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First examination of varying health outcomes of the chronically homeless according to Housing First configuration

First examination of varying health outcomes of the chronically homeless according to Housing... Homelessness is a diverse phenomenon that has been attributed to both individual and structural factors.1 Interventions that target both sets of factors are critical,1 with policy makers placing an increasing emphasis on addressing the social determinants of health to eliminate chronic homelessness.2 Homeless individuals experience disproportionately higher rates of premature mortality; three times the rate of the general population.1,2 Co‐occurring mental health disorders and substance misuse are higher among homeless populations1 and strongly associated with both the entry into, and duration of, homelessness episodes.3 Poor physical and mental health status among homeless individuals is worsened by barriers to accessing primary health care, resulting in greater use of acute health care services.2Improved health outcomes among individuals with chronic homelessness histories have been associated with the provision of stable housing.2,4 In recent years notable improvements have been documented among individuals in Housing First programs, which rapidly allocate individuals to long‐term housing with attached support.5 However, it remains unknown whether a particular type of Housing First configuration is associated with superior health‐related outcomes. Adaptations of the Housing First program have comprised two common configurations: scattered site (SS – private rental dwellings head‐leased by a community housing provider) and congregated site (CS – single public housing block with onsite services). This preliminary study aimed to identify whether SS and CS configurations are differentially effective across individual health outcomes.Full details of the study have been published elsewhere.6 Briefly, the study utilised a longitudinal, quantitative design and was conducted in Sydney, Australia. Individual outcomes were compared using baseline and 12‐month follow‐up interviews for participants of the SS and CS programs. While allocation into the SS and CS programs occurred prior to this study and was not randomised, eligibility criteria into both configurations were the same. The study was approved by the NSW Population and Health Services Research Ethics Committee and the Human Research Ethics Committee of UNSW (HC11120/HC12625).Eligible participants were at least 18 years old, provided informed consent, had a chronic homelessness history (defined in Australia as sleeping rough for at least six months), and currently engaged with the SS or CS programs. Eighty participants (recruitment rate 66%) were administered a baseline survey from November 2012 to May 2013. Sixty‐three consented and completed the 12‐month follow‐up survey (79% follow‐up rate). This survey was administered on average 12.7 months post‐baseline. Participants received an $40 food voucher after each survey.Measures included: socio‐demographic characteristics (sex, age, Indigenous status, health diagnoses, homelessness history); physical and psychological quality of life (World Health Organization's Quality of Life‐BREF instrument); psychological symptoms (Brief System Inventory); greater than weekly use of specific substances in the three months prior to interview (tobacco, alcohol, cannabis, amphetamines, opioids, and non‐medical injection of any drug); and utilisation of various health services over the past 12 months (general practitioner (GP), ambulance, emergency department (ED) for physical health (PH) or mental health (MH), inpatient hospital for PH or MH, MH specialist, and drug and alcohol (D&A) treatment facility).SPSS 22.0 was used to compare whether the changes within groups differed significantly from baseline to follow‐up between the two configurations. Unadjusted means and proportions of outcomes were calculated for each group at baseline and follow‐up, as well as within‐group changes. Multiple linear/logistic regressions were used, depending on the nature of the dependent variable, to estimate the difference in outcomes between configurations at follow‐up, after adjusting for baseline housing duration and baseline outcome value.ResultsThe 63 