The attendees’ view of quality in community-based day centre services for people with psychiatric disabilities

Abstract

Background/aims: Community-based day centres in Sweden are well-established arenas for psychiatric rehabilitation, but little is known of the attendees’ perception of the quality of the service provided. The aim of the study was thus to describe and investigate the quality of the services in community-based day centre for people with psychiatric disabilities.

Methods: A sample of 218 attendees in 14 community-based day centre services in Sweden completed the Quality in Psychiatric Care – Daily Activities (QPC-DA).

Results: The results showed that people with psychiatric disabilities perceived the quality of community-based day centre services as high. Most notably, quality of service was rated higher by those with lower educational level, had waited shorter time to attend the centre, and had better mental and physical health. However, particularly aspects of a secluded environment and participation (information) may be areas with potential for improvement.

Conclusion/significance: From an occupational science perspective, the results adhere to the importance of occupational balance, with periods of rest/privacy during the time at the centre.

Keywords:

• Daily activities
• occupational balance
• quality of care
• participation

Introduction

Engagement in meaningful daily activities has a positive influence on health, well-being and quality of life among people with psychiatric disabilities [1,2]. The municipalities in Sweden are required to provide daily activity services for this group [3]. The activities are designed and adapted to individual needs in order to provide people with psychiatric disabilities with something interesting and meaningful to do, which is in line with the core principals in occupational therapy [4]. There are two types of community-based centres in Sweden: work-oriented and meeting-place oriented. Work-oriented centres are based on the concept of increasing the attendees’ chances of receiving employment and include activities such as work in second-hand shops, catering, property maintenance and transport. Meeting-placed oriented centres have more of a drop-in nature and offer less demanding activities, such as computer café, creative activities, or just socializing over a cup of coffee [5].

Attendees experience day centre activities as giving them joy, feelings of belongingness, competence, insight into their capacity, and a daily structure [6,7]. However, people who attend community-based day centres aimed at providing regular, structured and meaningful activities, are not more satisfied or perceive better health and wellbeing than people with psychiatric disabilities who do not participate in day centre activities [8,9]. These findings may question the quality of services provided at day centres. However, few studies have investigated the quality of day centre services. This is surprising given the importance measurement of service quality has in order to assess whether services fulfil quality requirements [10] or to provide a basis for improvement of the service quality [11]. One reason is the lack of reliable and valid instruments for measuring day centre service quality from the attendee’s perspective.

The Quality of Psychiatric Care – Daily Activity (QPC-DA) has recently been developed to meet this need [12]. The QPC-DA is part of a family of instruments built on a definition of psychiatric care from interviews with psychiatric in-patients and out-patients [13]. In addition to day centre service, the QPC family of instruments currently cover a number of psychiatric service contexts such as in-patient [14], outpatient [15,16], forensic inpatient [17–22] and housing services [23,24]. The QPC-DA has been psychometrically tested and shows adequate reliability and validity [12], which makes it suitable for assessing the quality of day centre service from the attendees’ perspective. The aim of the present study was thus to describe and investigate the quality of the services provided in community-based day centres for people with psychiatric disabilities.

Material and methods

Participants

The day centres from the municipalities in one region in central Sweden, who took part in a Quality project run by a national user organization (National Partnership for Mental Health), were invited to participate in the study. A total of 373 people with psychiatric disabilities attending 14 community-based day centre services in seven of these municipalities accepted to participate. Inclusion criteria were: having a psychiatric disability, attending day centre service, being able to understand Swedish and cognitively able to answer the questionnaire in a valid way, as evaluated by the staff when asking for participation in the study. No attendee was found cognitively unable to complete the questionnaire. Forty-four attendees did not meet the inclusion criteria and 81 declined to participate. A total of 248 attendees thus completed the questionnaire. Thirty of them had 30% or more not applicable or missing items, and were excluded from the analysis. The final sample thus consisted of 218 attendees, generating a 66% response rate among the eligible respondents.

