Social Relationships of Dually Diagnosed Homeless Adults Following Enrollment in Housing First or Traditional Treatment Services

[Stigma in homelessness and health care: reflections from a Housing First program in Barcelona, Spain]

The experience of homelessness is associated with strong stigmatization processes, which are often reflected in the treatment received from professionals and the healthcare system itself. This article aims to analyze the experiences of participants in a program for homeless individuals in Barcelona called Primer la Llar within the healthcare system, and how the stigma they suffer affects the care processes. This program follows the Housing First model, a social intervention that proposes providing housing without preconditions to individuals with long histories of street living, who suffer from severe mental disorders and/or addictions. Based on individual interviews with 20 participants conducted between 2016 and 2020, it is observed that in certain cases, entering the program, having housing availability, support from professionals, and the development of their own strategies had positive effects on improving their health, although they continue to perceive discriminatory attitudes in some medical settings. It is suggested that the transformation regarding stigmatization be understood broadly, affecting individuals, institutions, and society as a whole.

Beyond housing: Understanding community integration among homeless-experienced veteran families in the United States

Community integration is important to address among homeless-experienced individuals. Little is known about helping veteran families (families with a parent who is a veteran) integrate into the community after homelessness. We sought to understand the experiences of community integration among homeless-experienced veteran families. We used a two-stage, community-partnered approach. First, we analysed 16 interviews with homeless-experienced veteran parents (parents who served in the military; n = 9) living in permanent housing and providers of homeless services (n = 7), conducted from February to September 2016, for themes of community integration. Second, we developed a workgroup of nine homeless-experienced veteran parents living in a permanent housing facility, who met four times from December 2016 to July 2017 to further understand community integration. We audio-recorded, transcribed and analysed the interviews and workgroups for community integration themes. For the analysis, we developed community integration categories based on interactions outside of the household and built a codebook describing each topic. We used the codebook to code the individual interviews and parent workgroup sessions after concluding that the workgroup and interview topics were consistent. Findings were shared with the workgroup. We describe our findings across three stages of community integration: (a) first housed, (b) adjusting to housing and the community, and (c) housing maintenance and community integration. We found that parents tended to isolate after transitioning into permanent housing. After this, families encountered new challenges and were guarded about losing housing. One facilitator to community integration was connecting through children to other parents and community institutions (e.g. schools). Although parents felt safe around other veterans, many felt judged by non-veterans. Parents and providers reported a need for resources and advocacy after obtaining housing. We share implications for improving community integration among homeless-experienced veteran families, including providing resources after obtaining housing, involving schools in facilitating social connections, and combating stigma.

Social networks and subjective wellbeing of adults in a Housing First program

This study explored the social network properties and the correlates between social networks and subjective wellbeing of adults (N = 80) in a Housing First (HF) program. Using structured interviews, participants' social network properties were assessed. Bivariate correlations and backward multiple regression analyses were conducted to determine the association between social networks and subjective wellbeing. Findings indicate a combination of years of homelessness, years in housing, frequency of contact, intimate relationship, and perceived social support significantly predicted subjective wellbeing (F (5, 74) = 2.74, p = 0.025). While perceived social support was positively associated with subjective wellbeing, frequency of contact was negatively associated with subjective wellbeing. It is recommended that service providers develop strengths-focused perspectives of the social networks of HF residents as potential contributors to subjective wellbeing. Service providers may need to pay more attention to HF residents with frequent contacts with network members, as they may have more distress.

Changes in Physical Assault Among Adults Moving Into Permanent Supportive Housing

People experiencing homelessness experience high rates of physical assault. While this high risk for victimization is well established, there is no research that examines whether victimization rates change over time as persons transition into permanent supportive housing (PSH). Data are from a longitudinal study of adults moving into PSH in the Los Angeles, CA area. Interviews were conducted prior to or within 5 days of moving in, with follow-up interviews at 3, 6, and 12 months after move-in (n = 370 participants completing all four interviews). Each interview assessed characteristics of past 3-month physical assault. Analyses examined change in rates of assault over time and differences by demographic subgroups. We also present findings on the most common locations and perpetrators of assault. Overall, rates of physical assault decreased after participants entered PSH. Statistically significant differences by subgroups varied by time point. Differences identified include higher rates of physical assault among Latino/a respondents, lower rates among African Americans, and higher rates of physical assault among lesbian, gay, bisexual, and transgender (LGBT) respondents. The most frequent location of assault was outside at baseline, 3- and 6-month time points. Strangers were the most common perpetrator at all time points. Rates of perpetration by neighbors nearly doubled from baseline to the 12-month time point, and inside locations for assault were most common at this time point as well. While PSH is an effective intervention in reducing chronic homelessness, it is important to consider other risks to overall health and well-being, such as physical victimization.

