Abstract

Housing First (HF) has spread on the international scene as an evidence-based intervention to overcome homelessness among people with mental health problems. In Brazil, the HF has been adopted as a reference in the development of initiatives geared to people living in the streets who make harmful use of drugs. Studies point to the need for greater understanding of the dynamics of implementation in different settings. Thus, using the literature review method, we analyzed the factors that facilitate and hinder the implementation of HF. Sixty-eight papers published from 2003 to 2020 were selected from the PubMed, Scopus, PsychoINFO, Embase, Lilacs, and Scielo databases. We identified factors in four dimensions: intervention characteristics, implementation context, institutional aspects, and implementation process. The unavailability of housing, the lack of coordination of the services needed by residents, and the resistance of implementing agents to the HF principles are factors that hinder the implementation. In turn, agents with values, attitudes, and skills converging with the model and continuing education appear as facilitators. We point out the need to understand and favor the HF integration process in the existing social protection systems.

Key words:
Housing; Homeless people; Mental health; Implementation science

Introduction

The understanding of housing as a social right that plays a fundamental role in the exercise of citizenship is the central argument for the creation of supported housing interventions¹1 Friesinger JG, Topor A, Bøe TD, Larsen IB. Studies regarding supported housing and the built environment for people with mental health problems: A mixed-methods literature review. Health and Place 2019; 57:44-53.^,22 Dorvil H, Morin P, Beaulieu A, Robert D. Housing as a social integration factor for people classified as mentally Ill. Hous Stud 2005; 20(3):497-519., such as Housing First³3 Tsemberis S. Housing First: The Pathways Model to End Homelessness for People with Mental Health and Substance Use Disorders. Minnesota: Hazelden; 2015.. Originally developed in the United States in 1992⁴4 Tsemberis S, Eisenberg RF. Pathways to housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities. Prim Care Companion J Clin Psychiatry 2001; 3(1):34-35., Housing First (HF) seeks to face the homeless situation among people with mental health problems by offering permanent housing integrated with housing, clinical, and community integration support services³3 Tsemberis S. Housing First: The Pathways Model to End Homelessness for People with Mental Health and Substance Use Disorders. Minnesota: Hazelden; 2015..

HF differs from traditional services for People Living on the Streets (PLS) by providing access to housing without fulfilling requirements, such as adherence to health treatments or drug use abstinence. The fundamental assumption the model assumes is that the stability and security of permanent housing are decisive for addressing other issues, such as harmful drug use³3 Tsemberis S. Housing First: The Pathways Model to End Homelessness for People with Mental Health and Substance Use Disorders. Minnesota: Hazelden; 2015.^,55 Stefancic A, Tsemberis S, Messeri P, Drake R, Goering PAS. The pathways housing first fidelity scale for individuals with psychiatric disabilities. Am J Psychiatr Rehabil 2013; 16(4):240-261.. In this sense, although support services are offered, they are made available independently of the house, and beneficiaries decide whether they want to and how they will participate (type of follow-up, intensity, and frequency).

HF was disseminated in the United States⁴4 Tsemberis S, Eisenberg RF. Pathways to housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities. Prim Care Companion J Clin Psychiatry 2001; 3(1):34-35., Canada⁶6 Goering P, Veldhuizen S, Watson A, Adair C, Kopp B, Latimer E, Nelson G, Macnaughton E, Streiner D, Aubry T. National at Home/Chez Soi Final Report. Calgary; 2014 [cited 2020 ago 25]. Available from: www.mentalhealthcommission.ca/English/at-home#national
www.mentalhealthcommission.ca/English/at... , European countries⁷7 Busch-Geertsema V. Housing First Europe-Results of a European Social Experimentation Project. Eur J Homelessness 2014; 8(1)., and Australia⁸8 Johnson G, Parkinson S, Parsell C, Institute AH and UR, Centre RR. Policy shift or program drift? Implementing Housing First in Australia. AHURI Final Rep [Internet] 2012;184. [cited 2020 ago 25]. Available from: https://www.ahuri.edu.au/research/final-reports/184
https://www.ahuri.edu.au/research/final-... through experimental projects, integrated with evaluative research, which showed its greater effectiveness than traditional housing interventions for PLS. In these studies, length of stay is the main indicator of effectiveness used, represented by the percentage of people (which in the HF reaches 80%) who remain in the house for more than two years⁹9 Padgett D, Henwood BF, Tsemberis SJ. Housing first : ending homelessness, transforming systems, and changing lives. New York: Oxford University; 2016. 228 p..

