Table 2

Summary of Evidence Table: Interventions for Homeless People



Interventions for Homeless People with Mental Illness

Forchuk et al., 2008 [82]

• Study design: Randomized controlled trial (RCT)

• Sample size: 14

• Study population: Patients being discharged from psychiatric wards to shelters and 'no fixed address'.

• Approach: This pilot study examined the effectiveness of an intervention in preventing homelessness upon discharge from a psychiatric admission.

All the individuals in the intervention group maintained housed status at 3 and 6 months following hospital discharge. All but one participant in the control group remained homeless after 3 and 6 months (p < .001)

Interventions for Homeless People with Substance Abuse

Larimer et al., 2009 [83]

• Study design: Quasi-experimental with four data points (baseline, 3, 6 and 12 months)

• Sample size: 134

• Study population: Study reports drawing from a 'chronically homeless' list of individuals with high local crisis services utilization patterns. Chronic homelessness is not further defined.

• Approach: This study evaluated the association of a Housing First intervention for chronically homeless individuals with severe alcohol problems with health care use and costs.

Median number of drinks dropped from 15.7 per day prior to housing to 14.0, 12.5, and 10.6 per day at 6, 9, and 12 months in housing respectively. Poisson GEE with a linear time covariate showed a similar trend to the medians, with an approximately 2% decrease per month in daily drinking while participants were housed (RR, 0.98; 95% CI, 0.96-0.99).

Milby et al., 2004; Milby et al., 2003; Milby et al., 2000 [14-16]

• Study design: RCT

• Sample size: 110 (Milby et al., 2000); 141 (Milby et al., 2003; 2004)

• Study population: Homeless population defined as lacking a fixed overnight residence, including shelters or temporary accommodations, or were at immediate risk of being homeless.

• Approach: This study the effectiveness of behavioural day treatment plus abstinence-contingent housing and work therapy (DT+) versus behavioural day treatment (DT) alone on abstinence and housing outcomes.

Percentages of days abstinent over proceeding 60 days at 2 months were for DT 41% versus DT+ 71%, and at 6 months were for DT 15% versus DT+ 41%. Of the 117 participants who established complete or partial abstinence, lapse (i.e., drug use during 1 week or less) was lower in the DT group than the DT+ group (45% vs 61%). Relapse (i.e., drug use in at least 2 consecutive weeks over the 24-weeek period), however, was considerably higher with DT compared to DT+ treatment (81% vs 55%). The only significant difference in percentage days housed between DT and DT+ was at the 6-month point. The number of mean days housed in the past 60 days increased in both groups.

Milby et al., 2005; Kertesz et al., 2007 [17,18]

• Study design: RCT

• Sample size: 196

• Study population: Homeless population defined as lacking a fixed overnight residence, including shelters or temporary accommodations, or were at immediate risk of being homeless.

• Approach: This RCT examined how substance abuse treatment outcomes were affected under 3 different housing provision conditions (N = 195).

There was evidence of an overall housing group effect and an effect of attendance on abstinence. The mean adjusted consecutive weeks of abstinence for the 'No Housing' (NH), 'non-abstinence-contingent housing' (NACH) and abstinence-contingent housing (ACH) groups were 5.28, 4.68, and 7.32, with a significant difference between the ACH group and the NH group and between the ACH group and the NACH groups, but no difference between the NACH group and the NH group. There were significant within-group housing changes from baseline to 12 months for all groups and for each group.

Gulcur et al., 2003; Tsemberis et al., 2004; Tsemberis et al., 2003; Padgett et al., 2006; Greenwood et al., 2005; Stefancic et al., 2004 [20-22,52-54]

• Study design: RCT

• Sample size: 225

• Study population: Met the following criteria for homelessness: spent 15 out of the last 30 days on the street (not including shelters) and experienced period of 'housing instability' (not defined) within last six months.

• Approach: This set of papers reported on an RCT that examined two approaches to housing chronically homeless individuals with psychiatric disabilities and substance abuse (Pathways First; Continuum of Care) (N = 225).

