Research Matters Blog
Earlier this month, I wrote a blog post titled 10 Things to Know About the At Home/Chez Soi (AHCS) Study, a homelessness study which I argue is one of the most ambitious randomized controlled trials in Canadian history. The intent of that post was to provide background information about the report prior to its release. Now that the final report has been released, I have compiled another ‘Top 10’ list.
But first, a bit of background:
- All participants in this study were homeless at the start of the program—they were either sleeping in emergency shelters or sleeping outside when the study began. On average, each study participant had experienced a lifetime total of five years of homelessness upon enrollment in the study.
- All participants also “had one or more serious mental illness.” Among other things, this means that this was not a representative sample of Canada’s homeless population, nor was it intended to be. (The Street Health Report 2007, which surveyed a representative sample of Toronto’s homeless population in 2007, found that just 35% of their sample had received a mental health diagnosis from a physician at some point in their lifetime.)
- Study participants were recruited in Vancouver, Winnipeg, Toronto, Montreal and Moncton.
- Participants were interviewed every three months over a two-year period.
- To assess the extent to which participants were using publicly-funded services in the justice, health and social services sectors outside of those provided by the study team, information about the use of such services was collected from national and provincial administrative data sources, as well as from study participants themselves. The information estimated service use by participants both before and after the study started.
- Members of the treatment group received assistance finding an apartment and were provided with a rent supplement (i.e. money to assist with the rent so that no member of the intervention group paid more than 30% of income on rent during the study). The financial assistance in question, known as a “rent supplement,” was generally between $400 and $500 per month. Members of the treatment group were also offered professional health and ‘social work’ support (in some cases medium-intensity, and in other cases higher-intensity).
- Most of the housing used by members of the study’s treatment group was owned and operated by for-profit landlords.
Against this backdrop, here are 10 ‘take aways’ from the final report of the AHCS homelessness study:
- Histories of both trauma and head injuries are common among homeless persons. At baseline, 38% of participants reported having been sexually abused in childhood, while 55% reported having been physically abused as children. Moreover, almost two-thirds of participants reported “a history of one or more traumatic head injuries involving unconsciousness.” For more on the risk factors associated with homelessness, see this 2009 background document. For more on traumatic brain injuries among homeless persons, see this 2012 piece.
- A large proportion of homeless persons suffer from chronic physical health problems. I was surprised to learn that more than 90% of study participants “had at least one chronic physical health problem.” Admittedly, it was more than a decade ago that Dr. Stephen Hwang wrote: “Homeless people in their forties and fifties often develop health disabilities that are more commonly seen only in people who are decades older.” Moreover, findings of this general nature were confirmed in The Street Health Report 2007. Nevertheless, I found this “more than 90%” figure from the AHCS study to be rather astonishing. I was not surprised to learn that at least 85 of the study’s participants are known to have died during the study period. For more on mortality rates among homeless and marginally-housed persons, see this 2009 study.
- In most cases, providing homeless persons with affordable housing and professional support can be effective at ending a person’s homelessness (keeping in mind that this was not a representative sample of Canada’s homeless population). Having personally spent 10 years working with homeless persons in Toronto (including seven as a mental health outreach worker) I did not need the results of a $110-million research study to be convinced of that. But only two randomized controlled trials of this nature had ever been conducted; each had fewer than 100 participants, and both had been done in the United States. As the report’s authors note in the AHCS final report: “Given the difference in social policy and health care delivery between the U.S. and Canada, it is vital that evidence about homelessness interventions be grounded in the Canadian context.”
- People who consume large amount of alcohol and drugs can still maintain their housing. Researchers found that study participants “with substance use problems at baseline maintained stable housing to a similar degree as the overall sample.” I think this helps to debunk the ‘old school’ notion that homeless persons must first ‘rehabilitate’ before being provided with access to permanent housing. For a recent article that explores the provision of housing to homeless persons who are heavy users of drugs or alcohol, see this 2013 article. For an open-access on the same topic, see this 2011 piece.
