Adopting a citizenship approach to make sense of people's lived experiences of mental health recovery: developing a model of citizenship for health and social care practice

Background: People with lived experience of mental health problems (MHPs) are often marginalised and can have difficulty achieving community inclusion. Citizenship, a relatively novel concept in mental health, provides a means of understanding what is important for marginalised individuals and groups to gain a sense of belonging within their communities. Aim: This study aimed to 1) develop a greater understanding of the construct of citizenship from the perspective of those who had experienced "life disruptions" (including mental health problems) and 2) develop a measure of citizenship that reflected the multi-faceted and dynamic nature of the concept. Methods: A mixed-method, community based participatory approach was adopted. Ten focus groups (n=77) were conducted to generate statement items about the meaning of citizenship followed by concept-mapping sessions with participants (n=45) to categorise and rate items in terms of importance and achievability. Participants were people with recent experience of mental illness, a long-term physical health condition, or involvement with the criminal justice system, as well as to people who did not primarily identify as having experienced any of these major life disruptions. Multidimensional scaling and hierarchical cluster analysis were used to develop a five-cluster model of citizenship; this informed the development of a citizenship measure. Findings: A five cluster-model of citizenship was developed: building relationships, autonomy and acceptance, access to services and supports, values and social roles, and civic rights and responsibilities. These clusters informed the development of a measure of citizenship to be applied within health and social care policy and practice. Conclusion: This multidimensional model of citizenship highlights the interplay between the relational and structural aspects of citizenship and provides an empirical framework for policy makers and practitioners to develop citizenship-based initiatives that contribute to the recovery and social inclusion of people who have experienced mental health problems and/or other major life disruptions.