Distal supports, capabilities, and growth-focused recovery: A comparison of Housing First and the staircase continuum of care.

Adults who have substantial histories of homelessness and complex support needs may feel ambivalent about integrating into their communities and find it difficult to do so. Being familiar to and recognized by others as a resident in a neighborhood or community are sources of "distal support" that provide individuals with feelings of belonging to their community and are important to recovery from homelessness. We hypothesized that individuals engaged with Housing First (HF) programs would report more distal support than individuals engaged with traditional homeless services (treatment as usual, TAU), and that distal support would predict more community integration, growth-related recovery, and achieved capabilities. We analyzed data collected from homeless services users (n = 445) engaged with either HF or TAU in eight European countries. Measures included achieved capabilities, growth-focused recovery, distal supports, and community integration. Serial mediation analyses confirmed our hypothesis that the effects of HF on growth-related recovery and achieved capabilities are indirect, mediated by distal supports and community integration. Findings are discussed in relation to the importance of modeling the effects of HF on social and psychological outcomes as indirect and identifying important mediators that translate the effects of HF components on social and psychological outcomes. We also note the importance of case management activities that encourage clients to develop and sustain distal supports with others who live and work in their neighborhoods.

Disordered alcohol and substance use in Irish farmers: A cross-sectional survey.

PURPOSE: Farming is a high-pressure occupation. Populations of farmers face significant health risks, including injury, mental illness, and in some cases, heavy alcohol use. However, there is little research on farmers' use of substances beyond alcohol. This study examines factors relating to Irish farmers' disordered alcohol and substance use. METHODS: In accordance with STROBE guidelines for cross-sectional research and reporting, we examined disordered alcohol and substance use in 351 Irish farmers using the Alcohol Use Disorders Identification Tool (AUDIT) and Drug Use Disorders Identification Tool (DUDIT). FINDINGS: While 28% of farmers did not drink, 40% of those who did drink exceeded the AUDIT threshold for disordered use. Similarly, while 95% of farmers did not use substances, 78% of farmers who did use substances exceeded the DUDIT threshold for disordered use. Age was the most important risk factor for disordered alcohol and substance use and correlated with other main risk factors: lower income, no children, part-time farmer, and full-time off-farm roles. Disordered drinking was highest in farmers engaged in full-time education. CONCLUSIONS: This population of Irish farmers report broadly healthy alcohol and substance use behaviors. Irish farmers may serve as a model group whose strengths can be utilized in interventions within and beyond the Irish farming community. Our results confirm the importance of analyzing demographic factors in farmers' drinking and identify younger farmers as especially at-risk for harmful alcohol and substance use.

Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis.

The objective of this prospectively registered systematic review was to identify the factors that contribute to sense of safety, victimization, and overdose risk in homeless shelters, as well as groups that are at greater risk of shelter-based victimization. Fifty-five articles were included in the review. Findings demonstrated that fears of violence and other forms of harm were prominent concerns for people experiencing homelessness when accessing shelters. Service users' perceptions of shelter dangerousness were shaped by the service model and environment, interpersonal relationships and interactions in shelter, availability of drugs, and previous living arrangements. 2SLGBTQ+ individuals were identified as being at heightened risk of victimization in shelters. No studies examined rates of shelter-based victimization or tested interventions to improve safety, with the exception of overdose risk. These knowledge gaps hinder the establishment of evidence-based practices for promoting safety and preventing violence in shelter settings.

Psychometric properties of the measure of achieved capabilities in homeless services.

