A mixed methods randomised control trial to evaluate the effectiveness of the journey to social inclusion - phase 2 intervention for chronically homeless adults: study protocol.

BACKGROUND: Chronic homelessness is a problem characterised by longstanding inability to attain or maintain secure accommodation. Longitudinal research with homeless populations is challenging, and randomised controlled trials that evaluate the effectiveness of intensive, case management interventions aimed at improving housing and health-related outcomes for chronically homelessness people are scant. More research is needed to inform programmatic design and policy frameworks in this area. This study protocol details an evaluation of the Journey to Social Inclusion - Phase 2 program, an intervention designed to reduce homelessness and improve outcomes in chronically homeless adults. METHODS/DESIGN: J2SI Phase 2 is a three-year, mixed methods, multi-site, RCT that enrolled 186 participants aged 25 to 50 years between 07 January 2016 and 30 September 2016 in Melbourne. The intervention group (n = 90 recruited) receives the J2SI Phase 2 program, a trauma-informed intervention that integrates intensive case management and service coordination; transition to housing and support to sustain tenancy; and support to build social connections, obtain employment and foster independence. The comparison group (n = 96 recruited) receives standard service provision. Prior to randomisation, participants completed a baseline survey. Follow-up surveys will be completed every six months for three years (six in total). In addition to self-report data on history of homelessness and housing, physical and mental health, substance use, quality of life, social connectedness and public service utilisation, linked administrative data on participants' public services utilisation (e.g., hospitalisation, justice system) will be obtained for the three-year period pre- and post-randomisation. Semi-structured, qualitative interviews will be conducted with a randomly selected subset of participants and service providers at three time-points to explore changes in key outcome variables and to examine individual experiences with the intervention and standard service provision. An economic evaluation of the intervention and associated costs will also be undertaken. DISCUSSION: Results of this trial will provide robust evidence on the effectiveness of J2SI Phase 2 compared to standard service provision. If the intervention demonstrates effectiveness in improving housing, health, quality-of-life, and other social outcomes, it may be considered for broader national and international dissemination to improve outcomes among chronically homeless adults. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000162415 (retrospectively registered 10-February-2016).

A place to call home: study protocol for a longitudinal, mixed methods evaluation of two housing first adaptations in Sydney, Australia.

BACKGROUND: This protocol describes a study evaluating two 'Housing First' programs, Platform 70 and Common Ground, presently being implemented in the inner-city region of Sydney, Australia. The Housing First approach prioritises housing individuals who are homeless in standard lease agreement tenancies as rapidly as possible to lock in the benefits from long-term accommodation, even where the person may not be seen as 'housing ready'. METHODS/DESIGN: The longitudinal, mixed methods evaluation utilises both quantitative and qualitative data collected at baseline and 12-month follow-up time points. For the quantitative component, clients of each program were invited to complete client surveys that reported on several factors associated with chronic homelessness and were hypothesised to improve under stable housing, including physical and mental health status and treatment rates, quality of life, substance use patterns, and contact with the health and criminal justice systems. Semi-structured interviews with clients and stakeholders comprised the qualitative component and focused on individual experiences with, and perceptions of, the two programs. In addition, program data on housing stability, rental subsidies and support levels provided to clients by agencies was collected and will be used in conjunction with the client survey data to undertake an economic evaluation of the two programs. DISCUSSION: This study will systematically evaluate the efficacy of a scatter site model (Platform 70) and a congregated model (Common Ground) of the Housing First approach; an examination that has not yet been made either in Australia or internationally. A clear strength of the study is its timing. It was designed and implemented as the programs in question themselves were introduced. Moreover, the programs were introduced when the Australian Government, with State and Territory support, began a more focused, coordinated response to homelessness and funded rapid expansion of innovative homelessness programs across the country, including Common Ground supportive housing developments.

Mental illness and housing outcomes among a sample of homeless men in an Australian urban centre.

OBJECTIVE: The over-representation of mental illness among homeless people across the globe is well documented. However, there is a dearth of Australian literature on the mental health needs of homeless individuals. Furthermore, longitudinal research examining the factors that contribute to better housing outcomes among this population is sparse. The aim of this research is to describe the mental illness profile of a sample of homeless men in an Australian urban centre (in Sydney) and examine the factors associated with better housing outcomes at 12-month follow-up. METHODS: A longitudinal survey was administered to 253 homeless men who were involved in the Michael Project: a 3-year initiative which combined existing accommodation support services with assertive case management and access to coordinated additional specialist allied health and support services. A total of 107 participants were followed up 12 months later. The survey examined the demographics of the sample and lifetime mental disorder diagnoses, and also included psychological screeners for current substance use and dependence, psychological distress, psychosis, and post-traumatic stress. RESULTS: Consistent with existing literature, the prevalence of mental illness was significantly greater amongst this sample than the general Australian population. However, mental illness presentation was not associated with housing situation at 12-month follow-up. Instead, type of support service at baseline was the best predictor of housing outcome, wherein participants who received short to medium-term accommodation and support were significantly more likely to be housed in stable, long-term housing at the 12-month follow-up than participants who received outreach or emergency accommodation support. CONCLUSIONS: This study provides evidence to support an innovative support model for homeless people in Australia and contributes to the limited Australian research on mental illness in this population.

