Parent-child relationship outcomes in a randomized controlled trial of housing first for indigenous and non-Indigenous parents experiencing homelessness, mental illness, and separation from their children.

OBJECTIVE: To examine the impacts of Housing First (HF) on parent-child relationships for Indigenous and non-Indigenous parents experiencing homelessness and mental illness. METHOD: Data on parent-child relationships were obtained through baseline and 18-month narrative interviews with parents (N = 43). Participants were randomly assigned to HF (N = 27) or treatment as usual (TAU; N = 16). Parent-child relationship changes were coded as positive or no change. Comparisons between HF and TAU groups were examined for Indigenous parents (N = 21) and non-Indigenous parents (N = 22). RESULTS: Parents in HF reported more positive changes, proportionally, in their relationships with their children, when compared with parents in the TAU group. Among Indigenous parents, proportionally more in HF (eight of 13 parents) reported positive changes in their relationships with their children, compared with those in TAU (one of eight parents). For non-Indigenous parents, however, those in HF (five of 14 parents) reported proportionally similar positive changes in relationships with their children to those in TAU (two of eight parents). Narratives of Indigenous parents in HF showed that they made considerable progress over 18 months in reconciling with their children. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings underscore the potential of HF to promote positive parent-child relationships. For Indigenous parents, HF programs that are designed, implemented, and staffed by Indigenous service-providers; guided by Indigenous worldviews; and employ culturally relevant and culturally safe practices are exemplars for understanding how HF programs can be adapted to positively impact parent-child relationships. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Shelter Bans Among People Experiencing Homelessness: an Exploratory Study of Predictors in Two Large Canadian Datasets.

Emergency shelters are a core component of homeless service systems that address immediate basic needs. Service bans, which refer to temporary or permanent disallowances from a program or organization, are an underresearched phenomenon that can leave people experiencing homelessness without needed supports. This exploratory study examined the factors associated with shelter bans among people experiencing homelessness using secondary data from two Canadian studies: (1) a multisite randomized controlled trial of Housing First (At Home/Chez Soi Demonstration Project) and (2) a cross-sectional survey of youth experiencing homelessness across Canada (2019 Without a Home-National Youth Homelessness Survey). The two datasets were analyzed separately using logistic regression models with similar predictors to maximize the comparability of the results. Participants who experienced homelessness at an earlier age and had recent criminal justice system involvement were more likely to have shelter bans in both datasets. Impaired impulse control, more chronic medical conditions and living in Toronto were associated with increased likelihood of shelter bans in the At Home/Chez Soi dataset, whereas more adverse childhood experiences, physical violence victimization, engagement in survival sex behaviours and longer current episodes of homelessness were significant predictors of bans in the Without A Home dataset. Overall, the findings suggest that victimization and criminalization during homelessness may increase the risk of shelter loss from bans and further exclusion. The observed regional differences also highlight the potential limits of individual-level predictors. Further research is needed on shelter ban outcomes, as well as how capacity limits and organizational policies affect banning decisions.

Longitudinal Mixed Modelling of Emergency Department Use Among a Sample of Homeless Participants in a Housing First Demonstration Trial.

The present Canadian study sought to identify predictors of emergency department (ED) use in a sample of adults who are homeless. Four hundred eighty-three participants were interviewed quarterly for two years, reporting their housing status, income, food security, physical/mental health, and other social determinants of health. Survey data were linked to administrative health and social services data. Predictors of ED visits were analyzed using negative binomial longitudinal mixed modelling. Emergency department visits were positively and reliably predicted by pre-baseline ED use, as well as by concurrent increased social assistance, primary care visits, ratings of physical health, substance use problems, and case management visits. Increased concurrent housing instability and food insecurity, and decreased homelessness history, positively predicted ED visits, but effect reliability was lower. Participant ill health appears to be a primary driver of ED utilization. The findings challenge misconceptions about the appropriateness of ED use among people who are homeless.

Overall and Gender-specific Associations between Dimensions of Adverse Childhood Experiences and Mental Health Outcomes among Homeless Adults: Associations Générales et Sexospécifiques Entre les Dimensions des Expériences Défavorables de L'enfance et les Résultats de Santé Mentale Chez les Adultes Sans Abri.

