Abstract
Introduction:
The financial crisis of the last decade has increased the number of people living in extreme poverty in Greece. Despite this fact, little evidence exists on their profile and psychosocial needs.
Method:
The current study explored the socioeconomic circumstances and psychosocial profile of 798 people confronted with severe poverty. This article further reports on brief interventions introduced at individual-, group-, and community level to address the psychosocial burden of these people.
Results:
A huge health and mental health burden was found among the participants. People also experienced long periods of unemployment, bad housing and living conditions, and absence of a supportive social/family network. Brief interventions increased people’s self-awareness, self-expression, and self-esteem and improved their problem-solving and coping skills.
Conclusions:
Integrated and family-focused care seems necessary. Mapping the biopsychosocial needs of these people is important for health care and social welfare planning.
Keywords
In Greece, the economic crisis of the last decade has severely impacted people’s lives. The loss of jobs, the financial uncertainty, and the inability to meet financial obligations have increased the psychological pressure and the search for alternative survival strategies (Giannitsis & Zografakis, 2015). The crisis is also associated with an increase in the population malnourished and living under poor housing conditions, as well as linked with rising rates of substance abuse, depression, suicide, violence and delinquency, unhealthy lifestyle, consumption of unhealthy food, tobacco and alcohol, human rights violations, and undereducation. Studies show that in times of crisis there is an increase in morbidity and mortality in the most vulnerable groups, namely the poor, the elderly, and young children, while the long-term unemployment leads many people to social exclusion (Amitsis, 2014).
The population at risk of poverty or social exclusion in Greece amounts to 35.6% of the total population of the country (Hellenic Statistical Authority, 2016). From 2009 onward, there seems to be an increase in material deprivation (i.e., deprivation of at least four basic goods and services) starting from 11.0% in 2009, 20.3% in 2013, and reaching 22.4% in 2016 (Hellenic Statistical Authority, 2016).
At the same time, the economic crisis has created problems in the financing of the health system, the government has been cutting budgets, while the viability of the private sector is being threatened and the operation of public health services is burdened (Karaiskou et al., 2012). Access to counseling services proves to be difficult, while cost of services, lack of insurance, childcare, and transportation serve as barriers to mental health treatment for people living in poverty (Davis et al., 2009).
Financial Crisis and Redefinition of Social Workers’ Professional Role
The economic crisis has shaped a new social reality and marked a series of social and institutional changes that have not left social work unaffected. The impact of the crisis created new challenges for social work profession, most notably the appearance of a new group of servants, those in middle class who were now confronted with poverty and exclusion. The increase in the number of vulnerable groups and families living on the edge and below the poverty line and the continuous cuts in the financing of social services have resulted in the exclusion of a large portion of people from social benefits. This inevitably led to phenomena such as the development of material support agencies led by international charities (Doctors of the World, 2013). The introduction of cash benefits and the increasing involvement of the private sector in the provision of social welfare services were unprecedented phenomena that developed rapidly. To the above developments, we should also add the reforms in the institutional framework of the local government (known as the “Kallikratis” reform) and the transfer of responsibilities from the higher levels of local government to the municipalities. Upon this reform, the professional tasks of social workers in municipal settings have been significantly expanded without increases in staff and resources (Papadakaki et al., 2015).
The new order of things resulted in social work running the danger of losing its scientific character with involvement in less traditional services (e.g., social groceries, social pharmacies, meals) and more administrative duties (e.g., food distribution) developed in response to the rapid increase of poverty and social exclusion. On the other hand, the new responsibilities transferred to the municipalities ran the risk of altering the role of community social workers who were often seen as state representatives in charge of law enforcement instead of advocates and defenders of the rights of the family and its members (Papadakaki et al., 2015).
In fact, social workers have long been criticized for lacking an approach that is sensitive to the issues of poverty and for failing to take into account in everyday professional practice, socioeconomic factors such as unemployment and inadequate housing (Davis & Wainwright, 2005). Literature also shows a tendency toward individual-oriented and less socially equitable intervention methods (Davis & Wainwright, 2005; Jones & Novak, 1993). Classification and intervention to social problems has often been based on individual or family pathologies (e.g., addictions, mental problems), while the socioeconomic factor in their occurrence is ignored (Krumer-Nevo et al., 2009).
Despite these circumstances, poverty, in fact, has always been considered intertwined with the duties of the social worker as it has always been a major reason for use of social services by the underserved (Waldegrave, 2005). In fact, social work from its inception, in the 19th century until today, from different positions and institutions, expressed its commitment to tackling poverty (Hare, 2004).
