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Abstract

In this chapter, we provide a framework for understanding and improving housing and quality of life (QOL). We begin by reviewing different approaches to the study of QOL, including the social indicators approach and the assessment of objective life conditions, subjective well-being, and positive psychological and social functioning. Adopting an ecological perspective, we show that QOL can be conceptualized at multiple levels of analysis ranging from the macro-system (the good society), to the meso-system (the good life), to the individual (well-being), and we note the correspondence between these levels and the different approaches to the study of QOL. The first part of the review of the literature on housing and QOL focuses on linkages between the macro-level and the meso-level and between the meso-level and the individual. We show that the macro-level conditions of poverty, racism, and declining social capital are associated with reduced access to high quality housing, and that the meso-level conditions of homelessness, housing quality, housing choice, and extra-housing factors (e.g., neighborhood qualities, social support) are related to individual well-being. The second part of the review examines programs and policies to improve housing and QOL. Research has shown that comprehensive housing and support programs have proven to be more effective in improving the QOL of individuals than more narrowly focused programs. Unfortunately, recent housing policies in Canada and the U.S. have not adequately supported comprehensive housing programs and, in fact, have led to an increase in the homeless population. Various advocacy efforts that are currently underway to improve housing policy are described. The purpose of this chapter is to provide a way of thinking about and improving housing and quality of life (QOL). We begin with an overview of the various approaches to the study of QOL. Next, we introduce an ecological framework to conceptualize housing and QOL and review literature on this topic in terms of this framework. In the following section we consider programs and policies designed to improve housing and QOL. While we touch on many different health issues in this review, we pay particular attention to mental health, as there has been a great deal of research on housing and QOL with people with mental health issues. As shown in Table 194‐1 , there have been 17 reviews of the literature dealing with housing and mental health, and 14 of those reviews have been published since 1997. We conclude with recommendations for future research and action

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... For example, in Canada, the Progressive Conservative Mulroney government eliminated federal funding for affordable housing in the 1980s, and the Liberal Chretien government downloaded responsibility for housing to the municipalities in the 1990s. Fewer than 1,000 units of low-income housing were created from 1993 to 2000, compared with 25,000 units that were created in 1980 alone (Nelson and Saegert 2009). It is within this context of neoliberalism and the political right's demands for austerity measures that Sarason's (1984) injunction for community psychologists to engage in public policy becomes both more compelling and more challenging. ...
... Homelessness is another social problem that is subject to contested viewpoints. Framing homelessness as a structural problem of income inequality, housing advocates in Canada have pushed for renewed federal involvement in the creation of affordable housing (Nelson and Saegert 2009). In contrast, when he was campaigning for the Ontario Progressive Conservative leadership in 2002, Jim Flaherty, now Minister of Finance in the federal government of Canada, called for homeless people to be jailed. ...
... Housing First for people with addictions and mental health issues focuses the problem as people with complex needs, not a lack of affordable housing. Also, the solution in Housing First lies in the private housing market, which has the support of landlords and property owners, not in the expansion of affordable housing, which has been cut back by neo-liberal policies (Nelson and Saegert 2009). The development of mental health consumer/survivor participation and CSIs occurred in the context of deinstitutionalization, which resulted, in part, because institutions were becoming expensive to operate (Nelson 2012). ...
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I present ideas about how community psychologists, as researcher-activists, can influence public policy. I begin by describing the current neo-liberal era, noting the immense obstacles it poses to progressive policy change. Next I contrast two approaches to understanding policy formation, evidence-based policy and discursive policy analysis, and argue that transformative policy change can benefit from both approaches. I then propose three types of policy outcomes that community psychology research and activism should aim to promote: (a) shaping problem definition, (b) controlling channels for debate and participation, and (c) allocating resources. I use examples from community psychologists' involvement in policy, mostly in Canada, to illustrate how such policy change can be both achieved and constrained. I conclude by discussing implications for theory and practice related to policy change.
... Housing is an important mental health determinant (Nelson and Saegert, 2009). There are, however, large differences within mental health services and across countries on housing support for people with psychiatric disabilities. ...
Purpose The purpose of the study was to test the psychometric properties and dimensionality of the instrument Quality in Psychiatric Care – Housing (QPC–H) and briefly describe the residents perception of quality of housing support. Design/methodology/approach A sample of 174 residents from 22 housing support services in nine Swedish municipalities participated in the study. Confirmatory factor analysis revealed that the QPC–H consisted of six dimensions and had a factor structure largely corresponding to that found among other instruments in the Quality in Psychiatric Care family of instruments Findings Confirmatory factor analysis revealed that the QPC–H consisted of six dimensions and had a factor structure largely corresponding to that found among other instruments in the Quality in Psychiatric Care family of instruments. The internal consistency of the factors was acceptable except in the case of secure and secluded environment, probably due to few numbers of items. With this exception, the QPC–H shows adequate psychometric properties. Originality/value The QPC–H includes important aspects of residents’ assessment of quality of housing service and offers a simple and inexpensive way to evaluate housing support services from the residents’ perspective.