- Not only is it cost effective to provide a homeless person with affordable housing and professional support, it sometimes even saves taxpayers money. For participants who were costing the broader social support system very considerable sums of money before the study began, the research team has calculated that, from a straight accounting perspective, providing such individuals with housing and professional support can actually save taxpayers money (a point made quite convincingly by Malcolm Gladwell in February 2006). Put differently, though it can cost between $14,000 and $22,000 annually* to provide a homeless person with affordable housing and professional support, for some homeless persons, this approach will result in savings on other publicly-funded services over and above that amount (on such things as psychiatric hospital stays and time spend in detention centres). For the 10% of participants who were using the most services upon enrolment in the AHCS study, every $1 invested in housing and professional support during the course of the study resulted in average savings of just over $2. And across all study participants, every $1 invested in housing and professional support resulted in $0.75 in savings on health, justice-related and social services. (For more on the costs of homelessness, see this 2005 report and this 2012 report.) Even with this evidence of savings in hand, however, there remains a key political challenge when it comes to implementation of such programming. As my colleague Paul Dowling points out, when it comes to providing affordable housing and professional support to homeless persons, “the department that pays and the department that saves are often not the same department.”
- Large urban centres in Canada already have programs that respond to homelessness; some of these programs, though underfunded, appear to be somewhat effective. Members of this study’s control group, in effect, got the short end of the stick, having been randomly placed into the group that did not receive help finding an apartment from the study team, did not receive a monthly rent supplement from the study team and did not receive professional health and social-work support from the study team. Yet, 31% of these individuals still managed to find housing for the duration of the study through status quo programs (i.e. social programs that were already in place before the AHCS program began); another 23% of them managed to be housed for part of the time. While it should be underlined that they were ‘outperformed’ by the treatment group (members of the treatment group spent more than twice as much time in stable housing than did members of the control group) to an extent I think the success of the control group speaks to the partial effectiveness of homelessness programs that were already in place well before the AHCS study began. In other words, it’s not as though there were no programs that responded to homelessness before the AHCS study got started! For an overview of the development of these programs in the Toronto context, see this 2009 policy report. Just how underfunded are homelessness programs in Canada? As I’ve said before, annual federal funding for homelessness in 2014 (after adjusting for inflation) represents just 35% of its 1999 level.
- Even with housing and professional support, not every homeless person can maintain their housing. Sixteen percent of the study participants who received help finding an apartment, were offered financial assistance to pay for the apartment and were offered health and social-work support were not able to hang on to an apartment for any significant length of time (in fact, some of them remained homeless the entire time). Going forward, what public policy response is warranted for this group of people? Do they need supportive housing with 24-hour-a-day on-site support, such as that offered at Strachan House in Toronto?
- Members of this study’s treatment group did not receive one treatment; they received several. Likewise, the study’s control group was not a control group in the narrow sense. Participants in this study’s treatment group were given a bundle of things—they were placed into an apartment, they were given a considerable amount of financial assistance to afford the unit, and they were provided with either moderate- or high-intensive services by a team of health and social-work professionals. Which of these three factors was the largest determinant of their housing success? I suspect we’ll never know. I do not mean this as a criticism of the study; rather, I think it’s simply worth underlining that interpreting the results of a randomized controlled trial is not always a straightforward process. Likewise, we know that members of the control group did not receive the specific intervention offered by the AHCS research project; but there was nothing stopping members of the control group from receiving affordable housing and professional support from another service provider in the city in question. For example, in Toronto, many member s of the control group may have become housed by (and received professional social-work support from) Toronto’s Streets to Homes program. Other members of the control group may have been housed by supportive housing providers who also provide permanent housing and professional support. That said, my guess is that fewer than 10% of members of the control group received affordable housing and professional support on par with the type offered to members of this study’s treatment group. Put differently, even though the control group may not have been a control group in the narrow sense (I am told that is why it was referred to as the study’s “treatment as usual group” as opposed to the study’s “control group”) that does not mean that the study’s findings should not be taken very seriously.