Housing and Social Connection: Older Formerly Homeless Veterans Living in Subsidized Housing and Receiving Supportive Services

Objectives: The purpose of this study was to (Aim 1) describe United States military veterans' experiences and attitudes about project-based housing (PBH) and tenant-based housing (TBH), including perceptions of their new environment, self-sufficiency, and social integration. We identified (Aim 2) features of program design and housing facilities associated with self-sufficiency and social integration including describing differences in veterans' experiences of housing (PBH vs. TBH).Methods: Interviews were conducted with 30 Veterans in the U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program (25 male and 5 female; average age 63). Thirteen lived in PBH and 17 in TBH in the Greater Boston Metro Area.Results: Social isolation may be a particular challenge of older formerly homeless adults. Veterans in both types of supportive housing struggled with social isolation despite social engagement opportunities available in PBH. Healthcare and transportation issues were important for veterans living in TBH while behavioral health issues were a major factor for those living in both types of housing. Both groups of veterans relied on their case management teams as a means of support and social engagement.Conclusions: To reduce social isolation and loneliness, more attention is needed by program staff to provide varied social engagement opportunities, from one-on-one to group activities.Clinical Implications: These findings can help providers recognize issues inhibiting formerly homeless veterans from being successful in supportive housing. Clinicians should consider how veterans' behavioral health impacts their ability to engage in social activities. Substance use disorder remains a challenge for many veterans interviewed. Its effects impact their perceptions of fellow residents, perceptions of housing, and recovery.

Social Network Change after Moving into Permanent Supportive Housing: Who Stays and Who Goes?

Social relationships are important among persons experiencing homelessness, but there is little research on changes in social networks among persons moving into permanent supportive housing (PSH). Using data collected as part of a longitudinal study of 405 adults (aged 39+) moving into PSH, this study describes network upheaval during this critical time of transition. Interviews conducted prior to and after three months of living in PSH assessed individual-level characteristics (demographics, homelessness history, health and mental health) and included a social network component that assessed network size and composition (demographics, relationship type, social support); interviewers utilized network member characteristics to assess whether network members were new or sustained between baseline and 3 months post-housing. Multilevel logistic regression models assessed what characteristics of network members were associated with being newly-gained or persisting in networks 3 months after moving into PSH. We found that only one-third of social networks were retained during the transition to PSH, and that veterans, African Americans and other persons of racial/ethnic minorities, and those living in scattered-site housing were more likely to experience network disruption. Relatives, romantic partners, and service providers were most likely to be retained after move-in. Some network change was moderated by tie strength, including the retention of street-met persons. Implications are discussed.

Loneliness in Homeless Participants of a Housing First Program: Outcomes of a Randomized Controlled Trial

People who are homeless are likely to experience loneliness. Housing First (HF) is a program aimed at providing home placement to homeless people who also have mental health and/or substance use-related problems. The current study was performed to assess feelings of loneliness among participants of a HF program. A randomized controlled trial was performed comparing participants in two groups, HF (n = 46) and treatment as usual (n = 41). No significant differences regarding loneliness between groups were noted at baseline (p = 0.841), 8-month follow up (p = 0.509), or 21-month follow up (p = 0.833); however, participants with severe mental illness reported higher feelings of loneliness at the 8-month assessment than at baseline. This increase was higher in HF participants. These findings are partially consistent with previous research and are of relevance for providers, policy makers, and teams working with HF programs. Findings indicate the need to address feelings of loneliness in this population. Further research is needed to ascertain the effectiveness of HF programs on loneliness. [Journal of Psychosocial Nursing and Mental Health Services, 59(3), 44-51.].

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.

Homeless Adults' Recovery Experiences in Housing First and Traditional Services Programs in Seven European Countries

Across Europe, as governments turn to housing-led strategies in attempts to reverse rising rates of homelessness, increasing numbers of Housing First (HF) programs are being implemented. As HF programs become more widespread, it is important to understand how service users experience them compared to the more prevalent traditional treatment-first approach to addressing long-term homelessness. Although there is a large body of research on service users' experiences of Housing First compared to treatment-first in North American contexts, comparatively less is known about how these two categories of homeless services are experienced in the European context. In a correlational and cross-sectional study, part of a larger examination of homelessness in Europe, participants (n = 520) engaged with either HF (n = 245) or traditional services (TS; n = 275) programs in seven countries completed measures of their experiences of services (consumer choice, housing quality, and service satisfaction) and recovery (time in independent housing, psychiatric symptoms, and community integration). Across the seven countries, participants engaged with HF programs reported experiencing more consumer choice, better perceived housing quality, and more satisfaction with services than participants engaged in TS programs. Participants in HF programs also reported a greater proportion of time in independent accommodation, fewer psychiatric symptoms, and more community integration. Varying patterns of association between experiences of services and recovery outcomes were observed. Findings indicate HF consistently predicts greater recovery than TS across diverse sociopolitical and economic contexts. Implications of findings for configurations of homeless services and homeless services policy are discussed.

Associations between housing stability and injecting frequency fluctuations: findings from a cohort of people who inject drugs in Montréal, Canada

BACKGROUND

The relationship between housing stability and drug injecting is complex, as both outcomes fluctuate over time. The objectives were to identify short-term trajectories of housing stability and injecting frequency among people who inject drugs (PWID) and examine how patterns of injecting frequency relate to those of housing stability.

