The pilot program was held from April 2017 to December 2018 at the Taipei Veterans General Hospital Yuli Branch (TVGH-YL). The hospital provides treatment and community care for patients with mental illness who reside in the rural area of eastern Taiwan. The TVGH-YL administers a half-way house, a community rehabilitation center, and a supported housing program. The hospital also provides sheltered and supported employment as part of its community care services for persons with mental illness . In one month before the program of Phase I or II, we recruited the participants by presenting posters on bulletin boards in the half-way house and community rehabilitation center. We invited participants who had cared for elderly persons in the past to join the training curriculum in the Phase I program, because these persons were peer support worker candidates for sharing work experiences from the Phase II program.
The inclusion criteria for both phases of the program were: (i) having disability certification with diagnoses of schizophrenia in the social welfare system, or catastrophic illness of schizophrenia in the health insurance system, (ii) living in half-way houses or receiving services from the supported housing program, (iii) participating in a sheltered or supported employment program, and (iv) showing interest in the job of care attendant. The exclusion criteria were: (i) comorbidity of severe physical illnesses which could lead to hospitalization, (ii) acute exacerbation of psychosis, and (iii) a reading ability below the age of 6 years. For Phase I, there was one additional inclusion criterion which required experience of caring for elderly persons in the community for at least 1 year.
Training for peer support workers
Initially, there were seven professionals who had at least five years of experience in community facilities discussing the framework and content of the training curriculum for peer support workers in the focus groups. These seven professionals specializing in 6 medical disciplines were also the teachers in the curriculum. Table 2 details the themes of curriculum at various intervention levels. At the end of each lecture session, there were four questions proposed by the teacher to examine the trainees with respect to the core concepts of the class. In the practice session, the performance of trainees was examined by case discussion or practice in role playing or simulated situations. There was no final examination in the Phase I program. However, the trainee was required to pass all classes with the assent of the teachers. If the trainee needed to improve knowledge or skills, he or she was allotted personal time with the teacher to receive more help.
The extended vocational rehabilitation services co-led & assisted by peer support workers
The program in Phase II was held twice in August of 2017 and June of 2018. Based on the needs of elderly persons with disabilities or dementia in local communities, the 2 occupational therapists organized the extended work training course, which focused on improvement of care skills of Phase II program participants (service users). The 2 occupational therapists also held workplace problem-solving groups once every 2 weeks for service users. The above interventions were originally part of supported employment service in the community rehabilitation center, but the participation rate was not previously satisfactory. Therefore, we integrated the peer support service into this service system. Before each training session, peer support workers discussed with 2 occupational therapists ("stakeholders") to decide on the content and process of the session. Peer support workers’ involvement should account for at least 50% of the session time to ensure intensity of support. The supervisor (KYC) had weekly discussions with the occupational therapist and monthly discussions with the peer support worker based on feedback in satisfaction questionnaires from service users and the group records. Four instances of observation by the supervision were also arranged to audit the performance of the occupational therapist and peer support workers in all the sessions of the Phase II program. More specifics on this phase of the program can be found in Table 1.
We used the Social Support Scale (SSS)—initially designed by Liu and later modified by Sung and Yeh —to measure the social support received by service users. The Kaiser–Meyer–Olkin (KMO) value of 0.82 and the Bartlett test of sphericity (BT) of 815.37 (P< 0.001) in factor analysis confirm the construct validity of the scale. Internal consistency is also confirmed by the Cronbach’s α of 0.86 . Three dimensions of social support were measured: relatives or family (SSS-R), staff or professionals (SSS-S), and friends or peers (SSS-F). There are 12 5-point questions for each dimension, with a possible total score ranging from 12 to 60.
Mental health and psychiatric symptoms
The Chinese Health Questionnaire-12 (CHQ-12) was employed to measure the mental health of service users. The value of the area under the Relative Operating Characteristic curve is 0.85, and the cutoff value is 3/4 . The sensitivity of the questionnaire is 78%, and the specificity, 77% . The lower the score, the better the mental health.
We also measured the psychiatric symptoms of the service users by using the Brief Psychiatric Rating Scale-18 (BPRS-18). According to Bell et al., the α values which measure internal consistency for positive, negative, and general symptoms in the BPRS are 0.69, 0.68, and 0.46, respectively, which are deemed satisfactory to acceptable . The interrater reliability (r= 0.87) is also deemed satisfactory .
We measured the social functions of service users objectively by using the Global Assessment of Functioning (GAF) and subjectively by using the Chinese version of the Social Functioning Scale (C-SFS). Jones et al. reported a reliability coefficient of 0.72 and a significant negative association between the GAF score and patients’ medication/support needs .
The Chinese version of the Social Functioning Scale (C-SFS) was adapted by Song  from the Social Functioning Scale (SFS) developed by Birchwood et al., by factoring in distinct cultural characteristics in Taiwan. The internal consistencies are deemed acceptable to good, with a Cronbach’s α value of 0.86 for the scale as a whole and Cronbach’s α values ranging from 0.48 to 0.88 for the subscales . The higher the score, the better the social function.
Earned income from employment
Service users' weekly wages from sheltered or supported employment were collected from users' records on file for the 3 months before and after the intervention of vocational rehabilitation. The weekly income and working hours on average during the 3 months was used as the measure of occupational outcome.
Process of assessment
The pre- and post-intervention self-report questionnaires were completed with assistance from the occupational therapist (MPK). The BPRS-18 and GAF scales were measured by a board psychiatrist (KYC) who had experience in the multiple-center clinical trial. The assistant and investigator both belonged to the intervention group, because there was no control group or blind procedure in the study design.
As all indicators examined in this study were continuous variables, we used the paired t-test to compare the measurements before and after the intervention. IBM SPSS Statistics 16.0 was employed for statistical analysis.