OBJECTIVE: The associations between adverse childhood experiences (ACEs) and psychopathology have been well-established in the general population. Research on ACEs in the homeless population has been limited. This study examined whether ACE exposure is associated with specific mental health outcomes among a national sample of homeless adults with mental illness and whether this association varies according to ACE dimension and gender. METHODS: This cross-sectional study utilized data from a national sample of 2,235 homeless adults with mental illness in Canada to evaluate their sociodemographic characteristics, exposure to ACEs, and mental health outcomes. Exploratory and confirmatory factor analyses were conducted to identify and confirm ACE dimensions (maltreatment, sexual abuse, neglect, divorce, and household dysfunction) from individual ACE items. Multivariable logistic regression was used to examine the associations between total ACE score and ACE dimensions with mental illness diagnoses and psychopathology severity. RESULTS: The mean total ACE score among all study participants was 4.44 (standard deviation [SD]: 2.99). Total ACE score was positively associated with several mental illness diagnoses and psychopathology severity. Unique associations were found between specific ACE dimensions and poor mental health outcomes. The prevalence of almost all ACEs was significantly higher among women. Yet, associations between several ACE dimensions and poor mental health outcomes existed uniquely among men. CONCLUSIONS: There are unique and gender-specific associations between specific ACE dimensions and mental health outcomes among homeless adults. Better understanding of the mechanisms underlying these associations is needed to inform screening, prevention, and treatment efforts, particularly given the very high prevalence of ACEs among this vulnerable and marginalized population.

Indigenous and non-Indigenous parents separated from their children and experiencing homelessness and mental illness in Canada.

The purpose of this study is to examine the parent-child experiences of Indigenous and non-Indigenous mothers and fathers experiencing homelessness, mental illness, and separation from their children. A qualitative thematic analysis of baseline and 18-month follow-up narrative interviews was used to compare 12 mothers (n = 8 Indigenous and n = 4 nonindigenous) with 24 fathers (n = 13 Indigenous and n = 11 non-Indigenous). First, it was found that children are more central in the lives of mothers than fathers. Second, Indigenous parents' narratives were characterized by interpersonal and systemic violence, racism and trauma, and cultural disconnection, but also more cultural healing resources. Third, an intersectional analysis showed that children were peripheral in the lives of non-Indigenous fathers, and most central to the identities of Indigenous mothers. Gender identity, Indigenous, and intersectional theories are used to interpret the findings. Implications for future theory, research, and culturally relevant intervention are discussed.

Cost-Effectiveness of Housing First With Assertive Community Treatment: Results From the Canadian At Home/Chez Soi Trial.

OBJECTIVE: The At Home/Chez Soi trial for homeless individuals with mental illness showed scattered-site Housing First with Assertive Community Treatment (ACT) to be more effective than treatment as usual. This study evaluated the cost-effectiveness of Housing First with ACT and treatment as usual. METHODS: Between October 2009 and June 2011, a total of 950 homeless individuals with serious mental illness were recruited in five Canadian cities: Vancouver, Winnipeg, Toronto, Montreal, and Moncton. Participants were randomly assigned to Housing First (N=469) or treatment as usual (N=481) and followed up for up to 24 months. The intervention consisted of scattered-site Housing First, using rent supplements, with ACT. The treatment-as-usual group had access to all other services. The perspective of society was adopted for the cost-effectiveness analysis. Days of stable housing served as the outcome measure. Retrospective questionnaires captured service use data. RESULTS: Most (69%) of the costs of the intervention were offset by savings in other costs, such as emergency shelters, reducing the net annual cost of the intervention to about Can$6,311 per person. The incremental cost-effectiveness ratio was Can$41.73 per day of stable housing (95% confidence interval=Can$1.96-$83.70). At up to Can$60 per day, Housing First had more than an 80% chance of being cost-effective, compared with treatment as usual. Cost-effectiveness did not vary by participant characteristics. CONCLUSIONS: Housing First with ACT appeared about as cost-effective as Housing First with intensive case management for people with moderate needs. The optimal mix between the two remains to be determined.

