Barriers and facilitators of implementing a multicomponent intervention to improve faecal immunochemical test (FIT) colorectal cancer screening in primary care clinics, Alberta.

BACKGROUND AND OBJECTIVE: Colorectal cancer (CRC) screening is effective at reducing the incidence and mortality of CRC. To address suboptimal CRC screening rates, a faecal immunochemical test (FIT) multicomponent intervention was piloted in four urban multidisciplinary primary care clinics in Alberta from September 2021 to April 2022. The interventions included in-clinic distribution of FIT kits, along with FIT-related patient education and follow-up. This study explored barriers and facilitators to implementing the intervention in four primary clinics using the Consolidated Framework for Implementation Research (CFIR). METHODS: In-depth qualitative semistructured key informant interviews, guided by the CFIR, were conducted with 14 participants to understand barriers and facilitators of the FIT intervention implementation. Key informants were physicians, quality improvement facilitators and clinical staff. Interviews were analysed following an inductive-deductive approach. Implementation barriers and facilitators were organised and interpreted using the CFIR to facilitate the identification of strategies to mitigate barriers and leverage facilitators for implementation at the clinic level. RESULTS: Key implementation facilitators reported by participants were patient perceived needs being met; the clinics' readiness to implement FIT, including staff's motivation, skills, knowledge, and resources to implement; intervention characteristics-evidence-based, adaptable and compatible with existing workflows; regular staff communications; and use of the electronic medical record (EMR) system. Key barriers to implementation were patient's limited awareness of FIT screening for CRC and discomfort with stool sample collection; the impacts of COVID-19 (patients missed appointment, staff coordination and communication were limited due to remote work); and limited clinic capacity (knowledge and skills using EMR system, staff turnover and shortage). CONCLUSION: Findings from the study facilitate the refinement and adaption of future FIT intervention implementation. Future research will explore implementation barriers and facilitators in rural settings and from patients' perspectives to enhance the spread and scale of the intervention.

Computer-Based Training for Cognitive Behavioural Therapy for Substance Use Disorder: A Randomized Controlled Trial Including Quantitative and Qualitative Health and Economic Outcomes: Formation informatisée pour la thérapie cognitivo-comportementale pour les troubles liés à l'usage de substances : un essai randomisé contrôlé y compris les résultats quantitatifs et qualitatifs en matière de santé et d'économie.

OBJECTIVES: Heavy alcohol and drug use is reported by a substantial number of Canadians; yet, only a minority of those experiencing substance use difficulties access specialized services. Computer-Based Training for Cognitive Behavioural Therapy (CBT4CBT) offers a low-cost method to deliver accessible and high-quality CBT for substance use difficulties. To date, CBT4CBT has primarily been evaluated in terms of quantitative outcomes within substance use disorder (SUD) samples in the United States. A comparison between CBT4CBT versus standard care for SUDs in a Canadian sample is critical to evaluate its potential for health services in Canada. We conducted a randomized controlled trial of CBT4CBT versus standard care for SUD. METHODS: Adults seeking outpatient treatment for SUD (N = 50) were randomly assigned to receive either CBT4CBT or treatment-as-usual (TAU) for 8 weeks. Measures of substance use and associated harms and quality of life were completed before and after treatment and at 6-month follow-up. Qualitative interviews were administered after treatment and at follow-up, and healthcare utilization and costs were extracted for the entire study period. RESULTS: Participants exhibited improvements on the primary outcome as well as several secondary outcomes; however, there were no differences between groups. A cost-effectiveness analysis found lower healthcare costs in CBT4CBT versus TAU in a subsample analysis, but more days of substance use in CBT4CBT. Qualitative analyses highlighted the benefits and challenges of CBT4CBT. DISCUSSION: Findings supported an overall improvement in clinical outcomes. Further investigation is warranted to identify opportunities for implementation of CBT4CBT in tertiary care settings.Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03767907.

