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Housing and Quality of Life: An Ecological Perspective
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
... 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). ...
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.
A variety of health conditions such as asthma, elevated blood lead levels (BLLs) in children, pesticide poisonings, and falls and trips injuries have been associated with substandard housing conditions, implying that improvement in housing can lead to improved health. This group of researchers previously developed and reported on a Habitability Element Rating Scores (HERS) to compare and rank the strength of habitability laws of US states. HERS considers a State's adoption of elements of Uniform Landlord and Tenant Act (URLTA) for upkeep of property (i.e., raw scores), and the potential of elements to influence tenant health (i.e., weighted scores). Here we examine the relationship of HERS raw scores with various state political and demographic features to investigate potential driving forces for the development/existence of comprehensive and equitable housing standards. Statistically significant associations reveal states tend to emphasise low or high HERS raw scores depending on factors such as rurality and the proportion of a state's legislative body, which indicates its political party affiliation. The group of states with moderately strong laws (n = 11) also tended to be Southern states, with concomitantly higher proportions of minorities in the state, female renters heading the household, and renters living in poverty.
An analysis is made of the influence from the resource and climate factors on the level of social guarantees in Siberia’s northern territories where the climatic resources differ greatly and are characterized by a different level of discomfort. The low standards of subsistence minimum for these territories are caused by imperfection of the existing zoning used in establishing these standards and by an inadequate monitoring network for prices employed by territorial bodies of the Federal State Statistics Service. There is a difference between the actual severity of climate and the standards for food consumption in the central and southern parts of the Sakha (Yakutia) Republic and nonfood consumer goods and services throughout the entire territory of the Extreme North. Furthermore, it is found that the cities used in the observation of prices only poorly reflect the geographical features of the regions, and they are located in the vicinities to the main roads, while the extensive polar regions with an extremely severe level of discomfort and difficult transport accessibility are not included in the monitoring of prices. To achieve substantial improvement in the quality of human life, it is important to make changes in the zoning used in assessing the standards, and in the monitoring network maintained by territorial bodies of the Federal State Statistics Service.
John David Hulchanski & Michael Shapcott, M. editors (2004). Finding room: Policy options for a Canadian rental housing strategy. Toronto: University of Toronto, Centre for Urban and Community Studies, CUCS Press (since 2018, School of Cities, University of Toronto).
ISBN 0-7727-1433-9
Finding Room is the first Canadian book to focus solely on the question of how to provide affordable rental housing for low-income households.
Two dozen authors — from business leaders to university researchers to representatives of the Aboriginal community — address this question.
The contributors offer analyses of the economics of low-rental housing; commentary on the relationship between housing and human rights; social perspectives on the lives and health of low-income renters; overviews of how the current system developed; suggestions for housing innovations; recommendations for all levels of government; and insights into the roles of public, private, and non-profit sectors.
Finding Room is intended to inform discussions of policy options for affordable housing by providing information and analysis from experts in the topic. The contributions suggest a growing consensus about the need for certain policy changes, although several controversial areas remain.
The book is a resource for community leaders, policy makers, researchers, and students. It includes a glossary, key documents relating to housing rights in Canada, and background on the economic and political context written in non-academic language.
—
J. David Hulchanski is director of the Centre for Urban and Community Studies and professor of housing and community development in the Factor Inwentash Faculty of Social Work, University of Toronto. In the 1980s he was a professor in the School of Community and Regional Planning at the University of British Columbia and Director of the UBC Centre for Human Settlements. He has a M.Sc. and Ph.D. in urban planning. In 1997 he was appointed to the only endowed chair in housing studies in North America, th Dr. Chow Yei Ching Chair in Housing.
Michael Shapcott is co-chair and a founding member of the National Housing and Homelessness Network and a founding member of the Toronto Disaster Relief Committee, the Toronto Coalition Against Homelessness, and the Bread Not Circuses Coalition. He is the coordinator of the Community/University Research Partnerships (CURP) program at the Centre for Urban and Community Studies, University of Toronto.
The authors describe the main forms of supported accommodation available to people with mental health problems in the UK. They address the questions of who needs supported accommodation and how people may be selected for the differing types of unit. Historical trends and policy in this area are reviewed and the general research evidence and evidence of cost-effectiveness are considered. A ‘total system’ approach to assessing accommodation need in a locality is advocated. The authors also consider key quality issues that should be addressed for supported accommodation to be effective.
