Moving from rhetoric to reality: adapting Housing First for homeless individuals with mental illness from ethno-racial groups

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

Background

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

Objectives

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

Search Methods

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

Selection Criteria

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

Data Collection and Analysis

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

Main Results

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

Case Management and Housing Outcomes

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

Case Management and Mental Health Outcomes

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

Case Management and Other Outcomes

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

Case Management Components

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

Characteristics of Persons Experiencing Homelessness

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

The Broader Context of Delivery of Case Management Programmes

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

Cost Effectiveness

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

Authors' Conclusions

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

Public Health Interventions to Address Housing and Mental Health amongst Migrants from Culturally and Linguistically Diverse Backgrounds Living in High-Income Countries: A Scoping Review

Migrants from culturally and linguistically diverse (CaLD) backgrounds experience factors that may increase health inequities related to a range of determinants of health including housing and mental health. However, the intersection between mental health and housing for migrants is poorly understood. A scoping review searched four academic databases for concepts related to cultural and linguistic diversity, housing conditions, and public health interventions to address homelessness. A total of 49 articles were included and seven key themes identified: housing provision; mental health intersections and interventions; complexity and needs beyond housing; substance use; service provider and policy issues; the role of cultural and linguistic diversity; and consumer experience. The intersection of ethnicity with other social determinants of health and housing was highlighted though there were limited interventions tailored for migrants. Studies generally pointed to the positive impacts of Housing First. Other sub-themes emerged: social connection and community; shame, stigma, and discrimination; health and support requirements; and employment, financial assistance, and income. Consumer choice was identified as vital, along with the need for systemic anti-racism work and interventions. To support secure housing for migrants and mitigate mental health impacts, closer attention is required towards migration factors along with broader, tailored services complementing housing provision.

Ethnic identity, stress, and personal recovery outcomes among young adults with serious mental health conditions

OBJECTIVE

Serious mental illnesses (SMI) often occur during early adulthood, just as young people are developing important aspects of their identity that can affect their recovery. Positive ethnic identity development is associated with stress coping and psychological well-being in young people. But, there is limited research to indicate how individual experiences of belonging and attachment to one's ethnic group influence personal recovery processes among young adults living with SMI.

METHOD

Young adults living with SMI (95% identified as ethnic/racial minorities) were recruited from four outpatient psychiatric rehabilitation programs (N = 83). Multivariate regressions were used to examine relationships between predictors (demographics, psychiatric symptomatology, ethnic identity) and the dependent variables (perceived stress and personal recovery).

RESULTS

A stronger, more developed ethnic identity and fewer depressive symptoms were associated with higher ratings of personal recovery. Increases in psychiatric symptoms predicted increased perceived stress. Post hoc analyses showed that Black, Latino/a, and multiracial study participants' ethnic identity ratings were similar to those of same ethnic/racial group of young adults without SMI.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Ethnic identity development could be a significant psychosocial factor shaping mental health recovery among minority young people living with SMI. Several factors associated with psychological well-being among ethnic and racial minority youth may account for this, including adaptive coping, social support, and a buffering effect against racism. Our findings indicate that assessing and developing a young person's ethnic identity-related strengths and resources as a means for improving the personalization of recovery services and enhancing the quality of care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Primary Care Engagement Among Individuals with Experiences of Homelessness and Serious Mental Illness: an Evidence Map

BACKGROUND

Experiences of homelessness and serious mental illness (SMI) negatively impact health and receipt of healthcare. Interventions that promote the use of primary care services for people with both SMI and homelessness may improve health outcomes, but this literature has not been evaluated systematically. This evidence map examines the breadth of literature to describe what intervention strategies have been studied for this population, elements of primary care integration with other services used, and the level of intervention complexity to highlight gaps for future intervention research and program development.

METHODS

We followed an a priori protocol developed in collaboration with clinical stakeholders. We systematically searched the published literature to identify interventions for adults with homelessness who also had SMI. We excluded case reports, editorials, letters, and conference abstracts. Data abstraction methods followed standard practice. Data were categorized into intervention strategies and primary care integration strategies. Then we applied the Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to characterize intervention complexity.

