Planning a Multi-site, Complex Intervention for Homeless People with Mental Illness: The Relationships Between the National Team and Local Sites in Canada’s At Home/Chez Soi Project
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- Nelson, G., Macnaughton, E., Goering, P. et al. Am J Community Psychol (2013) 51: 347. doi:10.1007/s10464-012-9554-2
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This research focused on the relationships between a national team and five project sites across Canada in planning a complex, community intervention for homeless people with mental illness called At Home/Chez Soi, which is based on the Housing First model. The research addressed two questions: (a) what are the challenges in planning? and (b) what factors that helped or hindered moving project planning forward? Using qualitative methods, 149 national, provincial, and local stakeholders participated in key informant or focus group interviews. We found that planning entails not only intervention and research tasks, but also relational processes that occur within an ecology of time, local context, and values. More specifically, the relationships between the national team and the project sites can be conceptualized as a collaborative process in which national and local partners bring different agendas to the planning process and must therefore listen to, negotiate, discuss, and compromise with one another. A collaborative process that involves power-sharing and having project coordinators at each site helped to bridge the differences between these two stakeholder groups, to find common ground, and to accomplish planning tasks within a compressed time frame. While local context and culture pushed towards unique adaptations of Housing First, the principles of the Housing First model provided a foundation for a common approach across sites and interventions. The implications of the findings for future planning and research of multi-site, complex, community interventions are noted.
KeywordsPlanningMental healthHomelessnessMulti-site complex community interventionsMental health services evaluation
With a few exceptions (Nelson et al., under review; Sylvestre et al. 1994), there is relatively little research on the planning of multi-site, complex, community mental health interventions. Seymour Sarason (1972) argued that it is important to understand how programs come into being, and that community psychologists should study programs “before the beginning.” Rather than focusing exclusively on program outcomes, Sarason (1993) stated that it is important to focus on [what] “we need to know if we are to begin to understand how outcomes were influenced or not influenced by the ups and downs, errors of omission and commission, the predictable and the unpredictable, the adaptations and compromises that were made” (p. 211). Similarly, Trickett (2009) stated that “ … multilevel interventions … involve a host of differing actions and interactions that, taken together, tell the story of the intervention in community context” (pp. 263–264). The purpose of this paper is to help fill this gap in knowledge about planning community mental health services by examining the relationships between a national team and five project sites in planning a longitudinal research demonstration project—the Canadian At Home/Chez Soi project.
The At Home/Chez Soi Project
Overview of the Project
The At Home/Chez Soi project received funding of $110 million for 4 years (2009–2013) from Health Canada through the Mental Health Commission of Canada (MHCC) and is being implemented in five cities across Canada. The Vancouver program on the west coast of Canada serves many, but not exclusively, individuals who have lived in the Downtown Eastside, with a high proportion of poly-substance users; the majority of participants in Winnipeg in the western Canadian prairies, are Aboriginal; the majority of participants in Toronto, Canada’s largest city, are immigrants (primarily from India, Pakistan, Sri Lanka, China, and the Caribbean); Montréal is home to a large French-speaking population with a long-standing claim as being culturally and linguistically distinct; and Moncton, in the eastern Maritime province of New Brunswick, contains a mixed French–English population in a semi-rural environment.
Housing First, modeled after the Pathways to Housing program in New York City, stands in contrast to “treatment first” approaches, by providing housing shortly after intake to homeless people with mental illness rather than offering housing as a reward for progress in treatment (Tsemberis et al. 2004). Housing First is based on consumer-driven services, including choice over housing, separation of housing and clinical treatment, a recovery orientation, and community integration (Nelson et al. 2012a). Rent supplements that reduce the financial barrier to obtaining housing are a key element of Housing First. Controlled outcome evaluations of Housing First have demonstrated its effectiveness in improving housing stability and reducing use of hospitalization and emergency services (Aubry et al., accepted).
The terms of the project were that At Home/Chez Soi would be a randomized controlled trial (RCT) of Housing First vs. Treatment as Usual (TAU). Furthermore, within each of these two experimental conditions, there were two groups of participants: those with high needs, who received Assertive Community Treatment (ACT) in the Housing First condition, and those with moderate needs, who received Intensive Case Management (ICM) in the Housing First condition. Additionally, sites had the option of developing a “third intervention arm” that was tailor-made to local conditions and needs. Between October, 2009 and June, 2011, more than 2,200 participants were enrolled in the At Home/Chez Soi research.