This paper reviews research on how a two-factor model explains relationships between life events and perceptions of life quality. Positive life events were found to have different effects than negative life events. People rated their distress higher after experiencing negative events, but they did not always rate the quality of their daily lives lower. Positive events increased ratings of positive affect but were usually unrelated to psychological distress. While these data fit a two-factor model of psychological well-being best, such a model left some important exceptions to that model unexplained. To address such issues, the review focused on those occasions when the effects of events crossed affective domains. This fuller assessment promises to provide an integrative approach to understanding some of the affective and congnitive processes linking life events to quality of life.
Recent studies suggest the importance of examining cumulative risk or
advantage as potential predictors of health over the life course. Researchers
investigating the cumulative health effects of education, however, have
mainly conceptualized education in years or degrees, often disregarding
educational quality and access to educational opportunities that may place
individuals on divergent academic trajectories. We investigate whether
educational advantages in youth are associated with an individual’s health
trajectory. We develop a novel index of educational advantage and employ
random-intercept modeling using data from the National Longitudinal Survey of
Youth. A widening health disparity was found in adulthood between respondents
with greater and those with fewer educational advantages in youth.
Furthermore, among respondents with few educational advantages, Blacks
experience a greater health burden as they age compared to Whites and
Hispanics. These results suggest that differential access to educational
advantages during youth may contribute to persisting health disparities in
adulthood.
David Rusk, former Mayor of Albuquerque, New Mexico, has observed that "bad neighborhoods defeat good programs". This paper identifies the underlying causes of bad neighbourhoods along with their costs to local residents and residents throughout the region. It is a critical essay that traces recent patterns of uneven metropolitan development, the social forces generating these patterns, their many costs and potential remedies. It demonstrates how the interrelated processes of sprawl, concentration of poverty and racial segregation shape the opportunity structure facing diverse segments of the nation's urban and metropolitan population. In so doing, it draws on recent scholarly literature from various disciplines, government data and documents, research institute reports and the mass media. Topics addressed include income and wealth disparities, employment opportunities, housing patterns, access to health care and exposure to crime. While recognising the role of individual choice and human capital, the paper focuses on public policy decisions and related private-sector activities in determining how place and race shape the opportunity structure of metropolitan areas. Finally, the paper explores various policy options to sever the linkages among place, race and privilege in the nation's urban communities.
This research tested hypotheses derived from motivation-hygiene theory that housing and social support would be differentially related to long-term psychiatric clients' Positive Affect and Negative Affect. The participants were 89 people between the ages of 18 and 65, who had been hospitalized for psychiatric problems at least twice and who had been diagnosed as schizophrenic, chronic depressive, or manic-depressive. Results indicated that the number of Housing Concerns was positively correlated with Negative Affect but not Positive Affect. Support Satisfaction was negatively correlated with Negative Affect, and Frequency of Support was positively correlated with Positive Affect. Interactions between the housing variable and Network Size were found for both Positive Affect and Negative Affect, thus supporting the stress-buffering hypothesis. The findings provided mixed support for motivation-hygiene theory.
Thinkers have discussed the good life and the desirable society for millennia. In the last decades, scientists offered several alternative approaches to defining and measuring quality of life: social indicators such as health and levels of crime, subjective well-being measures (assessing people''s evaluative reactions to their lives and societies), and economic indices. These alternative indicators assess three philosophical approaches to well-being that are based, respectively, on normative ideals, subjective experiences, and the ability to select goods and services that one desires. The strengths and weaknesses of the various approaches are reviewed. It is argued that social indicators and subjective well-being measures are necessary to evaluate a society, and add substantially to the regnant economic indicators that are now favored by policy makers. Each approach to measuring the quality of life contains information that is not contained in the other measures.
This study examined the potential link between housing quality and mental health. First, the development of a psychometrically sound, observer-based instrument to assess physical housing quality in ways conceptually relevant to psychological health is reported. Then 2 different studies, including a prospective longitudinal design, demonstrate that physical housing quality predicts mental health. Possible underlying psychosocial processes for the housing quality-psychological distress link are discussed.
