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Background: Despite growing interest among policymakers in comparative effectiveness and cost-effectiveness over the past two decades, remarkably few interventions used within the welfare sector can genuinely be described as “evidence-based”. However, even where evidence exists, significant questions remain about how well findings translate to real-world conditions and whether they are sufficient to inform decision-making. Such issues are further amplified when evaluating complex interventions, where experimental approaches alone are often insufficient, and need to be complemented by other methods.

This thesis forms part of a larger research project evaluating the intervention of Everyday Life Rehabilitation (ELR), a recovery- and activity-based intervention targeting persons with serious mental illness (SMI) living in supported accommodation. The thesis comprises four studies addressing the intervention’s effectiveness, cost-effectiveness, and early implementation. ELR involves residents, rehabilitation professionals, housing staff and their managers, aiming to promote personal recovery through engagement in meaningful everyday activities. The overall objective of this thesis is to evaluate ELR by integrating findings across four distinct analytical approaches, while contributing to the broader discussion on the role of evaluations in welfare settings.

Methods: The thesis revolves around a pragmatic cluster randomised controlled trial (RCT) evaluating the effectiveness and cost-effectiveness of ELR against treatment-as-usual in promoting personal recovery and quality of life among persons with SMI living in supported accommodation. Alongside the trial, data on resource use and early implementation have been collected, which are examined through a mixed-methods approach, drawing on health economics and implementation science.Study I is an internal pilot study (19 units and 48 participants) evaluating the feasibility of the trial and intervention, assessing the outcome measures, and informing an updated power calculation. Study II is the full-scale RCT (60 units and 161 participants) evaluating the effectiveness of ELR on the primary outcome measure Recovering Quality of Life (ReQoL). Study III is a trial-based cost-utility analysis estimating the interventions impact on costs and quality adjusted life years (QALYs). Finally, Study IV is a process evaluation exploring housing staff’s (n = 21)Vdiscourses in response to the early implementation process, based on seven focus group interviews conducted following the trial.

Results: The findings demonstrates that those who received ELR had significantly greater improvements in ReQoL scores at six months compared with the control (20.1, 95% CI: 15.8 to 24.4). This represents a strong and clinically meaningful effect, and high goal attainment were observed among those who received the intervention. In addition, analyses suggest that ELR has a high probability of being cost-effective, and that it is quite affordable. Despite positive findings, several implementational challenges were observed during the trial. Discourses among housing staff revealed a perceived sense of scarce resources and vague leadership, which constrained staff’s agency and fostered apprehension towards residents own choices, leading them to employ discursive strategies to rationalise resistance and gatekeeping.

Conclusions: ELR has been found to not only be an effective intervention, but also a cost-effective one. These findings represent robust empirical evidence, which is used to illustrate how findings can be contextualised through translational approaches, to enable more precise causal statements. While effects are context-dependent, the findings suggest that meaningful improvements in resident’s quality of life can be achieved with relatively modest efforts. ELR has been developed to fit well within the legal and organisational structures of supported accommodation in Sweden, and holds potential not only as an intervention, but as a means of integrating healthcare services, promoting resident’s agency, and enhancing the overall quality of services.

Background: Everyday Life Rehabilitation (ELR) is a recovery-oriented intervention that aims at improving residents’ quality of life through engagement in meaningful everyday activities. The intervention has been demonstrated to be effective in a randomized controlled trial (ClinicalTrials.gov: NCT05056415).

Method: A cost-utility analysis (CUA) was conducted using quality-adjusted life years (QALYs) derived from ReQoL-UI as the primary outcome. Both deterministic and probabilistic sensitivity analysis was used to explore critical assumptions. A budget impact analysis was used to estimate the incremental cost of scaling up ELR in routine practice.

Results: The intervention was found to be cost-effective compared to usual care, with an estimated incremental cost-effectiveness ratio (ICER) of 133 494 SEK (12 148 EUR) per QALY. Sensitivity analysis indicated that the findings were robust. The estimated average budget impact was estimated to be 10 118 SEK (921 EUR) per resident for one year of ELR. Overall, ELR demonstrated significant clinical benefits with minimal incremental costs.

