Understanding the social inclusion needs of people living in mental health supported accommodation

Abstract

Objectives

To identify the social inclusion needs that were (i) most commonly identified and (ii) most and least commonly prioritised as support planning goals for mental health service users living in supported accommodation, using the online Social Inclusion Questionnaire User Experience (SInQUE). We qualitatively examined mental health supported accommodation staff and servicer users’ views on barriers to offering support with two less commonly prioritised areas: help finding a partner and feeling less lonely.

Methods

Anonymous SInQUE data were collected during a completed study in which we developed and tested the online SInQUE. Four focus groups were conducted with mental health supported accommodation staff (N = 2) and service users (N = 2).

Results

The most common social inclusion needs identified by service users (N = 31) were leisure activities, finding transport options, and feeling less lonely. Of the needs identified, those that service users and staff least frequently prioritised as support planning goals were having company at mealtimes, getting one’s own furniture, feeling less lonely, help with finances, and help finding a partner. In the focus groups, staff and service users identified barriers to helping with loneliness and finding a partner which related to staff and service users themselves, supported accommodation services, and wider societal factors.

Introduction

Social exclusion occurs when an individual does not participate in the key activities of the society where they live as they would like to, for reasons beyond their control [1,2,3]. It has been conceptualised as encompassing five relevant domains: productivity, consumption, access to services, social integration, and political engagement [4]. Social inclusion affects many important aspects of someone’s life, including health, housing, employment, leisure activities, intimate relationships, and sense of community belonging [5].

People with serious mental health problems are among the most socially excluded in society [6]. Specifically, individuals living in mental health supported accommodation, which provides community-based support to people with particularly complex mental health problems [7], are often socially excluded [8]. They frequently report feelings of loneliness, low levels of employment, and a lack of intimate relationships [9, 10]. Among those with serious mental illnesses, social inclusion is associated with better quality of life, while social exclusion is associated with poorer mental health outcomes [11, 12]. However, people with serious mental illness often report that they do not get as much support as they would like with social inclusion, and specifically social relationships [13].

The SInQUE is a measure to assess social inclusion in people with severe mental illness [14]. It has been validated across different mental health populations, has established reliability, and is acceptable to service users [4, 11]. In a recent study, the measure was adapted and developed as an online tool to inform support planning for people living in mental health supported accommodation [15]. An online SInQUE assessment is completed by staff and service users collaboratively using a computer, tablet, or other hand-held device. It produces a list of the aspects of social inclusion that the person has said they would like more support with, and up to three of these can be selected for integration into their support plan. The online SInQUE has been deemed acceptable, user-friendly, cross-culturally appropriate, and potentially useful by supported accommodation staff and service users [15].

In the current paper, we examine the areas of social inclusion that were most commonly identified and which of these were least frequently prioritised as support planning goals by staff and service users who used the SInQUE during its development [15]. We also report staff and service users’ views, elicited from focus groups, on barriers to meeting identified social inclusion needs relating to social relationships. This paper reports findings from the completed ’SUSHI’ study (approved by the London Camden and Kings Cross Research Ethics Committee, reference: 21/LO/0657).

Aims

We used data from SInQUE assessments completed by staff and service users of mental health supported accommodation services in one inner London borough to explore:

• 1. Which aspects of social inclusion were most commonly identified by service users as areas where they would like more support?

• 2. Which of these identified needs were most and least frequently selected by staff and service users as priorities for support planning?

We also report findings from four focus groups, two of which were conducted with mental health supported accommodation staff (N = 11) and two with service users (N = 7), which explored perceived barriers to offering support with finding a partner and feeling less lonely – two needs that were infrequently prioritised for support planning.

Methods

SInQUE data

The online SInQUE [16] was made available for use in mental health supported accommodation services across one inner-London borough, along with an implementation strategy to encourage its use. A full description of the online SInQUE and the implementation strategy employed are reported elsewhere [15].

The online SInQUE randomly generates a unique identification number for each service user using the tool, so the identity of service users who have completed an assessment is not known. Anonymous responses were collected from those using the online SInQUE from the beginning of the implementation period, starting on the 11th of May 2022. Assessment responses up until the end of the study on the 30th of November 2022 were collated to identify the areas of social inclusion that participating supported accommodation service users across the borough most frequently wanted help with, and those that service users and staff most frequently prioritised as support planning goals.

Focus groups

We recruited both staff and service users who had and who had not used the online SInQUE for the four focus groups. The topic guide was informed by the collated responses from the online SInQUE. Questions related to aspects of social inclusion that were most frequently chosen as support planning priorities, and asked about potential barriers to support with areas of unmet need identified by the tool (for topic guide see Additional file 1).

We recruited staff participants through direct emails and phone calls. Two supported accommodation managers helped recruit participants for the service user focus groups by distributing the study information to individuals living in their respective services and then sending the contact details of those interested to the study team.

One staff focus group was entirely face-to-face, while one was a hybrid face-to-face and online meeting, via Microsoft Teams. Face-to-face meetings took place in the local mental health community rehabilitation team base. Both service user focus groups were face-to-face and took place onsite in each respective supported accommodation service. The study researcher discussed the information sheet with all participants at the start of each focus group, offering the opportunity for questions. Informed consent was collected with paper consent forms (audio recorded consent was collected for participants joining via video call). Focus groups were recorded using a digital voice recorder and audio recordings were transcribed by a professional transcription company. Service user participants were offered a £20 shopping voucher to thank them for their time.

