Year : 2021  |  Volume : 63  |  Issue : 1  |  Page : 15--27

Development and validation of Vellore Inventory of Life Skills among people with severe mental illness


Meghana C Chandran1, Febin Saji2, Reema Samuel1, KS Jacob1,  
1 Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, Tamil Nadu, India

Correspondence Address:
Reema Samuel
Occupational Therapy Education and Services, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu
India

Abstract

Background and Aim: Rehabilitation for people with severe mental illness is incomplete without life skills assessment and intervention. The aim of the study was develop a culturally specific performance-based measure assessing life skills of patients with severe mental illness. Materials and Methods: The items for the Vellore Inventory of Life Skills (VILS) were drawn after consultation with a reference group and from existing standardized scales. The items were categorized into two sections with six components each, which was further hierarchically arranged into activities at either basic, intermediate, or advanced level. One hundred consecutive clients between 18 and 60 years of age who provided written informed consent were assessed on the Comprehensive Evaluation of Basic Living Skills (CEBLS) and the VILS to evaluate convergent validity and inter-rater reliability. The General Health Questionnaire (GHQ-12) was used to evaluate divergent validity. The assessments were repeated after a week to evaluate test–retest reliability. Results: The scale had good inter-rater reliability 0.938 (95% confidence interval [CI] 0.887–0.967) and test–retest reliability 0.907 (95% CI 0.865–0.937). The correlation between total score of VILS and CEBLS (Pearson's correlation coefficient [PCC] = 0.611; P = 0.001) suggested moderate convergent validity. The correlation between total score of VILS and GHQ-12 (PCC = −0.260; P = 0.105) implied good divergent validity. Conclusion: Preliminary data suggest that the VILS is clinically useful for the Indian population.



How to cite this article:
Chandran MC, Saji F, Samuel R, Jacob K S. Development and validation of Vellore Inventory of Life Skills among people with severe mental illness.Indian J Psychiatry 2021;63:15-27


How to cite this URL:
Chandran MC, Saji F, Samuel R, Jacob K S. Development and validation of Vellore Inventory of Life Skills among people with severe mental illness. Indian J Psychiatry [serial online] 2021 [cited 2021 Mar 6 ];63:15-27
Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/1/15/309496


Full Text



 Introduction



Life skills, otherwise called as activities of daily living (ADLs), have been defined by the World Health Organization as abilities for adaptive positive behavior that enable us to deal effectively with the demands and the challenges of everyday life.[1] Life skills include basic ADL (BADLs), routine everyday activities like bathing, dressing, feeding, personal hygiene, grooming, and toilet hygiene. They also include instrumental ADL (IADLs), which are the more complex ADLs necessary for living in the community, including competence in skills such as shopping, cooking, and managing finances. They are essential for developing psychosocial, emotional, cognitive, behavioral, and resilience skills to negotiate everyday challenges and productive involvement in the community.[1] Impairments in adaptive life skills are a major source of disability in patients with chronic mental illnesses.[2] Interventions targeting optimal independent functioning have been found to be essential for re-integration of persons with mental illness.[3] Failure to focus on independent living skills is also thought to increase family burden and economic disadvantage.[4]

While assessing everyday performance, it is important to differentiate between what a person is able to do (functional capacity) and what he actually does (real-world performance), called as the competence/performance distinction.[5],[6] Among the assessment methods available for measuring functional capacity, performance-based measures are more predictive of real-world outcomes than self-report instruments and direct observation of behavior.[7] The University of California San Diego Performance-Based Skills Assessment (UPSA) is a widely used scale, assessing performance in five domains of independent community living skills-household chores, communication, finance, transportation, and planning recreational activities.[8] However, since the tasks in a performance-based measure vary according to the cultural context, and since everyday self-care activities are also essential for independent living, there is a need to tailor these assessments to meet local standards. For example, the use of spoons, forks, and knife by other populations cannot be compared with rural Indian population as hands are preferred for eating. The materials, procedures, and cuisines related to meal preparation vary significantly even within India. The use of electrical appliances in home management tasks like iron box, food processor, washing machine, and dishwasher is not as prevalent in rural populations as compared to manual hand techniques.

