Housing First Program Research Articles

Females and Housing First: An analysis of 18-month outcomes in a randomized controlled trial.

The main objective of this research was to qualitatively examine the impacts of Housing First (HF) specifically on those participants who identified themselves as female in response to question asking what their gender was. The data analyzed are from a larger, muti-site, randomized controlled trial. χ2 analysis was used to compare the life changes (coded as positive, neutral, or negative) experienced by 64 females (42 HF and 22 TAU). An in-depth qualitative analysis was conducted on 45 of these participants (23 HF and 22 TAU). Significantly more female HF participants reported making positive life changes from baseline to 18-month than those in TAU. Relative to females in TAU, female HF participants reported a number of specific positive changes, including enhanced safety, improved recovery in mental illness, greater reductions in drug use, and individual changes. The implications of findings for strengthening HF programs to meet the unique needs of female participants are discussed.

Youth, Crime, and the Potential Cost Offset to Housing First Programs

Housing First (HF) is an approach that emphasizes providing housing as a precondition for assisting people experiencing homelessness. To the extent that housing reduces contacts with police, HF may reduce criminal behaviour and so reduce costs borne by the justice system. This may be particularly true for youth whose homelessness often forces them to adopt survival behaviour that exposes them to police and bylaw enforcement officers. Using regression analysis, we employ linked administrative data sets from police and from HF programs to examine how interactions of youth with police change following admission to a HF program. An important contribution of our study is the use of administrative police records rather than self-reported data on the number of criminal incidents and their severity. Unconditional quantile regression is used to observe HF’s effect on changes in both the number and severity of criminal incidents. Controlling for demographic characteristics of youth and for type of housing program and using administrative police records as opposed to self-reported police interactions, we find only weak evidence to suggest that the number of criminal incidents falls following admission to a HF program and only weak evidence of a fall in the seriousness of crimes.

Narratives of people with serious mental illness in Housing First: a qualitative analysis of factors contributing to housing instability and housing stability

ABSTRACT There has been little previous research that has examined factors related to housing stability and instability among Housing First (HF) tenants. Qualitative research was used to determine themes related to housing stability and instability for people with mental illness participating in a HF program implemented in five Canadian cities. Data were gathered for all participants who completed qualitative interviews at baseline and an 18-month follow-up. At the 18-month follow-up interviews, those who were stably housed (n = 110) were significantly more likely to report positive life changes than those who were unstably housed (n = 75). Among a sub-sample of these participants, in-depth narratives were compared for stably housed (n = 25) and unstably housed (n = 21) tenants. Challenges to achieving housing stability included substance use and continued exposure to substance-using networks, evictions/multiple housing losses, incarceration and/or involvement with the legal system, and neighborhood location of housing. Themes promoting housing stability were having positive relationships with the HF program staff and program, achieving greater community integration, and making progress towards recovery. Recommendations for promoting housing stability were provided.

Providing Housing First services for an underserved population during the early wave of the COVID-19 pandemic: A qualitative study.

We assessed the critical role of Housing First (HF) programs and frontline workers in responding to challenges faced during the first wave of the COVID-19 pandemic. Semi-structured interviews were conducted with nine HF frontline workers from three HF programs between May 2020 and July 2020, in Toronto, Canada. Information was collected on challenges and adjustments needed to provide services to HF clients (people experiencing homelessness and mental disorders). We applied the Analytical Framework method and thematic analysis to our data. Inability to provide in-person support and socializing activities, barriers to appropriate mental health assessments, and limited virtual communication due to clients' lack of access to digital devices were among the most salient challenges that HF frontline workers reported during the COVID-19 pandemic. Implementing virtual support services, provision of urgent in-office or in-field support, distributing food aid, connecting clients with online healthcare services, increasing harm reduction education and referral, and meeting urgent housing needs were some of the strategies implemented by HF frontline workers to support the complex needs of their clients during the pandemic. HF frontline workers experienced workload burden, job insecurity and mental health problems (e.g. distress, worry, anxiety) as a consequence of their services during the first wave of the COVID-19 pandemic. Despite the several work-, programming- and structural-related challenges experienced by HF frontline workers when responding to the needs of their clients during the first wave of the COVID-19 pandemic, they played a critical role in meeting the communication, food, housing and health needs of their clients during the pandemic, even when it negatively affected their well-being. A more coordinated, integrated, innovative, sustainable, effective and well-funded support response is required to meet the intersecting and complex social, housing, health and financial needs of underserved and socio-economically excluded groups during and beyond health emergencies.