Data collection

A contact person at each of the 14 community-based day centre services informed all people eligible for participation in the study orally and by an informational letter. The contact person also made sure that clients were cognitively able to answer the questionnaire in a valid way. The participants were informed that their participation was voluntary and that they could withdraw at any time. Those who gave oral consent to participate were asked to complete the QPC–DA questionnaire and then put it in a sealed envelope in a locked letterbox at the community-based daily centre. Data were collected in 2014 during a four-month period. The study was approved by a Swedish regional research ethics committee. All individuals were legally competent to give their consent.

The instrument QPC-DA

The QPC-DA [12] consists of 35 items and is based on the Quality in Psychiatric Care – Inpatient (QPC-IP) [14,25]. Some items of the QPC-IP were reworded to fit the daily activity service context. The four items in the Discharge dimension of the QPC–IP were deemed irrelevant in the daily activity context and excluded. The QPC–DA consists of five general dimensions and a daily activity specific dimension (Table 3). The general dimensions are: Encounter (7 items), Participation (8 items), Support (5 items), Secluded environment (2 items), Secure environment (3 items). The Daily Activity-specific dimension consisted of 9 items that were based on the experiences of people with mental disorders performing activities as a part of their therapy [6]. All items of the QPC-DA were validated by a user panel.

All items in QPC-DA are related to the phrase: ‘I experienced that…’ and are scored on 4-point forced choice Likert scales, ranging from 1 (totally disagree) to 4 (totally agree). For all items, one can respond with a ‘not applicable’. The QPC-DA also includes a number of background questions concerning attendees’ socio-demography. At the end of the questionnaire, there is an open-ended question providing the opportunity for the respondent to give further comments.

The internal consistency in terms of Cronbach’s alpha of the QPC-DA in the present study was 0.97 of the full QPC-DA, 0.92 in Encounter, 0.90 in Participation, 0.87 in support, 0.81 in Secluded environment, 0.77 in Secure environment and 0.90 in the DA specific dimension.

Data analysis

Descriptive statistics were conducted using SPSS 22 (Chicago, IL). Before analysis, imputation was performed by replacing missing data points in questionnaires with the mean of that item in questionnaires having less than 30% missing items. Based on previous research on users perception of the quality of health services [16–28], we used 80% positive ratings (i.e. a score of at least 3 on QPC-DA items) as a cut off value defining satisfactory quality of service. Differences in frequencies were analyzed using the Chi-squared test with the Fischer exact test. The association between background variables (independent variables) and each of the QPC-DA dimension mean scores (dependent variables) were analyzed using univariate regression. A p-value less than .05 was regarded as statistically significant.

Results

The study group

Sociodemographic and clinical data are shown in Table 1. The participants in the study were between 19 years and 71 years old. There were approximately as many men as women. A majority lived alone and in their own accommodation. Almost all had completed at least elementary school and about one-fourth of them had completed university/college studies. Most of the participants reported that they knew their diagnosis. Almost half of the participants reported good or very good mental health and physical health. A majority had current contact with an outpatient clinic.

Table 1. Characteristics of the study group (n = 218).