Despite evidence supporting the importance of assessment and training in life skills for people with mental illness, research in this area has been minimal in India and is a need of the hour.[9] A recent meta-analysis also documents the lack of good evidence for the effectiveness of life skill programs and emphasizes the need for more robust studies.[10] The Vellore Inventory of Life Skills (VILS) was thus developed to address the dearth of a culturally relevant performance-based measure to assess the life skills of persons with severe mental illness in low- and middle-income countries (LMIC).

 Materials and Methods



Study setting

The study was conducted in the department of psychiatry of a 122-bedded tertiary referral center with an average daily footfall of around 500 outpatients. The treatment team consisting of psychiatrists, occupational therapists, psychiatric nurses, clinical psychologists, and psychiatric social workers employs a multidisciplinary approach in treating adults and children with mental and behavioral disorders. The center runs an inpatient occupational therapy program with a focus on improving various domains of life skills and occupational functioning. This inventory was developed specifically to aid in the assessment and thereafter goal setting for improving the life skills of inpatients undergoing the training program at the unit.

The study design and inventory construction was conceptualized by RS and KSJ, who aided by an expert committee of occupational therapists, reviewed current literature and provided input on items and scoring. It was found that there were no performance-based measures for daily living skills adapted for developing countries like India. Furthermore, most scales assessed either BADLs or IADLs, although developmentally, basic self-help skills act as precursors to advanced living skills, and both need to be essentially focused on in life skills training. Hence, focusing on a performance-based measure which assesses both BADLs and IADLs was thought to be more resource optimizing and reliable.

Construction of the inventory

Review of instruments

The contents, items, scoring, and interpretation of the following scales were reviewed during the search of literature: (1) Kohlman Evaluation of Living Skills,[11] (2) Life Skills Profile,[12] (3) Milwaukee Evaluation of Daily Living Skills,[13] (4) Lawton IADL Scale,[14] (5) Independent Living Skills Survey,[15] and (6) Comprehensive Evaluation of Basic Living Skills (CEBLS).[16]

Item collection and categorization

Each scale and their items were examined and the inventory was categorized into two domains, namely BADL and IADL, each with six components. Since the skills are multidimensional, the items were not distributed across a uniform scale but rather as an inventory of minimum skill levels achieved. Hence, each component was broken down into steps using task analysis and was hierarchically arranged into skills at either Basic, Intermediate, or Advanced level, keeping the self-help developmental milestones from childhood till adolescence as a reference. Thus, the final version of the VILS has six BADL components of (i) bathing, (ii) toilet hygiene, (iii) oral hygiene, (iv) dressing, (v) eating, (vi) grooming, and six IADL components of (i) financial management, (ii) food management, (iii) health management, (iv) community mobility (v) household management, and (vi) academic/vocational skills [Appendix 1].

Scoring

The scoring was prepared progressively from basic to advanced level, giving one score for each step that the person is able to perform at each level. For example, the component of bathing has four items each at the basic and intermediate level and three items at advanced level, adding up to a total possible score of 11. A person scoring from 1 to 4 will be considered to be at the basic level, 5 to 8 at the intermediate level, and 9 to 11 at the advanced level in bathing. Likewise, it would be possible to designate the current level of functioning of a person in each of the 12 components of the VILS. Subsequently, the goal of intervention would be to train the skills directly above the current functional level.

Study sample

The sample size calculation based on the guidelines for estimating sample size for intraclass correlation coefficient (ICC), for two observations, with a prespecified alpha value of 0.05, power of 0.9, and ICC value of 0.3 was 91.[17] Out of one hundred and ten consecutive inpatients recruited, ten assessments could not be completed due to unplanned discharge or emergence of psychotic symptoms; hence, data were collected till a sample size of 100 was reached. Patients with a diagnosis of schizophrenia or bipolar affective disorder attending the inpatient occupational therapy program at the department of psychiatry aged between 18 and 60 years of age and who gave written informed consent were included for the study. Clients with a clinical diagnosis of moderate to profound intellectual disability, those with organic mental disorders, and those with acute psychotic presentations were excluded from the study.