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.

Homemaking among the ‘chronically homeless’: a critical policy ethnography of Housing First

Housing First (HF) has become a prevalent public response to homelessness in North America and Europe. It supports individuals who have experienced long-term or ‘chronic’ homelessness in accessing independent housing without having to comply with addiction or mental health treatment. This article examines some of the challenges faced and expressed by HF program participants. Based on a critical policy ethnography of HF in two Canadian cities (Ottawa and Gatineau) and by drawing from a theoretical framework on meanings and feelings of home, it highlights how long term shelter users respond and adapt to housing with means of homemaking that challenge normative conceptions of ‘doing home’. Through fieldwork observations, the article describes how homeless shelters can represent ‘home-like’ sites and highlights a typology of homemaking, which reveals areas for policy improvement.

Assessing Housing First programs from a right to housing perspective

The notion that Housing First (HF) is a human-rights based approach to housing some of society’s most vulnerable citizens is often alluded to in the literature, but seldom interrogated. In this paper, we examine whether HF in Alberta, Canada is practiced in a way that realizes the right to housing for chronically homeless people. We do so using four human rights principles identified by Fukuda-Parr: non-discrimination, participation, adequate progress and remedy. Based on interviews with staff of 14 HF programs in three cities, we identify constraints to a human rights-based approach, including time-limited support, which necessitates a strong emphasis on housing sustainability. We also identify positive practices, such as client participation in decision-making and tenant rights education. The paper also provides a model for systematically assessing whether HF programs respect, protect and fulfil the right to housing.

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

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

Exploring the relationship between neighbourhood quality (NQ) and housing stability among formerly homeless individuals with mental illness in housing first

We developed, tested, and operationalized a comprehensive objective measurement tool, the Observer-rated Housing Quality Scale (OHQS), to assess housing unit, building, and neighbourhood characteristics in a large trial of Housing First (HF) in 5 Canadian cities. The OHQS provided an opportunity to explore the role of neighbourhood and its contribution to housing stability among formerly homeless individuals. A subset of 423 participants who had become housed in the second year of the trial were systematically selected. The psychometric properties of the neighbourhood quality (NQ) items were assessed within the OHQS. The association between NQ and housing stability was explored using ordinal logistic regression, adjusting for group, site, demographic, housing unit and building quality variables. Inter-rater reliability and internal consistency were very good for the NQ items and subscale. Although NQ was not predictive of housing stability after considering other residence and building features in the multivariable analysis, we assert further analysis is required to explore this relationship, especially for HF programs offering clients choice in housing and neighbourhood.

Employment experiences of formerly homeless adults with serious mental illness in Housing First versus treatment first supportive housing programs.

This paper examines how formerly homeless adults with serious mental illness living in Housing First (HF) and "treatment first" (TF) supportive housing programs experience employment. Research questions include: How do these individuals experience employment in the context of their mental health recovery? What do they perceive as the benefits of and obstacles to attaining employment? Are there programmatic differences in their employment experiences? Case study analyses of data from a federally funded qualitative study were conducted of 40 individuals purposively sampled from HF and TF programs. Data were independently analyzed and consensually discussed to develop cross-case themes. Three themes emerged: (a) the meaning of work, (b) working within the system, and (c) balancing treatment requirements and work. While none of the study participants had full-time jobs, more HF program clients had part-time employment than their TF counterparts. Of the 12 employed participants, all but 2 worked within their respective programs. Participants in both groups described similar benefits of obtaining employment, but TF program requirements inhibited job-seeking. These findings provide insight into the challenges of obtaining employment for formerly homeless individuals with serious mental illness residing in supportive housing. Despite the motivation to work, individual, structural, and organizational factors impeded employment. To address this problem, factors at each of these levels will need to be considered. Interventions such as supported employment offer promise to supportive housing programs committed to employment as a contributor to recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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

