Independent Housing Research Articles

Residential context and COVID-19 mortality among adults aged 70 years and older in Stockholm: a population-based, observational study using individual-level data

BackgroundHousing characteristics and neighbourhood context are considered risk factors for COVID-19 mortality among older adults. The aim of this study was to investigate how individual-level housing and neighbourhood characteristics are associated with COVID-19 mortality in older adults.MethodsFor this population-based, observational study, we used data from the cause-of-death register held by the Swedish National Board of Health and Welfare to identify recorded COVID-19 mortality and mortality from other causes among individuals (aged ≥70 years) in Stockholm county, Sweden, between March 12 and May 8, 2020. This information was linked to population-register data from December, 2019, including socioeconomic, demographic, and residential characteristics. We ran Cox proportional hazards regressions for the risk of dying from COVID-19 and from all other causes. The independent variables were area (m2) per individual in the household, the age structure of the household, type of housing, confirmed cases of COVID-19 in the borough, and neighbourhood population density. All models were adjusted for individual age, sex, country of birth, income, and education.FindingsOf 279 961 individuals identified to be aged 70 years or older on March 12, 2020, and residing in Stockholm in December, 2019, 274 712 met the eligibility criteria and were included in the study population. Between March 12 and May 8, 2020, 3386 deaths occurred, of which 1301 were reported as COVID-19 deaths. In fully adjusted models, household and neighbourhood characteristics were independently associated with COVID-19 mortality among older adults. Compared with living in a household with individuals aged 66 years or older, living with someone of working age (<66 years) was associated with increased COVID-19 mortality (hazard ratio 1·6; 95% CI 1·3–2·0). Living in a care home was associated with an increased risk of COVID-19 mortality (4·1; 3·5–4·9) compared with living in independent housing. Living in neighbourhoods with the highest population density (≥5000 individuals per km2) was associated with higher COVID-19 mortality (1·7; 1·1–2·4) compared with living in the least densely populated neighbourhoods (0 to <150 individuals per km2).InterpretationClose exposure to working-age household members and neighbours is associated with increased COVID-19 mortality among older adults. Similarly, living in a care home is associated with increased mortality, potentially through exposure to visitors and care workers, but also due to poor underlying health among care-home residents. These factors should be considered when developing strategies to protect this group.FundingSwedish Research Council for Health, Working Life and Welfare (FORTE), Swedish Foundation for Humanities and Social Sciences.

The Early Burden of Disability in Individuals With Mood and Other Common Mental Disorders in Ontario, Canada

Large population-based data on the trajectory to disability after the first diagnosis of a mood disorder are lacking. To assess the time between an incident mood disorder diagnosis and the receipt of disability services during a follow-up period of as long as 20 years. This cohort study used health administrative and social service data from ICES for 1 902 792 adults aged 18 to 59 years living in Ontario, Canada. A narrow cohort of individuals who had a new diagnosis of a mood disorder between October 1, 1997, and March 31, 2007, matched by sex and age to individuals with no history of mood disorder, included 278 296 participants. A broader cohort of individuals who had a new diagnosis of other common mental disorders during the same period, matched by sex and age to individuals with no history of mental disorder diagnosis, included 1 624 496 individuals. All individuals were followed up to a maximum end date of March 31, 2017. Data analysis was conducted from November 2017 to June 2018. Incident diagnosis of mood or common mental disorder. Disability outcomes were as follows: (1) entry into the Ontario Disability Support Program (ODSP), signifying long-term inability to work because of a disability, and (2) admission into a long-term care (LTC) residence, signifying the inability to live in independent housing. Cox proportional hazards models were used. In the full cohort of 1 902 792 individuals, 278 296 participants (14.6%) were included in the mood disorder cohort (mean [SD] age, 37.5 [11.9] years; 157 386 [56.6%] women), and 1 624 496 participants (85.4%) were included in the common mental disorder cohort (mean [SD], 36.5 [11.8] years; 932 545 [57.4%] women). The incidence of ODSP initiation was greater among individuals with mood disorders than those without (51.5 per 10 000 person-years vs 25.5 per 10 000 person-years; adjusted hazard ratio [aHR], 2.03; 95% CI, 1.95-2.11) and for those with common mental disorders (45.0 per 10 000 person-years vs 27.6 per 10 000 person-years; aHR, 1.57; 95% CI, 1.55-1.60). The aHR for admission to LTC was also higher among individuals with mood disorders compared with those without (aHR, 2.20; 95% CI, 1.80-2.69) and those with common mental disorders compared with those without (aHR, 1.21; 95% CI, 1.14-1.29). Individuals with bipolar disorders had greater ODSP rates than individuals with major depressive disorders (crude rate ratio: 4.31 [95% CI, 3.56-5.17] vs 1.82 [95% CI, 1.36-2.43]). This cohort study found that mood disorders were associated with elevated and early rates of disability services. Effective early intervention strategies targeting functional impairment in this population are encouraged.

