Adults and adolescents as the main source of Bordetella pertussis infection in newborns [9–12].
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"8929",leadTitle:null,fullTitle:"Modern Beekeeping - Bases for Sustainable Production",title:"Modern Beekeeping",subtitle:"Bases for Sustainable Production",reviewType:"peer-reviewed",abstract:"Beekeeping worldwide has seen remarkable development in the face of the growing demand for products from bees by consumers who demand increasingly innocuous products that do not harm the environment. 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Brunner, studied the plastic properties of high-purity W single crystals (1998). His researches span various areas of the physical metallurgy of high-purity refractory metals and alloys. In particular, he is interested in both theory and practice of growing single crystals and bicrystals of transition metals, studying the crystallographically related surface properties of high-purity refractory metals of 4, 5 and 6 groups of the Periodic Table. He is an expert in the electron-beam floating zone melting technique as well as in various techniques for high-temperature processing single-crystalline and polycrystalline high-purity refractory metals and alloys. Nowadays, scientific interests of Prof. Vadim Glebovsky extends from some aspects of application his high purity refractory metals and compounds as the effective diffusion barrier layers in Very-Large-Scale Intergration (VLSI) to a new generation of high-sensitivity detectors made of low-radioactivity Ti for registration of the “Dark Matter” particles. Prof. Vadim Glebovsky has published more than 320 scientific articles and patents, 1 book in Russian on levitation melting, 5 chapters and has edited 3 books on various aspects of functional materials.",institutionString:"Institute of Solid State Physics, Russian Academy of Sciences",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Institute of Solid State Physics",institutionURL:null,country:{name:"Russia"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"950",title:"Solid-State Chemistry",slug:"metals-and-nonmetals-solid-state-chemistry"}],chapters:[{id:"64240",title:"Introductory Chapter: Growing W Single Crystals by EBFZM for Studying Mechanical Behavior",slug:"introductory-chapter-growing-w-single-crystals-by-ebfzm-for-studying-mechanical-behavior",totalDownloads:331,totalCrossrefCites:0,authors:[{id:"101945",title:"Dr.",name:"Vadim",surname:"Glebovsky",slug:"vadim-glebovsky",fullName:"Vadim Glebovsky"}]},{id:"64886",title:"Doping of SiC Crystals during Sublimation Growth and Diffusion",slug:"doping-of-sic-crystals-during-sublimation-growth-and-diffusion",totalDownloads:773,totalCrossrefCites:0,authors:[{id:"56559",title:"Dr.",name:"Evgenii",surname:"Mokhov",slug:"evgenii-mokhov",fullName:"Evgenii Mokhov"}]},{id:"67610",title:"Numerical Analysis of Liquid Menisci in the EFG Technique",slug:"numerical-analysis-of-liquid-menisci-in-the-efg-technique",totalDownloads:328,totalCrossrefCites:0,authors:[{id:"267600",title:"Dr.",name:"Vladimir",surname:"Kurlov",slug:"vladimir-kurlov",fullName:"Vladimir Kurlov"},{id:"267604",title:"Dr.",name:"Sergei",surname:"Rossolenko",slug:"sergei-rossolenko",fullName:"Sergei Rossolenko"},{id:"303450",title:"Dr.",name:"Irina",surname:"Shikunova",slug:"irina-shikunova",fullName:"Irina Shikunova"},{id:"303451",title:"MSc.",name:"Dmitry",surname:"Stryukov",slug:"dmitry-stryukov",fullName:"Dmitry Stryukov"},{id:"305856",title:"Dr.",name:"Gleb",surname:"Katyba",slug:"gleb-katyba",fullName:"Gleb Katyba"},{id:"305857",title:"Dr.",name:"Irina",surname:"Dolganova",slug:"irina-dolganova",fullName:"Irina Dolganova"},{id:"305858",title:"Dr.",name:"Kirill",surname:"Zaitsev",slug:"kirill-zaitsev",fullName:"Kirill Zaitsev"}]},{id:"68309",title:"Growth of Single-Crystal LiNbO3 Particles by Aerosol-Assisted Chemical Vapor Deposition Method",slug:"growth-of-single-crystal-linbo-sub-3-sub-particles-by-aerosol-assisted-chemical-vapor-deposition-met",totalDownloads:293,totalCrossrefCites:0,authors:[{id:"266498",title:"Dr.",name:"Jose",surname:"Murillo",slug:"jose-murillo",fullName:"Jose Murillo"},{id:"309134",title:"Dr.",name:"Jose",surname:"Ocón",slug:"jose-ocon",fullName:"Jose Ocón"},{id:"309135",title:"Dr.",name:"Guillermo",surname:"Herrera",slug:"guillermo-herrera",fullName:"Guillermo Herrera"},{id:"309136",title:"Mr.",name:"Jose",surname:"Murillo-Ochoa",slug:"jose-murillo-ochoa",fullName:"Jose Murillo-Ochoa"},{id:"309137",title:"Prof.",name:"Gabriela",surname:"Ocón",slug:"gabriela-ocon",fullName:"Gabriela Ocón"}]},{id:"64923",title:"Epitaxial Growth of Thin Films",slug:"epitaxial-growth-of-thin-films",totalDownloads:653,totalCrossrefCites:1,authors:[{id:"265827",title:"Dr.",name:"Daniel",surname:"Rasic",slug:"daniel-rasic",fullName:"Daniel Rasic"},{id:"265828",title:"Prof.",name:"Jagdish",surname:"Narayan",slug:"jagdish-narayan",fullName:"Jagdish Narayan"}]},{id:"64633",title:"Conventional and Unconventional Crystallization Mechanisms",slug:"conventional-and-unconventional-crystallization-mechanisms",totalDownloads:721,totalCrossrefCites:0,authors:[{id:"270681",title:"M.Sc.",name:"Kamila",surname:"Chaves",slug:"kamila-chaves",fullName:"Kamila Chaves"},{id:"270682",title:"MSc.",name:"Thaís Jordânia",surname:"Silva",slug:"thais-jordania-silva",fullName:"Thaís Jordânia Silva"},{id:"270683",title:"Prof.",name:"Ana Paula Badan",surname:"Ribeiro",slug:"ana-paula-badan-ribeiro",fullName:"Ana Paula Badan Ribeiro"},{id:"271200",title:"Prof.",name:"Maria Aliciane",surname:"Fontenele Domingues",slug:"maria-aliciane-fontenele-domingues",fullName:"Maria Aliciane Fontenele Domingues"},{id:"282324",title:"Prof.",name:"Daniel",surname:"Barrera-Arellano",slug:"daniel-barrera-arellano",fullName:"Daniel Barrera-Arellano"}]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"177730",firstName:"Edi",lastName:"Lipovic",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/177730/images/4741_n.jpg",email:"edi@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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\nroutine vaccinations in children and adolescents under national immunization programs,
vaccinations in adults from risk groups (due to clinical recommendations, e.g. chronic diseases, and epidemiological recommendations, e.g. occupation, scheduled travels),
ring vaccination strategy (vaccination of a ring of close contacts of an ill person; it is a strategy used to stop an epidemic, as in the case of smallpox eradication in India) and
cocoon vaccination strategy.
A cocoon vaccination strategy refers to vaccinations in persons from the immediate environment of those patients who might develop an illness (they are susceptible to illnesses) but cannot be vaccinated due to permanent or temporary medical contraindications to a vaccination (e.g. patients in immunosuppression) or are too young to have a vaccination [1].
\nMost frequently, a cocoon vaccination strategy is associated with vaccinations in adults aimed at preventing the spread of an illness in children (e.g. pertussis vaccination or influenza vaccination), but it is worth considering whether this strategy should not be understood also as vaccinations in children with the view of protecting adults and the elderly against illnesses (e.g. influenza or pneumococcal diseases) [1].
\nThe aim of the cocoon strategy is to minimize the risk of the transmission of pathogens in the environment of a patient who is susceptible to an infection. A vaccinated patient is not a source of infection any more for a non-vaccinated patient [1, 2].
The concept of a cocoon vaccination strategy is connected with herd immunity and herd immunity threshold [3].
\nHerd immunity is a term that was coined as a result of observations which showed that the presence of persons immune to a particular infectious disease in a certain population decreases the probability of developing this disease by other persons in this population who are not immune to this disease. The earliest observation of this phenomenon was made in 1840 by an outstanding British hygienist, William Farr, who wrote in his report on births, deaths and marriages in England and in Wales that “smallpox transmission might be interrupted or sometimes stopped thanks to vaccinations which protect a part of the population” [3]. However, the very term “herd immunity” was used by Topley and Wilson for the first time. In their studies into epizootic in mice under laboratory conditions, they concluded that “immunity understood as a characteristic of a herd should be approached scientifically as a separate issue that is closely related to immunity of particular specimens, but at the same time constitutes a different issue in many aspects” [3]. The essence of herd immunity is that the higher the proportion of specimens immune to a disease in a population, the lower the probability of developing the illness by a specimen with no immunity to the disease. Thus, the term can be used with reference to infectious diseases in which some specimens infect the others [3].
