Introduction

Domestically and globally, promoting social inclusion of persons with mental health and/or substance use challenges remains an important political goal (Norwegian Directorate of Health, 2012, 2014, 2016; United Nations, 2006). Persons with mental health and/or substance use challenges face multiple obstacles to experiencing a sense of belonging (Ogundipe et al., 2020; Semb et al., 2019, 2021) and participating in the community (Ness et al., 2014; Skogens et al., 2018). This is therefore a core matter of concern, as social inclusion plays a crucial role in a person’s recovery process (De Ruysscher et al., 2017; Ness et al., 2014; Skogens et al., 2018) and is increasingly recognized as a key component of quality of life for this group (Filia et al., 2018).

Social inclusion is a multidimensional concept that includes subjective and objective dimensions such as a sense of belonging and community participation (Blank et al., 2016; Leonhardt et al., 2022; Lloyd et al., 2006; Ogundipe et al., 2020, 2022), where both dimensions have been identified as core facilitators of recovery (Brekke et al., 2017; Davidson et al., 2008; De Ruysscher et al., 2017; Skogens et al., 2018). Thus, it is vital to gain a deeper understanding of what characterizes social inclusion for this group. This meta-synthesis addresses this issue.

Articles 19 and 30 of the United Nations Convention on the Rights of Persons with Disabilities stress the importance of fully experiencing community inclusion, which includes social inclusion (United Nations, 2006). To achieve social inclusion, article 19 highlights everyone’s right to have a home and receive support in the community and to have the freedom to make choices related to their living conditions. Furthermore, article 30 emphasizes the right to participate in cultural life, recreation, leisure, and sports (United Nations, 2006). Despite these rights, residents with mental health and/or substance use challenges, many of whom live in supported housing, continue to experience obstacles to exercising these rights (Blank et al., 2016; Brekke, 2019; Fields, 2011; Ogundipe et al., 2020; Ogundipe et al., 2022; Pilla & Park-Taylor, 2021; Todd et al., 2004).

Historically and politically, the mental health deinstitutionalization process aimed to promote the social inclusion of persons with mental health and/or substance challenges in the community (Fakhoury & Priebe, 2007). Following deinstitutionalization, an array of community-based housing programs (Fakhoury et al., 2002), hereafter referred to as supported housing programs, were introduced to support persons with mental health and/or substance use challenges to live in regular neighborhoods. The ambition was that decentralized care and support would facilitate housing stability, recovery, and life goals, enabling service users and residents to participate and integrate into their local communities and society at large (Ware et al., 2007; Wong & Solomon, 2002). Supported housing programs vary from congregate residential sites with high levels of on-site staff supervision to scattered-site apartments with off-site support (Gonzalez & Andvig, 2015a). Although the level of support in supported housing programs may vary, social inclusion is considered a core aim in such programs (Fakhoury et al., 2002; Fakhoury & Priebe, 2007).

Social inclusion is a complex, multi-dimensional concept, which still lacks a consensual definition (Quilgars and Pleace, 2016). In the context of supported housing, social inclusion has been defined as “involving persons’ social interactions with community members and the structure of their social network” (Wong & Solomon, 2002, pp. 18–19). Although Wong and Solomon’s (2002) definition were coined more than two decades ago and is widely quoted, it has also been criticized for being too narrow (Gulcur et al., 2007; Quilgars & Pleace, 2016). In this meta-synthesis, a broad focus on social inclusion is adopted, in which a sense of belonging and various forms of community participation (e.g., social participation) are recognized as dimensions of social inclusion (Blank et al., 2016; Leonhardt et al., 2022; Lloyd et al., 2006; Ogundipe et al., 2020, 2022).

