The effectiveness of a Housing First adaptation for ethnic minority groups: findings of a pragmatic randomized controlled trial

Abstract Background Little is known about the effectiveness of Housing First (HF) among ethnic minority groups, despite its growing popularity for homeless adults experiencing mental illness. This randomized controlled trial tests the effectiveness of a HF program using rent supplements and intensive case management, enhanced by anti-racism and anti-oppression practices for homeless adults with mental illness from diverse ethnic minority backgrounds. Methods This unblinded pragmatic field trial was carried out in community settings in Toronto, Canada. Participants were 237 adults from ethnic minority groups experiencing mental illness and homelessness, who met study criteria for moderate needs for mental health services. Participants were randomized to either adapted HF (n = 135) or usual care (n = 102) and followed every 3 months for 24 months. The primary study outcome was housing stability; secondary outcomes included physical and mental health, social functioning, quality of life, arrests and health service use. Intention to treat statistical analyses examined the effectiveness of the intervention compared to usual care. Results During the 24-month study period, HF participants were stably housed a significantly greater proportion of time compared to usual care participants, 75 % (95 % CI 70 to 81) vs. 41 % (95 % CI 35 to 48), respectively, for a difference of 34 %, 95 % CI 25 to 43. HF also led to improvements in community integration over the course of the study: the change in the mean difference between treatment groups from baseline to 24-months was significantly greater among HF participants compared to those in usual care (change in mean difference = 2.2, 95 % CI 0.06 to 4.3). Baseline diagnosis of psychosis was associated with reduced likelihood of being housed ≥ 50 % of the study period (OR = 0.37, 95 % CI 0.18 to 0.72). Conclusion Housing First enhanced with anti-racism and anti-oppression practices can improve housing stability and community functioning among ethnically diverse homeless adults with mental illness. Trial registration International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374 , assigned August 18, 2009

The effectiveness of a Housing First adaptation for ethnic minority groups: findings of a pragmatic randomized controlled trial

Abstract Background Little is known about the effectiveness of Housing First (HF) among ethnic minority groups, despite its growing popularity for homeless adults experiencing mental illness. This randomized controlled trial tests the effectiveness of a HF program using rent supplements and intensive case management, enhanced by anti-racism and anti-oppression practices for homeless adults with mental illness from diverse ethnic minority backgrounds. Methods This unblinded pragmatic field trial was carried out in community settings in Toronto, Canada. Participants were 237 adults from ethnic minority groups experiencing mental illness and homelessness, who met study criteria for moderate needs for mental health services. Participants were randomized to either adapted HF (n = 135) or usual care (n = 102) and followed every 3 months for 24 months. The primary study outcome was housing stability; secondary outcomes included physical and mental health, social functioning, quality of life, arrests and health service use. Intention to treat statistical analyses examined the effectiveness of the intervention compared to usual care. Results During the 24-month study period, HF participants were stably housed a significantly greater proportion of time compared to usual care participants, 75 % (95 % CI 70 to 81) vs. 41 % (95 % CI 35 to 48), respectively, for a difference of 34 %, 95 % CI 25 to 43. HF also led to improvements in community integration over the course of the study: the change in the mean difference between treatment groups from baseline to 24-months was significantly greater among HF participants compared to those in usual care (change in mean difference = 2.2, 95 % CI 0.06 to 4.3). Baseline diagnosis of psychosis was associated with reduced likelihood of being housed ≥ 50 % of the study period (OR = 0.37, 95 % CI 0.18 to 0.72). Conclusion Housing First enhanced with anti-racism and anti-oppression practices can improve housing stability and community functioning among ethnically diverse homeless adults with mental illness. Trial registration International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374 , assigned August 18, 2009

Differential experiences of discrimination among ethnoracially diverse persons experiencing mental illness and homelessness

Abstract Background This mixed methods study explored the characteristics of and experiences with perceived discrimination in an ethnically diverse urban sample of adults experiencing homelessness and mental illness. Methods Data were collected in Toronto, Ontario, as part of a 4-year national randomized field trial of the Housing First treatment model. Rates of perceived discrimination were captured from survey questions regarding perceived discrimination among 231 ethnoracially diverse participants with moderate mental health needs. The qualitative component included thirty six in-depth interviews which explored how individuals who bear these multiple identities of oppression navigate stigma and discrimination, and what affects their capacity to do so. Results Quantitative analysis revealed very high rates of perceived discrimination related to: homelessness/poverty (61.5%), race/ethnicity/skin colour (50.6%) and mental illness/substance use (43.7%). Immigrants and those who had been homeless three or more years reported higher perceived discrimination on all three domains. Analysis of qualitative interviews revealed three common themes related to navigating these experiences of discrimination among participants: 1) social distancing; 2) old and new labels/identities; and, 3) ‘homeland’ cultures. Conclusions These study findings underscore poverty and homelessness as major sources of perceived discrimination, and expose underlying complexities in the navigation of multiple identities in responding to stigma and discrimination. Trial registration Current Controlled Trials ISRCTN42520374 . Registered 18 August 2009

Additional file 1: Table S1. of The effectiveness of a Housing First adaptation for ethnic minority groups: findings of a pragmatic randomized controlled trial

