Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: a realist approach to synthesizing evidence

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Mechanisms of school-based peer education interventions to improve young people's health literacy or health behaviours: A realist-informed systematic review

INTRODUCTION

Peer education interventions are widely used in secondary schools with an aim to improve students' health literacy and/or health behaviours. Although peer education is a popular intervention technique with some evidence of effectiveness, we know relatively little about the key components that lead to health improvements among young people, or components that may be less helpful. This review aims to identify the main mechanisms involved in school-based peer education health interventions for 11-18-year-olds.

METHODS

Five electronic databases were searched for eligible studies during October 2020, an updated search was then conducted in January 2023 to incorporate any new studies published between November 2020 and January 2023. To be included in the review, studies must have evaluated a school-based peer education intervention designed to address aspects of the health of students aged 11-18 years old and contain data relevant to mechanisms of effect of these interventions. No restrictions were placed on publication date, or country but only manuscripts available in English language were included.

RESULTS

Forty papers were identified for inclusion with a total of 116 references to intervention mechanisms which were subsequently grouped thematically into 10 key mechanisms. The four most common mechanisms discussed were: 1) Peerness; similar, relatable and credible 2) A balance between autonomy and support, 3) School values and broader change in school culture; and 4) Informal, innovative and personalised delivery methods. Mechanisms were identified in quantitative, qualitative and mixed methods intervention evaluations.

DISCUSSION

This study highlights a number of key mechanisms that can be used to inform development of future school-based peer education health interventions to maximise effectiveness. Future studies should aim to create theories of change or logic models, and then test the key mechanisms, rather than relying on untested theoretical assumptions. Future work should also examine whether particular mechanisms may lead to harm, and also whether certain mechanisms are more or less important to address different health issues, or whether a set of generic mechanisms always need to be activated for success.

Geospatial analysis of associations among mental health need, housing need, and involuntary psychiatric hospitalizations of people experiencing homelessness in Los Angeles County

The purpose of this study was to use geospatial indicators of mental health need and homelessness in Los Angeles County Service Planning Areas (SPAs) and a psychiatric sample of adults who were homeless to investigate 1) overlap between SPA level of mental health need and corresponding volume of involuntary psychiatric hospitalizations over time; 2) overlap between SPA level of unsheltered homelessness and corresponding volume of involuntary psychiatric hospitalizations over time; and 3) associations between SPA level of mental health need, SPA level of unsheltered homelessness, and initiation of a mental health conservatorship for grave disability. A sample of 373 adults who were homeless and hospitalized on an involuntary psychiatric hold from 2016 to 2018 were linked to data from the Greater Los Angeles Homeless Count on unsheltered homelessness and from the California Health Interview Survey on need for mental health services and suicidality, using admission zip codes to link variables at the SPA level. Geospatial mapping and bivariate tests were used to examine geographic overlap of SPA mental health need and unsheltered homelessness with volume of involuntary psychiatric admissions over the study period. Multiple logistic regression modeling was used to examine associations of SPA mental health need and unsheltered homelessness with conservatorship initiation. The volume of patients admitted from SPAs with higher levels of mental illness need grew from 2016 to 2018 (Tau = 0.27, P < 0.001; Tau = 0.40, P < 0.001), but there were fewer patients admitted from SPAs with higher levels of unsheltered homelessness over the same years (Tau of -0.33, P < 0.001). Being admitted from SPAs with the highest levels of unsheltered homelessness was associated with higher odds of conservatorship initiation (OR = 1.73, 95% CI = 1.82-16.74). Results suggest a need for targeted mental health and housing services to reach areas of highest need in Los Angeles County.

Depressive symptoms among people living with HIV in permanent supportive housing: Findings from a community-based participatory study in Vancouver, Canada

Permanent supportive housing (PSH) is an intervention addressing housing needs among marginally housed individuals. Little is known about whether and how PSH influences depressive symptoms among people living with HIV (PLHIV). This article shares results from a community-based study that, in 2016-2017, interviewed 24 residents of a PSH facility designated for PLHIV in Vancouver, Canada. The themes of taking control; social connectedness; conviviality; and relationships and supports described how the PSH environment affected depressive symptoms among the residents.

Education as drug policy: A realist synthesis of continuing professional development for opioid agonist therapy

BACKGROUND

Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts.

METHODS

A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development.

RESULTS

Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention.

CONCLUSION

OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.

Higher Education for Sustainability: A Critical Review of the Empirical Evidence 2013–2020

Higher education for sustainable development (HESD) has grown into a substantial field of research and practice. HESD proposes that higher education will be central in a transition towards more sustainable socio-ecological systems. However, the debates on what should be learned in HESD and how this should be learned have remained conceptually controversial and empirically inconclusive. This review examined the evidence that specific pedagogies and content lead to specific “sustainability outcomes” among graduates. Three hundred and fifty-seven studies published between 2013 and 2020 were analyzed. The reviewed research was case-driven and often undertheorized regarding learning processes and outcomes. Despite its volume, the literature did not provide coherent insights into what should be learned and how. If the project of HESD is to be pursued further, more courage will be needed in creating novel forms of higher education, while more purpose and conceptual precision will be required in future research.

Assessing the feasibility, acceptability and accessibility of a peer-delivered intervention to reduce harm and improve the well-being of people who experience homelessness with problem substance use: the SHARPS study

BACKGROUND

For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that the development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing.

METHODS

The study used mixed methods to assess the feasibility, acceptability and accessibility of a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning, for people experiencing homelessness and problem substance use. Four Peer Navigators were employed to support individuals (n = 68 total, intervention participants). They were based in outreach services and hostels in Scotland and England. Qualitative interviews were conducted with intervention participants, Peer Navigators and staff in services, and observations were conducted in all settings. Quantitative outcomes relating to participants' substance use, physical and mental health, and quality of the Peer Navigator relationship, were measured via a 'holistic health check' with six questionnaires completed at two time-points.

RESULTS

The intervention was found to be acceptable to, and feasible and accessible for, participants, Peer Navigators, and service staff. Participants reported improvements to service engagement, and feeling more equipped to access services independently. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling trusting, authentic, and meaningful relationships to be developed. Some challenges were experienced in relation to the 'fit' of the intervention within some settings. Among participants there were reductions in drug use and risky injecting practices. There were increases in the number of participants receiving opioid substitution therapy. Overall, the intervention was positively received, with collective recognition that the intervention was unique and highly valuable. While most of the measures chosen for the holistic health check were found to be suitable for this population, they should be streamlined to avoid duplication and participant burden.