For this report, our analysis focused on exploring experiences and perceived barriers to support with finding a partner and feeling less lonely – two areas of need which were rarely selected as targets for support. We used a deductive framework approach to analyse the focus groups, categorising findings based on whether they related to service users, staff, supported accommodation services, or wider society. These headings formed four primary themes, under which we inductively derived subthemes using thematic analysis. BLE developed the deductive analytic framework, and thematic coding was conducted by SE.

Results

SInQUE data

Of the 28 areas of life where all SInQUE respondents are asked if they would like to be more included, the participating service users said they would like to be more included for a median of 9 items. Table 1 shows the areas that service users most commonly selected as needs for greater inclusion (identified needs), and of these, the areas that staff and service users together most frequently selected as goals for support (addressed needs). Of the needs identified by at least 10 respondents, those most frequently addressed were going to a café or pub (70%) and leisure activities (58%). Five areas of need identified by at least 10 people were addressed for less than 20% of respondents: having company at mealtimes, getting one’s own furniture, feeling less lonely, help with finances, and help finding a partner.

Table 1 Social inclusion needs of mental health supported accommodation service users (N = 31)

Focus groups

In total, eleven staff members participated; seven took part in the first focus group and four took part in the second. Seven service users participated overall; three joined the first focus group and four joined the second. Participant characteristics are summarised in Table 2.

Table 2 Demographic characteristics of staff and service user focus group participants

Focus group respondents concurred that social relationships, specifically help with loneliness and finding a partner, were important needs. They identified a range of barriers to providing support to meet these needs, relating to staff and service users themselves, and wider service and societal factors. These are summarised in Table 3, with an illustrative quotation for each sub-theme generated through our analysis.

Table 3 Perceived barriers to supporting service users with developing relationships and loneliness

When discussing ways to help with personal relationships and loneliness, staff and service users acknowledged the complexity in discussing and addressing these issues. Both groups suggested confidence building as a potentially helpful approach for those seeking personal relationships. Service users also expressed a wish for increased opportunities for social activities, both within and outside their service. Some expressed a preference for such activities to take place in a different environment to where they live, though noted that they should remain local to the service to ensure accessibility.

Findings in context

These findings are in line with previous research suggesting that mental health service users often receive less help than they would like with social relationships [13]. It also corroborates previous research from the Netherlands identifying intimate relationships as a consistent area of unmet need across supported housing [9] and international literature highlighting loneliness and social isolation as a priorities among mental supported accommodation service users [10].

The barriers for staff offering support to service users in developing relationships and loneliness can be usefully understood in line with the capability-opportunity-motivation-behaviour (COM-B) framework of behaviour change [17]. This COM-B model offers a useful lens through which to consider perceived barriers to supporting service users with developing relationships and loneliness in mental health supported accommodation. Our focus group findings suggest barriers relate to all three elements of the COM-B framework: (i) capability (e.g. staff concerns about giving service users bad advice about relationships); (ii) motivation (e.g. staff feeling this is not a core part of their job and doubting whether service users would appreciate being asked about personal relationships); and (iii) opportunity (e.g. staffing levels and available funds limiting the help they can offer with social relationships).

Implications

The current study highlights potentially important unmet needs for service users living in mental health supported accommodation. It also raises a possible need for staff training on navigating the personal relationship goals of the service users they support. The potential value of offering staff clarity on the remit of their role as it relates to service users’ personal relationships is also demonstrated. Future research should aim to implement the online SInQUE with a larger sample of mental health supported accommodation services from diverse areas to obtain more generalisable and representative data on needs for social inclusion in these services.

Future research should also investigate staff and service user perspectives on the types of support that are feasible and acceptable relating to social inclusion needs in mental health supported accommodation, and how this support can be integrated into services. In particular, research should examine staff and service user perspectives on how best to help with social relationships. More insight is needed to understand the help that service users want in relation to loneliness and help finding a partner, whether any such support is currently being provided, and if so, what this support is, and a more in-depth exploration of what the perceived barriers are in providing support with these areas. These topics should be explored throughout a wide range of mental health care settings, to assess whether this issue extends across the mental health care system.

Limitations

This study has a number of limitations. The data collected from the online SInQUE was from a small sample, from mental health supported accommodation services within a single inner-London borough. As such, findings cannot be generalised to represent the social inclusion needs of people from different social circumstances. Due to the anonymity of the responses collected using the online SInQUE, we were unable to collect demographic information of the service users who completed an online SInQUE assessment. Therefore, results may not be representative of a wide range of people and may not be generalisable to other regions. This may also be true for the focus groups, participants of which were from the same inner-London borough. Furthermore, the service user focus groups involved participants from only two supported accommodation services, and did not include service users from floating support or residential care facilities. Thus, views expressed in these discussions may not reflect views of service users from other supported accommodation services or service types.

It is unclear whether the areas of need identified by the SInQUE that were not prioritised for support planning were not chosen because they were considered less important to service users, or because they were more difficult for staff to offer support with. The focus group discussions and analysis also predominantly focused on unmet needs relating to loneliness and help finding a partner; however, these are only two of multiple areas that were infrequently chosen as support planning priorities by staff and service users.