Cost-effectiveness of occupational therapy return-to-work interventions for people with mental health disorders: A systematic review.

BACKGROUND: Return-to-work (RTW) resources for persons with mental health disorders are limited and costs are typically shared by several stakeholders in society. Occupational therapists (OT) provide RTW interventions for this target group, however, increased knowledge of health, and employment effects, as well as costs are needed to better inform decision makers in their prioritisations. AIMS/OBJECTIVES: To identify and summarise evidence of cost-effectiveness of RTW interventions for persons with mental health disorders which OTs provide. MATERIALS AND METHODS: A systematic search was applied and resulted in 358 articles. After screening, nine articles met inclusion criteria and were reviewed. Quality assessment was conducted using the economic evaluation tool by Joanna Briggs Institute. RESULTS: Supported employment, Individual Placement and Support was cost-effective in several contexts while three studies showed larger effects and higher costs. An OT intervention added to treatment for major depression was indicated to be cost-beneficial and an advanced supported employment was cost-saving. The methodological quality varied considerably between studies. CONCLUSIONS AND SIGNIFICANCE: The results of the included studies are promising, however, to further strengthen the economic perspective in OT RTW interventions, the need for conducting more and methodologically robust economic evaluations is crucial in future studies.

The Nordic Housing Enabler: Inter-rater reliability in cross-Nordic occupational therapy practice. Previously published in Scandinavian Journal of Occupational Therapy 2010; 17: 258-266.

This study addresses development of a content-valid cross-Nordic version of the Housing Enabler and investigation of its inter-rater reliability when used in occupational therapy rating situations, involving occupational therapists, clients, and their home environments. The instrument was translated from the original Swedish version of the Housing Enabler, and adapted according to accessibility norms and guidelines for housing design in Sweden, Denmark, Finland, and Iceland. This iterative process involved occupational therapists, architects, building engineers, and professional translators, resulting in the Nordic Housing Enabler. For reliability testing, the sampling strategy and data collection procedures used were the same in all countries. Twenty voluntary occupational therapists, pair-wise but independently of each other, collected data from 106 cases by means of the Nordic Housing Enabler. Inter-rater reliability was calculated by means of percentage agreement and kappa statistics. Overall good percentage agreement for the personal and environmental components of the instrument was shown, indicating that the instrument was sufficiently reliable for application in practice and research in the Nordic context. The varying kappa results highlight the need for further study in order to understand the influence of prevalence more profoundly, which should be kept in mind when interpreting the results.

Self-reported versus professionally assessed functional limitations in community-dwelling very old individuals.

The objective of this study was to examine the relationship between self-reported and professionally assessed functional limitations in community-dwelling very old individuals. In total, 306 single-living adults aged 81-90 years were included in this cross-sectional study. The main outcome measure was the presence and absence of self-reported and professionally assessed functional limitations. A significant correlation was found between the total number of self-reported and professionally assessed functional limitations in the total sample (intraclass correlation=0.65) as well as in subgroups with respect to sex, age, and depression. When item-wise differences in the two assessments were assessed, the results showed significant differences for nine of the 15 functional limitations. In general, the participants reported more functional limitations as present than the professional did. In conclusion, research on self-reported and professionally assessed functional limitations contributes toward the understanding of how different modes of data collection influence the results. In this study, functional limitations were examined on a broad basis, including physical as well as cognitive and perceptual limitations. Once the assessments of self-reporting have been refined, we will have a more nuanced picture of functional limitations, incorporating self-report as well as professional assessments.

Evaluation of evidence within occupational therapy in stroke rehabilitation.

UNLABELLED: Evidence-based practice creates practice that integrates research-driven evidence with clinical expertise and patients' preferences in clinical decision-making. AIM: The aim of this study was to investigate and evaluate the quality and applicability of scientific research in occupational therapy intervention related to the use of everyday life occupations and client-centred practice within stroke rehabilitation. DESIGN: Systematic searches of research studies published in English during 2000-2007 in peer-reviewed journals were undertaken. Thirty-nine articles and one Cochrane review were appraised and the quality evaluated using an evidence taxonomy and an evidence hierarchy. RESULTS: Evidence arose providing support for a client-centred approach, entailing outcome related to better ability to recall goals, the patients feeling more involved and able to manage more everyday life occupations after rehabilitation. There is also considerable evidence for the use of everyday life occupations in occupational therapy. Occupational therapy was evaluated as an important aspect of stroke rehabilitation improving outcomes in everyday life occupations including activities of daily living (ADL) and participation. DISCUSSION: As research of relevance for the profession to a large extent includes qualitative research it gives rise to reflection on including more tools than the evidence hierarchy while evaluating evidence within occupational therapy.

