Training staff to promote self- management in people with intellectual disabilities

Background : People with intellectual disabilities have increasing difficulties managing their daily affairs. This study examined the effectiveness of a staff training, which teaches staff to promote self- management in people with intellectual disabilities. Method : Effectiveness was assessed with questionnaires addressing clients’ ( n = 26) independence and self- reliance, support needs and challenging behaviour, using a pre–posttest control group design. Additionally, focus groups were conducted with trained staff members 6 months after the training. Results : In the long term, the intervention group showed a significant increase in independence and self- reliance, in contrast to the comparison group. No effect was found on support needs and challenging behaviour. Trained staff members reported limited benefits of the training, but had noticed changes in their attitude and method of working afterwards. Conclusions : Further self- management research is required to investigate how independence and self- reliance can be promoted more effectively in this population. Future trainings should carefully consider their content, format, and implementation.

disabilities to function independently (Netherlands Institute for Social Research, 2014). Partially as a result of these developments, the demand for care for people with intellectual disabilities has grown considerably over the past few years in several north western European countries (Netherlands Institute for Social Research, 2014). Possibly related to this, the costs for the care for people with intellectual disabilities have greatly increased as well (Van der Kwartel, 2013) and support staff experience increasing difficulties to meet the care needs of their clients (Hermsen, Embregts, Hendriks, & Frielink, 2014). As different countries have different, and sometimes restricted, budgets and care systems, this could mean that people with intellectual disabilities do not always have sufficient access to the increasing amount of care they need. Altogether, this requires support staff to focus on promoting selfmanagement in people with intellectual disabilities, in order to make them more independent and self-reliant (Ferretti, Cavalier, Murphy, & Murphy, 1993;Netherlands Institute for Social Research, 2014).
Broadly, self-management refers to a variety of activities that are related to deliberately changing or maintaining behaviours in order to achieve self-selected outcomes (Browder & Shapiro, 1985). It can be seen as an overarching term, related to concepts such as self-determination, autonomy, independence and self-reliance. Self-determination and autonomy are centred around having personal control over making choices and decisions in order to lead one's life according to one's own preferences, free from external influences (e.g., Tonkens & Weijers, 1999;Wehmeyer, Kelchner, & Richards, 1996). Independence and selfreliance involve abilities to take actions to manage one's own affairs and to provide for oneself, thereby relying on one's own efforts, resources, judgement and abilities, without requiring help and support from others. Self-management thus includes the former, making self-selected choices, and the latter, having the capacities to shape one's own behaviour in order to achieve the personally desired outcomes.
Previous research on self-management in people with intellectual disabilities has focused mainly on specific behaviours or domains.
Although they showed some promising results, limitations such as a small sample size and a limited number of trained activities impede the generalisability of the findings. Whether these approaches would also be effective and applicable to promoting overall independence and self-reliance has not been investigated.
There is also a lack of research focusing on how support staff can be trained to improve their clients' level of independence and selfreliance. If support staff stimulate clients to do things themselves, instead of taking over, this could reduce clients' dependency, passivity, and "learned helplessness" (Sigafoos et al., 2005), regardless of whether someone has a mild or severe intellectual disability (Ramdoss et al., 2012). Several studies have investigated person-centred active support, an approach directed at active engagement and participation in meaningful activities (e.g., Beadle-Brown, Hutchinson, & Whelton, 2012;Mansell, Elliott, Beadle-Brown, Ashman, & Macdonald, 2002;Riches et al., 2011). Although this approach could enhance the ability of people with intellectual disabilities to manage (parts of) tasks independently, it is not its primary aim. What staff can do to effectively target overall independence and self-reliance has not been studied. In general, research on staff training in the field of intellectual disabilities has put forward the importance of practice leadership. Good practice leadership can lead to better implementation of a staff training, as a practice leader enables, encourages, coaches and reviews staff in order to ensure good support (Beadle-Brown, Bigby, & Bould, 2015).
Coaching was also found to be important in a meta-analysis by Van Oorsouw, Embregts, Bosman, and Jahoda (2009). They found that the most effective way to change client behaviour through staff training was by adding coaching-on-the-job and verbal feedback to classroom trainings. With adding an on-the-job component, it becomes more likely that performance of target skills acquired during a training will generalise to the regular work situation (Parsons, Rollyson, & Reid, 2012). Whether practice leadership and coaching-on-the-job are also essential for training staff to promote self-management is yet unknown.
The current study is the first to evaluate the effectiveness of a staff training aimed at promoting overall self-management of people with intellectual disabilities. The methodology of the training is called "On Your Own Two Feet" (Scholten & Schuurman, 2008) and is based on the method of Feuerstein (Feuerstein, Rand, & Rynders, 1993) and the "Own Initiative Model" (Timmer & De Vries, 2014). Inspired by Seligman's positive psychology (Seligman, 2002), staff are taught to focus on clients' abilities, instead of disabilities, and on expanding these abilities. By letting clients perform tasks that are within their zone of proximal development, they facilitate their learning process (Vygotski, 1964). According to the methodology, staff need to encourage clients to think and handle things themselves. This approach thus targets clients' general problem solving skills by teaching them to find the answers to their own questions, which could also help them become more independent and self-reliant (Mastropieri, Scruggs, & Shiah, 1997;Smith et al., 2016). The idea is that teaching such a pivotal skill as general problem solving, is more efficient than teaching someone a specific skill, since it could generalise more easily to untrained skills (Smith et al., 2015).
The primary aim of the current study was to investigate whether the staff training "On Your Own Two Feet" (Scholten & Schuurman, 2008), which promotes self-management, was effective in increasing the level of independence and self-reliance of people with intellectual disabilities and whether it would decrease the amount of required support. It was also hypothesised that the training would reduce the occurrence of behavioural problems. The secondary aim of the study was to explore the opinions of trained staff members regarding the effectiveness of the training.