\nHerd immunity threshold is the proportion of persons who need to be immune in order to stop an infectious disease from spreading in a population. For most diseases, it is over 80% [3]. Herd immunity threshold is influenced by the following factors: transplacental immunity, patient’s age at the time of vaccination, age-related differences in the frequency of contacts or in infection risks (as the result of the decrease in the frequency of contacts, the real herd immunity threshold is lower than the estimated one), seasonal changes in the frequency of contacts (the period of decreased seasonal infectivity decreases the real herd immunity threshold as compared to the estimated threshold), geographical heterogeneity and social structure (irregularities of risk distribution in various social groups) [3]. Herd immunity threshold for pertussis is high, and it amounts to 92–94%. However, considering the decrease in infectivity with age and the seasonality of the disease the estimates indicate 88% [3].
\nPopulation-based vaccine efficacy depends on a high proportion of the vaccinated individuals in a population. A good example may be measles, a highly contagious disease, which has become a re-emerging disease in countries where the proportion of those vaccinated has diminished (e.g. Germany, Great Britain) [4]. Population protection (herd immunity) resulting from breaking the infection transmission with the use of vaccinations has been observed in Australia for vaccinations against rotaviruses (e.g. after the introduction of common vaccinations against rotaviruses, the frequency of hospitalizations due to acute diarrhea decreased) and vaccinations against human papillomavirus (HPV), as well as in Great Britain for vaccinations against Haemophilus influenzae type b and the meningococcal group C [5].
Pertussis is a contagious bacterial disease of the respiratory system caused by gram-negative rod Bordetella pertussis. Infection is transmitted through droplets or contact, and the source of infection is an ill person (there are no carriers) [6]. The disease can be developed in people who have not been vaccinated, fully vaccinated, properly vaccinated or who were vaccinated against pertussis a long time ago, as well as those who have already suffered from it because infection-acquired immunity to pertussis lasts only up to 20 years. The incubation period of the disease ranges from 7–14 to 22 days [6]. In total, the illness lasts up to 3 months, which is why it was called a 100-day cough in the Chinese medicine. The most serious pertussis complications occur most frequently in newborns and infants, and they include pneumonia, other bacterial or viral superinfections, segmental atelectasis and replacement emphysema, pertussis encephalopathy, seizures and encephalitis [6]. Mortality rate amounts to 0.1–4% [7–9].
\nSince mid-1980s, it has been observed that the epidemiological situation of pertussis in developed European countries, North America, Australia and Japan has been deteriorating. This results from the decrease in post-vaccinal immunity, which is not lifelong, but it lasts for 5–10 years. Currently, the highest incidence of pertussis is reported in adolescents and adults, and the representatives of these age groups are the main known source of infection for newborns and young infants who were not vaccinated against pertussis (in most countries, the first vaccination is given in the 6th week of life), were vaccinated with a delay or did not receive the required number of vaccination doses [7, 8]. It was found that the source of Bordetella pertussis infection in 30–75% of disease cases in newborns hospitalized for pertussis was persons from newborns’ immediate environment (mothers, fathers or older siblings) (Table 1) [9–12].
Currently used strategies for pertussis prevention include [13–15] are listed below:
\nvaccinations in infants and small children, TDPw or TDPa vaccines,
booster vaccinations in children of pre-school age, TDPa or Tdpa vaccines, and in children of the school age (adolescents), Tdpa vaccine,
booster vaccinations in adults (recommended every 10 years), Tdpa vaccine,
vaccinations in pregnant women, Tdpa vaccine and
cocoon strategy for protective vaccination, Tdpa vaccine.
TDPw vaccines contain a whole cell pertussis component and may be used in infants older than 6 weeks till 36 months of age. However, due to a higher reactogenicity related to TDPw compared to TDPa vaccines [16, 17], the majority of high-income countries implemented TDPa vaccines into the national immunization schedules. On the other hand, it was reported that the duration of the immunity after TDPa vaccines may be shorter than TDPw vaccines [18]. Table 2 illustrates differences between TDPa and Tdpa vaccines. Tdpa vaccines contain a reduced antigen content, and they are recommended for individuals older than 4 years of age.
Contents of 0.5 ml of vaccine | TDPa | Tdpa |
---|---|---|
Diphtheria toxoid | >30 IU | >2 IU |
Tetanus toxoid | >40 IU | >20 IU |
Pertussis antigens: | 8.0 μg | 2.5 μg |
Pertactin | 25.0 μg | 8.0 μg |
Pertussis toxoid | 25.0 μg | 8.0 μg |
Filamentous hemagglutinin |
Differences between TDPa and Tdpa vaccines [6].
In response to the alarming increase in pertussis morbidity in 2001, Global Pertussis Initiative (GPI) consisting of experts from 17 countries was established. In 2005, the organization recommended the increase and extension of the scope of vaccination strategies and the implementation of booster vaccinations against pertussis in adolescents in developed countries. Special attention was drawn to pertussis prevention in newborns and infants who belong to the group, which is subject to the highest risk of severe pertussis. Three vaccination strategies were considered: vaccinations in mothers, vaccinations in newborns and cocoon strategy. On the basis of mathematical modeling, GPI estimated that routine vaccinations in adolescents connected with the cocoon strategy might diminish pertussis morbidity by 50%. These estimates resulted in national and international expert groups’ recommendations in 2006 to introduce cocoon strategy in all countries, which have appropriate measures to do this [19].
\nCocoon strategy involves administration of Tdpa to persons who have a close contact with newborns and infants (of up to 12 months of age), parents, grandparents, caregivers and older siblings. Optimal time of vaccination is at least 2 weeks before an expected contact with a child [14]. Strategies of vaccinations against pertussis in selected European countries are presented in Table 3.
Country | Basic vaccination | Booster vaccinations in children and adolescents | Booster vaccinations in adults |
---|---|---|---|
Austria | 2–4–6 months | 12–24 months, | Every 10 years |
13–16 years | |||
Belgium | 2–3–4 months | 15 months | Cocoon strategy |
5–7 years, 14–16 years | |||
Finland | 3–5–12 months | 4 years, | – |
14–15 years | |||
France | 2–3–4 months | 16–18 months, 11–13 years | 27–28 years, all healthcare employees (2008) |
Cocoon strategy | |||
Germany | 2–3–4 months | 5–6 years, 11–15 years | Cocoon strategy |
Healthcare employees (2003) | |||
Italy | 3–5–11 months | 5–6 years, | – |
11–15 years | |||
Netherlands | 2–3–4 months | 11 months | – |
14 years | |||
Poland | 2–4–6 months | 18–18 months, | Healthcare employees who have contact with infants (2015); |
6 years, 14 years | Adults > 19 years—every 10 years | ||
Cocoon strategy (2015) | |||
Switzerland | 2–4–6 months | 15–24 months | – |
4–7 years (11–15 years, catch up) | |||
Luxembourg | 12 months | 5–6 years, | Every 10 years |
15–16 years |
Strategies of vaccinations against pertussis in particular European countries [20].
In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended routine Tdpa vaccination in adults who have or are likely to have a close contact with children of up to 12 months of age. In 2011, ACIP decided that this recommendation should be extended and include vaccinations in adults above the age of 65 years, for example, grandparents, nursery and kindergarten employees as well as healthcare facility staff [14]. Currently, cocooning is recommended not only by ACIP but also by American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP) [21].
\nIt is estimated that 605 persons from immediate and distant environments of an infant have to be vaccinated in pertussis epidemiological situation in the USA in order to prevent one disease case, whereas in the case of vaccinations in adolescents, in order to observe the same effect, a four-times bigger group needs to be vaccinated, that is, 2325 persons [14]. This can be explained by the fact that although small children are the source of infection for other population groups in most infection cases (e.g. influenza, pneumococcal infections), in the case of pertussis, an opposite situation can be observed. Common vaccinations in infants and small children have resulted in the transmission of the disease to older age groups and thus household members, parents and adolescents have become the source of infection [6, 14].
\nAlthough cocoon strategy against pertussis is accepted by caregivers of young children, its implementation is at a low level. According to the data of 2008, only 5% of adults who had a close contact with infants were given Tdpa vaccinations [14]. Leboucher et al. [22] showed that the idea of cocooning was accepted by 97% of parents of newborns, which resulted in vaccinations in 69% of mothers and 63% of fathers. In 96% of cases, vaccinations were done under the conditions of ambulatory healthcare (at a family doctor) [22]. Decréquy et al. [23] observed that before the cocooning program was implemented on a chosen maternity ward, only 20% of mothers and 13% of fathers had been vaccinated against pertussis, whereas after the introduction of educational activities, the level of vaccinations increased to 77% in mothers and 57% in fathers. It was indicated that the continuation of vaccinations is necessary, not only at a local but also at a national level [23].
\nA few reasons that prevent cocoon strategy against pertussis from being commonly implemented and accepted were identified. It was indicated that to improve the cocooning strategy, it is required to combine parental education with free vaccinations in pediatric or maternal settings [14, 22]. However, implementation of the cocoon strategy on maternity and neonatal wards as well as in pediatric centers requires resources from a doctor to undertaking activities, which go beyond their scope of standard duties, not to mention financial issues related to costs and refunds. Furthermore, implementation of this strategy requires substantial financial resources and the increase in the number of healthcare personnel [6].
\nCurrently, data evaluating the effectiveness of a cocoon strategy are limited. Skowronski et al. [24] suggested that cocooning may not be cost-effective in areas where a disease incidence is low. The authors concluded that it would take 1 million parental immunizations to save one infant death, 100,000 parental immunizations to save one infant’s intensive care unit admission and 10,000 parental immunizations to prevent one infant’s hospitalization [24]. However, Westra et al. from the Netherlands found that maternal immunization or a cocooning program for both parents was cost-effective and even cost-saving [25] as compared to just an infant immunization program. Healy and Baker [26] found that up to 75% of infant pertussis cases are acquired from a household contact, and cocooning could lead to a 70% reduction in pertussis cases in infants of less than 3 months of age.