Ping-Pong Housing: Women’s Post-Incarceration Trajectories

This study examines the post-incarceration housing experiences of 33 women. Using Residential Timeline Followback methodology, participants were asked to report where they lived at arrest and every location since their release. Follow-up questions asked women to describe these locations, who they lived with, how much they paid, and whether or not they felt safe. Demographic information and criminal justice history were recorded. The data paint a complicated picture of social and community resources, persistence, and struggle. Housing assets lost at incarceration were difficult to recover. Most women bounced between various locations, relying heavily on short-term subsidized congregate housing programs and rarely securing independent housing. Participants described the family, friends, and acquaintances who housed them during reentry as overextended and vulnerable. Implications for policy and practice are explored.

The Effect of Discrimination on Stress among Public Housing Residents: A Comparative Study between Social-Mix and Independent Public Housing Complexes.

This study aims to examine the differential effect of discrimination on stress between social-mix and independent public housing complexes. We analyzed the 2017 Seoul Public Housing Residents Panel Study data that were collected from public housing residents living in Seoul, Korea by running ordinal logit analyses. The empirical analysis shows that discrimination has a lower effect on stress in social-mix housing complexes than in independent public housing complexes. In addition, the moderating effect of community-based activities on the relationship between discrimination and stress was found in the independent public housing complex model.

Personal health information management among healthy older adults: Varying needs and approaches.

With age, older adults experience a greater number of chronic diseases and medical visits, and an increased need to manage their health information. Technological advances in consumer health information technologies (HITs) help patients gather, track, and organize their health information within and outside of clinical settings. However, HITs have not focused on the needs of older adults and their caregivers. The goal of the SOARING (Studying Older Adults and Researching their Information Needs and Goals) Project was to understand older adult personal health information management (PHIM) needs and practices to inform the design of HITs that support older adults. Drawing on the Work System Model, we took an ecological approach to investigate PHIM needs and practices of older adults in different residential settings. We conducted in-depth interviews and surveys with adults 60 years of age and older. We performed on-site in-person interview sessions with 88 generally healthy older adults in various settings including independent housing, retirement communities, assisted living, and homelessness. Our analysis revealed 5 key PHIM activities that older adults engage in: seeking, tracking, organizing, sharing health information, and emergency planning. We identified 3 major themes influencing older adults' practice of PHIM: (1) older adults are most concerned with maintaining health and preventing illness, (2) older adults frequently involve others in PHIM activities, and (3) older adults' approach to PHIM is situational and context-dependent. Older adults' approaches to PHIM are dynamic and sensitive to changes in health, social networks, personal habits, motivations, and goals. PHIM tools that meet the needs of older adults should accommodate the dynamic nature of aging and variations in individual, organizational, and social contexts.

Better Habits, Brighter Futures: Outcomes of a Habit-Training Program for People in a Community-Based Supported-Housing Program

Abstract Date Presented 03/26/20 This presentation reports outcomes of a program designed for adults with substance-abuse disorder living in supported housing. Interventions stressed practical competencies and building functional habits and routines, including self-directed goal setting, to support participants’ recovery and capacity to transition to independent community housing. Collaboration with case managers and housing specialists enhanced outcomes and simultaneously built evidence for the distinct value of OT interventions. Primary Author and Speaker: YiNao Wang Additional Authors and Speakers: Jaime Muñoz Contributing Authors: Rev. Kellie Wild, John McCartin

Surgical Education in the Time of COVID: Understanding the Early Response of Surgical Training Programs to the Novel Coronavirus Pandemic

