The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities

This article was published in BMJ Open following peer review and can also be viewed on the journal’s website at http://bmjopen.bmj.comIntroduction: Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city, $110 million demonstration project and provides the rationale for key scientific decisions. Methods: A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy. Ethics and dissemination: Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project.This work was supported by a contract from Health Canada administrated by the Mental Health Commission of Canada

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

On the Declining Health Status of Welfare Caseloads: Emerging Dilemmas for Serving the Poor

An emerging concern for public policy is welfare reform’s potential to inadvertently affect caseload composition by increasing the proportion of recipients with health-related barriers to employment. We examine this using data from the Welfare Client Longitudinal Study, an in-depth case study of a large California county. Through quantitative analyses, we examine the extent of change in health-related problems since welfare reform and their potential to progressively impact overall composition of the caseload. We augment this with qualitative data on how local welfare providers are responding to the health-related needs of aid recipients. Results suggest that the burden of health-related problems is growing and that welfare providers may be poorly equipped to respond effectively on their own. The changing composition of welfare caseloads may foster several new policy dilemmas that demand broader attention: states and localities may face difficulties meeting federal workforce participation requirements, may need to restructure welfare-to-work programs to serve a more functionally impaired population, and take steps to better integrate health and welfare services at the local level

The role of gender in housing for individuals with severe mental illness: a qualitative study of the Canadian service context: Table 1

OBJECTIVE: This study was undertaken to examine the role of gender as it relates to access to housing among individuals with severe mental illness (SMI) in Canada. DESIGN: An exploratory, qualitative approach was used to assess the perspectives of Canadian housing experts. The focus of inquiry was on the role of gender and associated intersections (eg, ethnicity) in pathways to housing access and housing needs for individuals with SMI. SETTING: A purposeful sampling strategy was undertaken to access respondents across all Canadian geographic regions, with diversity across settings (urban and rural) and service sectors (hospital based and community based). PARTICIPANTS: –29 individuals (6 men and 23 women) considered to be experts in a housing service context as it pertains to SMI were recruited. On average, participants had worked for 15 years in services that specialised in the support and delivery of housing services to people with SMI. MEASURES: Semistructured interviews with participants focused on the role gender plays in access to housing in their specific context. Barriers and facilitators were examined as were intersections with other relevant factors, such as ethnicity, poverty and parenthood. Quantitative ratings of housing accessibility as a function of gender were also collected. RESULTS: Participants across geographic contexts described a lack of shelter facilities for women, leading to a reliance on exploitative circumstances. Other findings included a compounding of discrimination for ethnic minority women, the unique resource problems faced in rural contexts, and the difficulties that attend access to shelter and housing for parents with SMI. CONCLUSIONS: These findings suggest that, along with a generally poor availability of housing stock for individuals with SMI, access problems are compounded by a lack of attention to the unique needs and illness trajectories that attend gender

Pathways into homelessness: Understanding how both individual and structural factors contribute to and sustain homelessness in Canada

This qualitative study examined how homeless individuals with mental illness experience pathways into homelessness. Study participants were enrolled in the At Home/Chez Soi project, a Pan-Canadian Randomized Controlled Trial comparing the Housing First approach with Treatment as Usual for homeless individuals. This inquiry is grounded in social ecological perspective, which considers interactions between individual and structural factors. Findings from consumer narrative interviews ( n = 219) revealed that individual factors, such as substance abuse, relationship conflicts and mental health issues significantly contributed to homelessness, in addition to structural transitions from foster care and institutional settings into the community. Additional structural factors entrenched participants in unsafe communities, created obstacles to exiting homelessness and amplified individual risk factors. The study findings confirm the role of individual risk factors in pathways into homelessness, but underscore the need for policies and interventions to address structural factors that worsen individual risks and create barriers to exiting homelessness. </jats:p