\nThe concept of “number needed to treat” to estimate the number of adults that would need to be vaccinated (NNV) to prevent one case of disease, hospitalization and death due to pertussis was used and described by researchers from Ontario (Canada) [2]. After implementation of the cocoon strategy against pertussis, the NNV to prevent one case, hospitalization or death from pertussis was between 500–6400, 12,000–63,000 and 1.1–12.8 million, respectively (after adjusting for under-reporting). Rarer outcomes were associated with higher NNV [2]. The authors also demonstrated that NNV estimates for pertussis vary greatly depending on the frequency of the outcome, including the target age group, the degree of under-reporting believed to be in existence, the assumed vaccine effectiveness (VE) and the estimated proportion of infants infected by the mother and the father. It was concluded that the objectives of implementing a cocoon immunization strategy must be carefully considered if the strategy should be evaluated properly. If the objective of the program is to prevent pertussis in the population in general, a universal strategy should be considered. However, if the objective is to prevent deaths due to pertussis, a large number of adults need to be vaccinated [2]. A similar conclusion was presented by Italian authors [27].
\nThe cocoon strategy against pertussis was implemented in the USA in 2006. Data from two small studies reported conflicting results. One study documented a 50% decline in the incidence of pertussis in hospitals with a post-partum Tdap vaccination policy in 2006 (n = 48), while a 20% increase was observed among hospitals that did not have such a policy (n = 145) [28]. In contrast, Castagnini et al. [29] found no difference in the rates of illness, length of hospitalization or mortality in infants under 6 months of age when post-partum women were vaccinated prior to discharge. The authors recommended that all household members and key contacts of newborns should be immunized instead. There is also evidence that immunization coverage of high-risk groups increases when vaccination programs are universal rather than targeted [30, 31].
Influenza is a severe infectious disease caused by Orthomyxoviridae viruses. Influenza in child population is an undervalued, not to say underestimated, problem. This might result from the fact that disease symptoms are non-specific and the disease diagnostics is quite difficult, although accessible and feasible both on an outpatient and on an inpatient basis [32]. It is estimated that influenza virus infections cause 10–40% of acute febrile respiratory tract infections in children annually; however, in closed environments this rate might amount even to 50% [33].
\nIn the course of establishing worldwide influenza in children at the age of below 5 years in 2008, Nair et al. [34] estimated, on the basis of an analysis of 43 studies, that in that year there were 90-million influenza cases in the mentioned age group globally. A 13% of cases developed acute lower respiratory insufficiency (ALRI) and 28,000–111,500 cases resulted in death [34].
\nOccurrence of severe seasonal influenza cases in children and adolescents is described by the number of deaths and the number of hospitalizations in intensive care units. The actual occurrence of influenza in children is underestimated due to the fact that children who suffer from mild influenza are not even consulted on an outpatient basis [32, 33].
\nIn comparison with adults, children who suffer from influenza, especially infants below the age of 1 year, require a higher number of consultations on an outpatient basis [35]. According to the study, 24% of all outpatient influenza-related visits concerned children [36]. A big number of outpatient visits related to influenza and its complications generates not only direct costs but also indirect costs that are, for example, connected with the child caregivers’ absence from work and the loss of earnings [36]. Furthermore, these visits constitute an organizational challenge for medical facilities. The number of hospitalizations related to influenza and its complications in children in the USA is estimated to amount to 0.9/1000 children, and most of them concern children at the age of below 1 year [37]. The risk of influenza-related hospitalizations in children of pre-school age is comparable to the risk that is observed in the group of the elderly above the age of 65 years [37]. The number of hospitalizations for influenza in children at the age of up to 5 years amounts to 5/10,000 children and in adolescents, 1/10,000 persons [37]. A study by Rhim et al. [38] demonstrated that 7.3% of children who reported to admission rooms in pediatric hospitals due to influenza-like symptoms required hospitalization, whereas a study by Irving et al. [39] showed that 5% of outpatients diagnosed with influenza required hospitalizations.
\nInfluenza mortality in children is estimated at <1/100,000 patient-treatment years and unfortunately most deaths (even up to 50%) occur in children with no additional disease burden [40]. Deaths due to influenza in children are rare. In the USA in 2003/2004, mortality in this group of patients amounted to 2.1/1,000,000 [40]. In the twentieth and twenty-first centuries, influenza can be effectively prevented with vaccinations. It is worth noticing that influenza deaths in children occur also in those children who suffer from no additional burdening diseases that could classify them as patients who are subject to the risk of the severe course of the disease. For example, in 2003/2004 in Great Britain, 17 deaths due to influenza in children and adolescents aged below 18 years were observed and they all occurred in patients who were initially healthy [41]. Furthermore, sudden deaths in children caused by influenza B virus infections were reported. The causes of deaths were determined only in an autopsy (concerning intravital diagnosis, there were no symptoms from the respiratory system but from the digestive system) [42].
\nCocoon strategy in influenza prophylaxis was created on the basis of data concerning cocoon strategy in pertussis prevention. Justification of cocoon strategy for influenza is different than for pertussis because no influenza vaccination can be used in infants aged below 6 months due to low immunogenicity in this age group. As mentioned above, the risk of hospitalization in infants due to influenza is particularly high, and the greatest risk concerns children aged below 6 months. The frequency of influenza hospitalizations in healthy infants is similar to the frequency of hospitalizations in adults who are in a high-risk group. Therefore, effective solutions are necessary to provide appropriate protection for this particularly susceptible population group. Influenza prophylaxis includes hand hygiene, avoiding contact with the ill and vaccinations in persons who have a close contact with the ill.
\nIn the first year of their lives, newborns whose mothers were not vaccinated against influenza either have no immunity to influenza viruses or they have low adaptive immunity. Therefore, it is recommended to vaccinate household members and caregivers of infants at the age below 6 months. Such vaccinations should result in the increase in children protection through creating a protective cocoon. Not all adults are aware of the importance of influenza vaccinations in adults and in children. In order to increase the number of vaccinated persons, it is necessary to provide educational activities and develop initiatives addressed not only at the employees of healthcare facilities but also at patients.
\nTime is another factor that limits the implementation of cocoon strategy in influenza prophylaxis. The strategy can be effective only when all persons from the immediate environment of a newborn, as well as newborn’s relatives and caregivers, are vaccinated at least 4 weeks before the child is born because an immunologic response to a vaccination requires time. Gynecologists and obstetricians should propose vaccinations to women on their visits to health centers before they become pregnant or during the pregnancy. After persons from the immediate environment have been vaccinated, another method of infants’ protection against influenza is vaccinations in pregnant women. A recent study conducted in Bangladesh, which evaluated vaccinations against influenza in pregnant women, showed that the number of laboratory-confirmed influenza cases in infants of vaccinated mothers decreased by 63% [43].
\nCocoon strategy encourages education of patients and employees of healthcare facilities. Educational activities might increase the percentage of the vaccinated population. In families, the main sources of infections for newborns and infants are parents and siblings.
\nStudies show that providing parents of newborns with information on the benefits of influenza vaccinations, as well as providing free-of-charge vaccines, positively influences implementation of the cocoon strategy. Walter et al. [44] indicated that after such activities had been implemented in one maternity hospital, 54.9% of parents underwent vaccinations (vaccinations were given in maternity units and were free of charge for mothers only). Shah et al. [45] observed even higher indicators (86.9–95% in two consecutive years in parents of newborns in an intensive care unit).
Patients in immunosuppression resulting from anticancer or anti-inflammatory treatment (inflammatory bowel diseases [IBD], rheumatic diseases) might not achieve appropriate level of protection after the vaccination (vaccines that are considered to be safe for this group of patients are inactivated vaccines). This is why minimizing the risk of disease transmission in those patients’ environment is of significant importance. In particular, influenza, pertussis and chickenpox vaccinations are recommended [46]. Unfortunately, vaccinations in the contacts of patients in immunosuppression are at a low level, which proves that education in this group is highly necessary. Waszczuk et al. [47] conducted a self-completed survey among patients with inflammatory bowel disease (IBD) and reported that the use of recommended vaccines in family members of patients was insufficient (22–26%). There was a statistically significant association between the non-reimbursed vaccines coverage level and the educational status of patients [47].
Due to frequent contact with the ill, high infectivity of the diseases and lack of life-long immunity to diseases, healthcare personnel belong to a group which is highly at the risk of becoming infected with Bordetella pertussis or influenza virus.
\nIn the case of pertussis, it is estimated that the risk of developing an illness by healthcare professionals is almost two times higher as compared with the general population. Serological results of one study showed that Bordetella pertussis infection in healthcare professionals subject to five-year observations was 2 times higher in 55%, 3 times higher is 17% and 4 times higher in 4% of the personnel [48]. Pertussis might become a hospital infection and its source might be either a patient or a healthcare personnel. Outbreak of the disease in healthcare professionals threatens patients’ health, especially infants’ health. Activities to stop the outbreak might be costly and disturb the functioning of a healthcare facility. Ward et al. [49] described a pertussis outbreak in a 600-bed general hospital in Paris with 2100 employees. In November 2000, three pertussis cases in the personnel were observed there. An epidemiological investigation showed that the first case was a 51-year-old woman who infected three coworkers. A local committee for hospital infections decided to conduct screenings in all healthcare employees and patients. Personnel with respiratory symptoms were excluded from work for the first 5 days of antibiotic treatment. Eventually, pertussis was diagnosed in 17 persons, including 15 members of the personnel and 2 patients. The cost of controlling the outbreak, mostly diagnostic tests, treatment and the loss of productivity, amounted to over 46,000 Euro.