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

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

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

Managed alcohol programs in the context of Housing First

Purpose Recently, Managed Alcohol Programs (MAPs have emerged as an alcohol harm reduction model for those living with severe alcohol use disorder (AUD) and experiencing homelessness. There is still a lack of clarity about the role of these programs in relation to Housing First (HF) discourse. The authors examine the role of MAPs within a policy environment that has become dominated by a focus on HF approaches to addressing homelessness. This examination includes a focus on Canadian policy contexts where MAPs originated and are still predominately located. The purpose of this paper is to trace the development of MAPs as a novel response to homelessness among people experiencing severe AUD and to describe the place of MAPs within a HF context. Design/methodology/approach This conceptual paper outlines the development of discourses related to persons experiencing severe AUD and homelessness, with a focus on HF and MAPs as responses to these challenges. The authors compare the key characteristics of MAPs with “core principles” and values as outlined in various definitions of HF. Findings MAPs incorporate many of the core values or principles of HF as outlined in some definitions, although not all. MAPs (and other housing/treatment models) provide critical housing and support services for populations who might not fit well with or who might not prefer HF models. Originality/value The “silver bullet” discourse surrounding HF (and harm reduction) can obscure the importance of programs (such as MAPs) that do not fully align with all HF principles and program models. This is despite the fact that MAPs (and other models) provide critical housing and support services for populations who might fall between the cracks of HF models. There is the potential for MAPs to help fill a gap in the application of harm reduction in HF programs. The authors also suggest a need to move beyond HF discourse, to embrace complexity and move toward examining what mixture of different housing and harm reduction supports are needed to provide a complete or comprehensive array of services and supports for people who use substances and are experiencing homelessness.

‘Take whatever you can get’: practicing Housing First in Alberta

Housing First (HF) is an increasingly widespread and influential response to chronic homelessness. Programs using an HF approach typically rely on market apartments to house homeless clients as rapidly as possible. This reliance means HF programs are dependent on the availability and affordability of market housing. Little attention has been given to how shortages of affordable rental housing influence the practice of HF. To address this gap, we undertook qualitative research in Alberta, Canada. Interviews with service providers revealed that high rents and low vacancy rates had profound impacts on program operations, and complicated efforts to follow HF principles. Clients often experienced delays in being housed and felt pressure to accept the first apartment they were offered. In response, HF programs devoted resources to improve relationships with landlords. Ultimately, however, reliance on market housing undermined programs’ ability to fulfil the potential of HF in the Alberta context.

Knowledge, attitudes, and practices about homelessness and willingness-to-pay for housing-first across 8 European countries: a survey protocol

BackgroundMost European countries report rising numbers of people experiencing homelessness. For those with mental disorders, interventions are centered on achieving mental health and drug rehabilitation alongside housing readiness, often to the detriment of access to housing. Notwithstanding, more European countries are investing in a new model, Housing First (HF), which postulates immediate access to permanent housing with no initial requirements for treatment. While results of the European HF programs are published on individual-level data, little is known about the opinions of the general population about homelessness and the societal value of the HF model, which can represent barriers to the model’s dissemination. Therefore, we present the protocol of a study designed for the following objectives: 1) to explore the knowledge, attitudes, and practices (KAP) about homelessness within the general population of 8 European countries, 2) to assess the valuation of the HF model by European citizens, and 3) to estimate the lifetime prevalence of homelessness in the targeted countries.MethodsA telephone survey was conducted from March to December 2017 among adults selected from opt-in panels from France, Ireland, Italy, the Netherlands, Portugal, Spain, Poland, and Sweden. A total sample of 5600 interviews was expected, with 700 per country. The interviews included three sections: first, the KAP about homelessness; second, the valuation of the HF model by measuring a respondent’s willingness-to-pay (WTP) through the contingent valuation method; and third, an assessment of the lifetime prevalence of homelessness among the general population. Descriptive analyses and comparisons between countries will be conducted. KAP indicators will be created and their psychometric properties assessed. Determinants of WTP will be assessed through regression models.DiscussionThis survey will highlight Europeans’ views of homelessness, especially their level of tolerance towards homelessness, potential misconceptions and the most important barriers for the implementation of the HF model. Additionally, the results on the valuation of the HF model by citizens could be instrumental for key stakeholders in understanding the level of support from the general population. Ethics approval has been obtained from the Aix-Marseille University Ethics Committee (n° 2016-01-02-01) for this study, which is part of HOME_EU: Reversing Homelessness in Europe H2O20-SC6-REVINEQUAL-2016/GA726997.

