Housing First, but What Comes Second? A Qualitative Study of Resident, Staff and Management Perspectives on Single-Site Housing First Program Enhancement

'Everywhere I call, there's nothing available': Understanding the alcohol treatment landscape and needs among unstably housed people who use alcohol in Rhode Island

INTRODUCTION

Alcohol is a leading cause of morbidity and mortality in the United States and people who are unstably housed are disproportionately impacted by adverse alcohol-related health outcomes. Addressing the needs of unstably housed people with high-intensity alcohol use (i.e., heavy episodic use or binge drinking), including those whose goal is not abstinence, is critical to reducing harms among this population. This study explores the alcohol-related treatment and support needs among unstably housed people who use alcohol.

METHODS

Data collection included participant observation and semi-structured interviews (n = 25) with unstably housed people with high-intensity alcohol use. Data were analysed thematically, with attention to structural vulnerability and social-structural forces at shaping perceptions of and experiences with alcohol treatment.

RESULTS

Participants underscored how housing instability was critical in precipitating and maintaining heavy alcohol use, with alcohol often used to manage the stress and anxiety related to housing instability. While participants regularly engaged with alcohol treatment programs, program design and barriers to access undermined the effectiveness of these services for participants. Participants described the need for a range of program and service options across a continuum of care to be implemented to support participants in meeting their diverse needs and identified goals regarding alcohol use.

DISCUSSION AND CONCLUSIONS

Alcohol treatment and supports need to be modified so that they include a range of harm reduction and abstinence-based models to better meet people's diverse needs. Furthermore, treatment must be paired with permanent and affordable housing to address underlying drivers of alcohol-related harm for unstably housed people.

Harm Reduction Strategies for Severe Alcohol Use Disorder in the Context of Homelessness: A Rapid Review

Severe alcohol use disorder (AUD) in the context of housing instability remains one of the most complex health and social issues. Homelessness is related to increased vulnerability to stigma, marginalization and harmful ways of alcohol consumption, including non-beverage alcohol use (NBA). As a result, severe intoxication, alcohol poisoning, injury and death are common occurrences. Although harm minimization strategies have been readily proposed and examined in the context of drug use, applying the same principles to severe AUD remains controversial within the research and treatment community. This article summarizes the emerging research on managed alcohol programs to increase awareness about alcohol-related strategies that address severe AUD and provide other wrap-around supports such as housing, health and social services to mitigate various harms, including COVID-19.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

Content Analysis of Preferred Recovery Pathways Among Urban American Indians and Alaska Natives Experiencing Alcohol Use Disorders

Approximately three fourths of the American Indian and Alaska Native (AI/AN) population lives in urban areas, and urban AI/ANs are disproportionately affected by alcohol-related morbidity and mortality. Although no studies have documented alcohol use disorder (AUD) treatment outcomes specific to urban AI/ANs, studies in other Native communities highlight concerns about the cultural acceptability of directive, abstinence-based approaches, such as cognitive behavioral therapy and 12-step programs. Understanding this population’s desired recovery pathways in their own words may help providers create more culturally appropriate, patient-centered, and effective approaches. Participants ( N = 31) were urban AI/ANs who screened positive for AUD using the AUDIT-C. They participated in semi-structured interviews eliciting their experiences in AUD treatment to date and suggestions for redesigning AUD treatment in their own vision. Conventional content analysis was used to create a thematic description. Findings indicated that intrinsic motivation and not extrinsic pressure (e.g., mandated treatment) was associated with positive treatment engagement and outcomes. Participants appreciated feeling safe and supported in AUD treatment, but also felt AUD treatment could be institutional and oppressive. Participants preferred compassionate counselors with lived experience who could provide insights into recovery; they largely did not appreciate a “tough love” approach or power struggles with counselors. Native-led treatment centers providing access to cultural practices were preferred. Moving forward, participants suggested AUD treatment providers should help patients meet basic needs, prioritize patient-driven versus provider-driven goal-setting, support patients’ reconnection with meaningful activities, facilitate access to a supportive community network, and recognize cultural activities as important recovery pathways.

"Halfway Independent": Experiences of formerly homeless adults living in permanent supportive housing

Permanent supportive housing (PSH), which combines affordable public housing with social services, has become the dominant model in the United States for providing housing to formerly homeless people. PSH has been effective in reducing re-entry to homelessness, yet has shown limited evidence of improving formerly homeless individuals' mental health and quality of life. This study aimed to understand the lived experiences of formerly homeless adults' adjustment to tenancy in PSH, with a focus on how living in PSH has affected their meaningful activity and social engagement. Based on a phenomenological approach, a thematic analysis was conducted using semi-structured interviews with 17 individuals living in three PSH buildings in New York City. Results suggested that PSH was beneficial in fulfilling formerly homeless individual's basic needs and facilitating lifestyle improvements, yet many were dissatisfied with their living conditions and lacked meaningful activity, social integration, and community belongingness. These issues were found to develop in large part as a result of formerly homeless individuals' disharmonious relationships within the social context of PSH, consisting of staff members, other residents, and people in the surrounding community. The effects of the COVID-19 pandemic and implications for PSH social services are discussed.

