Social Determinants of Health Program Planning in Public Health: What’s the Evidence?

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Social Determinants of Health

Program Planning:

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What’s the evidence? Fitzpatrick-Lewis, D., Ganann, R., Krishnaratne, S.,

Ciliska, D., Kouyoumdjian, F., Hwang, S.W. (2011). Effectiveness of interventions to improve the health and housing status of homeless people: A rapid systematic review. BMC Public Health, 11: 638.

http://www.health-evidence.ca/articles/show/21957



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Social Determinants of Health

Program Planning:

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CIHR Funded MOP-238541

CIHR-Funded Reviews Hwang, S. W., Tolomiczenko, G., Kouyoumdjian, F. G., &

Garner, R. E. (2005). Interventions to improve the health of the homeless: A systematic review. American Journal of Preventive Medicine, 29(4), 311-319.

UPDATE: Fitzpatrick-Lewis, D., Ganann, R., Krishnaratne, S., Ciliska, D., Kouyoumdjian, F., Hwang, S.W. (2011). Effectiveness of interventions to improve the health and housing status of homeless people: A rapid systematic review. BMC Public Health, 11: 638.

Rapid Reviews Rapid reviews are literature reviews that use

methods to accelerate or streamline traditional systematic review processes.

(Ganann, 2010)

Questions?

Summary Statement: Fitzpatrick-Lewis (2011)

Overall Considerations

Considerations for Public Health Practice Conclusions from Health Evidence General Implications

Provision of housing for homeless or marginally housed populations leads to: • increased housing stability • small, but significant, decreases in

substance/alcohol use • longer durations of abstinence • reduced emergency department or

psychiatric inpatient use • improved quality of life





psychiatric inpatient use • improved quality of life Adding case management and/or day treatment services to housing provision for varying homeless populations leads to: • improved housing stability • less need for substance abuse treatment • improved antiretroviral adherence






Public health programs should include and/or support: • provision of housing with rent subsidy for

homeless people with mental illness • housing, preferably abstinent contingent, for

homeless people with substance abuse • individual counseling to reduce risk among

homeless people with HIV/AIDS • weekly educational sessions for homeless

or runaway youth • the provision of housing and/or moderate-

consistent case management for homeless people with HIV/AIDS












Non-abstinent contingent housing with case management is not recommended for homeless people with concurrent disorders to decrease psychiatric symptoms & substance, but is recommended to stabilize housing.

Homeless people with mental illness Studies Homelessness Definitions Forchuk et al., 2008 Patients being discharges from psychiatric wards to

shelters and no fixed address.

Interpreting the Evidence

Interventions for homeless people with mental illness (1 RCT)

What’s the evidence? Implications for practice & policy

• The provision of discharge support (i.e. assistance with finding housing and payment of first/last month’s rent) led to significant improvements in housing status up to 6 months post-discharge, compared to individuals receiving usual care (i.e. social work referral) (p < 0.001).


Interventions for homeless people with mental illness (1 RCT)


• The provision of discharge support (i.e. assistance with finding housing and payment of first/last month’s rent) led to significant improvements in housing status up to 6 months post-discharge, compared to individuals receiving usual care (i.e. social work referral) (p < 0.001).

• Public health decision makers should consider the positive impact supportive housing and rental assistance has on housing status of those discharged from psychiatric care, while acknowledging the effect is based on a single study.

Homeless people with substance abuse issues Studies Homelessness Definitions Larimer et al., 2009 ‘Chronically homeless’ list of individuals with high

local crisis services utilization patterns. Chronic homelessness is not further defined

Milby et al., 2004; Milby et al., 2003; Milby et al., 2000; Milby et al., 2005; Kertesz et al., 2007

Lacking a fixed overnight residence, including shelters or temporary accommodations, or were at immediate risk of being homeless.

Interventions for homeless people with substance abuse issues (3 studies)


• Housing + on-site case management minimally decreased the risk of alcohol consumption up to 12 months (RR 0.98; 95% CI 0.96 – 0.99)


What is relative risk? Ratio of the risk of an event among an exposed population (intervention group) to the risk among the unexposed (control group).

