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BackgroundMunicipalities play a crucial role in population health due to their community connections and influence on health determinants. Community-campus engagement (CCE), that is, collaboration between academic institutions and communities, is a promising approach to addressing community health priorities. However, evidence of CCE’s impact on population health remains limited. Measuring the impacts of CCE is inherently complex due to factors such as diverse stakeholders, context-specific variables, and dynamic interactions within a community. ObjectiveThis study aims to develop robust evidence on the impacts of CCE on population health outcomes in Ottawa and Thunder Bay, Ontario, Canada, focusing on 5 shared health priorities: housing, discrimination, poverty, violence, and mental health. MethodsWe will use a proven CCE model called CityStudio, which has been implemented in both cities. We will use Mayne's mixed methods contribution analysis in three stages: (1) formulating a theory of change that outlines the expected contributions of CCE to population health outcomes; (2) gathering qualitative and quantitative data in line with the established Theory of Change; the data will be collected from various sources, including case studies of existing CityStudio projects, a web-based CCE stakeholder survey, a literature review, and population and community health data; and (3) reviewing the gathered evidence to determine the extent of CCE impacts on population health. ResultsEthical approval for this project was granted in May 2023. We have since initiated stage 1 by reviewing the literature to inform the development of the theory of change. We expect to complete this study by May 2026. ConclusionsThis study will address two critical gaps about how improving health outcomes depends on CCE: (1) how academic institutions can best engage with their communities to improve population health outcomes, and (2) how municipalities can engage with academic institutions to address their community health priorities. Conducting our work in differing contexts will allow us to consider a broader range of other influences on outcomes, thus making our work applicable to various settings and outcomes. International Registered Report Identifier (IRRID)PRR1-10.2196/58546

Abstract Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Abstract Background It is estimated that around 160,000 households in Britain experience homelessness each year, although no definitive statistics exist. Between March and September 2020, as part of the initial ‘Everyone In’ government response to COVID-19 in England, 10,566 people were living in emergency accommodation and nearly 18,911 people had been moved into settled accommodation. However, some forms of temporary accommodation may not be suitable as shared facilities make it impossible for people to adhere to government guidelines to reduce the spread of COVID-19. Methods This is parallel group, pilot randomised controlled trial. The target is to recruit three local authorities, each of which will recruit 50 participants (thus a total of approximately 150 participants). Individuals are eligible if they are aged 18 and over, in a single-person homeless household, temporarily accommodated by the LA with recourse to public funds. Participants will be randomised to receive settled accommodation (intervention group) or temporary accommodation (control group). The intervention group includes settled housing such as Private Rented Sector (low and medium support), Social Housing (low and medium support), and Housing First (High support). The control group will maintain treatment as usual. The follow-up period will last 6 months. The primary outcome is to assess the feasibility of recruitment, retention, and acceptability of trial processes against progression criteria laid out in a traffic light system (green: all criteria are met, the trial should progress as designed in this pilot; amber: the majority of criteria are met and with adaptations to methods all criteria could be met; red: the minority of criteria are met and the pilot RCT should not proceed). Secondary outcomes include assessment of completeness of data collection at 3 and 6 months and percentage of participants consenting to data linkage, as well as a process evaluation and economic evaluation. Discussion This trial will address feasibility questions associated with progression to a fully powered effectiveness trial of models of housing to reduce risk of COVID-19 infection and homelessness. Trial registration ISRCTN69564614 . Registered on December 16, 2020.

Background: People experiencing homelessness have diverse patterns of healthcare use. This study examined the distribution and determinants of healthcare encounters among adults with a history of homelessness. Methods: Administrative healthcare records were linked with survey data for a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness. Binary and count models were used to identify factors associated with hospital admissions, emergency department visits and physician visits for comparison across the 2 cohorts. Results: During the 1-year follow-up period, a higher proportion of people in the cohort with a mental illness used any inpatient (27% vs 14%), emergency (63% vs 53%), or physician services (90% vs 76%) compared to the general homeless cohort. People from racialized groups were less likely use nearly all health services, most notably physician services. Other factors, such as reporting of a regular source of care, poor perceived general health, and diagnosed chronic conditions were associated with higher use of all health services except psychiatric inpatient care Conclusion: When implementing interventions for patients with the greatest health needs, we must consider the unique factors that contribute to higher healthcare use, as well as the barriers to healthcare access.