BACKGROUND: Purposeful participation in personally meaningful life tasks, enjoyment of positive reciprocal relationships, and opportunities to realize one's potential are growth-related aspects of a meaningful life that should be considered important dimensions of recovery from homelessness. The extent to which homeless services support individuals to achieve the capabilities they need to become who they want to be and do what they want to do is, in turn, an important indicator of their effectiveness. In this study, we developed a measure of achieved capabilities (MACHS) for use in homeless services settings, and assessed its construct and concurrent validity. METHODS: We analysed data collected from homeless services users at two time points in eight European countries to assess the factor structure and psychometric properties of the new measure. Participants were adults engaged with either Housing First (n = 245) or treatment as usual (n = 320). RESULTS: Exploratory and confirmatory factor analyses yielded a four-factor structure of the capabilities measure: community integration, optimism, safety, and self-determination. We obtained evidence for construct validity through observed correlations between achieved capabilities and recovery, working alliance and satisfaction with services. Moreover, we obtained evidence of the measure's concurrent validity from its positive association between HF and personal recovery, which was fully mediated by achieved capabilities. CONCLUSIONS: Findings demonstrate that the MACHS is a valid and reliable measure that may be used to assess the extent to which homeless services support their clients to develop capabilities needed for growth-related recovery. Implications for practice and future research directions are discussed.

Empowering Features and Outcomes of Homeless Interventions: A Systematic Review and Narrative Synthesis.

The purpose of this systematic review and narrative synthesis was to identify homeless interventions with empowering features and evaluate their effectiveness for developing the psychological empowerment of services users. To identify and evaluate intervention studies, we combined the theoretical frameworks of empowering settings and psychological empowerment (PE). Our conceptualization of PE included outcomes aligned with the intrapersonal, interactional, and behavioral components. Relational outcomes were also included and conceptualized as antecedents for PE development. After systematic searching and screening, 37 studies were included for review. Interventions with empowering features included supported housing, case management, skills and knowledge acquisition, and mutual support. Interventions that were competency-building effectively improved outcomes aligned with the intrapersonal PE component. Interventions that were collaborative and competency-building effectively improved outcomes aligned with the behavioral PE component. Weak evidence suggested that interventions with empowering features may effectively improve outcomes aligned with the interactional PE component. Interventions that promoted and developed support effectively improved relational antecedents. Findings align the empirical evidence for homeless interventions with theoretical conceptions of empowering features and processes. Findings may be applied to the design and implementation of homeless interventions to incorporate empowering features and to facilitate the development of homeless services users' PE. Highlights Empowerment theory was applied to review homeless interventions literature. Empowering homeless interventions included supported housing and mutual support, for example. Empowering interventions contributed to indicators of emotional and behavioral empowerment. Fewer empowering interventions contributed to indicators of cognitive empowerment. Service user involvement may facilitate improvements in indicators of psychological empowerment.

Europeans' willingness to pay for ending homelessness: A contingent valuation study.

The purpose of this study is to assess the utility value European citizens put on an innovative social program aimed at reducing homelessness. The Housing First (HF) model involves access to regular, scattered, independent and integrated housing in the community with the support of a multidisciplinary team. Currently, HF is not implemented by most European countries or funded by healthcare or social plans, but randomised controlled trials have stressed significant results for improved housing stability, recovery and healthcare services use. The broader implementation of HF across Europe would benefit from a better understanding of citizens' preferences and "willingness to pay" (WTP) for medico-social interventions like HF. We conducted a representative telephone survey between March and December 2017 in eight European countries (France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden). Respondent's WTP for HF (N = 5631) was assessed through a contingent valuation method with a bidding algorithm. 42.3% of respondents were willing to pay more taxes to reduce homelessness through the HF model, and significant differences were found between countries (p < 0.001); 30.4% of respondents who did not value the HF model were protest zeros (either contested the payment vehicle-taxes- or the survey instrument). Respondents were willing to pay €28.2 (±11) through annual taxation for the HF model. Respondents with higher educational attainment, who paid national taxes, reported positive attitudes about homelessness, or reported practices to reduce homelessness (donations, volunteering) were more likely to value the HF model, with some countries' differences also related to factors at the environmental level. These findings inform key stakeholders that European citizens are aware of the issue of homelessness in their countries and that scaling up the HF model across Europe is both feasible and likely to have public support.

Comparison of Housing First and Traditional Homeless Service Users in Eight European Countries: Protocol for a Mixed Methods, Multi-Site Study.