Why are some societies healthier than others? The consensus in development economics is that the health achievement of nations has to do with their levels of economic development. Higher per capita incomes, through steady and stable economic growth, increase a nation's capacity to purchase the necessary economic goods and services that promote health. In this paper, we review the conceptual and empirical linkages between poverty and poor health in both developing and developed countries. The empirical evidence is overwhelming that poverty, measured at the level of societies as well as individuals, is causally related to poor health of societies and individuals, respectively. Recent macroeconomic research has also drawn attention to the role of health as a form of human capital that is vital for achieving economic stability. In particular, attention has been drawn toward the ways in which unhealthy societies impede the process of economic development. However, the reciprocal connection between economic prosperity and improved health is neither automatic nor universal. Other features of society, such as the equality in the distribution of the national wealth, seem to matter as well for improving average population health and especially for reducing inequalities in health. We conclude by arguing for a need to reexamine the way in which health is conceptualized within the macroeconomic development framework.
Despite the increase in consumer-driven interventions for homeless and mentally ill individuals, there is little evidence that these programs enhance psychological outcomes. This study followed 197 homeless and mentally ill adults who were randomized into one of two conditions: a consumer-driven "Housing First" program or "treatment as usual" requiring psychiatric treatment and sobriety before housing. Proportion of time homeless, perceived choice, mastery, and psychiatric symptoms were measured at six time points. Results indicate a direct relationship between Housing First and decreased homelessness and increased perceived choice; the effect of choice on psychiatric symptoms was partially mediated by mastery. The strong and inverse relationship between perceived choice and psychiatric symptoms supports expansion of programs that increase consumer choice, thereby enhancing mastery and decreasing psychiatric symptoms.
This article summarizes the conception and diagnosis of the mental health continuum, the findings supporting the two continua model of mental health and illness, and the benefits of flourishing to individuals and society. Completely mentally healthy adults--individuals free of a 12-month mental disorder and flourishing--reported the fewest missed days of work, the fewest half-day or greater work cutbacks, the healthiest psychosocial functioning (i.e., low helplessness, clear goals in life, high resilience, and high intimacy), the lowest risk of cardiovascular disease, the lowest number of chronic physical diseases with age, the fewest health limitations of activities of daily living, and lower health care utilization. However, the prevalence of flourishing is barely 20% in the adult population, indicating the need for a national program on mental health promotion to complement ongoing efforts to prevent and treat mental illness. Findings reveal a Black advantage in mental health as flourishing and no gender disparity in flourishing among Whites.
Proposes a broader approach to research in human development that focuses on the progressive accommodation, throughout the life span, between the growing human organism and the changing environments in which it actually lives and grows. The latter include not only the immediate settings containing the developing person but also the larger social contexts, both formal and informal, in which these settings are embedded. In terms of method, the approach emphasizes the use of rigorously designed experiments, both naturalistic and contrived, beginning in the early stages of the research process. The changing relation between person and environment is conceived in systems terms. These systems properties are set forth in a series of propositions, each illustrated by concrete research examples. (1¼ p ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In this research, we examined the processes and outcomes of supportive housing for psychiatric consumer/survivors. To determine the relative effectiveness of supportive apartments (SA) and group homes (GH) operated by non-profit mental health agencies, we used a longitudinal design with a non-equivalent comparison group of people residing in private, for-profit board-and-care homes (BCH). A total of 107 psychiatric consumer/survivors completed an initial interview and a follow-up interview one year later. Both quantitative and qualitative data were collected in the interviews. In terms of housing and social support processes, the residents of SA and GH were more likely to have their own room, to spend less of their income on rent, and to have more control in decision-making in the residences than people living in BCH. Residents of group facilities (GH and BCH) had more staff support, more emotional and problem-solving support, and less emotional abuse than residents of SA. The outcome analyses showed that residents in all three types of housing increased their involvement in instrumental roles (e.g., work, education) over time, and residents of SA and GH reported more changes in terms of personal growth and increased community involvement and showed increases in independent functioning, as rated by staff, than residents of BCH. However, none of the groups showed improvement over time on measures of perceived control, resident-rated independent functioning, meaningful activity, positive and negative affect, and life satisfaction. The results are discussed in terms of previous literature and implications for future research. © 1997 John Wiley & Sons, Inc.
