An evaluation of the impact of a social inclusion programme on occupational functioning for forensic service users.
Introduction: The rehabilitation of forensic service users with
serious mental illness is an emerging specialism in occupational
therapy. However, there is little evidence to support the development of
this role. Government white papers and guidelines recommend a
rehabilitation process that involves a social inclusion agenda and the
literature supports the role of the occupational therapist in its
provision. This study was designed to provide evidence for, and to
guide, the practice of forensic occupational therapists working in a
Method: The study compared Model of Human Occupation Screening Tool (MOHOST) scores of forensic service users who received treatment as usual and participated in a social inclusion programme (n = 24) with the scores of those who received treatment as usual (n = 19) only.
Results: Although no difference was found in MOHOST scores between the two groups before intervention (p>0.05 at 0.493), a significant difference in scores was found in the intervention group post-intervention (p<0.05 at 0.006). This difference is hypothesised to represent change in occupational functioning and evidence of successful treatment outcomes.
Conclusion: The study concluded that forensic service users could benefit from occupational therapy programmes that include activities to promote social inclusion.
Social inclusion, forensic services, assessment.
Cognition disorders (Care and treatment)
Cognition disorders (Research)
Occupational therapy (Usage)
Practice guidelines (Medicine) (Usage)
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: Oct, 2011 Source Volume: 74 Source Issue: 10|
|Topic:||Event Code: 310 Science & research|
|Product:||Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Social inclusion is a central principle of United Kingdom government policy and a dominant agenda for mental health services (Department of Health [DH] 2000, College of Occupational Therapists 2006, Harrison and Sellers 2008). The National Service Framework for Mental Health (DH 1999) and No Health without Mental Health (DH 2011) require health and social services to reduce discrimination and social exclusion among service users. Education, training and employment have been identified in these papers as key to meeting these objectives. When considering offenders with mental health problems, in particular schizophrenia, specific care is required to ensure the assessment of occupational status and potential. Forensic occupational therapy has been described as a new specialism in forensic care and has the potential to fulfil the social inclusion expectation of policy (DH 2002, Duncan et al 2003, O'Connell and Farnworth 2007). However, much of the evidence to support the role of occupational therapy in this new specialism has lacked currency and there is little evidence to guide the occupational therapist in his or her practice (O'Connell and Farnworth 2007).
In 2006, the occupational therapy team from the Forensic and High Support Directorate (FHSD) within Pennine Care NHS Foundation Trust developed a social inclusion programme (SIP). Its aims were to increase engagement in community-based activity; to introduce complex task performance and goal-orientated activity to treatment; to engage patients in normative learning environments; to improve literacy and numeracy skills; and to provide a stepping stone to further education and work. An additional aim was to evaluate the social inclusion work and to demonstrate evidence for occupational therapy interventions, consistent with the research priorities of Duncan et al (2003) to investigate treatment outcomes, to link research to practice and to address occupational deprivation.
Mental illness is correlated with social exclusion (Fitzgibbon and Cameron 2007). Those experiencing serious mental illness (SMI) are one of the most excluded and disadvantaged groups in society (Social Exclusion Unit 2004) and those in forensic services are no exception (Lloyd 1987). The onset of SMI most commonly occurs during late adolescence or young adulthood, with a resulting interruption in secondary and tertiary education (McGorry 1992). This interruption can impair the development of essential social skills, such as problem solving, time management, motivation and the use of initiative (Bassett et al 2001). Social exclusion, experienced as stigma and the reduction of participation in relationships and mainstream social, cultural and economic activities, can often result from this impairment (Morgan and Bhugra 2010).
In addition to experiencing social exclusion, forensic service users are also prone to occupational deprivation. Occupational deprivation is a state in which an individual is unable to do what is necessary and meaningful in his or her life (Whiteford 2000, Mee and Sumsion 2001). Preece (1995) argued that in forensic services the medical model contributes to the experience of occupational deprivation because it shapes the types of professional intervention that lead to underachievement, low motivation and low self-esteem. Underachievement and low expectation can further decrease the service user's social networks and occupational opportunity which, in turn, increases the experience of social exclusion (Link et al 1989). Whiteford (2000) went further and stated that an occupational perspective is needed to support and develop treatment approaches, so as to provide alternative images and experiences of success to those of the medical model. Recent evidence supports the use of social inclusion interventions, such as education, vocational activity and work, to achieve this perspective in mental health services (Mowbray 2000, Bassett et al 2001, Becker et al 2002, Cheung et al 2006, Cook 2006).