- The effectiveness of non-profit housing was not a focus of this study. As I argued last October, providing a homeless person with immediate access to permanent housing without requiring that the individual ‘rehabilitate’ (often known as the “housing first” approach) has existed at least since homelessness became a prominent focus of public policy in the 1980s. In the 1980s in Toronto, such housing and professional support was usually provided by non-profit housing providers (such as Houselink Community Homes and Homes First Society). Non-profit housing providers were not part of the “intervention” in the present study, which might lead some naive observers to conclude that non-profit housing providers should not be viewed as part of the solution to homelessness. I would dispute such a suggestion. As I’ve blogged about here, there are advantages of having not-for-profit landlords (as opposed to for-profit landlords) own and operate housing for low-income individuals. I think this underlines the need for future research on the provision of permanent housing by non-profit housing providers who have a history of providing supportive housing (that is, permanent housing combined with professional support) to this population.
- There may have been a Hawthorne effect (admittedly, this one’s more for the research wonks out there!). If I knew I was part of a study’s treatment group (and was reminded of this every three months by a researcher) and that the goal of the study was to assess the extent to which a well-funded bundle of services and supports would keep me housed, that knowledge in and of itself might provide me with added incentive to maintain my housing. In other words, take the cameras away—and in this study, there were quite literally cameras in some cases—and I might not try as hard to be a success. Conversely, if I knew I was part of a study’s control group (and was reminded of this every three months by a researcher) the knowledge that I was part of the control group might make me feel less confident about securing and maintaining my own housing. Ergo: it’s possible there was a Hawthorne effect on study participants that exaggerated the success that the intervention might actually have in the ‘real world.’ That said, it’s not clear to me how exactly the research team could have realistically gone about measuring or controlling for a Hawthorne effect. At some point in the interview process (possibly near the end of the process) I would have liked it if the researchers had asked participants questions such as: “Since you know you were in the treatment group, can you discuss the impact that that knowledge has had on your recent behaviour? Has it motivated you to try harder to keep your housing?” To members of the control group, I would have liked it had they asked something like: “Since you’ve known all along that you’re a member of this study’s ‘treatment as usual group,’ did this knowledge affect your behaviour in any way? Do you think it discouraged you from finding housing?”
In Conclusion. I wish to commend the Mental Health Commission of Canada and the At Home/Chez Soi researchers for carrying out this massive research project. I believe that the findings of both the final report and the many other shorter articles coming out of the project will help Canadians to better understand policy responses to homelessness. Members of the international research c ommunity will also no doubt find this research helpful as they move forward in figuring out appropriate policy responses to homelessness. Dr. Paula Goering (the At Home/Chez Soi Lead Researcher) deserves especially strong praise for her role, along with her large team of researchers, the more than 2,000 research participants, the more than 200 service providers and the more than 260 landlords and property management companies that took part in this initiative. Finally, I wish to note that I received extremely helpful feedback on an earlier draft of this blog post from several individuals whose anonymity I wish to preserve.
* Note: these figures, which I’ve rounded to the nearest hundred, “include staff salaries and expenses such as travel, utilities, and rent supplements.”
Photographs by Shane Fester.
This week’s infographic Wednesday is original content from the Homeless Hub’s recent report A Safe and Decent Place to Live: Towards a Housing First Framework for Youth. This report was the result of collaboration between the Homeless Hub, the National Learning Community on Youth Homelessness and the Street Youth Planning Collaborative.
Rather than just asking whether Housing First works for youth (we know it does) the report examined how to adapt the core principles of Housing First to fit youth-centered programs.
This infographic demonstrates that HF is about more than simply housing youth. Good programs will ensure that youth also have access to various forms of support that are complimentary and meaningful and address the following needs:
This report makes the argument for client choice in housing programs. This means adapting the philosophy and core values of Housing First to all housing interventions for youth experiencing homelessness.
Youth should be able to decide on the level and format of housing support that works for them. It isn’t fair to expect all youth the fit into the same format of programming. Some of the options include:
This report is part of an emerging conversation about the application of Housing First to youth programs. It is important that programs for youth experiencing homelessness confront the unique barriers and opportunities that youth have. These differences have to do with pathways into homelessness, but also take into account psychological, social and physical stages of adolescent development.
