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Purpose Employees who experience sickness absence (SA) due to common mental disorders (CMD) are at increased risk of recurrent sickness absence (RSA). This systematic literature review examines the factors at different levels in the work and non-work context that increase or decrease the likelihood of RSA due to CMD. The resulting knowledge enables more accurate identification of employees at risk of RSA. Methods We conducted a search in June 2023 using the following databases: PubMed, PsycInfo, Web of Science, Cumulative Index to Nursing & Allied Health Literature (Cinahl), Embase and Business Source Ultimate (BSU). Inclusion criteria were as follows: (self-)employees, CMD, related factors, RSA. The quality of the studies was assessed using the Mixed Methods Appraisal Tool (MMAT). The Individual, Group, Leader, Organisation and Overarching/social context (IGLOO) model were used to cluster the found factors and these factors were graded by evidence grading. Results Nineteen quantitative and one qualitative studies of mainly high and some moderate quality were included in this review. A total of 78 factors were found. These factors were grouped according to the IGLOO levels and merged in 17 key factors. After evidence grading, we found that mainly low socioeconomic status (SES) and the type of previous SA (short-term SA and SA due to CMD) are predictors of an increased risk of RSA. Conclusions Having a low SES and previous experience of SA (short term, or due to CMD) are factors that predict the chance of RSA, implying the need for prolonged support from occupational health professionals after the employee has returned to work.

Background Interventions to address problematic alcohol use in older adults are needed as alcohol use is highly prevalent among those over 55 years of age. For interventions to be most effective, their working elements should be leveraged. However, understanding of working elements specifically in interventions for older adults is limited. The aim of this study was to understand how (i.e., which elements), in which context, and why (which mechanisms) interventions are successful in preventing or reducing (problematic) alcohol use among older adults, from the perspective of professionals providing these interventions. Methods Guided by a Realist Evaluation approach, an existing Initial Program Theory (IPT) on working elements in alcohol interventions, was tested by conducting semi-structured interviews with professionals (N = 20). These professionals provide interventions targeting alcohol use across several contexts: with or without practitioner involvement; in-person or not; and in an individual or in a group setting. Data were coded and links between contexts, elements, mechanisms and outcomes were sought for in order to confirm, refute or refine the IPT. Results Several general working elements were found: 1) pointing out the risks and consequences of drinking behavior, 2) paying attention to abstinence, 3) contact with peers, 4) personalized content and 5) providing support. We also found context-specific working elements:1) personalized content and conversations in interventions with practitioners, 2) safety, trust and feeling connected in in-person interventions and 3) sharing experiences and tips in group interventions. Conclusions Findings are in general in line with the IPT. Our findings emphasize the need for social contacts and support for older adults. The mechanisms awareness and accessibility were important contributors to positive interventions outcomes. Further research should study the perspective of older

Objectives This study set out to understand how (which elements), in what context and why (which mechanisms) interventions are successful in reducing (problematic) alcohol use among older adults, from the perspective of professionals providing these interventions. Design Guided by a realist evaluation approach, an existing initial programme theory (IPT) on working elements in alcohol interventions was evaluated by conducting semistructured interviews with professionals. Setting and participants These professionals (N=20) provide interventions across several contexts: with or without practitioner involvement; in-person or not and in an individual or group setting. Data were coded and links between contexts, elements, mechanisms and outcomes were sought for to confirm, refute or refine the IPT. Results From the perspective of professionals, there are several general working elements in interventions for older adults: (1) pointing out risks and consequences of drinking behaviour; (2) paying attention to abstinence; (3) promoting contact with peers; (4) providing personalised content and (5) providing support. We also found context-specific working elements: (1) providing personalised conversations and motivational interviewing with practitioners; (2) ensuring safety, trust and a sense of connection and a location nearby home or a location that people are familiar with in person and (3) sharing experiences and tips in group interventions. Furthermore, the mechanisms awareness and accessible and low threshold participation were important contributors to positive intervention outcomes. Conclusion In addition to the IPT, our findings emphasise the need for social contact and support, personalised content, and strong relationships (both between client and practitioner, and client and peers) in interventions for older adults.