Background variable	Participants, N (%)
Gender
Male	119 (55%)
Female	96 (44%)
Missing data	3 (1%)
Age (M ± SD)	46.4 ± 12.1
19–29	17 (8%)
30–39	47 (22%)
40–49	48 (22%)
50–59	67 (31%)
60–71	29 (13%)
Missing data	10 (5%)
Nationality
Swedish	186 (85%)
Non-Swedish	29 (13%)
Nordic countries	2 (1%)
European	9 (4%)
Non-European	12 (6%)
Missing data	3 (2%)
Education
Not completed elementary school	4 (2%)
Elementary school	66 (30%)
Upper secondary school	96 (44%)
College/University	49 (23%)
Missing data	3 (1%)
Living status
Living alone	170 (78%)
Living together	43 (20%)
Missing data	5 (2%)
Type of housing
Residence with special services	46 (21%)
Independent living	163 (75%)
Missing data	9 (4%)
Know ones diagnosis
Yes	154 (71%)
No	40 (18%)
Has not got a diagnosis	18 (8%)
Missing data	6 (3%)
Number of reported diagnoses (n = 154)
One	106 (69%)
Two	17 (11%)
Three or more	5 (3%)
Missing data	26 (17%)
Type of diagnosis, if yes (n = 154)
Psychosis/Schizophrenia	48 (31%)
Depressions	33 (21%)
Neuropsychiatric	30 (20%)
Anxiety	22 (14%)
Missing data	26 (17%)
Current contact with outpatient clinic
No	63 (29%)
Yes	152 (70%)
Missing data	3 (1%)
Frequency of contact with outpatient clinic (n = 152)
>1 times/week	9 (6%)
1 time/week	23 (15%)
2 times/month	17 (11%)
1 time/month	29 (19%)
6 times/year	5 (3%)
4 times/year	5 (3%)
≤2 times/year	15 (10%)
Missing data	49 (32%)
Current mental health
Very bad	7 (3%)
Bad	42 (19%)
Neither good nor bad	63 (29%)
Good	76 (35%)
Very good	28 (13%)
Missing data	2 (1%)
Current physical health
Very bad	8 (4%)
Bad	52 (24%)
Neither good nor bad	66 (30%)
Good	69 (32%)
Very good	19 (9%)
Missing data	4 (2%)
Daily occupation
Work oriented daily activities/student	100 (46%)
Meeting place oriented daily activities	113 (52%)
Missing data	5 (2%)
Type of activities (more than one is possible)
Property maintenance	52 (24%)
Handicraft	63 (29%)
Catering service	69 (32%)
Social activities	121(56%)
Missing data	5 (2%)
Length in daily activity (M ± SD)	5.3 ± 5.4
<1 year	43 (20%)
1–4 years	68 (31%)
5–9 years	32 (15%)
>10 years	46 (21%)
Missing data	29 (13%)
Waiting time for current day centre
No waiting time	104 (48%)
<1 month	70 (32%)
1–3 months	23 (11%)
>3 months	13 (6%)
Missing data	8 (4%)
Perceived time of waiting
Far too short	8 (4%)
Too short	55 (25%)
Neither short nor too long	120 (55%)
Too long	9 (4%)
Far too long	7 (3%)
Missing data	19 (9%)
Know responsible head of activity centre
No	27 (12%)
Yes	189 (87%)
Missing data	2 (1%)
Know where to complain
No	66 (30%)
Yes	149 (68%)
Missing data	3 (1%)
Recommend current activity centre
Certainly not	5 (2%)
Rather not	8 (4%)
Maybe	41 (19%)
Willingly	59 (27%)
Absolutely	104 (48%)
Missing data	1 (0%)

Daily activities

Approximately half of the participants had been at the community-based day centres for five years or more. Almost half of the attendees reported that they were in work training activities and a half had meeting place-oriented activities. The most frequent type of daily activity was social activity followed by catering, handicraft and property maintenance (Table 1).

Some of the daily activities were gender and age dependent. More men (29%) than women (16%) were engaged in property maintenance (χ²=5.66, p = .023). Attendees in the two youngest age groups together with those in the oldest age group were more engaged in catering services than those in the two middle age categories (42% versus 22%, χ²=5.87, p = .023). The older the attendees, the more they were engaged in social activities; from 29% among those in the youngest age group to 79% among those in the oldest age group (χ²=12.67, p < .001).

In addition, some of the daily activities were related to perceived physical (but not mental) health and type of diagnosis. That is, a greater proportion of the attendees rating their physical health as very bad or bad were more engaged in catering services and in activities of a social nature than those rating their physical health as neither good nor bad to very good (20% versus 37%, χ²=5.72, p = .022 and 73% versus 49%, χ²=10.61, p = .001, respectively). Fewer attendees with schizophrenia (15%) than other psychiatric illnesses (36%) were engaged in handicraft (χ²=7.22, p = .007), whereas more attendees with depression (69%) than other psychiatric illnesses (24%) were engaged in handicraft (χ² =10.1, p = .002). Since more women (63%) than men (38%) were diagnosed with depression the gender analysis was performed separately. This analysis showed no depression influence among men but among women, where those with depression were more engaged in handicraft than those without depression (55% versus 17%; χ²=9.62, p = .003).