ObjectiveDescribe the early impact of the COVID-19 pandemic on general surgery residency training nationwide.DesignA 31-question electronic survey was distributed to general surgery program directors. Qualitative data underwent iterative coding analysis. Quantitative data were evaluated with summary statistics and bivariate analyses.ParticipantsEighty-four residency programs (33.6% response rate) with representation across US geographic regions, program affiliations, and sizes.ResultsWidespread changes were observed in the surgical training environment. One hundred percent of programs reduced the number of residents on rounds and 95.2% reduced the size of their in-hospital resident workforce; on average, daytime staffing decreased by nearly half. With telehealth clinics (90.5%) and remote inpatient consults (26.2%), both clinical care and resident didactics (86.9%) were increasingly virtual, with similar impact across all program demographics. Conversely, availability of some wellness initiatives was significantly higher among university programs than independent programs, including childcare (51.2% vs 6.7%), housing (41.9% vs 13.3%), and virtual mental health services (83.7% vs 53.3%).ConclusionsChanges in clinical care delivery dramatically reduced in face-to-face learning opportunities for surgical trainees during the COVID-19 pandemic. While this effect had equal impact across all program types, sizes, and geographies, the same cannot be said for wellness initiatives. Though all programs initiated some strategies to protect resident health, the disparity between university programs and independent programs may be cause for action.

Independent Housing and Support for non-homeless individuals with severe mental illness: randomised controlled trial vs. observational study \u2013 study protocol

BackgroundSocial inclusion is essential for an adequate rehabilitation process for people with serious mental illness (SMI). Various supported housing settings aim to promote housing competencies and social inclusion in service users. Nevertheless, there is a strong preference in service users for independent living. We aim to evaluate the effectiveness and efficiency of Independent Housing and Support (IHS) compared to institutionalised residential care settings and other treatment as usual conditions (RCS/TAU) in two cities in Switzerland.MethodsThis is a prospective multi-centre, four-arm, non-inferiority cohort study investigating the effectiveness and efficiency of IHS and RCS/TAU for people with SMI. Effectiveness will be measured by a standardised measure of social inclusion as primary outcome as well as by measures of functioning and well-being. Efficiency will be analysed on the basis of service usage and costs associated with the different housing settings. Participants will be consecutively recruited and subsequently enrolled between April 2019 and December 2020 and assessed at baseline and after six, twelve and after 24 months. At one study site, 56 participants will be randomly assigned to one of the conditions; the other study site will be conducted as an observational study investigating 112 admitted participants.DiscussionWhile the UN Convention of the Rights of People with Disabilities aims to promote the opportunity to choose one’s place of residence, the limited supply of alternative forms of housing does not guarantee genuine freedom of choice. Increased diversification and flexibility of housing support is essential. If IHS shows non-inferiority in terms of their effectiveness and efficiency, users should be allowed to choose their kind of housing support.Trial registrationClinicalTrials.gov: NCT03815604, December 04, 2019.

Differences in housing transitions and changes in health and self-determination between formerly homeless individuals.

BackgroundTo reduce homelessness, it is important to gain a better understanding of the differences between homeless people who remain in institutions and those who gain and can sustain independent housing. This longitudinal study explores differences in housing transitions and differences in changes in health and self-determination between formerly homeless people still living in institutions 2.5 years later and those now living in independent housing in the Netherlands.MethodsThis study mapped the housing transitions of 263 participants from when they entered the social relief system (SRS) to 2.5 years later when they were in independent housing or institutions. These individuals were compared at the 2.5-year mark in terms of gender, age and retrospectively in terms of duration of homelessness. They were also compared with regard to changes in psychological distress, perceived health, substance use and self-determination.ResultsTwo and a half years after entering the SRS, 81% of participants were independently housed and 19% still lived in institutions. People in institutions had a longer lifetime duration of homelessness, were more often men, and their number of days of alcohol use had decreased significantly more, whereas independently housed people had shown a significant increase in their sense of autonomy and relatedness.ConclusionFormerly homeless people living in independent housing and in institutions show few health-related differences 2.5 years after entering the SRS, but changes in autonomy and relatedness are distinctly more prevalent, after the same period of time, in those who are independently housed.

Comparison of Housing First and Traditional Homeless Service Users in Eight European Countries: Protocol for a Mixed Methods, Multi-Site Study.