Drawing on psychological, health, and social science literature, a housing niche model is developed that focuses on (a) housing markets and other societal processes that constrain residential choice, (b) effects of residential environments on health and access to human and social capital, and (c) family dynamic effects on health and the intergenerational consequences of particular housing niches for future health and housing choices. The model requires the examination of cumulative risks, mediating and moderating processes, and the use of multilevel statistical models. The health consequences of existing housing policies are explored and future directions for research and policy suggested.
Despite the fact that people invest more financial, temporal, and psychological resources in their homes than in any other material entity, research on housing and mental health is remarkably underdeveloped. We critically review existing research on housing and mental health, considering housing type (e.g., single-family detached versus multiple dwelling), floor level, and housing quality (e.g., structural damage). We then discuss methodological and conceptual shortcomings of this literature and provide a theoretical framework for future research on housing quality and mental health.
This study examines how low-income minority communities build on their strengths to improve material conditions and how these actions lead to further empowerment at the individual and group level, and increase engagement with civic life. Based on earlier qualitative research, low-income limited equity housing co-ops were chosen as research. Using quantitative questionnaire data, a path model was tested in which variables were organized into four levels.Level One: Attributes of the person and the context were conceptualized asexogenous variables leading to activities first at the co-op level.Level Two:co-op activities were thought to affect living conditions in the building and evaluations of co-op ownership, which comprisedLevel Three,quality of life in the building. All preceding levels were thought to influenceempowerment, as measured atLevel Four through an attitudinal measure of empowerment, and reported participation in civic activities in the broader community.
The model, which emphasizes the collective and material nature of empowerment in addition to the psychological, seems justified by the data. It is especially significant that the aggregate measure of perceived participation of others predicted building quality, and that the aggregate measure of building quality went on to influence empowerment and voting behavior. Personal participation in building activities also proved a good predictor of empowerment, indicating that empowerment operates at both the individual and the group level. Furthermore, increased empowerment at the level of attitude did influence civic activities, in conjunction with personal characteristics and perceived neighborhood qualities. (Tests of causality in the opposite direction were not significant.) Our findings confirm the importance of all three components of empowerment, as articulated by Zimmerman and his colleagues (1992), that is, empowerment at the psychological, interactional, and behavioral level. It extends the conceptualization by introducing the group level of analysis.
The purpose of this paper is to trace the history of the social indicators or quality-of-life (QOL) research movement up to
today, forecast future developments, and pave the way for future growth. Broadly speaking, we tried to review historical antecedents
from the point of view of different disciplines, with specialists in each discipline preparing the basic text and co-authors
helping to polish the material into a finished product. Briefly, we begin with an overview of the conceptual and philosophical
foundations of our field of research. That is followed by a historical overview of the sociological roots of our field. In
the third section, the main contributions from the discipline of economics are reviewed. Following that, the fourth section
covers a historical overview of the literature on health-related quality of life is provided. Next, the history of QOL research
from a marketing perspective is reviewed followed by a history from the perspectives of industrial/organizational psychology
and management. Finally, we offer some forecasts for future QOL studies that are intended not only to predict what might happen,
but to encourage, stimulate and motivate researchers to undertake new initiatives.
This study examines the effects of perceived housing environment on selected well-being outcomes of a seriously mentally ill population in supported housing programs. Individuals live independently in their own apartments and use supportive mental health services as needed. The study conceptualizes one's housing environment as existing at the apartment, neighborhood and the surrounding community levels of analysis that, taken together, form a multi-dimensional construct of housing environment. Self-report data from interviews with a sample of seriously mentally ill adults is paired with (a) observer ratings of housing environments, (b) census profiles of the surrounding community and (c) case manager ratings of clients' functioning in order to explore the effects of supported housing environments on well-being outcomes. Well-being is operationalized here as levels of psychiatric distress, recovery orientation, residential satisfaction, and adaptive functioning. Hierarchical regression models posit that apartment, neighborhood and census tract level variables are unique predictors of these domains of well-being. Results show that neighborhood level variables, especially those relating to the social environment, are the most influential predictors for understanding variance in well-being, with apartment level variables also contributing to understanding of housing environment effects. The census tract level predictors did not contribute a significant amount of explanation of the variance in well-being outcomes. Implications for supported housing programs and the role of ecological levels of analysis in conceptualizing and measuring housing environment influence are discussed.
