Abstract
Objective: This paper is a methodological case study that describes the At Home/Chez Soi (Housing First) Initiative’s mixed-methods strategy for implementation evaluation and discusses the value of these methods in evaluating the implementation of such complex population health interventions.
Target Population: The Housing First (HF) model is being implemented in five cities: Vancouver, Winnipeg, Toronto, Montréal and Moncton.
Intervention: At Home/Chez Soi is an intervention trial that aims to address the issue of homelessness in people with mental health issues. The HF model emphasizes choices, hopefulness and connecting people with resources that make a difference to their quality of life. A component of HF is supported housing, which provides a rent subsidy and rapid access to housing of choice in private apartments; a second component is support. Quantitative and qualitative methods were used to evaluate HF implementation.
Outcomes: The findings of this case study illustrate how the critical ingredients of complex interventions, such as HF, can be adapted to different contexts while implementation fidelity is maintained at a theoretical level. The findings also illustrate how the project’s mixed methods approach helped to facilitate the adaptation process. Another value of this approach is that it identifies systemic and organizational factors (e.g., housing supply, discrimination, housing procurement strategy) that affect implementation of key elements of HF.
Conclusion: In general, the approach provides information about both whether and how key aspects of the intervention are implemented effectively across different settings. It thus provides implementation data that are rigorous, contextually relevant and practical.
Key words: Homelessness, mental health, complex community interventions
Résumé
Objectif: Ceci est une étude de cas méthodologique décrivant la stratégie à méthodes mixtes qui évalue la mise en œuvre du modèle de priorité au logement de l’initiative Chez Soi/At Home; nous traitons aussi de l’utilité de telles méthodes pour évaluer la mise en œuvre d’interventions complexes en santé des populations.
Population cible: Le modèle de priorité au logement (PL) est appliqué dans cinq villes: Vancouver, Winnipeg, Toronto, Montréal et Moncton.
Intervention: Chez Soi est un essai d’intervention qui s’attaque au problème de l’itinérance chez les personnes aux prises avec la maladie mentale. Le modèle de PL met l’accent sur les choix, l’espoir et la mise en rapport des gens avec des ressources qui comptent pour leur qualité de vie. L’un des éléments du modèle est le logement subventionné: une partie du loyer est payée par le projet, et les bénéficiaires ont un accès rapide à un appartement privé de leur choix; un deuxième élément est le soutien. Des méthodes quantitatives et qualitatives ont été utilisées pour évaluer la mise en œuvre du modèle.
Résultats: Selon les constatations de cette étude de cas, les ingrédients essentiels d’une intervention complexe, comme le modèle de PL, peuvent être adaptés à différents contextes tout en respectant la mise en œuvre de l’intervention sur le plan théorique. On a aussi constaté que l’emploi de méthodes mixtes facilite ce processus d’adaptation. Une autre utilité de cette approche est qu’elle permet de repérer les facteurs généraux et organisationnels (p. ex., l’offre de logements, la discrimination, la stratégie d’obtention de logements) qui influent sur la mise en œuvre des éléments clés du modèle de PL.
Conclusion: Dans l’ensemble, l’approche mixte permet de savoir si les aspects clés de l’intervention sont mis en œuvre efficacement à différents endroits, et de quelle façon. Elle fournit donc des données de mise en œuvre à la fois rigoureuses, pratiques et adaptées au contexte.
Mots clés: itinérance, santé mentale, interventions communautaires complexes
Footnotes
The research has been made possible through a financial contribution from Health Canada to the MHCC. The first author was supported through a fellowship from the Canadian Health Services Research Foundation. The views expressed herein represent solely those of the authors. The funders played no role in the research design, data collection or interpretation, or in the decision to submit the manuscript for publication.
Conflict of Interest: None to declare.
References
- 1.Frankish CJ, Hwang S, Quantz D. Homelessness and health in Canada: Research lessons and priorities. Can J Public Health. 2005;96:S23–S29. doi: 10.1007/BF03403700. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rosenheck R, Kasprow W, Frisman L, Liu-Mares W. Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry. 2003;60(9):940–51. doi: 10.1001/archpsyc.60.9.940. [DOI] [PubMed] [Google Scholar]
- 3.Nelson G, Goering P, Tsemberis S. Housing for people with lived experience of mental health issues: Housing First as a strategy to improve quality of life. In: Walker CJ, Johnson K, Cunningham L, editors. Community Psychology and the Socio-economics of Mental Distress: International Perspectives. Basingstoke, UK: Palgrave Macmillan; 2012. pp. 191–205. [Google Scholar]
- 4.Nelson G. Housing for people with serious mental illness: Approaches, evidence, and transformative change. J Sociology Social Welfare. 2010;37:123–46. [Google Scholar]
- 5.Tsemberis S, Asmussen S. From streets to homes: The pathways to housing consumer preference supported housing model. In: Hanrahan P, Matters MD, Conrad KJ, editors. Homelessness Prevention in Treatment of Substance Abuse and Mental Illness: Logic Models and Implementation of Eight American Projects. Philadelphia, PA: The Haworth Press; 1999. [Google Scholar]
- 6.Bond GR, Drake RE, Mueser KT, Latimer E. Assertive community treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes. 2001;9(3):141. doi: 10.2165/00115677-200109030-00003. [DOI] [Google Scholar]
- 7.Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94:651–56. doi: 10.2105/AJPH.94.4.651. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Aubry T, Ecker J, Jetté J. Supported housing as a promising Housing First approach for people with severe and persistent mental illness. In: Guirguis M, McNeil R, Hwang S (Eds.), Homelessness and Health; accepted.