Quality of day centre service

Most of the attendees (87%) perceived the overall quality as satisfactory (i.e. mean equal or larger than the scale mean score of 2.5) and as many as 30% (n = 65) of the attendees perceived the quality as unconditionally good (i.e. totally agree on all items). The highest ratings were found in Encounter followed by Support, Daily Activity-Specific, Secure Environment, Participation, and the lowest quality was found in Secluded Environment.

The results of the univariate regression analyses used to investigate background variable relationship with quality of day centre service showed that the higher the education level, the longer the waiting time for assigned day centre service, the longer the perceived time of waiting and the lower the perceived quality in all dimensions (Table 2). In addition, the better the attendees perceived their physical and mental health, the higher they perceived the quality in two and four of the six QPC-DA dimensions, respectively. Finally, knowing who the responsible head was and where to complain were positively related with five and six dimensions, respectively.

Table 2. Univariate regression standardized coefficients (β) on background questions for each QPC-DA dimension.

	Encounter	Participation	Support	Secluded environment	Secure environment	Daily activity specific
Gender	0.089	0.113	−0.002	0.126	0.028	0.086
Age (cont.)	−0.029	0.052	0.079	0.018	0.085	0.096
Nationality	0.052	0.032	0.055	−0.021	−0.009	0.050
Living status	0.019	−0.003	−0.006	0.033	−0.004	−0.037
Education	−0.145*	−0.217**	−0.136*	−0.208**	−0.179**	−0.203**
Type of housing	−0.089	−0.127	−0.027	−0.075	−0.102	−0.109
Daily occupation	0.054	0.129	0.095	0.036	0.006	0.055
Waiting time for current day center	−0.239***	−0.233***	−0.160*	−0.153*	−0.172*	− 0.261***
Perceived time of waiting	−0.198**	−0.211**	−0.114	−0.203**	−0.143*	−0.244***
Length in daily activity	−0.102	0.086	−0.008	0.044	0.056	0.141
Know ones diagnosis	0.105	0.049	0.052	−0.110	−0.003	−0.059
Number of reported diagnoses	−0.014	−0.057	−0.053	0.069	−0.082	−0.108
Current contact with outpatient clinic	0.013	−0.062	−0.032	−0.055	−0.035	−0.101
Frequency of contact with outpatient clinic	−0.028	−0.017	−0.019	−0.141	−0.057	−0.035
Current physical health	0.057	0.109	0.092	0.096	0.137*	0.170*
Current mental health	0.138*	0.171*	0.189**	0.113	0.124	0.256***
Know responsible head of activity center	0.293***	0.255***	0.255***	0.133	0.181**	0.170*
Know where to complain	0.233***	0.238***	0.227***	0.208**	0.184**	0.196**

*** p < .001;

** p < .01;

* p < 0.05.

Table 3. Attendees’ perception of the quality of day centre service.