Milestones in Planning and Proposal Development
The details of conception of the At Home/Chez Soi project are described in another paper (Macnaughton et al., under review). To summarize briefly, an executive team was formed in the spring of 2008 that consisted of the MHCC’s project lead, the research lead, and the Executive Director of the Pathways to Housing program who became part of the project’s national research team. Early on a decision was made to conceptualize At Home/Chez Soi as a pragmatic trial using a RCT design (Goering et al. 2011). Five project sites had been selected by the Chair of MHCC in negotiation with the federal government. The research lead began to form a national research team in the summer of 2008 that eventually included seven mental health researchers not associated with a particular site, the principal investigators from the five research sites, one researcher with lived experience, the project lead, and a knowledge translation worker.
The first visits to the five project sites were made in the summer of 2008 by the project lead and the Chair of MHCC. At a July meeting with a partially formed national research team and stakeholder representatives from the different sites, the decision was made to broaden the target population to include participants with moderate mental health needs (to be served by ICM), as well as those with high mental health needs (to be served by ACT). Housing First had not previously been tested with homeless people with moderate mental health needs. A draft Request for Applications (RFA) was completed in August of 2008; a national research team was finalized; and a second round of site visits to consult about the draft RFA was held in the early fall of 2008. In October, 2008, the national research team released a final revised RFA, which required collaboration between researchers and service-providers at each site to run the research and interventions. One RFA from each site was due in January, 2009, and the proposals were reviewed and awarded funding in March, 2009. It is important to note that since At Home/Chez Soi is a research demonstration project, site proposals included both the interventions, which consist of housing and support services, and the research.
Health and Mental Health Planning Approaches
Program planning refers to all the activities that occur prior to the implementation of a program, including deciding on the program model, an evaluation plan, and a plan for who does what, where, and when. There are two traditions to planning. The expert-driven approach is top-down with a focus on the adoption of an evidence-based program and adherence to the key components of the program model (Barrera et al. 2011). The expert-driven approach emphasizes the rational-empirical, technical, and instrumental components of planning and often includes a prescribed set of planning steps or stages (Mrazek and Haggerty 1994). In contrast, a community-driven approach is bottom-up, engaging community members in the planning process and striving to adapt or create programs that are a good fit for the community (Barrera et al. 2011; Laverack and Labonté 2000). The community-driven approach is organic in nature, emphasizing collaboration, values, and community empowerment (Nelson et al., under review).
There is a growing recognition that these two approaches are not incommensurate and that both focus on important and complementary aspects of the planning process (Green and Kreuter 2005; Laverack and Labonté 2000). Hybrid approaches include rational-empirical, technical, and instrumental planning, as well as flexible, participatory, empowering processes with communities. Barrera et al. (2011) identified several types of hybrid approaches, including cultural adaptation of evidence-based interventions, investigator-initiated culturally grounded interventions, and community-initiated indigenous interventions.
Key Elements of Planning
An integrated, hybrid approach to mental health planning includes the following elements: tasks, collaboration, and values (Nelson et al., under review). Tasks reflect the instrumental aspects of planning that are associated with the expert-driven approach. Chinman et al. (2008) outlined several different tasks in planning a program (e.g., choosing a problem focus, identifying goals). Wandersman et al. (2008) argued that technical assistance is critical in assisting community groups to accomplish these tasks.
Collaboration draws attention to the relational nature of planning and how tasks are accomplished. Collaboration is underscored in the community-driven approach and entails the development of partnerships among stakeholders. Moreover, collaborative approaches emphasize the key roles of stakeholder participation, leadership, transparent communication and decision-making, and power-sharing (Nelson et al., under review; Warburton et al. 2008). In a qualitative study of planning a prevention program in a high school, Peirson and Prilleltensky (1994) found that collaboration was related to the extent of ownership on the part of the different stakeholders for the program that was planned.