The Nordic Housing Enabler: inter-rater reliability in cross-Nordic occupational therapy practice.

This study addresses development of a content-valid cross-Nordic version of the Housing Enabler and investigation of its inter-rater reliability when used in occupational therapy rating situations, involving occupational therapists, clients, and their home environments. The instrument was translated from the original Swedish version of the Housing Enabler, and adapted according to accessibility norms and guidelines for housing design in Sweden, Denmark, Finland, and Iceland. This iterative process involved occupational therapists, architects, building engineers, and professional translators, resulting in the Nordic Housing Enabler. For reliability testing, the sampling strategy and data collection procedures used were the same in all countries. Twenty voluntary occupational therapists, pair-wise but independently of each other, collected data from 106 cases by means of the Nordic Housing Enabler. Inter-rater reliability was calculated by means of percentage agreement and kappa statistics. Overall good percentage agreement for the personal and environmental components of the instrument was shown, indicating that the instrument was sufficiently reliable for application in practice and research in the Nordic context. The varying kappa results highlight the need for further study in order to understand the influence of prevalence more profoundly, which should be kept in mind when interpreting the results.

Very old Swedish women's experiences of mobility devices in everyday occupation: a longitudinal case study.

The use of mobility devices, such as walking sticks and rollators, increases during the ageing process. Our aim was to explore how very old single-living Swedish women experience the use of mobility devices over time, in relation to everyday occupation. A multiple case study strategy involving quantitative and qualitative data was used. The findings indicate that the use of mobility devices, rollators in particular, starts off as support for walking but over time becomes more involved in occupational performance, resulting in complex transactions between personal, environmental, and task components. Personal factors such as ability to adjust and adapt to different situations seem to be crucial for optimal mobility device use. Strategies and adaptive behavior were developed over the years while striving for maintained independence and participation. The use of mobility devices was described as something one has to accept, but also a constant reminder of your limitations, or as a possibility to remain active and to manage everyday occupation. The findings stress the need to adopt a comprehensive view when trying to facilitate everyday occupations in very old age. Physical, social, psychological aspects, combinations among assistive devices, and home modification all need to be reflected on and monitored over time.

Negotiating and effectuating relocation to sheltered housing in old age: a Swedish study over 11 years.

The aim of this study was to explore how very old people consider and arrive at decisions on relocation, with specific attention to housing and health relationships during the process of ageing. The sample included 13 very old participants of an 11-year longitudinal study of relationships between housing and health. Applying a mixed-methods approach, data from qualitative interviews and quantitative survey data from three data collection waves were utilised. The quantitative data were interwoven with the qualitative findings into a coherent body of text. The core theme "Negotiating and effectuating relocation is a long process" indicates a non-linear process consisting of five phases constituting the main categories of our findings. In the first phase, some informants considered relocation while others avoided thinking about it. Next, relations between health and home changed and led to turning points triggering relocation, i.e. when dependence in everyday activities reached critical points or when sudden illness forced an involuntary move. In the third phase, once the decision to relocate was made it was set in stone by the individual, but often questioned by the authorities, leading to a situation causing much frustration. While waiting for the relocation, doubts as well as expectations about the new home were expressed. Finally, even though the actual move caused different feelings, it was most often a positive experience and resulted in subjective health improvement and increased social contacts. The results can be used for the development of positive, proactive strategies for improved housing provision along the ageing process.

The 39 item Parkinson's disease questionnaire (PDQ-39) revisited: implications for evidence based medicine.