Assessment tools used

CEBLS:[16] This is a measure with seven domains of basic living skills, (i) meal planning (ii) telephone (iii) bus (iv) shopping (v) meal preparation (vi) serving and eating and (vii) meal cleanup. Each component is marked on a scale of 1–4 where 1 is “can't perform,” 2 is “requires much assistance,” 3 is “requires some assistance,” and 4 is “performs independently and correctly.” It has a maximum possible score of 232 across 58 items. This scale was chosen to evaluate convergent validity as the scale had domains similar to the IADL domains of VILS and was also the only one to include few BADL components alsoThe General Health Questionnaire (GHQ):[18] This is a measure of current mental health originally developed as a 60-item instrument; for the current study, the 12-item GHQ-12 was used. The GHQ-0011 scoring method was used, which yields a maximum possible score of 12. The GHQ-12 was used to evaluate divergent validity as the construct of psychological well-being is sufficiently dissimilar to that of independent living skillsBrief Psychiatric Rating Scale (BPRS):[19] The BPRS assesses psychiatric symptoms and consists of 18 items with scores ranging from 1 (not present) to 7 (extremely severe) and 0 for not assessed, with a maximum possible score of 126. The BPRS scores, which are routinely rated by the primary treating psychiatrist, were documentedVILS: The final version of the inventory has 12 domains, six each under BADLs and IADLs.

Procedure

The details of the study were explained to all participants, and written informed consent was obtained. The VILS was scored by two investigators (MCC and FS) independently and simultaneously for evaluating inter-rater reliability. The BADL items were scored during direct observation of performance in the patient's residential area. For the items of bathing and toilet hygiene, to respect patient privacy, investigators only observed preparations made for the activity and information was supplemented from caregiver report. The IADL items of food management, health management, and household management were also scored with direct observation in the patient's residential area. The items of community mobility and financial management were scored while taking the patient out to nearby shops/bank/ATM kiosk, accompanied by the caregiver. The component of academic/vocational skills was simulated in the therapy setting. The assessments were timed to coincide with the usual time patients routinely performed the ADLs and thus were not completed at a stretch. Overall, each assessment took around an hour to complete. A third investigator (RS) scored the participants on the CEBLS and GHQ-12 for evaluating convergent and divergent validity. The VILS was scored again by one investigator (MCC) after a week to evaluate test–retest reliability.

Data analysis

Summary statistics, mean and standard deviation, frequencies, and percentages were used for reporting demographic and clinical characteristics. The correlation of VILS with the CEBLS, BPRS, GHQ-12, and continuous sociodemographic variables was evaluated using the Pearson's correlation coefficient (PCC). Differences were considered significant at P < 0.05. The association between categorical sociodemographic variables and the VILS was measured using one-way ANOVA test. The initial assessment score of VILS administered by MCC was used for the correlation and association tests. Inter-rater and test–retest reliabilities were evaluated using the ICC with a 95% confidence interval (CI). All the statistical analyses were performed using SPSS 18.0 (SPSS Inc., Chicago, Ill., USA).

 Results



One hundred participants were recruited for the study. The majority of the participants were male, young adults, single, with undergraduate education, middle socioeconomic status, and currently employed. The sociodemographic characteristics of the sample are shown in [Table 1].{Table 1}

Validity

The CEBLS was used to measure convergent validity. The correlation between the total scores on the two scales was moderate (PCC = 0.611; P = 0.001), suggesting that these scales seem to assess similar constructs. The GHQ-12 scores, which is a measure of overall mental health, when correlated with the VILS, provided low correlation (PCC = −0.260; P = 0.105), suggesting divergent validity. The details of the correlations are shown in [Table 2].{Table 2}

Reliability

The test–retest and inter-rater reliability scores of all domains of the VILS have been documented in [Table 3]. Most individual domains of VILS as well as the total score recorded good inter-rater reliability; the domains of 'eating' and 'grooming' had moderate levels of reliability. Most individual domains of VILS as well as the total score also recorded good test-retest reliability; the domains of “bathing,” “oral hygiene,” “dressing,” “eating,” and “grooming” had moderate levels of reliability.{Table 3}

