"I Don't Have to Sleep with One Eye Open:" Tenants' Perspectives on Health after Moving into Permanent Supportive Housing

Background: Permanent supportive housing (PSH) is an evidence-based practice that has been shown to improve housing stability for individuals with a history of chronic homelessness and is expected to improve the health of tenants by reducing barriers to accessing health care. However, some studies show no significant effects of PSH on tenants’ mental and physical health. Because of this discrepancy between program expectations and outcomes, we investigated the relationship between permanent supportive housing and health from the perspective of tenants. Our research question was: How do formerly chronically homeless tenants perceive single-site PSH with onsite supportive services to affect their health?

Methods: Data come from a larger PSH study in one mid-sized Midwestern city. This analysis focuses on tenants in a 24-unit, single-site PSH program who experienced chronic homelessness. Data presented here come from semi-structured interviews of twenty-five tenants conducted 6, 12, and 24 months after move-in. Tenants were primarily male, white, and older. We asked tenants about the most important change since moving in, a typical day, future goals, and opinions of the program. We coded verbatim interview transcripts in Dedoose following a general inductive approach and conducted a second-order thematic analysis in Excel. We used peer consultation at each level of coding and analysis to discuss areas of agreement and divergence to improve validity.

Results: Four themes emerged from the data: 1) return to humanity, 2) housing plus onsite services support care tasks, 3) balancing autonomy and community living, and 4) recovery takes time. Tenants described how moving off the streets into stable housing led to a reduction in stress and vigilance due to basic needs being met and feeling “human” again. The combination of housing and onsite supportive services removed barriers to health care and promoted caring for themselves through instrumental, emotional, and informational support. Tenants described the tension between the need for autonomy in choosing what services to use and wanting staff to intervene in other tenants’ antagonistic behaviors seen as disruptive to community living. Antagonistic interactions between tenants increased tenant stress and decreased perceived quality of life. Lastly, some tenants identified that recovery from chronic homelessness takes more time than expected by themselves and others. Notably, themes were consistent over time, contrary to our expectation that the emphasis on feeling “human” again and the importance meeting basic needs would diminish over time.

Conclusions: Findings suggest that tenants’ reported changes in health during interviews can be understood as: 1) PSH interrupting stress proliferation caused by chronic homelessness through a return to humanity and social support, 2) community living as a new stressor, and 3) recovery is a slow process. Staff patience and flexibility in developing working relationships perceived by tenants to be supportive is essential due to the importance tenants place on social support in improving their health. However, stress caused by negative interactions among tenants may negatively impact health. Future research on single-site PSH should examine how staff can navigate the tension between supporting the autonomy of tenants while creating a supportive, healthy living environment.