Aim and Objectives
In 2015, the Fund for European Aid to the Most Deprived (FEAD) was launched with the objective of eliminating the worst kinds of poverty and material deprivation across the European Union (Regulation (EU) No 223/2014 of the European Parliament and of the Council of 11 March 2014 on the Fund for European Aid to the Most Deprived). FEAD supports member state’s actions by allocating funding for programs and projects that support nonfinancial assistance (e.g., distribution of food and basic material goods) combined with measures of social integration. The nature of poverty and social exclusion fluctuates across member states, calling for interventions to be tailored to suit local circumstances (Ruitinga et al., 2018). The scope of FEAD is specialized in Greece through the Operational Program of Food and Basic Material Assistance. Social Welfare Administration of Crete Region is in charge of the program in Crete Region. The Program is implemented through social partnerships (e.g., municipalities, nongovernmental organizations, consumer organizations), and the beneficiaries are selected according to income and property criteria. The program includes benefits in kind, such as food, personal hygiene items as well as services such as psychosocial support, legal assistance, social tutoring, and so on.
This article reports on the results of the first Greek survey that has been undertaken by the Hellenic Mediterranean University among the beneficiaries of FEAD program in Crete region, as part of the accompanying measures. The study seeks to investigate the profile, living conditions, health and mental health status of the beneficiaries served within 2016–2017 in Crete region in order to introduce recommendations for policy and action, tailor-made to local circumstances. The article also aims to present the design, content, and results of brief multilevel interventions that were introduced to alleviate the psychosocial burden shouldered by people living in extreme poverty, during the financial crisis.
Method
Study Design
A cross-sectional study was carried out in one of the 14 administrative regions of Greece (Region of Crete). The region of Crete has 600,000 residents (2011 census [ELSTAT, 2011]) and 17,858 beneficiaries (official regional administration data 2016). Eligible participants fulfilled the following criteria: (a) They were registered at their regional or local social service agencies as beneficiaries for material support benefits due to proven poverty (according to income-related criteria set by the central government), (b) they should be residents of Crete region, and (c) they were adults (>18 years).
Research Instrument
A structured questionnaire was developed for the purposes of the current study including the following: (a) sociodemographic characteristics of the participants (e.g., gender, education, social insurance); (b) occupational aspects (e.g., employment status, years of unemployment); (c) housing and living conditions (e.g., house ownership, basics of living such as electricity, heating system); (d) social network (e.g., number of cohabitants, quality of relationship, geographical distance); (e) level of perceived social support (in emergency situations such as in urgent money borrowing, child-keeping); (f) perceived health status (e.g., disability level, diagnosed disabilities, and chronic diseases); (g) functional status/assisted mobility (using the relevant The Short Form 36 Health Survey Questionnaire [the SF-36]); (h) health care utilization (e.g., health care visits, past hospitalizations, medication consumption); (i) mental health problems, including depression levels (using the nine-item Patient Health Questionnaire with response ranging from not at all to nearly every day), anxiety levels (using the seven-item Generalized Anxiety Disorder Scale), and severe alcohol/drug-related problems (using the four-item CAGE-AID Substance Abuse Screening Tool).
Procedures
All the people who were registered at their regional or local social service agencies as beneficiaries for material support benefits were eligible to be included in the study. Official approval to carry out research and intervention was granted by the regional social welfare authority (18.05.2016/969). The population of interest was approached either face-to-face or by phone, depending on their accessibility and availability. Contact information was received by the social service authorities with the assistance of the social care staff and upon participants’ consent. The days of benefit delivery (scheduled approximately once a month) were used as a complementary method to approach the individuals face-to-face and invite them to participate. Written consent was requested prior to participation.
Design of Brief Interventions
Multilevel interventions were introduced to alleviate the psychosocial burden shouldered by the participants. At individual level, a model of a “blended” therapeutic plan was employed, with distance and face-to-face consultations (Fitzpatrick et al., 2018; Goslar et al., 2017; Jiang et al., 2017; Leibert et al., 2006) to treat persons who required multidisciplinary family-focused care due to complex psychosocial needs. Therapy was offered by a professional team (general practitioner, psychologist, social worker) operating at a central unit under the Hellenic Mediterranean University in Greece. The local community social services served as a point for service inquiry.