Extent of life skills deficit

In terms of BADLs, most of the study population was at the advanced level, with only one person at the basic level. However, in the domain of IADLs, most of the population was at the intermediate level, with more than half of them being at a basic level in the domain of “household management.” The details regarding the extent of life skills deficit can be found in [Table 4].{Table 4}

Correlation between psychopathology and life skills

The correlation between the total score of VILS and BPRS was not statistically significant (PCC = −0.175; P = 0.321). Domain wise correlation of the VILS with the BPRS scores also failed to yield statistically significant results. The details regarding the BPRS scores are shown in [Table 2].

Comparison between sociodemographic factors and domains of life skills

The group means differences for “educational status” was statistically significant for BADL domains of “bathing” (F = 4.882; P = 0.003), “toilet hygiene” (F = 4.742; P = 0.004), “dressing” (F = 2.995; P = 0.036), “eating” (F = 2.848; P = 0.042) and for almost all IADL domains of “financial management” (F = 10.252; P = 0.001), “food management” (F = 7.006; P = 0.001), “health management” (F = 6.669; P = 0.001), “household management” (F = 4.665; P = 0.004), and “academic/vocational skills” (F = 7.213; P = 0.001). The group mean differences for “community mobility” neared significance (F = 2.646; P = 0.053) and the total VILS score was also statistically significant (F = 9.354; P = 0.001) between the groups. There were statistically significant differences between group means for diagnosis and the IADL domains of “financial management” (F = 4.273; P = 0.041), “community mobility” (F = 9.914; P = 0.002), and “health management” (F = 4.047; P = 0.047). There were also statistically significant differences between group means of employment status and the domains of “eating” (F = 4.046; P = 0.005), “financial management” (F = 3.836; P = 0.006), “community mobility” (F = 3.121; P = 0.019), “academic/vocational skills” (F = 2.661; P = 0.037) as well as the total VILS score (F = 2.715; P = 0.034). In comparing group means of various types of occupation among the employed participants, there were statistically significant differences in the IADL domains of “financial management” (F = 2.924; P = 0.020), “health management” (F = 2.455; P = 0.044), “'academic/vocational skills” (F = 2.743; P = 0.027), and the total VILS score (F = 2.821; P = 0.024). With respect to group mean differences in socioeconomic status, the IADL domains of “health management” (F = 3.381; P = 0.038), “community mobility” (F = 4.037; P = 0.021), and “academic/vocational skills” (F = 6.208; P = 0.003) were statistically significant. The IADL domains of “food management” (F = 5.876; P = 0.017) and “household management” (F = 8.200; P = 0.005) had statistically significant differences in group means when compared with gender.

When correlated with duration of illness, there were statistically significant results in the IADL domains of “financial management” (PCC = −0.206; P = 0.040) and “community mobility” (PCC = −0.200; P = 0.046) but not in the total score of VILS. Other than the BADL domain of “eating” (PCC = −0.239; P = 0.017), there was no statistically significant correlation between the various domains of VILS and age of participants. There was no statistically significant difference between group means when the VILS domains were compared with the marital status of the participants.

 Discussion



The VILS had only moderate correlation with the CEBLS scores; this could be because the CEBLS assesses only seven domains, one in BADL and six in IADL, as opposed to six BADL and IADL domains each of the VILS. Since the VILS was specifically formulated to comprise of domains not included in other assessments, this can be considered acceptable. The test–retest reliability of most of the BADL domains was lower than that of the IADL domains. The reason for the lower levels of reliability scores could be that the assessments were spaced a week apart; however, training on BADLs is initiated immediately after admission to the setting. The change in scores could be attributed to improvement in skills as a result of intervention. The BADL performance among the population was better than the IADL performance, which can be representative of the increased complexity of IADLs as compared to the BADL skills. The lack of correlation between the VILS and BPRS scores can imply that life skills dysfunction can be present irrespective of the severity of illness; this finding is similar to a previous study done at the same center.[3]

Many IADL domains also seem to have significant group differences when compared with sociodemographic variables of educational status, employment status, type of occupation, socioeconomic status, and gender. Longitudinal follow-up studies and interventional studies are warranted to understand the directionality of these associations.