	QPC-DA item by dimension	Agree^a (%)
	1. Encounter (7 items)
14.	The staff show me respect	89.3
10.	The staff treat me with kindness	88.6
9.	The staff are dedicated	86.3
15.	The staff understand my feelings	85.3
22.	The staff care about how I perceive the daily activities	84.2
7.	The staff talk with me when I need it	84.0
17.	The staff have time to listen to me	83.7
11.	The staff care about why I am angry	83.7
	2. Participation (8 items)
5.	My opinion of what is right is respected	86.4
6.	I am involved in decisions about my daily activities	85.7
26.	I have been informed of the various types of activities so that I can decide what is best for me	80.8
24.	I received information in an understandable way	77.9
12.	My previous experiences of what activities I can perform are optimally utilized	77.5
1.	I have influence over the activities I perform	76.7
25.	I learn about my psychiatric disabilities	69.5
13.	I learn to recognize signs of deteriorating mental health	59.4
	3. Support (5 items)
16.	Staff prevent me from hurting others	84.7
20.	Staff help me to understand that guilt and shame should never have to stop me from going to the day centre.	84.4
21.	The staff help me to understand that guilt and shame should never have to stop me from seeking care	82.9
19.	The staff will help me to understand that it is not shameful to have suffered from psychological disorders	82.7
18.	Staff prevent me from hurting myself.	82.4
	4. Secluded environment (2 items)
23.	When I perform activities in my daily job there is a secluded place where I can take a break	77.3
3.	I have access to secluded place at the centre	70.5
	5. Secure environment (3 items)
4.	I can feel safe with the other attendees	85.4
2.	The security is high at the centre	84.0
8.	I am not disturbed by the other attendees	74.8
	6. DA specific (9 items)
35.	It is fun to go to the centre	87.4
29.	I get to learn how to perform the activities	83.7
30.	Participation makes me feel fellowship with others	83.1
31.	I get an insight into what abilities I have	82.6
34.	The activities feel meaningful	82.4
32.	The activities are adapted to my abilities	82.3
27.	I have learned that it is important to be punctual	80.5
28.	The activities are useful in my everyday life	76.6
33.	I have a place that I feel is mine at the centre	66.7

n = 218. Items not meeting an acceptable quality level of 80% agree/totally agree are underscored.

Sorted by dimension and percentage agree:

^a agree (score 3) and totally agree (score 4) combined.

Agree/disagree

Further analysis was then performed on the item level. As shown in Table 3, 25 of the 35 statements in the QPC-DA were agreed upon by 80% or more of the attendees. Most of the attendees agreed to the item ‘The staff treated me with respect’ followed by ‘Staff treated me with kindness’ and ‘It is fun to go to the centre’. Among the 10 statements agreed upon by less than 80% of the attendees, the least agreed on statements were ‘I learn to recognize signs of deteriorating mental health’, ‘I have a place that I feel is mine’, followed by ‘I learn about my psychiatric disabilities’.

Quality in relation to type of daily activity

In relation to daily activity types, regression analyses showed that people participating in social activities rated the given support higher than those participating in any of the other three daily activity categories (β = .17, p = .013). Regression analysis at the item level showed that social activity compared to the other three daily activity categories had higher quality in regard to ‘having influence over the activities performed’ (β = .15, p = .030) but less in regard to ‘learning about my psychiatric disabilities’ (β = −.14, p = .038), both in the Participation dimension. Moreover, social activities had higher quality ratings in regard to ‘staff care about how I perceive the daily activities’ (β = .16, p = .015) in the Encounter dimension. In regard to the Support dimension, ‘staff help to understand that it is not shameful to have suffered from mental disorders, that guilt and shame should never be a hindrance to go to the day centre’ and ‘staff help to understand that guilt and shame should never be a hindrance from seeking care’ were rated higher by those in social activities than in the other three activity categories (β = .20, p = .004, β = .17, p = .013, and β = .14, p = .043, respectively). Finally, the only other association with type of activity was found for the property maintenance activity category where attendees perceived less of ‘I am not disturbed by the other clients’ in the Secure environment than attendees in the other activity categories (β = −.14, p = .041).

Discussion

The study aimed to describe and investigate the quality of community-based day centres services for people with psychiatric disability. The attendees generally perceived the quality of service as high based on an acceptable quality level of 80% endorsed items and underscored by the fact that four of five were willing to recommend the daily centre.

QPC dimensions

The quality of Encounter was rated highest among the six dimensions. This is in line with results from previous studies performed in other psychiatric contexts such as inpatient care [14] and outpatient care [15]. The most endorsed items were in Encounter: ‘The staff treated me with respect’ and ‘Staff treated me with kindness’.

