis 9.1
Analysis 9.1
Comparison 9 Time point 3 Child mental health, Outcome 1 Child behaviour problems continuous.
Analysis 9.2
Analysis 9.2
Comparison 9 Time point 3 Child mental health, Outcome 2 Child behaviour problem continuous excluding SSP Applicants.
Analysis 9.3
Analysis 9.3
Comparison 9 Time point 3 Child mental health, Outcome 3 NEWWS 2001 Child mental health.
Analysis 10.1
Analysis 10.1
Comparison 10 Time point 1 Child physical health, Outcome 1 General health rating (1‐5).
Analysis 11.1
Analysis 11.1
Comparison 11 Time point 2 Child physical health, Outcome 1 Child physical health continuous.
Analysis 11.2
Analysis 11.2
Comparison 11 Time point 2 Child physical health, Outcome 2 Child physical health dichotomous.
Analysis 12.1
Analysis 12.1
Comparison 12 Time point 3 Child physical health, Outcome 1 Child physical health continuous.
Analysis 12.2
Analysis 12.2
Comparison 12 Time point 3 Child physical health, Outcome 2 Child physical health dichotomous.
Analysis 13.1
Analysis 13.1
Comparison 13 Time point 1 Employment status, Outcome 1 Currently employed (%).
Analysis 13.2
Analysis 13.2
Comparison 13 Time point 1 Employment status, Outcome 2 Ever employed (%).
Analysis 14.1
Analysis 14.1
Comparison 14 Time point 2 Employment status, Outcome 1 Ever employed (%).
Analysis 14.2
Analysis 14.2
Comparison 14 Time point 2 Employment status, Outcome 2 Ever employed full‐time since randomisation (%).
Analysis 14.3
Analysis 14.3
Comparison 14 Time point 2 Employment status, Outcome 3 Ever employed full‐time excluding MFIP (%).
Analysis 14.4
Analysis 14.4
Comparison 14 Time point 2 Employment status, Outcome 4 Employed part‐time (%).
Analysis 15.1
Analysis 15.1
Comparison 15 Time point 3 Employment status, Outcome 1 Currently employed (%).
Analysis 15.2
Analysis 15.2
Comparison 15 Time point 3 Employment status, Outcome 2 Ever employed (%).
Analysis 15.3
Analysis 15.3
Comparison 15 Time point 3 Employment status, Outcome 3 Currently employed full‐time (%).
Analysis 15.4
Analysis 15.4
Comparison 15 Time point 3 Employment status, Outcome 4 Currently employed part‐time (%).
Analysis 16.1
Analysis 16.1
Comparison 16 Time point 1 Income, Outcome 1 Total income.
Analysis 16.2
Analysis 16.2
Comparison 16 Time point 1 Income, Outcome 2 Earnings.
Analysis 17.1
Analysis 17.1
Comparison 17 Time point 2 Income, Outcome 1 Total income.
Analysis 17.2
Analysis 17.2
Comparison 17 Time point 2 Income, Outcome 2 Total income excluding CJF.
Analysis 17.3
Analysis 17.3
Comparison 17 Time point 2 Income, Outcome 3 Average earnings in year of survey (USD).
Analysis 18.1
Analysis 18.1
Comparison 18 Time point 3 Income, Outcome 1 Total income.
Analysis 18.3
Analysis 18.3
Comparison 18 Time point 3 Income, Outcome 3 Total earnings.
Analysis 19.1
Analysis 19.1
Comparison 19 Time point 1 Welfare receipt, Outcome 1 Total AFDC received year 2 (USD).
Analysis 19.2
Analysis 19.2
Comparison 19 Time point 1 Welfare receipt, Outcome 2 Proportion of sample receiving welfare (%).
Analysis 20.1
Analysis 20.1
Comparison 20 Time point 2 Welfare receipt, Outcome 1 Average annual welfare benefit.
Analysis 20.2
Analysis 20.2
Comparison 20 Time point 2 Welfare receipt, Outcome 2 Average annual welfare benefit excluding MFIP.
Analysis 20.3
Analysis 20.3
Comparison 20 Time point 2 Welfare receipt, Outcome 3 Proportion of sample receiving welfare.
Analysis 21.1
Analysis 21.1
Comparison 21 Time point 3 Welfare receipt, Outcome 1 Total welfare benefit received.
Analysis 21.2
Analysis 21.2
Comparison 21 Time point 3 Welfare receipt, Outcome 2 Total welfare payments years 1‐5 (USD).
Analysis 21.5
Analysis 21.5
Comparison 21 Time point 3 Welfare receipt, Outcome 5 Proportion of sample receiving welfare.
Analysis 22.1
Analysis 22.1
Comparison 22 Time point 1 Health insurance, Outcome 1 Respondent has health insurance (%).
Analysis 22.2
Analysis 22.2
Comparison 22 Time point 1 Health insurance, Outcome 2 Child health insurance (%).
Analysis 23.1
Analysis 23.1
Comparison 23 Time point 2 Health insurance, Outcome 1 Health insurance (%).
Analysis 24.1
Analysis 24.1
Comparison 24 Time point 3 Health insurance, Outcome 1 Health insurance.
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References

References to studies included in this review

    1. Riccio JA, Friedlander D, Freedman S, Farrell M, Fellerath V, Fox S, Lehman DJ. GAIN: Benefits, Costs, and Three‐Year Impacts of a Welfare‐To‐Work Program. New York: Manpower Demonstration Research Corporation, 1994.
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References to studies excluded from this review

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    1. Bembry JX. Strengthening fragile families through research and practice. Journal of Family Social Work 2011;14(1):54‐67.
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    1. Basu S, Rehkopf DH, Siddiqi A, Glymour MM, Kawachi I. Health behaviors, mental health, and health care utilization among single mothers after welfare reforms in the 1990s. American Journal of Epidemiology 2016;183(6):531‐8. - PMC - PubMed
    1. Benzeval M. The self‐reported health status of lone parents. Social Science & Medicine 1998;46(10):1337‐53. - PubMed

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