Programming for youth experiencing homelessness shouldn’t end when youth are off the streets or ‘independent’. Instead, the goal should be to help provide access to the supports necessary for youth to transition into adulthood.
When you speak with people across Canada who work with young people who are homeless, a common question is, “In what ways can Housing First be used to address the needs of young people?” Is this just another example of taking a model for addressing adult homelessness, and by changing the age mandate, creating a “homelessness junior” version? Or is there real promise here?
These are all good questions, and there is actually an urgency to begin to figure these things out. For those looking for solutions to homelessness, Housing First is seemingly everywhere. The Government of Canada has made it a central feature of its five year renewal of the Homelessness Partnering Strategy. The At Home/Chez Soi project, the world’s largest study of the process, outcomes and impact of Housing First, has provided impressive results as demonstrated in the final report released several weeks ago. In a nutshell, At Home/Chez Soi has demonstrated what should perhaps seem obvious – that if you take someone who is homeless, provide them with the housing and supports they need, they generally stay housed and for chronically homeless persons, the recovery begins.
So can we just apply this approach in a straightforward way for youth? For 16-year-olds as well as 23-year-olds? The research on youth in Housing First programs is not extensive. The best known example, the Infinity Project (run by the Boys and Girls Clubs of Calgary) shows impressive results, with 95% of the young people in the program retaining their housing after a year. Other research by Cheryl Forchuk suggests that the transitions to independence for young people can be more complicated, and that many youth prefer to address some of their personal issues before they take on the responsibility of a lease.
The uncertainty about the effectiveness of this program model for youth is creating nervousness in many communities, where funders are now expecting a shift in focus to Housing First with a prioritization of chronically homeless – and mostly adult – persons for the program. The questions regarding whether Housing First can actually meet the needs of young people, how it works with other existing program models and approaches, and what this will mean for communities struggling to address youth homelessness need to be addressed.
The new report released today by the Homeless Hub A Safe and Decent Place to Live: Towards a Housing First Framework for Youth seeks to answer some of these questions and concerns. The key theme of this report is that Housing First can indeed work for youth – it actually can work for anybody – but that the program delivery model must be designed and implemented in a way that takes into account the needs of the developing adolescent and young adult. Youth homelessness is distinct from adult homelessness both in terms of its causes and conditions, and therefore so must be the remedies.
The core principles of Housing First for youth are therefore modified from the version found in the Framework for Housing First that the Homeless Hub published last year, to address the special needs of young people. Also important to note here is that the models of accommodation are broadened to include, for instance, the possibility of returning home (through family reconnection) and transitional housing. While the latter has fallen out of favour in some quarters based on the success of Housing First, it is argued here that many young people prefer congregate living models with higher levels of supports in early years, before they are ready to go out on their own. Many fear the isolation and risks that go with that. Others, of course, are ready for independent living in a scattered site model. The key here is that if choice is at the centre of Housing First, there need to be a range of housing options available.
The supports that young people may require also have to reflect their needs as they transition to adulthood. Many young people will have little or no experience running a household and may be in the throws of adolescent development, meaning they have special challenges regarding decision-making, managing relationships and juggling complex responsibilities. Young people who want to return to school should be supported to do this. The supports young people need should be in place for as long as they need them – not just for one year. The point is that in developing a model of Housing First for youth, we should base it on what any young person needs, which is the necessary supports required to move into adulthood and the time allowed to do it. What is good for me, for my children, is also good for young people who experience homelessness.
So, Housing First can work for young people, if done properly and built around their needs. Young people who experience homelessness will do better if they are provided with housing and supports designed to help them transition to adulthood.
A couple of important things to consider with this approach:
As communities rush to implement Housing First for youth, it is crucial that there is fidelity to the model presented here. That is, we cannot take a half-baked program that simply drops young people into housing without providing necessary and appropriate supports. We need to ensure that appropriate accommodation AND supports (and the funding to ensure these are delivered properly) are in place.
Finally, we need to always remember that Housing First is an important intervention for homeless youth, but not the only one. There will continue to be the need for a focus on prevention, for shelter diversion programs, for emergency services and alternative models of housing and supports.
Housing First can work for young people, but lets make sure we get it right.