Substance use and posttraumatic stress disorder: 12-month outcomes among adults experiencing chronic homelessness in Australia.

INTRODUCTION: Substance use disorder and posttraumatic stress disorder (PTSD) are highly prevalent among individuals who experience homelessness. However, evaluations of interventions that combine housing and mental health services have reported inconsistent mental health and substance use outcomes when compared to usual services. We investigated 12-month change in substance use severity and PTSD symptom severity among adults experiencing chronic homelessness and tested whether observed differences were associated with housing, support from mental health services or the Journey to Social Inclusion (J2SI) program. METHODS: A randomised controlled trial compared the J2SI program with standard service provision (N = 135). Secondary analyses compared those who obtained housing or received mental health services with those who did not. Primary outcomes were alcohol and illicit substance use severity (alcohol, smoking and substance involvement screening test) and PTSD symptom severity (six-item PTSD checklist). RESULTS: There was significant improvement at 12 months in alcohol use severity, illicit substance use severity and PTSD symptoms in the overall sample. Having seen a mental health professional in the previous 12 months was associated with a significant reduction in alcohol and illicit substance use severity but was not associated with changes in PTSD symptom severity. Being housed at 12 months was associated with significantly higher alcohol use severity. DISCUSSION AND CONCLUSIONS: Findings highlight the importance of access to mental health care for people with a history of chronic homelessness. Research is needed to develop and test therapeutic and housing approaches to reduce PTSD symptom severity among people with experience of homelessness.

Women sleeping rough: The health, social and economic costs of homelessness.

This study seeks to assess the health, social and economic outcomes associated with rough sleeping among women and compare those outcomes with those of (1) men sleeping rough, and (2) women experiencing other forms of homelessness (such as being housed in temporary supported accommodation due to family and domestic violence). The paper analyses survey data using the Vulnerability Index-Service Prioritization Decision Analysis Tool (VI-SPDAT) collected from 2735 women experiencing homelessness and 3124 men sleeping rough in Australian cities from 2010 to 2017. We find that women sleeping rough report poorer physical and mental health outcomes and greater problematic drug and or alcohol use relative to both men sleeping rough and women experiencing other types of homelessness (all p < 0.5). Women sleeping rough report significantly higher levels of crisis service utilisation (Β = 17.9, SE = 3.9, p < 0.001) and interactions with police in the previous 6 months (Β = 1.9, SE = 0.3, p < 0.001) than women experiencing homelessness not sleeping rough. Women sleeping rough also report greater healthcare utilisation, and, therefore, healthcare costs, than women experiencing homelessness not sleeping rough and men sleeping rough (all p < 0.05). From a policy perspective, the evidence presented in this paper supports a social determinants approach that moves from addressing symptoms of poor health outcomes associated with homelessness to preventing and ending homelessness with a particular focus on the life trajectories of women. Integrated services and homelessness strategies need to be developed through a gender lens, providing women sleeping rough with tailored permanent housing with wrap-around supportive housing to address poor health outcomes.

Out of the trenches; prevalence of Australian veterans among the homeless population and the implications for public health.

OBJECTIVES: To examine the prevalence of Australian Defence Force veterans among people sleeping rough and explore their health and social needs relative to non-veteran rough sleepers. METHOD: Analysis of responses to the Vulnerability Index - Service Prioritisation Decision Assistance Tool (VI-SPDAT) collected from 8,027 rough sleepers across five Australian States from 2010-2017. RESULTS: Veterans were found to comprise 5.6% of people sleeping rough in Australia, with veterans reporting having spent an average of 6.3 years on the street or in emergency accommodation (compared with an average of five years for their non-veterans counterparts). Veterans had a higher prevalence of self-reported physical health, mental health and social issues compared with non-veteran rough sleepers. CONCLUSIONS: This is the first study of its kind to elucidate the presence of Australian veterans among people sleeping rough. That they are likely to have spent more years on the street, and have a higher prevalence of health and social issues, highlights the imperative for earlier intervention and prevention of veteran homelessness itself, and its health impacts. IMPLICATIONS FOR PUBLIC HEALTH: Veteran homelessness has been comparatively hidden in Australia compared to other countries, and consequently the myriad of health, psychosocial and adjustment issues faced by homeless veterans has also been hidden. With heightened attention on veteran suicide and self-harm, earlier intervention to prevent veterans becoming homeless constitutes sound public health prevention and mental health policy.