CONCLUSIONS

The study established that a peer-delivered, relational harm reduction intervention is acceptable to, and feasible and accessible for, people experiencing homelessness and problem substance use. While the study was not outcomes-focused, participants did experience a range of positive outcomes. A full randomised controlled trial is now required to assess intervention effectiveness.

TRIAL REGISTRATION

Study registered with ISRCTN: 15900054.

A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study

BACKGROUND

For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues.

OBJECTIVES

The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial.

DESIGN

A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures.

SETTING

The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England.

PARTICIPANTS

Participants were people experiencing homelessness and problem substance use (n = 68) (intervention).

INTERVENTION

This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support.

MAIN OUTCOME MEASURES

Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure.

RESULTS

The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies.

LIMITATIONS

Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited.

CONCLUSIONS

A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention.

FUTURE WORK

A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments.

TRIAL REGISTRATION

This trial is registered as ISRCTN15900054.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.

Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization

PURPOSE

High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization.

METHODS

Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018.

RESULTS

Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups' post-intervention slopes for numbers of primary care visits (difference in slopes =-0.16 visits/100 patients/month; 95% CI -0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI -0.16, 0.32; p=0.50), mental health visits (difference in slopes = -1.37 visits/month; 95% CI -2.95, 0.20; p= 0.09), and psychiatric hospitalizations (-0.005 admissions/100 patients/month; 95% CI -0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations.

CONCLUSIONS

Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals' capabilities to care for vulnerable populations.

A Rapid Realist Review of Effective Mental Health Interventions for Individuals with Chronic Physical Health Conditions during the COVID-19 Pandemic Using a Systems-Level Mental Health Promotion Framework

The 2020 global outbreak of COVID-19 exposed and heightened threats to mental health across societies. Research has indicated that individuals with chronic physical health conditions are at high risk for suffering from severe COVID-19 illness and from the adverse consequences of public health responses to COVID-19, such as social isolation. This paper reports on the findings of a rapid realist review conducted alongside a scoping review to explore contextual factors and underlying mechanisms or drivers associated with effective mental health interventions within and across macro-meso-micro systems levels for individuals with chronic physical health conditions. This rapid realist review extracted 14 qualified studies across 11 countries and identified four key mechanisms from COVID-19 literature-trust, social connectedness, accountability, and resilience. These mechanisms are discussed in relation to contextual factors and outcomes reported in the COVID literature. Realist reviews include iterative searches to refine their program theories and context-mechanism-outcome explanations. A purposive search of pre-COVID realist reviews on the study topic was undertaken, looking for evidence of the robustness of these mechanisms. There were differences in some of the pre-COVID mechanisms due to contextual factors. Importantly, an additional mechanism-power-sharing-was highlighted in the pre-COVID literature, but absent in the COVID literature. Pre-existing realist reviews were used to identify potential substantive theories and models associated with key mechanisms. Based on the overall findings, implications are provided for mental health promotion policy, practice, and research.

What treatment and services are effective for people who are homeless and use drugs? A systematic 'review of reviews'

BACKGROUND

People who experience homelessness and those vulnerably housed experience disproportionately high rates of drug use and associated harms, yet barriers to services and support are common. We undertook a systematic 'review of reviews' to investigate the effects of interventions for this population on substance use, housing, and related outcomes, as well as on treatment engagement, retention and successful completion.

METHODS AND FINDINGS

We searched ten electronic databases from inception to October 2020 for reviews and syntheses, conducted a grey literature search, and hand searched reference lists of included studies. We selected reviews that synthesised evidence on any type of treatment or intervention that reported substance use outcomes for people who reported being homeless. We appraised the quality of included reviews using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses and the Scale for the Assessment of Narrative Review Articles. Our search identified 843 citations, and 25 reviews met the inclusion criteria. Regarding substance use outcomes, there was evidence that harm reduction approaches lead to decreases in drug-related risk behaviour and fatal overdoses, and reduce mortality, morbidity, and substance use. Case management interventions were significantly better than treatment as usual in reducing substance use among people who are homeless. The evidence indicates that Housing First does not lead to significant changes in substance use. Evidence regarding housing and other outcomes is mixed.

CONCLUSIONS

People who are homeless and use drugs experience many barriers to accessing healthcare and treatment. Evidence regarding interventions designed specifically for this population is limited, but harm reduction and case management approaches can lead to improvements in substance use outcomes, whilst some housing interventions improve housing outcomes and may provide more stability. More research is needed regarding optimal treatment length as well as qualitative insights from people experiencing or at risk of homelessness.

Differences in housing transitions and changes in health and self-determination between formerly homeless individuals

Background

To reduce homelessness, it is important to gain a better understanding of the differences between homeless people who remain in institutions and those who gain and can sustain independent housing. This longitudinal study explores differences in housing transitions and differences in changes in health and self-determination between formerly homeless people still living in institutions 2.5 years later and those now living in independent housing in the Netherlands.

Methods

This study mapped the housing transitions of 263 participants from when they entered the social relief system (SRS) to 2.5 years later when they were in independent housing or institutions. These individuals were compared at the 2.5-year mark in terms of gender, age and retrospectively in terms of duration of homelessness. They were also compared with regard to changes in psychological distress, perceived health, substance use and self-determination.

Results

Two and a half years after entering the SRS, 81% of participants were independently housed and 19% still lived in institutions. People in institutions had a longer lifetime duration of homelessness, were more often men, and their number of days of alcohol use had decreased significantly more, whereas independently housed people had shown a significant increase in their sense of autonomy and relatedness.

Conclusion

Formerly homeless people living in independent housing and in institutions show few health-related differences 2.5 years after entering the SRS, but changes in autonomy and relatedness are distinctly more prevalent, after the same period of time, in those who are independently housed.

Neighbourhoods and dementia: An updated realist review of the qualitative literature to inform contemporary practice and policy understanding

This realist review of the literature provided a contemporary understanding of neighbourhoods and dementia and described how people living with dementia and their neighbourhood interacted via ongoing place-making and remaking processes. Drawing on 44 articles, neighbourhoods were revealed to have fluid and dynamic qualities where people with dementia used their strength and resources to connect to significant people and places. The review also indicated that the person with dementia-neighbourhood relationship was underpinned by four themes: 'home', 'social interactions', 'activities' and 'transportation'. Further research is encouraged to use innovative, participatory methods to explore the neighbourhood-dementia nexus in depth whilst paying close attention to social inclusion and diversity.