Support was rated somewhat lower than encounter, but still at a high level; all items were endorsed by more than 80% of the attendees, which is in line with day centres’ supportive role and provision of structure, routines and a shelter from the experienced stress in society [29].

Quality of DA specific was perceived at a high level despite relatively few experiencing the activities at the day centre as being useful in their everyday life. This was somewhat surprising given that opportunities for learning various skills are among the most important aspects of daily activities [30], however, it could be considered reasonable as day centre activities can generally include routine occupations and thus experienced as stagnating and lacking a challenge [29].

The perceived level of Secure Environment at the day centres was high, while a number experienced ‘being disturbed by the other attendees’. It is not possible to choose one’s fellow attendees, these can vary from day to day and one may not get along with everyone there. Indeed, attendees reported stopping visiting day centres because they did not feel comfortable with some of the attendees [29].

Participation was the second lowest rated quality dimension, and not significantly different from Secluded Environment. Participation is an important aspect of rehabilitation [31] and a hallmark of daily activity service in Sweden [32]. Participation is, however, among the lowest rated quality dimensions across different psychiatric contexts such as psychiatric in-patient care [14], psychiatric out-patient care [15], psychiatric forensic in-patient care [17,19], and housing support services [23,24]. Given the importance of participation on the recovery process, it is remarkable that it is generally perceived at a low level.

Interestingly, Kjellberg et al. [33] found that occupational therapists working within the mental health area (the majority of whom worked with daily activities) perceived that the primary barriers for participation were the clients’ lack of knowledge and inability to participate, thus locating the barriers outside themselves. This stands in contrast to the present study where attendees had low ratings on ‘I received information in an understandable way’, ‘My previous experiences of what activities I can perform are optimally utilized’ and ‘I have influence over the activities I perform’. Given that one of the roles of occupational therapists is to support client involvement at levels that are appropriate and comfortable for them, the present results suggest that occupational therapists should consider whether greater efforts are needed in supporting and educating day centre attendees in different compensatory strategies in order to increase their ability to participate. This is further underscored by the present study where ‘I learn to recognize signs of deteriorating mental health’ and ‘I learn about my psychiatric disabilities’ were among the least endorsed items. Although more than two thirds of the attendees knew their diagnosis, this result may indicate that attendees’ need to learn more about their mental illness, which is in line with previous research showing that day centre support often does not correspond to the attendees’ needs [34]. On the other hand, the results illustrate the problem concerning what day centres should focus on, as in the case of secluded environment above, and whether the remit to provide meaningful activities should also include teaching about mental illness. Information and this type of teaching is mandatory in psychiatric in- and out-patient care, the present results suggest that attendees would also benefit from education directed at encouragement of mental health and wellness at day centres. The results show that only one-third of the attendees have contact with an outpatient clinic more than once a month, thus indicating that cooperation between different healthcare service providers would be beneficial for people with psychiatric disabilities. Further studies are, however, needed to shed light on this.

It is notable that Encounter is rated as the dimension with the highest quality and Participation as one with the lowest quality. When staff and clients work together and strive for mutual agreement, they both achieve higher levels of satisfaction with the treatment encounter [35]. This reciprocal exchange of information is seen as vital for the decision-making process that actively involves the client. In the study by Kjellberg et al. [33], about 70% of the clients’ decision processes were jointly and collaboratively performed with the occupational therapists. Clients tend to be more satisfied with such exchanges and take more responsibility for and adhere better to treatment choices that are made jointly. It can thus be hypothesized that high quality of encounter and participation is necessary for recovery; however, further research is warranted to detect the reason for this encounter-participation discrepancy.