Examining the Relationships between Cumulative Childhood Adversity and the Risk of Criminal Justice Involvement and Victimization among Homeless Adults with Mental Illnesses after Receiving Housing First Intervention.

OBJECTIVES: Exposure to adverse childhood experiences (ACEs) is associated with increased risk of criminal justice involvement and repeated victimization among homeless individuals. This study aimed to (1) examine whether the relationship between cumulative ACE score and odds of experiencing criminal justice involvement and victimization remains significant over time after receiving the Housing First (HF) intervention and (2) investigate the moderating effect of cumulative ACE score on the effectiveness of the HF intervention on the likelihood of experiencing these outcomes among homeless individuals with mental illnesses. METHODS: We used longitudinal data over the 2-year follow-up period from the At Home/Chez Soi demonstration project that provided HF versus treatment as usual (TAU) to homeless adults with mental illness in five Canadian cities (N = 1,888). RESULTS: In all 4 follow-up time points, the relationship between cumulative ACE score and both outcomes remained significant, regardless of study arm (HF vs. TAU) and other confounding factors. However, cumulative ACE score did not moderate intervention effects on odds of experiencing either outcome, suggesting that the effectiveness of HF versus TAU, with regard to the odds of being victimized or criminal justice involvement, did not differ by cumulative ACE scores over the course of study. CONCLUSIONS: Findings suggest that providing services for homeless individuals with mental illness should be trauma informed and include specialized treatment strategies targeting the experience of ACEs and trauma to improve their treatment outcomes. An intensive approach is required to directly address the problem of criminal justice involvement and victimization in these individuals.

Effectiveness of Housing First for Homeless Adults with Mental Illness Who Frequently Use Emergency Departments in a Multisite Randomized Controlled Trial.

Frequent emergency department (ED) users experiencing homelessness are associated with high costs for healthcare systems yet interventions for this group have been minimally investigated. This study used 24-month data from a multisite randomized controlled trial of Housing First (HF) to examine how effective the intervention is in helping frequent ED users with a mental illness to achieve housing stability, improve behavioural health and functioning, and reduce their ED use. Findings showed that HF is effective in stably housing frequent ED users despite their complex health needs. Reductions in ED use and substance use problems, and improvements in mental health symptoms and community functioning were found for frequent ED users in both the HF and treatment as usual conditions.

Fixed Nodes of Transience: Narratives of Homelessness and Emergency Department Use.

Discourse in popular media, public policy, and academic literature contends that people who are homeless frequently make inappropriate use of hospital emergency department (ED) services. Although researchers have investigated the ED experiences of people who are homeless, no previous studies have examined how this population understands the role of the ED in their health care and in their day-to-day lives. In the present study, 16 individuals participated in semistructured interviews regarding their ED experiences, and narrative analysis was applied to their responses. Within the context of narratives of disempowerment and discrimination, participants viewed the ED in differing ways, but they generally interpreted it as a public, accessible space where they could exert agency. ED narratives were also paradoxical, depicting it as a fixed place for transient care, or a place where they were isolated yet felt a sense of belonging. Implications for policy and practice are discussed.

Gender differences among Indigenous Canadians experiencing homelessness and mental illness.