The VILS addresses two pertinent issues related to the assessment of life skills in LMIC. The direct, performance-based nature of assessment yields more reliable results than self- or proxy-rated checklists. The combining of BADLs and IADLs in one assessment ensures ease of goal setting and seamless progression in life skills training. Although the assessment is time consuming and can only be done in a residential/home setting; considering that the purpose of any functional training is the generalization of skills to real-life performance, assessing skills in such settings is justified. Since most of the assessment utilizes direct observation in the residential area, the person-specific context of skill performance is retained, thus making it feasible to be used across varying social and cultural backgrounds.

Limitations

The VILS is not feasible to be used in outpatient settings and its exhaustive nature precludes completion of the entire assessment at one stretch. It is also necessary to have key informants present during the assessment to complement the information given, which can be cumbersome in some healthcare settings. Since the VILS was developed with the aim of measuring progress in life skills as a result of intervention, longitudinal studies of repeated assessments will also have to be conducted. Recommendations for future would include evaluating the predictive validity of the VILS for employment/independent living and validation in the adolescent age group when life skills are developing.

 Conclusion



The VILS was developed to aid in baseline assessment and subsequent documentation of progress in facilities providing life skills training for persons with severe mental illness. Preliminary data suggest that VILS seems to meet this requirement. The findings would need to be reinforced with longitudinal data to evaluate change over time.

Financial support and sponsorship

This study was approved and funded by the Institutional Review and Ethics Board, Christian Medical College, Vellore (IRB Min. No. 11585). The funding source had no further involvement in the conduct of the research or preparation of the article.

Conflicts of interest

There are no conflicts of interest.

 Appendix



Appendix 1: Vellore Inventory of Life Skills

Instructions

To be scored by therapist after direct observation of performance in life situations. Simulation can be done only when the above is not possible.

Scoring

Scoring should be progressively done from basic to advanced level. A score of 1 can be given for each item that the person is able to do adequately at each level. Thus, maximum score possible for basic level of bathing is 4. If a person has scored maximum at the basic level, therapist can set the items at the intermediate level as goals of therapy, and so on.

Items

[INLINE:1]

Basic Activities of Daily Living

1. Bathing (Washing and drying one's whole body/body parts; obtaining and using water and appropriate cleaning/drying materials or methods; includes soaping, rinsing, and drying body parts adequately)

Items required: Bucket, soap, towel, mug

Basic

Can cooperate when being bathedCan assist in pouring water, applying soapCan identify materials used like soap, towel, mugCan perform one step actions (e.g., pour water) with physical or verbal prompts.

Intermediate

Can collect items required for bathing by selfCan perform multiple steps (take mug, pour water, apply soap) with supervisionCan understand safety precautions required (e.g., guard against falls)Can ensure adequate hygiene during bathing.

Advanced

Can do all steps without supervisionCan problem solve adequately, e.g., what to do if water runs outCan make competent decisions on time, duration and frequency of bathing.

2. Toilet hygiene (Planning and carrying out the elimination of human waste (menstruation, urination and defecation), and cleaning oneself afterwards; includes managing clothing, cleaning body, and caring for menstrual and continence needs)

Items required: Bucket, mug, towel, soap

Basic

Can indicate need for toiletingCan be continentCan identify appropriate place for toiletingCan exhibit regular bladder and bowel patternsCan assist in undressing/dressing related to toileting.

Intermediate

Can do toileting with verbal/physical promptsCan wash self adequately with verbal/physical promptsCan undress/dress self independentlyCan understand safety precautions required (e.g., guard against falls).

Advanced

Can do all steps of toileting including washing self without supervisionCan problem solve adequately, e.g., what to do if water runs outCan ensure privacy and safety while toileting.