People with SMI value work (Mowbray 2000) but lack the necessary skills, training and support to overcome functional deficits, social impairments and discrimination (Cook 2006, Corrigan 2006). Davis and Rinaldi (2004), in their study, successfully supported mental health service users back to employment through the development and implementation of a trust-wide vocational services strategy. It involved partnership working with service users, occupational therapists, mental health employment coordinators and care coordinators in the assessment, planning, placement and support of service users into work.
Supported education programmes are designed to foster self-confidence and self-esteem, to encourage skill acquisition and academic credentials and to normalise identity (Becker et al 2002, Westwood 2003). In Mowbray's (2000) study (n = 397), adults with SMI were supported for matriculation at a community college. Participants were randomly assigned to an active treatment group that involved small group exercises and experiential learning over two 14-week semesters, and a control group that did not participate in these structured and scheduled interventions. Participants in the active treatment group showed significant improvement in quality of life, self-esteem and social adjustment and a threefold increase in productive activity at 6 months follow-up. Westwood (2003) used semi-structured interviews to explore the benefits, barriers, drawbacks, enabling factors and impact on mental health for 12 individuals who attended college. The individuals found improvements in confidence, self-esteem, socialisation and motivation to have resulted from their attendance at college. Other authors have found reduced symptomatology, reduced relapses, increased ability to cope and increased daily structure to have resulted from supported education programmes (Dench and Regan 2000).
Work is an important step in the recovery process (Westwood 2003, Davis and Rinaldi 2004, National Social Inclusion Programme 2006) and supported education can serve as a stepping stone to work (Westwood 2003). Occupational therapy is a profession that promotes choice, participation and empowerment and provides a key role in coordinating, implementing and evaluating activity (Mee and Sumsion 2001, DH 2002, Dunn and Seymour 2008). By using activities that enable or support opportunities for social inclusion within a broader rehabilitation programme, the occupational therapist can meet service framework expectations, reduce occupational deprivation and provide the real possibility of enabling change in the lives of forensic service users (Whiteford 2000, Dunn and Seymour 2008).
The social inclusion programme (SIP)
The SIP (see Table 1) was made available to all 62 service users in four long-stay units in the FHSD, a low-secure, rehabilitation forensic service at Pennine Care NHS Foundation Trust. The programme entailed graded community engagement and one-to-one goal planning with a unit-based occupational therapist, in addition to normal treatment. As prerequisite referral criteria for admission to the FHSD, all service users had a history of poor insight and poor engagement; more than half had a history of violence, 46% had an index offence and all were subject to the Mental Health Act (1983).
Initially, the SIP was proposed to senior directorate managers. This was important because some of the programmes had financial implications and approval for this expenditure had to be agreed early on in the process. The unit-based occupational therapists worked collaboratively, sharing resources across all FHSD units. The SIP became an agenda item in the inpatient managers meeting, the service-wide occupational therapy meeting and the senior directorate managers meeting. This served to improve communication, review progress and identify good practice.
Service users were encouraged to attend activities that were assessed to be appropriate to their needs. However, there was a hierarchy of complexity, with leisure groups being the least and college work the most task demanding. As service user presentations stabilised, functional ability improved and risk reduced (as determined by the multidisciplinary team and monthly care planning meetings), they were encouraged to engage in more complex and task demanding activities until they were engaged in an individualised college/work-based programme.
The purpose of the evaluation
The purpose of the evaluation was to test for a difference in occupational functioning between service users attending the SIP and those who did not. A pre-test and post-test, between-group comparison design was used (see Table 2). Occupational functioning was measured by the Model of Human Occupation Screening Tool (MOHOST). The activities that make up the SIP provided the opportunity for service users to experience social inclusion. The outcome measure, the MOHOST, was used to look at whether these activities improved occupational functioning.
All service users were offered the SIP and none were excluded from the programme once they had agreed to engage. Of those who consented to participate in the study, 24 agreed to engage in the SIP and therefore became the SIP group while 19 refused to engage in the SIP and thus became the treatment as usual (TAU) group. Group membership was, therefore, self-selecting. Due to this being an exploratory study, and for the ethical reason that random allocation would have denied treatment, participants were not allocated to groups. Both groups received TAU but only the intervention group engaged in the SIP. The SIP contained additional interventions to the TAU group and involved prescribed activity that was part of a clinical framework that connected the SIP to short-term and long-term treatment goals.