Urban Stress Indirectly Influences Psychological Symptoms through Its Association with Distress Tolerance and Perceived Social Support among Adults Experiencing Homelessness

Traditionally, intrapersonal characteristics (distress tolerance) and interpersonal characteristics (social support) have been studied separately rather than simultaneously. In the current study, we address this gap by simultaneously examining these characteristics as potential indirect associations linking established urban stress-depression and urban stress-Post-Traumatic Stress Disorder (PTSD) relationships. Adults experiencing homelessness were recruited from six homeless shelters in Oklahoma City (n = 567). Participants self-reported urban life stress (Urban Life Stress Scale), distress tolerance (Distress Tolerance Scale), social support (Interpersonal Support Evaluation List 12), major depressive disorder (Patient Health Questionnaire-8), and PTSD symptoms (Primary Care Post-Traumatic Stress Disorder screener). Covariate-adjusted structural equation models indicated a significant indirect effect of distress tolerance on the urban stress-depression (b = 0.101, 95% CI = 0.061, 0.147) and urban stress-PTSD (b = 0.065, 95% CI = 0.023, 0.112) relationships. Additionally, a significant indirect effect of social support on the urban stress-depression (b = 0.091, 95% CI = 0.053, 0.133) and urban stress-PTSD relationships (b = 0.043, 95% CI = 0.006, 0.082) was evident. Further, both the urban stress-depression (b = 0.022, 95% CI = 0.011, 0.037) and urban stress-PTSD relationships (b = 0.014, 95% CI = 0.005, 0.026) were associated indirectly through social support to distress tolerance. Interventions that aim to increase social support may also increase distress tolerance skills and indirectly reduce depressive and PTSD symptoms in the context of urban stress among adults experiencing homelessness.

Evaluating a specialist primary care service for patients experiencing homelessness: a qualitative study

BACKGROUND

People experiencing homelessness (PEH) often experience poor health, multimorbidity, and early mortality and experience barriers to accessing high quality health care. Little is known about how best to provide specialist primary care for these patients.

AIM

To evaluate the health care provided to patients experiencing homelessness who were seen in a specialist primary care service.

DESIGN & SETTING

A qualitative evaluation of a city centre primary healthcare service for excluded and vulnerable people, such as rough sleepers, who find it difficult to visit mainstream GP services.

METHOD

Data on patient characteristics and service use were extracted from primary care records using electronic and free-text searches to provide context to the evaluation. Semi-structured interviews with 11 patients and four staff were used to explore attitudes and experiences.

RESULTS

Patients had high needs compared with the general population. Patients valued continuity of care, ease of access, multidisciplinary care, and person-centred care. Staff were concerned that they lacked opportunities for reflection and learning, and that low clinical capacity affected service safety and quality. Staff also wanted more patient involvement in service planning.

CONCLUSION

PEH's complex health and social problems benefited from a specialist primary care service, which is thought to reduce barriers to access, treat potentially challenging patients in a non-judgmental way, and provide personal continuity of care in order to develop trust.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

BACKGROUND

Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations.

METHODS AND FINDINGS

We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management.

CONCLUSIONS

Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Health Care While Homeless: Barriers, Facilitators, and the Lived Experiences of Homeless Individuals Accessing Health Care in a Canadian Regional Municipality

Persons struggling with housing remain significantly disadvantaged when considering access to health care. Effective advocacy for their needs will require understanding the factors which impact their health care, and which of those most concern patients themselves. A qualitative descriptive study through the lens of a transformative framework was used to identify barriers and facilitators to accessing health care as perceived by people experiencing homelessness in the regional municipality of Niagara, Canada. In-person, semi-structured interviews with 16 participants were completed, and inductive thematic analysis identified nine barriers and eight facilitators. Barriers included affordability, challenges finding primary care, inadequacy of the psychiatric model, inappropriate management, lack of trust in health care providers, poor therapeutic relationships, systemic issues, and transportation and accessibility. Facilitators included accessibility of services, community health care outreach, positive relationships, and shelters coordinating health care. Knowledge of the direct experiences of marginalized individuals can help create new health policies and enhance the provision of clinical care.

Supporting Harm Reduction through Peer Support (SHARPS): testing the feasibility and acceptability of a peer-delivered, relational intervention for people with problem substance use who are homeless, to improve health outcomes, quality of life and social functioning and reduce harms: study protocol

BACKGROUND

While people who are homeless often experience poor mental and physical health and problem substance use, getting access to appropriate services can be challenging. The development of trusting relationships with non-judgemental staff can facilitate initial and sustained engagement with health and wider support services. Peer-delivered approaches seem to have particular promise, but there is limited evidence regarding peer interventions that are both acceptable to, and effective for, people who are homeless and using drugs and/or alcohol. In the proposed study, we will develop and test the use of a peer-to-peer relational intervention with people experiencing homelessness. Drawing on the concept of psychologically informed environments, it will focus on building trusting and supportive relationships and providing practical elements of support such as access to primary care, treatment and housing options.

METHODS

A mixed-method feasibility study with concurrent process evaluation will be conducted to explore the feasibility and acceptability of a peer-delivered, relational intervention for people with problem substance use who are homeless. Peer Navigators will be based in homelessness outreach and residential services in Scotland and England. Peer Navigators will work with a small number of participants for up to 12 months providing both practical and emotional support. The sample size for the intervention is 60. Those receiving the intervention must be currently homeless or at risk of homelessness, over the age of 18 years and self-report alcohol/drug problems. A holistic health check will be conducted in the first few months of the intervention and repeated towards the end. Health checks will be conducted by a researcher in the service where the Peer Navigator is based. Semi-structured qualitative interviews with intervention participants and staff in both intervention and standard care settings, and all Peer Navigators, will be conducted to explore their experiences with the intervention. Non-participant observation will be conducted in intervention and standard care sites to document similarities and differences between care pathways.

DISCUSSION

The SHARPS study will provide evidence regarding whether a peer-delivered harm reduction intervention is feasible and acceptable to people experiencing homelessness and problem substance use in order to develop a definitive trial.

TRIAL REGISTRATION

SRCTN registry ISRCTN15900054, protocol version 1.3, March 12, 2018.

