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

Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness

BACKGROUND

This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group.

METHODS

Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months.

RESULTS

Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income.

DISCUSSION

This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).

Motives for alcohol use, risky drinking patterns and harm reduction practices among people who experience homelessness and alcohol dependence in Montreal

BACKGROUND

People experiencing homelessness are disproportionately affected by harms related to alcohol use. Indeed, their alcohol dependence is associated with numerous physical and mental health problems along with strikingly high rates of alcohol-related mortality. Recent research has extensively examined alcohol use patterns among people experiencing homelessness in an effort to develop interventions and treatments for this problem. However, only a few studies have incorporated the perspectives of the individuals under study about their drinking or examined the ways in which they manage the associated harms. To bridge this gap, we conducted a qualitative study exploring the relation between the drinking motives, risky drinking patterns and harm reduction practices of a group of people (n = 34) experiencing homelessness in Montreal, Canada.

METHODS

The qualitative methods we used consisted of semi-structured interviews (n = 12) and focus groups (n = 2, with a total of 22 participants). The content of the collected data was then analyzed.

RESULTS

Participants identified their various motives for alcohol use (coping with painful memories, dealing with harsh living conditions, socializing/seeking a sense of belonging, enjoying themselves/having fun); their risky drinking patterns (binge drinking, mixing alcohol with drugs, non-beverage alcohol drinking, failing to keep sufficient alcohol on hand to prevent acute withdrawal, drinking in public settings); their harm reduction practices (planning how much to drink, keeping a supply of alcohol to prevent acute withdrawal, hiding to drink, concealing alcohol, drinking alone, drinking/hanging out with others, drinking non-beverage alcohol, and taking benzodiazepines, cocaine or other stimulant drugs); and the rationales underpinning their alcohol use and harm reduction practices.

CONCLUSION

Associating the drinking motives of a group of study participants with their risky drinking patterns and harm reduction practices shed light on their rationales for alcohol use, yielding insights that could be used to better tailor policies and interventions to their needs.

Being homeless at the "End" of homelessness navigating the symbolic and social boundaries of housing first

Housing First (HF) has emerged as the dominant paradigm in homelessness policy and has been praised for bringing an "end" to the homelessness crisis. Others claim, however, that HF facilitates further sociospatial exclusion of people experiencing homelessness (PEH). To advance this debate and understand HF within its larger sociological context, this article examines how HF policies translate to the lived experiences of those who remain in shelters and on the streets. Through interviews with 22 PEH, we demonstrate how HF confronts PEH with a set of strategic dilemmas that we frame using the concept of "boundary-work." First, PEH must negotiate the symbolic boundaries that HF establishes between "worthy" and "unworthy" for the purposes of distributing housing. Second, once housed, PEH face challenges in navigating the social boundaries that separate the private space of the dwelling, the transitional spaces of homelessness (e.g., streets, shelters), and the increasingly gentrified public spaces of the city. We end by discussing the implications of these findings for evaluating HF programs and demonstrating the value of a boundary-work perspective on homelessness.

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.

Perceived Social Support Attenuates the Association between Stress and Health-Related Quality of Life among Adults Experiencing Homelessness

Health-related quality of life (HRQoL) is defined as a multidimensional subjective assessment of one’s physical and mental health. Homelessness is associated with numerous stressors that can reduce HRQoL. Social support is defined as the availability of individuals, or resources provided by individuals, to cope with stress. Interpersonal social support may be important in buffering HRQoL from the negative implications of stress. Here, we examine this association in a marginalized group known for high rates of physical and mental health comorbidities: adults experiencing homelessness. Participants (N = 581; 63.7% men; M_age = 43.6 ± 12.2) were recruited from homeless-serving agencies in Oklahoma City. Social support was measured with the 12-item Interpersonal Support Evaluation List (ISEL). HRQoL was measured by the Behavioral Risk Factor Surveillance System (BRFSS) survey using self-rated health, the number of poor mental and poor physical health days over the preceding 30 days, as well as the number of limited activity days as the result of poor mental and/or physical health. Perceived stress was assessed using the 4-item Perceived Stress Scale (PSS). The potential moderation effect of social support was examined by assessing the interaction term of social support and stress in a series of linear regression analyses, controlling for sex, age, months homeless, race, education, health insurance status, serious mental illness diagnosis, and recruitment agency/site. There was a significant interaction effect of social support and stress on the prediction of days of poor physical health, days of poor mental health, and days of limited activity (p in all cases ≤ 0.05). Results add to a growing literature on the potentially protective benefits of social support for HRQoL, extend them to a large sample of adults experiencing homelessness in the South, and demonstrate the significance of this moderating effect of social support over and above the influence of several prominent sociodemographic and diagnostic variables. Future work should determine if interventions designed to enhance social support can buffer HRQoL from the deleterious effects of stress among this vulnerable population.