BACKGROUND: Indigenous people are over represented among homeless populations worldwide and the prevalence of Indigenous homelessness appears to be increasing in Canadian cities. Violence against Indigenous women in Canada has been widely publicized but has not informed the planning of housing interventions. Despite historical policies leading to disenfranchisement of Indigenous rights in gender-specific ways, little is known about contemporary differences in need between homeless Indigenous men and women. This study investigated mental health, substance use and service use among Indigenous people who met criteria for homelessness and mental illness, and hypothesized that, compared to men, women would have significantly higher rates of trauma, suicidality, substance dependence, and experiences of violence. METHODS: This study was conducted using baseline (pre-randomization) data from a multi-site trial. Inclusion in the current analyses was restricted to participants who self-reported Indigenous ethnicity, and combined eligible participants from Vancouver, BC and Winnipeg, MB. Logistic regression analyses were used to model the independent associations between gender and outcome variables. RESULTS: In multivariable regression models among Indigenous participants (n = 439), female gender was predictive of meeting criteria for PTSD, multiple mental disorders, current high suicidality and current substance dependence. Female gender was also significantly associated with reported physical (AOR: 1.52, 95% CI = 1.10-2.23) and sexual (AOR: 6.31, 95% CI = 2.78-14.31) violence. CONCLUSIONS: Our analyses of Indigenous men and women who are homeless illustrate the distinct legacy of colonization on the experiences of Indigenous women. Our findings are consistent with the widely documented violence against Indigenous women in Canada. Housing policies and services are urgently needed that take Indigenous historical contexts, trauma and gender into account. TRIAL REGISTRATION: This trial has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374 ; ISRCTN57595077 ; ISRCTN66721740 .

The entrepreneurship of survival among urban adults experiencing homelessness and mental illness.

AIMS: Using an entrepreneurship lens, this study examined the narratives of urban adults experiencing homelessness and living with mental illness, to explore strategies used for day-to-day survival. METHODS: Semi-structured qualitative interviews were conducted with 14 females, 30 males, and one individual identifying as "other," living in a mid-sized Canadian city. The average age was 39 years. Data were transcribed verbatim and analyzed using thematic analysis informed by grounded theory. FINDINGS: Participants described creative and intentional strategies for managing life on the street without permanent shelter, including recognition of opportunities, mobilization of their own or acquired resources, and use of social connections and communication skills, and strategies that demonstrated entrepreneurial processes. CONCLUSIONS: Findings suggest that participants used survival entrepreneurship strategies and processes to navigate daily life while experiencing homelessness. Recognition and validation of the propensity for enterprise and self-sufficiency are central for both individual recovery and ending homelessness within similar populations.

Indigenous and non-Indigenous people experiencing homelessness and mental illness in two Canadian cities: A retrospective analysis and implications for culturally informed action.

OBJECTIVES: Indigenous people in Canada are not only over-represented among the homeless population but their pathways to homelessness may differ from those of non-Indigenous people. This study investigated the history and current status of Indigenous and non-Indigenous people experiencing homelessness and mental illness. We hypothesised that compared with non-Indigenous people, those who are Indigenous would demonstrate histories of displacement earlier in life, higher rates of trauma and self-medication with alcohol and other substances. DESIGN AND SETTING: Retrospective data were collected from a sample recruited through referral from diverse social and health agencies in Winnipeg and Vancouver. PARTICIPANTS: Eligibility included being 19 years or older, current mental disorder and homelessness. MEASURES: Data were collected via interviews, using questionnaires, on sociodemographics (eg, age, ethnicity, education), mental illness, substance use, physical health, service use and quality of life. Univariate and multivariable models were used to model the association between Indigenous ethnicity and dependent variables. RESULTS: A total of 1010 people met the inclusion criteria, of whom 439 self-identified as Indigenous. In adjusted models, Indigenous ethnicity was independently associated with being homeless at a younger age, having a lifetime duration of homelessness longer than 3 years, post-traumatic stress disorder, less severe mental disorder, alcohol dependence, more severe substance use in the past month and infectious disease. Indigenous participants were also nearly twice as likely as others (47% vs 25%) to have children younger than 18 years. CONCLUSIONS: Among Canadians who are homeless and mentally ill, those who are Indigenous have distinct histories and current needs that are consistent with the legacy of colonisation. Responses to Indigenous homelessness must be developed within the context of reconciliation between Indigenous and non-Indigenous Canadians, addressing trauma, substance use and family separations. TRIAL REGISTRATION NUMBER: ISRCTN42520374, ISRCTN57595077, ISRCTN66721740.

Knowledge translation and implementation of housing first in Canada: A qualitative assessment of capacity building needs for an evidence-based program.