BackgroundHomeless services expend considerable resources to provide for service users’ most basic needs, such as food and shelter, but their track record for ending homelessness is disappointing. An alternative model, Housing First, reversed the order of services so that homeless individuals are offered immediate access to independent housing, with wraparound supports but no treatment or abstinence requirements. Although the evidence base for Housing First’s effectiveness in ending homelessness is robust, less is known about its effectiveness in promoting recovery.ObjectiveThe objective of this research is to compare rehabilitation- and recovery-related outcomes of homeless services users who are engaged in either Housing First or traditional staircase services in eight European countries: France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden.MethodsA mixed methods, multi-site investigation of Housing First and traditional services will compare quantitative outcomes at two time points. Key rehabilitation outcomes include stable housing and psychiatric symptoms. Key growth outcomes include community integration and acquired capabilities. Semistructured interviews will be used to examine service users’ experiences of environmental constraints and affordances on acquired capabilities to identify features of homeless services that enhance service users’ capabilities sets. Multi-level modelling will be used to test for group differences—Housing First versus traditional services—on key outcome variables. Thematic analysis will be used to understand the ways in which service users make sense of internal and external affordances and constraints on capabilities.ResultsThe study is registered with the European Commission (registration number: H2020-SC6-REVINEQUAL-2016/ GA726997). Two press releases, a research report to the funding body, two peer-reviewed articles, and an e-book chapter are planned for dissemination of the final results. The project was funded from September 2016 through September 2019. Expected results will be disseminated in 2019 and 2020.ConclusionsWe will use the findings from this research to formulate recommendations for European social policy on the configuration of homeless services and the scaling up and scaling out of Housing First programs. From our findings, we will draw conclusions about the setting features that promote individuals’ exits from homelessness, rehabilitation, and recovery.International Registered Report Identifier (IRRID)RR1-10.2196/14584

Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial.

Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether independent housing with mental health support teams with a recovery-oriented approach (Housing First (HF) program) for people who are homeless with severe mental disorders improves hospital and emergency department use. We did a randomised controlled trial in four French cities: Lille, Marseille, Paris and Toulouse. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD) and were required to have a high level of needs (moderate-to-severe disability and past hospitalisations over the last 5 years or comorbid alcohol or substance use disorder). Participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalisation admissions and inpatient days at 24 months. Secondary outcomes were recovery (Recovery Assessment Scale), quality of life (SQOL and SF36), mental health symptoms, addiction issues, stably housed days and cost savings from a societal perspective. Intention-to-treat analysis was performed. Eligible patients were randomly assigned to the HF group (n = 353) or TAU group (n = 350). No differences were found in the number of hospital admissions (relative risk (95% CI), 0.96 (0.76-1.21)) or ED visits (0.89 (0.66-1.21)). Significantly less inpatient days were found for HF v. TAU (0.62 (0.48-0.80)). The HF group exhibited higher housing stability (difference in slope, 116 (103-128)) and higher scores for sub-dimensions of S-QOL scale (psychological well-being and autonomy). No differences were found for physical composite score SF36, mental health symptoms and rates of alcohol or substance dependence. Mean difference in costs was €-217 per patient over 24 months in favour of the HF group. HF was associated with cost savings in healthcare costs (RR 0.62(0.48-0.78)) and residential costs (0.07 (0.05-0.11)). An immediate access to independent housing and support from a mental health team resulted in decreased inpatient days, higher housing stability and cost savings in homeless persons with SCZ or BP disorders.

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.

AFFORDABLE SENIOR HOUSING AND HEALTH AMONG LOW-INCOME OLDER IMMIGRANTS: THE ROLE OF SERVICE USES

Older immigrants in affordable senior housing face a unique set of challenges due to their demographic, social, economic, and cultural diversity. Existing knowledge about health among this unique but increasing aging subgroup population is extremely limited. Focusing on older immigrants subgroups (Asian and Russian older adults) in affordable senior housing in St.Louis, MO, this study aimed to examine to what extent different ethnic minority elders’ health varies by their uses of services available in the housing. Data came from the survey interviews at a subsidized independent senior housing in St. Louis (n=136). Hierarchical multiple regressions were used to examine ethnic differences in self-rated health and the role of services for the health of low-income ethnic minor elders in senior housing. Compared to the non-immigrants (White/African older adults), Asian (b=0.67, p<.05) and Russian residents (b=0.89, p<.05) were likely to have lower self-rated health. Interestingly, for both ethnic groups, they report a better self-rated health when they use supportive daily service (i.e. e.g. meal delivery, transportation, housekeeping and others) (b= -0.84, p<.05 for Asian, b=- 0.90, p<.05.for Russian) and social service (e.g. recreational, wellness, and exercise programs) (b= -0.73, p<.05 for Asian, b=- 0.83, p<.05.for Russian). Our findings point to an important role of services for the health of low-income ethnic minor elders in senior housing. As the first attempt to examine services that explicitly focus on ethnic minority elders, our study provides meaningful implications for future research on the health and service needs for older immigrant populations in senior housing.