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The aim of this present study is to examine whether overall subjective quality of life and specific domains of quality of life change among homeless adults after they become housed, and if so, what factors predict changes in satisfaction. The data analysed here were collected through face-to-face interviews with a sample of 485 homeless adults who were interviewed as often as bi-monthly over a 16-month period. Bivariate analyses examined initial differences between three groups: homeless people who did not exit from homelessness; those with an exit from homelessness to dependent housing; and those with an exit to independent housing. Bivariate analyses also examined differences in subjective quality of life before and after an exit from homelessness among the three groups. Multivariate analyses identified predictors of changes in quality of life before and after exit. This study has three main findings. First, homeless people who obtained independent housing had the largest positive and significant improvements in satisfaction with overall quality of life, and in satisfaction with housing, leisure and money. Second, becoming housed was not a predictor of changes in overall quality of life perceived by homeless people, nor in their satisfaction with leisure, clothing, food, and social life. Furthermore, a positive change in housing satisfaction was not associated with all types of exits from homelessness; only a move into independent housing predicted such a change, but a move into dependent housing did not. Finally, of all the covariates included as predictors at baseline, only two variables seemed to consistently predict changes in satisfaction; namely, self-assessed general health and self-assessed self-help skills. This study suggested that becoming independently housed may improve some aspects of quality of life for homeless people, but not others. The results suggest that homeless people prefer to be independently housed relative to remaining homeless or staying in a dependent housing situation, but that independent housing does not necessarily improve other aspects of their lives.
Article
Among several viable explanations for the ubiquitous SES-health gradient is differential exposure to environmental risk. We document evidence of inverse relations between income and other indices of SES with environmental risk factors including hazardous wastes and other toxins, ambient and indoor air pollutants, water quality, ambient noise, residential crowding, housing quality, educational facilities, work environments, and neighborhood conditions. We then briefly overview evidence that such exposures are inimical to health and well-being. We conclude with a discussion of the research and policy implications of environmental justice, arguing that a particularly salient feature of poverty for health consequences is exposure to multiple environmental risk factors.
Article
De-institutionalization has led to the provision of various forms of housing with or without support for people with mental illness in the community. In this paper, we review the conceptual issues related to the provision of supported housing schemes, the characteristics of residents, research methods and outcomes, and the factors influencing the quality of care provided. A Medline and hand search of published literature was complemented by information derived from contacting expert researchers in the field. There is considerable diversity of models of supported housing and inconsistent use of terminology to describe them. This makes it difficult to compare schemes, processes, and outcomes. Patients in supported housing are characterized by deficits in self-care and general functioning, whilst behavioral problems such as violence, drug abuse and extreme antisocial habits predict exclusion from supported housing. Most evaluative studies are merely descriptive. In terms of outcomes, it seems that functioning can improve, social integration can be facilitated, and residents are generally more satisfied in supported housing compared with conventional hospital care. Further evidence suggests that most patients prefer regimes with low restrictiveness and more independent living arrangements, although loneliness and isolation have occasionally been reported to be a problem. Little information is available on the factors that mediate outcomes and on skills required by staff. Research in supported housing for psychiatric patients has so far been neglected. Large scale surveys on structure, process, and outcomes across a variety of housing schemes may be useful in the future to identify some of the key variables influencing outcomes. The use of direct observation methods in conjunction with other more conventional, standardized instruments may also highlight areas for improvement. In conducting research, structure and process, as well as outcomes, need to be considered. Thus, we need to know not just what to provide, but how to provide it in such a way that it will maximize beneficial outcomes. This represents a considerable research agenda.
Article
We sought to characterize and to evaluate the success of current public health interventions related to housing. Two reviewers content-analyzed 72 articles selected from 12 electronic databases of US interventions from 1990 to 2001. Ninety-two percent of the interventions addressed a single condition, most often lead poisoning, injury, or asthma. Fifty-seven percent targeted children, and 13% targeted seniors. The most common intervention strategies employed a one-time treatment to improve the environment; to change behavior, attitudes, or knowledge; or both. Most studies reported statistically significant improvements, but few (14%) were judged extremely successful. Current interventions are limited by narrow definitions of housing and health, by brief time spans, and by limited geographic and social scales. An ecological paradigm is recommended as a guide to more effective approaches.