\nBaggett et al. [50] described two pertussis outbreaks in hospitals in King county in the United States of Washington which occurred in 2004:
\n1. In the first hospital, the source of infection was a 38-year-old doctor who worked on an emergency ward (at that moment when she developed the illness, she was in the 37th week of pregnancy, coughing fits and vomiting after the fits lasted for 37 days, and the doctor associated them with the exacerbation of concurrent bronchial asthma). Epidemiological investigation identified five probable cases, which met the pertussis clinic definition of Centers for Disease Control and Prevention (CDC) at that time, and two cases were confirmed. Disease cases concerned two nurses, a receptionist, a close friend of the infected doctor and the doctor’s husband. The woman put 738 persons at risk of infection, including 388 hospital workers, 265 patients and 85 visitors. Among them, 600 persons were examined (80%) and 516 persons were administered antibiotics. Furthermore, one patient who was admitted to the hospital for an emergency appendicitis operation and had contact with the infected doctor in the admission room had a positive polymerase chain reaction (PCR) result without typical clinical symptoms. This resulted in testing 95 persons who had contact with the infected woman (92 persons were given antibiotics) and 29 PCR tests (all results were negative). Hospital pertussis outbreak had significant economic and organizational consequences. The costs included diagnostic tests, antibiotics for all hospital employees with respiratory symptoms who had contact with the persons diagnosed with pertussis and excluding them from work for the first 5 days of treatment and
2. In the other hospital, a 38-year-old physiotherapist working in an intensive care pediatric unit visited a company doctor due to persistent coughing fits which lasted for 22 days. Although the cultivation and testing of the PCR material from nasopharynx were negative and so was the direct immunofluorescence test, an epidemiological investigation was initiated since clinical criteria were fulfilled by the physiotherapist. Pertussis was diagnosed and confirmed in three nurses from the intensive care unit and in one resident doctor who had contact with the ill person. It was estimated that 417 hospital workers, 200 hospital visitors and 120 patients were potentially exposed to the disease. Bordetella pertussis infection was confirmed with the PCR method in four members of the hospital personnel. At the expense of the hospital, antibiotics were administered to 343 workers and 70 visitors and patients. Employees with respiratory symptoms were expelled from work for 1 day until obtaining the negative PCR result. The costs of activities connected with controlling the outbreaks exceeded 260,00 US dollars in the first hospital and 120,000 US dollars in the other hospital, and they were connected mostly with the costs of overtime related to expelling persons at risk of pertussis from work and with remuneration for additional work for the hospital infection team.
Calugar et al. [51] focused on cost-effectiveness of pertussis vaccinations in healthcare personnel. They analyzed a pertussis outbreak which occurred in 2003 in a specialist clinic in the USA after a 1-day exposure of healthcare personnel to an infant with a confirmed pertussis diagnosis [51]. Three hundred and seven members of healthcare personnel were at risk and seven of them had symptomatic pertussis. The authors estimated that vaccinations in healthcare professionals would prevent over 46% of pertussis cases, and from the perspective of the hospital, they would decrease the costs of controlling the outbreak. The authors concluded that pertussis might disturb the functioning of the hospital and that personnel vaccinations could decrease the number of infected workers and could enable the hospital to achieve savings. Members of healthcare personnel who are at the highest risk of developing pertussis are persons who work on pediatric wards and in pediatric centers.
\nAccording to ACIP recommendations, it is advisable to promote pertussis vaccinations in healthcare personnel and to facilitate access to these vaccinations (e.g. through facilitating vaccinations at the place of work, providing free-of-charge vaccines, etc.). Activities aiming at performing vaccinations in a vast number of workers should also include educational activities concerning the illness and its consequences (for the personnel and patients), and informative activities regarding the vaccines, their safety and effectiveness. It is not recommended to do serological tests for pertussis before the vaccination and after it. Recovering from pertussis is no contraindication for the vaccination [52].
\nIt was estimated that the costs of including healthcare personnel, who have a direct and close contact with patients, in a pertussis vaccination program in the USA could be two times lower in a 10-year perspective than controlling pertussis epidemics in healthcare facilities [52].
\nOn the basis of serological tests, it can be estimated that even 25% of healthcare professionals have contact with influenza viruses on an annual basis [53]. Interestingly, 25% of persons who had direct contact with patients whose serological tests proved past influenza infections did not provide disease symptoms in the interview [54]. This might indicate a possible mild course of the infection or an infection accompanied with very few symptoms. Nonetheless, these persons can still be a source of infection both for patients and for other members of healthcare personnel [54]. Infectious disease epidemics, including influenza outbreaks, in healthcare facilities might bring measurable and significant consequences for the finance, for example costs of controlling and epidemic outbreaks (patient isolation, implementation of antivirus treatment), costs of temporary termination of medical services due to cancellation of admissions, costs of employing special personnel to care about particular patients suffering from influenza, consequences for the hospital image—loss of trust among patients, impediments in patient visits and legal consequences—and compensation claims [48]. Healthcare professionals are exposed to infections through droplets or contact with influenza viruses at the place of work and they might become the source of infection for patients. Most of them belong to a group which is at a high risk of the severe course of disease and influenza complications due to their age and chronic illnesses, for example, respiratory system diseases (bronchial asthma, chronic obstructive pulmonary disease), cardiovascular diseases or metabolic diseases (e.g. diabetes). According to the studies, 75% of doctors admit that they perform their professional duties despite having disease symptoms, which indicate a current respiratory system infection [52, 53]. Influenza complications, hospitalizations and deaths related to influenza or its consequences occur mostly in chronic patients, infants and young children (aged 2–5 years), senior citizens and pregnant women [54]. Vaccinations in healthcare personnel are particularly beneficial for those patients who cannot be given a vaccination, for example patients who are too young (infants at the age 6 months for whom there are no registered vaccines—it needs to be stressed that influenza infections have been observed even in newborns), patients with medical contraindications to vaccinations (e.g. occurrence of a strong anaphylactic reaction after influenza vaccination confirmed allergy to any component of the vaccine), patients who do not respond to vaccination appropriately (e.g. persons aged 85 and more, patients in immunosuppression) and persons who cannot be treated with antiviral medications due to medical contraindications (mostly neuraminidase inhibitors). Thus, influenza vaccinations in healthcare personnel constitute an element of cocoon strategy for protective vaccinations [55]. The results of published studies indicate that influenza vaccinations in healthcare professionals in medical facilities ensure a significant decrease in general mortality and flu-like disease morbidity in patients requiring long-term care [56–58]. Carman et al. [56] showed that achieving 50% level of vaccinations in the personnel of a nursing home for the elderly results in the reduction of mortality among the elderly residents by 40%. Individual benefits for the personnel arising from influenza vaccinations are less documented [56–58]; however, it was observed, for example that the number of days absent from work due to respiratory system infections decreased and so did the risk of influenza virus infections (88–89% on average) [59, 60]. A slight decrease in the number of days absent from work (by approx. 0.5 days) was also obtained in the population of vaccinated healthy persons of working age [59, 60]. Salgado et al. [61] showed that the number of laboratory-confirmed influenza cases and the percentage of hospital respiratory system infections diminished from 42 to 9 and from 32 to 3%, respectively, in a group of influenza-vaccinated medical professionals.
\nScientific literature gives examples of influenza epidemics in hospital wards which spread in patients requiring special care. In 1998, an epidemic broke out in a neonatal intensive care unit which resulted in disease cases in 19 out of 54 patients and a death of 1 child. Only 15% of the personnel had been vaccinated and 29 persons admitted to taking care of patients while having symptoms of a respiratory system infection [62]. In the same year, 10 patients developed influenza in a bone marrow unit and 1 person died. In this case, 12% of the personnel had been vaccinated and five personnel members were at work with disease symptoms [63]. Influenza virus outbreaks were also observed in liver transplantation, hematological, neonatal and pediatric units (in the last two units, additional risk factors for influenza virus infections were identified: artificial ventilation system and multiple pregnancy) [64–67]. A group of patients who are particularly at risk of hospital epidemics are residents of facilities, which render care and treatment services for patients with chronic illnesses. During the occurrence of an influenza outbreak in a facility whose residents were at the age of above 65 years, the percentage of infected patients in an epidemic season was very high and it could reach even 60% [68]. The facts that influenza vaccinations in the elderly are not as effective as vaccinations in a younger population (30–40% vs 70–90%), and that influenza epidemics occurred in the populations of the residents of nursing homes, where influenza immunization was very high and reached even 90%, prove that it is necessary to perform vaccinations in healthcare professionals in order to protect the patients [69, 70].
\nUnfortunately, percentage of medical professionals who are vaccinated against pertussis in developed countries is relatively low. According to the studies, although educational activities result in the increased interest in the vaccinations, only a small group of healthcare personnel are vaccinated despite their initial intentions of undergoing a vaccination. Pertussis education for medical professionals could solve this problem. Tdpa vaccine is safe and effective. Pertussis booster vaccinations for healthcare personnel might be the most effective to diminish the risk of pertussis cases and the occurrence of hospital infections in healthcare facilities.