AGING IN COMMUNITY: A LEGAL MAPPING ANALYSIS OF MASSACHUSETTS MUNICIPAL ACCESSORY DWELLING UNIT ZONING BYLAWS

Accessory-dwelling units (ADUs) are one alternative housing arrangement that enable older adults to remain in the home despite functional decline. Functional decline increases with age making older adults more susceptible to loosing independent housing. Involuntary relocation to institutional care can result in a decline of functional health, reduced life satisfaction, impairment of psychological well-being and increased mortality rate. The majority of older Americans (93%) wish to remain in their home for as long as possible. ADUs function to maintain, stimulate and support an older adult as a means to prevent relocation to an institution. The modified environment coupled with adaptable features maintains and supports activities of daily living (ADL) within a familiar place. Under Massachusetts law MGL c. 40A, the state gives authority to cities and towns to adopt ordinances and bylaws to regulate the use of land, buildings and structures. Restrictive zoning laws limit the ability to construct health-promoting built-environments to age-in-community. All 351 Massachusetts municipalities Accessory Dwelling Unit (ADU) zoning bylaws were coded using the ADU Friendliness Score. Once scored, the 351 municipalities were placed into four categories based off their ADU score; the four categories are poor (0-24), fair (25-49), good (50-74), and excellent (75-100). Eighty-nine municipalities (25%) are in the poor category; thirty municipalities (8.5%) are in the fair category; one hundred and eighty-five municipalities (53%) are in the good category; forty-seven municipalities (13.5%) are in the excellent category. These findings contributed to a model ADU bylaw specific for aging Americans for municipalities to adopt.

Cost-effectiveness analysis of the Un Chez Soi d’Abord randomized controlled trial: a Markov model

Abstract Objectives Providing permanent supported housing (rent subsidies), integrating clinical and social services to homeless people may represent a financial barrier for building a healthier European public policy. Our objective was to conduct a cost-effectiveness analysis of the French Housing First program. Design and methods Between 2011 and 2014, homeless people with severe mental illness from 4 French major cities were randomized to Housing First (HF, n = 353) or Treatment as Usual (TAU, n = 350) and followed over 24 months. Housing stability and survival were assessed. Costs incurred by health (ED visits, hospital admissions, physician consultations), social (shelters, supported accommodations, other residential structures), justice services (court appearances, detention and penitentiary centres), and welfare benefits were collected over 24 months. Markov models of 6-month transition probabilities were compared among HF group (offering an independent house and support from outpatient mental health and social team) and TAU group (receiving pre-existing dedicated homeless-targeted programs and services). Three Markov states were defined: stable housing (at least 90 nights in an independent housing), unstable housing (i.e. inverse) and death. A societal perspective and a life-time horizon were chosen. Robust sensitivity analyses were performed, including Tornado diagram and Monte-Carlo simulations. Results There is evidence of changes (P&amp;lt;.001) in housing stability (246% more days housed) for the HF group compared with TAU group. From the societal perspective, HF was €10,163 (3%) more costly than usual care. ICER was €5.32 per additional night spent in independent housing. In sensitivity analyses, HF was less costly and more effective in 28% of iterations. Conclusions HF proves to be cost-effective in homeless people with mental disorders and may assist decision-makers in defining conditions for further implementation of these innovations in Europe. Key messages Housing First model proves to be cost-effective in homeless people with mental disorders. Housing First model was less costly and more effective in 28% of ieration compared to treatment as usual.