| Procedure
The Medical Ethics Committee of the Leiden University Medical Center evaluated the study protocol and declared that no formal medical ethical approval nor written informed consent was required, because the study did not fall under the Medical Research Involving Human Subjects Act. All participating people with intellectual disabilities, their legal representatives and support staff were informed about the study beforehand. People with intellectual disabilities and their legal representatives were informed by letter and were invited to an information meeting. Staff were informed during team meetings. They were notified that all data would be handled confidentially and anonymously for the purpose of a scientific study and publication. They were given the opportunity to ask questions for further clarification. People with intellectual disabilities or their legal representatives could decline participation. If someone would have objected to participation, the person in question would have been excluded from the study. However, no one declined. As this study was conducted in collaboration with Raamwerk, a health care organisation in Noordwijkerhout, the Netherlands, data collection took place at this location. Preceding the training sessions (T0), questionnaires about the participating people with intellectual disabilities were filled in. This was repeated 3 (T1) and 6 months (T2) after the training.
In addition, 6 months after the training, focus groups were held with trained staff members to evaluate the training and to see whether they had experienced any changes in the past half year. Trained staff members were informed about the focus groups during their team meeting and were asked to participate on a voluntary basis. They were told beforehand that the data from the focus groups would be handled confidentially and anonymously, and that it would be used for the publication of a scientific study. Participation occurred during work hours.

| Staff training
In total, 28 staff members (11 men and 17 women) received the training in promoting self-management. They worked either as support staff in group homes (n = 17) or day care services (n = 10), or as a remedial educationalist (n = 1). Their ages ranged from 23.24 to 59.24 years (mean [M] age = 33.26; standard deviation [SD] = 9.47), the years of work experience with people with intellectual disabilities varied from 2 to 20 years (M = 9.45; SD = 4.29). They were divided into three groups that received the training on three different occasions. The training was provided by professional trainers who were instructed by the developers of the training and who all had experience in the field of intellectual disabilities.
The training that was provided is called "On Your Own Two Feet" ("Op Eigen Benen" in Dutch) and is developed and described in greater detail by Scholten and Schuurman (2008). During the two consecutive days of the classroom training, lasting about 12 hr in total, staff are provided with a theoretical framework of the methodology and participate in exercises and role-play to practice different techniques.
They start with evaluating and discussing their current attitudes and ways of providing support when working with people with ID, by means of a self-report questionnaire. Next, the philosophy behind the methodology is explained, which is based on the method of Feuerstein (Feuerstein et al., 1993), the "Own Initiative Model" (Timmer & De Vries, 2014), positive psychology (Seligman, 2002) and the zone of proximal development (Vygotski, 1964). The ideology concerns looking at people with intellectual disabilities as unique individuals and having a positive attitude towards them by focusing on each person's strengths, capacities, abilities to learn and way of learning. This is illustrated by an exercise to show that each individual has his or her own talents and that an individual approach is therefore necessary. In another exercise, staff are trained to rephrase difficult behaviours in a positive way.
The role of staff also forms an important part of the training. Staff are taught to adopt the role of a coach or a mediator, who encourages people with intellectual disabilities to think, find out, and do things for themselves, instead of taking over or telling them what to do. It is explained how they can promote self-management in their clients, which is practised with a role-playing exercise on coaching people towards the proper execution of a task by asking them questions, while not giving away the answers. Staff are also taught to build on an individual's existing strengths, interests, knowledge and abilities to stimulate learning and development. This can be achieved by letting clients perform tasks for which they still need some assistance and letting them discover themselves how to execute something. This is also practised with various exercises that teach staff how to connect to another person's knowledge, skills and style of learning in order to adapt their way of coaching. Attention is also paid to the importance of fostering selfworth and building an equal, trusting and respectful relationship with clients. Toward the end of the training, the changes in the attitude and role of staff throughout various phases of learning are also addressed.
Where providing safety and trust are important in the initial stage of learning, as clients progress, it becomes more important for staff to step back and provide room for their clients to experiment. Finally, it is discussed that it is important to support the transfer of learnt skills to daily life and to include the social network of clients.