The main benefit of cocoon strategy is that it decreases the risk of the transmission of an infectious disease in the environment of a patient who might become infected but cannot be vaccinated. A universal adult pertussis program does not only serve to decrease the disease in the overall risk of disease among infants (beyond that which might be achieved with a more focused cocoon strategy) but it also protects adults against the disease.
\nThe main drawback of a cocoon strategy is that it is characterized by a low level of recommendation implementations and a small percentage of vaccinated persons, which impairs the performance of this strategy. It is critical to the success of a universal program to ensure that adequate vaccine coverage is achieved. A comparison of various immunization strategies suggests that the coverage of at least 40% within the adult population is required to achieve herd immunity [2]. In practice, achievement of such high indicators is impossible.
\nBarriers to receiving vaccines by close contacts include lack of knowledge about the disease and the benefits of vaccination, time and monetary constraints, forgetting about vaccine recommendations if previously received.
\nAlthough it is recommended to vaccinate all close contacts under a cocoon strategy, vaccinations are frequently limited to mothers, which also influence negatively the effectiveness of the strategy. Vaccinations should be universal and cover caregivers of all infants instead of being addressed solely to the families of children from risk groups.
\nTo conclude, cocoon strategy for protective vaccinations constitutes a valuable complement to universal vaccination programs. Nonetheless, it should not be the only recommended strategy but it should be an element of a comprehensive strategy for preventing infectious diseases.
Human is a social being, which occupies in different ways to survive. Occupations are all of the daily activities in one’s life that make him who he is. Occupations are formed by cultural backgrounds and include all the tasks performed to fulfill the time and give life meaning. Occupational therapy is a treatment option for individuals with physical, mental or developmental conditions that focus on health and well-being by using meaningful and purposeful occupations for individuals for the development, improvement or maintenance of the essential skills needed to be successful in their environment [1].
\nForensic occupational therapy refers the occupational therapy service that assesses and makes interventions to the individuals with occupational problems in the criminal justice system [2]. The forensic settings can be variable and be challenging, but the main point here to pay attention is the holistic and humanistic view of occupational therapy which says that occupation is vital for human and is essential for health and well-being. From this view, forensic occupational therapy is the same as the mental health occupational therapy practice in some ways [3]. The main difference is the legal context and the restrictive correctional environment. The legal context is usually built upon deprivation of some occupations, and this alienates the individual to the occupation. Also, labeling and stigma affect reintegration to the community [4].
\nIn terms of the individual, occupational therapy is an important necessity for occupational participation and occupational balance. With these, occupational therapy prepares the person for community life and protects the individual from recidivism [5]. This is not the sole benefit of occupational therapy. Also, there are benefits for the community; reducing crime provides social well-being and also increases social welfare by contributing to the individual’s productivity activities, so that, forensic occupational therapy has dual aim both for the individual and the community.
\nThe forensic population is growing all over the world and brings challenges with this growing population [5, 6, 7, 8]. These challenges can depend on the person, environment and/or activity. The thing that should never be ignored is the legal context, and the therapists must consider the needs of individuals in the legal context [9].
\nOffenders’ rehabilitation is a multidisciplinary teamwork, and occupational therapy is a key part of the treatment and rehabilitation. The methods are similar to other mental health settings. The key focuses for the occupational therapists working in forensic settings are assessment, prevention of occupational deprivation, development of occupations to prevent recidivism, preparation for discharge and activities of daily living (ADLs), preparation to community and the vocational rehabilitation.
\nThis chapter describes the occupational therapy in forensic settings such as prisons, secure hospitals and community reintegration services. The chapter also discusses the assessments, models that can be used in forensic settings, interventions and challenges in forensic settings.
\nCorrectional administration is the reinstatement and retraining of a person’s antisocial behavior and feelings through confinement for treatment purposes. Correctional settings regulate the individual’s psychosocial status and provide health care service for the prisoners [10].
\nCorrectional settings are a way to facilitate the mental health recovery of the inmates. Since, many of the inmates have serious mental disorders, the forensic unit, of the correctional facility, plays an important part in their recovery. The unit reduces the risk associated with the inmates and facilitates their transition into the community or less restricted settings. However, the same results could be achieved with occupational therapists. The two main methods that are adopted by occupational therapists (OTs) are the reduction of occupation deprivation and increasing skills by occupational participation. Hence, the inmates are provided with an opportunity to play a purposeful and meaningful occupation in society [3].
\nPatients, who are admitted to the forensic units and get in contact with the criminal justice system as a consequence of their committed crimes, are detained in accordance with the country-specific mental health legislation. However, some patients are admitted due to severe behavioral issues.
\nThere are several types of correctional settings where charged offenders are held. The main institutions are forensic mental health settings, jails and prisons. Forensic mental health settings include the following: high secure units, medium secure units, low secure units, psychiatric/acute mental health units, community, forensic hostel, special hospital, acute unit of a forensic hospital, high-security section of a forensic hospital, sub-acute unit of a forensic hospital, consultation/liaison position in the community sector, tertiary mental health facility, extended forensic/psychiatric safe care and medium to high secure unit [11].
\nJails and prisons are the main correctional facilities since they are able to hold the greatest number of people. There are approximately 12 million jail admissions, which is approximately 19 times that of state and federal prisons [12].
\nJails and prisons served for different purposes; have restricted opportunities for rehabilitation; offer a similar grade of occupational deprivation, inadequate access to health services and poorly planned methods; are temporary in nature and lack systematic regulation and resources [13].
\nJails and prisons provide care for mentally disturbed offenders in ill-equipped correctional institutions. In particular, jails are used for temporary confinement and are usually lacking in mental health screenings and treatment received by inmates in jails is more limited. Prisons, however, might offer inmates the opportunity to access consulting service for substance abuse treatment even though the service delivery is generally insufficient [14].
\nJails serve as an introduction to the incarceration system. They are local correctional facilities operated by a city or country instead of the federal or state government. The main purpose of jails and prisoner distribution centers is to confine a person before and after court judgments and to filter prisoners to and from courts and other correctional facilities. Some people in jails have been sentenced, while others might be waiting to be convicted. Many individuals receive an imprisonment of less than 2 years [3].
\nJudgment is mostly a complex process of sentencing. In this respect, inmates in forensic settings might either be arraigned or experiencing the trial process.
\nPrisons are classified as high, medium and low security institutions that are typically used for convicted criminals who have been sentenced to at least a year of imprisonment in U.S. Federal Bureau of Prisons. In addition, depending on the severity of the crime, some individuals are sentenced to either state or federal prisons. However, compared to jails, prisons offer a far more stable environment for the inmates and restrict their interaction with society for longer periods of time [3].
\nThe primary purpose of prisons is to ensure public safety and the security of inmates. In addition to incarcerating criminals, prisons offer them programs to address their criminogenic needs related to education, substance abuse, employment and transition to the community.
\nBasic services in prisons involve intake and screening of psychotropic medicines and to provide occupational therapy services. Those services are substantially provided for prisoners to decrease their social isolation and increase their problem solving and adaptation skills, self-efficacy and self-esteem. The occupational therapy services also promote emotional regulation abilities and social and emotional skills in order for the inmate to deal with prison life and take this opportunity to improve on self-efficacy and occupational engagement [15].
High-security units: Individuals classified as high risk to public safety have been sentenced to life imprisonment and are receiving long term treatment, are housed in high-security prisons. The physical environment in these facilities consists of a number of physical and structural barriers between the facilities and the external environment of the institution.
In high-security prisons with highest number of staff, and both multiple and single cells, criminals remain in their cells or in an outer cage in the facilities’ yard. Each cell is equipped with a toilet, screwed to its floor, and prisoners are permitted up to three 10-min showers per week. Movement is firmly restricted and activity within the cellblock does not occur without other constraints, such as handcuffs, leg irons and corrective officer escorts [3]. Orientation can be considered as essential because it gives the staff the chance to be acquainted with the prisoners. The ward program focus areas, such as improving awareness of self, others and the environment; orientation to time, place and situation; probing cognitive abilities and teaching of new skills to improve leisure time use and psychomotor activation, should be maintained after discharge [16].
Medium-security prisons: Those institutions house individuals with a criminal background and requiring 2–5 years of treatment [17]. Medium-security prisons, where prisoners’ accessibility to prison gardens and exercise areas, libraries, showers and health services are high, offer far more opportunities in terms of interaction, movement and activity in-between prisoners [3]. Medium-security prisons usually have a wide diversity of work-oriented and treatment programs. Parole is more frequently granted in medium-security prisons and may be classified as supervised (always less than 1 h), limited (sent to wards for only 1 or 2 h), occupational therapy parole (join structured activities or subcontract work) and unlimited parole (mostly on weekends and during the week when they do not join specific rehabilitation activities).
Patients included in the rehabilitation process are integrated into community life by developing intellectual and emotional insight, self-care and self-expression skills and general work abilities. Furthermore, providing stress and anger management, psychoeducation and prevention programs for substance abuse in psychoeducation groups facilitates the patients/inmates return to society [16].
Low-security prisons: These facilities have windows and open spaces that allow the prisoners to move and interact freely within the environment. Even though low-security prisons are surrounded by double-rings, they have no prison fences or other secured perimeter and are often unpatrolled by armed guards. Since the inmates might work on agriculture, transport or conservation projects, they can provide training to the prison’s staff; in addition to meeting the labor force needs of other institutions [3].