Background: The COVID-19 pandemic and measures have placed various burdens on societies and individuals. Emerging evidence suggests that people in drug addiction recovery were negatively affected. This study investigates whether risk and protective factors associated with return to problematic substance use differed between the periods before and during the pandemic for those in recovery. Methods: A convenience sample of persons in drug addiction recovery for at least three months completed an assessment at baseline before the pandemic (T0, N = 367) and at two consecutive follow-ups 12 months apart (T1, N = 311; T2, N = 246). The final follow-up took place during the pandemic (2020− 2021). We analyzed rates and predictors of problematic substance use in both periods, and whether relations between predictors and problematic use differed between the periods. Results: Rates of problematic use did not differ significantly before and during the pandemic for those who were followed-up. However, the relationship between problematic use and commitment to sobriety differed between both periods (OR = 3.24, P = 0.010), as higher commitment was only associated with lower odds of problematic use during (OR = 0.27, P < 0.001), but not before, the pandemic (OR = 0.93, P = 0.762). In both periods, persons who were engaged in psychosocial support had lower odds of problematic use. Conclusions: The COVID-19 pandemic was not followed by significant return to problematic substance use in a cohort of people who were already in drug addiction recovery for some time before the pandemic. However, with restricted access to environmental resources, they may have been more dependent on internal motivations. Targeting personal recovery resources with interventions could therefore reduce the chances of return to problematic substance use during a pandemic.

Understandings of drug addiction recovery are still being debated. Research on perspectives from first-hand experiences with recovery is rare and often contains short-term experiences in the context of a treatment setting. We aim to gain further understanding of recovery by analyzing autobiographical data from persons in different stages of drug addiction recovery who are not linked to any specific treatment service. We conducted 30 in-depth qualitative interviews with participants from various parts of the Netherlands. Participants self-identified as being “in recovery” or “recovered” from drug addiction for at least 3 months. Men and women are equally represented, and the sample consists of an equal number of participants in early (<1 year, n = 10), sustained (1–5 years, n = 10), and stable (>5 years, n = 10) recovery. We undertook a data-driven thematic analysis. Participants described that recovery is a broad process of change because addiction is interwoven with everything (theme 1); that recovery is reconsidering identity, seeing things in a new light (theme 2); that recovery is a staged long-term process (theme 3); and that universal life processes are part of recovery (theme 4). Thus, Drug addiction recovery is experienced as an interwoven long-term process, including identity change and common or universal life processes. Policy and clinical practice should therefore be aimed at supporting long-term tailored recovery goals and disseminating first-hand recovery experiences to enhance long-term outcomes and reduce stigmatization.

We aimed to examine determinants of criminal victimization (i.e. both personal and property crime victimization) in outpatients with severe mental illness. Data was collected using a multisite epidemiological survey including a random sample of 956 adult outpatients with SMI. Data on 12-month victimization prevalence and frequency were obtained using the victimization scale of the Dutch Crime and Victimization Survey. Demographic characteristics, clinical diagnosis, psychosocial functioning, drug use and alcohol abuse over the past 12 months, co-morbid PTSD diagnosis, physical abuse, physical neglect and sexual abuse in childhood, perpetration of violence over the past 12-months, and anger disposition were assessed as determinants. Univariable and multivariable hurdle regression analyses were conducted to test associations of the potential determinants with victimization prevalence and frequency. We found that different sets of demographic and clinical characteristics were associated with personal and property crime victimization. Clinical characteristics were more pronounced regarding personal crime victimization. In the multivariable model, presence of psychotic disorder, drug use, childhood physical and sexual abuse, and recent violent perpetration were associated with the 12-month prevalence or frequency rate of personal crime victimization. Native Dutch and divorced patients were more at risk as well. Next to this being employed, poor social functioning, having perpetrated a violent crime, as well as alcohol abuse and recent drug use were all significantly related to property crime prevalence or frequency rate in the multivariable model.