The quality of Secluded Environment was rated lowest among the dimensions. The relatively low ratings and large number of disagree scores indicate that the attendees were in need of a place for privacy or to retire to when needing a break. This result is somewhat in contrast to the goal of community-based day centre services in Sweden, which is to satisfy social needs for people with psychiatric disabilities; not to provide privacy and stillness [36]. The result is, however, in keeping with previous findings indicating an ambivalent attitude to social interaction and attendees’ need for withdrawal and the use of the day centre as a sheltered environment [29]. It has been argued that a place for privacy could create space for self-reflexion and a distance from everyday concerns and be part of the recovery process [37]. This is in line with the results of the present study on mental and physical health where both were positively related with ‘having a place that I feel is mine’. Attendees thus express a desire for a better balance between social stimulation and withdrawal during their stay at the day centre. In terms of occupational balance, one could understand this desire as finding the right type and amount of occupation and the right variation between occupations [38]. What is the right type, amount and variation, may vary across time and attendees’ health status, and should be taken into account when planning community-based daily activities [39].

Quality of service in relation to sociodemographic variables

There were some significant relationships between the assessed sociodemographic variables and quality of service dimensions. Attendees with higher education levels perceived a lower quality of the daily activity service than those with lower education level. This is in line with previous research [11,22,40] and it is hypothesized that people with more education also have greater demands on the given service [41], thus possibly having greater expectations for the quality of daily activities service and, if not fulfilled, have lower quality ratings.

A majority of the attendees had been at the current day centre for more than a year and less than 10% had waited more than three months (the recommended maximum waiting time), it is therefore somewhat surprising that waiting time and perceived waiting time still influenced the attendees’ perceived day centre quality. Waiting time variables are possibly markers for some other, confounding variable. However, additional follow-up tests showed no significant relationship with any of the demographic variables.

Approximately the same number of attendees was in work training activities as in meeting activities and there was no difference in perceived quality between these two common types of day centre services. The type and form of activities thus seems to have minor influence on perceived quality and instead individual engagement and a spirit of togetherness and getting empowered in activities may have mattered [7].

About half of the attendees perceived their mental and physical health as good or very good, respectively, and the higher the perceived quality of service, the better was the perceived health. This is consistent with previous findings in psychiatric care showing that improved quality of care lead to better health outcome [42]. However, the present study is cross-sectional and we cannot determine whether high quality leads to improved health among the attendee’s or whether better health influences the perception of day centre service quality. Future studies may shed light on to what extent improved quality of day centre service may influence attendees’ mental and physical health.

A majority of the respondents knew who the responsible head of centre was and where to complain and they also perceived the quality of the centre as higher than those not having this information. Consistent with other findings in the present study, information seems to play an important role on various structural levels: on the intrapersonal level between staff and attendees in terms of mental illness education and on the organizational level in terms of information in terms of knowing who the responsible head is and where to complain. Interestingly, these results are consistent with findings in other psychiatric services such as outpatient care [16], forensic psychiatry [17], and housing support [24]. This phenomenon appears to be of a general nature applicable to the various contexts where people with psychiatric disabilities attend, thus signifying the importance of adapting the information to the individual [43].

Limitations

The response rate was about 66%, which is comparable with that of other similar samples and therefore deemed acceptable given the problem people with psychiatric disability may have when answering questionnaires. It can be argued that attendees with lower perceived mental health would have more trouble answering the questionnaires resulting in more missing data. There were, however, no significant correlations between the number of missing data and self-reported mental health among the attendees in the study. It is still possible that the most vulnerable attendees chose not to participate in the study, which may limit the generalisability of the result in regard to the most vulnerable attendees.

The inclusion of a relatively large sample of participants from several day centres across central Sweden was performed to capture the heterogeneity of day centres and attendees with psychiatric impairments. However, the survey relied on centres to volunteer their participation, which may have biased the study towards centres having an interest in quality improvement and thus assigning staff to administer the data collection.

Conclusions

The study shows that people with psychiatric disabilities perceived the quality of community-based day centre services as high. However, particular aspects of secluded environment and participation (information) may be areas with potential of improvement. From an occupational science perspective, the results adhere to the importance of occupational balance, with periods of rest/privacy during the time at the centre.

Acknowledgements

We thank NSPH (National Partnership for Mental Health) for support.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Funding

We thank NSPH (National Partnership for Mental Health) for support.