Harm reduction in a Norwegian housing first project: a qualitative study of the treatment providers’ practice

Fatores contextuais e implantação da intervenção Housing First: uma revisão da literatura

Resumo O Housing First (HF) tem se difundido no cenário internacional como uma intervenção baseada em evidência para superar a situação de rua entre pessoas com agravos de saúde mental. No Brasil, o HF tem sido adotado como referência no desenvolvimento de iniciativas voltadas para pessoas em situação de rua que fazem uso prejudicial de drogas. Estudos apontam a necessidade de maior compreensão da dinâmica implantação do modelo HF em diferentes cenários. De tal modo, utilizando o método de revisão de literatura, analisamos os fatores que facilitam e dificultam a implantação do HF. Foram selecionados 68 artigos, publicados entre 2003 e 2020, nas bases PubMed, Scopus, PsychoINFO, Embase, Lilacs e Scielo. Identificamos fatores em quatro dimensões: características da intervenção, contexto de implantação, aspectos institucionais e processo de implantação. A indisponibilidade de habitações, a falta de coordenação dos serviços necessários aos moradores e a resistência dos agentes implantadores aos princípios do HF são fatores que dificultam a implantação. Por sua vez, agentes com valores, atitudes e competências convergentes ao modelo e educação permanente aparecem como facilitadores. Apontamos a necessidade de se compreender e favorecer o processo de integração do HF aos sistemas de proteção social existentes.

Part III: Recovery-Oriented Practices in Community Mental Health and Substance Abuse Services: A Meta-Synthesis

In recent decades, recovery-oriented practice has become the major approach in mental health and substance abuse care, especially in community mental health and substance abuse services. Various models of recovery-oriented practice have come to form the basis of the integration of this approach in service settings. The study aims to elucidate the characteristics of recovery-oriented practice as experienced by participants in the practice. The method used was a qualitative meta-synthesis that integrated the findings from thirty-four empirical papers published by one research group. Four meta-themes were developed: (a) helping and supporting, (b) collaborating and relating, (c) identity integration in practice, and (d) generating hope through nurturing and helping. These themes emphasize the value of relationships and connectedness, contextuality, and resources that can be mobilized in practice. The results emphasize the need to incorporate the elements in the four major themes as “working capital” for practitioners to realize recovery-oriented practice. The concepts of personal, social, and economic capital as working capital are elaborated, drawing from the meta-themes as the basis for recovery-oriented practice in mental health and substance abuse services.

Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review

BACKGROUND

Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First.

METHODS

A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar. Harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use.

RESULTS

A total of 35 articles were included in the review, 23 of which examined harm reduction outcomes and 12 of which investigated harm reduction practices in Housing First. Harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain. More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising. Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. Research on harm reduction practices highlighted that Housing First providers experience both flexibility and ambiguity in their work using a harm reduction approach, and the importance of empathetic working relationships for engagement in harm reduction work.

CONCLUSIONS

Harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.

Strategies for Sustaining Fidelity: A Multi-state Qualitative Analysis in Housing First Programs

Little is known about long-term fidelity of evidence-based interventions (EBIs) under changing conditions. This study examines how staff at 'mature' (eight or more years in operation) Housing First (HF) programs strategize to sustain EBI fit in different geographic areas in the Mid-Atlantic/Northeastern United States. Six focus groups (FGs) at three purposively selected HF programs were conducted with separate FGs for case managers and supervisors at each site. FG discussions elicited participants' service approaches and strategies in addressing fidelity amidst ongoing changes affecting each program. Thematic content analysis of FG transcripts was conducted using the five HF fidelity domains (housing choice/structure, separation of housing and services, service philosophy, service array, and program structure) as a priori themes with inductive content analyses conducted on data in each theme. Strategies for rigor were employed. Case managers (N = 17) and supervisors (N = 16) were predominantly white (76%) and female (60%). Across the themes, challenges included lack of affordable housing and choice, funders' restrictions and practice 'drift.' Strategies included community engagement and hiring, strong leadership and 'bending the rules.' There were no differences across sites. Later-stage implementation challenges show the need for continued vigilance in fidelity to EBIs. Among the strategies used to address fidelity in this study, the pursuit of pro-active community engagement to attract knowledgeable staff as well as increase local buy-in was considered pivotal at all three sites. These findings underscore the need to attend to the external setting as well as to internal program operations.

Harm reduction: Philosophical drivers of conceptual tensions and ways forward

Of the various debates surrounding harm reduction, a conceptual tension that perhaps has the most relevance for the provision of services is that of harm reduction as a technical solution versus a contextualized social practice. The aim of this paper was to examine this conceptual tension. First, the two perspectives will be presented through the use of examples. Second, philosophical drivers that serve to underpin and justify each perspective will be explicated at the level of the knowledge that we privilege; the ideologies that we subscribe to; and the interests that we stand to serve. In this paper, I argue that the existing tension between technical and social approaches to harm reduction is embedded within discord pertaining to ways of knowing, paradigms of inquiry, prevailing ideologies, and notions of harm and risk. Building on these sources of tension, I suggest a means of philosophical reconciliation between the two approaches and ways forward, namely through acknowledging multiple sources of knowledge, through embracing paradigmatic incommensurability, through considering alternative conceptions of people who use drugs as political subjects, through involving service providers and end-users in shared decision-making, and lastly through reaffirming people who use drugs as the intended beneficiaries of services.