Since 2008, unemployment has risen sharply in many European countries due to the global economic crisis and the prolonged recession. In addition, the European Union imposed a political agenda of austerity on Southern European countries in exchange for financial assistance, and this contributed to exceptionally high unemployment rates in Spain, Italy, Greece, and Portugal . Unemployment has multiple striking social effects, including poor physical and mental health, and low subjective well-being and life satisfaction , and is one of the most important social determinants of health inequalities .
During the 1990s, and for economic reasons, many countries introduced Active Labour Market Programmes (ALMPs) in an effort to reduce unemployment . ALMPs aim to reintroduce participants into the labour market through vocational training courses, improved job search skills, work experience (internships and subsidized jobs), and behavioural programmes, among others [4, 5]. In terms of health and wellbeing, ALMPs are thought to ease the negative effects of unemployment through different psychosocial mechanisms .
A recent review showed that most studies that assessed the health effects of ALMPs focused on ALMPs implemented in Anglo-Saxon and Nordic countries . However, the effects of the recent economic crisis were most strongly felt in Southern European countries, but to date little is known about the health impact of ALMPs in these countries. To our knowledge, only one study has evaluated the health effects of an ALMP implemented in Spain , and no similar study has been conducted in other Southern European countries . In addition, few reports on this topic discuss the mechanisms involved in this improvement.
“Employment in the Neighbourhoods” (EiN) is an ALMP implemented in Barcelona, Spain, that aims to reduce social inequalities through labour market insertion of people living in neighbourhoods with the highest unemployment rates in the city, and who have the greatest material needs. A pre-post intervention study using quantitative research methods showed improved mental health among participants, while self-perceived health status remained stable or worsened .
The general objective of this paper is to describe the effects of EiN on quality of life and the mechanisms involved, according to the perception of the program’s participants and the technical staff who assisted them. Technical staff members are those professionals who accompany participants through the entire process as personal guidance counsellor.
Unemployment and health: pathways and mechanisms
Unemployment has been shown to cause poor health through material and psychosocial pathways. Material effects are primarily due to poverty resulting from lost income and financial strain. Psychosocial factors include the loss of non-economic resources provided by employment. According to Jahoda’s “latent functions” theory , while people primarily engage in paid work to earn their living (the manifest function of employment), they also profit from five latent functions that are unintended by-products of employment, namely time structure, social contact, collective purpose, social identity/status, and activity. Moreover, uncertainty about one’s future work situation is also a stressor that leads to physiological changes, risky health behaviours, and consequently, poorer health [10, 11].
ALMPs and health: effects, pathways and mechanisms
ALMPs are thought to ease the negative effects of unemployment on health and wellbeing by promoting participation in work-related activities . ALMPs alter unemployed people’s environment by providing an opportunity to meet, socialize, and strengthen social networks, and offer daily activities, routine and structure . In terms of status, vocational training courses may provide the perception of involvement in a legitimate alternative status to employment, namely education status . Improved job search and related skills, such as writing a CV and learning to respond in a job interview, could increase one’s feeling of control over one’s life course, and workplace participation through work experience and training in a regular market could reduce the psychosocial need for employment by providing a more employment-like life situation .
Based on the above theoretical knowledge, we can generally expect involvement in an ALMP to have a positive impact on health and wellbeing compared to open unemployment situations (i.e. being unemployed not being enrolled in any ALMP). A recent scoping review including 36 quantitative and qualitative studies conducted from the 1990s to the present day, showed mainly positive health impact of ALMPs in high-income countries. 80.6% of the studies included in the review found a positive impact on health or quality of life, and the rest showed no effects . Of all types of the ALMPs implemented, the only type that always showed a positive effect on mental health was the one that offered job search assistance accompanied by a psychological component, such as improving self-confidence, self-image, or self-efficacy . This result was the same for the different countries where it was implemented (Australia, EUA, Finland). The rest of types showed controversial results. The heterogeneity of contexts where these programs were implemented and the heterogeneity of programs’ content could partly justify these controversial results. For example, the diverse effects of such programs on health in the same context are evidenced by Strandh et al. , who showed that in Sweden at the end of the 90’s, unemployed individuals involved in workplace participation reported better mental health than those in open unemployment; however, those involved in vocational training did not experience improved mental health.
Few of the studies mentioned above explored the mechanisms underlying the health changes caused by participation in the ALMP. Quantitative evaluation of programs offering job search assistance and psychological component (e.g. inoculation against setbacks or increasing self-efficacy) reported positive results in terms of Fryer’s theory of gaining mastery and control over one’s life course . Sense of mastery and a general increase in labour market engagement could be related to improved mental health . This type of program has only been implemented in the USA , Finland  and Australia . Similarly, qualitative evaluation of the programs offering job search activities to young people in Finland  reported positive results in terms of Jahoda’s model of latent function, by providing a structure of life . The study showed how this type of programs help transform unemployment into a meaningful pattern of time use, especially through work-like activities or education. Moreover, in line with the idea of sense of mastery and economic control, participants reported seeing new possibilities in the labour market, and having economic support from the program.