The SIP treatment goals were regularly reviewed and planned with the service user and his or her multidisciplinary team, but did not have a set number of sessions or a prescribed time period. Service user engagement was ongoing and progression was related to goal planning and its graded outcomes. The SIP was, therefore, a coherent set of interventions that only the SIP group received, and was above and beyond that which all service users received as usual. Details of age, race, gender, diagnosis (schizophrenia, schizophreniform, bipolar disorder), medication (typical or atypical, mood stabiliser, atypical with mood stabiliser) and whether an index offence was present or not were also collected.
Forty-three out of 62 service users consented to have their data used in the study, 14 refused to consent and five were discharged from the service. Ethical approval was sought through National Health Service (NHS) Central Ethics and approved by the North Manchester Research Ethics Committee (ref: 08/H1006/40). Pennine Care NHS Foundation Trust provided local approval (ref: SC/LSRA). Written and signed consent was obtained at least 24 hours after potential participants had been provided with a study information sheet.
Consent was given to allow the chief investigator to have access to and use of MOHOST scores for the data analysis. Because the SIP intervention was an established treatment, consent to receive the intervention was not required from participants. Anonymity of participants was guaranteed at all times.
Occupational function was assessed using the MOHOST (version 2). The MOHOST is based on the concepts of the Model of Human Occupation (MOHO), which assesses motivation, performance and organisation of occupational behaviour (Parkinson et al 2006). It was developed by British occupational therapists in conjunction with the MOHO team in Chicago (Parkinson et al 2008). It contains 24 items, four for each of the six subsections of volition, habituation, communication, processing skills, motor skills and environment (Parkinson et al 2006). The first five sections assess the person's participation in occupation, while the last assesses how the environment supports that occupation (Parkinson et al 2006).
The MOHOST is designed to be scored from a variety of data sources (Parkinson et al 2008), is flexible and straightforward enough to be used in a range of settings and was designed to document progress towards occupational therapy goals (Parkinson et al 2006). It has been extensively pilot tested (Parkinson et al 2006) and a study of its psychometric properties is forthcoming (Parkinson et al 2008, Forsyth et al, in press).
Although there are other assessments that assess similar occupational areas, the MOHOST was chosen because it is specifically designed to assess and measure a person's overall occupational participation, regardless of symptoms, disorder and treatment stage (Parkinson et al 2006), and is considered to be well placed to evaluate the effectiveness of occupational therapy interventions (Parkinson et al 2008). Following discussion with the MOHOST authors, the nominal MOHOST scale of F (Facilitates), A (Allows), I (Inhibits) and R (Restricts) was changed to the ordinal scale of 4, 3, 2, 1 respectively, so as to facilitate statistical analysis.
Participants were approached by their occupational therapist for consent. After this, demographic data (see Table 3) and MOHOST scores, which are routinely used for baseline care programme approach assessment, were collected from service users' files by the chief investigator. The chief investigator was not involved in providing any of the interventions.
The MOHOSTs used in this study were completed by occupational therapists, who also ran the SIP groups. Thus the potential for bias, the uncontrolled influence on outcomes, may have resulted. The SIP occupational therapists had caseloads of 12 service users, not all of whom would be engaged in the SIP at any one time. Although each therapist was involved in the running of the groups, they were not necessarily involved in the groups attended by their caseload. Most groups were run by other occupational therapists, unqualified staff or by outside agencies, such as education. In addition, none of the SIP occupational therapists were involved in the research (other than completing the MOHOST for those on their caseload), data collection or analysis. As a result of this, the risk of bias was reduced.
The data were analysed using SPSS Version 17.0 (SPSS 2009). All significance tests were two tailed, with p = 0.05. Descriptive statistics (see Table 4) were run on all variables but conditions for parametric testing were not met. Nonparametric, Mann-Whitney U Test (see Table 5 for rank scores and Table 6 for test statistics) was run for overall and subscale scores to answer the research questions:
1. Was there any difference in MOHOST scores between the two groups pre-intervention?
2. Was there any difference in MOHOST scores between the two groups post-intervention?
There were 43 participants overall (SIP group n = 24, TAU group n = 19); 84% were male (SIP group n = 21, TAU group n = 15) and 16% female (SIP group n = 3, TAU group n = 4) (Table 3). Their ages ranged from 21 to 59 years, with an average age of 36.19 years. The TAU group was slightly older, at 39.53 years, than the SIP group, at 33.54 years.