Background Recovery Colleges (RCs) have spread across the globe as a new way of supporting people with mental vulnerabilities in their recovery journey. RCs focus on ‘learning’ rather than ‘curing’ and in that line facilitate a transition from being a passive, dependent patient/client to an active, empowered student learning to live life, despite vulnerabilities. Peer support and co-creation are central in RCs, as peers learn from each other by sharing personal experiences with mental vulnerabilities in an accessible, inspiring and stimulating atmosphere. The implementation of RCs is highly encouraged internationally, and as a result RCs and related self-help initiatives increasingly emerge. However, high-quality research on RCs is scarce and there is a call for thorough investigation of (cost-)effectiveness, mechanisms of action, cross-border fidelity and positioning of RCs. In response, this research project aims to fill these gaps. Methods This research project entails (1) a prospective quasi-experimental effectiveness study and economic evaluation, (2) a multifaceted qualitative study to elaborate on the mechanisms of action of RCs for those involved (3) a study to develop a (Dutch) Fidelity Measure of Recovery Colleges, and (4) an organisational case study to describe the positioning of RCs in relation to other mental health care services and community-based initiatives. Following the ideals of co-creation and empowerment in RCs we conduct this research project in co-creation with RC students from Enik Recovery College in Utrecht, the Netherlands. Discussion This research project will lead to one of the first longitudinal controlled quantitative evaluations of both cost-effectiveness and effectiveness of RC attendance in a broad sense (beyond attending courses alone). Moreover, we will gather data on a micro level (i.e., impact on RC students), meso level (i.e., organisational fidelity) and macro level (i.e., positioning in the car

Introduction Problematic alcohol use has been increasing in older adults (55+). Many of the interventions that are available to prevent or reduce alcohol consumption are aimed at adults in general. It is unclear whether these interventions also work for older adults. The objective of this review was to understand in what way (i.e., which elements), in which context and why interventions (which mechanisms) are successful in preventing or reducing (problematic) alcohol consumption among older adults. Methods A systematic review of articles published between 2000 and 2022 was performed using PubMed, PsycINFO, Web of Science and CINAHL. A realist evaluation approach was used to analyze the data. Results We found 61 studies on interventions aimed at preventing or reducing (problematic) alcohol use, of which most interventions were not specifically designed for older adults. Three major effective elements of interventions were found: 1) providing information on the consequences of alcohol consumption; 2) personalized feedback about drinking behavior; and 3) being in contact with others and communicating with them about (alcohol) problems. The first two elements were used in interventions designed for older adults. Conclusion More research is needed on interventions aimed at preventing or reducing (problematic) alcohol use among older adults and on how older adults can be provided help in making contacts with people who support their decision to reduce alcohol consumption.

Purpose: Disclosure of mental illness to a supervisor can have positive (e.g. supervisor support) and negative consequences (e.g. stigma). However, research on the association between disclosure and sustainable employability and well-being at work is scarce. The aim of this study was to investigate the association between the disclosure decision (yes/no), experiences with the decision (positive/negative) and sustainable employment and well-being at work among military personnel with mental illness (N = 323). Methods: A cross-sectional questionnaire study was conducted. Descriptive and regression (linear and ordinal) analyses were performed. Comparisons were made between those with positive and negative disclosure experiences. Results: Disclosure decision (yes/no) was not significantly associated with any of the measures of sustainable employability and well-being at work. However, positive disclosure experiences were significantly associated with higher scores on almost all measures of sustainable employability and well-being at work. Those with negative disclosure experiences reported significantly more shame (Mpos = 2.42, Mneg = 2.78, p < .05) and discrimination (Mpos = 1.70, Mneg = 2.84, p < .001). Those with a positive disclosure experience, reported significantly more supervisor support (Mpos = 3.20, Mneg = 1.94, p < .001). Conclusion: We did not find evidence that the disclosure decision itself is related to measures of sustainable employment and well-being at work. In contrast, how participants had experienced their (non-)disclosure decision was significantly related to almost all measures. This emphasizes the importance of the work environments reactions to disclosure and mental illness in the workplace. Future research and interventions should focus on increasing the likelihood of positive disclosure experiences through creating a more inclusive work environment, with more supervisor support and less stig