participants were similar in socio‐demographic composition to all individuals within the two Housing First programs in Sydney.6 Most participants were male (81%) and Australian born (79%), and 16 per cent identified as Indigenous. Participants were, on average, 44 years old and diagnosed with a mean of four physical health conditions (most commonly dental problems (69%), chronic pain (48%), and chronic infections (43%)). Participants had typically been diagnosed with two mental health disorders, including mood (69%), anxiety (51%) and substance misuse (47%) disorders. Four‐in‐five participants screened positive for a cognitive impairment of some degree (81%), and over half reported a rough sleeping history of more than five years (60%).In the longitudinal comparisons, no between‐groups differences were found for quality of life or psychological distress, with both groups showing comparable improvements across outcomes over time (Table ). Similarly, no differences were found between groups for the specific substances used. However, there was a significant within‐group increase over time in the proportion of CS participants who injected more than weekly (AOR 3.4, 95%CI 0.6–18.2).Self‐reported outcomes by housing configuration group (SS vs CS) (n=63).OutcomeBaselineFollow‐upChange95%CIAdjusted effecta95%CIN%N%Physical and psychological health outcomesWHOQOL‐BREF physical health (M±SD)  SS  CS 3522 52±2353±26 3522 58±1863±19 610 −12, 121, 20−0.1−13.1, 3.7WHOQOL‐BREF psychological health (M±SD)  SS  CS 3522 58±2152±23 3522 61±1759±21 37 −3, 8−1, 14−0.1−8.0, 7.6BSI psychological distress (M±SD)  SS  CS 3322 1.4±1.01.5±1.0 3322 1.0±0.81.0±0.8 −0.4−0.5 −0.6, −0.2−0.9, −0.10.1−0.3, 0.4Substance use outcomes: Greater than weekly useTobacco  SS  CS 3626 7865 3626 7281 −616 −17, 61, 307.80.8, 78.9Alcohol  SS  CS 3726 2215 3726 2715 50 −8, 19−11, 110.40.1, 2.3Cannabis  SS  CS 3726 1931 3726 1935 0−4 −18, 18−18, 101.20.3, 4.8Amphetamine  SS  CS 3726 08 3726 34 3−4 −3, 8−18, 10#Opioids  SS  CS 3726 00 3726 812 812 −1, 17−2, 251.20.2, 7.2Injection  SS  CS 3726 315 3726 831 516 −5, 161, 303.40.6, 18.2Health service outcomes: Utilisation in the past 12 monthsGP  SS  CS 3722 89100 3722 7391 −16−9 −29, −4−22, 43.20.5, 18.7Ambulance call‐out  SS  CS 3722 3055 3722 2750 −3−5 −23, 17−26, 172.00.6, 6.7ED attendance (PH reason)  SS  CS 3721 3052 3721 3248 2−4 −17, 23−32, 221.20.4, 4.1ED attendance (MH reason)  SS  CS 3722 1132 3722 1132 00 −14, 14−27, 275.81.1, 31.3*Hospital inpatient (PH reason)  SS  CS 3722 1932 3722 2232 30 −12, 17−24, 241.00.3, 4.0Hospital inpatient (MH reason)  SS  CS 3722 1427 3722 323 −11−4 −24, 2−30, 2111.61.1, 127.7*MH specialist  SS  CS 3622 5364 3622 4268 −114 −27, 5−24, 333.81.0, 14.0*D&A treatment facility  SS  CS 3721 1419 3721 310 −11−9 −21, −0.1−29, 101.80.1, 37.5a: Adjusted for baseline housing duration and baseline score; # Not estimated due to low number of events; * p<.05SS, scattered site; CS, congregated site; WHOQOL‐BREF, World Health Organization's Quality of Life‐BREF, BSI, Brief Symptom Inventory; GP, general practitioner; MH, mental health; D&A, drug and alcohol; ED, emergency department; PH, physical health; n, number; M, Mean; SD, Standard Deviation; CI, Confidence Interval.For health service utilisation, between‐group differences were found firstly for the proportions of participants who attended the ED for MH reasons (AOR 5.6, 95%CI 1.1–31.3), and secondly, for the proportion who engaged with a MH specialist (AOR 3.8, 95%CI 1.0–14.0). CS participants had notably higher service utilisation rates for these MH services, despite similar self‐report rates of MH disorders between SS and CS groups. Table also shows reductions for SS participants’ engagement with GPs and D&A treatment facilities over time.DiscussionBoth groups reported similar rates of improvement for quality of life and psychological distress, which suggests the provision of stable housing with attached support, regardless of configuration, improved these outcomes over 12 months. These findings replicate those found in past Housing First studies,4,7 however this is the first evidence of trends across configurations, which may inform Housing First staff that they should expect to see improvements in these health outcomes regardless of configuration.Consistent with results from Housing First programs