Moving Beyond Housing: Service Implications for Veterans Entering Permanent Supportive Housing

As a result of efforts to end homelessness among U.S. veterans, more former service members are entering permanent supportive housing (PSH). While PSH has been successfully used to house homeless veterans, more research is needed about services beyond housing placement and retention. This study uses the Gelberg-Andersen behavioral model for vulnerable populations to determine associations between predisposing, enabling, and need characteristics and recent service use (i.e., services to satisfy basic needs, occupational development, financial, healthcare, mental health) among unaccompanied homeless veterans (N=126) entering PSH in Los Angeles. Among the significant findings, as indicated using univariable logistic regression models, were veterans who had incarceration histories were more likely to utilize basic needs services, compared to those without incarceration histories. Veterans who received an honorable discharge were more likely to utilize occupational development services, compared to veterans with other discharge statuses. Veterans who had a case manager were more likely to utilize mental health services than those without a case manager, while those who received social security were less likely to utilize mental health services compared to veterans who did not receive social security. Veterans who met criteria for a psychological disability and veterans who met criteria for probable PTSD were more likely to use basic needs services and mental health services than veterans who fell below these thresholds. Clinical implications for social workers including "equal access to services," "enhancing economic stability," "providing safe and affordable housing with trauma-informed services," and "training service social workers to deliver well-informed linkages and services" are discussed.

Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada

OBJECTIVE

Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study.

METHODS

In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months.

RESULTS

Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders.

CONCLUSIONS

Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.

What works in implementation of integrated care programs for older adults with complex needs? A realist review

PURPOSE

A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.

DATA SOURCES

International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.

STUDY SELECTION

Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.

DATA EXTRACTION

Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.

RESULTS OF DATA SYNTHESIS

A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.

CONCLUSIONS

This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.

Predicting homeless people's perceived health after entering the social relief system in The Netherlands

Objectives

We explored whether changes in the perceived health of homeless people after entering the social relief system (SRS) in The Netherlands were predicted by housing, income, hours of work, social support, unmet care needs, arrests, physical and mental health, substance use, and experiences of autonomy, competence and relatedness, in addition to perceived health at baseline, demographics, suspected intellectual disability, the duration of homelessness and the company of children in the shelter facility.

Methods

A hierarchical regression analysis was used to explore the significant predictors of the perceived health of 344 homeless persons 18 months after entering the social relief system.

Results

A decrease in psychological distress and an increase in hours of (paid/voluntary) work as well as competence predicted a better perceived health.

Conclusions

Perceived health is not only influenced by objective circumstances related to work and mental health, but also self-determination, as shown by the influence of competence. Services should aim to reduce psychological distress of homeless people, support them in increasing their working hours and focus on strengthening their competence.

Efficacité de l’approche « logement d’abord » : une revue systématique

Les personnes itinérantes aux prises avec des problèmes de santé mentale et de toxicomanie qui souhaitent obtenir un logement se butent à des programmes dans lesquels l’abstinence et les traitements psychiatriques sont obligatoires. Ce type de programmes se base sur l’approche « traitement d’abord » selon laquelle ces personnes doivent d’abord être traitées avant de pouvoir aller en logement.

Cette approche est remise en question et un changement de paradigme s’opère à la suite de l’implantation aux États-Unis du modèle Pathways to Housing. Ce modèle est fondé sur le principe qu’une personne doit être logée avant de pouvoir se concentrer sur ses autres besoins. Les logements privés sont privilégiés dans ce modèle et ceux-ci sont offerts conjointement avec un soutien d’intensité variable ou un suivi intensif dans la communauté.

Le modèle Pathways to Housing a influencé la création de plusieurs programmes hybrides basés sur l’approche « logement d’abord » combinée à une offre de services et de logements diversifiés. Cette approche est basée sur la même philosophie d’obligation minimale que le modèle original, voulant que les personnes n’aient pas à être abstinentes ou à suivre un traitement psychiatrique pour accéder à un logement.

Au Canada, le gouvernement envisage de subventionner principalement les programmes basés sur cette approche. Cette annonce a mené à un soulèvement au Québec, notamment en raison des logements sociaux qui y sont actuellement priorisés.

Cet article présente les résultats d’une revue systématique de la littérature réalisée afin de statuer sur l’efficacité des programmes basés sur l’approche « logement d’abord ».

Les résultats de cette revue nous permettent de conclure que la mise en place au Québec de programmes basés sur cette approche devrait être favorisée. Les modalités et interventions offertes dans ces programmes auraient également avantage à être diversifiées.

Realist theory construction for a mixed method multilevel study of neighbourhood context and postnatal depression

BACKGROUND

We have recently described a protocol for a study that aims to build a theory of neighbourhood context and postnatal depression. That protocol proposed a critical realist Explanatory Theory Building Method comprising of an: (1) emergent phase, (2) construction phase, and (3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design was described. The protocol also described in detail the Theory Construction Phase which will be presented here.

METHODS

The Theory Construction Phase will include: (1) defining stratified levels; (2) analytic resolution; (3) abductive reasoning; (4) comparative analysis (triangulation); (5) retroduction; (6) postulate and proposition development; (7) comparison and assessment of theories; and (8) conceptual frameworks and model development.

THEORY CONSTRUCTION

The stratified levels of analysis in this study were predominantly social and psychological. The abductive analysis used the theoretical frames of: Stress Process; Social Isolation; Social Exclusion; Social Services; Social Capital, Acculturation Theory and Global-economic level mechanisms. Realist propositions are presented for each analysis of triangulated data. Inference to best explanation is used to assess and compare theories. A conceptual framework of maternal depression, stress and context is presented that includes examples of mechanisms at psychological, social, cultural and global-economic levels. Stress was identified as a necessary mechanism that has the tendency to cause several outcomes including depression, anxiety, and health harming behaviours. The conceptual framework subsequently included conditional mechanisms identified through the retroduction including the stressors of isolation and expectations and buffers of social support and trust.

CONCLUSION

The meta-theory of critical realism is used here to generate and construct social epidemiological theory using stratified ontology and both abductive and retroductive analysis. The findings will be applied to the development of a middle range theory and subsequent programme theory for local perinatal child and family interventions.