Incorporating values is also important for planning (Nelson et al., under review; Prilleltensky et al. 1994), as values address the fundamental question of why stakeholders should plan a program. Developing a shared vision, values, and principles is the foundation for planning. In planning, it is important for stakeholders to have a superordinate goal towards which they are working. Ownership and “buy in” are also enhanced when partners have a shared vision and values (Peirson and Prilleltensky 1994; Prilleltensky et al. 1994; Warburton et al. 2008).
Complex, Community Health Interventions: An Ecological Perspective
Many health and social problems, such as mental illness and homelessness, are complex, culturally-situated, and influenced by factors at multiple levels of analysis (Trickett 2009). As such, there is a growing recognition that complex problems require complex, multi-component community interventions (Allred et al. 2005; Trickett et al. 2011). Wolff (2001) argued that complex, community interventions have diverse staffing, ambiguous protocols, and “permeable external boundaries in which the performance of the intervention is dependent on the social setting” (p. 124). Raghavan et al. (2008) asserted that planning complex interventions requires attention to the policy ecology surrounding program adoption, including mental health organizations and government funding and regulatory environments. For instance, planning at the organizational level can be a challenge because resources, such as ongoing training and technical assistance provided by government departments, are often lacking (Wandersman et al. 2008). Similarly, Trickett (2009) suggested that an ecological perspective on complex interventions focuses on: resource development, synergy among intervention components, the interdependence of individuals and their environments, collaborative processes, community-level effects, and unintended consequences. Rather than thinking of complex interventions as a package of treatment components, Hawe et al. (2009) asserted that such interventions are better conceived of as events in systems.
Research on Planning Multi-site, Complex Health Interventions
While there is a growing body of research on the evaluation of multi-site, complex interventions (e.g., Dewa et al. 2002; Katz et al. 2011; King et al. 2011), there has been little research on planning such interventions. One exception is Sylvestre et al.’s (1994) qualitative examination of the relationship between government and community stakeholders, both residents and service-providers, in the planning of the project Better Beginnings, Better Futures, a multi-site, complex, health promotion/prevention research demonstration project for children living in disadvantaged communities in Ontario that has been shown to have long-term impacts (Nelson et al. 2012b; Peters et al. 2010). They found that there was a tension between government and community stakeholders, both residents and service-providers, about the role of research in the project, with some community stakeholders fearing that research needs would take precedence over those of the community. This fear was reduced by the project researchers using a highly participatory and collaborative approach, including the use of site research committees, extensive consultation about all research approaches, tools, and procedures, and hiring local residents to help conduct the research.
Another concern was the tight timelines for planning. However, the authors asserted that time constraints may have actually helped community stakeholders to resolve differences that may have otherwise stalled planning. Community stakeholders also expressed concerns about some of the parameters of the project, including the targeted age groups of children who could be involved in the program. While there were limitations on the age group to be served, local sites had considerable autonomy to develop programs that met their expressed needs within the broad parameters of the project. Finally, the participation of low-income residents in the development of program proposals was limited at most sites. As well, those residents who were involved reported feeling intimidated by professionals. This problem diminished over time, as government set an expectation that local residents would constitute 51 % of the projects’ steering committees to ensure that the community had a strong voice in the projects. Therefore, past research suggests the importance of transparency, a collaborative approach, and community involvement as critical to the success of multi-site, complex interventions.
From the perspective of both national/provincial and site stakeholders, what were the challenges in planning At Home/Chez Soi?
From the perspective of both national/provincial and site stakeholders, what factors helped or hindered the planning of At Home/Chez Soi move forward?
Consistent with the argument of Farquar et al. (2006) that “the use of qualitative methods can provide an in-depth understanding of the issues and … can help to inform the planning of health promotion programs and interventions” (p. 234), we used qualitative methods. Moreover, we adopted a social constructionist approach (Guba et al. 2011) to reflect the multiple constructions of people who played a role in planning At Home/Chez Soi, including both national/provincial stakeholders and stakeholders at each of the five sites. Moreover, a multiple case study approach (Stake 2005) was used. Each site has a qualitative research team. As well, there is a national qualitative research team that consists of members of the national research team and paid project research staff. Through regular conference calls (at least one per month) and one annual, face-to-face meeting, the national qualitative research team and the site qualitative research teams plan and discuss all the common qualitative research that is conducted.