We examined communities' expressed needs for capacity building in the implementation of Housing First (HF) for persons experiencing homelessness. The findings are based on thematic analyses of qualitative data obtained from participants (n = 77) in 11 focus groups conducted in seven Canadian cities. We identified capacity building needs in the areas of training (e.g., HF principles, clinical services, landlord engagement) and technical assistance (e.g., intake coordination, client prioritization, fidelity assessment). These findings were used to tailor training and technical assessment (TTA) to the stages of HF implementation in these cities. Limitations and implications for future theory, research, and practice are discussed.

Predictors of Mental Health Recovery in Homeless Adults with Mental Illness.

For people with mental illness, experiences of homelessness can complicate mental health recovery processes. This study used longitudinal data from a randomized controlled trial of housing first (HF) to examine predictors of recovery among homeless people with mental illness. Findings showed that health and community predictors were most strongly associated with mental health recovery. Receipt of HF did not have any effect on changes in recovery scores at follow-up. Overall, the findings suggest that interventions aimed at preventing chronic homelessness, strengthening social networks and community involvement, and providing case management services will facilitate mental health recovery.

Public housing and healthcare use: an investigation using linked administrative data.

OBJECTIVE: This study investigated whether a move to public housing affects people's use of healthcare services. METHOD: Using administrative data from Manitoba, the number of hospitalizations, general practitioner (GP), specialist and emergency department (ED) visits, and prescription drugs dispensed in the years before and after the housing move-in date (2012/2013) were measured for a public housing and matched cohort. Generalized linear models with generalized estimating equations tested for differences between the cohorts in utilization trends. The data were modeled using Poisson (rate ratio, RR), negative binomial (incident rate ratio, IRR), and binomial (odds ratio, OR) distributions. RESULTS: GP visits (IRR = 1.04, 95% CI 1.01-1.06) and prescriptions (IRR = 1.04, 95% CI 1.02-1.05) increased, while ED visits (RR = 0.90, 95% CI 0.82-1.00) and hospitalizations (OR = 0.95, 95% CI 0.93-0.96) decreased over time. The public housing cohort had a significantly higher rate of GP visits (IRR = 1.08, 95% CI 1.04-1.13), ED visits (RR = 1.18, 95% CI 1.01-1.37), and prescriptions (IRR = 1.09, 95% CI 1.05-1.13), and was more likely to be hospitalized (OR = 1.39, 95% CI 1.21-1.61) compared to the matched cohort. The rate of inpatient days significantly decreased for the public housing cohort, but did not change for the matched cohort. CONCLUSION: Healthcare use changed similarly over time (except inpatient days) for the two cohorts. Public housing provides a basic need to a population who has a high burden of disease and who may not be able to obtain and maintain housing in the private market.

Systems change in the context of an initiative to scale up Housing First in Canada.

In this study, we examine changes in the homeless-serving system in the context of a training and technical assistance initiative to scale up Housing First (HF) in 6 Canadian communities. Based on qualitative data from focus groups and individual interviews with key stakeholders (k = 7, n = 35) and field notes gathered over a 3-year period (n = 146), we found 2 main system changes: (a) changes in the capacity of the service delivery system at multiple levels of analysis (from individual to policy) to implement HF, and (b) changes in the coordination of parts of the service delivery system and collaboration among local stakeholders to enhance HF implementation. These changes were facilitated or constrained by the larger context of evidence, climate, policy, and funding. The findings were discussed in terms of systems change theory and implications for transformative systems change in the mental health and homelessness sectors.

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.

Changes in healthcare use among individuals who move into public housing: a population-based investigation.

