Community-Based Services for Homeless Adults Experiencing Concurrent Mental Health and Substance Use Disorders: A Realist Approach to Synthesizing Evidence

The Centre for Research on Inner City Health, The Keenan Research Centre, LiKaShing Knowledge Institute, St. Michael's Hospital, Toronto, Canada. O'
Journal of Urban Health (Impact Factor: 1.9). 09/2009; 86(6):965-89. DOI: 10.1007/s11524-009-9392-1
Source: PubMed


Consultations with community-based service providers in Toronto identified a lack of strong research evidence about successful community-based interventions that address the needs of homeless clients experiencing concurrent mental health and substance use disorders. We undertook a collaborative research effort between academic-based and community-based partners to conduct a systematic evidence synthesis drawing heavily from Pawson's realist review methodology to focus on both whether programs are successful and why and how they lead to improved outcomes. We examined scholarly and nonscholarly literature to explore program approaches and program elements that lead to improvements in mental health and substance use disorders among homeless individuals with concurrent disorders (CD). Information related to program contexts, elements, and successes and failures were extracted and further supplemented by key informant interviews and author communication regarding reviewed published studies. From the ten programs that we reviewed, we identified six important and promising program strategies that reduce mental health and, to a far lesser degree, substance use problems: client choice in treatment decision-making, positive interpersonal relationships between client and provider, assertive community treatment approaches, providing supportive housing, providing supports for instrumental needs, and nonrestrictive program approaches. These promising program strategies function, in part, by promoting and supporting autonomy among homeless adults experiencing CD. Our realist informed review is a useful methodology for synthesizing complex programming information on community-based interventions.

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Available from: Patricia O'Campo, Mar 14, 2015
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    • "We have used here the meta-theory of critical realism for the generation of causal explanations in social epidemiology as a response to the criticisms put forward by Muntaner (1999), O’Campo [36] and Raphael [38]. The development of realist methodologies in epidemiology and population health is relatively new although advances have been made in policy and program evaluation [73] and evidence based reviews [74]. As a meta-theory, critical realism seems to be ideally suited for social epidemiology theory building and testing. "
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    ABSTRACT: The aim of the qualitative study reported here was to: 1) explain the observed clustering of postnatal depressive symptoms in South Western Sydney; and 2) identify group-level mechanisms that would add to our understanding of the social determinants of maternal depression. Critical realism provided the methodological underpinning for the study. The setting was four local government areas in South Western Sydney, Australia. Child and Family practitioners and mothers in naturally occurring mothers groups were interviewed. Using an open coding approach to maximise emergence of patterns and relationships we have identified seven theoretical concepts that might explain the observed spatial clustering of maternal depression. The theoretical concepts identified were: Community-level social networks; Social Capital and Social Cohesion; "Depressed community"; Access to services at the group level; Ethnic segregation and diversity; Supportive social policy; and Big business. We postulate that these regional structural, economic, social and cultural mechanisms partially explain the pattern of maternal depression observed in families and communities within South Western Sydney. We further observe that powerful global economic and political forces are having an impact on the local situation. The challenge for policy and practice is to support mothers and their families within this adverse regional and global-economic context.
    BMC Pregnancy and Childbirth 01/2014; 14(1):47. DOI:10.1186/1471-2393-14-47 · 2.19 Impact Factor
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    • "As a meta-theory critical realism seems to be ideally suited for social epidemiology theory building and testing. Qualitative methods for confirmatory studies are well supported by critical realism (Sayer 2000; Danermark et al. 2002) and realist approaches are gaining credibility in relation to evidence-based policy and programme evaluation (Pawson 2006; O'Campo et al. 2009a; McGuire 2005). From a critical realist perspective quantitative modelling can be very useful to test out possible explanations (Mingers 2006) but findings are “not assumed as closure on reality” (Olsen and Morgan 2005). "
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    ABSTRACT: A recent criticism of social epidemiological studies, and multi-level studies in particular has been a paucity of theory. We will present here the protocol for a study that aims to build a theory of the social epidemiology of maternal depression. We use a critical realist approach which is trans-disciplinary, encompassing both quantitative and qualitative traditions, and that assumes both ontological and hierarchical stratification of reality. We describe a critical realist Explanatory Theory Building Method comprising of an: 1) emergent phase, 2) construction phase, and 3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design is described. The Emergent Phase uses: interviews, focus groups, exploratory data analysis, exploratory factor analysis, regression, and multilevel Bayesian spatial data analysis to detect and describe phenomena. Abductive and retroductive reasoning will be applied to: categorical principal component analysis, exploratory factor analysis, regression, coding of concepts and categories, constant comparative analysis, drawing of conceptual networks, and situational analysis to generate theoretical concepts. The Theory Construction Phase will include: 1) defining stratified levels; 2) analytic resolution; 3) abductive reasoning; 4) comparative analysis (triangulation); 5) retroduction; 6) postulate and proposition development; 7) comparison and assessment of theories; and 8) conceptual frameworks and model development. The strength of the critical realist methodology described is the extent to which this paradigm is able to support the epistemological, ontological, axiological, methodological and rhetorical positions of both quantitative and qualitative research in the field of social epidemiology. The extensive multilevel Bayesian studies, intensive qualitative studies, latent variable theory, abductive triangulation, and Inference to Best Explanation provide a strong foundation for Theory Construction. The study will contribute to defining the role that realism and mixed methods can play in explaining the social determinants and developmental origins of health and disease.
    SpringerPlus 01/2014; 3(1):12. DOI:10.1186/2193-1801-3-12
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    • "En effet, ces théories sont rarement explicitées dans les travaux publiés, notamment du fait des contraintes de mots imposées par les revues. Ces restrictions expliquent également la difficulté pour les auteurs de synthèses de trouver des éléments contextuels (Kane, Gerretsen, Scherpbier, Dal Poz, & Dieleman, 2010; O'Campo et al., 2009), ou encore les mécanismes en oeuvre (Dieleman et al.; Leeman et al., 2010). Il peut aussi arriver que plusieurs théories soient sous-jacentes à une seule intervention, mais que les analyses menées sur cette intervention ne concernent qu'une ou certaines de ces théories. "

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