Housing First increased housing tenure and reduced hospitalization. This successful program offers housing first and has a focus on client choice. Proportion of time homeless: At the end of 6 months after baseline 79% of the experimental group were living in stable housing compared to 27% in the control group. Proportion of time hospitalized: The control group spent significantly more time in hospitals than the experimental group. Substance use: There were no differences in either alcohol or drug use between the 2 groups. Substance use treatment utilization: The control group reported higher use of substance abuse treatment programs than the Housing First group. A decrease in service use occurred in the Housing First group and an increase occurred in the control group over time. Psychiatric symptoms: No significant differences in psychiatric symptoms between groups.

Interventions for Homeless People with HIV

Kushel et al., 2006 [101]

• Study design: Prospective observational cohort

• Sample size: 280

• Study population: HIV+ homeless and marginally housed individuals. Homeless was defined as ≥ one night on street or in shelter in last quarter, whereas marginally housed was defined as ≥ 90% of nights in single-room occupancy dwelling in past quarter with no nights spent on street or in shelter.

• Approach: This study examined the effect of case management on acute health services use and health outcomes in homeless or marginally housed persons with HIV.

Health services utilization: Moderate CM was associated with increased adherence to antiretroviral therapy compared to no or rare CM. CM was not associated with increased use of primary care or hospital-based services. Health/biological: Both consistent and moderate CM were associated with ≥ 50% improvements in CD4+ cell count.

Rotheram-Borus et al., 2009 [97]

• Study design: RCT, sub-group analysis

• Sample size: 270

• Study population: HIV+ marginally housed individuals including reports of currently being homeless, living in a shelter or welfare hotel, or having lived in either condition within the 12 months prior to each assessment.

• Approach: The subgroup analysis (N = 270) of participants in a larger RCT (N = 936) examined the efficacy of the Healthy Living Program in reducing sexual behaviour and substance use among adults with HIV who were marginally housed. The intervention might have worked by inducing abstinence from targeted behaviours or by reducing frequency of acts.

Risk behaviours: no statistically significant differences in intervention effects (P values ranged from .072 days using alcohol or marijuana to .275 for number of partners who were HIV-negative or of unknown serostatus). Most significant effects were the numbers of partners who were HIV-negative or of unknown serostatus and the number of days of alcohol or marijuana use. The intervention also reduced the number of risky sexual acts and the number of days of hard drug use compared to the control.

Schwarcz et al., 2009 [98]

• Study design: Retrospective observational study

• Sample size: 6,558

• Study population: HIV+ individuals. Cases were defined as homeless if medical records documented individuals were homeless or if addresses listed in chart were for shelters, health care clinics, or a general delivery address not connected to an address.

• Approach: This study examined the effect of homeless on the mortality of persons with AIDS and the effect of supportive housing on AIDS survival.

After adjusting for confounders, homelessness was significantly associated with increased mortality (RH 1.20; 95% CL 1.03, 1.41). Receiving housing post diagnosis improved survival rates (adjusted RH 0.20; 95% CL 0.05, 0.81).

Slesnick et al., 2007; Slesnick & Kang, 2008 [33,34]

• Study design: RCT

• Sample size: 172

• Study population: Homeless youth, with homelessness defined as having no place of shelter and is in need of services and shelter where supervision and care are provided.

• Approach: This RCT (N = 180) evaluated change in HIV risk behaviours among a sample of homeless youth.

Youth who received the Community Reinforcement Approach therapy + HIV education reported better improvement on the frequency of condom use than the control treatment as usual group. Youth in the intervention group showed a greater decrease in substance free days than in the control group.

Woliski et al., 2009; Kidder et al., 2007 [55,56]

• Study design: RCT

• Sample size: 644

• Study population: HIV+ individuals living in the following housing contexts: having one's own place to live, being unstably housed (staying temporarily with others/living in a transitional setting and had not been homeless), or being homeless ≥ one night (e.g., sleeping in shelters or locations not suitable for human habitation) in the last 90 days.

• Approach: This study evaluated the effectiveness of providing rental assistance to homeless people living with HIV/AIDS on physical health, access to medical care, treatment adherence, HIV risk behaviours, and mental health status.

At 18 months, 51% of the comparison group had housing. Intent-to-treat analysis indicated significant improvements in self-reported physical and mental health. Significant improvements between stably housed versus homeless participants were found in as-treated analysis for health care utilization, perceived stress and detectable viral load.

Fitzpatrick-Lewis et al. BMC Public Health 2011 11:638   doi:10.1186/1471-2458-11-638

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