BACKGROUND: Homeless services expend considerable resources to provide for service users' most basic needs, such as food and shelter, but their track record for ending homelessness is disappointing. An alternative model, Housing First, reversed the order of services so that homeless individuals are offered immediate access to independent housing, with wraparound supports but no treatment or abstinence requirements. Although the evidence base for Housing First's effectiveness in ending homelessness is robust, less is known about its effectiveness in promoting recovery. OBJECTIVE: The objective of this research is to compare rehabilitation- and recovery-related outcomes of homeless services users who are engaged in either Housing First or traditional staircase services in eight European countries: France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden. METHODS: A mixed methods, multi-site investigation of Housing First and traditional services will compare quantitative outcomes at two time points. Key rehabilitation outcomes include stable housing and psychiatric symptoms. Key growth outcomes include community integration and acquired capabilities. Semistructured interviews will be used to examine service users' experiences of environmental constraints and affordances on acquired capabilities to identify features of homeless services that enhance service users' capabilities sets. Multi-level modelling will be used to test for group differences-Housing First versus traditional services-on key outcome variables. Thematic analysis will be used to understand the ways in which service users make sense of internal and external affordances and constraints on capabilities. RESULTS: The study is registered with the European Commission (registration number: H2020-SC6-REVINEQUAL-2016/ GA726997). Two press releases, a research report to the funding body, two peer-reviewed articles, and an e-book chapter are planned for dissemination of the final results. The project was funded from September 2016 through September 2019. Expected results will be disseminated in 2019 and 2020. CONCLUSIONS: We will use the findings from this research to formulate recommendations for European social policy on the configuration of homeless services and the scaling up and scaling out of Housing First programs. From our findings, we will draw conclusions about the setting features that promote individuals' exits from homelessness, rehabilitation, and recovery. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/14584.

Homeless Adults' Recovery Experiences in Housing First and Traditional Services Programs in Seven European Countries.

Across Europe, as governments turn to housing-led strategies in attempts to reverse rising rates of homelessness, increasing numbers of Housing First (HF) programs are being implemented. As HF programs become more widespread, it is important to understand how service users experience them compared to the more prevalent traditional treatment-first approach to addressing long-term homelessness. Although there is a large body of research on service users' experiences of Housing First compared to treatment-first in North American contexts, comparatively less is known about how these two categories of homeless services are experienced in the European context. In a correlational and cross-sectional study, part of a larger examination of homelessness in Europe, participants (n = 520) engaged with either HF (n = 245) or traditional services (TS; n = 275) programs in seven countries completed measures of their experiences of services (consumer choice, housing quality, and service satisfaction) and recovery (time in independent housing, psychiatric symptoms, and community integration). Across the seven countries, participants engaged with HF programs reported experiencing more consumer choice, better perceived housing quality, and more satisfaction with services than participants engaged in TS programs. Participants in HF programs also reported a greater proportion of time in independent accommodation, fewer psychiatric symptoms, and more community integration. Varying patterns of association between experiences of services and recovery outcomes were observed. Findings indicate HF consistently predicts greater recovery than TS across diverse sociopolitical and economic contexts. Implications of findings for configurations of homeless services and homeless services policy are discussed.

Goals and Principles of Providers Working with People Experiencing Homelessness: A Comparison Between Housing First and Traditional Staircase Services in Eight European Countries.

The implementation and adaptation of the Housing First (HF) model represented profound changes the structure and delivery, goals, and principles of homeless services. These features of homeless services directly influence providers, their work performance and the clients' outcomes. The present research, conducted in eight European countries, investigated how social providers working in HF or TS (Traditional Staircase) describe and conceptualize the goals and the principles of their services. Data were collected through 29 focus group discussions involving 121 providers. The results showed that HF and TS had similar and different goals for their clients in the following areas: support, social integration, satisfaction of needs, housing, and well-being. HF providers emphasized clients' autonomy and ability to determine their personal goals, with housing being considered a start on the path of recovery, while TS were more focused on individual clients' basic needs with respect to food, health and finding temporary accommodations. HF providers privileged the person-centered approach and housing as a right, while TS providers were more focused on helping everyone. Implications of the results are discussed as suggestions both for practice and for research.