Previous research on social inclusion in the context of supported housing has shown that receiving housing is only one step towards perceived inclusion among persons with mental health and/or substance use challenges. However, there is still a distinct difference between receiving housing in the community and feeling socially included and part of the community where one lives. This recognition has led some researchers to state that persons with mental health and/or substance use challenges are “in the community, but not part of it” (Ware et al., 2007, p. 469). This argument underscores the need to promote experiences of social inclusion that go beyond assigning housing (Ogundipe et al., 2020; Ware et al., 2007; Wong & Solomon, 2002). A key issue regarding supported housing and social inclusion is the question of what social inclusion means for residents (Quilgars & Pleace, 2016). This calls for an in-depth understanding of what characterizes the core dimensions of social inclusion for persons with mental health and/or substance use challenges living in supported housing. This study therefore aimed to synthesize findings from qualitative studies addressing social inclusion for this group from the perspectives of residents, and we asked the following research question:

What characterizes the core dimensions of social inclusion for persons with mental health and/or substance use challenges living in supported housing?

Methods

Design

For this meta-synthesis, we applied a flexible descriptive design, leaning on the recommendations of Sandelowski and Barroso (2007). The methodological approach applied in this meta-synthesis followed six phases: (1) formulating the research question, (2) conducting a systematic literature search, (3) screening and selecting appropriate research papers, (4) analyzing and synthesizing qualitative findings, (5) maintaining quality control, and (6) presenting findings.

Databases and Search Strategy

Six databases were considered relevant for systematic searches to identify relevant papers addressing core dimensions of social inclusion in a supported housing context: Ovid Medline, Embase, CINAHL Complete, PsycINFO, Web of Science, and Scopus. The chosen databases cover general health issues, psychological issues, and interdisciplinary issues, all relevant to the aim of this meta-synthesis. Keywords and terms from the controlled vocabularies of the selected databases, where these were available, covering the three main categories/themes, housing AND social inclusion AND mental health/substance use/co-occurring disorders, were identified. Further possible search words were identified by the authors based on their knowledge of keywords used in the research literature.

In the housing literature, the terms “supported housing” and “supportive housing” are frequently defined in similar ways (Rog, 2004), and are often used interchangeably (Tabol et al., 2010). Thus, research papers addressing persons living in housing program contexts identified as supported housing and supportive housing were included. Likewise, papers addressing other housing programs with similar principles, such as resident empowerment, choice, community inclusion, and flexible support, were also included. Core information about the housing programs in the included papers is presented in Table 1.

Table 1 Characteristics of the housing programs in the included papers
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We applied a search filter for identify qualitative papers developed by Biomedical Information of the Dutch Library Association and further adapted to several other databases by librarians at the University of Stavanger. The search was limited to papers published in English or Scandinavian languages. The search was performed in February 2022 by a specialist health librarian at the University of South-Eastern Norway. An outline of the search strategy is presented in Fig. 1. A detailed search strategy is available from the authors upon request.

Fig. 1
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The search strategy

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Inclusion Criteria

The inclusion criteria for qualitative research papers were: (1) papers published in peer-reviewed journals, (2) papers addressing social inclusion, and (3) papers with a qualitative design or mixed studies reporting findings from qualitative results.

Retrieval of Papers

The search strategy identified a total of 1549 papers. Of these, 772 were removed as they were duplicates. The abstracts from the remaining 777 papers were thoroughly reviewed, resulting in 638 papers being excluded for reasons related to the inclusion criteria. The remaining 139 papers were obtained, and a full-text screening of these led to the elimination of 114 papers. At this stage, papers addressing homelessness and transitioning from streets or institutions to housing were removed. The remaining 25 papers were thoroughly assessed with the study aim and research question of the meta-synthesis in mind, resulting in the exclusion of an additional 11 papers. Finally, 14 papers were left for further analysis. The paper retrieval process is presented in the flow chart in Fig. 2.

Fig. 2
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PRISMA flow chart presenting the process of paper retrieval