To obtain data on the effectiveness of the psychiatric halfway house and to update information about such facilities, 26 recent statistical reports were examined. Only two studies include control group comparisons. In addition to descriptive information, data are reported in terms of employment or school attendance and independent living as contrasted with rehospitalization. Results indicate that a median of approximately 80 per cent of halfway house residents adjusts to community living. Despite differences among halfway houses in resident selection, length of stay, rehabilitative criteria, and nature of follow-up, data suggest that rehospitalization rates are lower after residence in a halfway house. Some cautions are drawn regarding evaluative studies and potential attenuation of halfway house facilities to low-quality custodial care.
This study assessed the relationship between homelessness and specific quality-of-life problems for persons with severe and persistent mental illness.
The objective and subjective quality of life of 106 homeless persons with severe mental illness who lived on the streets or in shelters in Baltimore was compared with that of 146 domiciled persons with severe mental illness who lived in the community.
Objective and subjective quality of life of the homeless subjects was clearly worse than that of the domiciled group in the areas of living situation, family and social relations, employment, daily activities, and legal and safety problems. Homeless subjects were also less likely to have federal disability entitlements.
Poorer quality of life is associated with homelessness among persons with severe mental illness. Their quality of life may be improved by efforts to increase their access to disability entitlements and treatment services and to help them develop supportive social networks.
Consumer choice is a central principle of psychosocial rehabilitation and supported housing approaches. This study assessed level of housing choice and the relationship of choice to community success in supported housing demonstration projects in five states. Assessment of level of choice about housing revealed very limited housing options and a high degree of influence from service providers over housing choice. Despite few options, most respondents liked their housing option(s) and felt they had enough information to make a good housing decision. The relationship of choice to community success over time demonstrated that choice was positively related to housing satisfaction, residential stability, and psychological well-being. Discussion focuses on implications of the findings for mental health services and public policy.
In order to provide clinicians, researchers, program evaluators, and administrators with current information on the assessment of humanistic outcomes of services for persons with severe and persistent mental illnesses (SPMI), the literature on measuring quality of life (QOL) for these persons is summarized. The literature on QOL assessment procedures up to the end of October 1992 for persons with SPMI is reviewed, covering QOL measures that at a minimum assess subjective well-being. Measures are summarized according to purpose, content, psychometric properties, patient subgroups with whom used, and key references. Ten QOL measures are summarized and reflect considerable variability on the parameters examined. Comprehensive, reliable, and valid measures of QOL are available although further development of QOL assessment methodologies is needed. More importantly, we must strive for a better understanding of how to interpret and use QOL outcome information.
In this research, we examine the relationships between the housing characteristics and dimensions of community adaptation for 107 psychiatric consumer/survivors. Hypotheses about which housing characteristics best predict which dimensions of adaptation were made based on previous research and theory. Using a longitudinal research design, we found, after controlling for demographic variables and prior adaptation, that the number of living companions, housing concerns, and having a private room all significantly predicted different dimensions of community adaptation. The findings partially support our theoretical expectations and illuminate the relationship between physical, social and organizational aspects of community-based housing and the adaptation of psychiatric consumer/survivors. We discuss the implications of the results for policy and practice in providing housing for this population.
There has been a recent upsurge of interest in the relationship between income inequality and health within nations and between nations. On the latter topic Wilkinson and others believe that, in the advanced capitalist countries, higher income inequality leads to lowered social cohesion which in turn produces poorer health status. I argue that, despite a by-now voluminous literature, not enough attention has been paid to the social context of income inequality--health relationships or to the causes of income inequality itself. In this paper I contend that there is a particular affinity between neo-liberal (market-oriented) political doctrines, income inequality and lowered social cohesion. Neo-liberalism, it is argued, produces both higher income inequality and lowered social cohesion. Part of the negative effect of neo-liberalism on health status is due to its undermining of the welfare state. The welfare state may have direct effects on health as well as being one of the underlying structural causes of social cohesion. The rise of neo-liberalism and the decline of the welfare state are themselves tied to globalization and the changing class structures of the advanced capitalist societies. More attention should be paid to understanding the causes of income inequalities and not just to its effects because income inequalities are neither necessary nor inevitable. Moreover, understanding the contextual causes of inequality may also influence our notion of the causal pathways involved in inequality-health status relationships (and vice versa).
