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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.