Perspectives of socioeconomically disadvantaged parents on their children's coping during COVID-19: Implications for practice.

Disruptions caused by COVID-19 have the potential to create long-term negative impacts on children's well-being and development, especially among socioeconomically disadvantaged children. However, we know little about how socioeconomically disadvantaged families are coping with the pandemic, nor the types of support needed. This study presents qualitative analysis of responses to an open-ended question asking parents how children are coping with the restrictions associated with COVID-19, to identify areas in which these cohorts can be supported. Four main themes were identified: health concerns, schooling difficulties, social isolation and adjustment to restrictions. Health concerns included exacerbation of pre-existing health conditions, fear about the virus, difficulty getting children to understand the pandemic and increased sedentary behaviour. Schooling difficulties referred to the challenges of home schooling, which were behavioural (e.g. difficulty concentrating) and logistical (e.g. technology). Social isolation, expressed as missing friends, family and/or institutions was common. Finally, parents expressed that children experienced both positive adjustments to restrictions, such as spending more time with family, and negative adjustments such as increased screen time. Many responses from parents touched on topics across multiple themes, indicating a need for comprehensive, holistic assessment of children's and families' needs in the provision of support services. The content of the themes supports calls for resources to support children and families including increased financial and practical accessibility of social services, physical health and exercise support, mental health support and COVID-19 communication guides.

Food Insecurity and Socioeconomic Disadvantage in Australia.

Research on food insecurity in Australia has typically relied on a single-item measure and finds that approximately 5% of the population experiences food insecurity. This research also finds that demographic characteristics such as household composition and marital status affect levels of food insecurity, independent of income level. The present study examines the prevalence and correlates of food insecurity in a cohort (n = 400) of people experiencing entrenched disadvantage in Perth, Western Australia. Using the US Department of Agriculture Household Food Security Survey Module, we find that food insecurity at the household, adult, and child level is at sharply elevated levels, with 82.8% of the sample reporting household food insecurity, 80.8% and 58.3% experiencing food insecurity among adults and children, respectively. Demographic characteristics do not significantly affect levels of food insecurity, and food insecurity is associated with negative physical and mental health outcomes. Food insecurity is positively correlated with access to food emergency relief services, indicating that these services are being used by those most in need, but do not address the root causes of food insecurity. Policy and practice should focus on increasing stable access to adequate quantities and quality of food and addressing the structural causes of food insecurity.

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

OBJECTIVE: To determine whether two Housing First configurations (scattered site [SS] versus congregated site [CS]) are associated with different health-related outcomes. METHODS: This ecological study employed a longitudinal, quantitative design to compare the outcomes from 63 individuals (SS: n=37; CS: n=26) in Sydney, Australia, over 12 months. RESULTS: Both configurations showed similar improvements in quality of life and psychological distress. While recent use of substances remained stable across the two configurations over time, a marginally greater increase in the proportion of CS individuals injecting more than weekly was found. For health service utilisation, CS participants had notably higher service utilisation rates for mental health specialists and the emergency department for mental health reasons at follow-up than SS participants. CONCLUSION: Preliminary evidence of differential injecting and health service utilisation outcomes between configurations emerged within this small-scale study over the 12-month period. Implications for public health: Given the rapid expansion of both SS and CS Housing First configurations across Western countries and the indications from this initial study that outcomes may differ according to configuration, there remains a need for robust evaluative evidence on the efficacy of various supported housing models on long-term individual outcomes.

Associations of Housing First Configuration and Crime and Social Connectedness Among Persons With Chronic Homelessness Histories.

OBJECTIVE: This study compared changes in criminal justice contact, quality of life, and social connectedness over a 12-month follow-up period between participants in two Housing First configurations (scattered site [SS] and congregate site [CS]). METHODS: A longitudinal, quantitative design was utilized for this ecological study. Changes in individual outcomes over time were compared for SS and CS participants who completed both baseline and 12-month follow-up surveys (N=63). RESULTS: The number of contacts with various types of criminal justice system channels differed significantly between SS and CS participants, decreasing significantly among SS participants and increasing significantly among CS participants. The two groups did not differ on quality-of-life outcomes or social-connectedness measures, with the exception of case management engagement, whereby a greater proportion of SS participants disengaged from this service over time compared with CS participants. At follow-up, significant within-group changes over time emerged, with increased boredom reported among SS participants, whereas CS participants reported improvements in social relationships, with fewer reporting losing their temper. CONCLUSIONS: The findings supported the notion that the Housing First approach has the potential to significantly improve the lives of persons who have experienced chronic homelessness, a traditionally marginalized and vulnerable group. Over time, this may result in a reduction in the use of acute services, thereby reducing societal costs. The challenge remains to identify the suitability of particular configurations of housing and support and how service delivery can optimize individual outcomes so positive outcomes are maintained in the longer term.