This study aimed to examine the unique predictive validity of debt regarding recidivism and what elements are specifically predictive. This was done based on a Dutch sample of 250 people on probation using an explorative research tool, the Finances, Debt, and Offending Scale (FDOS). Cox survival regression and receiver operating characteristics analyses were conducted on the total FDOS and its individual items as predictors and diverse recidivism criteria. The average follow-up duration was 5.41 years. The results show that debt moderately predicts recidivism (adjusted for other predictors). The FDOS significantly predicted recidivism on all three levels of severity, and regarding the type of crime, it predicted recidivism in property and drug-related crime. Earlier debt and probation officers’ indications of whether finances are criminogenic were especially predictive. These insights may help frontline service providers better understand the role of finances in recidivism, measure financial problems in risk assessment, and select interventions.

Little research exists on what works in the supervision of offenders with debt problems. This qualitative study aims to provide insight into the barriers probation officers and clients experience during supervision regarding debt and the support that clients need. Interviews were conducted with 33 Dutch probation officers and 16 clients. The results show that debt often negatively influences clients’ lives and hinders their resocialization. Probation officers lack effective methods to support clients with debt problems. To adequately help clients with debt problems, probation officers should obtain more knowledge about effective interventions and collaborate more closely with debt specialists from the probation supervision outset.

Interactions among peers in residential youth care are an important dynamic factor affecting behavioral adjustment and treatment success. Assessment and monitoring of the quality of peer interactions are potentially important for promoting a positive peer culture at the living group, contributing to a positive social climate. However, currently, there are no measures available to assess peer interactions in residential youth care. The present study describes the development, construct validity, and reliability of the Peer Interactions in Residential Youth Care questionnaire (PIRY) in a sample of 345 adolescents (age M = 15.45, SD = 1.59, 44.9% male) in the Netherlands. Confirmatory factor analysis of a two-factor model (peer support and acceptance, and relational aggression) showed a good fit to the data, and internal consistency reliabilities were good for both scales. Partial strict measurement invariance for gender was established, and no significant differences were found between boys and girls on latent factor means. The PIRY can be used in practice to assess and monitor both positive and negative peer interactions in residential youth care at the group level. Implications for research and practice are discussed.

Background: To reduce homelessness, it is important to gain a better understanding of the differences between homeless people who remain in institutions and those who gain and can sustain independent housing. This longitudinal study explores differences in housing transitions and differences in changes in health and selfdetermination between formerly homeless people still living in institutions 2.5 years later and those now living in independent housing in the Netherlands. Methods: This study mapped the housing transitions of 263 participants from when they entered the social relief system (SRS) to 2.5 years later when they were in independent housing or institutions. These individuals were compared at the 2.5-year mark in terms of gender, age and retrospectively in terms of duration of homelessness. They were also compared with regard to changes in psychological distress, perceived health, substance use and self-determination. Results: Two and a half years after entering the SRS, 81% of participants were independently housed and 19% still lived in institutions. People in institutions had a longer lifetime duration of homelessness, were more often men, and their number of days of alcohol use had decreased significantly more, whereas independently housed people had shown a significant increase in their sense of autonomy and relatedness. Conclusion: Formerly homeless people living in independent housing and in institutions show few health-related differences 2.5 years after entering the SRS, but changes in autonomy and relatedness are distinctly more prevalent, after the same period of time, in those who are independently housed. ....................