Eighty-six per cent of participants had a diagnosis of schizophrenia (n = 37), 9% had a schizoaffective disorder (n = 4) and 5% a bipolar disorder (n = 2). Ninety-two per cent of participants in the SIP group had a diagnosis of schizophrenia (n = 22) as opposed to 79% of the TAU group (n = 15). More people with a mood component, 21%, were in the TAU group as opposed to 8% in the SIP group. Participants with bipolar disorder were represented in the TAU group only.
The majority of participants were white British, 86% (n = 37). The only minority ethnic groups were British Afro-Caribbean and British Pakistani-Asian, who were equally represented at 7% (n = 3). Ethnicity was evenly represented in both groups.
Seventy-two per cent of participants (n = 31) were on atypical medication, 21% (n = 9) on typical medication, 2% (n = 1) on mood stabilisers and 5% (n = 2) on atypical medication and mood stabilisers. Proportionally, more people, 37% (n = 7), were on typical medication in the TAU group as compared with 8% (n = 2) in the SIP group. More people were on atypical medication in the SIP group 87% (n = 21) than in the TAU group 53% (n = 10).
Almost half of participants, 46% (n = 20), had an index offence and represented 46% (n = 11) of the SIP group and 47% of the TAU group (n = 9). Just over half of participants, 53% (n = 23), did not have an index offence and represented 54% (n = 13) of the SIP group and 53% (n = 10) of the TAU group.
Because the mean age values indicate that the SIP group was younger than the TAU group, a post-hoc t-test was performed. The difference in age was not significant (t = -1.829, df = 36.468 p = 0.076).
The overall mean pre-intervention and post-intervention scores showed a mean increase for the SIP group (Table 4). The pre-intervention SIP group showed a mean of 66.29 and the pre-intervention TAU group showed a mean of 63.26. Post-intervention mean scores for the SIP group increased to 72.50, while the post-intervention TAU mean score decreased to 61.26. The SIP group scored higher at post-intervention as compared with pre-intervention and the TAU group had a lower post-intervention score as compared with their pre-intervention score. This pattern continued for the subscale scores of motivation for occupation, communication and interaction skills and process skills. Pattern of occupation and environment subscale scores improved for both groups, although the SIP group had the larger increase. Motor skills were the only subscale to show a decrease in mean scores for both groups, although the TAU group showed the greater decrease. The standard deviations show that both groups, at pre-intervention and post-intervention, had similar levels of variability. The data were normally distributed and there were no extreme scores.
Overall, the SIP group scored significantly better than the TAU group post-intervention, with a mean rank of 26.67, against the TAU group mean rank of 16.11, p<0.05 at 0.006 (Table 5). The two groups were not significantly different before the intervention, with SIP and TAU showing mean ranks of 23.17 and 20.53 respectively, p>0.05 at 0.493.
Further analysis of MOHOST subscale scores showed no significant difference in mean rank scores before intervention, but a significant difference post-intervention for four of the six subscales (Table 6). Motivation for occupation showed pre-intervention scores of 23.81 and 19.71 for SIP and TAU with p>0.05 at 0.284, and a significant difference in scores post-intervention with mean ranks of 27.25 and 15.37 for SIP and TAU with p<0.05 at 0.002. Pattern of occupation showed a significant difference in scores with SIP at 22.96 and TAU at 20.79 with p>0.05 at 0.571 for pre-intervention scores, and 27.13 and 15.53 for SIP and TAU with p< 0.05 at 0.002 for post-intervention scores.
There was no significant difference in communication and interaction skills, with pre-intervention scores of 22.17 and 21.79 respectively for SIP and TAU with p>0.05 at 0.922 and post-intervention scores of 24.44 and 18.92 with p>0.05 at 0.149. Process skills also showed no significant difference, with pre-intervention scores of 21.94 and TAU of 22.08 with p> 0.05 at 0.970 and post-intervention of 24.46 for SIP and 18.89 for TAU with p>0.05 at 0.146.
There was a significant difference in motor skills, with ranks pre-intervention scores showing 22.94 and 20.82 for SIP and TAU with p>0.05 at 0.577 and post-intervention scores of 25.48 and 17.61 for SIP and TAU with p<0.05 at 0.037. Environment subscale pre-intervention scores of 23.65 for SIP and 19.92 for TAU with p>0.05 at 0.326 and post-intervention scores of 25.56 for SIP and 17.50 for TAU with p< 0.05 at 0.033 also showed a significant difference in scores.