in North America,8 the use of substances remained unchanged over 12 months in both configurations. However, our study points to a potential differential impact of configuration on injecting behaviour: one‐third of CS participants reported greater than weekly injecting at follow‐up compared to 8% of SS participants. We also found higher engagement with MH specialists and the ED for MH reasons among CS participants. A possible explanation for these differential findings is that the SS configuration stabilised individuals’ injecting behaviours and MH more so than CS housing in the 12‐month period. Alternatively, the set‐up of the CS configuration may have facilitated continued or increased injecting behaviours if fellow residents were also injecting. Onsite CS staff may have more closely observed residents compared to SS participants who were visited by case managers weekly, and consequently the likelihood of referral to MH treatment may have been higher at the CS. While these findings should be interpreted with caution due to small sample sizes, they are potentially important if replicated in future studies, as it would have significant ramifications for program planning, resource allocation and harm minimisation strategies adopted by Housing First programs.Study limitations included non‐random participant assignment into programs, small sample sizes, baseline interviews occurring at a set point in time rather than housing entry, and self‐report data. While findings should be interpreted with caution, this study raises the issue of differential outcomes associated with specific configurations; a critical understanding given the expansion of SS and CS configurations across Western countries despite a limited evidence‐base.ConclusionsThis is the first study to examine specifically whether the configuration and consequently, access to onsite support services in Housing First models, has a differential impact on individuals’ health status and service utilisation. Although the programs examined were small in size, this type of research is crucial for generating questions that could be addressed by larger studies. Our results suggest that further research with larger sample sizes is required to determine which specific individuals show greater health improvements in particular housing configurations. Obtaining a clearer understanding of how different configurations of supported housing influence the health and well‐being of homeless individuals is critical for informing the expansion of community‐based solutions.ReferencesFazel S, Geddes JR, Kushel M. The health of homeless people in high‐income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014; 384(9953): 1529–40.Larimer ME, Malone DK, Garner MD, Atkins DC, Burlingham B, Lonczak HS, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009; 301(13): 1349–57.Patterson ML, Somers JM, Moniruzzaman A. Prolonged and persistent homelessness: Multivariable analyses in a cohort experiencing current homelessness and mental illness in Vancouver, British Columbia. Mental Health Subst Use. 2011; 5(2): 85–101.Greenwood RM, Schaefer‐McDaniel NJ, Winkel G, Tsemberis SJ. Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. Am J Community Psychol. 2005; 36(3–4): 223–38.Padgett DK, Henwood BF, Tsemberis S. Housing First: Ending Homelessness, Transforming Systems, and Changing Lives, New York (NY): Oxford University Press; 2015.Whittaker E, Swift W, Flatau P, Dobbins T, Schollar‐Root O, Burns L. A place to call home: Study protocol for a longitudinal, mixed methods evaluation of two Housing First adaptations in Sydney, Australia. BMC Public Health. 2015; 15: 342–51.Patterson M, Moniruzzaman A, Palepu A, Zabkiewicz D, Frankish CJ, Krausz M, et al. Housing First improves subjective quality of life among homeless adults with mental illness: 12‐month findings from a randomized controlled trial in Vancouver, British Columbia. Soc Psychiatry Psychiatr Epidemiol. 2013; 48(8): 1245–59.Somers JM, Moniruzzaman A, Palepu A. Changes in daily substance use among people experiencing homelessness and mental illness: 24‐month outcomes following randomization to Housing First or usual care. Addiction. 2015; 110(10): 1605–14. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

First examination of varying health outcomes of the chronically homeless according to Housing First configuration