Many studies on addiction recovery focus on recovery initiation and short-term outcomes for alcohol addictions. In this study, we examine associations between three recovery stages and recovery markers for persons in drug addiction recovery. Data were collected for a multi-country study (REC-PATH) among 722 individuals living in the UK, the Netherlands, and Belgium, who consider themselves in addiction recovery for a period of three months or more. We focus on typical life domains that characterize recovery: housing, crime, work or education, and substance use. The relation with time in recovery was examined for three recovery stages: early (<1 year), sustained (1–5 years), and stable (>5 years). Using the Life in Recovery survey, cross-sectional analyses reveal that participants in later recovery stages have lower odds of having housing problems, being involved in crime, and using illicit hard drugs and higher odds of having work or education, when compared to participants in the early recovery stage. This study provides further empirical support for defining drug addiction recovery as a gradual, long-term process that is associated with various life domains beyond abstinence. The findings suggest that drug policy, treatment and research need to be oriented towards long-term objectives and recovery goals that cover multiple life domains in order to support stable recovery.

Objective: In the Netherlands, enforcement of the alcohol age limit is low and inconsistent because of limited resources. A solution is to optimize the efforts of enforcement officers by prioritizing ways in which they regulate commercial alcohol availability. This could increase compliance by sellers, curbing commercial availability. The objective of this study is to present the development of a commercial alcohol availability estimate (CAAE) for all vendor types selling alcohol and to propose a priority ranking. Method: A multi-method design was used, combining data (collected in 2015) from national studies reporting behavior of minors purchasing alcohol themselves and the success rate (noncompliance) of alcohol vendors (interviewing 510 minors by telephone and conducting 1,373 purchase attempts of alcohol by minors, respectively). Descriptive data and the development of the CAAE are presented. Results: Compared with other vendor types (e.g., sports bars or supermarkets), bars/cafes/discos scored highest on the CAAE, indicating that 7.7% of 16- to 17-year-olds in the survey reported successfully purchasing their own alcohol at this vendor type. Conclusions: To control commercial alcohol availability efficiently for minors in the Netherlands, our estimates suggest that enforcement and prevention efforts should prioritize bars/cafes/discos. However, local authorities should also consider local circumstances and maintain a base amount of attention for all vendor types. Ultimately, the CAAE has the potential to improve enforcer capacity and efficiency in policing commercial alcohol regulation, and prevention workers could align their interventions or campaigns to high-ranked vendor types.

Background Globally, millions are exposed to stressors at work that increase their vulnerability to develop mental health conditions and substance misuse (such as soldiers, policemen, doctors). However, these types of professionals especially are expected to be strong and healthy, and this contrast may worsen their treatment gap. Although the treatment gap in the military has been studied before, perspectives of different stakeholders involved have largely been ignored, even though they play an important role. Aims To study the barriers and facilitators for treatment-seeking in the military, from three different perspectives. Method In total, 46 people participated, divided into eight homogeneous focus groups, including three perspectives: soldiers with mental health conditions and substance misuse (n = 20), soldiers without mental health conditions and substance misuse (n = 10) and mental health professionals (n = 16). Sessions were audio-taped and transcribed verbatim. Content analysis was done by applying a general inductive approach using ATLAS.ti-8.4.4 software. Results Five barriers for treatment-seeking were identified: fear of negative career consequences, fear of social rejection, confidentiality concerns, the ‘strong worker’ workplace culture and practical barriers. Three facilitators were identified: social support, accessibility and knowledge, and healthcare within the military. The views of the different stakeholder groups were highly congruent. Conclusions Barriers for treatment-seeking were mostly stigma related (fear of career consequences, fear of social rejection and the ‘strong worker’ workplace culture) and this was widely recognised by all groups. Social support from family, peers, supervisors and professionals were identified as important facilitators. A decrease in the treatment gap for mental health conditions and substance misuse is needed and these findings provide direction for future