Characterizing components of and attendance at resident-driven Housing First programming in the context of community-based participatory research

AIMS

This secondary study characterized components of and engagement in the life-enhancing alcohol-management program (LEAP), which is resident-driven housing first programming.

METHODS

We used a process akin to conventional content analysis to operationalize the LEAP according to its component activities. We used generalized linear modeling to identify predictors of LEAP activity participation and to predict alcohol and quality-of-life outcomes from participation in specific LEAP activities categories.

RESULTS

Overall, 86% of participants attended at least one LEAP activity, which comprised three categories: administrative leadership opportunities, meaningful activities, and pathways to recovery. Employment status alone predicted LEAP activity attendance: Employed residents attended 88% fewer LEAP activities than unemployed residents. Participants who sought out more pathways to recovery activities were more likely daily drinkers and more impacted by alcohol-related harm. Those engaging in administrative leadership opportunities were overall less impacted by alcohol use and had a higher quality of life generally, and their alcohol outcomes further improved over time.

CONCLUSIONS

Programming developed with Housing First residents was well-attended but could be made more inclusive by including evening programming to accommodate residents employed full time and engaging more severely impacted participants in administrative leadership activities, where the greatest benefits of programming were seen.

Combining behavioral harm-reduction treatment and extended-release naltrexone for people experiencing homelessness and alcohol use disorder in the USA: a randomised clinical trial

BACKGROUND

The rate of alcohol-related mortality in people experiencing homelessness and alcohol use disorder is high and necessitates accessible and effective treatment for alcohol use disorder. However, typical abstinence-based treatments do not optimally engage this population. Recent studies have shown that harm-reduction treatment, which does not require abstinence, but instead aims to incrementally reduce alcohol-related harm and improve health-related quality of life, is acceptable to and effective for this population. The aim of this study was to test the efficacy of combined pharmacological and behavioural harm-reduction treatment for alcohol use disorder (HaRT-A) in people experiencing homelessness and alcohol use disorder.

METHODS

This randomised clinical trial was done at three community-based service sites (low-barrier shelters and housing programmes) in Seattle (WA, USA). Eligible participants were adults (aged 21-65 years) who met the DSM-IV-TR criteria for alcohol use disorder and who experienced homelessness in the past year. Participants were randomly assigned (1:1:1:1) by permuted block randomisation, stratified by site, to receive either HaRT-A plus intramuscular injections of 380 mg extended-release naltrexone (XR-NTX; HaRT-A plus XR-NTX group); HaRT-A plus placebo injection (HaRT-A plus placebo group); HaRT-A alone (HaRT-A alone group); or community-based supportive services as usual (services-as-usual control group). Patients assigned to receive HaRT-A attended sessions at baseline (week 0) and in weeks 1, 4, 8, and 12. XR-NTX and placebo injections were administered in weeks 0, 4, and 8. During the study, participants, interventionists, and investigators were masked to group assignment in the two injection arms. All participants were invited to follow-up assessments at weeks 4, 8, 12, 24, and 36. The primary outcomes were self-reported alcohol use quantity (ie, alcohol quantity consumed on peak drinking occasion, as measured with the Alcohol Quantity Use Assessment questionnaire) and frequency (measured with the Addiction Severity Index), alcohol-related harm (measured with the Short Inventory of Problems-2R questionnaire), and physical and mental health-related quality of life (measured with the Short Form-12 survey). Using piecewise growth modelling and an intention-to-treat model, we compared the effects of the three active treatment groups with the services-as-usual control group, and the HaRT-A plus XR-NTX group with the HaRT-A plus placebo group, over the 12-week treatment course and during the 24 weeks following treatment withdrawal. Safety analyses were done on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT01932801.