Key informants with knowledge of project planning were identified by the At Home/Chez Soi national project lead and research lead. A total of 18 key informants, who were involved in different spheres of interest (political, policy-making, and site coordination levels) were interviewed for this research.
Between October, 2009 and March, 2010, members of the national qualitative research team interviewed key informants in-person or by telephone. Interviews were based on a semi-structured guide that covered key topics such as how the project got started, who was involved, and how the research design and intervention were selected. The interviews lasted 30–90 min, and they were audio-recorded and transcribed verbatim. Key program documents were also reviewed.
The analysis was done by one of the authors who conducted the majority of the interviews and coded all the transcripts. This author was not part of the planning process. To help ensure rigor, the other members of the national qualitative research team were also involved in the analysis, as each member reviewed the coding from selected groups of transcripts of interviews. Following a dialogue with each member, a revised coding framework was developed. For this paper, the data were coded within two broad issues: challenges and factors that helped or hindered project planning. The lead researcher completed a draft report that was reviewed by other team members. This report was sent out to key informants who were interviewed to ensure that quotes had been used in their correct context and to gather feedback on the emerging analysis.
At each of the five sites, individuals who played a key role in planning were purposefully selected and interviewed individually. Individuals involved in the planning to a lesser extent were interviewed in focus groups. In all, 75 key informant interviews and 10 focus groups with 56 participants were conducted.
Common key informant and focus group protocols that focused on several topics (e.g., the environment, stakeholders, relationships) were used across the sites. Key informant interviews and focus groups were conducted, in either English or in French, at the participants’ workplaces or at project offices by site qualitative researchers between October 2009 and February 2010. The interviews were between 45 and 90 min in duration and were audio-recorded and transcribed verbatim.
The approach to data analysis at each of the sites involved thematic analysis (Morse and Field 1995). Site researchers sought and identified “common threads” throughout the data, drawing out significant concepts that emerged from individual interviews along with concepts that linked interviews together. They also used the constant comparative method of making comparisons during each stage of the analysis to further develop themes (Charmaz 2006). Each site went through a process of member-checking by sharing a draft site report with people who were interviewed for the site reports to establish the trustworthiness of the data. Qualitative researchers at each of the sites produced site reports on the planning and proposal development process using a common reporting template (Dudley and Moradzadeh 2010; Fleury et al. 2010; Gaucher et al. 2010; Kirst et al. 2010; Patterson et al. 2010).
After reviewing the site reports, the national qualitative research team decided that the data could be grouped into two broad issues: planning challenges and factors that helped or hindered moving the project planning forward. Codes were taken from the site reports that pertained to these two issues. The national qualitative research team shared a draft of the cross-site analysis with site researchers and invited them to read it over along with other stakeholders at the sites. Comments from each site were incorporated into the final version of the cross-site analysis.
Objections to and Concerns About the Research
There were concerns that the RCT design and TAU assignment would deny services to a vulnerable population, and that services would be withdrawn from participants in the intervention group at the conclusion of the trial. In addition, stakeholders expressed concern that too much emphasis would be placed on the priorities of researchers at the expense of service delivery. Finally, given the negative experience of certain stakeholders (e.g., Aboriginal communities) with research, there was a degree of suspicion about the research in general.
Relationship of the Project to Existing Local Services
Another challenge had to do with addressing concerns about the relationship between the initiative and existing services. In some sites this was less pressing, given the perception that the approach was complementary to existing approaches or that it would fill a service void. In other sites, however, there was discomfort about participating in a project that featured head-to-head comparisons between an externally developed intervention, Housing First, and local approaches. It was feared that the initiative would jeopardize existing resources that were already considered successful. In addition, the Housing First model, with its emphasis on private apartments, was seen by some stakeholders at two of the sites as incompatible with the locally valued social housing or congregate housing approaches. As one key informant stated: “If this project shows that scatter-site housing based on vouchers is extremely effective for this population, … and it costs a hell of a lot less than the average social housing unit, well, then, it’s threatening and disrupting” (national stakeholder). All of these concerns were exacerbated by the fact that resources to continue providing service were not guaranteed beyond the period of the demonstration project.