Abstract Background Healthcare costs are disproportionately incurred by a relatively small group of people often described as high-cost users. Understanding the factors associated with high-cost use of health services among people experiencing homelessness could help guide service planning. Methods Survey data from a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness were linked with administrative healthcare records in Ontario, Canada. Total costs were calculated using a validated costing algorithm and categorized based on population cut points for the top 5%, top 6–10%, top 11–50% and bottom 50% of users in Ontario. Multinomial logistic regression was used to identify the predisposing, enabling, and need factors associated with higher healthcare costs (with bottom 50% as the reference). Results Sixteen percent of the general homeless cohort and 30% percent of the cohort with a mental illness were in the top 5% of healthcare users in Ontario. Most healthcare costs for the top 5% of users were attributed to emergency department and inpatient service costs, while the costs from other strata were mostly for physician services, hospital outpatient clinics, and medications. The odds of being within the top 5% of users were higher for people who reported female gender, a regular medical doctor, past year acute service use, poor perceived general health and two or more diagnosed chronic conditions, and were lower for Black participants and other racialized groups. Older age was not consistently associated with higher cost use; the odds of being in the top 5% were highest for 35-to-49-year year age group in the cohort with a mental illness and similar for the 35–49 and ≥ 50-year age groups in the general homeless cohort. Conclusions This study combines survey and administrative data from two cohorts of homeless adults to describe the distribution of healthcare costs and identify factors associated with higher cost use. These findings can inform the development of targeted interventions to improve healthcare delivery and support for people experiencing homelessness.

Purpose: Much of the extant research on quality-of-life (QoL) in homelessness has focused narrowly on health-related QoL. Far less is known about broader subjective quality-of-life (SQoL). The purpose of this study was to examine levels and predictors of SQoL among homeless and vulnerably housed individuals in a 4-year longitudinal study. Methods: Data were from the Health and Housing in Transition (HHiT) study, a prospective cohort study of 1190 individuals from three Canadian cities who were homeless or vulnerably housed. SQoL was measured using a scale designed specifically for this population. Predictor variables were time-varying indicators of housing status, substance use, and social support as well as baseline measures of physical and mental health problems. Generalized estimating equation (GEE) analysis examined these predictors of SQoL, adjusting for baseline age, gender, ethnicity, employment, income, and city of residence. Results: Participants at baseline were 18 to 80 years old (M = 42.2; SD = 10.6), 66% male, 63% White, 60% unemployed, and 50% were currently homeless. Most areas of SQoL tended toward slight satisfaction, with dissatisfaction concerning finance and employment as notable exceptions. Demographic variables were not associated with SQoL. Homelessness and self-reported presence of 3+ chronic health conditions, mental health problems, and problematic substance use, as well as lower perceived social support, were independently associated with lower SQoL. Conclusions: SQoL shows variation across different life areas for homeless and vulnerably housed individuals. In order to improve SQoL in this population, it is important to address poverty, employment, housing challenges, mental and physical health problems, and substance use as well as increase social supports.

Abstract Background The paper presents two-year findings from a study investigating the effectiveness of Housing First (HF) with assertive community treatment (ACT) in helping individuals with serious mental illness, who are homeless or precariously housed and living in a small city, to become stably housed. Methods The research design was a parallel group non-blinded RCT with participants randomly assigned after the baseline interview to receive HF with ACT (N = 100) or treatment as usual (TAU; N = 101). Participants were interviewed every 3 months over 21/24 months to investigate changes on a range of housing and psychosocial outcomes. The primary outcomes were housing stability (as defined by a joint function of number of days housed and number of moves) and improvement in community functioning. Secondary predicted outcomes were improvements in self-rated physical and mental health status, substance use problems, quality of life, community integration, and recovery. Results An intent-to-treat analysis was conducted. Compared to TAU participants, HF participants who entered housing did so more quickly (23.30 versus 88.25 days, d = 1.02, 95% CI [0.50–1.53], p