(DiCenso, Guyatt, & Ciliska, 2005)




• Behavioural day treatment + abstinence-contingent housing and therapy (DT+) increased proportion of days abstinent at 2 months (71% vs. 41%) and 6 months (41% vs. 15%) vs. day treatment alone (DT). Relapse was lower in the DT+ vs DT group (55% vs. 81%).






• Abstinence-contingent housing increased mean consecutive weeks of abstinence (7.32) vs. the no-housing group (5.28) (p = 0.024), and vs. the non-abstinent-contingent group (4.68) (p = 0.0031) with days housed increased for all groups (p < 0.0001).




• Housing + on-site case management minimally decreased alcohol consumption up to 12 months (RR 0.98; 95% CI 0.96 – 0.99)


• Abstinence-contingent housing decreased mean consecutive weeks of abstinence (7.32) vs. the no-housing group (5.28) (p = 0.024), and vs. the non-abstinent-contingent group (4.68) (p = 0.0031) with days housed increased for all groups (p < 0.0001).

• Public health decision makers should promote and support the provision of housing, preferably abstinence-contingent with on-site case management, to reduce substance use among homeless people with substance abuse issues. DT+ can also be used to increase days abstinent and also reduce relapse among homeless people with substance abuse issues.



Interventions with no impact for homeless people with substance abuse issues


• No impact on days housed in those receiving DT+ compared to those receiving day treatment only; or, weeks of abstinence for the non-abstinent contingent housing group compared to the no housing group (p = 0.51)

• Public health should not promote or use DT+ if the sole purpose is to increase the number of days housed.

Homeless people with concurrent disorders Studies Homelessness Definitions Gulcur et al., 2003; Tsemberis et al., 2004; Tsemberis et al., 2003; Padgett et al., 2006; Greenwood et al., 2005; Stefancic et al., 2004

Spent 15 out of the last 30 days on the street (not including shelters) and experienced period of ‘housing instability’ (not defined) within last six months.


Interventions for homeless people with concurrent disorders (1 RCT)


• Study participants given independent apartments without requirement of abstinence/psychiatric care spent 66% fewer days homeless (p < 0.001), and had less need for substance abuse treatment at 36 months compared to participants receiving outreach/drop-in services plus group living (p = 0.05). The independent-living, group, however utilized health care services slightly more, at 48 months post-intervention (p = 0.025).


Interventions for homeless people with concurrent disorders (1 RCT)


• Study participants given independent apartments without requirement of abstinence/psychiatric care spent 66% fewer days homeless (p < 0.001), and had less need for substance abuse treatment at 36 months compared to participants receiving outreach/drop-in services plus group living (p = 0.05). The independent-living, group, however utilized health care services slightly more, at 48 months post-intervention (p = 0.025).

• Public health decision makers may advocate non abstinence-contingent, independent housing as a way to improve housing stability and decrease need for substance abuse treatment for homeless individuals with concurrent disorders, while acknowledging that positive findings are limited to a single study.


Interventions with no impact for homeless people with concurrent disorders


• No difference between groups in psychiatric symptoms and substance use.

• Non-abstinent contingent housing should not be used to improve psychiatric symptoms, decrease substance use rates, or decrease healthcare utilization.

Homeless people with HIV Studies Homelessness Definitions Woliski et al., 2009; Kidder et al., 2007

HIV+ individuals living in the following housing contexts: having one’s own place to live, being unstably housed (staying temporarily with others/living in a transitional setting and had not been homeless), or being homeless ≥ one night (e.g., sleeping in shelters or locations not suitable for human habitation) in the last 90 days.

Rotheram-Borus et al., 2009

HIV+ marginally housed individuals including reports of currently being homeless, living in a shelter/welfare hotel, or having lived in other condition within the 12 months prior to each assessment.