Contextual factors matter
The impact of ALMPs may depend on various social and political factors, such as the “model of activation” , gender roles, family as a social institution, and the culture of work. “Model of activation” refers to the policy strategy aimed at reducing unemployment, as well as the corresponding social protection system for the unemployed. There are two major activation models, “work-first” or “liberal type” and the “universalistic type”. In “work-first” or liberal type, the role of ALMPs and social policies is limited to inciting individuals to seek work, providing quick information and simple matching services, investing in short-term vocational training, inciting people to be as active as possible throughout life, and accepting any job on offer . On the other hand, the “universalistic type” of activation guarantees relatively high standards of living for unemployed people and does not push them to accept any job in the market . The liberal model is typical of Anglo-Saxon countries, and the universalistic of Scandinavia, while most other countries, such as continental and Southern European countries, oscillate between these two.
For example, in Germany “One-Euro-Jobs” is an ALMP based on subsidized employment that includes coercive elements in line with those of the liberal model. Individuals who participate in this program did not perceive improved integration in comparison to those in open unemployment . The authors argue that paternalistic programmes that work through directive methods and impose unilateral obligations can affect individual’s interpretations of their role and status in society.
Gender and family also have a fundamental influence on the unemployment experience, with some authors suggesting that non-work is less damaging in societies where there is a stronger emphasis on family life [20, 21], such as for example the Southern European countries. In these countries, where the Welfare State is weaker in terms of universal social policies, additional material and non-material support is provided by the family. In that case, we could hypothesise that ALMPs are not considered to be as important for social support as in other countries, if the traditional family plays its role. On the other hand, in these countries, where the Welfare State is less developed, women are still most responsible for informal care, while men still play the breadwinner role, at least in archetypal terms. It has been shown that in countries where gender roles are still traditional and differentiated, unemployment has a greater effect on males, because it impairs their individual/social identity . In that sense if ALMPs contribute to supporting this identity, they could play a very important role among unemployed men.
In terms of culture, it has been proposed that the moral virtues of work characteristic of the Protestant ethic are central to the Nordic work ethic. In this culture, work provides good role models and stimulates good behaviour . Work ethics has an important influence on the significance of employment, probably on the unemployment experience, and thus, in the meaning and effects of ALMPs.
In this sense, it is particularly relevant that most evaluations of ALMPs were conducted in Anglo-Saxon and Scandinavian countries, and only one study has been carried out in Eastern Europe countries  and one in Southern . Thus, it is at least reasonable to question whether the health outcomes and the underlying mechanisms of ALMPs are transferable to different contexts. There is a lack of empirical and theoretical studies addressing these issues.
ALMPs in Spain
Spain is one of the countries that spends the smallest fraction of its GDP on ALMPs, which is thought to be an important determinant of health and wellbeing among unemployed people . Spain’s unemployment benefits are less generous than Nordic ones, and unlike the liberal model of activation, unemployment benefits are not compulsorily linked to ALMPs. In terms of gender and family, Spain is characterized by a strong “familialism”, with a family solidarity model based on an asymmetric gender division of work and low female participation in the labour market. Spain has residual family policies with lack of support for families, making them rely on unpaid work . To our knowledge, ALMPs in Spain have not been evaluated in detail, with the exception of one study  that evaluated the effects of the Madrid Government’s minimum income program (IMI) on health and wellbeing.
“Employment in the Neighbourhoods”: an ALMP to reduce social inequalities in Barcelona, Spain
In 12 neighbourhoods of Barcelona (Catalonia, Spain), an innovative tailor-made ALMP called “Employment in the Neighbourhoods” (EiN) (“Treball als Barris” in Catalan) was implemented to get people from deprived, high-unemployment neighbourhoods back to work, and to promote socioeconomic revitalization of these neighbourhoods. This program is part of a broader initiative, “The Neighbourhoods Law”, launched in 2004, to reduce social inequality in Catalonia by improving the quality of life in specific neighbourhoods primarily through urban renewal projects (DPTOP, 2009).
EiN is run by Barcelona City Council through its employment promotion agency, “Barcelona Activa”, and is partly financed by the Catalan Employment Service (Autonomous Government of Catalonia). Enrolment in the program is voluntary, and participants are required to be registered as a job seeker and to reside in one of the neighbourhoods where the program is implemented. The program prioritises people at risk of exclusion, i.e. those aged > 50 years who are long-term unemployed, those under 35 years who left school early, those with low professional qualifications, women who have suffered gender violence, women who want to re-join labour market, and people with physical disabilities.
The program enrols 1500–2000 people per year, most of whom have a basic or no formal education. A high percentage of participants are foreigners, mostly non-EU nationals, and most are long-term unemployed who are not eligible for contributory unemployment benefits. Unemployed persons who wish to join the program first attend a personal interview with a trained professional to evaluate their occupational status and develop a tailored job-search plan. The duration of the program depends on each specific job-search, and can range from a few weeks to a few months, with a maximum of one year.
The program’s methodology is based on customized integration pathways that combine several insertion measures. It mostly provides job search guidance and professional skills training to increase employability, and promotes social and professional integration support for people with special difficulties, considering the specific needs and potential of each neighbourhood and working in close coordination with local associations and the main social agents (See Table S1 for specific actions).
Thus, we expect EiN to ease the negative effects of unemployment on participants’ health and wellbeing by providing an opportunity to socialize and strengthen social networks, and, for those who participate for at least several weeks, a routine and structure through daily activities. More specifically, we expect them to have greater control over their life course through job search activities, the perception of involvement in a legitimate alternative to employment through professional skills training, and a reduction of the psychosocial need for employment through social integration support.
In order to describe the effects of EiN on quality of life and the mechanisms involved, we developed two conceptual maps with a cluster approach based on the perceptions of the participants and technical staff using the Concept Mapping technique.