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The 14 papers included in this meta-synthesis came from Canada (n = 7), the USA (n = 5), Norway (n = 1), and Sweden (n = 1) and were published between 1999 and 2021. One paper was published in 1999 (Boydell et al., 1999), two papers between 2000 and 2010 (Walker & Seasons, 2002; Wong et al., 2006), while 11 papers were published in 2011–2021 (Chan, 2020; Estrella et al., 2021; Fields, 2011; Golembiewski et al., 2017; Henwood et al., 2018; Kirst et al., 2020; Macnaughton et al., 2016; Ogundipe et al., 2020; Piat et al., 2017a, 2017b; Tjörnstrand et al., 2020). The total number of residents as informants across the papers was 758. The sample size ranged from 5 to 195 across the papers. Eleven papers had a qualitative design only (Boydell et al., 1999; Chan, 2020; Estrella et al., 2021; Fields, 2011; Henwood et al., 2018; Macnaughton et al., 2016; Ogundipe et al., 2020; Piat et al., 2017a, 2017b; Walker & Seasons, 2002; Wong, 2006), while three papers used a mixed methods design with qualitative and quantitative methods (Golembiewski et al., 2017; Kirst et al., 2020; Tjörnstrand et al., 2020). Notably, in the three mixed methods papers the authors used the qualitative data only. Data analysis was based on reported qualitative findings from a total of 758 participants. Table 2 provides an overview of the characteristics of the 14 papers included.

Table 2 Characteristics of the included papers
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Quality Appraisal

The 14 included papers were assessed and scored based on the Critical Appraisal Skills Programme (CASP) for qualitative studies: (1) a clear statement of aim, (2) a qualitative methodology is appropriate, (3) congruence between research design and research aims, (4) recruitment strategy appropriate to meet the research aim, (5) the data collection method addresses the research issue, (6) relationship between the researcher and the participants described, (7) ethical issues have been considered, (8) a rigorous data analysis, and (9) a clear statement of the findings (CASP, 2013). Papers received one point for each CASP criterion met, giving a possible maximum score of nine for each paper. As suggested by Eriksen et al. (2020, 2022), a score of nine indicated a high methodological quality, a score of 7–8 implied moderate quality, and papers with a score of 6 or less were of low quality. As recommended by Sandelowski and Barroso (2007), no papers were excluded based on quality criteria only. The quality assessment was performed independently by two authors. After scoring separately, the two authors met to compare and discuss their assessments and revised the scores until a consensus was reached. The final CASP scores are presented in Table 3. The paper where the first author was one of the authors was appraised by the last author only.

Table 3 Quality ratings assigned to each research paper
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Data Extraction

The research question with “core dimensions of social inclusion” as the units of analysis guided the extraction of relevant information constituting data from the included papers. This involved detailed data providing any relevant information on residents’ experiences of social inclusion, sense of belonging, and social participation. These data were extracted into a data extraction sheet consisting of three columns. The first column listed the main themes, subthemes, categories, and subcategories from the extracted findings as reported in each paper. The second column comprised the original authors’ descriptions of the findings. The final column consisted of the quotes the original authors presented in their papers.

Data Analysis

Data were analyzed using the five phases of content analysis proposed by Graneheim and Lundman (2004). The first phase requires selecting the relevant text in line with the research question and thus the units of analysis. Texts that in any way described experiences of social inclusion, belonging, and social participation of persons with mental health and/or substance use challenges were extracted into an extraction sheet prepared for further analysis of the data. The second phase involves identifying meaning units. The third phase centers on the process of condensation. In the fourth phase, the condensed meaning units are coded and gathered into subcategories. In the fifth phase, subcategories are further developed into categories.

In the first phase, the first and last author independently performed a close reading of the data extraction sheet to obtain an overall impression of the data, while also noting potentially relevant topics and patterns. Thereafter, the two authors met to compare and discuss their extracted data, and then modified the extraction sheet as necessary. In the second phase, the authors individually and repeatedly read the data extraction sheet to identify meaning units (i.e., sentences or paragraphs that contained aspects related to the units of analysis) (Graneheim & Lundman, 2004). While reading the data extraction sheet line by line, meaning units were highlighted in color. When the reading was completed, the meaning units identified were copied into a new column labeled “meaning units” in the extraction sheet. The third phase of analysis involved the process of condensing the meaning units. The authors aimed to keep the condensation close to the original text by using the original language from the meaning units to ensure that valuable information was not lost. In the fourth phase of analysis, the condensed meaning units were abstracted. The process of abstraction occurred in two steps. First, each condensed meaning unit was coded to organize the material. Afterward, the authors proceeded to group these codes. Grouping was achieved by identifying similarities and differences and then gathering the codes into subcategories, describing the manifest meaning of the data in the extraction sheet. Moreover, grouping required reading and re-reading the data extraction sheet to ensure that valuable information was not lost. In the fifth and final phase, subcategories were further sorted into categories.