In open wards (low or minimum-security prisons), during the therapeutic leave and discharge periods, greater priority is given to preparation of patient participation. Patients are expected to adhere to hospital rules and regulations, but are allowed to freely leave their wards and take the opportunity to practice skills acquired in the medium secure wards and joining educational training programs outside the health services [3].
The intensive life skills training program is comprised of communication, conflict management and criticism handling, problem-solving, money handling (budgeting, current price trends) and work-related skills (job seeking, application for a job, writing of curriculum vitae, work interviews through the use of role play). In addition, recreational activity program, and specific work skills-related programs are implemented to enhance psychosocial interactions [15, 16].
\nForensic psychiatric settings are generally located in secure units that rehabilitate individuals deemed unfit to stand trial or not criminally responsible. Those inmates pose a serious threat to either themselves or others because of severe mental illness. A forensic psychiatric setting provides treatment-based approaches with a view to rehabilitating patients while keeping the public safe. Patients, temporarily transferred from correctional facilities or incarcerated environment, are assessed and treated for mental illness in the facility that consists of secure, closed and open common units [17].
\nForensic psychiatric hospitals reintegrate patients systematically into the community with well-equipped and specialized clinical services, as well as an exhaustive range of vocational and rehabilitative programs. Treatment is typically long-term, in order to improve and safely stabilize patients’ mental well-being.
\nReentry centers are facilities that help inmates by offering structured and supervised residential settings just before or after their release. In addition to providing a permanent residence to the individuals, assistance in financial management and facilitating, their return to the society is also arranged. These centers might be especially useful, because the psychological adaptation required for offenders, with expansive criminal histories, returning to the community after a long period of imprisonment, can be particularly demanding.
\nA crucial component of community reentry centers is substance abuse management and mental health treatment and counseling. Growing prison populations are largely due to drug-related crime and drug abuse, but relatively few prisoners receive the appropriate treatment. In this respect, community-based correctional settings have launched out prison-based drug treatment programs during the past few years [3].
\nThere are two main models of psychology about correctional treatment. The risk, need and responsivity model (RNR model) was built up by Andrews and Bonta, and they describe the criminal risk variables named ‘central eight’ (Tables 1) [18]. Good lives model (GLM) is the other model which claims, that rather than addressing criminogenic needs, the focus of treatment should be on the enhancement offenders’ abilities to obtain primary human goods [19]. Purvis describes 11 primary human goods (Tables 2) [20].
\n1. History of antisocial behavior: If there is an early involvement in antisocial acts and if they are still continuing, it is a big risk variable. | \n
2. Antisocial personality: Adventurous, pleasure-seeking, poor self-control personality pattern are other risk factors. | \n
3. Antisocial cognition: Attitudes, values and beliefs supporting crime cause a personal identity favorable to crime. | \n
4. Antisocial associates: Quality of relationship affects the behavior. So that, having close association with criminal peers and relative isolation from prosocial others because of either the individual or the community affects the criminal behavior. | \n
5. Family/marital: Problematic circumstances of home, lack of nurturing relationship and/or poor monitoring behavior. | \n
6. School/work: Circumstances such as low levels of performance and satisfaction in school or work | \n
7. Leisure/recreation: Low levels of involvement and satisfaction in prosocial activities such as leisure time activities | \n
8. Substance abuse: Abuse of alcohol or drugs affects the criminal behaviors. | \n
The ‘central eight’ criminal risk variables.
1. Life (including healthy living and optimal physical functioning, sexual satisfaction) | \n
2. Knowledge(how well informed one feels about things that are important to them) | \n
3. Excellence in work (including mastery experiences) | \n
4. Excellence in play (hobbies and recreational pursuits) | \n
5. Excellence in agency (autonomy and self-directedness) | \n
6. Inner peace (freedom from emotional turmoil and stress) | \n
7. Relatedness (including intimate, romantic and family relationships) | \n
8. Community (connection to wider social groups) | \n
9. Spirituality (in the broad sense of finding meaning and purpose in life) | \n
10. Pleasure (feeling good in the here and now) | \n
11. Creativity (expressing oneself through alternative forms) | \n
The ‘primary human goods’.
If it is examined the models, both are similar, but RNR Model is based on cognitive-behavioral and the GLM is based on humanistic philosophy. The GLM identifies 11 ‘primary human goods’ and RNR identifies ‘central eight’ which are inverse overlap. It can be said that GLM ‘primary human goods’ are inverse restatements of the ‘central eight’ risk factors, viewed from the lens of humanistic psychology [19]. Depending on these criminal risk factors, it is argued that the criminal procedure of the individual can be predicted and therefore the criminal procedure can be prevented by taking the necessary precautions. However, the RNR model is not compatible with occupational therapy outlook in the view of the possibility of irreversible risk factors and bias holding against the individual.
\nThe use of occupational therapy models in forensic rehabilitation focus on client-centered, holistic and occupation-focused practice with the approach of clinical reasoning based on individual preferences and needs. Normally, individuals engage in occupations which they prefer or want throughout their life; however, in secure environment situations, this ability of the individual can be limited or can be restricted by the individual’s mental health/disorder/learning disability, their perceived and their actual risks to themselves or others and institutional regulations, policies or legal restrictions. Individuals who need forensic rehabilitation face some participation limitations to all or a combination of activities and this can cause occupational deprivation additionally to the sense of hopelessness and poor mental health [6, 11, 15]. Moreover, community life skills and performing daily living activities and interaction with the environment of the individual can be limited. Therefore, group or individual occupational therapy programs often target basic living skills, self-care, vocational skills, adaptive coping strategies, creative arts and anger or stress management. The general aim of occupational therapy is to enable individual to experience occupational enrichment and achieve optimal occupational functioning. Occupational enrichment in forensic settings can be considered as both the goal and process of occupational therapy interventions, so evidence-based practice is very important [15].
\nOccupational therapy guideline recommendations show that Model of Human Occupation (MOHO) and its associated assessments are the most used occupational therapy model in forensic occupational therapy. The model was developed in the 1980s by Professor Gary Kielhofner and has had some revisions and collaborations until now. MOHO supports that human occupation is motivated, patterned and performed. Humans are conceptualized as three interrelated components: volition, habituation and performance capacity [16]. Also, environmental considerations are very important to increase the occupational participation of the individual having forensic occupational therapy and rehabilitation [15].
\nVolition presents the individual’s motivation for occupation and relates to individual’s motivation to participate to occupations combined with their self-belief and capacity to succeed which means personal causation. Motivation and personal causation can be affected by the individual’s mental health (such as depression, schizophrenia, personality disorder) or their perception of the reason and need for their admission. Therefore, the literature supports that it is important to establish the individual’s own goals to ensure treatment readiness. Some individuals can have complex occupational histories, which are situated within social tensions related to their antisocial or criminal occupations present lack of motivation to engage and participate activities they want and these individuals can view the environment as a barrier to participation in usual activities which can impact the individual’s mental health and well-being negatively. It is supported that volitional problems are likely to be highly relevant in the secure setting which can cause decrease in personal causation, difficulty in identifying or having unrealistic goals and an inability to and meaning or interest in activities [15, 16].
\nOccupational therapists have the skills and expertise to assess and engage people in those occupations which are meaningful and motivating. This requires a careful understanding and appreciation of what underlies the motivation and creating occupational opportunities like self-care, productivity and recreational activities. Occupational therapists also help people to identify and achieve their own hopes and aspirations such as vocational rehabilitation and work skills [15, 16].
\nHabituation refers the individual’s roles and behavior patterns consistent with his/her lifestyle. It presents automatically and effectively doing routine tasks related to their environment. Roles of the individual are responsibilities of the individual associated with personal identity, occupations and activities of daily life and extraordinary occupations. Individual with criminal lifestyles can have problems on participating prosocial roles with their daily routines and occupations [15, 16].
\nOccupational therapy interventions in secure environments help individual to participate in prosocial roles and occupations in an effort to live within society without resorting to previous criminal or new antisocial behaviors. The imposed legal and security restrictions in secure environments can mean that patients are unable to participate in their habitual or chosen occupations; this may be because such occupations are antisocial, or due to lack of resources, facilities or particular environments being available in secure settings. Often patients benefit from the structure, stability and consistency of admission [19].
\nFor occupational therapy interventions age, ethnicity and culture, finding the ‘right’ occupations that are culturally relevant, risk-managed and appropriate to the ‘typical’ forensic population can be challenging. The literature supports that not only redesigning lifestyle but also technological advances have an impact on the range of occupations that occupational therapist is able to offer to extend the inclusion level of the individual such as contemporary videogames and Nintendo® WiiTM additionally to participating actual sports and recreation activities [16].
\nAccording to the Model of Human Occupation, performance capacity is related to an individual’s adaptive interaction with the environment, and the ability to do activities provided by physical and mental components and the associated subjective experience. Occupationally restricted individuals have problems with occupational performance skills for independence in daily living. Moreover, performance skills may not be acquired or learned during transition from child to adult. Occupational therapists in secure environments have a major role to play in helping patients to develop, maintain or acquire new skills for successful community reintegration or transition to less secure settings, for example in the area of vocational rehabilitation. Occupational therapists can guide individuals to identify possible vocational areas such as study/education, voluntary or paid employment [16, 20, 21].
