Article

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

ABSTRACT

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.

Download full-text

Full-text

Available from: Patricia O'Campo, Mar 14, 2015
  • Source
    • "Current approaches to evaluation, including evaluation of Housing First programs, have tended to emphasize outcome measures focussed on individual change (Pauly et al., 2012). Several authors have identified the need for research that draws on methodological approaches which provide a better understanding of the context or systems in which interventions are being implemented and impacts on program success (Gaetz et al., 2013b;Dunn et al., 2013;Fitzpatrick, 2005;O'Campo et al., 2009;Nelson et al., 2014;Johnsen and Teixeira, 2012). AsDunn et al. (2013)observes in relation to implementation of Housing First, knowledge of the context is essential to understand the conditions in which program outcomes were achieved in order to facilitate transfer of knowledge from one jurisdiction to another. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose -The purpose of this paper is to provide rationale, methodological guidance and clarity in the use of case study designs and theory driven approaches to evaluation of interventions to end homelessness.
    Full-text · Article · Dec 2014 · Housing, Care and Support
  • Source
    • "In addition, a more specific intervention model or " program theory " is often needed to help explain how and why the intervention is designed to achieve its intended primary outcome(s). Although the method is relatively unknown among U.S. public health and biomedical researchers, it has been applied to projects in numerous subject areas in the United Kingdom, Canada, Australia, and New Zealand, including assessing threats to public health legislative interventions (Wong, Pawson, & Owen, 2011), effects of housing on mental health (Jackson et al., 2009), assessing which combination of services best supports homeless people with substance use and mental health disorders (O'Campo et al., 2009), and retention of health workers in rural areas (Dieleman, Kan, Zwanikken, & Gerretsen, 2011). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The objective of this study was to determine the environmental features that best support aging in place. We conducted a realist synthesis, a theory-driven interpretive method of evidence synthesis, of 120+ articles (published 1991-2011) that attempts to explain how place may influence older adults' decisions about mobility (e.g., physical activity). We developed an initial program theory, reviewed the literature, identified outcomes, analyzed and synthesized patterns, and created a final program theory. Safety was a central mechanism, serving as one of the bridges between environmental components (e.g., connectivity, aesthetics, retail and services) and decisions about mobility. Population density, sidewalk presence, and park proximity did not emerge as key factors. Safety considerations are one of the most prominent influences of older adults' decisions about mobility. Street connectivity, pedestrian access and transit, and retail and services were also important. These factors are amenable to change and can help promote mobility for older adults.
    Full-text · Article · Apr 2014 · Journal of Aging and Health
  • Source
    • "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. "
    [Show abstract] [Hide abstract]
    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.
    Full-text · Article · Jan 2014 · BMC Pregnancy and Childbirth
Show more