This study found little difference in overall MOHOST scores between the SIP and the TAU groups before intervention and a significant difference in the scores of the SIP group following intervention. This difference continued to be evident in four of the six subscales scores, with motivation for occupation, pattern of occupation, motor skills and environment all showing significant difference.
These findings are consistent with the evidence in the literature and the expectation of this study. Those who experience SMI endure poor motivation, cognitive dysfunction and habitual deskilling, which can impair the rehabilitation process (McGorry 1992, Mee and Sumsion 2001, Gopal and Variend 2005). In addition, the rehabilitation process can itself prejudice skill acquisition through occupational deprivation (Preece 1995, Whiteford 2000). However, as the condition of occupational deprivation improves and the individual experiences skill-enhancing activities that positively redefine roles, habits and identity, a corresponding improvement in motivation and behaviour can be expected (Mowbray 2000, Westwood 2003). The SIP provided such an opportunity and those service users who engaged in the programme evidently improved in their occupational performance, as measured by their before-and-after MOHOST scores.
This study focused on the need to evidence an occupational therapy intervention within a forensic setting. The need to provide social inclusion within the framework of a mental health setting is well established (Davis and Rinaldi 2004, National Social Inclusion Programme 2006). Evidence already exists to support the use of social inclusion activities as interventions in forensic settings (Mowbray 2000, Becker et al 2002, Cheung et al 2006), but there is little evidence to support such an intervention in the remediation of established MOHO domains, as explored by the MOHOST. Improvements in these domains are hypothesised to represent improved occupational functioning, progress within an occupational therapy programme and evidence for prognostic change (Parkinson et al 2006). On the face of it, these findings suggest that a SIP that engages service users in the experience of social inclusion can be successful in improving the occupational performance of forensic service users.
Limitations and strengths of the study
This was a small study, limited to four long-stay units at one NHS site, and participants were not randomly assigned to groups. Despite a 69% recruitment rate, the sample size was small and the ability to generalise limited. Reproduction of this study could benefit from a longer time scale and the use of multiple NHS sites so as to increase recruitment rate and sample size.
Statistically, there was no significant difference between the SIP and TAU groups before intervention. However, the SIP group had better before-intervention MOHOST scores and the TAU group had more people with a mood component to their illness. This may have affected results, and randomisation of participants in any future study would be useful in controlling for this. Another potential bias, the administration of MOHOSTs by occupational therapists who also run the SIP groups, is an issue. Reproduction of this study should therefore use independent MOHOST administrators.
No breakdown of SIP sessions into duration, frequency and numbers attending are available. The study is therefore unable to comment on the benefits or otherwise of particular SIP groups.
This was the first study to use the MOHOST to assess the effectiveness of social inclusion interventions in a forensic occupational therapy programme. The results showed a significant difference in intervention scores against treatment as usual scores and, although the sample size was small, the degree of significance was encouraging. It was also encouraging to see that the intervention group was well represented with participants who experienced schizophrenia and who had index offences. Previous research has suggested that disengagement remains a significant problem for service users who experience schizophrenia (Lieberman et al 2005, Kreyenbuh et al 2009). This research provides evidence to suggest that this is not necessarily the case.
This study would merit follow up to assess the extent to which the changes, as measured on the MOHOST, endure over time. It also recommends reproduction at further sites with a larger sample size. Because self-selection was used to allocate group membership, the TAU group chose not to engage in the SIP. Further study could benefit from randomised allocation of participants to groups so as to eliminate potential bias.
This study did not assess mental state, risk profile, psychosis, self-esteem, self-worth or self-efficacy. Self-esteem, self-worth and self-efficacy have been found to benefit from social inclusion work (Mowbray 2000) and may provide insight into why some service users can be successfully engaged in social inclusion work while others remain reluctant.
Finally, this evaluation focused on measuring the impact of social inclusion activities on occupational functioning. It did not investigate whether it promoted service users' experience of social inclusion. Further investigation could therefore benefit from exploring service users' experience of social inclusion resulting from their engagement in activities described in this study.
As a growing specialism in the treatment and assessment of forensic service users, occupational therapy needs to evidence its practice. Forensic service users are prone to occupational deprivation, with resulting deficits in motivation and performance. Occupational therapy provides a key role in coordinating, implementing and evaluating activity that has been hypothesised to improve performance in these areas.