Ethical Considerations

Ethical approval was not required for this paper, as the data originated from published papers.

Results

The qualitative content analysis aimed to answer the following research question: What characterizes the core dimensions of social inclusion for persons with mental health and/or substance abuse challenges living in supported housing? The data analysis resulted in three categories, each divided into three subcategories, describing in-depth core dimensions of the experience of social inclusion of persons with mental health and/or substance use challenges living in supported housing. The dimensions (categories) were (1) having access to core resources, (2) actively participating oneself, and (3) being existentially anchored. The categories with subcategories are presented in Table 4.

Table 4 Categories and subcategories characterizing core dimensions of social inclusion
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Having Access to Core Resources

Having access to core resources was an essential dimension of social inclusion. This category consisted of three subcategories: (1) having a safe place to live, (2) having support from family members and professionals, and (3) having support from a broader community.

Having a Safe Place to Live

Having a safe home appeared to be crucial for establishing and re-establishing a social network, and thus feeling socially integrated. This allowed residents to pursue new social relationships (Golembiewski et al., 2017), usually with other residents (Golembiewski et al., 2017; Piat et al., 2017b; Tjörnstrand et al., 2020) and with people outside the housing facility (Macnaughton et al., 2016; Piat et al., 2017a, 2017b). Having a safe place to live motivated residents to re-establish important and meaningful relationships, often with family members (e.g., children, siblings, parents) or earlier friends and romantic partners (Golembiewski et al., 2017; Kirst et al., 2020; Macnaughton et al., 2016).

Having a safe home entailed having a place where one could enjoy oneself (Piat et al., 2017b), sharing good moments, and thereby achieving closer relationships (Chan, 2020; Tjörnstrand et al., 2020). Furthermore, having core resources such as storage possibilities, a television, computer, and furniture helped residents to be engaged and informed, thus facilitating social participation and ultimately an experience of being socially integrated. Likewise, having a home also made it easier to have a pet to help combat loneliness, and facilitated forming new relationships (Macnaughton et al., 2016; Piat et al., 2017b), which could lead to social networking and greater integration.

Having Support from Family Members and Professionals

Having support from family members and professionals was described as vital for managing social connections and integration outside the housing setting (Fields, 2011; Kirst et al., 2020; Macnaughton et al., 2016; Piat et al., 2017a, 2017b). The support referred to how family members for shorter or longer periods often had to make up for residents’ few friends and limited social life (Golembiewski et al., 2017; Piat et al., 2017b). Moreover, families’ financial and material support and driving the residents to activities were vital to enable them to participate socially in their local communities (10, 11). Likewise, support from staff involved providing necessary information on important social venues and social events (Kirst et al., 2020; Macnaughton et al., 2016), as well as assistance with everyday challenges. Support from staff in the pursuit of personal goals (Estrella et al., 2021; Golembiewski et al., 2017; Ogundipe et al., 2020; Piat et al., 2017a) was experienced as an encouragement to participate in the local community. Furthermore, staff-led activities in the housing facility (Piat et al., 2017b; Tjörnstrand et al., 2020) and staff as “friend-like” conversation partners (Tjörnstrand et al., 2020) were vital for residents’ feeling of social inclusion in the housing setting.

Having Support from a Broader Community

Support from the broader local community represented a vital resource for a sense of social inclusion. Having support to remain in their preferred neighborhood (Fields, 2011) or to pursue educational and vocational goals (Macnaughton et al., 2016), and to return to work, or to stay in a job (Kirst et al., 2020) depended on support and flexibility from neighbors (Wong et al., 2006), landlords (Fields, 2011), employers, and other community members (Kirst et al., 2020; Wong et al., 2006). The qualities most valued for an experience of social inclusion were unity, solidarity, respect, and kindness (Fields, 2011; Kirst et al., 2020; Ogundipe et al., 2020; Wong et al., 2006).

