Housing as a Health Intervention for Individuals with Mental Health Conditions: Lessons Learned through Community Based Participatory Research

Background and Purpose: Housing First programs end homelessness for individuals diagnosed with serious mental illnesses by providing immediate access to permanent independent housing. Once housed, community support services can help target numerous chronic medical conditions that have resulted in striking health disparities in this population, yet how best to do this remains poorly understood. Using a community based participatory research (CBPR) framework, this study elicited the involvement of tenants enrolled in a Housing First program in order to design and execute a research agenda aimed to improve integrated care. In this paper, we discuss both process and outcomes when advocating for more widespread use of participatory research within social work.

Methods: This pilot study brought together 11 tenants (who responded to a flyer advertising the project and who could commit to working in a group setting), the agency's clinical director and primary care physician, and a researcher with expertise in CBPR to form a group of co-investigators. The group began by discussing the intent of the study, yet there was no set agenda in order to allow all participants to shape the inquiry process. Using hermeneutic phenomenological methods, over the course of 9 weekly meetings the group: (1) met each week to brainstorm topics that started with “what is good health?” (2) recorded group discussions through audiotapes, note-taking, and meeting minutes, and (3) reviewed the content of each week's discussion to identify themes and develop new questions. This process included the development of a conceptual framework that used “housing” as an analytic axis from which to formulate the relationship between decision making and one's health.

Results: The developed framework revealed a dynamic interplay between decision making and one's health status both while homeless and now having an apartment. Key themes included: (a) without housing, health cannot be a priority - decisions are based primarily on avoiding pain; (b) transitioning into housing is a process in which “health becomes relevant”; (c) the process of transitioning requires prolonged engagement, trusting relationships, and a sense of being cared for. As part of the project, the group has begun presenting these findings in a variety of research, educational, and service settings and continues to work together on analyzing both process and data, on developing a resource guide for others who have encountered homelessness, and on writing an article intended for publication and a proposal for a new CBPR project.

Conclusion and Implications: These findings suggest that access to health care may have limited impact on the health of individuals experiencing homelessness except in the case of painful, life-threatening conditions. While housing and access to care are necessary for improved health, it also requires sustained support and the caring of others. This project also demonstrated that service users can join as investigators to form research agendas, conduct data analysis, and disseminate findings that have a direct impact at an individual or local level while continuing to provide an evidence base for broader systems change.