Long-term effects of a housing support intervention in homeless people with severe mental illness

Abstract Objectives Recent studies have suggested that the Housing First model is a promising strategy for providing effective services to homeless people with mental illness at a short-term horizon. The paper assesses the long-term effects of an independent housing with a recovery-oriented approach in homeless people with severe mental illness on social recovery, mental symptoms and quality of life among homeless adults with high support needs for mental and physical health services. Design and methods “Un Chez Soi d’Abord” was a randomized controlled trial conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. From August 2011 to April 2014, homeless participants with a DSM-IV-TR diagnosis of bipolar disorder or schizophrenia (N = 703) were randomly assigned to Housing First (n = 353) or Treatment as Usual (n = 350). Mental symptoms (MCSI), social recovery (RAS), global physical and mental status (SF-36), subjective quality of life (S-QoL) and addictions (MINI) were collected every 6 months over 48 months. Mixed models using a longitudinal and cluster design were performed, and adjusted to age on the street, gender and mental disorder diagnosis and testing for time*group and site*time interactions. Results HF patients exhibited higher recovery (β = 3.6, 95%CI: 0.4 to 6.9), higher S-QoL (4.7, 1.1 to 8.3) such as the self-esteem (10.9, 5.8 to 15.6) and physical well-being (8.4, 3.1 to 13.8) sub-dimensions, and improved mental health symptoms (-3.1, -5.4 to -0.9) over the 4-year follow-up. No significant differences were observed for SF36 scores. HF and TAU participants experienced similar alcohol or substance dependence evolution between baseline and 48 months. Conclusions HF is a highly effective intervention associated with improved relational environment, enhancing recovery and quality of life in homeless people with schizophrenia or bipolar disorders. Addiction issues have been identified and should be targeted so as to further improve the Housing First approach. Key messages Housing First model is a highly effective intervention. Housing First model enhances recovery and quality of life in homeless people.

SOCIAL VARIABLES LEADING TO URBAN DISTORTION CASE STUDY ON A GROUP OF EGYPTIAN CITIES

The study aimed to identify the phenomenon of Social variables leading to urban distortion. The study was applied on a sample of three cities in the Delta (Shebin El-Koum - Ashmon - Benha). This study belongs to the descriptive type of studies, using the social survey through a random sample of (200) items distributed on three cities using the questionnaire form. The researchers relied on some statistical methods, including (T) test, frequencies, ratios and correlation coefficients. The study reached to a number of results as follows: there are some causes and factors that led to the urban distortion such as: the increase in population density, deterioration of public services in some areas especially; health, education, water and other services, in addition to, the deterioration of the urban structure and its fragility. The study also displayed that the emergence of the Military Governor's Law at the end of this period No. 1 of 1996, with the prohibition of building on the agricultural land, except in the narrowest extent of building or using it for non-agriculture, led to moving to the cities and building in random ways. The study also showed that the economic openness which started in the 1970s in the real estate market was very high, in addition to the tendency of the Egyptians working abroad to invest in real estate especially in the urban districts. The results of the study also indicated that the high level living and the emergence of migration returning from the Arab Gulf countries to invest their revenue in urban expansion, which in turn encouraged the construction outside the old block which is crowded with the population, which suffer from the mixing of the use of land due to the urban accumulation to the emergence of modern buildings and constructions from features and formations that may be beautiful in their homeland but exotic in our environments and civilizations that are contrary to the customs, traditions and social values of our society. The study also showed that people desire to move according to their changed economic conditions towards the independent housing because the rural houses contain generations of the same family. The elevations are exaggerated in the midst of low-rise surrounding buildings, leading to a lapse of privacy for nearby buildings. The study recommends the following: working on activation of the control role by the local councils and quarters in order to eliminate the slums phenomenon and restrict the informal building that distorts beauty of the city. Setting determinant designing frames for the city's buildings to restrict or prohibit the advertisement banners and to make them du to specific criteria regarding the color, the size, the font type, lightening, colors of doors of shops and unifying the umbrellas' limits and jutting-outs; this can create aesthetic touch to the city. Working on re-directing of people beliefs, values, and behaviors through encountering the problems of the social and changes, so, youth can act positively in every city through participation in fields organized by the official authorities in each governorate.

"We have a roof over our head, but we have to eat too:" Exploring shifting foodscapes from homelessness into Housing First in Kingston, Ontario.

