Are resilience and perceived stress related to social support and housing stability among homeless adults with mental illness?

Perceived stress has been associated with adverse health outcomes. Although people experiencing homelessness often report multiple acute and chronic stressors, research on resilience and perceived stress on the general homeless population is limited. This longitudinal study examined homeless adults with mental illness who were part of a 24-month trial of Housing First to explore: (a) changes in levels of resilience and perceived stress during the trial, and (b) the association between levels of resilience and perceived stress with measures of social support, social functioning and percentage of days stably housed over the study period. This longitudinal study (2009-2013) that used trial data included 575 participants in Toronto, Ontario. Of these individuals, 507 were included in this study. Connor-Davidson Resilience Scale and Perceived Stress Scales (PSS) measured the two outcomes, resilience and perceived stress. Time (baseline, 12 and 24 months), housing stability and three measures of social support and social functioning were the main predictors. A longitudinal analysis was done with repeated measures analysis of resilience and perceived stress using linear mixed models with random intercepts. Mean resilience scores increased (baseline: 5.1 [95% CI: 4.9, 5.2], 12 months: 5.5 [95% CI: 5.3, 5.7], 24 months: 5.6 [95% CI: 5.4, 5.8]), and PSS scores decreased (baseline: 22.3 [95% CI: 21.5, 23.0], 24 months: 18.6 [95% CI: 17.9, 19.4]). In the multivariable analyses, increased resilience was associated with higher scores on the three social support and social functioning measures, (estimates = 0.12, 0.04, 0.02) but not percentage days stably housed. Lower PSS scores were associated with higher scores on all three social support and social functioning measures (-0.20, -0.33, -0.21) and higher percentages of days stably housed (-0.015). Strong social support and social functioning may minimise the harmful effects of stressful life events on homeless individuals by increasing resilience and reducing stress. Interventions to help homeless people build appropriate support networks should be delivered in parallel to efforts that increase housing stability.

The use of semistructured interviews to assess quality of life impacts for patients with uveal melanoma.

OBJECTIVE: There are limited studies on uveal melanoma and patient quality of life. However, the burden of implementing a patient-reported outcome measure to collect this information in a clinical setting is unknown. The objectives of this study were (i) to understand the issues of quality of life that are most important to patients undergoing treatment for uveal melanoma, (ii) to explore patient views on the European Organization for Research and Treatment of Cancer's (EORTC) ophthalmic oncology quality of life questionnaire (QLQ-OPT30), and (iii) to assess patient willingness to complete questionnaires measuring quality of life on an ongoing basis. DESIGN: This was a qualitative study. PARTICIPANTS: The study included 10 patients treated for uveal melanoma with brachytherapy at the Alberta Ocular Brachytherapy Program, with a mean follow-up period of 16.3 months (range 5-33 months) after diagnosis. METHODS: The participants completed a qualitative interview over the phone with a trained interviewer between November 2014 and January 2015. Participants completed the QLQ-OPT30 according to their current symptoms and then elaborated on their responses. The participants then completed a semistructured interview to provide more information about the symptoms or issues that had the most impact on quality of life. RESULTS: The participants expressed positive feelings about the QLQ-OPT30; however, the participants' responses revealed that several themes, including mental health, impact of diagnosis and treatment on family, travel and financial burdens of treatment, and impact on work and home life, were missing in the questionnaire. CONCLUSIONS: The QLQ-OPT30 performed well, but some missing constructs were identified. Furthermore, participants took 23 minutes to complete the QLQ-OPT30 with a trained interviewer, and this could present logistical challenges when using it at the point of care.

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.

Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes.

Housing quality (HQ) is associated with mental health, and may mediate outcomes in housing interventions. However, studies of housing interventions rarely report HQ. The purpose of this study was to describe HQ in a multi-site randomized controlled trial of Housing First (HF) in five Canadian cities and to examine possible differences by treatment group (HF recipients and treatment-as-usual (TAU) participants who were able to find housing through other programs or on their own). We also examined the association between HQ and the primary trial outcome: housing stability. The performance of a new multi-dimensional standardized observer-rated housing quality scale (the OHQS) in a relatively large cross-site sample was also of interest. HQ was rated by trained research assistants for 204 HF participants and 228 TAU participants using the OHQS. General linear regression models were used to examine unit/building quality scores by group and site adjusting for other group differences, and as a predictor of housing stability outcomes after 24 months of follow-up. The OHQS was found to have good reliability and validity, but because most of the neighborhood subscale items were negatively correlated with the overall scale, only unit and building items were included in the total HQ score (possible scores ranging from 13.5 to 135). Unit/building HQ was significantly better for the HF group overall (91.2 (95 % CI = 89.6-92.9) vs. 88.3 (95 % CI = 86.1-90.5); p = .036), and in one site. HQ in the TAU group was much more variable than the HF group overall (W (mean) = 24.7; p < .001) and in four of five sites. Unit/building HQ scores were positively associated with housing stability: (73.4 (95 % CI 68.3-78.5) for those housed none of the time; 91.1 (95 % CI 89.2-93.0) for those housed some of the time; and 93.1 (95 % CI 91.4-94.9)) for those housed all of the time (F = 43.9 p < .001). This association held after adjusting for site, housing characteristics, participant ethnocultural status, community functioning, and social support. This study demonstrates that HQ can be as good or better, and less variable, in HF programs in Canada that systematically and predominantly source housing stock from the private sector compared to housing procured outside of an HF program. HQ is also an important predictor of housing stability outcomes.

One-year outcomes of a randomized controlled trial of housing first with ACT in five Canadian cities.

OBJECTIVE: Housing First is a groundbreaking approach to ending chronic homelessness among people with mental illness. This article presents one-year findings from a multisite randomized controlled trial (RCT) comparing Housing First with treatment as usual. METHODS: The study was a nonblind, parallel-group RCT conducted in five Canadian cities. A sample of 950 high-need participants with severe mental illness, who were either absolutely homeless or precariously housed, was randomly assigned to Housing First (N=469) or treatment as usual (N=481). Housing First participants received a rent supplement, assistance to find housing, and assertive community treatment. Treatment-as-usual participants had access to all other existing programs. RESULTS: At one-year follow-up, 73% of Housing First participants and 31% of treatment-as-usual participants resided in stable housing (p<.001, odds ratio=6.35, covariate adjusted difference=42%, 95% confidence interval [CI]=36%-48%). Improvement in overall quality of life was significantly greater among Housing First participants compared with treatment-as-usual participants (p<.001, d=.31, CI=.16-.46). Housing First participants also showed greater improvements in community functioning compared with treatment-as-usual participants (p=.003, d=.25, CI=.09-.41). CONCLUSIONS: Compared with treatment as usual, Housing First produced greater improvements in housing stability, quality of life, and community functioning after one year of enrollment. The study provides support for adopting Housing First as an approach for ending chronic homelessness among persons with severe mental illness, even if they are actively symptomatic or using substances.

Patterns and predictors of attrition in a trial of a housing intervention for homeless people with mental illness.

PURPOSE: Participant retention is an important challenge in longitudinal research on homeless people. High attrition can threaten validity, and may represent lost opportunities to deliver interventions. In this article, we report on attrition in the At Home/Chez Soi study, a multi-site randomized controlled trial of a housing intervention for homeless people with mental illness. METHODS: We first calculate life tables, and then use clustered logistic regression to implement a discrete-time survival model. We use splines and indicator variables to capture non-linear and group-specific variation over time in the hazard function. As potential predictors, we consider study group, site, date of recruitment, age, sex, baseline substance dependence, baseline psychotic disorder, time homeless in life, community functioning, and education. RESULTS: The study recruited 2,148 homeless people with mental illness. Of these, 1,158 were randomized to the housing first intervention (HF), and 990 to treatment as usual (TAU). Excluding 79 people known to have died, attrition was 14%. This proportion was higher in TAU than in HF (21 vs. 8%, p < 0.01). Attrition was significantly lower in one site than elsewhere, and was also lower among those with substance dependence (13 vs. 18%, p < 0.01) and among those enrolled earlier in the study. The hazard varied over time in complex ways. CONCLUSIONS: Results imply that study factors are more important than participant characteristics as determinants of retention, and that the immediate period after randomization is a crucial one. The high overall retention demonstrates the effectiveness of existing techniques for retaining participants.

Development and initial validation of the Observer-Rated Housing Quality Scale (OHQS) in a multisite trial of housing first.

Quality of housing has been shown to be related to health outcomes, including mental health and well-being, yet "objective" or observer-rated housing quality is rarely measured in housing intervention research. This may be due to a lack of standardized, reliable, and valid housing quality instruments. The objective of this research was to develop and validate the Observer-Rated Housing Quality Scale (OHQS) for use in a multisite trial of a "housing first" intervention for homeless individuals with mental illness. A list of 79 housing unit, building, and neighborhood characteristics was generated from a review of the relevant literature and three focus groups with consumers and housing service providers. The characteristics were then ranked by 47 researchers, consumers, and service providers on perceived importance, generalizability, universality of value, and evidence base. Items were then drafted, scaled (five points, half values allowed), and pretested in seven housing units and with seven raters using cognitive interviewing techniques. The draft scale was piloted in 55 housing units in Toronto and Winnipeg, Canada. Items were rated independently in each unit by two trained research assistants and a housing expert. Data were analyzed using classical psychometric approaches and intraclass correlation coefficients (ICC) for inter-rater reliability. The draft scale consisted of 34 items assessing three domains: the unit, the building, and the neighborhood. Five of 18 unit items and 3 of 7 building items displayed ceiling or floor effects and were adjusted accordingly. Internal consistency was very good (Cronbach's alpha = 0.90 for the unit items, 0.80 for the building items, and 0.92 total (unit and building)). Percent agreement ranged from 89 to 100 % within one response scale value and 67 to 91 % within one half scale value. Inter-rater reliability was also good (ICCs were 0.87 for the unit, 0.85 for the building, and 0.93 for the total scale). Three neighborhood items (e.g., distance to transit) were found to be most efficiently rated using publicly available information. The physical quality of housing can be reliably rated by trained but nonexpert raters using the OHQS. The tool has potential for improved measurement in housing-related health research, including addressing the limitations of self-report, and may also enable documenting the quality of housing that is provided by publicly funded housing programs.

Use of child death review to inform sudden unexplained infant deaths occurring in a large urban setting.

OBJECTIVE: To illustrate the benefits and utility of the child death review (CDR) reporting system when examining risk factors associated with infant death occurring within two subgroups of sudden unexpected infant deaths (SUID)-unintentional suffocation and sudden infant death syndrome (SIDS)-in a large urban county in Wisconsin. DESIGN: Retrospective CDR data were analysed, 2007-2008, for Milwaukee County, Wisconsin. PATIENTS OR SUBJECTS: Unintentional suffocation and SIDS infant deaths under 1 year of age in Milwaukee County, Wisconsin, 2007-2008, with a CDR record indicating a death in a sleep environment. Main outcome measure Study examined demographic characteristics, bed-sharing, incident sleep location, position of child when put to sleep, position of child when found, child's usual sleep place, crib in home, and other objects found in sleep environment. RESULTS: Unintentional suffocation (n=11) and SIDS (n=40) classified deaths with CDR data made up 18% (51/283) of all infant deaths in Milwaukee County from 2007 to 2008. The majority of infants who died of unintentional suffocation (n=9, 81.8%) or SIDS (n=26, 65.0%) were black and under the age of 3 months. Bed-sharing was involved in most of the unintentional suffocation deaths (n=10, 90.9%) and the SIDS deaths (n=28, 70.0%). All unintentional suffocation deaths (n=11, 100%) and the majority of SIDS deaths (n=31, 77.5%) took place in a non-crib sleeping environment. CONCLUSIONS: The study demonstrates how CDR provides enhanced documentation of risk factors to help steer prevention efforts regarding SUID deaths in a community and reaffirms infants in an unsafe sleep environment have an increased risk of death.