Abstract Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social‐protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental‐health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost‐effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi‐experimental studies conducted among populations experiencing homelessness in high‐income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance‐use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random‐effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost‐effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high‐ and moderate‐needs populations with significant cimorbid mental illness and substance‐use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental‐health or substance‐use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short‐term improvement in depression and perceived stress levels were reported, no evidence of the long‐term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical‐ and social‐services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost‐effectiveness of income‐assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, −$19, −$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost‐offset or cost‐effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High‐intensity case management and income‐assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID‐19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence‐based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

We developed, tested, and operationalized a comprehensive objective measurement tool, the Observer-rated Housing Quality Scale (OHQS), to assess housing unit, building, and neighbourhood characteristics in a large trial of Housing First (HF) in 5 Canadian cities. The OHQS provided an opportunity to explore the role of neighbourhood and its contribution to housing stability among formerly homeless individuals. A subset of 423 participants who had become housed in the second year of the trial were systematically selected. The psychometric properties of the neighbourhood quality (NQ) items were assessed within the OHQS. The association between NQ and housing stability was explored using ordinal logistic regression, adjusting for group, site, demographic, housing unit and building quality variables. Inter-rater reliability and internal consistency were very good for the NQ items and subscale. Although NQ was not predictive of housing stability after considering other residence and building features in the multivariable analysis, we assert further analysis is required to explore this relationship, especially for HF programs offering clients choice in housing and neighbourhood.

IntroductionPregnant and postpartum women face major psychological stressors that put them at higher risk of developing common mental disorders, such as depression and anxiety. Yet, their limited access to and uptake of traditional mental health care is inequitable, especially during the COVID-19 pandemic. Mobile interventions emerged as a potential solution to this discontinued healthcare access, but more knowledge is needed about their effectiveness and impact on health equity. This equity-focused systematic review examined the effectiveness and equity impact of mobile interventions targeting common mental disorders among pregnant and postpartum women.Methods and resultsWe systematically searched MEDLINE, EMBASE, PsychINFO and 3 other databases, from date of database inception and until January 2021, for experimental studies on mobile interventions targeting pregnant and postpartum women. We used pooled and narrative synthesis methods to analyze effectiveness and equity data, critically appraised the methodological rigour of included studies using Cochrane tools, and assessed the certainty of evidence using the GRADE approach. Our search identified 6148 records, of which 18 randomized and non-randomized controlled trials were included. Mobile interventions had a clinically important impact on reducing the occurrence of depression (OR = 0.51 [95% CI 0.41 to 0.64]; absolute risk reduction RD: 7.14% [95% CI 4.92 to 9.36]; pConclusionAs the COVID-19 pandemic has increased the need for virtual mental health care, mobile interventions show promise in preventing and managing common mental disorders among pregnant and postpartum women. Such interventions carry the potential to address health inequity but more rigorous research that examines patients' intersecting social identities is needed.

Abstract Background Housing First is an effective intervention to stably house and alter service use patterns in a large proportion of homeless people with mental illness. However, it is unknown whether there are differences in the patterns of service use over time among those who do or do not become stably housed and what effect, if any, Housing First has on these differing service use patterns. This study explored changes in the service use of people with mental illness who received Housing First compared to standard care, and how patterns of use differed among people who did and did not become stably housed. Methods The study design was a multi-site randomized controlled trial of Housing First, a supported housing intervention. 2039 participants (Housing First: n = 1131; standard care: n = 908) were included in this study. Outcome variables include nine types of self-reported service use over 24 months. Linear mixed models examined what effects the intervention and housing stability had on service use. Results Participants who achieved housing stability, across the two groups, had decreased use of inpatient psychiatric hospitals and increased use of food banks. Within the Housing First group, unstably housed participants spent more time in prison over the study period. The Housing First and standard care groups both had decreased use of emergency departments and homeless shelters. Conclusions The temporal service use changes that occurred as homeless people with mental illness became stably housed are similar for those receiving Housing First or standard care, with the exception of time in prison. Service use patterns, particularly with regard to psychiatric hospitalizations and time in prison, may signify persons who are at-risk of recurrent homelessness. Housing support teams should be alert to the impacts of stay-based services, such as hospitalizations and incarcerations, on housing stability and offer an increased level of support to tenants during critical periods, such as discharges. Trial registration ISRCTN. ISRCTN42520374. Registered 18 August 2009.