BACKGROUND: The 39 item Parkinson's disease questionnaire (PDQ-39) is the most widely used patient reported rating scale in Parkinson's disease. However, several fundamental measurement assumptions necessary for confident use and interpretation of the eight PDQ-39 scales have not been fully addressed. METHODS: Postal survey PDQ-39 data from 202 people with Parkinson's disease (54% men; mean age 70 years) were analysed regarding psychometric properties using traditional and Rasch measurement methods. RESULTS: Data quality was good (mean missing item responses, 2%) and there was general support for the legitimacy of summing items within scales without weighting or standardisation. Score reliabilities were adequate (Cronbach's alpha 0.72-0.95; test-retest 0.76-0.93). The validity of the current grouping of items into scales was not supported by scaling success rates (mean 56.2%), or factor and Rasch analyses. All scales represented more health problems than that experienced by the sample (mean floor effect 15%) and showed compromised score precision towards the less severe end. CONCLUSIONS: Our results provide general support for the acceptability and reliability of the PDQ-39. However, they also demonstrate limitations that have implications for the use of the PDQ-39 in clinical research. The grouping of items into scales appears overly complex and the meaning of scale scores is unclear, which hampers their interpretation. Suboptimal targeting limits measurement precision and, therefore, probably also responsiveness. These observations have implications for the role of the PDQ-39 in clinical trials and evidence based medicine. PDQ-39 derived endpoints should be interpreted and selected cautiously, particularly regarding small but clinically important effects among people with less severe problems.

Relationships between objective and perceived housing in very old age.

PURPOSE: Our purpose in this study was to explore relationships between aspects of objective and perceived housing in five European samples of very old adults, as well as to investigate whether cross-national comparable patterns exist. DESIGN AND METHODS: We utilized data from the first wave of the ENABLE-AGE Survey Study. The five national samples totalled 1,918 individuals aged 75 to 89 years. Objective assessments of the home environment covered the number of environmental barriers as well as the magnitude of accessibility problems (an aspect of person-environment fit). To assess perceptions of housing, we used instruments on usability, meaning of home, and housing satisfaction. We also assessed housing-related control. RESULTS: Overall, the results revealed that the magnitude of accessibility problems, rather than the number of physical environmental barriers, was associated with perceptions of activity-oriented aspects of housing. That is, very old people living in more accessible housing perceived their homes as more useful and meaningful in relation to their routines and everyday activities, and they were less dependent on external control in relation to their housing. The patterns of such relationships were similar in the five national samples. IMPLICATIONS: Objective and perceived aspects of housing have to be considered in order to understand the dynamics of aging in place, and the results can be used in practice contexts that target housing for senior citizens.

Relationships between housing and healthy aging in very old age.

PURPOSE: The aim of this work is to examine the relationship between aspects of objective and perceived housing and aspects of healthy aging, defined as independence in daily activities and subjective well-being. Furthermore, this research examined the comparability of relationships between housing and healthy aging in the five European countries. DESIGN AND METHODS: Data were drawn from the ENABLE-AGE Project, from home interviews with a sample of 1,918 very old people aged 75 to 89 years living alone in their own homes in Swedish, German, British, Hungarian and Latvian urban areas. RESULTS: Participants living in better accessible homes, who perceive their home as meaningful and useful, and who think that external influences are not responsible for their housing situation are more independent in daily activities and have a better sense of well-being. Moreover, these results apply to all five national samples. IMPLICATIONS: The findings can widen the perspective when striving for barrier-free building standards, to encompass a holistic approach that takes both objective and perceived aspects of housing into account. Home modification and relocation should not be prescribed, but need to be negotiated with older adults to take into account their personal preferences.

Use of mobility devices and changes over 12 months among very old people in five European countries.