BACKGROUND: Residence in public housing, a subsidized and managed government program, may affect health and healthcare utilization. We compared healthcare use in the year before individuals moved into public housing with usage during their first year of tenancy. We also described trends in use. METHODS: We used linked population-based administrative data housed in the Population Research Data Repository at the Manitoba Centre for Health Policy. The cohort consisted of individuals who moved into public housing in 2009 and 2010. We counted the number of hospitalizations, general practitioner (GP) visits, specialist visits, emergency department visits, and prescriptions drugs dispensed in the twelve 30-day intervals (i.e., months) immediately preceding and following the public housing move-in date. Generalized linear models with generalized estimating equations tested for a period (pre/post-move-in) by month interaction. Odds ratios (ORs), incident rate ratios (IRRs), and means are reported along with 95% confidence intervals (95% CIs). RESULTS: The cohort included 1942 individuals; the majority were female (73.4%) who lived in low income areas and received government assistance (68.1%). On average, the cohort had more than four health conditions. Over the 24 30-day intervals, the percentage of the cohort that visited a GP, specialist, and an emergency department ranged between 37.0% and 43.0%, 10.0% and 14.0%, and 6.0% and 10.0%, respectively, while the percentage of the cohort hospitalized ranged from 1.0% to 5.0%. Generally, these percentages were highest in the few months before the move-in date and lowest in the few months after the move-in date. The period by month interaction was statistically significant for hospitalizations, GP visits, and prescription drug use. The average change in the odds, rate, or mean was smaller in the post-move-in period than in the pre-move-in period. CONCLUSIONS: Use of some healthcare services declined after people moved into public housing; however, the decrease was only observed in the first few months and utilization rebounded. Knowledge of healthcare trends before individuals move in are informative for ensuring the appropriate supports are available to new public housing residents. Further study is needed to determine if decreased healthcare utilization following a move is attributable to decreased access.

The effects of housing stability on service use among homeless adults with mental illness in a randomized controlled trial of housing first.

BACKGROUND: Housing First is an effective intervention to stably house and alter service use patterns in a large proportion of homeless people with mental illness. However, it is unknown whether there are differences in the patterns of service use over time among those who do or do not become stably housed and what effect, if any, Housing First has on these differing service use patterns. This study explored changes in the service use of people with mental illness who received Housing First compared to standard care, and how patterns of use differed among people who did and did not become stably housed. METHODS: The study design was a multi-site randomized controlled trial of Housing First, a supported housing intervention. 2039 participants (Housing First: n = 1131; standard care: n = 908) were included in this study. Outcome variables include nine types of self-reported service use over 24 months. Linear mixed models examined what effects the intervention and housing stability had on service use. RESULTS: Participants who achieved housing stability, across the two groups, had decreased use of inpatient psychiatric hospitals and increased use of food banks. Within the Housing First group, unstably housed participants spent more time in prison over the study period. The Housing First and standard care groups both had decreased use of emergency departments and homeless shelters. CONCLUSIONS: The temporal service use changes that occurred as homeless people with mental illness became stably housed are similar for those receiving Housing First or standard care, with the exception of time in prison. Service use patterns, particularly with regard to psychiatric hospitalizations and time in prison, may signify persons who are at-risk of recurrent homelessness. Housing support teams should be alert to the impacts of stay-based services, such as hospitalizations and incarcerations, on housing stability and offer an increased level of support to tenants during critical periods, such as discharges. TRIAL REGISTRATION: ISRCTN. ISRCTN42520374 . Registered 18 August 2009.

Understanding Systems Change in Early Implementation of Housing First in Canadian Communities: An Examination of Facilitators/Barriers, Training/Technical Assistance, and Points of Leverage.

We present interim findings of a cross-site case study of an initiative to expand Housing First (HF) in Canada through training and technical assistance (TTA). HF is an evidence-based practice designed to end chronic homelessness for consumers of mental health services. We draw upon concepts from implementation science and systems change theory to examine how early implementation occurs within a system. Case studies examining HF early implementation were conducted in six Canadian communities receiving HF TTA. The primary data are field notes gathered over 1.5 years and evaluations from site-specific training events (k = 5, n = 302) and regional network training events (k = 4, n = 276). We report findings related to: (a) the facilitators of and barriers to early implementation, (b) the influence of TTA on early implementation, and (c) the "levers" used to facilitate broader systems change. Systems change theory enabled us to understand how various "levers" created opportunities for change within the communities, including establishing system boundaries, understanding how systems components can function as causes of or solutions to a problem, and assessing and changing systems interactions. We conclude by arguing that systems theory adds value to existing implementation science frameworks and can be helpful in future research on the implementation of evidence-based practices such as HF which is a complex community intervention. Implications for community psychology are discussed.