In-country activities

BiH | Occupational Therapy Services in Mental Health Facilities

Introduction
Occupational therapy aims at helping people achieve independence, significance and fulfilment of all aspects of their life. An occupational therapist applies specific knowledge to enable individuals to perform day-to-day activities that have personal meaning and value. It enables, improves, maintains or returns a function, no matter whether its performance has been lost due to an injury or illness, whether it has been caused by physical or psychological disability. (WFOT 2012)
 
A model of one-year education in occupational therapy in mental health was designed and successfully organised at two faculties in BiH (Medical Faculty of Zenica and High Medical School in Prijedor), with support by the Mental Health Project in BiH. The project is supported by the Swiss Government and implemented by a local NGO Association XY, in partnership with the two entity Ministries of Health.
 
During the academic year of 2016/17, 117 nurses (70% women) were trained in the patient-centred and recovery-oriented occupational therapy in mental health. They came from 77 mental health institutions, i.e. 55 Community Mental Health Centres, 11 psychiatric clinics and hospitals, 4 social institutions, 5 institutes for addiction diseases and 1 gerontology centre. By successfully passing the exams, these nurses demonstrated that they have acquired the knowledge and skills needed to reduce effects of mental disorders and improve the quality of life of people with mental disabilities through occupational therapy. With their certificates they were awarded 60 ECTS. Furthermore, graduate and postgraduate courses in occupational therapy have been opened at the faculties.  
 
During 2017, eight supervisory-educational training sessions were held to monitor the application of occupational therapy in mental health facilities. The occupational therapy provided to the service users has been measured and researched by the Project, using a new measuring instrument of the Multifocal Evaluation of Activity in Occupational Therapy (EMAE-2)[1]. This paper presents only the key elements of this research. The questionnaire was obtained from the Community Psychiatry Service from the University Clinic of Lausanne in Switzerland and has been modified to fit the local circumstances and needs.
 
Methodology
The questionnaire played a dual role in the implementation of the Project: first, in evaluating the increase in the capacities of the mental health professionals to provide an innovative recovery-oriented service, and second in measuring the recovery of service users from severe mental disorder. Recovery was measured to the following 9 dimensions: frame, choice, behaviour, motivation, basic and complex cognitive abilities, motoric functions, self-consciousness and relationship with others. Separate measurements of achievement of short-term and long-term therapeutic goals were made.
 
The aim of each measurement was to compare the results and assessments of five patients per therapist from the first and second application of the EMAE-2 questionnaire (change before and at the end of occupational therapy), so the effectiveness of the therapy could be determined. The first measurements were done in August 2017 and re-evaluation in December 2017, on a sample of 388 occupational therapy service users. The second measurements were done in July 2018 with re-evaluation in December 2018 on a sample of 208 service users. Users’ overall satisfaction with occupational therapy services was measured with the Client Satisfaction Questionnaire (CSQ).
 
Results and Discussion
Demographics on a sample of all patients who have undergone pre- and post-evaluation of occupational therapy in BiH
Demographic data on the total sample shows a ratio of 45% and 46% of female patients to 55% and 54% male, which generally corresponds with the gender structure of the patients with severe mental health problems. By age, patients were elderly – 68% of them were older than 40 in first testing, and 60% of patients in the second one. 23% of patients were aged between 41 and 50 and 23% between 51 and 60. Finally, 20% were not older than 30.
 
Concerning their work status, unemployment was as high as 48% in 2017 and 52% in 2018, and only 7% in 2017 and 8% in 2018 were employed, while 22% in 2017 and 16% in 2018 testing were pensioners. According to marital status, more than half of the examined patients were single (53% / 45%), while a quarter were divorced (24% / 22%). Married were 19% / 26% of the patients included in the sample, while for 4% and 7% of them no information on marital status was provided.
 