Evaluating a digital intervention targeting substance use difficultiesPlain Language SummaryWhy was the study done?Heavy alcohol and drug use is frequent in the Canadian population, although very few people have access to treatment. The digital intervention, Computer-Based Training for Cognitive Behavioural Therapy (CBT4CBT), may provide a low-cost, high-quality, and easily accessible method of treatment for substance use difficulties. Limited research on this digital intervention has been conducted in Canadian populations, and few studies thus far have evaluated participants' subjective experience using the intervention, along with the cost on the Canadian healthcare system.What did the researchers do?The research team recruited participants and provided access to either CBT4CBT or to standard care at a mental health hospital for 8 weeks. Participants were asked questions about their substance use and related consequences, quality of life, and thoughts on the treatment they received. Information regarding healthcare use and the cost to the healthcare system was also gathered.What did the researchers find?Participants in both groups improved with regards to their substance use, some related consequences, and psychological quality of life. Participants provided insight on the benefits and challenges of both types of treatment. It was also found that the CBT4CBT intervention was less costly.What do these findings mean?These findings support that adults receiving CBT4CBT and standard care both improved to a similar degree in this sample. Participant feedback may inform future studies of how best to implement this intervention in clinical studies. Future studies with larger samples are needed to further examine whether CBT4CBT can increase access to supports and be beneficial in the Canadian healthcare system.

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).

The association between the built environment and intervention-facilitated physical activity: a narrative systematic review.

BACKGROUND: A diverse range of interventions increase physical activity (PA) but few studies have explored the contextual factors that may be associated with intervention effectiveness. The built environment (BE) may enhance or reduce the effectiveness of PA interventions, especially interventions that encourage PA in neighbourhood settings. Several studies have investigated the effects of the neighbourhood BE on intervention-facilitated PA, however, a comprehensive review of evidence has yet to be conducted. In our systematic review, we synthesize evidence from quantitative studies that have examined the relationships between objectively-measured neighbourhood BE and intervention-facilitated PA in adults. METHOD: In October 2021, we searched 7 databases (Medline, CINAHL, Embase, Web of Science, SPORTDiscus, Environment Complete, and Cochrane Central Register of Controlled Trials) for English-language studies reporting on randomized and non-randomized experiments of physical activity interventions involving adults (≥18 years) and that estimated the association between objectively-measured BE and intervention-facilitated physical activity. RESULTS: Twenty articles, published between 2009 and 2021, were eligible for inclusion in the review. Among the 20 articles in this review, 13 included multi-arm experiments and 7 included single-arm experiments. Three studies examined PA interventions delivered at the population level and 17 examined interventions delivered at the individual level. PA intervention characteristics were heterogeneous and one-half of the interventions were implemented for at least 12-months (n = 10). Most studies were undertaken in North America (n = 11) and most studies (n = 14) included samples from populations identified as at risk of poor health (i.e., metabolic disorders, coronary heart disease, overweight, cancer, high blood pressure, and inactivity). Fourteen studies found evidence of a neighbourhood BE variable being negatively or positively associated with intervention-facilitated PA. CONCLUSION: Approximately 70% of all studies reviewed found evidence for an association between a BE variable and intervention-facilitated PA. The BE's potential to enhance or constrain the effectiveness of PA interventions should be considered in their design and implementation.

Social Support and Body Image in Group Physical Activity Programs for Older Women.

Physical declines with aging may negatively impact women's body image. Group physical activity can be a source of social support that may improve body image. We examined how social support experienced in group physical activity programs impacts older women's body image. Guided by interpretive description, we interviewed 14 women age 65 years and older who participated in group physical activity classes. Although women experienced both positive and negative body image, body image was generally positively impacted by physical activity. Four themes described social support processes that affected body image in the physical activity context: fitting in and being inspired through identifying with others; what is discussed and not discussed; providing comfort, understanding, and acceptance; and skilled and empathetic interactions with instructors. Understanding how social support in group physical activity can promote positive body image throughout aging can inform practical guidelines for facilitating and improving support in this context.

Updates in the treatment of gonococcal infections.

ABSTRACT: This article highlights important changes in treatment of gonococcal infections secondary to rising infection rates, as well as increased drug-resistance to previous therapy recommendations. The article is intended to assist clinicians in both the ambulatory as well as inpatient setting when treating patients with sexually transmitted infections.

Crystal structure of a human MUC16 SEA domain reveals insight into the nature of the CA125 tumor marker.