Navigating Complex Implementation Contexts: Overcoming Barriers and Achieving Outcomes in a National Initiative to Scale Out Housing First in Canada

The scaling out of Housing First (HF) programs was examined in six Canadian communities, in which a multi-component HF training and technical assistance (TTA) was provided. Three research questions were addressed: (a) What were the outcomes of the TTA in terms of the development of new, sustained, or enhanced programs, and fidelity to the HF model? (b) How did the TTA contribute to implementation and fidelity? and (c) What contextual factors facilitated or challenged implementation and fidelity? A total of 14 new HF programs were created, and nine HF programs were sustained or enhanced. Fidelity assessments for 10 HF programs revealed an average score of 3.3/4, which compares favorably with other HF programs during early implementation. The TTA influenced fidelity by addressing misconceptions about the model, encouraging team-based practice, and facilitating case-based dialogue on site specific implementation challenges. The findings were discussed in terms of the importance of TTA for enhancing the capacities of the HF service delivery system-practitioners, teams, and communities-while respecting complex community contexts, including differences in policy climate across sites. Policy climate surrounding accessibility of housing subsidies, and use of Assertive Community Treatment teams (vs. Intensive Case Management) were two key implementation issues.

Changing the method of working with homeless people: a photovoice project in Italy

ABSTRACTIn Italy, many organizations are experimenting with the Housing First (HF) model to promote a change in how they work with homeless people. This change creates some difficulties, especially in promoting freedom of choice in people involved in the HF programs. This study explored the definition of “home” in homeless people’s points of view. The study participants were 5 homeless men involved in a HF program called “The Road Home” implemented in the city of Padua. Data were collected using Photovoice, a photographic method based on participatory action research. During the project, the participants took photographs to illustrate their definitions of “home” and then engaged in a critical dialogue about the images represented in the photographs. The results of the study showed that occupants identified the home as being related to family, friendship, cohabitation, and hope for the future. The Photovoice project provided an opportunity to promote discussions that revealed the true needs of the people involved, and in the meantime, it brought a change to the program and to the community, in addition to promoting the HF model in the community.

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

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

What Happens After the Demonstration Phase? The Sustainability of Canada's At Home/Chez Soi Housing First Programs for Homeless Persons with Mental Illness.

This research examined the sustainability of Canada's At Home/Chez Soi Housing First (HF) programs for homeless persons with mental illness 2years after the end of the demonstration phase of a large (more than 2000 participants enrolled), five-site, randomized controlled trial. Qualitative interviews were conducted with 142 participants (key informants, HF staff, and persons with lived experience) to understand sustainability outcomes and factors that influenced those outcomes. Also, a self-report HF fidelity measure was completed for nine HF programs that continued after the demonstration project. A cross-site analysis was performed, using the five sites as case studies. The findings revealed that nine of the 12 HF programs (75%) were sustained, and that seven of the nine programs reported a high level of fidelity (achieving an overall score of 3.5 or higher on a 4-point scale). The sites varied in terms of the level of systems integration and expansion of HF that were achieved. Factors that promoted or impeded sustainability were observed at multiple ecological levels: broad contextual (i.e., dissemination of research evidence, the policy context), community (i.e., partnerships, the presence of HF champions), organizational (i.e., leadership, ongoing training, and technical assistance), and individual (i.e., staff turnover, changes, and capacity). The findings are discussed in terms of the implementation science literature and their implications for how evidence-based programs like HF can be sustained.

Housing first on a large scale: Fidelity strengths and challenges in the VA's HUD-VASH program.

Housing First (HF) combines permanent supportive housing and supportive services for homeless individuals and removes traditional treatment-related preconditions for housing entry. There has been little research describing strengths and shortfalls of HF implementation outside of research demonstration projects. The U.S. Department of Veterans Affairs (VA) has transitioned to an HF approach in a supportive housing program serving over 85,000 persons. This offers a naturalistic window to study fidelity when HF is adopted on a large scale. We operationalized HF into 20 criteria grouped into 5 domains. We assessed 8 VA medical centers twice (1 year apart), scoring each criterion using a scale ranging from 1 (low fidelity) to 4 (high fidelity). There were 2 HF domains (no preconditions and rapidly offering permanent housing) for which high fidelity was readily attained. There was uneven progress in prioritizing the most vulnerable clients for housing support. Two HF domains (sufficient supportive services and a modern recovery philosophy) had considerably lower fidelity. Interviews suggested that operational issues such as shortfalls in staffing and training likely hindered performance in these 2 domains. In this ambitious national HF program, the largest to date, we found substantial fidelity in focusing on permanent housing and removal of preconditions to housing entry. Areas of concern included the adequacy of supportive services and adequacy in deployment of a modern recovery philosophy. Under real-world conditions, large-scale implementation of HF is likely to require significant additional investment in client service supports to assure that results are concordant with those found in research studies. (PsycINFO Database Record