\nOccupational therapy interventions should help the individual to identify prevocational needs and sometimes individuals have not been or will not have a productive activity like working again and therefore the therapists need to help them to establish different prosocial, productive and meaningful occupations to increase health, wellbeing, occupational performance and general quality of life. For these reasons, it is important for occupational therapists to measure and follow the progress of the individual with outcome measures during daily living activities [17, 18, 21].
\nSocial and physical isolation of the individuals can cause problems to access their own complex occupational and environmental worlds. Being cut from own life can cause limitations over occupational choices and experience, so environmental changes and supports during activity performance can provide opportunities, constraints and demands to the individual. The literature supports that individuals in secure environments spend much of their time in passive leisure, personal care and rest occupations and occupational therapists are one of the core elements in increasing activity participation of the individual and develop occupations of their choice [15, 16]. Also, occupational therapists can facilitate the exploration of new or unknown occupations to increase positive life experiences of the individual.
\nAs it is given earlier, there is a great model need to understand the volition, habituation, performance skills, physical and social environments in which an individual’s occupation takes place. MOHO assists the understanding of occupation(s) and problems of occupation that occur in terms of volition, habituation, performance capacity and environmental context. This system-based model includes well-designed assessments, observational, self-report and interview schedules. One of the advantages of this model is that because of its extensive use in mental health settings; a forensic version of an assessment tool ‘Occupational Circumstances Assessment and Interview and Rating Scale’ was designed. But, the literature also supports that this tool is not the only one for the use of occupational therapists, and occupational therapists may find any particular model, or standardized assessment/outcome measures to support their interventions [4, 15, 16, 21, 22].The literature supports that the use of occupational therapy models in forensic mental health may increase evidence-based practice and help the professionals to show the effect of occupational therapy. As Model of Human Occupation is seen to be the most used occupational therapy model, models including environmental and individual issues such as psychological issues, desires, wants, activity performance and satisfaction from the activity performance can help the occupational therapist to plan more effective assessments and interventions. Although the literature is still limited; different occupational models such as KAWA model, creative ability model, PEOP (Person, environment, occupation, performance), the Canadian model of occupational performance and engagement and the individual placement and support model with can be effectively used with standardized assessments and outcome measures in various individuals, situations, cultures and environments in provision of occupational therapy services in a cost-effective way [6, 15, 16].
\nOccupational therapy process commences with contiguity between the offender and occupational therapy service. Collecting information about the person and making special evaluations is the first step in this process. Gathering information about the individual and special assessments helps to determine the problems and needs, as well as the reason for the intervention. It also allows for the setting of intervention targets and the determination of the intervention plan. In the process of occupational therapy, the intervention plan is followed by the implementation of the intervention. The intermediate evaluation may be needed to determine the effectiveness of the intervention or to reveal new intervention goals and plans. After intervention plans that have been modified or reorganized after the interim evaluation are applied, the intervention is assessed. As seen in the abovementioned occupational therapies process, information gathering and evaluation also play an important role in the intervention for forensic occupational therapy applications. In summary, an occupational therapist working with prisoners should use a three-stage assessment of initial assessment, interim evaluation and outcome measurement during the occupational therapy intervention process [15, 21].
\nOccupational therapy sees people as active and social entities and treats the person, his occupations and the environment holistically in order for the individual to achieve or regain well-being. It is also important to assess the individual as a whole in the information gathering and evaluation process for the creation of a suitable intervention plan [15] . According to the occupational therapy reference frame written by AOTA [15], personal factors include the individual’s values, interests, and spirituality as well as body structure and functions. Having knowledge about the boundaries and areas of internal energy in prisoners’ participation in occupations can be useful to guide activity preferences and motivation processes. The things that constitute the meaning of prisoners’ lives are values and beliefs they believe to be worth trying and taking the time. The occupational therapist in forensic setting desires recreates occupational identification of offenders who lose their roles by being isolated from the social environment. For this reason, it is very important to understand the value, relevance, strengths and limitations of the individual [4, 16, 22].
\nIt is also necessary to assess the sensory, motor and cognitive skills involved in the body structure and functions of the person in need to meet the occupation requirements they wish to perform. These skills can make or break an individual’s daily life. One point that should not be overlooked here is that during the process of occupational therapy collecting and evaluating information, the prisoner does not play a passive role, so the occupational therapist does not seem to be running a process alone. The occupational therapist and the prisoner are in the business association during the presentation of information, evaluation and outcome measures, and the prisoner is actively involved in this process.
\nOccupational therapists are aware that the occupational performance of an individual is influenced by factors related to the individual as well as by the performance patterns and the environment. Roles, routines, rituals, and habits constitute performance patterns [15]. Routines and habits allow the individual to perform his/her daily activities without thinking about how to move, without trying to remember. Occupational therapists working in forensic health services care about whether the prisoner has useful habits and routines for him. It is necessary to know how individuals spend their days and which routines they create from day to guide to get new routines and habits to use the time and energy more efficiently when the living conditions change [11]. Roles are the whole of the behaviors that an individual imposes on his/her responsibility, which is imposed by the environment and culture. Rituals are symbolic behaviors that are understood by social, cultural and spiritual values that shape the occupational identity of the individual. During the evaluations, the roles of the prisoner and the importance of these roles and the determination of meaningful rituals in the individual’s life provide significant benefits for the therapist’s intervention plan. Changes in location and time can also cause changes in the roles and rituals of individuals. The change in the role and ritual of the individual after conviction can cause occupational alienation in the individual. In the context of a forensic health service, acquisition of the prisoner’s new skills and habits, and the new roles and rituals that are well integrated with the environment make an important contribution to the occupational balance of the individual [3, 16, 23].
\nUnderstanding the environments in which occupational performance takes place, it is important for occupational therapists to understand the underlying effects of occupational participation. The environment includes dimensions related to physical, social (including individuals in the individual’s life) and policies, and at the same time creates a supportive or restrictive effect for the occupational adaptation of the individual. Situations such as an absence of freedom for the individual, individual secrecy, and the meaningful and socially acceptable occupations constitute a barrier to prisoners’ participation in their environment and occupation [15, 24]. Occupational therapists should also be thoroughly evaluating the environment of individuals who are establishing an intervention plan with prisoners applying to the occupational therapy service.
\nWe have already mentioned the preferred models for forensic occupational therapy applications. MOHO, one of these theories, includes structured and unstructured assessment and information gathering tools [3, 4, 11] for collecting and evaluating information about offenders. Some of those:
Occupational performance history interview (OPHI II)—A semi-structured measure of self-care and information about the individual’s life history;
Assessment of communication and interaction skills (ACIS)—evaluates three subdomain individuals, including the physical dimension of communication, information exchange, and relationships, in an occupational pattern or in a social group [25];
The Model of Human Occupation Screening Tool (MOHOST)—gives the client a holistic view of his or her motivation to achieve occupation, communication and interaction skills, occupation patterns and the individual’s process and motor skills as well as the environment. MOHOST also allows a highly effective assessment of the effectiveness of occupational therapy interventions [26];
Occupational Self-Assessment (OSA)—a method of assessment that reveals how the individual focuses on the occupational competence of the individual about his/her occupational adaptation, helping to shape the needs and values of the individual. OSA is a highly recommended assessment tool for evaluating forensic occupational therapy. Individuals are given a very wide list of daily occupations, individualists are asked to evaluate the occupations in their own eyes and the level of their own performance [26];
Occupational circumstances assessment interview and rating scale (OCAIRS-Forensic Mental Health Version)—the therapist has extensive content to get detailed information about the offender. It gives the individual an accurate and holistic view of occupational functionality. If the more fully involved the offender is in the evaluation process, the higher the participation in intervention practices [27, 28].
Evaluations such as Canadian occupational performance measurement, assessment of motor and process skill, independent living scale, and the role checklist are other measures preferred by occupational therapists [3, 24].
\nAnother assessment heading in the forensic occupational therapy process is risk assessment. When considering the evaluation processes mentioned earlier, a prisoner who has forensic settings should be considered as a means of risk assessment to determine the potential for another crime or previous crime. Occupational therapists take into account the risk assessment and management of risks posed by each client and to increase the occupational involvement of individuals by taking environmental precautions and managing them to manage risks in environments such as high-risk kitchens and workshops to improve individual skills as well as providing positive risk-taking opportunities to enhance the capabilities of both individuals.
\nCurrent risk factors such as age and gender, substance use status, criminal history and potential risk factors such as marital status, occupational participation level in the forensic setting, family support should be considered in the risk assessment. Occupational therapists pay attention to the influence of the person-environment-occupation interaction on the occupational adaptation of the individual. Occupational therapists can estimate the effects of individual’s personality and sociodemographic characteristics (physical, cognitive and psychological), their level of skill and the environmental risk factors, including interpersonal interaction, social support network, hospice environment, social security status on the possible risk factors. For this reason, they may play an active role in providing counseling to minimize the risks faced by prisoners and these risks’ adverse effects on occupational adaptation [3, 21].
\nAs already mentioned, offender rehabilitation in forensic settings is not different from other mental services. Intervention methods used by occupational therapists must include life skills development (such as ADLs, IADLs, and health management), occupational development, awareness (such as self-awareness and social awareness), self-management, skill-building (such as social, relationship, vocational skills), education etc.
\nThe GLM is a model that overlaps the humanistic point of view of occupational therapy. Although the GLM is a psychology-based model, it supports occupational therapies’ application models such as PEO, MOHO, CMOP and role acquisition model. Occupational therapists may develop interventions taking into account the GLM’s the primary human goods components. Some intervention recommendations based on the ‘primary human goods’ are given in Table 3.