As rupturas sociais e o cotidiano de pessoas em situação de rua: estudo etnográfico

RESUMO Objetivo Conhecer os fatores geradores das rupturas das redes sociais de suporte, identificar o cotidiano e os projetos de vida de pessoas em situação de rua. Método Estudo etnográfico desenvolvido entre 2012 e 2013 em Ribeirão Preto-SP, Brasil. Quinze pessoas participaram do estudo. A coleta de dados foi realizada através de entrevistas de histórias de vida filmadas e de diário de campo. A análise foi realizada com base no referencial da Teoria da Ação Comunicativa de Habermas. Resultados Os resultados mostraram que iniquidades estão presentes há gerações passadas nas famílias e que o cotidiano é marcado por violência e morte, pobreza e exclusão, rupturas das redes sociais e isolamento, uso de álcool e outras drogas e doenças socialmente determinadas. Conclusão A situação de rua decorre de múltiplos fatores que se apresentam na organização social brasileira e de determinantes sociais que condicionam a vida e a saúde das pessoas em situação de rua.

A realist review of brief interventions for alcohol misuse delivered in emergency departments

BACKGROUND

Brief interventions (BIs) involve screening for alcohol misuse and providing feedback to patients about their use, with the aim of reducing alcohol consumption and related consequences. BIs have been implemented in various healthcare settings, including emergency departments (ED), where they have been found to contribute mixed results in their ability to address alcohol misuse among adults. Mechanisms through which BIs work and contextual factors impacting BI effectiveness are not clear. The purpose of this review was to understand how, for whom, and under what circumstances BIs work for adults misusing alcohol and who have been admitted to an ED. A realist review was chosen to answer these questions as realist reviews create context-mechanism-outcome configurations, leading to the development of comprehensive and detailed theories; in this case explaining how and for whom BIs work.

METHODS

Databases including PsycINFO, Healthstar, CINAHL, Medline, and Nursing and Allied Health were searched for articles published until December 2013. The search strategy focused on studies examining BIs that targeted alcohol misuse among adults admitted into the ED. The search identified 145 relevant abstracts, of which 36 were included in the review. The literature was synthesized qualitatively (immersion/crystallization).

RESULTS

Four mechanisms were found within reviewed studies, including engagement in/retention of BI materials, resolving ambivalence, increased awareness/insight into consequences of drinking, and increased self-efficacy/empowerment to use skills for change. The following contexts were found to impact mechanisms: emotional state, injury attributed to alcohol use, severity of alcohol use, and baseline stage of change.

CONCLUSIONS

This realist review provides advances in theories regarding which mechanisms to target during a BI and which contexts create the most favorable conditions for these mechanisms to occur, ultimately leading to optimal BI outcomes. These results can inform future clinical decision-making when delivering BIs in ED settings. Future research should conduct quantitative examination to confirm these findings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013006549.

Protocol: realist synthesis of the impact of unemployment insurance policies on poverty and health

Unemployment insurance is an important social protection policy that buffers unemployed workers against poverty and poor health. Most unemployment insurance studies focus on whether increases in unemployment insurance generosity are predictive of poverty and health outcomes. Less work has used theory-driven approaches to understand and explain how and why unemployment insurance works, for whom, and under what circumstances. Given this, we present a realist synthesis protocol that seeks to unpack how contextual influences trigger relevant mechanisms to generate poverty and health outcomes. In this protocol, we conceptualize unemployment insurance as a key social protection policy; provide a supporting rationale on the need for a realist synthesis; and describe our process on identifying context-mechanism-outcome pattern configurations. Six methodological steps are described: initial theory development, search strategy; selection and appraisal of documents; data extraction; analysis and synthesis process; and presentation and dissemination of revised theory. Our forthcoming realist synthesis will be the first to build and test theory on the intended and unintended outcomes of unemployment insurance policies. Anticipated findings will allow policymakers to move beyond 'black box' approaches to consider 'mechanism-based' explanations that explicate the logic on how and why unemployment insurance matters.

How design of places promotes or inhibits mobility of older adults: realist synthesis of 20 years of research

OBJECTIVE

The objective of this study was to determine the environmental features that best support aging in place.

METHOD

We conducted a realist synthesis, a theory-driven interpretive method of evidence synthesis, of 120+ articles (published 1991-2011) that attempts to explain how place may influence older adults' decisions about mobility (e.g., physical activity). We developed an initial program theory, reviewed the literature, identified outcomes, analyzed and synthesized patterns, and created a final program theory.

RESULTS

Safety was a central mechanism, serving as one of the bridges between environmental components (e.g., connectivity, aesthetics, retail and services) and decisions about mobility. Population density, sidewalk presence, and park proximity did not emerge as key factors.

DISCUSSION

Safety considerations are one of the most prominent influences of older adults' decisions about mobility. Street connectivity, pedestrian access and transit, and retail and services were also important. These factors are amenable to change and can help promote mobility for older adults.

Housing status and HIV risk behaviors among transgender women in Los Angeles

Due to social stigma, lack of social support, and minimal legal employment opportunities, transgender women (transwomen) face elevated rates of unstable housing. This study examined the association between housing status and HIV risk behaviors among 517 transwomen encountered through street outreach. Seven variables (including sociodemographics, HIV status, housing status, and sexual partner type) were used to estimate partial associations during multivariable analyses; housing status was coded trichotomously (housed, marginally housed, and homeless) for these analyses. Results demonstrated that homeless and marginally housed transwomen engaged in significantly higher rates of illicit drug use than housed transwomen; however, marginally housed and housed transwomen engaged in significantly higher rates of illegal hormone injections than homeless transwomen. Rates of sex work were high in the sample as a whole, though sex with an exchange partner was most common among the marginally housed transwomen. Multivariate logistic regression revealed that unstable housing moderated the association between HIV status and engagement in unprotected serodiscordant anal intercourse. The marginally housed transwomen exhibited the greatest risk profile for HIV acquisition or transmission.

Health interventions for people who are homeless

Homelessness has serious implications for the health of individuals and populations. Primary health-care programmes specifically tailored to homeless individuals might be more effective than standard primary health care. Standard case management, assertive community treatment, and critical time intervention are effective models of mental health-care delivery. Housing First, with immediate provision of housing in independent units with support, improves outcomes for individuals with serious mental illnesses. Many different types of interventions, including case management, are effective in the reduction of substance misuse. Interventions that provide case management and supportive housing have the greatest effect when they target individuals who are the most intensive users of services. Medical respite programmes are an effective intervention for homeless patients leaving the hospital. Although the scientific literature provides guidance on interventions to improve the health of homeless individuals, health-care providers should also seek to address social policies and structural factors that result in homelessness.

Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work

BACKGROUND

For over 50 years, methadone has been prescribed to opioid-dependent individuals as a pharmacological approach for alleviating the symptoms of opioid withdrawal. However, individuals prescribed methadone sometimes require additional interventions (e.g., counseling) to further improve their health. This study undertook a realist synthesis of evaluations of interventions aimed at improving the psychosocial and employment outcomes of individuals on methadone treatment, to determine what interventions work (or not) and why.

METHODS

The realist synthesis method was utilized because it uncovers the processes (or mechanisms) that lead to particular outcomes, and the contexts within which this occurs. A comprehensive search process resulted in 31 articles for review. Data were extracted from the articles, and placed in four templates to assist with analysis. Data analysis was an iterative process and involved comparing and contrasting data within and across each template, and cross checking with original articles to determine key patterns in the data.

RESULTS

For individuals on methadone, engagement with an intervention appears to be important for improved psychosocial and/or employment outcomes. The engagement process involves attendance at interventions as well as an investment in what is offered. Three intervention contexts (often in some combination) support the engagement process: a) client-centered contexts (or those where clients' psychosocial and/or employment needs/issues/skills are recognized and/or addressed); b) contexts which address clients' socio-economic conditions and needs; and, c) contexts where there are positive client-counselor and/or peer relationships. There is some evidence that sometimes ongoing engagement is necessary to maintain positive outcomes. There is also some evidence that complete abstinence from drugs (e.g., cocaine, heroin) is not necessary for engagement.

CONCLUSIONS

It is important to consider how the contexts of interventions might elicit and/or support clients' engagement. Further research is needed to explore how an individual's background (e.g., involvement with different interventions over an extended period) may influence engagement. Long-term engagement may be necessary to sustain some positive outcomes although how long is unclear and requires further research. Engagement can occur without complete abstinence from such drugs as cocaine or heroin, but additional research is required as engagement may be influenced by the extent and type of drug use.

Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project

Background

There is growing interest in theory-driven, qualitative and mixed-method approaches to systematic review, such as realist and meta-narrative review. These approaches offer the potential to expand the knowledge base in policy-relevant areas. However, the quality of such reviews can be difficult to assess.

Objectives

The aim of this project was to produce methodological guidance, publication standards and training resources for those seeking to undertake realist and/or meta-narrative reviews.

Methods/design

We (1) collated and summarised existing literature on the principles of good practice in realist and meta-narrative systematic reviews; (2) considered the extent to which these principles had been followed by published and in-progress reviews, thereby identifying how rigour may have been lost and how existing methods could be improved; (3) used an online Delphi method with an interdisciplinary panel of experts from academia and policy, to produce a draft set of methodological steps and publication standards; (4) produced training materials with learning objectives linked to these steps; (5) refined these standards and training materials prospectively on real reviews in progress, capturing methodological and other challenges as they arose; (6) synthesised expert input, evidence review and real-time problem analysis into more definitive guidance and standards; and (7) disseminated outputs to audiences in academia and policy.

Results

An important element of this study was the establishment of an e-mail mailing list to bring together researches in the field (www.jiscmail.ac.uk/RAMESES). Our literature review identified 35 and nine realist and meta-narrative reviews respectively. Analysis and discussion within the project team produced a summary of the published literature, and common questions and challenges into briefing materials for the Delphi panel, comprising 37 and 33 members (for realist and meta-narrative reviews respectively). Within three rounds this panel had reached a consensus on 19 (realist) and 20 (meta-narrative) key publication standards, with an overall response rate of 90% and 91% respectively. The Realist And Meta-narrative Evidence Syntheses – Evolving Standards (RAMESES) publication standards for realist syntheses and meta-narrative reviews were published in open-access journals and quickly became highly accessed. The RAMESES quality standards and training materials drew together the following sources of data: (1) personal expertise as researchers and trainers; (2) data from the Delphi panels; (3) feedback from participants at training sessions we ran; and (4) comments made on RAMESES mailing list. The quality standards and training materials are freely available online (www.ramesesproject.org).

Discussion

The production of these standards and guidance drew on multiple sources of knowledge and expertise, and a high degree of a consensus was achieved despite ongoing debate among researchers about the overall place of these methodologies in the secondary research toolkit. As with all secondary research methods, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency of studies. We anticipate that as more reviews are undertaken, further refinement will be needed to the publication and quality standards and training materials.

Limitations

The project’s outputs are not definitive and in the future updating and further development is likely to be needed.

Conclusion

An initial set of publication standards, quality standards and training materials have been produced for researchers, users and funders of realist or meta-narrative reviews. As realist and meta-narrative reviews are relatively new approaches to evidence synthesis, methodological development is needed for both review approaches.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Can assertive community treatment remedy patients dropping out of treatment due to fragmented services?

Previously, many patients with severe mental illness had difficulties to engage with fragmented mental health services, thus not receiving care. In a Dutch city, Assertive Community Treatment (ACT) was introduced to cater specifically for this group of patients. In a pre-post comparison, changes in mental health care consumption were examined. All mental health care contacts, ACT and non-ACT, of patients in the newly started ACT-teams were extracted from the regional Psychiatric Case Register. Analyses of mental health care usage were performed comparing the period before ACT introduction with the period thereafter. After the introduction of ACT, mental health care use increased in this group of patients, although not all patients remained under the care of ACT teams. ACT may succeed in delivering more mental health care to patients with severe mental illness and treatment needs who previously had difficulties engaging with fragmented mental health care services.

Explaining ecological clusters of maternal depression in South Western Sydney

BACKGROUND

The aim of the qualitative study reported here was to: 1) explain the observed clustering of postnatal depressive symptoms in South Western Sydney; and 2) identify group-level mechanisms that would add to our understanding of the social determinants of maternal depression.

METHODS

Critical realism provided the methodological underpinning for the study. The setting was four local government areas in South Western Sydney, Australia. Child and Family practitioners and mothers in naturally occurring mothers groups were interviewed.

RESULTS

Using an open coding approach to maximise emergence of patterns and relationships we have identified seven theoretical concepts that might explain the observed spatial clustering of maternal depression. The theoretical concepts identified were: Community-level social networks; Social Capital and Social Cohesion; "Depressed community"; Access to services at the group level; Ethnic segregation and diversity; Supportive social policy; and Big business.