BACKGROUND AND AIMS: Mobility devices (MDs) such as walking sticks, rollators and wheelchairs, often play an important role for older people living at home, striving to remain independent in everyday activities. The aim of this study was to explore how the use of MDs changes over time among very old people in five European countries. METHODS: Empirical data from the ENABLE-AGE Survey Study, part of a major interdisciplinary research project carried out in Sweden (n=314), Germany (n=322), the United Kingdom (n=316), Hungary (n=179), and Latvia (n=225), were used. RESULTS: The use of MDs in the Swedish, German and UK samples showed a significant increase between the first occasion of data collection (T1) and the second (T2), 12 months later. A walking stick was the most common MD on both occasions, with the exception that the number of users of rollators outdoors exceeded the number of users of walking sticks in the Swedish sample at T2. Among non-users of MDs at T1, 12-21% became new users at T2. Continued use was seen between T1 and T2 (80-94%) in the various samples, but the type of MD used changed. In the Swedish, German and UK samples, significant changes were seen in the use of MDs with greater assistive potential over the year. CONCLUSIONS: This study shows that the pattern of MD use changes over a short period of time. More research is needed to determine outcomes of MD use in very old age, focusing on the extent to which MDs decrease disability during the aging process, not least in a European perspective.

Cross-national and multi-professional inter-rater reliability of the Housing Enabler.

In order to render reliable assessment of housing accessibility in a cross-national context possible, the objective of this study was to investigate multi-professional, cross-national inter-rater reliability of the ENABLE-AGE project-specific version of the Housing Enabler instrument. The data collection was performed with elderly persons in ordinary housing in five European countries. After participation in rater training courses, 26 raters representing different nationalities and professions performed data collection in independent pairs of raters, n = 64. Inter-rater reliability was calculated by means of percentage agreement as well as Cohen's kappa. The results demonstrated moderate to good overall inter-rater reliability of the project-specific version of the Housing Enabler instrument. The mean agreement for the personal component part of the instrument was 91%. For 13 of the 15 items in this part kappa values could be defined, kappa = 0.43, indicating moderate agreement. In the environmental component part the mean agreement for all 188 items was 85%, while kappa = 0.50, indicating moderate agreement. Given the complexity of the instrument and the number of different professions and countries involved, we consider the Housing Enabler as useful for cross-national research targeting housing accessibility, even if the agreement levels reached were moderate. However, the moderate agreement levels pinpoint the importance of rater training.

Assistive devices among very old people in five European countries.

The aim of this study was to investigate the use and need of assistive devices (ADs) in a cross-national European sample of very old persons, focusing on national similarities and differences as well as similarities and differences according to age and level of health status. Data from the ENABLE-AGE research project were utilized involving very old persons in Sweden, Germany, Latvia, Hungary, and the United Kingdom (UK). Personal interviews with single-living old persons were conducted (n = 1918). Of the total sample 65% reported that they had and used one or more ADs, and 24% reported unfilled need. The most commonly used ADs were devices for communication, followed by devices for mobility. Participants in Hungary and Latvia used a lower total number of ADs. Comparisons among sub-groups according to age between the Western and the Eastern European national samples showed significant differences. The result can to some extent be explained by different welfare systems and presumably differences in knowledge and awareness of ADs, and further research is called for. However, the result can serve as input for future planning and development of information, services, and community-based occupational therapy, to improve healthcare and social services for older people.

Challenges of cross-national housing research with older persons: lessons from the ENABLE-AGE project.

Although it is generally acknowledged that housing is a major issue regarding health in old and very old age, most empirical research still tends to treat the role of the housing environment in a rather superficial manner. The cross-national project Enabling Autonomy, Participation, and Well-Being in Old Age: The Home Environment as a Determinant for Healthy Ageing (ENABLE-AGE) seeks to make a substantial contribution to this shortcoming. The main objective of the project is to examine subjective and objective aspects of housing and their impact on health in very old age, while health is understood mainly in terms of autonomy, participation and well-being. The project involves five European Union member countries, i.e. Sweden (coordinating unit), Germany, the United Kingdom, Latvia and Hungary. The total sample includes 1,918 older adults in the age range of 75-89 years and living in single households. We provide a systematic analysis of major challenges coming with cross-national research in the housing and ageing domain based on the experience of the ENABLE-AGE Project. Treated are: challenges related to sampling and data collection procedures, challenges related to inclusion and exclusion criteria based on housing characteristics, challenges related to differences in housing legislation, norms, and guidelines, challenges related different availability of professional expertise for person-environment assessments, challenges related to valid and reliable person-environment assessments, and challenges related to the interpretation of housing-related findings.