| Participants
Raamwerk selected three group homes for people with intellectual disabilities whose support staff would receive the training in promoting self-management. The participants of the intervention group were thus selected by means of purposive sampling. This intervention group consisted of 15 people with intellectual disabilities. Between T1 and T2, three of these people moved away and therefore dropped out of the study. The comparison group was put together by two remedial educationalists of Raamwerk, who selected people with intellectual disabilities that were as comparable as possible to the intervention group with respect to the level of the intellectual disability, age and gender. This group consisted of 11 people with intellectual disabilities, living in four different group homes whose support staff were not trained. Descriptive statistics of the participants are presented in Table 1. Diagnostic information was obtained from their electronic client records.

| Independence and self-reliance
The Social Functioning Scale for the Mentally Retarded (SFSMR; Kraijer, Kema, & De Bildt, 2004) was used, which consists of 31 items addressing several components of independent functioning and selfreliance at home and in social situations (e.g., getting dressed, setting the table, cleaning up, language expression). Items can be rated on four levels, objectively reflecting what a participant currently does by himself, with higher scores indicating better functioning. The raw total scores were used for the analyses, which could range from 0 to 124.
The questionnaire was filled in by the client's personal tutor, together with either the remedial educationalist or another staff member who frequently worked with the participant at home or at day care. The questionnaire is widely used in Dutch health care organisations for people with intellectual disabilities. The psychometric properties of the questionnaire regarding both the reliability and construct and criterion validity have been found to be good (Egberink, Janssen, & Vermeulen, 2004).

| Support needs
To evaluate the support needs of the participating people with intellectual disabilities, the Dutch version of the Supports Intensity Scale (SIS; Thompson et al., 2010) was used. The SIS was only filled in at T0 and T2, since we only expected an effect on support needs in the long term. The SIS is a semi-structured interview that assesses the intensity of support that an individual with an intellectual disability requires to successfully perform several activities. Section 1 of the SIS includes 49 activities that are grouped into six domains; home living, community living, lifelong learning, employment, health and safety and social activities. Section 2 consists of eight items that address protection and advocacy. For the analyses, the sum of the raw total score of Sections 1 and 2 was used, which could range

| Behavioural problems
The Dutch version of the Developmental Behaviour Checklist (DBC; Koot & Dekker, 2001) was filled in by the client's personal tutor to assess the occurrence of emotional and behavioural problems.
These concerned disruptive/antisocial, self-absorbed, communication, anxiety and social problems. In this questionnaire, 95 items are rated on a 3-point scale, indicating the frequency of occurrence of a particular type of behaviour (0 = not at all, 1 = a little or sometimes and 2 = clearly, often). The raw total score was used for the analyses, with higher scores reflecting more behavioural problems. This score could range from 0 to 190. Although the questionnaire is aimed at minors with intellectual disabilities, it has been

| Statistical analysis
A pre-test/post-test follow-up control group design was used to study whether the staff training in promoting self-management had an effect on the level of self-reliance, the support needs, and the oc- Longitudinal multilevel analyses were conducted to examine the differences between the groups in the scores on the three different questionnaires. This type of analysis accounts for missing data. We included a random intercept and the fixed factor of group. In addition, for the analysis of the SFSMR and the DBC, two dummy variables for time were created (Time 1 and Time 2), representing the short term (T1 versus T0) and long term (T2 versus T0), respectively. Only for these two questionnaires, to analyse the short-and long-term effects of the staff training, the interaction terms (i.e., cross-products) between group and each of the two dummy variables for time were included. For the SIS, only one post-test was available, therefore the two dummy variables for time were not used, but merely the fixed factor of time and the interaction between group and time.
Given the small sample size, non-parametric Mann-Whitney tests were conducted as well on the difference scores between T1 and T0 (only for the SFSMR and DBC) and T2 and T0, in order to check whether the results from the longitudinal multilevel analyses could be confirmed.

| Focus groups
To further evaluate the staff training in promoting self-management, two focus groups were held with trained staff members of Raamwerk 6 months after the training. Unlike individual interviews and surveys, focus groups use group interaction to generate a better understanding of not only what people think, but also how they think and why they think that way. It is a particularly useful method for exploring people's knowledge, attitude and experiences, and for gaining insight into behaviour, organisational issues and needs (Kitzinger, 1995;Krueger & Casey, 2015). One focus group was with support staff working in the group homes that were part of the training (n = 6; 1 man and 5 women; mean age = 36.29 ± 12.51 SD). The other focus group was held with trained staff members working in day care services (n = 7; 5 men and 2 women; mean age = 33.60 ± 9.33 SD). The addressed topics included what they had learnt from the training and whether they had noticed any changes afterwards in knowledge, attitude, skills and method of working of themselves and their team members. If so, they were asked what might have caused these changes. Moreover, they were asked whether they missed anything within the training. The focus groups were chaired by an independent moderator with experience in the field of intellectual disabilities. The primary researcher (first author) observed both meetings and took notes, but did not actively participate in the discussions. The focus groups were audio-recorded with the participants' consent and were transcribed verbatim.

| Qualitative analysis
For the secondary research question, a qualitative analysis was performed to study the opinions of trained staff members regarding the effectiveness of the staff training in promoting self-management.
Analysis of the data took a general inductive approach (Thomas, 2006), using ATLAS.ti 7.5.6 software. The four questions addressed in the focus groups served as a framework for the analysis. Two coders independently listened to the recordings, while reading and coding the transcripts. Discrepancies between coding were discussed until consensus was reached. In case of a remaining disagreement, a senior T A B L E 2 Descriptive statistics for total raw scores on the questionnaires for participant groups researcher was asked to make a final decision. The definitive codes were analysed and categories were inductively identified based on how extensively codes were discussed.

| Baseline characteristics
The intervention group and the comparison group had a similar gender balance and did not differ in age. The level of severity of the intellectual disability, IQ and the presence of comorbid psychiatric diagnoses also did not differ significantly between the groups. Baseline scores on all three questionnaires were not significantly different either. Overall descriptive statistics for both groups per questionnaire per measurement point are presented in Table 2. Table 3 presents the results of the longitudinal multilevel analysis.

| Effect of the training on independence and selfreliance
There was a significant interaction effect of Group by Time 2. In the long term (T2 versus T0), the intervention group showed a significant increase in the score on the SFSMR, in contrast to the comparison group.

| Effect of the training on support needs
The results of the longitudinal multilevel analysis of the SIS indicated that there was no Group by Time effect, indicating that the support needs of the intervention group did not significantly differ (from T0 to T2) compared to the comparison group (Table 4).

| Effect of the training on behavioural problems
The longitudinal multilevel analysis of the DBC did not show a Group by Time effect, which means that there were no significant differences in the occurrence of behavioural problems, neither in the short term nor in the long term. The results that are reported (Table 5) are from the analysis with the outlier included, since there were no differences in terms of statistical significance between the outcomes of the analyses with and without the outlier.

| Non-parametric tests
In addition to the longitudinal multilevel analyses, non-parametric Mann-Whitney tests were performed to see whether the abovementioned results could be confirmed. Again, only the difference score on the SFSMR between T2 and T0 differed significantly between the groups, U = 9.00, p < .01. The difference scores on the DBC, the SIS and the SFSMR between T1 and T0 were not significantly different between the groups (all p-values >.05).

| Focus groups
The content of the focus group discussions were mostly comparable between those working in group homes and those working in day care services. Table 6 summarises the identified categories and lists several illustrative quotes. Overall, according to the trained staff members, the training provided them with little new information. What they had learnt, however was (how) to ask their clients more questions.
Although the various teams did not make any new agreements on how to guide their clients after the training, they had noticed several changes since then, especially within the group homes. Some staff T A B L E 3 Results of the longitudinal multilevel analysis of the Social Functioning Scale for the Mentally Retarded To me it was more a confirmation. What was said in the training, yes, that is how we work as well.

