Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review

Abstract

Background Permanent supportive housing and income assistance are valuable interventions for homeless individuals. Homelessness can reduce physical and social wellbeing, presenting public health risks for infectious diseases, disability, and death. We did a systematic review, meta-analysis, and narrative synthesis to investigate the effectiveness and cost-effectiveness of permanent supportive housing and income interventions on the health and social wellbeing of individuals who are homeless in high-income countries.Methods We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, NIHR-HTA, NHS EED, DARE, and the Cochrane Central Register of Controlled Trials from database inception to Feb 10, 2020, for studies on permanent supportive housing and income interventions for homeless populations. We included only randomised controlled trials, quasi-experimental studies, and cost-effectiveness studies from high-income countries that reported at least one outcome of interest (housing stability, mental health, quality of life, substance use, hospital admission, earned income, or employment). We screened studies using a standardised data collection form and pooled data from published studies. We synthesised results using random effects meta-analysis and narrative synthesis. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. FindingsOur search identified 15 908 citations, of which 72 articles were included for analysis (15 studies on permanent supportive housing across 41 publications, ten studies on income interventions across 15 publications, and 21 publications on cost or cost-effectiveness). Permanent supportive housing interventions increased long-term (6 year) housing stability for participants with moderate support needs (one study; rate ratio [RR] 1•13 [95% CI 1•01-1•26]) and high support needs (RR 1•42 [1•19-1•69]) when compared with usual care. Permanent supportive housing had no measurable effect on the severity of psychiatric symptoms (ten studies), substance use (nine studies), income (two studies), or employment outcomes (one study) when compared with usual social services. Income interventions, particularly housing subsidies with case management, showed long-term improvements in the number of days stably housed (one study; mean difference at 3 years between intervention and usual services 8•58 days; p<0•004), whereas the effects on mental health and employment outcomes were unclear. Interpretation Permanent supportive housing and income assistance interventions were effective in reducing homelessness and achieving housing stability. Future research should focus on the long-term effects of housing and income interventions on physical and mental health, substance use, and quality-of-life outcomes. Funding Inner City Health Associates.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

“…This may be due to their capacity to address some of the underlying social determinants of health that contribute to the cycle of homelessness, such as poverty, which requires longitudinal engagement with case managers. A parallel review also suggests that case management can have significant impacts when provided in conjunction with permanent housing [35]. Given the heterogeneity of these complex interventions, we cannot be certain of the precise mechanisms and key features that promote effectiveness.…”

“…All peerreviewed studies that assessed case management interventions among homeless or vulnerably housed populations and that reported on relevant outcomes were included. We excluded articles where case management was delivered as a component of a permanent supportive housing intervention as this is covered by a parallel review [35].…”

Randomized trials of housing interventions to prevent malaria and Aedes-transmitted diseases: A systematic review and meta-analysis

“…While the public sphere may exhibit a degree of scepticism with regard to provision of decent homes for political or humanitarian reasons, it is indeed crucial to collect more evidence along the lines of housing as a social determinant of health in the context of public expenditure. Integration of housing interventions within health and social care systems may improve physical, mental, and social wellbeing as well as reduce public health risks for infectious diseases and disability [79]. To glean a maximally precise picture concerning this nascent area of research, the approach would prove sufficient if it is bundled with clinical and cost-effectiveness findings from adequately powered, well-designed, and well-executed trials that can be applied to a diverse population, thereby garnering source of financial support from industry, public sector, and philanthropic organizations.…”

Finding Security on Skid Row: The Positive Role of Organizational and Social Ties in Service Hubs in the United States and Japan

“…In various national contexts, persons who have accessed PSH generally return to homelessness at lower rates than those housed through other approaches (Hombs 2011). Additionally, placement in PSH has the potential to produce broad improvements in health, income, and other outcomes among those who receive this placement (Aubry et al 2020). One understudied outcome with linkages to other forms of long-term security and well-being is ontological security.…”