At group level, counseling was offered on weekly basis by psychologists/psychotherapists to small groups of participants experiencing common stressful situations (e.g., carers of patients with chronic diseases) at nine community settings. Interventions were informed by previous research (Fogarty et al., 2019; Johns et al, 2016; Spidel et al., 2017; Swan et al., 2004).
At community level, 11 interactive workshops were organized at various geographical areas across Crete, aiming to promote mental health and well-being of people living in extreme poverty. Overall, the workshops aimed at knowledge gain and skill building on various topics including domestic violence, substance abuse, learning disabilities, healthy parenting, and so on, and targeted various population groups including single parents, unemployed, elderly, disabled. Most importantly, the workshops shared an experiential design and employed various interactive activities (e.g., role-plays, videos, skill building) in order to engage people of mixed educational levels and cultural backgrounds into a dialogue.
Results
Sociodemographic Profile
A total of 798 individuals from the four prefectures of Crete consented to participate in the study and completed the questionnaire (Heraklion: n = 435, 54.5%; Chania: n = 177, 22.2%; Rethymno: n = 90, 11.3%; Lasithi: n = 96, 12.0%). Nearly half were married and a large percentage of them were primary school graduates (32.6%). 47.7% of the participants were unemployed and 25.8% uninsured. The average duration of unemployment was 4.2 years. Out of the employed, 48.3% reported occasional employment. Details on the socioeconomic profile of the participants are shown in Tables 1 and 2.
Sociodemographic Characteristics of the Participants.
amean / standard deviation.
Occupational Characteristics.
Living conditions and social support
A total of 39.5% of participants reported accommodation in owned house and 26.8% in a relative’s house. As for the living conditions, 82.0% sustained a heating medium in their house, and approximately 10.0% lacked a restroom; 12.0% of them lacked all types of social support (see Tables 3 and 4).
Living Conditions of the Participants.
Social Support.
Health and mental health
Disability: 47.0% reported a chronic disease and 24.1% a certified disability. Alcohol problems: 4.9% experienced serious problems with alcohol consumption. Depression: 49.3% experienced “mild” to “severe” depression, and 26.0% were “marginally positive.” Anxiety: 40.5% experienced “mild” to “severe” symptoms of anxiety (see Table 5).
Health and Mental Health Status.
Factors increasing vulnerability to mental health problems
The effect size between gender and anxiety disorders is small (V = .15) implying a weak positive association and the effect size between gender and alcohol problems is also small (Φ = −.15) which means a weak negative association. The effect size of the age category and depression is medium (γ = 0.28) and the same stands for the effect size of the age category and anxiety disorder (γ = 0.23), which indicates a moderate association in both cases. The value of γ = 0.19 between the educational level and anxiety disorder indicates a weak effect size, which also means a weak positive association. Between the number of children and anxiety disorder, there is a medium effect size implying a moderate positive association (γ = 0.28) and between the number of children and alcohol problems, there is a weak effect size, which also means a weak association (V = .11). The effect size between the uninsured and depression as well as between the uninsured and the alcohol problems is small (V = .13 and Φ = .11 correspondingly) implying a weak association. Between disability and depression, there is a moderate effect size which indicates a moderate association (V = .29), and the value of Cramer’s V test between disability and anxiety disorders shows a small effect size, which means a weak association. Finally, the value of Cramer’s V test between chronic disease and depression shows a medium to relatively strong effect size, which implies a relatively strong association (V = .39), and the effect size of chronic disease and anxiety disorder is moderate, which also means a medium association (V = .27)
Overall, those of older age, the uninsured, the disabled, and those sustaining a chronic disease were shown to experience more symptoms of depression as compared with individuals in the respective categories. As for anxiety, women of older age groups and lower educational level, those having more children, those with a disability and a chronic disease were shown to be more vulnerable to anxiety. Lastly, participants with more children, the uninsured, and those reporting a chronic disease were shown to be more vulnerable to severe alcohol problems (see Tables 6 and 7).
Factors Affecting Participants’ Mental Health Status.
Summary of Variables With Statistically Significant Effect on Mental Health.
Brief Interventions
Individual Counseling
Eighty people with complex biopsychosocial problems from 14 community settings were offered individual counseling across Crete. Of those served, 55.0% were women, their average age was 48.6 years, 37.5% were single, 35.0% had no children, and 25.0% lived alone. A minimum of three biopsychosocial circumstances were addressed per participant. More precisely, 95.0% experienced problems with their physical and mental health, 77.5% financial problems (lack of resources, debts, etc), 65.0% problems with employment/unemployment, 55.0% housing issues, 45.0% parenting problems, 37.5% children’s learning difficulties, 27.5% problems related to family links with the community, 20.0% problems with alcohol consumption and substance use, 17.5% delinquent behavior, and 15.0% mourning. In most of the cases, multisectoral collaboration was necessary (at least two agencies contacted per case).
Group Counseling
A total of 108 persons participated in 36 group sessions. The majority identified an increase in self-esteem and gains in problem-solving and coping skills. Among the most common achievements reported in the evaluation forms were stress reduction (85.0%), grief and anger management (72.0%). Many participants also identified an improved understanding of family relations (68.0%) and children’s behavior as well as a number of skills in rule setting (66.0%).
Interactive Workshops
The workshops were attended by approximately 1,200 beneficiaries, 300 service providers, and more than 400 persons from the general population. Through the 11 interactive workshops, communication skills were strengthened as a useful means in achieving healthy relationships and knowledge was gained on various topics.
The following key issues emerged from participants’ contribution during the workshops and their responses to questions raised in the final evaluation form: (a) lack of parenting skills, (b) myths and stereotypes regarding parenting, and (c) ineffective child–parent communication. Local culture has been shown to contribute to the normalization of stereotyped thinking regarding family matters and relationships (e.g., women need to marry young to avoid problems with reproduction,” “I earn enough money, so there is no need for my wife to work”). The majority of participants seemed to have adopted a child-centered parenting style, with many freedoms, low boundaries, many expectations and emotional transfers and dependencies (e.g., “I don’t get it…my son gets whatever he wishes, but he is ungrateful”). Parent counseling in the community seems to be a pressing need, especially for the rural and remote areas.
Discussion
The current study is the first to explore the profile of individuals faced with severe poverty in a country suffering the consequences of a long-lasting financial crisis. The study is also carried out in a timely manner, as a new strategic plan is currently under discussion at regional level, which should ideally reflect the actual needs of those in need.
From the results of this study, a complexity of family’s needs becomes evident. Poverty, unemployment, poor housing, substance misuse, and mental health problems were prevalent and interconnected issues. In line with the current findings, past research has shown that some harms (e.g., mental health, addiction, and domestic violence) often cluster together to form a so-called toxic trio (Cleaver, 1999; Middleton & Hardy, 2014). The “toxic trio” has entered the lexicon of social work as a proxy for the risks in families, where there were multiple problems. In fact, multiproblem families, those experiencing a combination of socioeconomic and psychosocial problems for a long time, have been said to be on the rise (Kolthof et al., 2014). These families are usually faced with many problems at the same time, in different areas of life, which makes them varied but also complex due to the interaction between them (Tausendfreund et al., 2016). According to Bodden and Dekovic (2010), such problems include parenting issues, financial debts, psychopathology problems, problems in member relationships, health, housing and living problems, as well as repeated contacts with social authorities or the justice system. Ennis et al (2000) have also pointed out the long-lasting and excessive distress in these families because of several factors such as financial uncertainty, frequent changes in their lives, interfamilial arguments and deprivation of opportunities (Kuruvilla & Jacob, 2007; Wadsworth et al., 2008). It has been noted that in multiproblem families, combinations of low functional levels, multiple stresses, multiple symptoms, and lack of support interact in a way that threatens the family’s ability to respond to the physical, social, and emotional needs of its members (Maurer & Smith, 2013).
Interestingly, our study revealed a huge mental health burden among the study participants. Depression and anxiety disorder appeared to be very prevalent in our population along with severe alcohol problems. Women as well as older individuals of lower educational levels and those with many children were shown to be more vulnerable to mental health problems. It has been noted elsewhere that factors such as low levels of education and resources increase the levels of stress in disadvantaged families (Shonkoff & Garner, 2012). What is probably most interesting of all is the fact that individuals residing in areas geographically remote from urban settings were more likely to have part-time or seasonal occupation, rent houses, and be more vulnerable to alcohol-related and mental health problems. Furthermore, in these rural and remote communities, where someone would expect a high level of informal support by community networks, individuals reported low social support, and this adds up to vulnerability deriving from resource shortage in remote areas. In general, our population lacked social support and many of the participants could not identify human or material support resources for practical issues in cases of family emergencies. This may indeed be a huge source of stress for disadvantaged families. In line with this finding, it has been suggested that in families who live in poverty, there is high incidence of toxic stress drawn from factors such as low levels of social support (Shonkoff & Garner, 2012).
What also stands out of the results of the current study is the fact that chronic diseases and disability were found to be very prevalent in our population and significantly associated with an increased likelihood of mental health problems. In line with this finding, it has been noted that people who are faced with multiproblematic situations, the so-called adversities, are at greater risk of developing health problems, mental health and social problems and should have access to a range of health and psychosocial interventions, even from nonspecialist care providers (Brunelle & Porter, 2013; World Health Organization, 2016). Integrated and family-focused care is deemed necessary to meet the individual problems of family members and increase the quality of life of the family. However, there seems to be a great difficulty in organizing appropriate support for these families due to the moderate coordination between care services (Ghesquière, 1993). For example, it often happens that multiple service providers are in contact with the multiproblematic family system at the same time, but there is not enough coordination of the care offered to them. It is also common for a service to overlook the interaction of problems with other areas. The asymmetry created by separate service systems generates challenges for both service providers and individuals seeking services (Koppelman, 2004; McKay & Bannon, 2004). Besides system limitations, multiproblematic families are impeded from accessing mental health services due to logistical barriers (e.g., transportation, financial, and childcare difficulties) and often more potent perceptual obstacles such as negative perceptions about mental health and treatment, mistrust of the mental health system, and stigma (Garcia & Weisz, 2002; Gopalan et al., 2010).
Speaking about interventions targeting families who live in poverty, we shouldn’t forget to mention a large number of intervention models aiming at improved parenting and child developmental outcomes that hold a lot of promise in reducing individual, familial, and societal burden and enhancing the lives of children and their families (Acri et al., 2016; Cates et al., 2016). Although programs vary with respect to level of intensity and documentation of effect, taken together, evidence indicates their far-reaching potential. In the United States, there have been many examples of home-visiting models (typically addressing parenting issues through strategies such as counseling, modeling behaviors) for which “evidence of effectiveness” has been shown on the basis of rigorous research evaluation (Cates et al., 2016). However, many questions remain regarding how to maximize the effect of preventive intervention in the community setting.
In our interventions, we have noticed that especially in rural areas, people tended to know each other and found it difficult to share personal thoughts in group and community activities. Fear of public exposure and judgment seems to play an important role in opening up and getting meaningful help. This evidence underlines the importance for community interventions not to only focus on quantitative outcomes but also on qualitative ones. Some have also pointed out that community should be perceived and treated as an ecosystem that holds the potential to generate its own solutions for its problems identified within the community (Hawe, 1994).
Last but not least, we need to mention that the training of social workers cannot ignore the above challenges. Education should provide students with opportunities to acquire theoretical knowledge from a variety of disciplines (sociology, psychology, law, social policy, political economy, education), with an emphasis on linking causal theories and ideological positions and policies to intervention practices. Education should also provide opportunities for self-assessment through internal processes of exploring personal and cultural values, attitudes, and beliefs about poverty (Hodge et al., 2007). In this way, students will be able to recognize stereotypical attitudes and give structural instead of personal interpretations of poverty-related behaviors. Opportunities to gain practical experience in the subject should be reinforced. Community welfare services are a good “labs” for students to practice models of intervention based on advocacy, individual and group counseling, empowerment, and so on. In fact, research in social work demonstrates a growing interest in the theory and practice of working with families in poverty (Gupta & Blumhardt, 2016). For example, the poverty-aware social work paradigm developed by Krumer-Nevo (2016) offers theoretical advances through updated connection between social work and the developing body of poverty knowledge termed new welfare theorizing (Lister, 2004). Students will thus be able to recognize how policies and models of intervention relate to theories and ideological positions.
Conclusions
The project not only contributed significantly to the recognition and initial treatment of the daily problems that individuals face at the individual and family level but also highlighted the need for further information and counseling. The absence of mental health counseling services in the community emerged as a significant deficit. Likewise, the need to continue and systematize community interventions.
Footnotes
Authors’ Note
Maria-Aggeliki Stamouli is now affiliated to Institute of Agri-Food and Life Sciences Agro-Health, Hellenic Mediterranean University Research Center, Greece.
Acknowledgments
We would like to express our gratitude to all the individuals who participated in the study. Special thanks to Ms. Afroditi Menioudaki for her contribution to the project organization.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study received grants by the Fund for European Aid to the Most Deprived (FEAD), which is specialized in Greece through the “Food and/or Basic Material Assistance” Operational Program (Crete Regional Unit, ID 5000183).