Article
This study examined the various living arrangements among formerly homeless adults with mental illness 12 months after they entered case management. The study surveyed 5,325 clients who received intensive case management services in the Access to Community Care and Effective Services and Supports (ACCESS) program. Living arrangements 12 months after program entry were classified into six types on the basis of residential setting, the presence of others in the home, and stability (living in the same place for 60 days). Differences in perceived housing quality, unmet housing needs, and overall satisfaction were compared across living arrangements by using analysis of covariance. One year after entering case management, 37 percent of clients had been independently housed during the previous 60 days (29 percent lived alone in their own place and 8 percent lived with others in their own place), 52 percent had been dependently housed during the previous 60 days (11 percent lived in someone else's place, 10 percent lived in an institution, and 31 percent lived in multiple places), and 11 percent had literally been homeless during the previous 60 days. Clients with less severe mental health and addiction problems at baseline and those in communities that had higher social capital and more affordable housing were more likely to become independently housed, to show greater clinical improvement, and to have greater access to housing services. After the analysis adjusted for potentially confounding factors, independently housed clients were more satisfied with life overall. However, no significant association was found between specific living arrangements and either perceived housing quality or perceived unmet needs for housing. Living independently was positively associated with satisfaction of life overall, but it was not associated with the perception that the quality of housing was better or that there was less of a need for permanent housing.
Article
Supported housing is broadly defined as independent housing in the community that is coupled with the provision of community mental health and support service. Recent studies have provided more rigorous examination of housing and supports for persons with mental illnesses. These studies, reviewed in this article,have examined a broad range of independent housing with a range of supports. Some have been developed out of the mental health tradition of "housing as housing," most typically called "supported housing," and other models that have emerged from a movement focused on affordable housing as a means to decrease homelessness. The evidence base on supported housing is small, less than perfect, and nascent despite the length of time that the mental health service system has been debating the housing issues. There is enough quality evidence offered by the studies, however, to guide mental health providers in how best to meet the housing needs of their clients. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Article
To carry out a preliminary systematic review of literature to address the question - among rich nations (or states within nations) what is the evidence that income inequality and differences in macro-level social policy affect rates of infant mortality and low birthweight (LBW)? A systematic literature review. Medline database (1968-August 2003) was searched for empirical studies of the relationship between macro-level economic and social policies in rich nations and rates of infant mortality (IMR) and LBW. Cross-national comparison of infant mortality and LBW that did not compare the effects of macro-level economic and social policies was excluded from the review as were studies including less developed countries. Keywords representing IMR and LBW were entered into Medline along with exposures related to international comparison and macro-level policy. Abstracts obtained from the initial search were reviewed for relevant studies. Full papers of potentially relevant studies were obtained and reviewed for inclusion. Secondary search of papers cited in included papers was undertaken. For this review, papers were not excluded on the basis of quality although methodological limitations were commented on and taken into account in interpreting the results. Summary statistics were not estimated. Twelve studies, fulfilling the inclusion criteria, were identified. Ten studies examined the association of IMR with income inequality, eight of which reported a statistically significant positive association with higher levels of inequality after adjustment for a range of variables. Six studies reported significant positive associations of IMR with other indicators of less re-distributive social and economic policy. Associations with LBW were reported in four studies; three showed significant positive associations with higher levels of income inequality and one showed no association with low levels of parental leave entitlement. Methodological differences, particularly the wide range of variables used to adjust for confounding, make interpretation of the findings difficult. The results of this review represent a preliminary attempt to summarize the literature linking macro-level economic and social policies in rich nations with IMR and LBW. The findings, taking account of the methodological limitations of the review and of the included studies, suggest a statistically significant association between IMR and higher income inequality and other indicators of less re-distributive social policy. Only three studies examined the association of income inequality with LBW and, although they suggest a significant association, further studies will be needed to confirm this finding.
Article
Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people. MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria. Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes. Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.
Article
This research examined two premises of supported housing: (a) that consumer choice/control over housing and support and the quality of housing are important contributors to the subjective quality of life and adaptation to community living of people with mental illness, and (b) that apartments provide mental health consumers with more choice/control over housing and support than group living arrangements. To test these two hypotheses, we collected data from participants with mental illness housed through a government initiative in Ontario, Canada. A total of 130 participants completed a baseline interview, and 91 of those participants also completed a follow-up interview 9-months later. Support was found for both hypotheses. The results were discussed in terms of the paradigm of supported housing, previous research, and implications for housing policy and program development in the community mental health sector.