"It's not the end of the story:" Understanding the continued recovery from homelessness using Photovoice and content analysis

In this multipart study, participants in a Housing First program on the Island of O'ahu conducted a Photovoice project involving participatory analysis to investigate the recovery process from homelessness several years after being housed. University researchers then conducted a secondary analysis of the Photovoice study content to expand on findings and examine the unique contributions of the different methods. Findings suggest that individuals who have experienced homelessness will likely need continued support, particularly social support and opportunities for community engagement, well after initial housing. Findings also suggests that a combination of iterative analytic methods that remain participatory may be most useful for examining lived experiences of individuals recovering from homelessness. The study represents a participatory investigation of recovery from homelessness, as well as a rigorous inquiry into the research methods best suited to investigate this lived experience.

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.

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

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

Patterns and effects of social integration on housing stability, mental health and substance use outcomes among participants in a randomized controlled Housing First trial

INTRODUCTION

Recent research has shown that social integration, involving community integration and social support, can be protective resources for the health of homeless individuals. However, it is not clear how social integration affects health in the transition from homelessness into housing, and subsequent housing retention. This paper examines, through mixed quantitative and qualitative methods, how social integration changes over time, and how these changes relate to housing stability, substance use and mental health outcomes among a sample of homeless individuals experiencing mental illness participating in the At Home/Chez Soi Housing First randomized controlled trial in Canada.

METHODS

Longitudinal quantitative data (baseline, 6, 12, 24 month) and qualitative data ( 18 month) from the five trial sites (Moncton, Montreal, Toronto, Winnipeg and Vancouver) were examined using mixed models, mediation analyses, and thematic analysis.

RESULTS

Social integration (i.e., social network size, social interest, psychological integration) increased over time among study participants, with social network size increasing significantly more among Housing First participants than Treatment as Usual participants. Social network size mediated the effect of the intervention on the percentage of days in stable housing, indicating that the Housing First intervention may have increased participants' social network size, which in turn increased the percentage of days stably housed. No significant mediation of social integration on the effects of the intervention on mental health and substance use outcomes was found. Findings from the qualitative interviews support and expand upon these quantitative findings.

Sick Enough? Mental Illness and Service Eligibility for Homeless Individuals at the Border

This paper measures mental illness among individuals experiencing homelessness in a border city and compares it to the general housed population. We use original data from a homeless survey conducted in El Paso, Texas. Respondents self-reported any possible mental illness or related symptoms. We find that mental illness is not disproportionally common among the homeless, yet this is something that is often claimed by laypersons, some social service workers, and some researchers that limit sampling to institutionalized settings where formal mental illness is often among the prerequisites for admission. We find that “severe mental illness” among homeless persons is 6.2% (only around 2–3% higher than the general population), and “any mental illness” is 20.8% (only 1–3% higher than in the general population). Our results are consistent with other research focusing on street samples.

Veterans' assignment to single-site versus scattered-site permanent supportive housing

To address homelessness among Veterans, a growing proportion of permanent supportive housing units supported by the U.S. Departments of Housing and Urban Development and Veterans Affairs Supportive Housing (HUD-VASH) program are allocated to programs where multiple Veterans with a history of homelessness live in a particular building, referred to as single-site housing. This mixed-methods study-including administrative data from Veterans who moved into HUD-VASH housing and qualitative data from focus groups with services providers at 10 single-site programs-describes the characteristics and needs of Veterans who moved into single-site HUD-VASH programs, the rationale for developing single-site HUD-VASH programs, and the services provided in single-site programs that are responsive to Veterans' needs. Based on quantitative analyses, Veterans who were older and had chronic medical and mental health conditions and sought related care were at increased odds of receiving single-site housing. Qualitatively, we found that HUD-VASH programs developed single-site programs for two reasons: to ensure that the most vulnerable Veterans remained housed through the provision of supportive services and to increase housing options for hard-to-house Veterans, including those who require more support because of medical, mental health, or substance use disorders; physical disabilities; or lack of ability to live independently for other reasons. Due to the high needs of Veterans served by single-site programs, development of these programs should consider both space and staffing needs. Future research should assess the relationship between assignment to housing type and health and housing outcomes for participants as well as service enhancements to address Veterans' needs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Using Facebook for Improving the Psychological Well-Being of Individuals Experiencing Homelessness: Experimental and Longitudinal Study

BACKGROUND

Web-based social networks are a powerful communicative element and their use is increasingly widespread. Persons living in extreme social exclusion such as individuals experiencing homelessness can benefit from the positive elements of communication and relationship associated with social networking sites.