People facing extended periods of homelessness exhibit a remarkable degree of agency and resilience in procuring food. The literature on foodscapes considers the sociospatial contexts of food procurement, finding that what happens within and along the way to sites of food acquisition and consumption are important considerations in fully understanding and realizing food security. This study explores the shift in foodscapes of people who are transitioning from homelessness into scattered-site independent housing via a municipal Housing First program and considers implications for health and wellbeing. Our mixed-method approach included observational research at 11 local food providers and drop-in centres that provided context for semi-structured interviews with 10 Housing First clients in Kingston, Ontario between November 2016 and March 2017. The findings confirm that the provision of stable housing makes it possible for people to store, prepare, and consume food at home. An increased ability to have control over when, where, and what is eaten had a positive impact on people's sense of health and wellbeing. However, other effective markers of wellbeing were enacted along people's everyday routines and activities that had negative impacts. Interviewees remained heavily dependent on charitable food programs, including increased use of foodbanks. Others reported increasing detachment and social isolation from previously established food routines. Finally, the structured transition perpetuated a circuit of dependence and marginalization that fell short of contributing to improved food security as well as health and wellbeing. Understanding the relational geography of foodscape transitions is critical to the design of effective Housing First programs. Addressing the root causes of homelessness and poverty requires investments in comprehensive housing strategies including adequate social assistance and community supports that take a sociospatially holistic approach to wellbeing.

Examining the risk factors and needs of veterans involuntarily doubling-up with family or friends

ABSTRACTPrior research has found that individuals who are involuntarily doubling-up are at greater risk of experiencing homelessness and continued housing instability. Using intake assessment data from community organizations that provide homelessness prevention services to Veterans, this study examines the risk factors and needs of those living in the home of another involuntarily on a temporary basis to inform programs aimed at addressing barriers to stable independent housing. Those with a poor housing history, physical disability, chronic health condition, mental health issue, or substance abuse problem have greater odds of living in the home of another involuntarily. The needs of those involuntarily doubling-up could be addressed through increased connections to healthcare, housing assistance, child care, and basic necessities.

Effectiveness of a Housing Support Team Intervention with a Recovery-Oriented Approach on Hospital and Emergency Department Use by Homeless People with Severe Mental Illness: A Randomized Controlled Trial

Background: Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether an independent housing with mental health support teams with a recovery-oriented approach (Housing First program) in people who are homeless with severe mental disorders improves hospital and emergency department use. Methods: We did a randomized controlled trial in 4 French cities: Lille, Marseille, Paris, and Toulouse, including a cost effectiveness analysis. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD), and were required to have a high level of needs (moderate-to-severe disability and past hospitalizations over the last 5 years or comorbid alcohol or substance use disorder. Using computer-generated random numbers, participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist, and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalization admissions, and inpatient days at 24 months. Secondary outcomes were recovery (RAS), quality of life (SQOL and SF36), mental health symptoms (MCSI), addiction issues, stably housed days and cost savings from a societal perspective. Findings: Between August 2011and April 2014, 703 eligible patients were randomly assigned to the HF group (n=353) or TAU group (n=350). No differences were found in the number of hospital admissions (success rate difference [95% CI], -0.03 [-0.12 to 0.05]) or ED visits (-0.05 [-0.14 to 0.3]). Significant less inpatient days were found for HF versus TAU (-0.16 [-0.23 to -0.08]). HF group exhibited higher housing stability (standardized Beta, 20.2 [18 to 22.3]) and higher scores for some sub-dimensions of the SQOL scale (psychological well-being and autonomy). No differences were found for SF36, mental health symptoms, rates of alcohol or substance dependence. HF was associated with cost savings in healthcare costs (-0.21[-0.29 to -0.13]) and residential costs (-0.81[-0.85 to -0.77]). Interpretation: An immediate access to independent housing and support from an Assertive Community Treatment team resulted in decreased inpatient days and cost savings in people who are homeless with SCZ or BP disorders. Trial Registration: This study is registered with ClinicalTrials.gov, number NCT01570712. Funding Statement: French institutional grant from the Programme Hospitalier de Recherche Clinique National (DGOS), Janssen Pharmaceutical Company, and the Fondation de France. Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at http://www.thelancet.com/forauthors/forms#icmje-coi, and stated that no conflicts of interest exist. Ethics Approval Statement: The local ethics committee (Comite de Protection des Personnes Sud-Mediterranee V, France: trial number 11.050) and the French Drug and Device Regulation Agency (trial number 2011-A00668-33) approved this study.