Complex Terrain of Interests and Perspectives
Another challenge for the national team was negotiating the complex terrain of interests and perspectives that existed at each of the sites. As one national key informant described it, this terrain was a “minefield” that had to be “negotiated carefully.” This was further complicated by power differences, questions regarding who would be involved, and who would lead. In addition there was a tension between “ways of working” between the political sphere of the project, where decision-making was quick, organic, and network-based, and its community sphere, where there was desire for transparency and collaboration. In seeking to understand this terrain and develop partnerships, the project’s leaders and researchers continued to work informally through networks. This resulted in tensions between the positioning that arose out of this organic environment and the desire for a more reflective, inclusive process for choosing partners and bringing in local expertise.
While all sites saw the project as an opportunity to provide innovative services in their communities, to work more collaboratively with local partners, and to transform the way that housing and supports are provided to the population, they also identified several challenges in planning.
The Pre-determined Nature of the Intervention and the Research
Some participants thought that both the intervention approach and research design, the two key planning tasks, had already been decided upon and thus limited their input into the intervention, research, and population to be served. “I would say the project description was already relatively complete. The design was… pretty much defined by the time we received it so our capacity to be responsive to other perspectives for appropriate research design and appropriate factors to evaluate was limited” (Kirst et al. 2010, p. 6).
Another challenge was how local conditions impacted on sites’ ability to carry out the RFA process. This took two different forms. Some sites noted that it was challenging to complete a proposal because of the lack of a local infrastructure for housing and homelessness, leadership, service capacity, or human resources upon which to draw. “Local people didn’t really have a good sense of what an ACT team was. That it was a very well defined criterion in the literature, that it wasn’t something that we could make up” (Gaucher et al. 2010, p. 10). At the other extreme were sites that had a well-developed infrastructure and leadership capacity, which posed different challenges. For example, the Toronto site was challenged by not having sufficient time to consult with the large number of other service-providers that existed. Thus, both a lack of capacity in some cases and complex environments with many experienced players in the areas of mental illness and homelessness were both experienced as challenges.
Mistrust and Discomfort
Another challenge to the planning and proposal development process was a degree of mistrust and discomfort over the project that existed on the part of some stakeholders. This was expressed in different ways.
… Local players … had had an opportunity to express their views, many of whom disapproved of the project in its present form. This period was characterized by mounting tension among the key players, revealing different cultures and diverging interests. Ensuing conflicts resulted in the departure from the consortium of major players in the areas of homelessness and delays in the recruitment of caregivers and service-providers. (Fleury et al. 2010, pp. 17–18)
The fact that At Home/Chez Soi was a time-limited research demonstration project with no guarantees about its sustainability was a major source of discomfort.
Tight timelines for planning was mentioned as a problem at all the sites and compounded other challenges, such as mistrust. In addition to writing the proposals, those who were involved in planning and proposal development at the sites had to assemble a team of researchers and service-providers who would lead the project. The multi-faceted and complex undertaking of planning and proposal development for At Home/Chez Soi was compacted into a very short timeframe. Furthermore, the need to get proposals submitted quickly clashed with the desire to engage in a planning approach that was participatory and collaborative. More time was needed to address the concerns of key stakeholders and merge national and local interests. It is important to note that these challenges were not universal across the sites, nor were they even consistently experienced within a given site. Rather the challenges experienced were a function of the very complexity of the intervention itself, which demanded a diverse mix of partners and stakeholder groups, each with its own culture and expectations. There were, however, a number of key factors that allowed the project stakeholders both nationally and locally to move the project forward in a timely and effective manner.
Factors That Helped or Hindered the Project from Moving Forward
Framing the Project as “Adding Innovative Services”
As was mentioned previously, the RCT design and TAU condition were contentious. While the TAU condition was frequently misperceived as meaning that participants in this condition would receive no service, sites eventually acceded to this component of the research design. To some extent, this occurred because the Executive Director of Pathways was seen as highly credible by service-providers, and was able during community consultations to frame the project and research design as “adding and not taking away” resources. As well, the sites understood that while TAU participants would not obtain housing and/or support through At Home/Chez Soi, they could obtain housing and/or support through existing services at the sites. Overall, the research came to be seen as necessary for influencing policy and practice in the longer term, which enabled communities to see the risks of proceeding as tolerable despite concerns about project sustainability. Over time, stakeholders recognized that the research would not dominate the service delivery aspect of the project, given that the evolving research design would allow communities the opportunity to adapt to local circumstances.
