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Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes

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Housing quality (HQ) is associated with mental health, and may mediate outcomes in housing interventions. However, studies of housing interventions rarely report HQ. The purpose of this study was to describe HQ in a multi-site randomized controlled trial of Housing First (HF) in five Canadian cities and to examine possible differences by treatment group (HF recipients and treatment-as-usual (TAU) participants who were able to find housing through other programs or on their own). We also examined the association between HQ and the primary trial outcome: housing stability. The performance of a new multi-dimensional standardized observer-rated housing quality scale (the OHQS) in a relatively large cross-site sample was also of interest. HQ was rated by trained research assistants for 204 HF participants and 228 TAU participants using the OHQS. General linear regression models were used to examine unit/building quality scores by group and site adjusting for other group differences, and as a predictor of housing stability outcomes after 24 months of follow-up. The OHQS was found to have good reliability and validity, but because most of the neighborhood subscale items were negatively correlated with the overall scale, only unit and building items were included in the total HQ score (possible scores ranging from 13.5 to 135). Unit/building HQ was significantly better for the HF group overall (91.2 (95 % CI = 89.6–92.9) vs. 88.3 (95 % CI = 86.1–90.5); p = .036), and in one site. HQ in the TAU group was much more variable than the HF group overall (W (mean) = 24.7; p < .001) and in four of five sites. Unit/building HQ scores were positively associated with housing stability: (73.4 (95 % CI 68.3–78.5) for those housed none of the time; 91.1 (95 % CI 89.2–93.0) for those housed some of the time; and 93.1 (95 % CI 91.4–94.9)) for those housed all of the time (F = 43.9 p < .001). This association held after adjusting for site, housing characteristics, participant ethnocultural status, community functioning, and social support. This study demonstrates that HQ can be as good or better, and less variable, in HF programs in Canada that systematically and predominantly source housing stock from the private sector compared to housing procured outside of an HF program. HQ is also an important predictor of housing stability outcomes.

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The authors wish to dedicate this paper to the memory of our senior co-author Dr. Paula Goering, who passed away on May 24, 2016. Dr. Goering was the lead investigator on the At Home/Chez Soi trial – the largest study of its kind in the world, from 2007 to 2016.  She was a consummate collaborator, leader and visionary, lighting the way for our research and practice teams to succeed, and also had an unwavering commitment to the involvement of people with lived experience in research.  Through the study she not only oversaw the provision of housing and supports to more than 1000 Canadians, but her legacy lives on in national policy, including funding support for Housing First.  In the study, and more broadly, she was a champion for improving the lives of marginalized and vulnerable people and their families.

We are grateful for the privilege of working with her and learning from her. We also thank Jayne Barker (2008–11), Cameron Keller (2011–12), and Catharine Hume (2012–2015), Mental Health Commission of Canada At Home/Chez Soi National Project Leads, as well as the National Research Team, the five site research teams, the site coordinators, the numerous service and housing providers, and people with lived experience who contributed to the original At Home/Chez Soi research demonstration project. We would, most especially, like to acknowledge the contributions of At Home/Chez Soi participants, whose willingness to share their lives, and open their homes for quality assessments were central and essential to the project.

The original research was made possible through a financial contribution from Health Canada. The views expressed herein are solely those of the authors.

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Correspondence to Carol E. Adair.

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Adair, C.E., Kopp, B., Distasio, J. et al. Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes. J Urban Health 93, 682–697 (2016).

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