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Publisher
Wiley
Copyright
© 2017 Public Health Association of Australia
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/1753-6405.12631
pmid
28110511
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Abstract

Homelessness is a diverse phenomenon that has been attributed to both individual and structural factors.1 Interventions that target both sets of factors are critical,1 with policy makers placing an increasing emphasis on addressing the social determinants of health to eliminate chronic homelessness.2 Homeless individuals experience disproportionately higher rates of premature mortality; three times the rate of the general population.1,2 Co‐occurring mental health disorders and substance misuse are higher among homeless populations1 and strongly associated with both the entry into, and duration of, homelessness episodes.3 Poor physical and mental health status among homeless individuals is worsened by barriers to accessing primary health care, resulting in greater use of acute health care services.2Improved health outcomes among individuals with chronic homelessness histories have been associated with the provision of stable housing.2,4 In recent years notable improvements have been documented among individuals in Housing First programs, which rapidly allocate individuals to long‐term housing with attached support.5 However, it remains unknown whether a particular type of Housing First configuration is associated with superior health‐related outcomes. Adaptations of the Housing First program have comprised two common configurations: scattered site (SS – private rental dwellings head‐leased by a community housing provider) and congregated site (CS – single public housing block with onsite services). This preliminary study aimed to identify whether SS and CS configurations are differentially effective across individual health outcomes.Full details of the study have been published elsewhere.6 Briefly, the study utilised a longitudinal, quantitative design and was conducted in Sydney, Australia. Individual outcomes were compared using baseline and 12‐month follow‐up interviews for participants of the SS and CS programs. While allocation into the SS and CS programs occurred prior to this study and was not randomised, eligibility criteria into both configurations were the same. The study was approved by the NSW Population and Health Services Research Ethics Committee and the Human Research Ethics Committee of UNSW (HC11120/HC12625).Eligible participants were at least 18 years old, provided informed consent, had a chronic homelessness history (defined in Australia as sleeping rough for at least six months), and currently engaged with the SS or CS programs. Eighty participants (recruitment rate 66%) were administered a baseline survey from November 2012 to May 2013. Sixty‐three consented and completed the 12‐month follow‐up survey (79% follow‐up rate). This survey was administered on average 12.7 months post‐baseline. Participants received an $40 food voucher after each survey.Measures included: socio‐demographic characteristics (sex, age, Indigenous status, health diagnoses, homelessness history); physical and psychological quality of life (World Health Organization's Quality of Life‐BREF instrument); psychological symptoms (Brief System Inventory); greater than weekly use of specific substances in the three months prior to interview (tobacco, alcohol, cannabis, amphetamines, opioids, and non‐medical injection of any drug); and utilisation of various health services over the past 12 months (general practitioner (GP), ambulance, emergency department (ED) for physical health (PH) or mental health (MH), inpatient hospital for PH or MH, MH specialist, and drug and alcohol (D&A) treatment facility).SPSS 22.0 was used to compare whether the changes within groups differed significantly from baseline to follow‐up between the two configurations. Unadjusted means and proportions of outcomes were calculated for each group at baseline and follow‐up, as well as within‐group changes. Multiple linear/logistic regressions were used, depending on the nature of the dependent variable, to estimate the difference in outcomes between configurations at follow‐up, after adjusting for baseline housing duration and baseline