METHODS

At three-month intervals, PWID enrolled between 2011 and 2016 in the Hepatitis Cohort completed an interviewer-administered questionnaire and were tested for hepatitis C and HIV infections. At each visit, participants reported, for each of the past three months, the accommodation they lived in the longest (stable/unstable) and the number of injecting days (0-30). Group-based dual trajectory modeling was conducted to identify housing stability and injecting frequency trajectories evolving concomitantly over 12 months and estimate the probabilities of following injecting trajectories conditional upon housing trajectories.

RESULTS

386 participants were included (mean age 40.0, 82 % male). Three housing stability trajectories were identified: sustained (53 %), declining (20 %), and improving (27 %). Five injecting frequency trajectories were identified: sporadic (26 %), infrequent (34 %), increasing (15 %), decreasing (11 %), and frequent (13 %). PWID with improving housing were less likely to increase injecting (8 %) compared to those with sustained (17 %) or declining housing (17 %).

CONCLUSIONS

Improving housing was associated with a lower probability of increasing injecting compared to declining housing, while sustained housing stability was associated with a higher probability of increasing injecting compared to improving housing. Therefore, policies to improve PWID's access to stable housing are warranted and may reduce, to some extent, drug injecting and related harms.

Life Goals Over Time Among Homeless Adults in Permanent Supportive Housing

Permanent supportive housing (PSH) is a widely-accepted solution to the challenge of chronic homelessness. While housing support and retention, physical health, and healthcare continue to be important for formerly homeless persons in PSH, "higher-order" and humanistic needs such as thriving have received less attention and as a result are less well understood in this population. One important indicator of thriving is the ability to establish and articulate life goals. This study utilizes longitudinal data from 421 formerly homeless adults prior to their move into PSH, and at 3-, 6- and 12-months after move-in (369 respondents completed all four interviews), to examine what life goals are articulated by this population and how those goals change over time. Prior to housing, most respondents articulated housing attainment as their primary life goal, whereas at follow-up interviews health goals, housing relocation, and financial goals became more prevalent. Aspirational goals (e.g., independence, self-improvement, artistic pursuits) were also common, but demonstrated a decrease over time in housing. Relationship goals remained common and consistent over time. Findings indicate that housing is a necessary, but perhaps not sufficient, step for improving thriving among formerly homeless adults. Implications for practice and future research are discussed.

Social Network Decay as Potential Recovery from Homelessness: A Mixed Methods Study in Housing First Programming

The positive relationship between social support and mental health has been well documented, but individuals experiencing chronic homelessness face serious disruptions to their social networks. Housing First (HF) programming has been shown to improve health and stability of formerly chronically homeless individuals. However, researchers are only just starting to understand the impact HF has on residents’ individual social integration. The purpose of the current study was to describe and understand changes in social networks of residents living in a HF program. Researchers employed a longitudinal, convergent parallel mixed method design, collecting quantitative social network data through structured interviews (n = 13) and qualitative data through semi-structured interviews (n = 20). Quantitative results demonstrated a reduction in network size over the course of one year. However, increases in both network density and frequency of contact with network members increased. Qualitative interviews demonstrated a strengthening in the quality of relationships with family and housing providers and a shedding of burdensome and abusive relationships. These results suggest network decay is a possible indicator of participants’ recovery process as they discontinued negative relationships and strengthened positive ones.

Housing First and harm reduction: a rapid review and document analysis of the US and Canadian open-access literature

BACKGROUND

Housing First is an evidence-based practice intended to serve chronically homeless individuals with co-occurring serious mental illness and substance use disorders. Despite housing active substance users, harm reduction is an often-overlooked element during the Housing First implementation process in real-world settings. In this paper, we explore the representation of the Housing First model within the open-access scholarly literature as a potential contributing factor for this oversight.

METHODS

We conducted a rapid review of the US and Canadian open-access Housing First literature. We followed a document analysis approach, to form an interpretation of the articles' content related to our primary research questions.

RESULTS

A total of 55 articles on Housing First were included in the final analysis. Only 21 of these articles (38.1%) included explicit mention of harm reduction. Of the 34 articles that did not discuss harm reduction, 22 provided a description of the Housing First model indicating it does not require abstinence from substance use; however, descriptions did not all clearly indicate abstinence was not required beyond program entry. Additional Housing First descriptions focused on the low-barrier entry criteria and/or the intervention's client-centeredness.

CONCLUSIONS

Our review demonstrated a lack of both explicit mention and informed discussion of harm reduction in the Housing First literature, which is likely contributing to the Housing First research-practice gap to some degree. Future Housing First literature should accurately explain the role of harm reduction when discussing it in the context of Housing First programming, and public agencies promoting Housing First uptake should provide resources for proper implementation and monitor program fidelity to prevent model drift.

Differences in Health and Social Support between Homeless Men and Women Entering Permanent Supportive Housing

BACKGROUND

Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH.

METHODS

This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area.

RESULTS

Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict.

CONCLUSIONS

There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.