Transitional housing refers to a supportive – yet temporary – type of accommodation that is meant to bridge the gap from homelessness to permanent housing by offering structure, supervision, support (for addictions and mental health, for instance), life skills, and in some cases, education and training.
“Transitional housing is conceptualized as an intermediate step between emergency crisis shelter and permanent housing. It is more long-term, service-intensive and private than emergency shelters, yet remains time-limited to stays of three months to three years. It is meant to provide a safe, supportive environment where residents can overcome trauma, begin to address the issues that led to homelessness or kept them homeless, and begin to rebuild their support network.”
Historically, transitional housing programs were situated within dedicated, building-specific environments, where there was more common space and less private space than might be the case in permanent housing environments. However, as the concept of transitional housing has evolved, new approaches that incorporate scattered-site housing are now being adopted. In such cases, some of the transitional ‘supports’ are considered portable.
Transitional housing, as an approach, has long been seen as part of the housing continuum for people who are homeless, and in particular for sub-populations such as youth. However, in recent years it has become somewhat controversial, particularly in light of the success of Housing First models, which do not require ‘readiness’ for a transition. Eberle Planning and Research identified two key concerns:
- Transitional programs reward those who do well by requiring them to move on; and
- They can only be effective if affordable independent housing is available to move to afterwards.
An additional concern has to do with the time-limited nature of transitional housing. Most programs in Canada determine a maximum length of stay, which is often quite short (usually one year, but there are some examples in Canada where young people can stay eighteen months or more). Nevertheless, in spite of these criticisms an argument can be made that transitional or ‘interim’ housing is still necessary in contexts where there isn’t an adequate supply of affordable housing, and also when dealing with sub-populations such as youth.
Though there have been some broader Canadian studies on the role of transitional housing as part of a range of housing options for people experiencing homelessness, there is surprisingly little evaluative research on the effectiveness of transitional housing programs for youth in Canada. Key exceptions include the recent report Live, Learn, Grow, which surveys the literature on the Foyer model; a study of Eva’s Phoenix, a Toronto-based program that has demonstrated positive outcomes, and Peel Youth Village. However, are no longitudinal studies on the long term effectiveness of such programs for youth in Canada, or of their success in helping young people transition to stable housing afterward.
The situation is the same in the United States. In their policy briefing on youth homelessness for the 2010 Opening Doors Homelessness Strategy, the United States Interagency Council on Homelessness lamented that while there were an estimated 130 transitional housing programs in the US serving 4,000 young people annually, there was very little data in existence regarding the effectiveness of these programs. There are now a number of research projects on transitional housing underway in the United States, however.
This infographic by Food Banks Canada was part of the HungerCount report. The report states that while there was a drop of approximately 40,000 food bank users between 2012 – 2013, there were 833,000 food bank users in Canada. This is 23% more than the number of people who accessed food banks prior to the 2008 recession. PROOF’s Household Food Insecurity in Canada 2012 report, stated that approximately 1.4 Million households experience food insecurity in Canada.
Programs that offer emergency food services vary in their makeup. A large majority of those in the HungerCount study (78%) offer non-traditional services. These services include:
- Food focused programs
- Skill building programs
- Social service programs
- Referral to other services
Some of the recommendations in this report are aimed at reducing future reliance on food banks in Canada. A few of the main recommendations include:
- Expanding benefits for Employment Insurance
- Increasing Social Assistance levels
- Reforms to ‘flexible’ labour laws that privilege employers
It is important to recognize that those facing food insecurity are also likely facing insecurity in other areas such as housing and employment. Those who are at risk of losing their housing may be unable to access good food without the support of emergency food services. Affordable housing, rent supplements and rent geared to income are also important in ensuring that lower paid workers are still able to access good, nutritious and culturally relevant food. Unfortunately with recent federal changes there will be 10,500 fewer social housing units funded. The HungerCount report also notes that 1.6M families currently spend over 30% of their income on housing.
Overall, it is important that we continue to look at the connection between poverty, food security and homelessness. Policy decisions at every jurisdictional level should address the current needs while implementing preventative measures that will decrease reliance on emergency services in the future.
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