MUC16 is a membrane bound glycoprotein involved in the progression and metastasis of pancreatic and ovarian cancer. The protein is shed into the serum and the resulting cancer antigen 125 (CA125) can be detected by immunoassays. The CA125 epitope is used for monitoring ovarian cancer treatment progression, and has emerged as a potential target for antibody mediated immunotherapy. The extracellular tandem repeat domain of the protein is composed of repeating segments of heavily glycosylated sequence intermixed with homologous SEA (Sperm protein, Enterokinase and Agrin) domains. Here we report the purification and the first X-ray structure of a human MUC16 SEA domain. The structure was solved by molecular replacement using a Rosetta generated structure as a search model. The SEA domain reacted with three different MUC16 therapeutic antibodies, confirming that the CA125 epitope is localized to the SEA domain. The structure revealed a canonical ferredoxin-like fold, and contained a conserved disulfide bond. Analysis of the relative solvent accessibility of side chains within the SEA domain clarified the assignment of N-linked and O-linked glycosylation sites within the domain. A model of the glycosylated SEA domain revealed two major accessible faces, which likely represent the binding sites of CA125 specific antibodies. The results presented here will serve to accelerate future work to understand the functional role of MUC16 SEA domains and antibody recognition of the CA125 epitope.

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.

Consequences of the vaping epidemic on adolescents.

The prevalence of vaping has seen a dramatic increase in the last decade, especially among adolescent populations. This article discusses the background, prevalence, and associated risk factors of e-cigarettes.

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 .

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.

The difference is more than floating: factors affecting breast cancer survivors' decisions to join and maintain participation in dragon boat teams and support groups.

Purpose: Peer support can be helpful in rehabilitation from breast cancer, but participation in peer support groups is low. Groups that provide support opportunities in physical activity contexts are an attractive alternative for some survivors. This study examined survivors' reasons for joining and maintaining participation on a dragon boat team, along with perceptions of barriers and attractions to traditional peer support groups. Materials and methods: Seventeen breast cancer survivors were interviewed on five occasions over their first two seasons of a newly formed dragon boating team to explore their perceptions of peer support groups and dragon boating. Data were inductively analyzed using thematic analysis. Results: Categories surrounding physical, psychological, social and community features were identified with several themes emerging within each. Advantages of dragon boating included opportunities to get a combination of physical, psychosocial and community benefits; health improvement and behavior change; and obtaining social support without the focus being on cancer. Peer support groups were identified as having advantages for forming relationships and avoiding barriers associated with physical activity. Conclusions: While neither type of program meets all needs, practical considerations are identified for incorporating advantages of both programs to improve participation. Implications for rehabilitation Further understanding of perceptions, and attractions and challenges to taking part in group programs will inform development of accessible programs that target multiple rehabilitation needs. Physical activity can provide a positive, alternative focus that takes the emphasis off of cancer, which is more accessible to some survivors. Physical activity also provides opportunities to build relationships around a common, positive goal, which can be a foundation for providing support for coping with cancer.

Continuity of Care among People Experiencing Homelessness and Mental Illness: Does Community Follow-up Reduce Rehospitalization?

OBJECTIVE: To examine whether timely outpatient follow-up after hospital discharge reduces the risk of subsequent rehospitalization among people experiencing homelessness and mental illness. DATA SOURCES: Comprehensive linked administrative data including hospital admissions, laboratory services, and community medical services. STUDY DESIGN: Participants were recruited to the Vancouver At Home study based on a-priori criteria for homelessness and mental illness (n = 497). Logistic regression analysis was used to assess the relationship between outpatient care within 7 days postdischarge and subsequent rehospitalization over a 1-year period. DATA EXTRACTION: Data were extracted for a consenting subsample of participants (n = 433) spanning 5 years prior to study enrollment. PRINCIPAL FINDINGS: More than half of the eligible sample (53 percent; n = 128) were rehospitalized within 1 year following an index hospital discharge. Neither outpatient medical services nor laboratory services within 7 days following discharge were associated with a significantly reduced likelihood of rehospitalization within 2 months (AOR = 1.17 [CI = 0.94, 1.46]), 6 months (AOR = 1.00 [CI = 0.82, 1.23]) or 12 months (AOR = 1.24 [CI = 1.02, 1.52]). CONCLUSIONS: In contrast to evidence from nonhomeless samples, we found no association between timely outpatient follow-up and the likelihood of rehospitalization in our homeless, mentally ill cohort. Our findings indicate a need to address housing as an essential component of discharge planning alongside outpatient care.