FINDINGS

Between Oct 14, 2013, and Nov 30, 2017, 417 individuals experiencing homelessness and alcohol use disorder were screened, of whom 308 were eligible and randomly assigned to the HaRT-A plus XR-NTX group (n=74), the HaRT-A plus placebo group (n=78), the HaRT-A alone group (n=79), or the services-as-usual control group (n=77). Compared with the services-as-usual control group, the HaRT-A plus XR-NTX group showed significant improvements from baseline to 12 weeks post-treatment across four of the five primary outcomes: peak alcohol quantity (linear B -0·48 [95% CI -0·79 to -0·18] p=0·010; full model Cohen's d=-0·68), alcohol frequency (linear B -4·42 [-8·09 to -0·76], p=0·047; full model Cohen's d=-0·16), alcohol-related harm (linear B -2·22 [-3·39 to -1·06], p=0·002; full model Cohen's d=-0·56), and physical health-related quality of life (linear B 0·66 [0·23 to 1·10], p=0·012; full model Cohen's d=0·43). Compared with the services-as-usual control group, the HaRT-A plus placebo group showed significant improvements in three of the five primary outcomes: peak alcohol quantity (linear B -0·41 [95% CI -0·67 to -0·15] p=0·010; full model Cohen's d=-0·23), alcohol frequency (linear B -5·95 [-9·72 to -2·19], p=0·009; full model Cohen's d=-0·13), and physical health-related quality of life (linear B 0·53 [0·09 to 0·98], p=0·050; full model Cohen's d=0·35). Compared with the services-as-usual control group, the HaRT-A alone group showed significant improvements in two of the five primary outcomes: alcohol-related harm (linear B -1·58 [95% CI -2·73 to -0·42] p=0·025; full model Cohen's d=-0·40) and physical health-related quality of life (linear B 0·63 [0·18 to 1·07], p=0·020; full model Cohen's d=0·41). After treatment discontinuation at 12 weeks, the active treatment groups plateaued, whereas the services-as-usual group showed improvements. Thus, during the post-treatment period (weeks 12 to 36), the services-as-usual control group showed greater reductions in alcohol-related harm compared with both the HaRT-A plus XR-NTX group (linear B 0·96 [0·24 to 1·67], p=0·028; full model Cohen's d=0·24) and the HaRT-A alone group (linear B 1·02 [0·35 to 1·70], p=0·013; full model Cohen's d=0·26). During the post-treatment period, the services-as-usual control group significantly improved on mental health-related quality of life compared with the HaRT-A alone group (linear B -0·46 [-0·79 to -0·12], p=0·024; full model Cohen's d=-0·28), and on physical health-related quality of life compared with the HaRT-A plus XR-NTX group (linear B -0·42 [-0·67 to -0·17], p=0·006; full model Cohen's d=-0·27), the HaRT-A plus placebo group (linear B -0·42 [-0·69 to -0·15], p=0·009; full model Cohen's d=-0·27), and the HaRT-A alone group (linear B -0·47 [-0·72 to -0·22], p=0·002; full model Cohen's d=-0·31). For all other primary outcomes, there were no significant linear differences between the services-as-usual and active treatment groups. When comparing the HaRT-A plus placebo group with the HaRT-A plus XR-NTX group, there were no significant differences for any of the primary outcomes. Missing data analysis indicated that participants were more likely to drop out in the services-as-usual control group than in the active treatment groups; however, primary outcome findings were found to be robust to attrition. Participants in the HaRT-A plus XR-NTX, HaRT-A plus placebo, and HaRT-A alone groups were not more likely to experience adverse events than those in the services-as-usual control group.

INTERPRETATION

Compared with existing services, combined pharmacological and behavioural harm-reduction treatment resulted in decreased alcohol use and alcohol-related harm and improved physical health-related quality of life during the 12-week treatment period for people experiencing homelessness and alcohol use disorder. Although not as consistent, there were also positive findings for behavioural harm-reduction treatment alone. Considering the non-significant differences between participants receiving HaRT-A plus placebo and HaRT-A plus XR-NTX, the combined pharmacological and behavioural treatment effect cannot be attributed to XR-NTX alone. Future studies are needed to further investigate the relative contributions of the pharmacological and behavioural components of harm-reduction treatment for alcohol use disorder, and to ascertain whether a maintenance treatment approach could extend these positive outcome trajectories.

FUNDING

National Institute on Alcohol Abuse and Alcoholism.

Content Analysis of Health Concerns among Housing First Residents with a History of Alcohol Use Disorder

Previous research has utilized survey and administrative data to document health problems among Housing First (HF) residents; however, little is known about residents' personal perspectives on their health. The purpose of this study was to utilize conventional content analysis to analyze health-related concerns among HF residents with histories of alcohol use disorder. Between June and December 2013, we interviewed 44 adults who had histories of chronic homelessness and alcohol use disorder and were residing in single-site HF in Seattle, Washington. Responses centered on five primary topics: alcohol-related harm, perceived health vulnerability, concern for fellow residents' health, end of life, and health and safety promotion. HF residents experience complex alcohol-exacerbated health difficulties and existing health services may not meet the needs of those whose health is particularly compromised. Considering that HF facilitates aging in place, end-of-life care and grief counseling should be integrated into HF services.