Kushel et al., 2006 HIV+ homeless and marginally housed individuals. Homeless was defined as ≥ one night on street or in shelter in the last quarter, whereas marginally housed was defined as ≥ 90% of nights in single-room occupancy dwelling in past quarter with no nights spent on street or in shelter.

Schwarcz et al., 2009

HIV+ individuals. Cases were defined as homeless if medical records documented individuals were homeless or if addresses listed in chart were for shelters, health care clinics, or a general delivery address not connected to an address.

Interventions for homeless people with HIV (4 studies)

What’s the evidence? Implications

• Rental assistance + case management improved self-reported physical/mental health, and housing status (88% intervention group housed at 18 months vs. 51% with no intervention, p ≤ 0.0001).





• Three individual counselling modules (five 90-minute sessions), led to significant decreases in: # days alcohol/marijuana use (35.77 to 27.54, p = 0.002); # of risky sexual acts (5.03 to 1.75, p = 0.037); and # days of hard drug use (27.76 to 24.00, p = 0.042), vs. no intervention.






• Moderate case management improved antiretroviral adherence (β = 0.13; 95% CI, 0.02-0.25) vs. none or minimal case management. Consistent and moderate case management led to 50% improvement in CD4+ cell count.






• Moderate case management improved antiretroviral adherence (β = 0.13; 95% CI, 0.02-0.25) vs. none or minimal case management. Consistent and moderate case management led to 50% improvement in CD4+ cell count.

• Risk of death was 20% higher for those not receiving supportive housing post-HIV diagnosis (Relative Hazard 1.20; 95% CI 1.03, 1.41).






• Moderate case management improved antiretroviral adherence (β = 0.13; 95% CI, 0.02-0.25) vs. no or minimal case management. Consistent and moderate case management led to 50% improvement in CD4+ cell count.


• Public health should support housing provision programs, preferably with moderate to consistent case management to improve the health and housing status of homeless people with HIV, and to reduce HIV-risk behaviours and risk of death.






• Moderate case management improved antiretroviral adherence (β = 0.13; 95% CI, 0.02-0.25) vs. no or minimal case management. Consistent and moderate case management led to 50% improvement in CD4+ cell count.


• Public health should support housing provision programs, preferably with moderate to consistent case management to improve the health and housing status of homeless people with HIV, and to reduce HIV-risk behaviours and risk of death.

• Decision makers should advocate for case management support for homeless people with HIV, to promote adherence to anti-retroviral therapy and improve CD4+ cell counts.



Interventions with no impact for homeless people with HIV


• No impact of multiple individual counselling sessions compared to no intervention on abstinence, or provision of rental assistance with case management on # of sexual partners, condom use, or sex trading.

• Public health should not rely on multiple individual counselling sessions to achieve substance use abstinence.

• Public health should not use rental subsidy with case management to impact # of sexual partners, condom use or sex trading

Homeless or runaway youth Studies Homelessness Definitions Gulcur et al., 2003; Tsemberis et al., 2004; Tsemberis et al., 2003; Padgett et al., 2006; Greenwood et al., 2005; Stefancic et al., 2004

Spent 15 out of the last 30 days on the street (not including shelters) and experienced period of ‘housing instability’ (not defined) within last six months.


Interventions for homeless or runaway youth (1 RCT)


• 12 weekly sessions covering life skills and psychiatric issues plus HIV/AIDS education led to a greater reduction in substance use from baseline (37%) compared with usual care (17%) (time effect p < 0.001).


Interventions for homeless or runaway youth (1 RCT)


• 12 weekly sessions covering life skills and psychiatric issues plus HIV/AIDS education led to a greater reduction in substance use from baseline (37%) compared with usual care (17%) (time effect p < 0.001).

• Public health decision makers should consider weekly education sessions covering life skills, mental health and HIV/AIDS education to reduce substance use among homeless youth, while acknowledging that positive findings are limited to a single study.












Non-abstinent contingent housing with case management is not recommended for homeless people with concurrent disorders to decrease psychiatric symptoms & substance, but is recommended for stable housing.

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Social Determinants of Health Program Planning in Public Health: What’s the Evidence?