outcome value.ResultsThe 63 participants were similar in socio‐demographic composition to all individuals within the two Housing First programs in Sydney.6 Most participants were male (81%) and Australian born (79%), and 16 per cent identified as Indigenous. Participants were, on average, 44 years old and diagnosed with a mean of four physical health conditions (most commonly dental problems (69%), chronic pain (48%), and chronic infections (43%)). Participants had typically been diagnosed with two mental health disorders, including mood (69%), anxiety (51%) and substance misuse (47%) disorders. Four‐in‐five participants screened positive for a cognitive impairment of some degree (81%), and over half reported a rough sleeping history of more than five years (60%).In the longitudinal comparisons, no between‐groups differences were found for quality of life or psychological distress, with both groups showing comparable improvements across outcomes over time (Table ). Similarly, no differences were found between groups for the specific substances used. However, there was a significant within‐group increase over time in the proportion of CS participants who injected more than weekly (AOR 3.4, 95%CI 0.6–18.2).Self‐reported outcomes by housing configuration group (SS vs CS) (n=63).OutcomeBaselineFollow‐upChange95%CIAdjusted effecta95%CIN%N%Physical and psychological health outcomesWHOQOL‐BREF physical health (M±SD)  SS  CS 3522 52±2353±26 3522 58±1863±19 610 −12, 121, 20−0.1−13.1, 3.7WHOQOL‐BREF psychological health (M±SD)  SS  CS 3522 58±2152±23 3522 61±1759±21 37 −3, 8−1, 14−0.1−8.0, 7.6BSI psychological distress (M±SD)  SS  CS 3322 1.4±1.01.5±1.0 3322 1.0±0.81.0±0.8 −0.4−0.5 −0.6, −0.2−0.9, −0.10.1−0.3, 0.4Substance use outcomes: Greater than weekly useTobacco  SS  CS 3626 7865 3626 7281 −616 −17, 61, 307.80.8, 78.9Alcohol  SS  CS 3726 2215 3726 2715 50 −8, 19−11, 110.40.1, 2.3Cannabis  SS  CS 3726 1931 3726 1935 0−4 −18, 18−18, 101.20.3, 4.8Amphetamine  SS  CS 3726 08 3726 34 3−4 −3, 8−18, 10#Opioids  SS  CS 3726 00 3726 812 812 −1, 17−2, 251.20.2, 7.2Injection  SS  CS 3726 315 3726 831 516 −5, 161, 303.40.6, 18.2Health service outcomes: Utilisation in the past 12 monthsGP  SS  CS 3722 89100 3722 7391 −16−9 −29, −4−22, 43.20.5, 18.7Ambulance call‐out  SS  CS 3722 3055 3722 2750 −3−5 −23, 17−26, 172.00.6, 6.7ED attendance (PH reason)  SS  CS 3721 3052 3721 3248 2−4 −17, 23−32, 221.20.4, 4.1ED attendance (MH reason)  SS  CS 3722 1132 3722 1132 00 −14, 14−27, 275.81.1, 31.3*Hospital inpatient (PH reason)  SS  CS 3722 1932 3722 2232 30 −12, 17−24, 241.00.3, 4.0Hospital inpatient (MH reason)  SS  CS 3722 1427 3722 323 −11−4 −24, 2−30, 2111.61.1, 127.7*MH specialist  SS  CS 3622 5364 3622 4268 −114 −27, 5−24, 333.81.0, 14.0*D&A treatment facility  SS  CS 3721 1419 3721 310 −11−9 −21, −0.1−29, 101.80.1, 37.5a: Adjusted for baseline housing duration and baseline score; # Not estimated due to low number of events; * p<.05SS, scattered site; CS, congregated site; WHOQOL‐BREF, World Health Organization's Quality of Life‐BREF, BSI, Brief Symptom Inventory; GP, general practitioner; MH, mental health; D&A, drug and alcohol; ED, emergency department; PH, physical health; n, number; M, Mean; SD, Standard Deviation; CI, Confidence Interval.For health service utilisation, between‐group differences were found firstly for the proportions of participants who attended the ED for MH reasons (AOR 5.6, 95%CI 1.1–31.3), and secondly, for the proportion who engaged with a MH specialist (AOR 3.8, 95%CI 1.0–14.0). CS participants had notably higher service utilisation rates for these MH services, despite similar self‐report rates of MH disorders between SS and CS groups. Table also shows reductions for SS participants’ engagement with GPs and D&A treatment facilities over time.DiscussionBoth groups reported similar rates of improvement for quality of life and psychological distress, which suggests the provision of stable housing with attached support, regardless of configuration, improved these outcomes over 12 months. These findings replicate those found in past Housing First studies,4,7 however this is the first evidence of trends across configurations, which may inform Housing First staff that they should expect to see improvements in these health outcomes regardless of configuration.Consistent with results