Diagnosis, symptoms of disorder, hospitalization and pharmacotherapy on the total sample
Among the patients involved in occupational therapy, the most frequent diagnosis was schizophrenia, schizotypal and delusional disorders (53% / 54%). in 14% / 22% of patients mood disorders (affective disorders) were identified. In 12% / 11% of patients, mental retardation with mental disorders were found, and 10% / 6% of patients were with behavioural disorders caused by the use of psychoactive substances. Stress-related disorders were on an increase in the two samples from 5% to 10%. Most of respondents (76%) had been hospitalized at some point, while 16% / 8% of the patients included in the sample were not hospitalized during the testing. Regardless of the type of diagnosis, the therapists reported differently on the onset of illness (in case they did indicate the onset of illness – and 25% of the therapist did not indicate it) and they classified it in accordance with the point in time or with reference to a certain situation or event in a patient's life.
 
Related to pharmacotherapy, 75% of the sampled patients used a particular type of drug, and only 6% / 1% of the patients in the therapeutic process did not use any pharmacotherapy. It is significant that 19% / 24% of answers did not include any information on use of pharmacotherapy, which implies that the anamnesis is an area which needs to be further improved. 
 
Presentation of the results at the level of outcomes
The quality of services and the satisfaction of service users have been raised throughout the mental health facilities in BiH thanks to the occupational therapy provided in a standardized manner (78.5% of institutions applied this new service). The number of Community Mental Health Centres that provide occupational therapy increased from 40% in 2009 to 74.32% in 2016. It is worth noting that centres in 2009 in fact used only some elements of the occupational therapy, without adequate measurements and not provided by formally trained therapists. In addition to the community centres, 21 other mental health facilities now provide patient-cantered and recovery-oriented occupational therapy by trained therapists: 11 psychiatric clinics and hospitals, 4 social care institutions, 5 institutes treating addictions and one gerontology centre.
 
The use of skills by the occupational therapists trained through the Mental Health Project and recovery of service users measured in domains of social, health and psychological functioning have been significantly improved, as evidenced by the analysis of the EMAE-2 instrument. In 2017, on the sample of 388 users, the measurement showed that 78.6% (85.4% of female and 70.3% of male) recovered. One year later, the score of recovery was 87% (85% of female and 88% of male), measured on the sample of 208 service users (Charts 1 and 2).
 
Realization of set goals and achieved progress in BiH
The obtained results show that in 2017 and 2018 respectively, in 88% and 83% of cases the goals set at the start of the therapy were achieved, while only 13% and 16% of the set goals were not achieved. These results firmly indicate that the occupational therapists mastered the new knowledge, adequately planed their activities, pursued the goals that they had set and successfully realized them, and significantly approached their full realization in 2018.
 
When the therapy goals were compared in the evaluation and re-evaluation processes, it is evident that certain adjustments were made in the re-evaluation process. This indicated the ability of the therapists to evaluate and improve their work towards desired outcome. Namely, during the evaluation 16% / 18% of therapists indicated the strengthening of the person's existing resources and the acquisition of new knowledge as targets of the therapy. In the re-evaluation process, this percentage dropped to 11% and 14%, which is statistically significant and indicating that some of the set goals were evaluated as achieved and that the therapy focused on some other areas aimed to be improved after the evaluation.
 
Conclusions
The measurements show that continuity of the innovative occupational therapy services have been provided in 80% of the mental health facilities in BiH.  Improved recovery of users with severe mental health disorders was achieved in the areas selected as priority through an individualized approach and set as therapeutic goals (an increase of 8.4% compared to already high score of recovery in the first measurement). The quality of provided service and the satisfaction of service users have been raised.
 
Therefore, all the applied interventions have contributed to:
•   application of innovative services of occupational therapy in 80% of mental health facilities in BiH
•   improved users’ recovery in areas that were selected as priority
•   monitored and followed recovery of the service users and improved therapy through supervision sessions and workshops
•   raised the quality of service and the satisfaction of service users


[1] Pfister, A.-C., Pomini, V., Gatti, L., I Ducret, M. (1998)

Related resources

http://www.mentalnozdravlje.ba/eng

Author

Irina Rizvan, Component Leader