Background: QoL-ME is a digital visual personalized quality of life assessment app for people with severe mental health problems. Research reveals that e-mental health apps frequently suffer from low engagement and fall short of expectations regarding their impact on patients' daily lives. Studies often indicate that e-mental health apps ought to respect the needs and preferences of end users to achieve optimal user engagement.Objective: The aim of this study was to explore the experiences of users regarding the usability and functionality of QoL-ME and whether the app is actionable and beneficial for patients.Methods: End users (n=8) of QoL-ME contributed to semistructured interviews. An interview guide was used to direct the interviews. All interviews were audiorecorded and transcribed verbatim. Transcriptions were analyzed and coded thematically.Results: Analysis revealed 3 main themes: (1) benefit, (2) actionability, and (3) characteristics of the QoL-ME. The first theme reveals that the QoL-ME app was beneficial for the majority of respondents, primarily by prompting them to reflect on their quality of life. The current version is not yet actionable; the actionability of the QoL-ME app may be improved by enabling users to view their scores over time and by supplying practical advice for quality of life improvements. Overall, participants had positive experiences with the usability, design, and content of the app.Conclusions: The QoL-ME app can be beneficial to users as it provides them with insight into their quality of life and elicits reflection. Incorporating more functionalities that facilitate self-management, such as advice and strategies for improving areas that are lacking, will likely make the app actionable. Patients positively regarded the usability, design, and contents of the QoL-ME app.

The number of older homeless people with a limited life expectancy is increasing. European studies on their health‐related characteristics are lacking. This study compared self‐reported health, healthcare service use and health‐related needs of older and younger homeless people in the Netherlands. It is part of a cohort study that followed 513 homeless people in the four major Dutch cities for a period of 2.5 years, starting from the moment they registered at the social relief system in 2011. Using cross‐sectional data from 378 participants who completed 2.5‐year follow‐up, we analysed differences in self‐reported health, healthcare service use, and health‐related needs between homeless adults aged ≥50 years (N = 97) and <50 years (N = 281) by means of logistic regression. Results show that statistically significantly more older than younger homeless people reported cardiovascular diseases (23.7% versus 10.3%), visual problems (26.8% versus 14.6%), limited social support from family (33.0% versus 19.6%) and friends or acquaintances (27.8% versus 14.6%), and medical hospital care use in the past year (50.5% versus 34.5%). Older homeless people statistically significantly less often reported cannabis (12.4% versus 45.2%) and excessive alcohol (16.5% versus 27.0%) use in the past month and dental (20.6% versus 46.6%) and mental (16.5% versus 25.6%) healthcare use in the past year. In both age groups, few people reported unmet health‐related needs. In conclusion, compared to younger homeless adults, older homeless adults report fewer substance use problems, but a similar number of dental and mental problems, and more physical and social problems. The multiple health problems experienced by both age groups are not always expressed as needs or addressed by healthcare services. Older homeless people seem to use more medical hospital care and less non‐acute, preventive healthcare than younger homeless people. This vulnerable group might benefit from shelter‐based or comm

Background: Quality of life (QoL) is a prominent outcome measure in mental health. However, conventional methods for QoL assessment rely heavily on language-based communication and therefore may not be optimal for all individuals with severe mental health problems. In addition, QoL assessment is usually based on a fixed number of life domains. This approach conflicts with the notion that QoL is influenced by individual values and preferences. A digital assessment app facilitates both the accessibility and personalization of QoL assessment and may, therefore, help to further advance QoL assessment among individuals with severe mental health problems.Objective: This study focused on the development of an innovative, visual, and personalized QoL assessment app for people with severe mental health problems: the QoL-ME.Methods: This study targeted 3 groups of individuals with severe mental health problems: (1) people with psychiatric problems, (2) people treated in forensic psychiatry, and (3) people who are homeless. A group of 59 participants contributed to the 6 iterations of the cocreative development of the QoL-ME. In the brainstorming stage, consisting of the first iteration, participants' previous experiences with questionnaires and mobile apps were explored. Participants gave their feedback on initial designs and wireframes in the second to fourth iterations that made up the design stage. In the usability stage that comprised the final 2 iterations, the usability of the QoL-ME was evaluated.Results: In the brainstorming stage, participants stressed the importance of privacy and data security and of receiving feedback when answering questionnaires. Participants in the design stage indicated a preference for paging over scrolling, linear navigation, a clean and minimalist layout, the use of touchscreen functionality in various modes of interaction, and the use of visual analog scales. The usability evaluation in t