Associations between methadone maintenance treatment and crime: a 17-year longitudinal cohort study of Canadian provincial offenders.

AIMS: To estimate and test the difference in rates of violent and non-violent crime during medicated and non-medicated methadone treatment episodes. DESIGN, SETTING AND PARTICIPANTS: The study involved linkage of population level administrative data (health and justice) for all individuals (n = 14 530) in British Columbia, Canada with a history of conviction and who filled a methadone prescription between 1 January 1998 and 31 March 2015. Methadone maintenance treatment was the primary independent variable and was treated as a time-varying exposure. Each participant's follow-up (mean: 8 years) was divided into medicated (methadone was dispensed) and non-medicated (methadone was not dispensed) periods with mean durations of 3.3 and 4.6 years, respectively. MEASUREMENTS: Socio-demographics of participants were examined along with the main outcomes of violent and non-violent offences. FINDINGS: During the first 2 years of treatment (≤ 2.0 years), periods in which methadone was dispensed were associated with a 33% lower rate of violent crime [0.67 adjusted hazard ratio (AHR), 95% confidence intervals (CI) = 0.59, 0.76] and a 35% lower rate of non-violent crime (0.65 AHR, 95% CI = 0.62, 0.69) compared with non-medicated periods. This equates to a risk difference of 3.6 (95% CI = 2.6, 4.4) and 37.2 (95% CI = 33.0, 40.4) fewer violent and non-violent offences per 100 person-years, respectively. Significant but smaller protective effects of dispensed methadone were observed across longer treatment intervals (2.0 to ≤ 5.0 years, 5.0 to ≤ 10.0 years). CONCLUSIONS: Among a cohort of Canadian offenders, rates of violent and non-violent offending were lower during periods when individuals were dispensed methadone compared with periods in which they were not dispensed methadone.

Effects of comorbid substance use disorders on outcomes in a Housing First intervention for homeless people with mental illness.

BACKGROUND AND AIMS: Evidence supports the effectiveness of Housing First (HF) programmes for people who are experiencing homelessness and mental illness; however, questions remain about its use in people with comorbid substance use disorders (SUD). The aim of this project was to test whether SUD modifies the effectiveness of an HF intervention. DESIGN: Secondary analysis of data from a randomized controlled trial of HF versus treatment-as-usual (TAU) with 24-month follow-up, comparing those with and without SUD at trial entry. SETTING: Vancouver, Toronto, Winnipeg, Moncton and Montreal, Canada. PARTICIPANTS: A total of 2154 participants recruited from 2009 to 2013 and randomized to HF versus TAU (67% male, mean age 40.8 ± 11.2, 25% ethno-cultural minority). All were homeless and had a mental disorder at baseline; 35% reported symptoms consistent with SUD. INTERVENTION: Housing paired with Intensive Case Management or Assertive Community Treatment. MEASUREMENTS: Primary outcomes were days housed and community functioning. Secondary outcomes were general and health-related quality of life and mental health symptoms. Predictors were SUD status crossed with intervention group (HF versus TAU). FINDINGS: People with SUD in both the HF and TAU groups spent less time in stable housing, but the effect of HF did not vary by SUD status [odds ratio (OR) = 1.17, 95% confidence interval (CI) = -0.77, 1.76]. Similarly, there was no difference between those with and without SUD in the effect of HF (over TAU) on community functioning (b = 0.75, 95% CI = -0.36, 1.87), quality of life (b = -1.27, 95% CI = -4.17, 1.63), health-related quality of life (b = -0.01, 95% CI = -0.03, 0.02) or mental health symptoms (b = 0.43, 95% CI = -0.99, 1.86). CONCLUSIONS: Housing First programs in Canada are equally effective in people with and without comorbid substance use disorder (SUD). Overall, the intervention appears to be able to engage people with SUD and is reasonably successful at housing them, without housing being contingent upon abstinence or treatment.