By comparing an intervention that promotes social inclusion with a non-intervention group that received treatment as usual, this study has provided some evidence to support the role of occupational therapy in forensic practice. No significant difference was found between these two groups pre-intervention but a significant difference was found post-intervention. The study concludes that social inclusion work can improve occupational performance for forensic service users and, therefore, recommends it as an occupational therapy intervention for forensic services.
Conflict of interest: None declared.
* Occupational therapy, because of its key role in coordinating, implementing and evaluating activity, is well placed to support social inclusion in forensic services.
* The intervention group demonstrated improved occupational functioning as measured by MOHOST scores.
What the study has added
This study provides evidence to support the use of the MOHOST to measure occupational change in forensic service users engaged in social inclusion programmes.
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Correspondence to: Martin Fitzgerald, Head Occupational Therapist, Forensic and High Support Services, Pennine Care NHS Foundation Trust, Heathfield House, Cale Green, Manchester SK2 6RA.
Reference: Fitzgerald M (2011) An evaluation of the impact of a social inclusion programme on occupational functioning for forensic service users. British Journal of Occupational Therapy, 74(10), 465-472.
Submitted: 23 June 2010.
Accepted: 14 July 2011.
Table I. The FHSD social inclusion programme Intervention Description Aims type Leisure Sports, swimming, cinema, 1. Provide community-based groups women's group, snooker, engagement summer holidays, weekly 2. Develop adaptive role, football tournaments, identity and habits fishing, green gym and 3. Normalise social conservation activities activities 4. Develop wider social network 5. Practise adaptive coping 6. Provide graded exposure to complex task demands and goal-orientated activity Literacy Developing literacy 1. Provide communitygroup skills and entry-level based engagement qualifications, using 2. Provide an information technology introduction to (IT) and accessing public community education, libraries in particular numeracy, Stepping Supporting people back literacy and IT stone into mainstream 3. Provide recognised education education/vocation qualifications 4. Identify individual Progressing from education and prevocational training to vocational based needs supported and unsupported beyond the SIP education and employment via pathways to wider services College Foundation courses in IT, 1. Provide communitycreative writing, based engagement cooking, music, drama and 2. Provide a broad range skills for life, and pre- of educational and GCSE courses in literacy vocational subjects and numeracy and activities to initiate community education 3. Facilitate progress from prevocational training to supported and unsupported education and employment 4. Enable the attainment of recognised qualifications 5. Identify individual education and vocational based needs beyond the SIP 1. Provide individual education and vocational engagement beyond the SIP 2. Focus on community engagement and community living Work Paid, vocational and 1. Maintaining and voluntary developing roles, habits and identity that underpin normalised community living Table 2. Study criteria Study criteria All FHSD service users in residence from 2006 to 2008 SIP group (1) Service users who had attended the SIP and received treatment as usual from 2006 to 2008. TAU group (2) Service users who had received treatment as usual only from 2006 to 2008. SIP = Social inclusion programme; TAU = Treatment as usual. Table 3. Demographic data for SIP and TAU groups Sample overall SIP group TAU group (n = 43) (n = 24) (n = 19) Age Range (years) 21-59 