Estimated outcome values at each study visit, by treatment group. (DOCX 13.9 kb

Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial

<div><p>Housing First (HF) is being widely disseminated in efforts to end homelessness among homeless adults with psychiatric disabilities. This study evaluates the effectiveness of HF with Intensive Case Management (ICM) among ethnically diverse homeless adults in an urban setting. 378 participants were randomized to HF with ICM or treatment-as-usual (TAU) in Toronto (Canada), and followed for 24 months. Measures of effectiveness included housing stability, physical (EQ5D-VAS) and mental (CSI, GAIN-SS) health, social functioning (MCAS), quality of life (QoLI20), and health service use. Two-thirds of the sample (63%) was from racialized groups and half (50%) were born outside Canada. Over the 24 months of follow-up, HF participants spent a significantly greater percentage of time in stable residences compared to TAU participants (75.1% 95% CI 70.5 to 79.7 vs. 39.3% 95% CI 34.3 to 44.2, respectively). Similarly, community functioning (MCAS) improved significantly from baseline in HF compared to TAU participants (change in mean difference = +1.67 95% CI 0.04 to 3.30). There was a significant reduction in the number of days spent experiencing alcohol problems among the HF compared to TAU participants at 24 months (ratio of rate ratios = 0.47 95% CI 0.22 to 0.99) relative to baseline, a reduction of 53%. Although the number of emergency department visits and days in hospital over 24 months did not differ significantly between HF and TAU participants, fewer HF participants compared to TAU participants had 1 or more hospitalizations during this period (70.4% vs. 81.1%, respectively; P=0.044). Compared to non-racialized HF participants, racialized HF participants saw an increase in the amount of money spent on alcohol (change in mean difference = $112.90 95% CI 5.84 to 219.96) and a reduction in physical community integration (ratio of rate ratios = 0.67 95% CI 0.47 to 0.96) from baseline to 24 months. Secondary analyses found a significant reduction in the number of days experiencing problems due to alcohol use among foreign-born (vs. Canadian-born) HF participants at 24 months (ratio of rate ratios = 0.19 95% 0.04 to 0.88), relative to baseline. Compared to usual care, HF with ICM can improve housing stability and community functioning and reduce the days of alcohol related problems in an ethnically diverse sample of homeless adults with mental illness within 2-years.</p><p>Trial Registration</p><p>Controlled-Trials.com <a href="http://www.controlled-trials.com/ISRCTN42520374" target="_blank">ISRCTN42520374</a>.</p></div

Primary study outcome, by treatment group and ethnicity.

<p>Values correspond to adjusted means and bars correspond to standard errors from linear regression model (using a mixed effect model framework) for the percentage of days stably housed over 24 month follow-up period for HF-ICM and TAU groups among participants, by ethnicity.</p

Participant flow through the study.

<p>Participant flow through the study.</p

Select secondary outcomes, mean (95% CI), by treatment group over time.

<p>Solid and dashed lines indicate the HF-ICM and TAU groups, respectively.</p

Baseline sample characteristics.

<p><i>P</i> Values correspond to chi-square tests for categorical variables and Mann-Whitney tests for continuous variables.</p><p>¹For the total sample, percentages shown were calculated as proportion of the total sample (N = 378) except for the following variables which had missing values: Marital status (N = 1); Number of children (N = 2); Total length of homelessness (N = 5); Longest period of homelessness (N = 3); Education History (N = 1). For group value calculations, percentages are calculated out of the total available data (excluding missing); therefore column totals for each variable add up to 100%. However, for questions with “yes/no” answers, only the proportion of individuals who indicated “yes” are provided.</p><p>²For Gender, individuals who self-identified as Other/Transgendered/Transsexual were not included (N = 8) due to small cell size</p><p>³ “Racialized” includes participants who indicated the following ethnic or cultural identities: East Asian (e.g. China, Japan, Korea), South Asian (e.g. India, Pakistan, Sri Lanka), South East Asian (e.g. Malaysia, Philippines, Vietnam), Black African (e.g. Ghana, Kenya, Somalia), Black Canadian/American, Black Caribbean Region (e.g. Jamaica, Trinidad, Tobago), Latin American (e.g. Argentina, Chile, Costa Rica), Indian-Caribbean (e.g. Guyana with origins in India), Middle Eastern (e.g. Egypt, Iran, Israel, Palestine) or Mixed background (that included at least one of the ethnic groups listed above).</p><p>⁴ The “Non Racialized” category includes participants who indicated the following ethnicities: White-Canada, White-Europe and Other and includes participants who self-identified as Aboriginal (n = 18).</p><p>⁵ Median values (y) for Total Length of Homelessness: Full sample: 2.67, Housing First with ICM: 2.50, Treatment as Usual: 2.83.</p><p>⁶Median values (y) for Longest Period of Homelessness: Full sample: 1.0, Housing First with ICM: 1.0, Treatment as Usual: 1.0.</p><p>⁷Median values for MCAS score: Full sample: 65.0, Housing First with ICM: 65.0, Treatment As Usual: 65.0</p><p>⁸MINI Diagnoses all represent current diagnoses established at baseline.</p><p>⁹Suicidality was assessed as low, medium, or high; results here are shown with categories collapsed.</p><p>Baseline sample characteristics.</p