Skills
General Asking questions Yes, skills have grown, in my opinion.
With regard to skills, we have learnt questioning techniques.
Have you noticed any changes after the training in knowledge, attitude, skills, method of working?

Category Subcategory Quotes
Awareness General I tend to take things over a lot from clients, but I am now more aware that I should do that less frequently.
We are now more aware that clients can do much more themselves.

Attitude
Focus on abilities I now focus more on clients' possibilities to develop, which makes my job more fun.

Client in control
Taking over In our group home, we should sit with our feet up more often, give some guidance, and do nothing more. Just follow them with your hands behind your back. If I look back 6 to 12 months to see whether this has happened, then, yes. Now you can, so to speak, really sit with your feet up on the table and say 'Go ahead, what would you do'? We let the client take control more often than before. We dare to let go more often. Less automatic thinking, but listening more to the client, what he wants. More letting go, letting them think for themselves more, letting them do things themselves more.

Little changes General Team agreements
We already did a lot of those things. In our group home, little changed. After the training, there was no meeting on how to implement this within the team and in our way of guiding clients.
What might have caused these changes?

Training Training effect No training effect
The awareness has increased because of the training. I do not think these changes are caused by the training.
Have you missed anything within the training?

Category Subcategory Quotes
Application Daily practice Putting it into practice was not discussed that much.
Own case studies General It [the training] was more with the use of pictures and case studies, but it is different when you focus on your own client: 'I am running into these difficulties with this client, how can we approach that?'… Everyone from the other group homes can learn from that as well. That is an easier way to help each other and give each other advice than with a picture.
Coaching-onthe-job General Shadow me for a day, a couple of hours, and observe how I am doing within my group home.

Techniques Communication
Yes, conversational techniques. How are you going to motivate clients that find it difficult to devise themselves how to do something, to still find this out themselves? members attributed these changes to the training, whereas others did not. Changes included a difference in their attitude towards clients and an increased awareness that they should not take over from them but instead focus on what their clients are able to do themselves.
Furthermore, many noticed an alteration in their method of working.
They listened more carefully to their clients, instead of (automatically) thinking on their behalf. They did not take over tasks from them as much as they used to and they more often dared to let go and let the clients take charge. When asked whether they missed anything within the staff training, additional coaching-on-the-job was mentioned, next to learning new techniques and learning how to apply the training to their own daily practice at work, for example by discussing and practising with their own case studies.