Participating Actively Oneself

To be the one actively taking the initiative to participate was a crucial dimension for experiencing social inclusion. This category included three subcategories illustrating how residents’ efforts at participation played a crucial role in a feeling of social inclusion. The subcategories were: (1) participating in available social settings, (2) participating by adapting to fit in, and (3) participating in reciprocal relationships.

Participating in Available Social Settings

Participating actively in social settings was underlined as necessary to become socially included in the local community (Estrella et al., 2021; Fields, 2011; Macnaughton et al., 2016). Active participation entailed taking the initiative to interact with others at local places and events, such as bus stops, local stores, town watch meetings, or neighborhood clean-ups (Wong et al., 2006). The residents further underlined the importance of participating in leisure activities (Estrella et al., 2021; Fields, 2011; Kirst et al., 2020; Macnaughton et al., 2016), as these activities provided stronger experiences of social connections and interaction with people in their communities (Estrella et al., 2021; Walker & Seasons, 2002), and thus a sense of belonging and social inclusion. Leisure activities involving active participation in the community were gardening, excursions, celebrating special occasions, visits, sports, exercise, and cooking (Kirst et al., 2020; Piat et al., 2017a, 2017b; Tjörnstrand et al., 2020).

Participating by Adapting to Fit in

The residents intentionally adapted to and applied strategies and behaviors they deemed necessary for being socially included. Such strategies were described as remembering to mind their own business, trying to be invisible, or trying to blend and thereby fit in (Boydell et al., 1999; Fields, 2011; Wong et al., 2006). Participating by adapting one’s strategy was also due to limited finances (Piat et al., 2017a; Walker & Seasons, 2002) and could be exemplified by taking part in leisure activities, such as billiards, during hours when prices were lower or visiting places were buying something to eat or drink was not required to participate (Piat et al., 2017a).

Participating in Reciprocal Relationships

The residents clearly described how participating in reciprocal relationships involving mutual exchanges of support was important for feeling socially included. They underlined working actively towards becoming a source of support for others and having the possibility to be involved in reciprocal relationships.

Establishing reciprocal relationships involved taking practical steps towards becoming an active contributing member of one’s community. This entailed supporting others with daily chores, providing financial support if necessary to their family (Piat et al., 2017a), signing up to be a volunteer (Kirst et al., 2020; Macnaughton et al., 2016), or calling each other when the smoke detector alarm went off (Wong et al., 2006). Being supportive and thereby a resource for others seemed to help residents persist in participating in their communities (Kirst et al., 2020; Macnaughton et al., 2016). Likewise, experiencing kindness from others and being a source of kindness to others were vital elements. Moreover, engaging or reengaging in social roles such as being a parent, grandparent, student, or employee was also underlined (Chan, 2020; Kirst et al., 2020; Macnaughton et al., 2016).

Being Existentially Anchored

Experiencing oneself socially included also involved the dimension of being existentially anchored. The category being existentially anchored comprised three subcategories: (1) being in the process of belonging, (2) being autonomous and free to make choices, and (3) being able to be oneself.

Being in the Process of Belonging

Becoming socially included was seen as a process over time, requiring patience. Understanding and experiencing social inclusion as an ongoing process of belonging helped residents to internalize and keep alive hope for a better future (Kirst et al., 2020; Macnaughton et al., 2016; Wong et al., 2006). Belonging was described as a long-term process related to the fact that residents often only felt a temporary sense of belonging. Despite a sense of belonging, or temporary belonging, to their current community, the desire to belong elsewhere in the future was voiced (Ogundipe et al., 2020).

Being Autonomous and Free to make Choices

Being autonomous and having the freedom to choose and decide how to participate and how to belong was a core existential dimension of experiencing oneself as socially included (Chan, 2020; Ogundipe et al., 2020; Tjörnstrand et al., 2020). The feeling of being autonomous included the freedom to decide on one’s social closeness or distance with others, particularly those whose company the residents believed would jeopardize their efforts to become autonomous people capable of living in their community (Fields, 2011; Piat et al., 2017b). Moreover, having greater control and choices over when and how to interact with others was vital for autonomy and thus a sense of inclusion (Kirst et al., 2020; Macnaughton et al., 2016).