21-58 22-59 Mean 36.19 33.54 39.53 Median 34 30 40 SD 10.81 9.96 11 Gender Male 36 84% 21 85% 1 5 79% Female 7 16% 3 12% 4 21% Diagnosis Schizophrenia 37 86% 22 92% 1 5 79% Schizoaffective 4 9% 2 8% 2 10% Bipolar disorder 2 5% 0 2 10% Race White British 37 86% 21 85% 16 84% British Afro-Caribbean 3 7% 1 4% 2 10% British Pakistani-Asian 3 7% 2 8% 1 5% Medication Atypical 31 72% 21 87% 10 53% Typical 9 21% 2 8% 7 37% Mood stabiliser 1 2% 0 1 5% Atypical and mood stabiliser 2 5% 1 4% 1 5% Index offence Index offence 20 46% 11 46% 9 47% No index offence 23 53% 13 54% 10 53% SIP = Social inclusion programme; TAU = Treatment as usual. Table 4. Descriptive data of pre-intervention and post-intervention SIP and TAU groups (Group 1 = SIP and Group 2 = TAU) Pre-SIP intervention n Minimum Maximum Mean SD Overall Group 1 SIP 24 49 95 66.29 12.192 2 TAU 19 37 84 63.26 13.888 Motivation for occupation Group 1 SIP 24 6 16 10.00 2.703 2 TAU 19 5 13 8.89 2.424 Pattern of occupation Group 1 SIP 24 5 16 9.00 2.859 2 TAU 19 5 12 8.26 2.353 Communication and interaction skills Group 1 SIP 24 7 16 11.08 2.948 2 TAU 19 6 15 11 00 3.232 Process skills Group 1 SIP 24 7 16 10.48 2.702 2 TAU 19 5 16 10.53 3.438 Motor skills Group 1 SIP 24 8 16 13.29 2.43 2 TAU 19 8 16 12.89 2.644 Environment Group 1 SIP 24 8 16 12.46 1.933 2 TAU 19 6 16 11.68 2.382 Post-SIP intervention n Minimum Maximum Mean SD Overall Group 1 SIP 24 51 95 72.50 11.699 2 TAU 19 32 79 61.26 12.036 Motivation for occupation Group 1 SIP 24 7 16 11.21 2.797 2 TAU 19 4 12 8.21 2.507 Pattern of occupation Group 1 SIP 24 7 16 10.67 2.599 2 TAU 19 4 16 9.12 2.645 Communication and interaction skills Group 1 SIP 24 6 16 11.83 2.599 2 TAU 19 4 14 10.42 3.254 Process skills Group 1 SIP 24 7 16 11.33 2.823 2 TAU 19 4 15 9.79 3.242 Motor skills Group 1 SIP 24 7 16 13.24 2.483 2 TAU 19 7 16 12.47 2.653 Environment Group 1 SIP 24 9 16 13.37 1.929 2 TAU 19 7 16 12.21 2.123 SIP = Social inclusion programme; TAU = Treatment as usual. Table 5. Mann-Whitney U mean rank and sum of rank scores for SIP and TAU groups Pr-SIP intervention Group n Mean Sum of rank ranks Overall 1 SIP 24 23.17 556.00 2 TAU 19 20.53 390.00 Motivation for occupation 1 SIP 24 23.81 571.50 2 TAU 19 19.71 374.50 Pattern of occupation 1 SIP 24 22.96 551.00 2 TAU 19 20.79 395.00 Communication and interaction skills 1 SIP 24 22.17 532.00 2 TAU 19 21.79 414.00 Process skills 1 SIP 24 21.94 526.50 2 TAU 19 22.08 419.50 Motor skills 1 SIP 24 22.94 550.50 2 TAU 19 20.82 395.50 Environment 1 SIP 24 23.65 567.50 2 TAU 19 19.92 378.50 Post-SIP intervention Group n Mean Sum of rank ranks Overall 1 SIP 24 26.67 640.00 2 TAU 19 16.11 306.00 Motivation for occupation 1 SIP 24 27.25 654.00 2 TAU 19 15.37 292.00 Pattern of occupation 1 SIP 24 27.13 651.00 2 TAU 19 15.53 295.00 Communication and interaction skills 1 SIP 24 24.44 586.50 2 TAU 19 18.92 359.50 Process skills 1 SIP 24 24.46 587.00 2 TAU 19 18.89 359.00 Motor skills 1 SIP 24 25.48 611.50 2 TAU 19 17.61 334.50 Environment 1 SIP 24 25.56 613.50 2 TAU 19 17.5 332.50 SIP = Social inclusion programme; TAU = Treatment as usual. Table 6. Mann-Whitney U overall and subscale MOHOST test statistics Test statistics Overall Overall 1 1 Pre Post Pre Post Mann-Whitney U 200.000 116.000 184.500 102.000 Asymp.sig. (2-tailed) 0.493 0.006 0.284 0.002 Test statistics 2 2 3 3 Pre Post Pre Post Mann-Whitney U 205.000 105.000 224.000 169.500 Asymp.sig. (2-tailed) 0.571 0.002 0.922 0.149 Test statistics 4 4 5 5 Pre Post Pre Post Mann-Whitney U 226.500 169.000 205.500 144.500 Asymp.sig. (2-tailed) 0.970 0.146 0.577 0.037 Test statistics 6 6 Pre Post Mann-Whitney U 188.500 142.500 Asymp.sig. (2-tailed) 0.326 0.033 1 = Motivation for occupation; 2 = Pattern of occupation; 3 = Communication and interaction skills; 4 = Process skills; 5 = Motor skills; 6 = Environment.
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