Article
In 1992, the US Department of Housing and Urban Development (HUD) and the US Department of Veterans Affairs (VA) established the HUD-VA Supported Housing (HUD-VASH) Program to provide integrated clinical and housing services to homeless veterans with psychiatric and/or substance abuse disorders at 19 sites. At four sites, 460 subjects were randomly assigned to one of the three groups: (1) HUD-VASH, with both Section 8 vouchers and intensive case management; (2) case management only; and (3) standard VA care. A previous publication found HUD-VASH resulted in superior housing outcomes but yielded no benefits on clinical outcomes. Since many participants missed prescheduled visits during the follow-up period and follow-up rates were quite different across the groups, we reanalyzed these data using multiple imputation statistical methods to account for the missing observations. Significant benefits were found for HUD-VASH in drug and alcohol abuse outcomes that had not previously been identified.
Article
This article contrasts values associated with the delivery of housing programs for people with serious mental illness with the typical topics pertaining to housing that are studied by researchers. Six values were identified through a search and content analysis of the literature on housing for people with serious mental illness. A second review of the literature was conducted to identify research on housing for this population. A comparison of findings from the two reviews suggested that whereas values concerned with the therapeutic benefits of housing had received considerable research attention, those concerned with a citizenship dimension had received relatively little. The findings are discussed in terms of their implications for the delivery of housing services and for housing research.
Article
A review of 16 controlled outcome evaluations of housing and support interventions for people with mental illness who have been homeless revealed significant reductions in homelessness and hospitalization and improvements in other outcomes (e.g., well-being) resulting from programs that provided permanent housing and support, assertive community treatment (ACT), and intensive case management (ICM). The best outcomes for housing stability were found for programs that combined housing and support (effect size = .67), followed by ACT alone (effect size = .47), while the weakest outcomes were found for ICM programs alone (effect size = .28). The results of this review were discussed in terms of their implications for policy, practice, and future research.
Article
Individuals with severe and persistent mental illness (SPMI) identify housing as an important factor in achieving and maintaining their health. However, many live in substandard accommodations that are physically inadequate, crowded, noisy and located in undesirable neighbourhoods. In much of the research on housing for persons with SPMI, the central outcome of interest is remaining housed; however, it is worth investigating whether housing has other benefits. This paper is a systematic review of studies that investigated the relationship between housing-related independent variables and health-related dependent variables. Ten online databases were searched for studies published since 1980 that had study populations of adults with SPMI, analysed primary or secondary empirical data, and measured housing-related independent variables and health-related dependent variables. Clearly defined epidemiological criteria were used to assess the strength of evidence of the selected studies. Twenty-nine studies met the suitability criteria, of which 14 reported healthcare utilisation outcomes; 12 examined mental status outcomes; and 9 reported quality-of-life outcomes. The findings of the review suggest that there is good evidence that housing interventions benefit the homeless population; however more research is needed about housing solutions for individuals with SPMI who are housed, but in precarious or inappropriate housing situations. Study methodologies could be improved by emphasising longitudinal designs that focus on participant retention and by implementing matched control groups or randomised interventions to strengthen internal validity. Ensuring that a person is adequately housed upon discharge from hospital should be a treatment priority. When housing eligibility is not dependent on psychiatric treatment compliance and sobriety, providing permanent housing minimises harm and may free people to voluntarily seek treatment. Housing that offers an unlimited length of stay is recommended because SPMI is a chronic and fluctuating condition that requires stable surroundings to maintain health.
Article
This paper describes and critiques the income inequality approach to health inequalities. It then presents an alternative class-based model through a focus on the causes and not only the consequences of income inequalities. In this model, the relationship between income inequality and health appears as a special case within a broader causal chain. It is argued that global and national socio-political-economic trends have increased the power of business classes and lowered that of working classes. The neo-liberal policies accompanying these trends led to increased income inequality but also poverty and unequal access to many other health-relevant resources. But international pressures towards neo-liberal doctrines and policies are differentially resisted by various nations because of historically embedded variation in class and institutional structures. Data presented indicates that neo-liberalism is associated with greater poverty and income inequalities, and greater health inequalities within nations. Furthermore, countries with Social Democratic forms of welfare regimes (i.e., those that are less neo-liberal) have better health than do those that are more neo-liberal. The paper concludes with discussion of what further steps are needed to "go beyond" the income inequality hypothesis towards consideration of a broader set of the social determinants of health.
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  • Commonwealth Fund
In: Westhues A (ed.) Canadian Social Policy: Issues and Perspectives
  • L Caragata
Return to Community: Building Support Systems for People with Psychiatric Disabilities
  • Pj Carling