3. Oral hygiene (Taking care of dental hygiene; includes cleaning mouth and brushing teeth)

Items required: Tooth brush, tooth paste, towel

Basic

Can cooperate with brushing, rinsing mouthCan identify materials like own brush, pasteCan perform one step actions (e.g., brush front teeth) with physical or verbal prompts.

Intermediate

Can collect items required for brushing by selfCan perform multiple steps (apply paste, rinse mouth) with supervisionCan ensure adequate hygiene during brushing with verbal/physical prompts.

Advanced

Can perform all steps hygienically without supervisionCan make decisions adequately, e.g., amount of tooth paste to be usedCan make competent decisions on time, duration and frequency of brushing.

4. Dressing (carrying out the coordinated actions and tasks of putting on and taking off clothes and footwear in sequence; in keeping with weather, occasion, time of day and social conditions; includes selecting clothing and accessories appropriately, obtaining clothing from storage area, dressing and undressing in a sequential fashion, fastening and adjusting clothing and shoes)

Items required: Clothes such as t-shirt, pants with zippers and shirts, churidar, sandals or shoes

Basic

Can cooperate/assist in dressing or undressingCan identify own clothes and place where they are storedCan perform simple steps with supervision, e.g., putting hands into sleeves.

Intermediate

Can perform multiple steps, e.g., pull t-shirt over head, and put hands into sleeves, with physical/verbal promptsCan choose clothes appropriate to situation and weatherCan ensure need for privacy while dressing or undressing.

Advanced

Can perform all steps in dressing/undressing independentlyCan use fasteners, zippers, girdles without assistanceCan make competent decisions on need for changing clothes.

5. Eating (Carrying out the coordinated tasks and actions of eating food that has been served, bringing it to the mouth and consuming it in culturally acceptable ways; includes cutting or breaking food into pieces, opening bottles and cans, using eating implements and having meals)

Items required: Plate, glass, spoon, regular food

Basic

Can indicate hunger and thirstCan identify foods consumed regularlyCan take food to mouth, chew and swallow with supervision.

Intermediate

Can take food to mouth, chew and swallow without supervisionCan consume food and water without spilling or chokingCan follow regular meal times and snack times.

Advanced

Can serve and consume a meal independentlyCan exhibit adequate table mannersCan discriminate food that is too hot/coldCan identify spoilt food.

6. Grooming (planning and carrying out the coordinated tasks of removing body hair, combing, caring for nails (hands and feet), caring for skin, ears, eyes, and nose, putting on make-up)

Items required: Comb, powder, soap, razor, deodorant

Basic

Can identify own comb, razor, etc.Can perform simple tasks e.g., combing, washing face after shaving, applying bindi, etc., with supervisionCan identify the need for grooming, e.g., when hair is untidy.

Intermediate

Can perform multiple steps, e.g., shaving beard, washing face, with verbal/physical promptsCan retrieve own items, identify need for replacementCan perform steps with adequate hygiene appropriateness to context.

Advanced

Can choose items needed for grooming independentlyCan replace items when necessaryCan perform activity in different ways, e. g. change hair style, make up, shape of beard, etc., as necessary.

Instrumental Activities of Daily Living

1. Financial management (Using fiscal resources, including alternate methods of financial transaction, in exchange for money, goods and services required for daily living; planning and using finances with long-term and short-term goals)

Items required: Coins, currency, packed grocery items, calculator, ATM card, bank forms, paper, pen, check book

Basic

Can understand values of coins and currencyCan make a complete cash transactionCan shop according to a given list of itemsCan understand the concept of MRPCan identify one way to save money on purchasesCan use a calculator to quantify purchasesCan understand difference between essentials and nonessentials.

Intermediate

Can use an ATM machine for cash withdrawalCan use a Debit/Credit card for transactionsCan open a savings or fixed deposit accountCan write checks/make withdrawals and make depositsCan make list of items needed for a weekCan understand the concept of insurance policies and saving plans.

Advanced

Can draw up a monthly budget planCan compare between various commodities on price, quality, etc.Can balance a check book and address discrepanciesCan understand tax and procedure for filing tax formsCan understand buying on EMI, loans, and related interest rates.