RESULTS

Twenty-two articles met our inclusion criteria evaluating 15 unique interventions to promote engagement in primary care for adults with experiences of homelessness and SMI. Study designs varied widely from randomized controlled trials and cohort studies to single-site program evaluations. Intervention strategies varied across studies but primarily targeted patients directly (e.g., health education, evidence-based interactions such as motivational interviewing) with fewer strategies employed at the clinic (e.g., employee training, multidisciplinary teams) or system levels (e.g., data sharing). We identified elements of primary care integration, including referral strategies, co-location, and interdisciplinary care planning. Interventions displayed notable complexity around the number of intervention components, interaction between intervention components, and extent to which interventions were tailored to specific patient populations.

DISCUSSION

We identified and categorized elements used in various combinations to address the primary care needs of individuals with experiences of homeless and SMI.

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.

"We Die 25 Years Sooner:" Addressing Physical Health Among Persons with Serious Mental Illness in Supportive Housing

People diagnosed with serious mental illness (SMI) experience significant health disparities, including high rates of premature mortality. Supportive housing may serve as a critical service setting for addressing physical health, but comprehensive health-related services within these programs remain an exception. This study sought to identify barriers, and potential solutions, to addressing the physical health needs of people with SMI within supportive housing. Semi-structured interviews and focus groups were conducted with multiple stakeholders (clients, peer specialists, non-peer staff, leadership) across three supportive housing agencies. There was general consensus regarding multiple barriers at the individual, organizational, policy/system, and community levels. Nevertheless, stakeholders also identified strategies in domains such as staffing, organizational culture, partnerships, communication, and infrastructure for addressing barriers. These findings can inform planning for implementation of health initiatives within supportive housing while also highlighting the need for broader community, systems, and policy change.Trial Registration Number: NCT02175641.

Effect of a Housing Intervention on Selected Cardiovascular Risk Factors Among Homeless Adults With Mental Illness: 24-Month Follow-Up of a Randomized Controlled Trial

Background Cardiovascular disease is a leading cause of mortality among people experiencing homelessness. This study investigated whether housing intervention affects cardiovascular disease risk factors among homeless adults with mental illnesses over a 24-month period. Methods and Results We conducted a randomized controlled trial of a Housing First intervention that provided community-based scattered-site housing and support services. Five hundred seventy-five participants were randomized to the intervention (n=301) or treatment as usual (TAU) (n=274). Analyses were performed according to the intention-to-treat principle using generalized estimating equations. There were no differences in change over 24 months between the 2 groups for blood pressure, tobacco, and cocaine/crack use. However, the intervention had an impact on reducing the number of days of alcohol intoxication by 1.58 days compared with TAU (95% CI, -2.88 to -0.27, P=0.0018). Over the 24-month period, both the intervention and TAU groups had significant reductions in tobacco and cocaine use. Conclusions The intervention, compared with TAU, did not result in greater improvements in many of the selected cardiovascular risk factors. Since the study took place in a service-rich city with a range of pre-existing supportive services and universal health insurance, the high level of usual services available to the TAU group may have contributed to reductions in their cardiovascular disease risk factors. Further research is needed to develop interventions to reduce risk factors of cardiovascular disease among people experiencing homelessness and mental illness beyond existing treatments. REGISTRATION www.isrctn.comURL: www.isrctn.com. Unique Identifier: ISRCTN42520374.

Mental and substance use disorders and food insecurity among homeless adults participating in the At Home/Chez Soi study

BACKGROUND

Few studies have examined how food insecurity changes over time when living with severe mental disorders or substance use disorders. This study identifies food insecurity trajectories of homeless adults participating in a trial of a housing intervention and examines whether receiving the intervention and having specific mental and substance disorders predict food insecurity trajectories.