Community and Housing First: A qualitative analysis of USA residents' perspectives

Plymouth Housing is a Housing First organisation in Seattle, WA (USA) that provides far more than housing for its residents-staff are equally concerned with building community and creating a sense of belonging. The objective of this study was to interview residents about their experiences of community and collect their suggestions for improving community, building efforts within this organisation. This exploratory qualitative study was conducted across eight buildings and included 38 participants from November 2018 to February 2019. Data were collected by the researchers in the form of focus groups and individual interviews, utilising a semi-structured interview protocol. The interviews were recorded, transcribed and analysed using thematic analysis. Themes were identified by each researcher separately and then cross referenced for validity using direct quotes from participants. Five main themes emerged from the data: 'really good community here'; mutual support and care; interpersonal connections; gatherings and events; lack of community. This study demonstrates that regularly held events and activities help to build community, create a sense of stability and increase familiarity and trust amongst residents. An implication of this study is the importance of actively soliciting residents' input to guide community building efforts. This is a small-scale exploratory study and although the findings are applicable to the participants' experiences, further research is needed to build on these findings in other parts of the USA as well as internationally.

Pathways to Recovery among Homeless People with Mental Illness: Is Impulsiveness Getting in the Way?

OBJECTIVE

This study investigates the association between impulsiveness and six dimensions of recovery among homeless people with mental illness.

METHOD

The sample was composed of 418 participants of a randomized controlled trial of Housing First, a recovery-oriented program that provides immediate access to permanent housing. The reliable change index method was used to provide an estimate of the statistical and clinical significance of the change from baseline to 24 months (i.e., clinically meaningful improvement), on outcomes that pertain to recovery dimensions: psychiatric symptoms (clinical), physical health and substance use problems (physical), residential stability (functional), arrests (criminological), community integration (social), and hope and personal confidence (existential). We tested for the effect of impulsiveness, assessed with the Barratt Impulsiveness Scale-11, on clinically meaningful improvement on each specific outcome, adjusting for age, gender and intervention assignment, as both intervention arms were included in the analysis.

RESULTS

For every increase in total impulsiveness score by one standard deviation, the odds of experiencing clinically meaningful improvement decreased by 29% (OR = 0.71, 95% CI, 0.55 to 0.91) on the clinical dimension and by 53% (OR = 0.47, 95% CI, 0.32 to 0.68) on the existential dimension. However, changes in outcomes pertaining to physical, functional, criminological, and social dimensions were not significantly influenced by impulsiveness.

CONCLUSIONS

Findings highlight the importance of addressing impulsiveness in the context of recovery-oriented interventions for homeless people with mental illness. Further research may be required to improve interventions that are responsive to unique needs of impulsive individuals to support clinical and existential recovery.

The life-enhancing alcohol-management program: Results from a 6-month nonrandomized controlled pilot study assessing a community based participatory research program in housing first

A 2-arm, 6-month, nonrandomized controlled pilot trial was conducted to test the initial effectiveness of the Life Enhancing Alcohol-management Program (LEAP) as an adjunct to Housing First (HF; e.g., permanent supportive housing) on alcohol and quality-of-life (QoL) outcomes. The LEAP entails resident-driven leadership opportunities, meaningful activities, and pathways to recovery aimed at reducing alcohol-related harm and improving QoL. Data analyses were conducted to test between- and within-subjects effects of the LEAP on self-reported alcohol and QoL outcomes among HF residents. At the 6-month follow up, between groups analysis revealed nonsignificant findings for alcohol quantity or alcohol-related harm (ps  >  0.06); however, LEAP participants reported significantly more engagement in meaningful activities than control participants (p  <  .001), and within-subjects analyses indicated that high levels of LEAP programming engagement predicted significant reductions in alcohol quantity and alcohol-related harm (ps  <  0.01). The LEAP was associated with increased engagement in meaningful activities, and greater involvement in the LEAP programming was associated with reduced alcohol use and alcohol-related harm. Planning is underway for a future, large-scale randomized controlled trial to establish the efficacy of this approach, its generalizability across HF programs, and potential mechanisms of action.

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Background

People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group.

Methods

Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model.

Results

Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user’s perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people’s lives.

Conclusion

This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted. The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals’ complex lives.