BACKGROUND:Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline. METHODS:We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys. FINDINGS:Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants. INTERPRETATION:The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines.

Abstract Background Homelessness is a major concern in many urban communities across North America. Since vulnerably housed individuals are at risk of experiencing homelessness, it is important to identify predictive factors linked to subsequent homelessness in this population. The objectives of this study were to determine the probability of experiencing homelessness among vulnerably housed adults over three years and factors associated with higher risk of homelessness. Methods Vulnerably housed adults were recruited in three Canadian cities. Data on demographic characteristics, chronic health conditions, and drug use problems were collected through structured interviews. Housing history was obtained at baseline and annual follow-up interviews. Generalized estimating equations were used to characterize associations between candidate predictors and subsequent experiences of homelessness during each follow-up year. Results Among 561 participants, the prevalence of homelessness was 29.2 % over three years. Male gender (AOR = 1.59, 95 % CI: 1.14–2.21) and severe drug use problems (AOR = 1.98, 95 % CI: 1.22–3.20) were independently associated with experiencing homelessness during the follow-up period. Having ≥3 chronic conditions (AOR = 0.55, 95 % CI: 0.33–0.94) and reporting higher housing quality (AOR = 0.99, 95 % CI: 0.97–1.00) were protective against homelessness. Conclusions Vulnerably housed individuals are at high risk for experiencing homelessness. The study has public health implications, highlighting the need for enhanced access to addiction treatment and improved housing quality for this population.

We examined the prevalence of substance use disorders among homeless and vulnerably housed persons in three Canadian cities and its association with unmet health care needs and access to addiction treatment using baseline data from the Health and Housing in Transition Study.In 2009, 1191 homeless and vulnerably housed persons were recruited in Vancouver, Toronto, and Ottawa, Canada. Interviewer administered questionnaires collected data on socio-demographics, housing history, chronic health conditions, mental health diagnoses, problematic drug use (DAST-10≥6), problematic alcohol use (AUDIT≥20), unmet physical and mental health care needs, addiction treatment in the past 12 months. Three multiple logistic regression models were fit to examine the independent association of substance use with unmet physical health care need, unmet mental health care need, and addiction treatment.Substance use was highly prevalent, with over half (53%) screening positive for the DAST-10 and 38% screening positive for the AUDIT. Problematic drug use was 29%, problematic alcohol use was lower at 16% and 7% had both problematic drug and alcohol use. In multiple regression models for unmet need, we found that problematic drug use was independently associated with unmet physical (adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI] 1.43-2.64) and unmet mental (AOR 3.06; 95% CI 2.17-4.30) health care needs. Problematic alcohol use was not associated with unmet health care needs. Among those with problematic substance use, problematic drug use was associated with a greater likelihood of accessing addiction treatment compared to those with problematic alcohol use alone (AOR 2.32; 95% CI 1.18-4.54).Problematic drug use among homeless and vulnerably housed individuals was associated with having unmet health care needs and accessing addiction treatment. Strategies to provide comprehensive health services including addiction treatment should be developed and integrated within community supported models of care.

L’article décrit les contextes entourant les politiques qui soutiennent l’application du modèle d’intervention qui accorde la priorité au logement (Housing First) pour les personnes itinérantes présentant des troubles mentaux au Canada et en France. Le modèle consiste en une modalité d’intervention complexe qui élargit le concept de traitement en santé mentale pour y inclure la notion de logement. La démarche, axée sur le rétablissement, place le choix de l’usager quant au logement et aux services de soutien au centre de la philosophie de la prestation de soins. L’article décrit deux essais multicentriques liés à l’intervention qui se déroulent dans deux pays et précise en quoi ils se ressemblent ou diffèrent, compte tenu des particularités culturelles et sociales. Les essais pragmatiques portant sur des modalités d’intervention complexes représentent des défis et ont un pouvoir d’influence unique. C’est ce dont tiennent compte les deux études.