Discussion
blurred
To our knowledge, this is the first trial to evaluate the effectiveness of a co-led peer occupational therapy intervention combining group sessions with individual sessions and the option of individual support. Findings from the trial did not confirm our study hypothesis, as MA&R was not superior to standard mental health care in improving activity engagement, personal recovery, functioning or quality of life. We still consider it important to study activity engagement, since occupational therapy services are delivered in institutional facilities but target services users` engagement in everyday life outside the institution. It is therefore critical to develop interventions that address the challenges of transferring gains from interventional settings to meaningful everyday life activities in the community [First, the differences between the RCT arms may have been smaller than anticipated. The control condition in this study, care as usual, may explain why MA&R was not superior, since some of the core components in MA&R were also available in standard mental health care. For instance, peer support and occupational therapy were part of standard mental health care in several sites and therefore available to the control group, too.Another potential explanation concerns the strategy to support transfer of gains (skills, competences) acquired during sessions to activity engagement in the community. Contrary to the BEL intervention, MA&R did not incorporate home assignments to be practiced in real life conditions. Instead, MA&R offered individual support, but this component of the intervention was optional. Thus, the utilization of individual support was much lower than we anticipated when designing MA&R. While COVID-19 may partly explain the low uptake of individualized support and transition of activities in the community, the low use of support may also be a result of implementation failure. Perhaps the individual support component was too vaguely described in the MA&R manual. The manual emphasized that support should be flexible and tailored to the participants’ preferences. Within occupational therapy literature, conceptual practice models exist [As this RCT was a multicenter trial, between-group comparisons may have been blurred by differences in standard mental health care across sites. To explore this further, we conducted a between-group comparison of activity engagement, personal recovery, functioning, and quality of life, stratified by type of services (CMCHs vs. municipal mental health services). However, the post hoc analysis did not show substantial differences in treatment effects between the CMCHs and the municipal health services. Results from the analysis are presented in the supplementary table 