Assessing the relationship between housing and health among medically complex, chronically homeless individuals experiencing frequent hospital use in the United States

In the United States and abroad, health systems have begun to address housing insecurity through programs that adhere to the Housing First model. The model provides permanent supportive housing without disqualification due to current mental health problems or substance use, along with optional case management services. This study used qualitative methods to explore how housing stability affected chronic disease management and social and community relationships among individuals with complex health and social needs and patterns of high hospital utilisation who were housed as part of a scattered-site Housing First program in a mid-size city in the northeastern United States. 26 individual, semi-structured interviews were conducted with Housing First clients in their homes or day program sites between March and July 2017. Interviews were digitally recorded and transcripts were analysed using a qualitative descriptive methodology until thematic saturation was reached. Findings suggest that housing provided the physical location to manage the logistical aspects of care for these clients, and an environment where they were better able to focus on their health and wellness. Study participants reported less frequent use of emergency services and more regular interaction with primary care providers. Additionally, case managers' role in connecting clients to behavioural health services removed barriers to care that clients had previously faced. Housing also facilitated reconnection with family and friends whose relationships with participants had become strained or distant. Changes to physical and social communities sometimes resulted in experiences of stigmatisation and exclusion, especially for clients who moved to areas with less racial and socioeconomic diversity, but participation in the program promoted an increased sense of safety and security for many clients.

Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder

BACKGROUND

People experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, harm reduction treatment for alcohol (HaRT-A) was developed together with people with lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. A three-month, two-arm randomized controlled trial was conducted to test the initial efficacy of HaRT-A compared to a services-as-usual control condition.

METHODS

People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Self-reported alcohol use, alcohol-related harm, motivation, and QoL as well as urinary ethyl glucuronide were assessed over a 3-month follow-up. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: a) collaborative tracking of participant-preferred alcohol metrics, b) elicitation of harm-reduction and QoL goals, and c) discussion of safer-drinking strategies.

RESULTS

Compared to control participants, HaRT-A participants reported significantly greater increases in confidence to engage in harm reduction and decreases in peak alcohol use, alcohol-related harm, AUD symptoms, and positive urinary ethyl glucuronide tests (ps < .05). Findings were inconclusive regarding group differences on QoL (ps > .12).

CONCLUSION

A low-barrier, low-intensity, patient-driven, harm-reduction approach has at least short-term efficacy in improving AUD outcomes in this population. Future studies are needed to establish its longer-term efficacy.

Perceived harms and harm reduction strategies among people who drink non-beverage alcohol: Community-based qualitative research in Vancouver, Canada

BACKGROUND

There has been increasing interest in harm reduction initiatives for street-involved people who drink alcohol, including non-beverage alcohol such as mouthwash and hand sanitizer. Limited evidence exists to guide these initiatives, and a particular gap is in research that prioritizes the experiences and perspectives of drinkers themselves. This research was conducted to explore the harms of what participants termed "illicit drinking" as perceived by people who engage in it, to characterize the steps this population takes to reduce harms, and to identify additional interventions that may be of benefit.

METHODS

This participatory qualitative research drew on ethnographic approaches including a series of 14″town hall"-style meetings facilitatied and attended by people who self identify as drinking illicit or non-beverage alcohol (n = 60) in Vancouver, British Columbia. This fieldwork was supplemented with four focus groups to explore emerging issues.

RESULTS

Participants in the meetings described the harms they experienced as including unintentional injury; harms to physical health; withdrawal; violence, theft, and being taken advantage of; harms to mental health; reduced access to services; and interactions with police. Current harm reduction strategies involved balancing the risks and benefits of drinking in groups and adopting techniques to avoid withdrawal. Proposed future initiatives included non-residential managed alcohol programs and peer-based supports.

CONCLUSIONS

Illicit drinkers describe harms and harm reductions strategies that have much in common with those of other illicit substances, and can be interpreted as examples of and responses to structural and everyday violence. Understanding the perceived harms of alcohol use by socially marginalized drinkers and their ideas about harm reduction will help tailor programs to meet their needs.

Religious and Spiritual Practices Among Home-less Urban American Indians and Alaska Natives with Severe Alcohol Problems

Engagement in religious and spiritual practices may be protective for homeless individuals with alcohol-related problems. However, little is known in this regard for urban-dwelling American Indians and Alaska Natives (AI/ANs) who have disproportionately high rates of homelessness and co-occurring alcohol use problems. Using secondary data from a nonrandomized controlled study testing a Housing First intervention, AI/AN participants (n = 52) and non-AI/AN participants (n = 82) were compared on demographic variables, alcohol use problems, religious affiliations, and religious/spiritual practices (importance, frequency, and type). AI/ANs who engaged in Native-specific independent spiritual practices had significantly lower alcohol use frequency in comparison to AI/ANs who did not.