Accommodating Local Approaches
… So the [eventual solution] was trying to figure out how to incorporate both the Canadian experience and the American experience and bring them together … It also became clear to us that we didn’t want … to say we’re replicating a model program. We wanted to say, these are examples of applications of this philosophy and approach … but we wanted to leave the exact … details about the implementation open …” (national key informant)
The other significant modification, the addition of the projects’ local “third arms,” allowed the adoption of locally and culturally appropriate variations to Housing First principles (e.g., an ethnocultural ICM arm in Toronto, an Aboriginal-focused ICM intervention in Winnipeg), as well as locally valued approaches (e.g., social housing with existing supports in Montréal, congregate housing with on-site services in Vancouver). Each site took advantage of this opportunity to have a “third arm,” which allowed the initiative to build on what was already available.
Developing a Process for Bringing in the “Right” People and Partners
Basing the coordinator in “neutral territory” or within a site which acted as a “hub” where various networks connected facilitated the process of … bringing together the sometimes disparate players and perspectives that needed to be at the table, establishing trust, and moving them towards a common vision of the project (national key informant)
What Worked Well
Excitement About Innovative Services and the Potential for Transformative Change
Respondents saw their involvement not only as an opportunity to conduct research and provide essential services to an underserved population, but also as a chance to promote real change in the types of services offered and the way those services are delivered… Overall, respondents expressed excitement and enthusiasm for the project, viewing it as an opportunity to implement the Housing First model in Vancouver and provide critical services to an underserved, marginalized population. Prior to initiation of the project, services such as Housing First, ACT, and ICM, were virtually absent from the landscape of care in Vancouver (Patterson et al. 2010, pp. 6 and 31).
Expectations of One Proposal Per Site
With very little time to produce a proposal, the group had to gel into a team. The intensiveness of the work meant that partners got to know each other quickly. It was, as one key informant said, “like a cauldron and we were forged as a team” (Kirst et al. 2010, p. 10).
Collaborative Style of the MHCC
The Commission and those working to assemble the Winnipeg Site immediately corrected this oversight and then proceeded under the assumption of Aboriginal leadership and interest. The MHCC then hired the Site Coordinator and a Co-site Coordinator, the latter coming from the Aboriginal community, which allayed some concerns and helped to keep community groups engaged in the process. Then a “working committee” coalesced as the beginning of what would become the Advisory Committee, and they began developing a Terms of Reference (Dudley and Moradzadeh 2010, p. 7).
Moreover, the majority of individuals who were involved in planning and proposal development at the sites saw the national team as committed, responsive, and available to negotiate issues. “Everyone recognized how committed, mobilized, and available the national team was. When presented with a problem, it responded promptly and never hesitated to come to Montréal to meet with local players and counsellors” (Fleury et al. 2010, p. 16).
What Worked Less Well
Limits to Collaboration
Some described the parameters set by the MHCC as a top-down approach, one that stood in opposition to the project’s principle of collaboration. This approach limited the shaping of the local response and created some tensions between the national team and the Vancouver site (Patterson et al. 2010, p. 15).
Insufficient Time to Engage People with Lived Experience in Planning
If there was one thing we could have done better it would have been [engaging people with lived experience of mental illness in planning]. We tried, but it was probably minimal. We were so far behind, building the knowledge base, build[ing] these teams, we just didn’t have the time or the capacity to do that to the extent that we probably should have (Dudley and Moradzadeh 2010, p. 16).
Well, during the proposal development phase, unfortunately the communication between the national team was poor … We did all the engagement and this was another frustration because trying to manage writing the proposal and preparing the proposal and at the same time having to navigate a very rich community such as ours with so many stakeholders … It would have been a great help if at that stage some of that had been taken off our plate and actually been done by somebody neutral (Kirst et al. 2010, p. 8).
The language difference remained a source of major frustration: English-only documents or poor French translations were sent and few players at the national level spoke French, resulting in major communication challenges. (Fleury et al. 2010, p. 15)
As recommended by Sarason (1993) and Trickett (2009), this research sought to tell the story of the planning of a complex, community intervention. The planning of At Home/Chez Soi used neither an expert-driven nor a community-driven approach, but rather a hybrid model in which both the national team and local sites negotiated the nature of the project (Laverack and Labonté 2000). Consistent with the hybrid model, we found that planning mental health programs is both relational and task-oriented in nature.
We conceptualize the relationships between the national team and the five sites in terms of a process of negotiation. Each party brings an agenda to the relationship and enters into a process of negotiation in the planning process. When planning is viewed from an ecological perspective, it quickly becomes apparent that different stakeholders have different agendas (Trickett 2009). The central concerns of the national team were to overcome site resistance, to secure ownership and “buy in” of critical components of the intervention (Housing First) and the research approach (use of a RCT design), and to accommodate local perspectives and needs. The central concerns of sites were to establish local partnerships and teams, both service and research, and to have local approaches appreciated and incorporated into the project. The concerns of the national research team and local stakeholders, including service-providers, people with lived experience of mental illness and homelessness, and Aboriginal and ethnoracial groups, were in tension with one another. In planning, it is important to acknowledge these tensions, to normalize the multiple, competing agendas and worldviews of different stakeholders, and to find common ground.
In the process of negotiation, engaging in a collaborative planning process and hiring Site Coordinators were key to bridging between the national team and the sites. As has been shown in previous research (Nelson et al., under review; Peirson and Prilleltensky 1994; Warburton et al. 2008), the flexibility and collaborative style of the national team were viewed by site stakeholders as critical to the planning of the project and developing ownership. For example, the decision of the national team to have only one proposal per site helped to build local teams and overcome competition. Also, responding to site desires to build on existing programs led the national team to incorporate second and third intervention arms into the project and research design.
One of the themes in this research pertained to bringing in the “right people.” The partners who were recruited into the project not only brought in diverse expertise and experience, but they also possessed what Foster-Fishman et al. (2001) have called member capacity and relational capacity. Member capacity includes the knowledge, skills, and motivation to collaborate with others and plan programs, while relational capacity refers to developing a positive work climate and shared vision, promoting power-sharing, and valuing diversity. These member and relational capacities are vital for collaboration.
While a collaborative project culture was noted, stakeholders also noted barriers to collaboration in At Home/Chez Soi. Since the federal government funded the project, it had to be a research demonstration project, as only the provinces, not the federal government, can fund health services in Canada. Thus, the parameter that At Home/Chez Soi was a research demonstration project was non-negotiable. Also, within the context of a cross-site RCT design, there were other non-negotiables, including having a common research design, measures, intervention approach, and population. Although there was a common research design, Principal Investigators, Site Coordinators, and other stakeholders at the sites had considerable opportunities for input on both research issues and intervention programs. This finding is more congruent with Leykum et al.’s (2009) assertion that participatory processes can incorporated into a RCT design, than King et al.’s (2011) position that “an evaluator managing a multisite evaluation can involve people in some ways to increase ownership, but should never relinquish control of decisions” (p. 60). Moreover, contrary to Trickett’s (2011) observations of the Katz et al. (2011) multi-site intervention study, it appears that the iterative and flexible nature of the At Home/Chez Soi project and research planning can successfully blend community-based participatory research (CBPR) with a RCT design, rather than having the former subservient to the latter. However, neither CBPR nor the RCT were implemented in their “pure” or ideal forms. Rather there were tradeoffs, compromises, and constraints that resulted from the blending of these two approaches.
Another limitation to collaboration was the tight timelines. These timelines limited the input of people with lived experience into planning and proposal development. Sylvestre et al. (1994) also found that tight timelines limited the involvement of low-income community residents in the planning process for the Better Beginnings, Better Futures project. Poor communication was sometimes experienced between the sites and the national team, which may have also been related to the compressed timeline.