OBJECTIVE

This study aimed to suggest the comparison of a Facebook training course and an office software course and their effect on psychological well-being in a group of individuals experiencing homelessness.

METHODS

An experimental and longitudinal study was designed. Individuals experiencing homelessness were randomly assigned to either the Facebook group or the office software group, and their social skills, self-esteem, self-efficacy, and satisfaction with life were measured on 4 occasions: pretest, at the end of the training course, 1 month later, and 3 months later. A mixed analysis of variance of repeated measures (2×4) was performed.

RESULTS

A total of 92 individuals experiencing homelessness participated in the study. The number of cases in which the 4 measurements were completed was 71 (35 in the intervention group and 36 in the control group). The mixed analysis of variance of repeated measures and the multiple regression analysis indicated a significant increase of the 4 analyzed parameters, with greater significance in the areas of social skills and self-esteem. The critical levels associated to the interaction Time×Program were significant in all variables and levels. Therefore, the scores in the 4 analyzed constructs were not equal according to the program carried out throughout the work. The effect size associated to the interaction Time×Program in the social skills scores was large (η²=0.32); in the self-esteem and self-efficacy scores, it was medium, (η²=0.13); and in the satisfaction with life scores, it was small (η²=0.09). The results of the adjustment of the different models of multiple linear regression indicate that the number of hours devoted weekly to the use of Facebook was a predictor of the increase in the scores of social skills (B=3.43, r²=.405) and self-esteem (B=.382). Age (B=.175) and self-efficacy (B=.09) were also variables, which with independence and in equal conditions, predicted self-esteem (r²=.29). Finally, self-esteem (B=.69) was also a predictor variable of the increase of satisfaction with life (r²=.195).

CONCLUSIONS

These findings suggest that Facebook could be a key element in homeless psychological well-being and socialization.

Permanent Supportive Housing and Specialized Co-Occurring Disorders Wraparound Services for Homeless Individuals

OBJECTIVE

Among individuals experiencing chronic homelessness, there is a high rate of co-occurring mental health and substance use, which has traditionally been addressed through the delivery of permanent supportive housing along with substance use and mental health services. However, this population often has difficulty engaging in treatment for co-occurring disorders, which can result in exacerbation of symptoms and housing loss. Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION) is a co-occurring mental health and substance use wraparound approach that was pilot-tested alongside Permanent Supportive Housing (PSH) to improve treatment access and engagement. This pilot was part of a state plan to end homelessness in the Boston metro area.

METHODS

This open pilot study enrolled 136 individuals who were chronically homeless and offered one year of MISSION along with PSH. Program participants also received baseline and 6- and 12-month follow-up assessments.

RESULTS

At one-year follow-up, 82.4% of the program participants were housed in PSH. However, due to limited affordable housing in the Boston metro area, it took on average 6.20 months to house the program participants. Furthermore, while MISSION was feasible to implement alongside PSH, fidelity to the MISSION model was lower than expected. This pilot also examined the role of housing status on clinical outcomes and found that the program participants who were housed at the time of discharge displayed a statistically significant improvement in emergency room visits for mental health complaints, the Psychosis subscale of the Behavior and Symptom Identification Scale (BASIS-32), illegal drug use, and pharmacotherapy treatment.

CONCLUSIONS

This pilot study demonstrated that systematically integrating PSH and MISSION can improve access and engagement in care, housing retention, and mental health outcomes. Despite the preliminary success and while taking into account the limitations of the open single-group pre/post design, this study also identified the lack of affordable housing as a potential barrier to placement as well as the critical role of housing for improved clinical outcomes. Randomized controlled trials are needed to test MISSION with PSH as well as perhaps PSH with and without MISSION to tease apart the effects of integrating both approaches simultaneously.