Life: Life skills training is a commonly used occupational therapy intervention in mental health [30]. Offenders are at a higher risk for poverty, unemployment and difficulties in relationships. The life skills training interventions can focus on self-care, self-maintenance, intrinsic gratification, social contribution and interpersonal relatedness skills. The interventions must be client centered and the context must be well evaluated. While working with an offender, the balance of daily occupations should be kept in mind for a healthy lifestyle.
Knowledge: The development of interventions for improving self-awareness is very important in offenders’ rehabilitation. Self-awareness is the ability to recognize him/herself as an individual who is different from other individuals. Self-awareness is having a clear perception of personality, including strengths, weaknesses, thoughts, beliefs, motivation and emotions. The aim of the interventions is to gain a sense of self-worth. Facilitatory interventions, such as education, feedback, behavior therapy and psychotherapy have been recommended to a greater extent than compensatory interventions.
Excellence in work: The main problem of ex-offenders is employment to maintain their lives [31]. Unemployment concerns begin to increase still they are in prison. They face substantial barriers to many types of legal employment [32]. These barriers are poor basic skills, low self-esteem, a lack of recent work experience, employer discrimination, behavioral and health problems. Interventions must include prevocational training, job search skills, work-related practice and also work hardening.
Excellence in play: Recreational activities and hobbies are the enjoyable, activities that are restorative in which the clients’ choice and control often associated with leisure time. Recreational pursuits and hobbies are the power of life. The main aim of the therapeutic recreation is to enhance the patient’s quality of life and ability to participate in leisure and/or play. Also, it can improve social participation and social skills which is very important for the offenders.
Excellence in agency: Self-directedness is the ability to organize and adapt a behavior to achieve individual selected goals and values. Self-directedness includes the concept of an autonomous individual and concepts of personal integrity, self-respect, dignity, efficacy and feelings about one’s life [33].
Inner peace: Anger management problems affect all parts of a persons’ life. The goals of treatment are to increase the client’s resources for coping with stress and try to decrease the demands made on the client. Treatment is first achieved by increasing awareness of the client about the relationship between anger and stress and then increasing the effective use of the stress management techniques that the client is able to cope with [11, 34]. Anger management interventions begin with recognizing the triggers of anger. The client must take responsibility for his/her own change so that the problem can be solved. The second stage of the intervention is the awareness of the behaviors when the client is angry, such as, shouting, swearing, treating verbal, postural or gestures, abusive behaviors such as phone calls, messaging or other communication ways, harassments, emotional abuses or violent. Also in this stage, the therapist must help the client to identify times when his/her thoughts do not lead to logical or rational conclusions. The third stage is teaching specific skills to help the client to manage triggers for anger effectively, such as relaxation techniques, mindfulness and assertiveness.
Relatedness: Group interventions in which the family members and friends are engaged are suitable for relatedness [35]. The aim of the interventions must be establishing and maintaining relationships with others, resisting inappropriate social pressure, working in cooperation, preventing and resolving interpersonal conflict, asking for help when necessary [29].
Community: Deficits in social skills are often seen in forensic groups. Social skills training is the main intervention method for being active in a group [36]. For being in a group, it is also important to make responsible decision to identify and evaluate the problems correctly, making decisions based on ethical and social norms, to evaluate decisions in context, contribute to the welfare of society, accurately identify and evaluate problems, make decisions based on ethical and social norms, consider context in decisions, contribute to well-being of community [29]. Social skills training consists of learning activities that use behavioral techniques that enable individuals to acquire independent life skills for better functioning in their communities. Direct teaching, modeling, role playing, behavior rehearsal, and social reinforcement can be used during the interventions.
Spirituality: The spirituality is the ‘meaning and purpose in life, the life force or integrating aspect of the person and transcendence or connectedness unrelated to belief in a higher being’ in occupational therapy perspective [37] . The meaning of spirituality is different for everyone, can be participating a religion, visiting religious places (such as churches, mosques, synagogues etc.) regularly and can be different for some praying alone, yoga, meditation, being in the nature, walking and so on. There can be challenges about talking about the beliefs and spirituality with the client and that much of spiritual experience can be culturally influenced [37]. Motivation techniques can be used to find meaning and purpose in life.
Pleasure: Pleasure is one of the subjective experiences of the human need-based experiences to engage in occupations [38]. It influences productivity, restoration and being active to engage occupations [39]. Motivational and increasing self-esteem and confidence interventions can be used to improve pleasure.
Creativity: It is stated that ‘creativity is part of everyday practice; the use of creativity as a conscious approach; creativity involves risk-taking; creativity needs a supportive environment; and creativity is the use of expressive arts in therapy’ [40]. Especially creative arts increase the capacities of offenders, help to explore their own resources, assist them to locate hope and motivation, recognize their interconnectedness with others without external pressure to comply [41].
The ‘primary human goods’ | \nIntervention recommendations | \n
---|---|
1. Life (including healthy living and optimal physical functioning, sexual satisfaction) | \nAim: Understand themselves, reach personal satisfaction, live life better and achieve their goals Occupational strategies: Functional life skills Role development Independent living skills Literacy and education ADLs IADLs Health management Gender-specific issues Money management | \n
2. Knowledge (how well informed one feels about things that are important to them) | \nAim: Identify one’s emotions, thoughts, interests, and values; understand how internal characteristics influence actions; maintain a sense of self-confidence and self-efficacy Occupational strategies: Self-awareness Drug and alcohol awareness | \n
3. Excellence in work (including mastery experiences) | \nAim: To keep the physical, psychological and social needs of the individual together, to increase the independence of the individual and to work with a holistic and customer-centric approach in the role of the worker. Occupational strategies: Prevocational training Job search skills Work-related practice Vocational rehabilitation: work preparation, voluntary and paid work Work hardening | \n
4. Excellence in play (hobbies and recreational pursuits) | \nAim: To build up hobbies, recreational pursuits Occupational strategies: Recreational skills Time management | \n
5. Excellence in agency (autonomy and self-directedness) | \nAim: To organize and adapt a behavior to achieve individually selected goals and values Occupational strategies: Anger management Stress management Problem solving skills Motivation | \n
6. Inner peace (freedom from emotional turmoil and stress) | \nAim: Regulate emotions, thoughts and behaviors across contexts; cope with stress and manage impulses; set goals Occupational strategies: Self-management Increase self-esteem and confidence by promoting personal responsibility | \n
7. Relatedness (including intimate, romantic and family relationships) | \nAim: Establishing and maintaining relationships with others; resisting inappropriate social pressure; working in cooperation; preventing and resolving interpersonal conflict; asking for help when necessary [29]. Occupational strategies: Relationship skills Complex relationship building Facilitating development of supportive relationships Social skills | \n
8. Community (connection to wider social groups) | \nAim: Being active in social groups Occupational strategies: Social skills Social awareness Responsible decision-making Graded community engagement and one-to-one goal planning Empathy | \n
9. Spirituality (in the broad sense of finding meaning and purpose in life) | \nAim: To find meaning and purpose of life Occupational strategies: Motivation | \n
10. Pleasure (feeling good in the here and now) | \nAim: Feeling good, loving life Occupational strategies: Motivation Increase self-esteem and confidence | \n
11. Creativity (expressing oneself through alternative forms). | \nAim: Knowing himself about what he can do Occupational strategies: Skills development Vocational activities include such as woodwork, crafts, graphics, horticulture | \n
Intervention recommendations in offender’s rehabilitation from the view of occupational therapy.
The main challenge is the context because of the complexity of the rules affecting the freedom of the offender and the occupational opportunities [7]. The heterogeneous client population is another challenging condition with in the context. Restricted daily living activities cause the loss of control and autonomy. Time use is another challenging factor, the lack of structured time use besides the loss of control and autonomy affects the client’s volitions, habits, and routines. Also, lack of opportunities for meaningful, individualized career choices for patients affects the client.
\nAlso, change, itself is a challenging condition. There are many factors that affect the daily living activities that are the volitions, habits of the individual and the environment. Therefore, it is not possible to catch the change in every environment. Even in a prison or in a secure hospital or a probation service, the offender has always an obligation and mostly a restricted occupational choice. Motivation or perceived lack of choice is an important challenge. Another challenge is the obligations dictate some occupations and this is not the individual’s choice. Occupational therapy is client-centered, but freedom deprivation is a challenge to make interventions. Occupational therapy is client-centered but freedom deprivation is a challenge to make interventions. Labeling and stigma are other challenging parts of the offenders’ participation in the occupations and the community.
\nKeeping the three justices—criminal justice, occupational justice and social justice—in a balance is the main aim of the offender’s rehabilitation and the most challenging part of the rehabilitation.
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\\n\\nAs a gold Open Access publisher, an Open Access Publishing Fee is payable on acceptance following peer review of the manuscript. In return, we provide high quality publishing services and exclusive benefits for all contributors. IntechOpen is the trusted publishing partner of over 118,000 international scientists and researchers.
\n\nThe Open Access Publishing Fee (OAPF) is payable only after your full chapter, monograph or Compacts monograph is accepted for publication.
\n\nOAPF Publishing Options
\n\n*These prices do not include Value-Added Tax (VAT). Residents of European Union countries need to add VAT based on the specific rate in their country of residence. Institutions and companies registered as VAT taxable entities in their own EU member state will not pay VAT as long as provision of the VAT registration number is made during the application process. This is made possible by the EU reverse charge method.
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