- 9.Nelson G, Aubry T, Lafrance A. A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management for persons with mental illness who have been homeless. Am J Orthopsychiatry. 2007;77:350–61. doi: 10.1037/0002-9432.77.3.350. [DOI] [PubMed] [Google Scholar]
- 10.Leff HS, Chow CM, Pepin R, Conley J, Allen IE, Seaman CA. Does one size fit all? What we can and can’t learn from a meta-analysis of housing models for persons with mental illness. Psychiatric Services. 2009;60:473–82. doi: 10.1176/ps.2009.60.4.473. [DOI] [PubMed] [Google Scholar]
- 11.O’Campo P, Kirst M, Schaefer-McDaniel N, Firestone M, Scott A, McShane K. Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: A realist approach to synthesizing evidence. J Urban Health: Bulletin of the New York Academy of Medicine. 2009;86:965–89. doi: 10.1007/s11524-009-9392-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Stefancic A, Tsemberis S, Messeri P, Drake R. The key ingredients of Pathways Housing First for individuals with psychiatric disabilities; under review.
- 13.Hawe P, Shiell A, Riley T. Complex interventions: How “out of control” can a randomised controlled trial be? BMJ. 2004;328(7455):1561–63. doi: 10.1136/bmj.328.7455.1561. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Anderson R. New MRC guidance on evaluating complex interventions. BMJ. 2008;337:a1937. doi: 10.1136/bmj.a1937. [DOI] [PubMed] [Google Scholar]
- 15.Hawe P, Potvin L. What is population health intervention research? Can J Public Health. 2009;100(1):I8–I14. doi: 10.1007/BF03405503. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Lewin S, Glenton C, Oxman A. Use of qualitative methods alongside randomised controlled trials of complex healthcare interventions: Methodological study. BMJ. 2009;339:b3496. doi: 10.1136/bmj.b3496. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Shepperd S, Lewin S, Straus S, Clarke M, Eccles MP, Fitzpatrick R, et al. Can we systematically review studies that evaluate complex interventions? PLoS Med. 2009;6(8):e1000086. doi: 10.1371/journal.pmed.1000086. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Cresswell JW, Garrett AL. The “movement” of mixed methods research and the role of educators. South African J Education. 2008;28:321–33. [Google Scholar]
- 19.Guba EG, Lincoln YS. Paradigmatic controversies, contradictions and emerging confluences. In: Denzin NK, Lincoln YS, editors. The Sage Handbook of Qualitative Research. Thousand Oaks, CA: Sage; 2005. pp. 165–82. [Google Scholar]
- 20.Chen H. Applying mixed methods under the framework of theory-driven evaluations. New Directions for Evaluation. 1997;74:61–72. doi: 10.1002/ev.1072. [DOI] [Google Scholar]
- 21.Morgan DL. Paradigms lost and pragmatism regained. J Mixed Methods Research. 2007;1(1):48–76. doi: 10.1177/2345678906292462. [DOI] [Google Scholar]
- 22.Morgan DL. Practical strategies for combining qualitative and quantitative methods: Applications to health research. Qualitative Health Research. 1998;8(3):362–76. doi: 10.1177/104973239800800307. [DOI] [PubMed] [Google Scholar]
- 23.Greene JC, Caracellik VJ, Graham W. Toward a conceptual framework for mixed-method evaluation designs. Educational Evaluation & Policy Analysis. 1989;11(3):255–74. doi: 10.3102/01623737011003255. [DOI] [Google Scholar]
- 24.Caracelli VJ, Greene JC. Crafting mixed-method designs. New Directions for Evaluation. 2008;74:19–32. [Google Scholar]
- 25.Cresswell JW, Fetters MD, Piano Clark VL, Morales A. Mixed methods intervention trials. In: Andrews S, Halcomb EJ, editors. Mixed Methods Research for Nursing and the Health Sciences. Sydney, Australia: Blackwell Publishing; 2009. pp. 161–80. [Google Scholar]
- 26.Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. London: Sage; 2006. [Google Scholar]
- 27.Nelson G, Rae J, Townley G, Goering P, Macnaughton E, Piat M, et al. Implementation and fidelity evaluation of the Mental Health Commission of Canada’s At Home/Chez soi project: Cross-site report. Ottawa, ON: Mental Health Commission of Canada; 2011. [Google Scholar]
- 28.Polvere L, Macnaughton E, Piat M. Participant perspectives on Housing First and recovery: Early findings from the At Home/Chez soi project. Psychiatric Rehabilitation journal; in press. [DOI] [PubMed]