Interpretation: Throughout the analysis, we have used highly conservative estimates. Despite this, the analysis concluded that the intervention has a high probability of being cost-effective. Thus, the study provides robust evidence for the value of ELR as a scalable and economically viable intervention.

För att fatta välgrundade beslut om resursfördelning krävs modeller som inte bara väger samman kostnader och hälsoutfall, utan också klarar att hantera både osäkerhet och komplexitet. Inom välfärdssektorn, där datatillgången ofta är begränsad och kunskapen om kausala samband osäker, ställs särskilda krav på beslutsfattare. I dessa sammanhang kan hälsoekonomiska modeller inte bara stödja prioriteringar, utan även bidra till större transparens och förståelse i beslutsprocessen. Den här texten belyser hur sådana modeller, när de tillämpas på rätt sätt, potentiellt kan stärka beslutsfattandet inom välfärdsområdet.

Background: Individuals with serious mental illness (SMI) living in supported accommodation often lead lonely and sedentary lives. Everyday Life Rehabilitation (ELR) is a collaborative, person-centred, activity-oriented and recovery-oriented intervention that integrates outreach rehabilitation efforts into routine practices. This intervention aims to enhance personal recovery and quality of life by promoting engagement in meaningful everyday activities within real-life contexts.

Objective: To evaluate the effectiveness of ELR on personal recovery and quality of life among residents with SMI in supported accommodation, compared with treatment-as-usual (TAU).

Methods: This was a pragmatic, parallel-group, cluster-randomised controlled trial (RCT) (NCT05056415) conducted in Sweden between August 2021 and June 2024. The RCT included 60 housing units (clusters) randomly assigned (1:1) to receive either ELR or TAU. Data were collected by independent, blinded assessors, with partial blinding of residents. The primary outcome, Recovering Quality of Life (ReQoL-20), was assessed at the individual level and analysed using a mixed-effects model and an intention-to-treat (ITT) approach by a statistician blinded to the allocation.

Findings: Participants in the intervention group showed significantly greater improvements in ReQoL scores at 6 months compared with the control group (20.1, 95% CI: 15.8 to 24.4), with a statistically significant between-group difference (p<0.001). The ITT analysis included 60 housing units with 161 participants (86 men and 72 women), of whom 90 were allocated to ELR (33 units) and 71 to TAU (27 units). The overall attrition rate was 24% in both groups, and no major adverse events were reported.

Conclusions: These findings indicate that ELR is an effective intervention with a clinically relevant impact on recovering quality of life for individuals with SMI living in supported accommodation. While these results should be interpreted within the context of the Swedish system, they contribute to the growing body of evidence supporting recovery-oriented and activity-oriented interventions in supported accommodation.

Clinical implications: Responsive, person-centred, goal-oriented activity training, grounded in collaborative alliance, represents a valid strategy for recovery-oriented interventions. While multilevel approaches must be tailored to specific contexts, the integration of occupational therapists may provide clinical benefits in supported accommodation.

Trial registration number: NCT05056415.

OBJECTIVE: Previous studies have shown that high workload affects health negatively. However, studies are lacking among home care workers. The aim of this study is to examine the burden of perceived workload on health-related quality of life (HRQoL) among home care workers and to determine whether psychosocial factors modify such a relationship.

METHODS: A cross-sectional study was conducted in which 1162 (58% response rate) home care workers participated. The psychosocial factors were measured by QPSnordic. HRQoL was measured by EuroQol 5 dimensions, from which responses were translated into quality-adjusted life year scores (QALY). Propensity scores were used with absolute risk differences (RD). Stratified analysis was used to test the buffer hypothesis of the demand-control-support model.

RESULTS: Personnel with a high workload had a statistically significant 0.035 lower QALY than personnel with a normal workload. This difference was also statistically significant for the Visual Analogue Scale (RD 5.0) and the mobility (RD 0.033) and anxiety/depression scales (RD 0.20) dimensions of EQ-5D. For QALY, the effect of a high workload compared to a normal workload was higher, with low (RD 0.045, significant) compared with high (RD 0.015, non-significant) social support; while it was similar, and non-significant results, for low and high control.

CONCLUSIONS: Our study shows that lowered work burden would be beneficial for home care personnel. Furthermore, our results suggest that interventions aimed at increasing social support could reduce work-related illness.