MATERIALS AND METHODS

We studied 520 participants in the Toronto site of the At Home/Chez-Soi project. Food insecurity data were collected at seven times during a follow-up period of up to 5.5 years. Mental and substance use disorders were assessed at baseline. Food insecurity trajectories were identified using group based-trajectory modeling. Multinomial logistic regression was used to examine the effects of the intervention and mental and substance use disorders on food insecurity trajectories.

RESULTS

Four food insecurity trajectories were identified: persistently high food insecurity, increasing food insecurity, decreasing food insecurity, and consistently low food insecurity. Receiving the intervention was not a predictor of membership in any specific food insecurity trajectory group. Individuals with major depressive episode, mood disorder with psychotic features, substance disorder, and co-occurring disorder (defined as having at least one alcohol or other substance use disorder and at least one non-substance related mental disorder] were more likely to remain in the persistently high food insecurity group than the consistently low food insecurity group.

CONCLUSION

A persistently high level of food insecurity is common among individuals with mental illness who have experienced homelessness, and the presence of certain mental health disorders increases this risk. Mental health services combined with access to resources for basic needs, and re-adaptation training are required to enhance the health and well-being of this population.

Defining the external implementation context: an integrative systematic literature review

Background

Proper implementation of evidence-based interventions is necessary for their full impact to be realized. However, the majority of research to date has overlooked facilitators and barriers existing outside the boundaries of the implementing organization(s). Better understanding and measurement of the external implementation context would be particularly beneficial in light of complex health interventions that extend into and interact with the larger environment they are embedded within. We conducted a integrative systematic literature review to identify external context constructs likely to impact implementation of complex evidence-based interventions.

Methods

The review process was iterative due to our goal to inductively develop the identified constructs. Data collection occurred in four primary stages: (1) an initial set of key literature across disciplines was identified and used to inform (2) journal and (3) author searches that, in turn, informed the design of the final (4) database search. Additionally, (5) we conducted citation searches of relevant literature reviews identified in each stage. We carried out an inductive thematic content analysis with the goal of developing homogenous, well-defined, and mutually exclusive categories.

Results

We identified eight external context constructs: (1) professional influences, (2) political support, (3) social climate, (4) local infrastructure, (5) policy and legal climate, (6) relational climate, (7) target population, and (8) funding and economic climate.

Conclusions

This is the first study to our knowledge to use a systematic review process to identify empirically observed external context factors documented to impact implementation. Comparison with four widely-utilized implementation frameworks supports the exhaustiveness of our review process. Future work should focus on the development of more stringent operationalization and measurement of these external constructs.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3046-5) contains supplementary material, which is available to authorized users.

Coping and resilience among ethnoracial individuals experiencing homelessness and mental illness

BACKGROUND

The multiple challenges that ethnoracial homeless individuals experiencing mental illness face are well documented. However, little is known about how this homeless subpopulation copes with the compounding stressors of racial discrimination, homelessness and mental illness.

AIMS

This study is an in-depth investigation of the personal perceived strengths, attitudes and coping behaviors of homeless adults of diverse ethnoracial backgrounds experiencing homelessness and mental illness in Toronto, Canada.

METHOD

Using qualitative methods, 36 in-depth semi-structured interviews were conducted to capture the perspectives of ethnoracial homeless participants with mental illness on coping and resilience. Transcripts were analyzed using thematic analysis.

RESULTS

Similar to prior findings in the general homeless population, study participants recognized personal strengths and attitudes as great sources of coping and resilience, describing hope and optimism, self-esteem and confidence, insight into their challenges and spirituality as instrumental to overcoming current challenges. In addition, participants described several coping strategies, including seeking support from family, friends and professionals; socializing with peers; engaging in meaningful activities; distancing from overwhelming challenges; and finding an anchor.

CONCLUSION

Findings suggest that homeless adults with mental illness from ethnoracial groups use similar coping strategies and sources of resilience with the general homeless population and highlight the need for existing services to foster hope, recognize and support individual coping strategies and sources of resilience of homeless individuals experiencing complex challenges.

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.