2. Food management (planning, organizing, cooking and serving nutritious meals for oneself and others; includes making a menu, selecting edible food and drink, getting together ingredients for preparing meals, cooking with heat and preparing cold foods and drinks, and serving the food and cleaning up food and utensils after meals)

Items required: Paper, pen, grocery list, regular food items, utensils

Basic

Can observe hygiene while washing and storing foodCan choose and order food in a restaurantCan understand foods that contribute to a balanced dietCan serve oneselfCan exhibit adequate table manners.

Intermediate

Can make a simple meal for oneCan use cooking utensils and appliances safelyCan prepare a grocery shopping list for a mealCan identify spoilt foodCan clean up adequately after a mealCan use a refrigerator.

Advanced

Can follow the instructions from a recipeCan adjust recipes according to needCan prepare and serve a meal for a few peopleCan plan a daily menu of three mealsCan do weekly grocery shopping.

3. Health management and maintenance (caring for oneself by being aware of the need and doing what is required to look after one's health, both to respond to risks to health and to prevent ill-health; includes seeking professional assistance; following medical and other health advice; and avoiding risks to health)

Items required: Basic medicines, First aid kit

Basic

Can identify own medicationCan understand that alcohol, tobacco and drugs are harmful to healthCan identify symptoms of common cold, fever, diarrhoea, etc.Can understand need for good diet, exercise and eating habits.

Intermediate

Can manage common cold, fever, diarrhoea, etc., with medicinesCan manage a minor cut or burn by selfCan take medication without supervisionCan understand how pregnancy occursCan understand the role of different health care workersCan dispose of medicines in a safe mannerCan use a First Aid Kit.

Advanced

Can take own temperature using a thermometerCan nurse self through cold or feverCan buy OTC medicines for pain, diarrhoea, fever, cold or allergyCan take an appointment for a doctorCan read a prescription label correctly and follow the instructionsCan understand methods of birth control and how to obtain birth control devices.

4. Community mobility (Planning and moving around in the community; using public or private transportation to move around as a passenger, such as being driven in a car or on a bus, rickshaw, taxi, train or aircraft)

Items required: Direction symbols, Map and Location on GPS app in phone

Basic

Can ride a bicycle safelyCan use seat belts/helmets on personal vehiclesCan use public transport like auto/bus/train with supervisionCan identify nearest public bus/train stationCan identify amount required for bus/train fare.

Intermediate

Can provide directions to home and nearby placesCan use public transport to familiar places without supervisionCan arrange for private transport to nearby placesCan fill fuel for private vehicleCan understand need for driving license/vehicle ownership forms.

Advanced

Can read a map and get locationCan use public transport with transfers or to unfamiliar placesCan do basic bike/car maintenanceCan organise car/bike insuranceCan understand RTO regulations.

5. Household management (managing and maintaining personal and household possessions and environment; includes cleaning the house by sweeping, mopping, washing counters, walls and other surfaces; collecting, washing, drying, folding and ironing clothes; using household appliances, storing food and disposing of garbage)

Items required: Bed linen, broom, mop, utensils

Basic

Can change bed linen and make a bedCan dispose of garbageCan use cup boards for storageCan sweep and dust floors and furnitureCan operate taps and electrical appliancesCan understand difference between rented and own accommodation.

Intermediate

Can wash and clean various rooms using appropriate cleaning productsCan clean refrigerator and stoveCan do routine house cleaning to maintain home and surroundings cleanCan arrange to get rid of household pestsCan understand rights and responsibilities with respect to neighbours.

Advanced

Can unclog sinks and toiletsCan change a fused bulb or reset circuit breakerCan do minor household repairsCan contact necessary personnel for major repairsCan measure furniture for upholstery.

6. Academic/Vocational skills (carrying out the tasks and actions required to engage in education, work and employment; seeking, finding and choosing employment, being hired and accepting employment, maintaining and advancing through a job, trade, occupation or profession, and leaving a job in an appropriate manner)

Items required: Model academic course/job application form, Model questions for mock interview

Basic

Can set realistic goals for academic plansCan understand the types of jobs available for respective qualificationCan exhibit adequate work habitsCan identify own responsibilities for studying/working.