Having effective leadership is another important component of collaboration (Foster-Fishman et al. 2001; Warburton et al. 2008). The important leadership role played by Site Coordinators was underscored in this research. In particular, it was noted that Site Coordinators and other leaders were able to bridge effectively between the national team and the sites, as well as between other stakeholders. Bond and Keys (1993) have referred to such people as “boundary spanners,” because they can easily work with and bring together different stakeholder groups who have different worldviews. They note that such individuals are particularly important for community collaboration.
In addition to these process issues, there were a number of planning tasks that needed to be accomplished in At Home/Chez Soi that closely mirrored those identified by Chinman et al. (2008) (e.g., adapting the program to the local context). Adding to the complexity of the planning was the fact that both the intervention and research to evaluate the intervention needed to be planned. Progress on these two major tasks occurred in a linear process and within a tight time frame in At Home/Chez Soi. While the timelines were tight, participants believed that they accelerated the process of collaboration and team-building, which is congruent with the finding of Sylvestre et al. (1994) in the context of Better Beginnings, Better Futures. These findings draw attention to the importance of time, which is an important consideration in an ecological perspective on planning (Hawe et al. 2009).
Wandersman et al. (2008) argued that technical assistance is critical in assisting community groups to accomplish these tasks in program planning. In At Home/Chez Soi, we found that the project sites very much appreciated the assistance of the national team in helping them to complete these planning tasks. Also, consistent with Wandersman et al.’s (2008) model, sites varied in their capacity to plan such an initiative. Therefore, some sites needed more assistance with capacity-building than others.
Overarching the process of negotiation between the national team and the sites regarding the tasks that needed to be accomplished were the diverse community contexts. These differences were important in fuelling the desire on the part of some stakeholders to pursue more unique, local solutions rather than adhere strictly to a common approach, and underscore the ecological emphasis on context in understanding the relationship between people and their environments (Trickett 2009).
Unlike most other multi-site studies of complex, community interventions, the At Home/Chez Soi sites had the option of developing a unique third arm that fit their particular context. So, Vancouver developed congregate housing with on-site services in one large building; Winnipeg developed an Aboriginal-focused ICM intervention; Toronto developed an anti-racism/anti-oppression ICM for diverse ethnoracial groups; Montréal included social housing with existing services; and Moncton developed a program for the surrounding rural area. Hawe et al. (2004) make a distinction between the form and function of complex, community interventions. They argue that in multi-site trials, it is important to maintain the function of the intervention across sites (i.e., the goals and principles of the intervention), but that the particular form the intervention takes in different sites can vary. All of the third arms that were developed varied in form, but they all adhered to the basic principles and goals of the Housing First model. The form-function distinction “… free[s] the RCT from a literal definition of standardization-as-repetition of the same activities across diverse communities” (Trickett 2011, p. 1354) and helps to move past the idea that fidelity and adaptation are in opposition to one another. The hybrid models presented by Barrera et al. (2011) and the findings from this study are good examples of how both are important and can be achieved.
The principles and goals of Housing First were the glue that bonded national and local stakeholders together. Not only did the Housing First model provide a shared vision and values, but various stakeholders found the principles of this approach to be inspirational and potentially transformative. In many of the sites, the medical model had been dominant, and At Home/Chez Soi was the first, large-scale project that promoted consumer choice, citizenship, recovery, and community integration. This speaks to the importance of having a value-based approach to planning (Nelson et al., under review; Prilleltensky et al. 1994).
The findings of this research have implications for practice and research. In terms of planning, others who embark on planning multi-site initiatives can benefit from an understanding of some of the key themes in the planning of At Home/Chez Soi, including negotiation, collaboration, boundary-spanning, task orientation, adaptation to context and culture, and values. Since there has been so little research on planning multi-site initiatives that entail both intervention and research, more research is needed in different contexts and with different populations and programs to help understand factors that facilitate and impede planning.
We thank Jayne Barker (2008–2011), Ph.D., and Cameron Keller (2011–present), Mental Health Commission of Canada At Home/Chez Soi national project leads, the national qualitative research team, the five qualitative site research teams, Site Coordinators, and the numerous service and housing providers, as well as persons with lived experience, who have contributed to this project and the research. This research has been made possible through a financial contribution from Health Canada. The views expressed herein solely represent the authors.