The effectiveness of a Housing First adaptation for ethnic minority groups: findings of a pragmatic randomized controlled trial

BACKGROUND

Little is known about the effectiveness of Housing First (HF) among ethnic minority groups, despite its growing popularity for homeless adults experiencing mental illness. This randomized controlled trial tests the effectiveness of a HF program using rent supplements and intensive case management, enhanced by anti-racism and anti-oppression practices for homeless adults with mental illness from diverse ethnic minority backgrounds.

METHODS

This unblinded pragmatic field trial was carried out in community settings in Toronto, Canada. Participants were 237 adults from ethnic minority groups experiencing mental illness and homelessness, who met study criteria for moderate needs for mental health services. Participants were randomized to either adapted HF (n = 135) or usual care (n = 102) and followed every 3 months for 24 months. The primary study outcome was housing stability; secondary outcomes included physical and mental health, social functioning, quality of life, arrests and health service use. Intention to treat statistical analyses examined the effectiveness of the intervention compared to usual care.

RESULTS

During the 24-month study period, HF participants were stably housed a significantly greater proportion of time compared to usual care participants, 75 % (95 % CI 70 to 81) vs. 41 % (95 % CI 35 to 48), respectively, for a difference of 34 %, 95 % CI 25 to 43. HF also led to improvements in community integration over the course of the study: the change in the mean difference between treatment groups from baseline to 24-months was significantly greater among HF participants compared to those in usual care (change in mean difference = 2.2, 95 % CI 0.06 to 4.3). Baseline diagnosis of psychosis was associated with reduced likelihood of being housed ≥ 50 % of the study period (OR = 0.37, 95 % CI 0.18 to 0.72).

CONCLUSION

Housing First enhanced with anti-racism and anti-oppression practices can improve housing stability and community functioning among ethnically diverse homeless adults with mental illness.

TRIAL REGISTRATION

International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374 , assigned August 18, 2009.

Collaboration and involvement of persons with lived experience in planning Canada's At Home/Chez Soi project

Planning the implementation of evidence-based mental health services entails commitment to both rigour and community relevance, which entails navigating the challenges of collaboration between professionals and community members in a planning environment which is neither 'top-down' nor 'bottom-up'. This research focused on collaboration among different stakeholders (e.g. researchers, service-providers, persons with lived experience [PWLE]) at five project sites across Canada in the planning of At Home/Chez Soi, a Housing First initiative for homeless people with mental health problems. The research addressed the question of what strategies worked well or less well in achieving successful collaboration, given the opportunities and challenges within this complex 'hybrid' planning environment. Using qualitative methods, 131 local stakeholders participated in key informant or focus group interviews between October 2009 and February 2010. Site researchers identified themes in the data, using the constant comparative method. Strategies that enhanced collaboration included the development of a common vision, values and purpose around the Housing First approach, developing a sense of belonging and commitment among stakeholders, bridging strategies employed by Site Co-ordinators and multiple strategies to engage PWLE. At the same time, a tight timeline, initial tensions, questions and resistance regarding project and research parameters, and lack of experience in engaging PWLE challenged collaboration. In a hybrid planning environment, clear communication and specific strategies are required that flow from an understanding that the process is neither fully participatory nor expert-driven, but rather a hybrid of both.

Housing First for People With Severe Mental Illness Who Are Homeless: A Review of the Research and Findings From the At Home-Chez soi Demonstration Project

OBJECTIVE

To provide a review of the extant research literature on Housing First (HF) for people with severe mental illness (SMI) who are homeless and to describe the findings of the recently completed At Home (AH)-Chez soi (CS) demonstration project. HF represents a paradigm shift in the delivery of community mental health services, whereby people with SMI who are homeless are supported through assertive community treatment or intensive case management to move into regular housing.

METHOD

The AH-CS demonstration project entailed a randomized controlled trial conducted in 5 Canadian cities between 2009 and 2013. Mixed methods were used to examine the implementation of HF programs and participant outcomes, comparing 1158 people receiving HF to 990 people receiving standard care.