from Housing First programs in North America,8 the use of substances remained unchanged over 12 months in both configurations. However, our study points to a potential differential impact of configuration on injecting behaviour: one‐third of CS participants reported greater than weekly injecting at follow‐up compared to 8% of SS participants. We also found higher engagement with MH specialists and the ED for MH reasons among CS participants. A possible explanation for these differential findings is that the SS configuration stabilised individuals’ injecting behaviours and MH more so than CS housing in the 12‐month period. Alternatively, the set‐up of the CS configuration may have facilitated continued or increased injecting behaviours if fellow residents were also injecting. Onsite CS staff may have more closely observed residents compared to SS participants who were visited by case managers weekly, and consequently the likelihood of referral to MH treatment may have been higher at the CS. While these findings should be interpreted with caution due to small sample sizes, they are potentially important if replicated in future studies, as it would have significant ramifications for program planning, resource allocation and harm minimisation strategies adopted by Housing First programs.Study limitations included non‐random participant assignment into programs, small sample sizes, baseline interviews occurring at a set point in time rather than housing entry, and self‐report data. While findings should be interpreted with caution, this study raises the issue of differential outcomes associated with specific configurations; a critical understanding given the expansion of SS and CS configurations across Western countries despite a limited evidence‐base.ConclusionsThis is the first study to examine specifically whether the configuration and consequently, access to onsite support services in Housing First models, has a differential impact on individuals’ health status and service utilisation. Although the programs examined were small in size, this type of research is crucial for generating questions that could be addressed by larger studies. Our results suggest that further research with larger sample sizes is required to determine which specific individuals show greater health improvements in particular housing configurations. Obtaining a clearer understanding of how different configurations of supported housing influence the health and well‐being of homeless individuals is critical for informing the expansion of community‐based solutions.ReferencesFazel S, Geddes JR, Kushel M. The health of homeless people in high‐income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014; 384(9953): 1529–40.Larimer ME, Malone DK, Garner MD, Atkins DC, Burlingham B, Lonczak HS, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009; 301(13): 1349–57.Patterson ML, Somers JM, Moniruzzaman A. Prolonged and persistent homelessness: Multivariable analyses in a cohort experiencing current homelessness and mental illness in Vancouver, British Columbia. Mental Health Subst Use. 2011; 5(2): 85–101.Greenwood RM, Schaefer‐McDaniel NJ, Winkel G, Tsemberis SJ. Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. Am J Community Psychol. 2005; 36(3–4): 223–38.Padgett DK, Henwood BF, Tsemberis S. Housing First: Ending Homelessness, Transforming Systems, and Changing Lives, New York (NY): Oxford University Press; 2015.Whittaker E, Swift W, Flatau P, Dobbins T, Schollar‐Root O, Burns L. A place to call home: Study protocol for a longitudinal, mixed methods evaluation of two Housing First adaptations in Sydney, Australia. BMC Public Health. 2015; 15: 342–51.Patterson M, Moniruzzaman A, Palepu A, Zabkiewicz D, Frankish CJ, Krausz M, et al. Housing First improves subjective quality of life among homeless adults with mental illness: 12‐month findings from a randomized controlled trial in Vancouver, British Columbia. Soc Psychiatry Psychiatr Epidemiol. 2013; 48(8): 1245–59.Somers JM, Moniruzzaman A, Palepu A. Changes in daily substance use among people experiencing homelessness and mental illness: 24‐month outcomes following randomization to Housing First or usual care. Addiction. 2015; 110(10): 1605–14.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Jun 1, 2017

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