Objectives: Conventional approaches to quality of life (QoL) measurement rely heavily on verbal, language-based communication. They require respondents to have significant cognitive and verbal ability, making them potentially unsuitable for people with severe mental health problems. To facilitate an alternative approach to QoL assessment, the current study aims to develop an alternative, visual representation of QoL for people with severe mental health problems. Methods: An alternative, visual adaptation of the concept mapping method was used to construct this visual representation of QoL. Eighty-two participants (i.e., patients, care professionals, and family members) contributed to this study. Results were processed statistically to construct the concept map. Results: The concept map contains 160 unique visual statements, grouped into 8 clusters labelled (1) Support and Attention, (2) Social Contacts, (3) Happiness and Love, (4) Relaxation and Harmony, (5) Leisure, (6) Lifestyle, (7) Finances, and (8) Health and Living. Examples of visual statements are pictures of family silhouettes, romantic couples, natural scenes, houses, sports activities, wallets and coins, smiley faces, and heart shapes. The clusters were interpreted and labelled by participants. Conclusions: Almost all of the statements correspond to clusters found in previous (non-visual) QoL research. Hence, QoL domains can also be presented visually.

Purpose: Quality of life (QoL) is a broad outcome that is often used to assess the impact of treatment and care interventions in mental health services. QoL, however, is known to be influenced by individual values and preferences. To investigate this heterogeneity on the individual level, this study aimed to distinguish classes with distinct QoL profiles in a broad group of people with severe mental health problems and to identify the QoL domains that are most strongly related to the classes. Methods: QoL data of seven studies that used the Lancashire quality of life profile (LQoLP) were used in a latent class analysis. Sociodemographic variables, health-related variables, and measures of well-being were used to characterise the classes. Additionally, univariate entropy scores were used to assess the strength of the association between the ten LQoLP domains and the latent classes. Results: Two of the three indices of fit pointed towards a three-class model. The three classes differed significantly on all of the LQoLP domains, on well-being, and on 'being in an intimate relationship'. No differences were found for the majority of the health-related and sociodemographic variables. The LQoLP domains 'family relations', 'positive self-esteem', and 'negative self-esteem' were most strongly related to the latent classes. Conclusions: The identification of three distinct classes of QoL scores re-emphasises the heterogenic nature of QoL. The lack of differences in sociodemographic or health-related characteristics between the three classes suggests that QoL is primarily determined by subjective, personal evaluations, rather than by objective characteristics and circumstances.

Objectives We explored whether changes in the perceived health of homeless people after entering the social relief system (SRS) in The Netherlands were predicted by housing, income, hours of work, social support, unmet care needs, arrests, physical and mental health, substance use, and experiences of autonomy, competence and relatedness, in addition to perceived health at baseline, demographics, suspected intellectual disability, the duration of homelessness and the company of children in the shelter facility. Methods A hierarchical regression analysis was used to explore the significant predictors of the perceived health of 344 homeless persons 18 months after entering the social relief system. Results A decrease in psychological distress and an increase in hours of (paid/voluntary) work as well as competence predicted a better perceived health. Conclusions Perceived health is not only influenced by objective circumstances related to work and mental health, but also self-determination, as shown by the influence of competence. Services should aim to reduce psychological distress of homeless people, support them in increasing their working hours and focus on strengthening their competence.