CONCLUSIONS

We postulate that these regional structural, economic, social and cultural mechanisms partially explain the pattern of maternal depression observed in families and communities within South Western Sydney. We further observe that powerful global economic and political forces are having an impact on the local situation. The challenge for policy and practice is to support mothers and their families within this adverse regional and global-economic context.

Realist explanatory theory building method for social epidemiology: a protocol for a mixed method multilevel study of neighbourhood context and postnatal depression

A recent criticism of social epidemiological studies, and multi-level studies in particular has been a paucity of theory. We will present here the protocol for a study that aims to build a theory of the social epidemiology of maternal depression. We use a critical realist approach which is trans-disciplinary, encompassing both quantitative and qualitative traditions, and that assumes both ontological and hierarchical stratification of reality. We describe a critical realist Explanatory Theory Building Method comprising of an: 1) emergent phase, 2) construction phase, and 3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design is described. The Emergent Phase uses: interviews, focus groups, exploratory data analysis, exploratory factor analysis, regression, and multilevel Bayesian spatial data analysis to detect and describe phenomena. Abductive and retroductive reasoning will be applied to: categorical principal component analysis, exploratory factor analysis, regression, coding of concepts and categories, constant comparative analysis, drawing of conceptual networks, and situational analysis to generate theoretical concepts. The Theory Construction Phase will include: 1) defining stratified levels; 2) analytic resolution; 3) abductive reasoning; 4) comparative analysis (triangulation); 5) retroduction; 6) postulate and proposition development; 7) comparison and assessment of theories; and 8) conceptual frameworks and model development. The strength of the critical realist methodology described is the extent to which this paradigm is able to support the epistemological, ontological, axiological, methodological and rhetorical positions of both quantitative and qualitative research in the field of social epidemiology. The extensive multilevel Bayesian studies, intensive qualitative studies, latent variable theory, abductive triangulation, and Inference to Best Explanation provide a strong foundation for Theory Construction. The study will contribute to defining the role that realism and mixed methods can play in explaining the social determinants and developmental origins of health and disease.

Perceived sources of stress and resilience in men in an African American community

BACKGROUND

Little is known about the perceived causes of stress and what strategies African American men use to promote resiliency. Participatory research approaches are recommended as an approach to engage minority communities. A key goal of participatory research is to shift the locus of control to community partners.

OBJECTIVE

To understand perceived sources of stress and tools used to promote resiliency in African American men in South Los Angeles.

METHODS

Our study utilized a community-partnered participatory research approach to collect and analyze open-ended responses from 295 African American men recruited at a local, cultural festival in Los Angeles using thematic analysis and the Levels of Racism framework.

RESULTS

Almost all men (93.2%) reported stress. Of those reporting stress, 60.8% reported finances and money and 43.2% reported racism as a specific cause. More than 60% (63.4%) reported that they perceived available sources of help to deal with stress. Of those noting a specific source of help for stress (n = 76), 42.1% identified religious faith. Almost all of participants (92.1%) mentioned specific sources of resiliency such as religion and family.

CONCLUSIONS

Stress owing to psychosocial factors such as finances and racism are common among African American men. But, at the same time, most men found support for resiliency to ameliorate stress in religion and family. Future work to engage African American men around alleviating stress and supporting resiliency should both take into account the perceived causes of stress and incorporate culturally appropriate sources of resiliency support.

Are we producing the right kind of actionable evidence for the social determinants of health?

Globally, health and social inequities are growing and are created, actively maintained, and aggravated by existing policies and practices. The call for evidence-based policy making to address this injustice seems a promising strategy to facilitate a reversal of existing strategies and the design of new effective programming. Acting on evidence to address inequities requires congruence between identifying the major drivers of disparities and the study of their causes and solutions. Yet, current research on inequities tends to focus on documenting disparities among individuals or subpopulations with little focus on identifying the macro-social causes of adverse population health. Moreover, the research base falls far short of a focus on the solutions to the complex multilevel drivers of disparities. This paper focuses upon recommendations to refocus and improve the public health research evidence generated to inform and create strong evidence-based recommendations for improving population health.

Mapping the Mixed Methods-Mixed Research Synthesis Terrain

Mixed methods-mixed research synthesis is a form of systematic review in which the findings of qualitative and quantitative studies are integrated via qualitative and/or quantitative methods. Although methodological advances have been made, efforts to differentiate research synthesis methods have been too focused on methods and not focused enough on the defining logics of research synthesis-each of which may be operationalized in different ways-or on the research findings themselves that are targeted for synthesis. The conduct of mixed methods-mixed research synthesis studies may more usefully be understood in terms of the logics of aggregation and configuration. Neither logic is preferable to the other nor tied exclusively to any one method or to any one side of the qualitative/quantitative binary.

Referral to health and social services for intimate partner violence in health care settings: a realist scoping review

Efficient and coordinated health care responses to intimate partner violence (IPV) are essential, given that health care settings are a major entry point for abused women who seek professional services. However, there is a lack of evidence on how IPV referrals are effectively made within health care settings. In order to help program planners and providers across sectors to address the complex and chronic issue of IPV, a greater understanding of the post-IPV identification referral process is essential. A scoping review of the evidence on IPV referral programs and processes in health care settings was undertaken to provide an overview of the state of evidence and identify pertinent gaps in existing research. The scoping review identified 13 evaluative studies and 6 qualitative, primarily nonevaluative studies that examined IPV referral programs and processes. Evaluative studies involved a variety of designs and IPV referral outcomes. Rich descriptions of barriers and facilitators to seeking referrals by victims and making referrals by health care providers emerged from the evaluative and qualitative studies, but were explored more in depth in the qualitative studies. This scoping review provides guidance on what is currently known about IPV referral programs in health care settings and provides a starting point for further research on effectiveness of referral processes.

Built environment and mobility of older adults: important policy and practice efforts

As people age, they prefer to "age in place." The concept of aging in place refers to the ability to live in one's own home, wherever that might be, for as long as one can feel confident and comfortable. Where people live and whether these environments can support them are critical questions for public health and public policy, especially since the baby boomers began to turn 65 on January 1, 2011. Equally important for public policy, those aged 85 and older are the fastest growing population group in the United States. The Health and Aging Policy Fellows Program, with the Centers for Disease Control and Prevention Healthy Aging Program, has supported a project to determine how design features of the built environment can support the mobility of older adults. Mobility refers to physical activity, usually walking, but also encompasses the ability to stay connected to nearby community resources and services. The project's purpose is to investigate features that support mobility in built environments. This policy brief introduces the realist synthesis method used in the project and selected national initiatives and activities to place this work in a broader context. Given the importance of mobility concerns to older adults, it must be determined without delay which design features support mobility and how local areas can better prepare to support the health of their aging populations.