RESULTS

Initial research conducted in the United States shows HF to be a promising approach, yielding superior outcomes in helping people to rapidly exit homelessness and establish stable housing. Findings from the AH-CS demonstration project reveal that HF can be successfully adapted to different contexts and for different populations without losing its fidelity. People receiving HF achieved superior housing outcomes and showed more rapid improvements in community functioning and quality of life than those receiving treatment as usual.

CONCLUSIONS

Knowledge translation efforts have been undertaken to disseminate the positive findings and lessons learned from the AH-CS project and to scale up the HF approach across Canada.

What qualitative research can contribute to a randomized controlled trial of a complex community intervention

Using the case of a large-scale, multi-site Canadian Housing First research demonstration project for homeless people with mental illness, At Home/Chez Soi, we illustrate the value of qualitative methods in a randomized controlled trial (RCT) of a complex community intervention. We argue that quantitative RCT research can neither capture the complexity nor tell the full story of a complex community intervention. We conceptualize complex community interventions as having multiple phases and dimensions that require both RCT and qualitative research components. Rather than assume that qualitative research and RCTs are incommensurate, a more pragmatic mixed methods approach was used, which included using both qualitative and quantitative methods to understand program implementation and outcomes. At the same time, qualitative research was used to examine aspects of the intervention that could not be understood through the RCT, such as its conception, planning, sustainability, and policy impacts. Through this example, we show how qualitative research can tell a more complete story about complex community interventions.

The interplay between drug-use behaviors, settings, and access to care: a qualitative study exploring attitudes and experiences of crack cocaine users in Rio de Janeiro and São Paulo, Brazil

Background

Despite the growing attention surrounding crack cocaine use in Brazil, little is understood about crack users’ histories, use patterns and the interplay of drug-use behaviors, settings, and access/barriers to care. Qualitative studies seldom cross-compare findings regarding people who use crack from different settings. This study aims to explore the insights of regular crack users in two major Brazilian cities and to examine how social and contextual factors, including stigma and marginalization, influence initial use and a range of health and social issues.

Methods

In-depth interviews and focus groups were conducted with 38 adult crack cocaine users recruited from impoverished neighborhoods in Rio de Janeiro and São Paulo. Interviews and focus groups were audio recorded and transcribed verbatim. Qualitative analysis was carried out, and content was organized and analyzed by recurrent themes relevant to study interests.

Results

For study participants from both cities, frequent crack cocaine use plays a central role in daily life and leads to a range of physical, psychological, and social consequences. Common concerns among users include excessive crack use, engagement in risky habits, infrequent health service utilization, marginalization, and difficulty reducing use.

Conclusions

Disadvantaged conditions in which many crack cocaine users grow up and live may perpetuate risk behaviors and stigma may further marginalize users from necessary health and recovery services. Reducing stigma and moralizing discourse related to drug use, especially among health professionals and law enforcement personnel, may help encourage users to seek necessary care. New harm-reduction-based care and treatment alternatives for marginalized drug users are being developed in parts of Brazil and elsewhere and should be adapted and expanded for other populations in need.

Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial

Housing First (HF) is being widely disseminated in efforts to end homelessness among homeless adults with psychiatric disabilities. This study evaluates the effectiveness of HF with Intensive Case Management (ICM) among ethnically diverse homeless adults in an urban setting. 378 participants were randomized to HF with ICM or treatment-as-usual (TAU) in Toronto (Canada), and followed for 24 months. Measures of effectiveness included housing stability, physical (EQ5D-VAS) and mental (CSI, GAIN-SS) health, social functioning (MCAS), quality of life (QoLI20), and health service use. Two-thirds of the sample (63%) was from racialized groups and half (50%) were born outside Canada. Over the 24 months of follow-up, HF participants spent a significantly greater percentage of time in stable residences compared to TAU participants (75.1% 95% CI 70.5 to 79.7 vs. 39.3% 95% CI 34.3 to 44.2, respectively). Similarly, community functioning (MCAS) improved significantly from baseline in HF compared to TAU participants (change in mean difference = +1.67 95% CI 0.04 to 3.30). There was a significant reduction in the number of days spent experiencing alcohol problems among the HF compared to TAU participants at 24 months (ratio of rate ratios = 0.47 95% CI 0.22 to 0.99) relative to baseline, a reduction of 53%. Although the number of emergency department visits and days in hospital over 24 months did not differ significantly between HF and TAU participants, fewer HF participants compared to TAU participants had 1 or more hospitalizations during this period (70.4% vs. 81.1%, respectively; P=0.044). Compared to non-racialized HF participants, racialized HF participants saw an increase in the amount of money spent on alcohol (change in mean difference = $112.90 95% CI 5.84 to 219.96) and a reduction in physical community integration (ratio of rate ratios = 0.67 95% CI 0.47 to 0.96) from baseline to 24 months. Secondary analyses found a significant reduction in the number of days experiencing problems due to alcohol use among foreign-born (vs. Canadian-born) HF participants at 24 months (ratio of rate ratios = 0.19 95% 0.04 to 0.88), relative to baseline. Compared to usual care, HF with ICM can improve housing stability and community functioning and reduce the days of alcohol related problems in an ethnically diverse sample of homeless adults with mental illness within 2-years.