Adverse Childhood Experiences and the Risk of Criminal Justice Involvement and Victimization Among Homeless Adults With Mental Illness.

OBJECTIVE: Exposure to adverse childhood experiences (ACEs) is highly prevalent among homeless individuals and is associated with negative consequences during homelessness. This study examined the effect of ACEs on the risk of criminal justice involvement and victimization among homeless individuals with mental illness. METHODS: The study used baseline data from a demonstration project (At Home/Chez Soi) that provided Housing First and recovery-oriented services to homeless adults with mental illness. The sample was recruited from five Canadian cities and included participants who provided valid responses on an ACEs questionnaire (N=1,888). RESULTS: Fifty percent reported more than four types of ACE, 19% reported three or four types, 19% reported one or two, and 12% reported none. Rates of criminal justice involvement and victimization were significantly higher among those with a history of ACEs. For victimization, the association was significant for all ten types of ACE, and for justice involvement, it was significant for seven types. Logistic regression models indicated that the effect of cumulative childhood adversity on the two outcomes was significant regardless of sociodemographic factors, duration of homelessness, and psychiatric diagnosis, with one exception: the relationship between cumulative childhood adversity and criminal justice involvement did not remain significant when the analysis controlled for a diagnosis of posttraumatic stress disorder and substance dependence. CONCLUSIONS: Findings support the need for early interventions for at-risk youths and trauma-informed practice and violence prevention policies that specifically target homeless populations.

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 2 years 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.

A Randomized Trial Examining Housing First in Congregate and Scattered Site Formats.

OBJECTIVE: No previous experimental trials have investigated Housing First (HF) in both scattered site (SHF) and congregate (CHF) formats. We hypothesized that CHF and SHF would be associated with a greater percentage of time stably housed as well as superior health and psychosocial outcomes over 24 months compared to treatment as usual (TAU). METHODS: Inclusion criteria were homelessness, mental illness, and high need for support. Participants were randomised to SHF, CHF, or TAU. SHF consisted of market rental apartments with support provided by Assertive Community Treatment (ACT). CHF consisted of a single building with supports equivalent to ACT. TAU included existing services and supports. RESULTS: Of 800 people screened, 297 were randomly assigned to CHF (107), SHF (90), or TAU (100). The percentage of time in stable housing over 24 months was 26.3% in TAU (reference; 95% confidence interval (CI) = 20.5, 32.0), compared to 74.3% in CHF (95% CI = 69.3, 79.3, p<0.001) and 74.5% in SHF (95% CI = 69.2, 79.7, p<0.001). Secondary outcomes favoured CHF but not SHF compared to TAU. CONCLUSION: HF in scattered and congregate formats is capable of achieving housing stability among people experiencing major mental illness and chronic homelessness. Only CHF was associated with improvement on select secondary outcomes. REGISTRATION: Current Controlled Trials: ISRCTN57595077.

Recruitment and retention of homeless individuals with mental illness in a housing first intervention study.

BACKGROUND: Homeless individuals with mental illness are challenging to recruit and retain in longitudinal research studies. The present study uses information from the Vancouver site of a Canadian multi-city longitudinal randomized controlled trial on housing first interventions for homeless individuals. We were able to recruit 500 participants and retain large number of homeless individuals with mental illness; 92% of the participants completed the 6-month follow up interview, 84% the 24-month follow up, while 80% completed all follow-up visits of the study. PURPOSE: In this article, we describe the strategies and practices that we considered as critical for successful recruitment and retention or participants in the study. METHODS: We discuss issues pertaining to research staff hiring and training, involvement of peers, relationship building with research participants, and the use of technology and social media, and managing challenging situations in the context of recruitment and retention of marginalized individuals. CONCLUSIONS: Recruitment and retention of homeless participant with mental illness in longitudinal studies is feasible. It requires flexible, unconventional and culturally competent strategies. Longitudinal research projects with vulnerable and hidden populations may benefit from extensive outreach work and collaborative approaches that are based on attitudes of mutual respect, contextual knowledge and trust.

Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First.

PURPOSE: Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF. METHODS: Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model. RESULTS: In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not. CONCLUSION: While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset.