Problems maintaining collaborative approaches with excluded populations in a randomised control trial: lessons learned implementing Housing First in France.

BACKGROUND: In 2006, a local collective combating homelessness set up an 'experimental squat' in an abandoned building in Marseille, France's second largest city. They envisioned the squat as an alternative to conventional health and social services for individuals experiencing long-term homelessness and severe psychiatric disorders. Building on what they learned from the squat, some then joined a larger coalition that succeeded in convincing national government decision-makers to develop a scientific, intervention-based programme based on the Housing First model. This article analyses the political process through which social movement activism gave way to support for a state-funded programme for homeless people with mental disorders. METHODS: A qualitative study of this political process was conducted between 2006 and 2014, using a hybrid theoretical perspective that combines attention to both top-down and bottom-up actions with a modified Advocacy Coalition Framework. In addition to document analysis of published and grey literature linked to the policy process, researchers drew on participant observation and observant participation of the political process. Data analysis consisted primarily of a thematic analysis of field-notes and semi-structured interviews with 65 relevant actors. RESULTS: A coalition of local activists, state officials and national service providers transformed knowledge about a local innovation (an experimental therapeutic squat) into the rationale for a national, scientifically based project consisting of a randomised controlled trial of four state-supported Housing First sites, costing several million euros. The coalition's strategy was two-pronged, namely to defend a social cause (the right to housing) and to promote a scientifically validated means of realising positive outcomes (housing tenure) and cost-effectiveness (reduced hospitalisation costs). CONCLUSION: Activists' self-agency, especially that of making themselves audible to public authorities, was enhanced by the coalition's ability to seize 'windows of opportunities' to their advantage. However, in contrast to the United States and Canadian Housing First contexts, which are driven by implementation science and related approaches, it was grassroots activists who promoted a scientific-technical approach among government officials unfamiliar with evidence-based practices in France. The windows of opportunity nevertheless failed to attract participation of those most in need of housing, raising the question of whether and how marginalised and/or subordinate groups can be integrated into collaborative research when a social movement-driven innovation turns into a scientific approach. TRIAL REGISTRATION: The current clinical trial number is NCT01570712 . Registered July 17, 2011. First patient enrolled August 18, 2011.

Negotiating care: patient tactics at an urban South African hospital.

OBJECTIVES: To examine the various ways in which patients sought to influence the care they received in the admission and adult medical services of a large urban, academic hospital in South Africa. These included the steps taken by patients to increase their access to services and improve their experience of care. METHODS: Part of a qualitative study of rationing behaviour, the methods combined, observations, interviews and a survey. RESULTS: Patient's actions were oriented to two main goals: obtaining care and preserving their sense of self and dignity. These actions shaped patients' pathways in five key ways: meeting the entry criteria for admission; presenting as a cooperative, expert patient; mobilizing social networks among health care staff; making use of complaints mechanisms; and deploying narratives of resistance. CONCLUSION: Patients made tactical use of small spaces at the margins of the health care system. Although, with some exceptions, they had limited impact on the care received in the hospital, they highlight patients as active players and point to the ways in which patient agency can be strengthened in the light of the shift towards chronic disease care and greater patient involvement in care.