A history in-care predicts unique characteristics in a homeless population with mental illness

Multiple studies of homeless persons report an increased prevalence of a history in-care, but there is a dearth of information on associated outcomes or relevant demographic profiles. This information is critical to understanding if certain individuals are at elevated risk or might benefit from specific intervention. Here, we investigate how a history in-care relates to demographics and multiple outcome measures in a homeless population with mental illness. Using the Mini International Neuropsychiatric Interview (MINI), the Short-Form 12, and a trauma questionnaire, we investigated baseline differences in demographics and length of homelessness in the At Home/Chez Soi Trial (N=504) Winnipeg homeless population with and without a history in-care. Approximately 50% of the homeless sample reported a history in-care. This group was significantly more likely to be young, female, married or cohabitating, of Aboriginal heritage, have less education, and have longer lifetime homelessness. Individuals of Aboriginal heritage with a history in-care were significantly more likely to report a familial history of residential school. Individuals with a history in-care experienced different prevalence rates of Axis 1 mental disorders. Those with a history in-care also reported significantly more traumatic events (particularly interpersonal). A distinctive high-risk profile emerged for individuals with a history in-care. Sociocultural factors of colonization and intergenerational transmission of trauma appear to be particularly relevant in the trajectories for individuals of Aboriginal heritage. Given the high prevalence of a history in-care, interventions and policy should reflect the specific vulnerability of this population, particularly in regards to trauma-informed services.

Voices of homeless alcoholics who frequent Bellevue Hospital: a qualitative study

STUDY OBJECTIVE

We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism.

METHODS

We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail.

RESULTS

Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants' perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma.

CONCLUSION

Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.

Understanding Housing Delays and Relocations Within the Housing First Model

This study explores factors contributing to delays and relocations during the implementation of the Housing First model in Toronto, Ontario. While interruptions in housing tenure are expected en route to recovery and housing stability, consumer and service provider views on finding and keeping housing remain largely unknown. In-person interviews and focus groups were conducted with 48 study participants, including 23 case managers or housing workers and 25 consumers. The following three factors contributed to housing delays and transfers: (1) the effectiveness of communication and collaboration among consumers and service providers, (2) consumer-driven preferences and ambivalence, and (3) provider prioritization of consumer choice over immediate housing access. Two strategies--targeted communications and consumer engagement in housing searches--supported the housing process. Several factors affect the timing and stability of housing. Communication between and among providers and consumers, and a shared understanding of consumer choice, can further support choice and recovery.

Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: a mixed methods approach

This research sought to determine whether the implementation of Housing First in a large-scale, multi-site Canadian project for homeless participants with mental illness shows high fidelity to the Pathways Housing First model, and what factors help or hinder implementation. Fidelity ratings for 10 Housing First programs in five cities were made by an external quality assurance team along five key dimensions of Housing First based on 84 key informant interviews, 10 consumer focus groups, and 100 chart reviews. An additional 72 key informant interviews and 35 focus groups yielded qualitative data on factors that helped or hindered implementation. Overall, the findings show a high degree of fidelity to the model with more than 71% of the fidelity items being scored higher than 3 on a 4-point scale. The qualitative research found that both delivery system factors, including community and organizational capacity, and support system factors, training and technical assistance, facilitated implementation. Fidelity challenges include the availability of housing, consumer representation in program operations, and limitations to the array of services offered. Factors that accounted for these challenges include low vacancy rates, challenges of involving recently homeless people in program operations, and a lack of services in some of the communities. The study demonstrates how the combined use of fidelity assessment and qualitative methods can be used in implementation evaluation to develop and improve a program.

Discovery of enzyme modulators via high-throughput time-resolved FRET in living cells

We have used a "two-color" SERCA (sarco/endoplasmic reticulum calcium ATPase) biosensor and a unique high-throughput fluorescence lifetime plate reader (FLT-PR) to develop a high-precision live-cell assay designed to screen for small molecules that perturb SERCA structure. A SERCA construct, in which red fluorescent protein (RFP) was fused to the N terminus and green fluorescent protein (GFP) to an interior loop, was stably expressed in an HEK cell line that grows in monolayer or suspension. Fluorescence resonance energy transfer (FRET) from GFP to RFP was measured in the FLT-PR, which increases precision 30-fold over intensity-based plate readers without sacrificing throughput. FRET was highly sensitive to known SERCA modulators. We screened a small chemical library and identified 10 compounds that significantly affected two-color SERCA FLT. Three of these compounds reproducibly lowered FRET and inhibited SERCA in a dose-dependent manner. This assay is ready for large-scale HTS campaigns and is adaptable to many other targets.

Qualitative and mixed methods in mental health services and implementation research

Qualitative and mixed methods play a prominent role in mental health services research. However, the standards for their use are not always evident, especially for those not trained in such methods. This article reviews the rationale and common approaches to using qualitative and mixed methods in mental health services and implementation research based on a review of the articles included in this special series along with representative examples from the literature. Qualitative methods are used to provide a "thick description" or depth of understanding to complement breadth of understanding afforded by quantitative methods, elicit the perspective of those being studied, explore issues that have not been well studied, develop conceptual theories or test hypotheses, or evaluate the process of a phenomenon or intervention. Qualitative methods adhere to many of the same principles of scientific rigor as quantitative methods but often differ with respect to study design, data collection, and data analysis strategies. For instance, participants for qualitative studies are usually sampled purposefully rather than at random and the design usually reflects an iterative process alternating between data collection and analysis. The most common techniques for data collection are individual semistructured interviews, focus groups, document reviews, and participant observation. Strategies for analysis are usually inductive, based on principles of grounded theory or phenomenology. Qualitative methods are also used in combination with quantitative methods in mixed-method designs for convergence, complementarity, expansion, development, and sampling. Rigorously applied qualitative methods offer great potential in contributing to the scientific foundation of mental health services research.

Service provision for mentally disordered homeless people

PURPOSE OF REVIEW

Mentally ill homeless persons are among the most neglected or marginalized patient groups. Their needs for mental healthcare are widely unmet. The current economic crisis probably accelerates the social decline and deterioration of physical and mental health in high-risk groups worldwide and increases the need for appropriate treatments, services, and prevention strategies.

RECENT FINDINGS

Research on service provision for mentally disordered homeless people (from 2010 to 2012) covers the following issues: epidemiology of mental ill health among homeless persons, service delivery and healthcare utilization, specific treatments, specific high-risk groups among homeless persons, and subjective experience with mental health service provision.

SUMMARY

The number of studies published on these issues between 2010 and 2012 may suggest an awareness for the need for adequate service provision of this marginalized clientele. Research evidence is still not sufficient. The majority of studies are from the United States. The methodological quality of the studies is still moderate, being descriptive in nature or applying qualitative approaches to small samples. Included are usually easy to access patients from inner-city regions. There is an encouraging trend to focus on younger age groups that supports the focus on primary or secondary prevention strategies for homelessness and mental disorders.