Being Able to Be Oneself

Being able to be oneself, and thus in tune with one’s authentic self, was important for a sense of belonging. Places in which this authentic and existential dimension was experienced were their own home (Chan, 2020) and some community settings (Fields, 2011). Being in tune with one’s true authentic self, appeared to be easier in community settings regarded as “less normative” and free from stigma and discrimination.

Discussion

This meta-synthesis aimed to answer the research question What characterizes the core dimensions of social inclusion for persons with mental health and/or substance use challenges living in supported housing? The synthesized findings from the 14 included papers add greater depth to knowledge of the characteristics of perceived social inclusion for this group. This in-depth knowledge holds the potential to further promote the rights of persons with mental health and/or substance use challenges to be included in their local communities and society at large.

The findings are particularly interesting when mirrored against articles 19 and 30 of the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2006). As elaborated on in the introduction, the findings correspond to article 19 in that having a home, and thus a safe place to live, is the core resource for experiencing social inclusion. These findings are also supported by findings reported in a meta-synthesis by Gonzalez and Andvig (2015b) showing that having a safe home is undoubtedly the most important resource for this group as for anybody else. Furthermore, article 30 underlines the right to participate. Despite this, residents with mental health and/or substance use challenges clearly encounter obstacles to exercising these rights (Fields, 2011; Ogundipe et al., 2020, 2022; Pilla & Park-Taylor, 2021).

On the issue of participation, our findings provide an in-depth understanding of what residents consider vital to participation beyond merely having the right. For the residents, participating entailed being actively involved, and having equal roles in reciprocal relationships and a diversity of social settings. Moreover, they found that participating actively also involved adapting to what they considered necessary to succeed and fit in. This in-depth understanding therefore adds the knowledge that just having the right to participate does not guarantee social inclusion; it is also necessary to take active steps to participate and to have the necessary support to enable participation.

Considering the findings in terms of history and mental health deinstitutionalization involving housing strategies with the overall aim of social inclusion of this group (Fakhoury & Priebe, 2007), our findings broaden and expand the understanding of what that means for the residents themselves. In this respect, our findings are in line with strategies highlighting the importance of housing stability, community participation, and the importance of each resident having life goals and hopes for the future. Moreover, our findings also revealed that social inclusion requires support on all levels, such as the residents’ families, professionals, and the broader local community. To what degree this support is adequate, comprehensive, and in line with the residents’ needs may be questioned. On this issue, a meta-synthesis by Gonzalez and Andvig (2015a) has reported the complexity and variety of service users’ support needs. Furthermore, staff working in supported housing facilities have stated that a lack of financial resources was a barrier to promoting and supporting residents’ experiences of being socially included in their local community (McCauley et al., 2015; Miler et al., 2022; Ogundipe et al., 2022), emphasizing that social inclusion remains an important goal in these settings.

Some attempts have been made to define social inclusion. The quite narrow, but often quoted, definition of social inclusion by Wong and Solomon (2002) is considered not to fully cover the dimensions of what the residents themselves find characteristic of being socially included. In the definition by Wong and Salomon (2002), a sense of belonging is seen as a psychological rather than a social process and is therefore referred to as psychological inclusion. Thus, our findings are more in line with the broader concept of social inclusion in which a sense of belonging and various forms of community participation (e.g., social participation) are key dimensions (Mahar et al., 2013; Lloyd et al., 2006). In the definition by Mahar et al. (2013), a sense of belonging is seen as a core issue that refers to a subjective sense of worth and respect derived from reciprocal relationships built on shared experiences, beliefs, or personal characteristics. The sense of belonging is further characterized as a dynamic process; hence social environments can enhance or detract from a person’s sense of belonging. These influences from social environments may be transitory or persistent in their impact on the sense of belonging. Social participation is seen as a dimension of social inclusion that involves participating actively in social activities that can potentially lead to experiences of friendship and happiness (Lloyd et al., 2006).