Intermediate

Can enrol self in an academic courseCan understand the kind of jobs available after completion of the courseCan understand the financial resources necessary for completing a courseCan fill out a job application formCan search for jobs through advertisements in various mediaCan attend a mock interviewCan exhibit appropriate behaviour with colleagues and supervisorsCan understand concept of leaves, performance appraisal, salary, etc.

Advanced

Can apply and attend a job interviewCan apply to employment agencies and choose between jobsCan prepare own resumeCan understand legal rights and grievance redressal mechanisms related to job.

*Definition of ADLs and IADLs based on

World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001Occupational Therapy Practice Framework. Domain and Process 3rd ed.. Am J Occup Ther 2014; 68:S1-48.

*Items required are given only as examples; therapists are encouraged to modify items as per patient specific needs.

References

1World Health Organization. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001.
2Bowie CR, Reichenberg A, Patterson TL, Heaton RK, Harvey PD. Determinants of real-world functional performance in schizophrenia subjects: Correlations with cognition, functional capacity, and symptoms. Am J Psychiatry 2006;163:418-25.
3Samuel R, Thomas E, Jacob KS. Instrumental activities of daily living dysfunction among people with schizophrenia. Indian J Psychol Med 2018;40:134-8.
4Saha S, Chauhan A, Buch B, Makwana S, Vikar S, Kotwani P, et al. Psychosocial rehabilitation of people living with mental illness: Lessons learned from community-based psychiatric rehabilitation centres in Gujarat. J Family Med Prim Care 2020;9:892-7.
5Harvey PD, Velligan DI, Bellack AS. Performance-based measures of functional skills: Usefulness in clinical treatment studies. Schizophr Bull 2007;33:1138-48.
6Mantovani LM, Teixeira AL, Salgado JV. Functional capacity: A new framework for the assessment of everyday functioning in schizophrenia. Rev Bras Psiquiatr 2015;37:249-55.
7McIntosh BJ, Zhang XY, Kosten T, Tan SP, Xiu MH, Rakofsky J, et al. Performance-based assessment of functional skills in severe mental illness: Results of a large-scale study in China. J Psychiatr Res 2011;45:1089-94.
8Patterson TL, Goldman S, McKibbin CL, Hughs T, Jeste DV. UCSD performance-based skills assessment: Development of a new measure of everyday functioning for severely mentally Ill adults. Schizophr Bull 2001;27:235-45.
9Chandrashekar H, Prashanth NR, Kasthuri P, Madhusudhan S. Psychiatric rehabilitation. Indian J Psychiatry 2010;52:S278-80.
10Tungpunkom P, Maayan N, Soares-Weiser K. Life skills programmes for chronic mental illnesses. Cochrane Database Syst Rev 2012;1:CD000381.
11Burnett J, Dyer CB, Naik AD. Convergent validation of the Kohlman evaluation of living skills as a screening tool of older adults' ability to live safely and independently in the community. Arch Phys Med Rehabil 2009;90:1948-52.
12Rosen A, Trauer T, Hadzi-Pavlovic D, Parker G. Development of a brief form of the life skills profile: The LSP-20. Aust N Z J Psychiatry 2001;35:677-83.
13Askew AY. The milwaukee evaluation of daily living skills: Evaluation in long-term psychiatric care. Am J Occup Ther 1990;44:474.
14Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-86.
15Wallace CJ, Liberman RP, Tauber R, Wallace J. The independent living skills survey: A Comprehensive measure of the community functioning of severely and persistently mentally ill individuals. Schizophr Bull 2000;26:631-58.
16Casanova JS, Ferber J. Comprehensive evaluation of basic living skills. Am J Occup Ther 1976;30:101-5.
17Bujanga MA, Baharum N. A simplified guide to determination of sample size requirements for estimating the value of intraclass correlation coefficient: A review. Arch Orofac Sci 2017;12:1-11.
18Goldberg D, Williams P. A User's Guide to the General Health Questionnaire. Slough, United Kingdom: NFER–Nelson; 1988.
19Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep 1962;10:799-812.