This qualitative study examined how homeless individuals with mental illness experience pathways into homelessness. Study participants were enrolled in the At Home/Chez Soi project, a Pan-Canadian Randomized Controlled Trial comparing the Housing First approach with Treatment as Usual for homeless individuals. This inquiry is grounded in social ecological perspective, which considers interactions between individual and structural factors. Findings from consumer narrative interviews (n = 219) revealed that individual factors, such as substance abuse, relationship conflicts and mental health issues significantly contributed to homelessness, in addition to structural transitions from foster care and institutional settings into the community. Additional structural factors entrenched participants in unsafe communities, created obstacles to exiting homelessness and amplified individual risk factors. The study findings confirm the role of individual risk factors in pathways into homelessness, but underscore the ...

/pdf/pathways-into-homelessness-understanding-how-both-individual-ol6p4rnpze.pdf

Pathways into homelessness: Understanding how both individual and structural factors contribute to and sustain homelessness in Canada

Integrated care occurs within micro, meso and macro levels of governance structures, which are shaped by complex power dynamics. Yet theoretically-led notions of power, and scrutiny of its meanings and its functioning, are neglected in the literature on integrated care. We explore an alternative approach. Following a discussion on governance, two streams of theorising power are presented: mainstream and second-stream. Mainstream concepts are based on the notion of power-as-capacity, of one agent ­having the capacity to influence another—so the overall idea is ‘power over  ’. Studies on integrated care ­typically employ mainstream ideas, which yield rather limited analyses. Second-stream concepts focus on ­strategies and relations of power—how it is channelled, negotiated and (re)produced. These notions align well with the contemporary shift away from the idea that power is centralised, towards more fluid ideas of power as dispersed and (re)negotiated throughout a range of societal structures, networks and actors. ­Accompanying this shift, the notion of governance is slowly being eclipsed by that of governmentality. We propose governmentality as a valuable perspective for analysing and understanding power in integrated care. Our contribution aims to address the need for more finely tuned theoretical frameworks that can be used to guide empirical work.

/pdf/power-and-integrated-health-care-shifting-from-governance-to-244e2mz360.pdf

Power and Integrated Health Care: Shifting from Governance to Governmentality

Mental illness is a well-known challenge to global development, particularly in low-to-middle income countries. A key health systems response to mental illness is different models of integrated health care, especially popular in the South African Development Community (SADC) region. This complex construct is often not well-defined in health policy, hampering implementation efforts. A key development in this vein has been the Rainbow Model of integrated care, a comprehensive framework and taxonomy of integrated care based on the integrative functions of primary care. The purpose of this study was to explore the nature and strategic forms of integrated mental health care in selected SADC countries, specifically how integrated care is outlined in state-driven policies. Health policies from five SADC countries were analysed using the Rainbow Model as framework. Electronic copies of policy documents were transferred into NVivo 10, which aided in the framework analysis on the different types of integrated mental health care promoted in the countries assessed. Several Rainbow Model components were emphasised. Clinical integration strategies (coordination of person-focused care) such as centrality of client needs, case management and continuity were central considerations, while others such as patient education and client satisfaction were largely lacking. Professional integration (inter-professional partnerships) was mentioned in terms of agreements on interdisciplinary collaboration and performance management, while organisational integration (inter-organisational relationships) emerged under the guise of inter-organisational governance, population needs and interest management. Among others, available resources, population management and stakeholder management fed into system integration strategies (horizontally and vertically integrated systems), while functional integration strategies (financial, management and information system functions) included human resource, information and resource management. Normative integration (a common frame of reference) included collective attitude, sense of urgency, and linking cultures, though aspects such as conflict management, quality features of the informal collaboration, and trust were largely lacking. Most countries stressed the importance of integrating mental health on primary healthcare level, though an absence of supporting strategies could prove to bar implementation. Inter-service collaboration emerged as a significant goal, though a lack of (especially) normative integration dimensions could prove to be a key omission. Despite the usefulness of the Rainbow Model, it failed to adequately frame regional governance aspects of integration, as the SADC Secretariat could play an important role in coordinating and supporting the development and strengthening of better mental health systems.

/pdf/health-policy-and-integrated-mental-health-care-in-the-sadc-5aqvf7zb80.pdf

Health policy and integrated mental health care in the SADC region: strategic clarification using the Rainbow Model

In consumer advocacy coalitions formed to advance health insurance coverage expansions, engaging in united advocacy activities soon after formation might be an important first step to effectively shape policy. This article uses social network analysis to examine how organizational characteristics and interorganizational relationships relate to early collaboration on advocacy activities. Findings suggest that organizations that have not worked together before can become engaged in collaborative activities at a relatively early stage. Furthermore, social network analysis techniques can be applied to advocacy evaluations.

Using Social Network Analysis to Predict Early Collaboration Within Health Advocacy Coalitions

This study assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with current or previous experience of homelessness. Participants were recruited from three different types of housing (shelter, temporary housing and permanent housing) in Montreal, Quebec (Canada). They were interviewed at baseline (T0), and again 12 months after recruitment (T1). Longitudinal data analyses were conducted on associations between a set of baseline predictors (T0) with the dependent variable (ED users vs. non-users) from T1. Predictors were identified according to the Gelberg–Andersen Behavioral Model. Findings revealed two needs factors associated with ED use: having a substance use disorder (SUD) and low perceived physical health. Two enabling factors, use of ambulatory specialized services and stigma, were also related to ED use. No predisposing factors were retained in the model, and ED use was not associated with type of housing. Improvements are needed in SUD and physical health management in order to reduce ED use, as well as interventions aimed at stigma prevention for this vulnerable population.

https://www.mdpi.com/1660-4601/16/24/4965/pdf

Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness.

Introduction : We know little about the intensity and determinants of interorganisational collaboration within the homeless network. This study describes the characteristics and relationships (along with the variables predicting their degree of interorganisational collaboration) of 68 organisations of such a network in Montreal (Quebec, Canada). Theory and methods : Data were collected primarily through a self-administered questionnaire. Descriptive analyses were conducted followed by social network and multivariate analyses. Results : The Montreal homeless network has a high density (50.5%) and a decentralised structure and maintains a mostly informal collaboration with the public and cross-sectorial sectors. The network density showed more frequent contacts among four types of organisations which could point to the existence of cliques. Four variables predicted interorganisational collaboration: organisation type, number of services offered, volume of referrals and satisfaction with the relationships with public organisations. Conclusions and discussion : The Montreal homeless network seems adequate to address non-complex homelessness problems. Considering, however, that most homeless individuals present chronic and complex profiles, it appears necessary to have a more formal and better integrated network of homeless organisations, particularly in the health and social service sectors, in order to improve services.

/pdf/network-collaboration-of-organizations-for-homeless-41ncnl1vjr.pdf

Network collaboration of organizations for homeless individuals in the Montreal region

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Network collaboration of organizations for homeless individuals in the Montreal region