There is now widespread interest in developing social policies and practices that are grounded in principles of independent living. The Independent Living (IL) paradigm reflects a shift in thinking away from traditional approaches to supporting persons with disabilities. Independent Living Centres (ILCs), which started in the early 1970s in the United States, and in the 1980s in Canada, are now a major force in the promotion of the IL concept worldwide. The guiding principles of these consumer-driven centres include: promoting an empowerment philosophy that incorporates consumer control/self-direction over decision-making; offering cross-disability support; providing options/choice and flexibility; and encouraging inclusion and full participation. Despite their prevalence, a surprisingly limited body of research exists on the impact of ILCs. A survey was used to investigate the impact of ILCs in Canada on their communities of interest (groups connected to the ILCs). Surveys were sent to formal organizations, informal groups, and family/friends. A final response rate of 52.6% was achieved (111 of 211 surveys returned). Overall, moderate to good levels of familiarity, involvement, and impact were found. The results affirmed the importance of independent living centres to individual empowerment, community change, and the IL movement.
About one-quarter of homeless Americans have serious mental illnesses. This review synthesizes research findings on the cost-effectiveness of services for this population and their relevance for policy and practice.
Service interventions for seriously mentally ill homeless people were grouped into three overlapping categories: 1) outreach, 2) case management, and 3) housing placement and transition to mainstream services. Data were reviewed both from experimental studies with high internal validity and from observational studies, which better reflect typical community practice.
In most studies, specialized interventions are associated with significantly improved outcomes, most consistently in the housing domain, but also in mental health status and quality of life. These programs are also associated with increased use of many types of health service and housing assistance, resulting in increased costs in most cases. The value of these programs to the public thus depends on whether their greater effectiveness is deemed to be worth their additional cost.
Innovative programs for seriously mentally ill homeless people are effective and are also likely to increase costs in many cases. Their value ultimately depends on the moral and political value society places on caring for its least-well-off members.
One area of positive psychology analyzes subjective well-being (SWB), people's cognitive and affective evaluations of their lives. Progress has been made in understanding the components of SWB, the importance of adaptation and goals to feelings of well-being, the temperament underpinnings of SWB, and the cultural influences on well-being. Representative selection of respondents, naturalistic experience sampling measures, and other methodological refinements are now used to study SWB and could be used to produce national indicators of happiness.
This paper critically reviews studies of the relationship between housing attributes and serious mental illness, highlights important gaps in the research, generates hypotheses to be tested, and suggests a research agenda.
Studies published between 1975 and March 2000 were identified through computerized searches, previous literature reviews, and consultation with mental health and housing researchers. Criteria for inclusion included the presentation of quantitative evidence, a systematic sample of known generalizability, and systematic analytic techniques.
The 32 studies that met these criteria relied on one or more of three conceptualizations of the role of housing: housing attributes or assessments as an outcome or dependent variable; housing attributes as inputs or independent variables in a model in which the outcome pertains to a nonhousing factor, such as a mental health outcome; or housing as both an input and an outcome. Three studies found no long-term effect of improved housing adequacy on housing satisfaction above and beyond case management. Three studies found better outcomes for settings that have fewer occupants. Another study suggested that persons who live in small-scale, good-quality, noninstitutional environments are less likely to engage in disruptive behavior when a larger proportion of other tenants also have serious mental illness. The strongest finding from the literature on housing as an input and an outcome was that living in independent housing was associated with greater satisfaction with housing and neighborhood. Most of the studies had methodological weaknesses, and few addressed key hypotheses. There is a critical need for a coherent agenda built around key hypotheses and for a uniform set of measures of housing an input and an outcome.
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.
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.
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.
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.
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.
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)
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.
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.
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.
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.
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.
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.
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.
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.
http:// www. comonwealthfund. org/ publications/ publications_ show. htm?
- 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