The findings of this meta-synthesis resonate well with the conceptualization of recovery as “a deeply social, unique, and shared process in which our living conditions, material surroundings, social relations, and sense of self evolve. Recovery is about striving to live satisfying, hopeful, and reciprocal lives …” (Topor et al., 2022, p. 11). The findings of this meta-synthesis also emphasize the significance of adequate living conditions, support at various levels, reciprocal relationships, and the ability to actively play a role oneself and to be oneself as core dimensions of residents’ experiences of social inclusion.

To our knowledge, no other reviews or meta-syntheses have been published aiming to summarize or synthesize qualitative findings describing what characterizes social inclusion from a person-centred perspective of persons with mental health and/or substance use challenges living in supported housing. However, Watson et al. (2019) conducted a qualitative meta-synthesis seeking to learn from the lived experiences of residents with persistent mental health challenges about how supported housing facilitates social connection and participation.

Yet another meta-synthesis by Gonzalez and Andvig (2015b), two dimensions of social inclusion were identified, namely a sense of belonging and social participation. These findings resonate well with our synthesized findings, and thus the findings of these two meta-syntheses mutually support each other’s findings, as well as our findings. Thus, the existential dimension of belonging and social participation should be integrated into the definition of social inclusion.

Holding the above elaborated findings together, it is pertinent to use the relevant and mutually supportive findings to propose a new definition of what characterizes social inclusion for residents living in supported housing. Hence, we suggested the following definition as the meta-level of this meta-synthesis: In the context of supported housing, social inclusion for persons with mental health and/or substance use challenges is characterized by having access to core resources like a safe place to live and support on different levels (families, professionals, and a broader community). It also involves participating actively oneself in social settings, being involved in reciprocal relationships, and being existentially anchored through experiences of belonging, autonomy, and authenticity.

Methodological Considerations

This meta-synthesis has both strengths and weaknesses. In our literature search, we meticulously selected the most relevant databases and used a comprehensive search strategy, which enhanced the strength of this study. In addition, this meta-synthesis was improved by using a competent academic librarian to perform the systematic searches. In including and excluding relevant papers and extracting data, the two researchers worked independently and engaged in discussions until they reached agreement. Moreover, we used a transparent definition of supported housing and provided a detailed description of the housing programs referenced in the included papers. Additionally, we presented the results of the quality appraisal of each study clearly and openly. These strategies are considered a study strength. Regarding the data analysis and synthesis, a strength of this study is that it provided a profound understanding of what characterizes the core dimensions of social inclusion for residents with mental health and/or substance use challenges. Furthermore, the reflexive process employed by several researchers engaged in data analysis serves to enhance the trustworthiness of this study.

Despite our efforts to ensure transparency in all our choices on all levels of this meta-synthesis, it is important to acknowledge that the inconsistent terminology and variation in housing programs in this field challenged the development of a precise search strategy and thus might have weakened the retrieval of papers. Furthermore, this inconsistency might also have influenced the extraction of information from each paper and the analysis and synthesis of the data (MacPherson et al., 2018).

Conclusion

The core findings in this meta-synthesis were having access to core resources, participating actively oneself, and being existentially anchored, along with the subcategories (please see Table 4). Based on these findings, we suggest a new definition of social inclusion in the context of supported housing: Social inclusion for persons with mental health and/or substance use challenges is characterized by having access to core resources like a safe place to live and support on different levels (families, professionals, and a broader community). It also involves participating actively oneself in social settings, being involved in reciprocal relationships, and being existentially anchored through experiences of belonging, autonomy, and authenticity.

Recommendations for Mental Health and Substance Use Services

Based on the findings, we recommend improvements in promoting social inclusion at the policy level, at the service and support level, and the resident level. At the policy level, any intervention that can strengthen access to core resources, facilitate active participation, and promote existential issues must be taken into consideration. At the service and support level, we recommend systematic training and support programs for staff to enhance staff knowledge, skills, and attitudes in these areas. At the resident level, we recommend assessing residents’ needs and challenges concerning social inclusion to provide individualized support to each resident.

Recommendations for Further Research

Based on the findings, we suggest that researchers in this field explore and/or try out various systematic training and support programs aiming to enhance social inclusion for the group in question. These could be individual or group-based social training programs or other educational, psychosocial, or therapeutic interventions at the group or individual level.