| DISCUSSION
The aim of this study was to evaluate a training for support staff, which teaches them how to promote self-management in people with intellectual disabilities. Apart from improvements in independence and self-reliance, it was hypothesised that the staff training would lead to reductions in support needs and behavioural problems of people with intellectual disabilities. The main finding of this study was that even though no differences between the intervention and comparison group were found in support needs and behavioural problems, the intervention group showed more improvement in independence and self-reliance in the long term. However, this latter effect was small, and thus overall, it can be concluded that the results only provide limited evidence for the effectiveness of the staff training.
Although various previous studies have found more convincing evidence for the effectiveness of self-management interventions, caution is still in order, for example because of their even smaller sample sizes and the lack of a comparison group (Cannella-Malone et al., 2006;Mechling et al., 2009;Storey, 2007). The heterogeneity of the studies' specific goals, designs and outcome measures also impedes a proper comparison of the interventions and their impact (Dannenberg, Mengoni, Gates, & Durand, 2016). However, important factors for an effective intervention seem to be that it can be adapted to the individual user and the specific context (Hale et al., 2011;Storey, 2007;Young et al., 2012), and that not only people with intellectual disabilities are involved, but also those who care for them (Hale et al., 2011;Wilson & Goodman, 2011;Young et al., 2012). Although both were the case in the intervention that we evaluated, its effect was still small.
In the focus groups, trained staff members also reported that the staff training had limited benefits. It mainly confirmed their knowledge and method of working. Nevertheless, after the training, some staff members had noticed positive alterations in their attitude towards clients and in their method of working. However, these were possibly too subtle to induce significant changes in their clients' level of functioning. Concerning the content of the training, support staff stated that they would have liked to learn more about things they did not know yet and could therefore develop during the training, such as new techniques for guiding their clients. They also would have liked to focus more on the application of the training's methodology to their own daily practice.
The above-mentioned findings from the focus groups could suggest that the training did not yet sufficiently clarify how the staff members could have promoted self-management in their own clients. This might explain why afterwards, none of the teams made new agreements on how to guide their clients based on the methodology that was taught. It seems that the actual implementation of good support staff practices in the field of intellectual disabilities is a difficult task, as was also seen in previous research (Beadle-Brown et al., 2015). A barrier to the implementation also possibly concerns insufficient encouragement from within the organisation to practice the methodology (Totsika, Toogood, Hastings, & Nash, 2008). If a practice leader would have been appointed, this person could have organised, encouraged, supervised and coached the trained staff to put the methodology of the training into practice. This could have improved the implementation of the training, the quality of staff practice, and therefore the outcomes for the people with intellectual disabilities who were supported by the trained staff members (Beadle-Brown et al., 2015).
Apart from an inadequate implementation, the format of the training also shows room for improvement. Because our study took place in a naturalistic setting, at the time, it was only feasible to provide a classroom training, whereas previous research has found that coaching is an important addition to this. This was confirmed by several staff members who stated in the focus groups that they would have liked additional coaching. Classroom training therefore seems to be insufficient for teaching staff to guide their clients towards greater self-management.
Apart from aspects related to the training, another explanation for the limited effects could pertain to the fact that people with intellectual disabilities need more time to develop their self-management skills, given their overall learning deficit (American Psychiatric Association, 2013). Therefore, it may well take more than 6 months before significant improvements in independence and self-reliance, support needs and behaviour can be observed. Furthermore, the questionnaires that were used in this study might not be sensitive enough to measure change in our population. On the DBC (Koot & Dekker, 2001), participants showed relatively low scores overall. As was mentioned, this questionnaire is aimed at minors with intellectual disabilities, which may explain why many of the behaviours that were addressed were uncommon in our adult participants. Conversely, there was a ceiling effect on the SFSMR , already at baseline. Therefore, for many participants, there was little room for improvement in scores, whereas in real life much progress in independence and self-reliance was possible. It should also be noted that the significant difference between the groups on this outcome measure could also be related to the fact that the scores of the comparison group slightly decreased over time, especially in the long term. Therefore, this significant result should be interpreted with caution. Furthermore, contrary to what would be expected, the intervention group had higher support needs in the long term, whereas the comparison group showed a decrease in support needs. These results were, however, not significantly different.
Besides the use of questionnaires that seem inadequate for our population, other limitations of the study include the small sample size and the fact that our follow-up measurements only lasted until 6 months after the training. In addition, quality of life was not assessed in this study, although this would have been a valuable outcome measure, as people can experience a higher quality of life when self-management is promoted (Dollar et al., 2012).
Furthermore, there was a non-random allocation of the homes to either the intervention or comparison group and participants could not be matched, given the diversity and complexity of their problems. Although there were no significant differences between the groups on several background characteristics, slight differences between the groups may still have influenced the results. Also, while there were no dropouts in the comparison group, there were three in the intervention group, who were all relatively well functioning people with intellectual disabilities.
Despite its limitations, this study could still offer a valuable contribution to the field of intellectual disabilities. Apart from being a mixedmethods study, it is to our best knowledge also the first to evaluate the effectiveness of a staff training aimed at promoting overall selfmanagement in people with intellectual disabilities. Thus, the study could serve as a starting point for the further development and evaluation of similar kind of trainings. When designing these trainings, the content and setup should be carefully considered, as well as the implementation and application into daily practice. Organising good practice leadership and coaching-on-the-job appear to be important factors to consider in this context. In future research, it would also be of interest to study the effects on different subgroups of people with intellectual disabilities, as well as the cost-effectiveness. Apart from selecting measurement instruments that are more appropriate for this population, such as the SFSMR for a higher level  or the Adult Behavior Checklist (Achenbach & Rescorla, 2003), it is also worthwhile to consider self-reports. This could be achieved by including people with intellectual disabilities when filling in questionnaires or by interviewing them to hear their perspectives and experiences.
Studying whether any improvements in quality of life occur, would be of interest as well. Furthermore, to avoid bias of trained staff members, investigating (changes in) client and staff behaviour by using a more direct and objective measure (e.g., through observations) would be a valuable addition to the more subjective experiences as collected through questionnaires and focus groups.
In conclusion, this study found limited evidence for the effectiveness of a staff training that promotes self-management in people with intellectual disabilities. Further research is required on how this can be achieved more effectively. Although the limitations should be kept in mind, this study could serve as a basis for the further development and evaluation of similar kind of trainings. In order to be more effective, the training's content, format, and implementation should be carefully considered, for example by paying more attention to its application into daily practice and including coaching-on-the-job.