Exploring the value of mixed methods within the At Home/Chez Soi housing first project: a strategy to evaluate the implementation of a complex population health intervention for people with mental illness who have been homeless

OBJECTIVE

This paper is a methodological case study that describes the At Home/Chez Soi (Housing First) Initiative's mixed-methods strategy for implementation evaluation and discusses the value of these methods in evaluating the implementation of such complex population health interventions.

TARGET POPULATION

The Housing First (HF) model is being implemented in five cities: Vancouver, Winnipeg, Toronto, Montréal and Moncton.

INTERVENTION

At Home/Chez Soi is an intervention trial that aims to address the issue of homelessness in people with mental health issues. The HF model emphasizes choices, hopefulness and connecting people with resources that make a difference to their quality of life. A component of HF is supported housing, which provides a rent subsidy and rapid access to housing of choice in private apartments; a second component is support. Quantitative and qualitative methods were used to evaluate HF implementation.

OUTCOMES

The findings of this case study illustrate how the critical ingredients of complex interventions, such as HF, can be adapted to different contexts while implementation fidelity is maintained at a theoretical level. The findings also illustrate how the project's mixed methods approach helped to facilitate the adaptation process. Another value of this approach is that it identifies systemic and organizational factors (e.g., housing supply, discrimination, housing procurement strategy) that affect implementation of key elements of HF.

CONCLUSION

In general, the approach provides information about both whether and how key aspects of the intervention are implemented effectively across different settings. It thus provides implementation data that are rigorous, contextually relevant and practical.

Exploring the value of mixed methods within the At Home/Chez Soi housing first project: a strategy to evaluate the implementation of a complex population health intervention for people with mental illness who have been homeless

OBJECTIVE

This paper is a methodological case study that describes the At Home/Chez Soi (Housing First) Initiative's mixed-methods strategy for implementation evaluation and discusses the value of these methods in evaluating the implementation of such complex population health interventions.

TARGET POPULATION

The Housing First (HF) model is being implemented in five cities: Vancouver, Winnipeg, Toronto, Montréal and Moncton.

INTERVENTION

At Home/Chez Soi is an intervention trial that aims to address the issue of homelessness in people with mental health issues. The HF model emphasizes choices, hopefulness and connecting people with resources that make a difference to their quality of life. A component of HF is supported housing, which provides a rent subsidy and rapid access to housing of choice in private apartments; a second component is support. Quantitative and qualitative methods were used to evaluate HF implementation.

OUTCOMES

The findings of this case study illustrate how the critical ingredients of complex interventions, such as HF, can be adapted to different contexts while implementation fidelity is maintained at a theoretical level. The findings also illustrate how the project's mixed methods approach helped to facilitate the adaptation process. Another value of this approach is that it identifies systemic and organizational factors (e.g., housing supply, discrimination, housing procurement strategy) that affect implementation of key elements of HF.

CONCLUSION

In general, the approach provides information about both whether and how key aspects of the intervention are implemented effectively across different settings. It thus provides implementation data that are rigorous, contextually relevant and practical.

Perceived competency and resolution of homelessness among women with substance abuse problems

Using a metasynthesis approach, our aim was to articulate new insights relating to the most efficient and effective means of helping homeless women with substance abuse problems to enhance their well-being and become more stably housed. Distorted perceptions of competency, which are shaped by dysfunctional relationships and mental health problems, make it challenging for women with substance abuse problems to resolve homelessness. Women with particularly low or high levels of perceived competency tend to grapple with challenges related to structure and control, trust, and hopelessness. Therapeutic strategies for approaching these women include careful assessment, caring, personalized structure and control, development of interpersonal trust, instillation of hope, and the targeted use of psychotherapeutic agents and counseling. Framing care for homeless women within the context of perceived competency offers a new way of understanding their plight and shaping interventions to more expeditiously move them toward healthy and stable lives.

Neighbourhoods and dementia in the health and social care context: a realist review of the literature and implications for UK policy development

The National Dementia Strategy in England has performed an essential role in transforming health and social care services and improving the commissioning architecture. However, to date, little attention has been paid to understanding the ways in which the outdoor and built environment impacts and intersects with the lives of people with dementia and their carers. One way of better understanding the outdoor and built environment is through a focus on the ‘neighbourhood’ as this is an area of public policy where attempts are being made across disciplines to unpack its meanings, significance and identity. This paper adopts a realist review method to detail the key findings and messages from the body of work that links the experience of living with dementia to the neighbourhood. Our findings from this review are assimilated and defined/presented under three headings, namely: outdoor spaces, built environment, and everyday technologies. These headings and our definitions are not discrete properties and there is some overlap in content. We found no research that sets out to enquire about how people with dementia might define their neighbourhood or that explores everyday neighbourhood practices for those living with the condition. Emerging concepts such as citizenship and, in the UK, the Coalition Government advancement of the ‘Big Society’, promote a vision of civic responsibilities and networked, dementia-capable communities, but evaluation of such initiatives are virtually absent from the literature. The review did uncover some interesting and innovative research methods that extend neighbourhood working, such as the ‘walking interview’. In order to develop a neighbourhood model for dementia, future research should examine the relationship and interaction between the neighbourhood as a social space and as a physical space alongside the active role of people with dementia as ‘place-makers’.

Realist methods in medical education research: what are they and what can they contribute?

CONTEXT

Education is a complex intervention which produces different outcomes in different circumstances. Education researchers have long recognised the need to supplement experimental studies of efficacy with a broader range of study designs that will help to unpack the 'how' and 'why' questions and illuminate the many, varied and interdependent mechanisms by which interventions may work (or fail to work) in different contexts.

METHODS

One promising approach is realist evaluation, which seeks to establish what works, for whom, in what circumstances, in what respects, to what extent, and why. This paper introduces the realist approach and explains why it is particularly suited to education research. It gives a brief introduction to the philosophical assumptions underlying realist methods and outlines key principles of realist evaluation (designed for empirical studies) and realist review (the application of realist methods to secondary research).

DISCUSSION

The paper warns that realist approaches are not a panacea and lists the circumstances in which they are likely to be particularly useful.