Positive results are also reported for community integration¹⁰10 O'Campo P, Stergiopoulos V, Nir P, Levy M, Misir V, Chum A, Arbach B, Nisenbaum R, To MJ, Hwang SW. How did a Housing First intervention improve health and social outcomes among homeless adults with mental illness in Toronto? Two-year outcomes from a randomised trial. BMJ Open 2016; 6(9):e010581., decreased use of alcohol and other drugs¹¹11 Kirst M, Zerger S, Misir V, Hwang S, Stergiopoulos V. The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness. Drug Alcohol Depend 2015; 146(1):24-29.^,1212 Padgett DK, Stanhope V, Henwood BF, Stefancic A. Substance use outcomes among homeless clients with serious mental illness: Comparing housing first with treatment first programs. Community Ment Health J 2011; 47(2):227-232., and HIV control¹³13 Buchanan D, Kee R, Sadowski LS, Garcia D. The health impact of supportive housing for HIV-positive homeless patients: a randomized controlled trial. Am J Public Health 2009; 99(Supl. 3).. Comparative analyses also show that HF is associated with lower costs caused by the reduced use of other public services, such as shelters, hospitals, and prisons¹⁴14 Gulcur L, Stefancic A, Shinn M, Tsemberis S, Fischer SN. Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes. J Community Appl Soc Psychol 2003; 13(2):171-186..

Recent years have witnessed an increased discussion about HF in Latin American countries and the implementation of initiatives inspired by the model in Uruguay¹⁵15 Rudnitzky F, Evans T. Evaluación Proyecto piloto "Incubar" [Internet]. Montevideo; 2020 [acceso 2020 set 14]. Disponible en: http://dspace.mides.gub.uy:8080/xmlui/bitstream/handle/123456789/1678/DocumentodetrabajoN63.INCUBARinformeevaluación..pdf?sequence=3&isAllowed=y
http://dspace.mides.gub.uy:8080/xmlui/bi... and Chile. In Brazil, in 2014, the Federal Government adopted the HF as a reference for the development of a set of local experiences of specific supported housing for PLS who are drug users¹⁶16 Garcia L, Kinoshita RT, Maximiano V. Uma perspectiva social para o problema do crack no Brasil: implicações para as políticas públicas. In: Pesquisa Nacional sobre o uso de crack: quem são os usuários de crack e/ou similares do Brasil? quantos são nas capitais brasileiras? Rio de Janeiro: Fiocruz; 2014.

17 Carvalho AP. Moradia Primeiro no contexto da política de drogas brasileira: análise da implantação de uma intervenção-piloto de moradia assistida para pessoas em situação de rua [dissertação]. São Paulo: Faculdade de Medicina da Universidade de São Paulo; 2020.^-1818 Nascimento ACP do, Rosa CM. O paradigma ético-estético-político da clínica na produção de subjetividades: o fazer clínico do Palmas que te acolhe. Polêm!ca 2020; 19(3):122-137.. Currently, the model is being debated in the country as a solution to the lack of housing for PLS in general¹⁹19 Moreira RS, Mendes APT, Sciammarella AP de O, Amado F. População em situação de rua: direitos humanos, políticas públicas e programas de housing first. Rio de Janeiro: Escola de Direito do Rio de Janeiro da Fundação Getulio Vargas.^,2020 Brasil. Ministério da Mulher, da Família e dos Direitos Humanos (MMFDH). É possível Housing First no Brasil?: experiências de moradia para população em situação de rua na Europa e no Brasil. Brasília: MMFDH; 2020. and was established as a national program - First Housing Program - linked to the current Ministry of Women, Family, and Human Rights²¹21 Brasil. Ministério da Mulher, da Família e dos Direitos Humanos (MMFDH). Portaria nº. 2.927, de 26 de agosto de 2021. Institui o Projeto Moradia Primeiro no âmbito do Ministério da Mulher, da Família e dos Direitos Humanos. Diário Oficial da União 163 ago 2021; Seção 1..

HF rapid expansion resulted in different modifications to the original US proposal, generating uncertainties as to how local particularities influence the intervention’s effectiveness⁵5 Stefancic A, Tsemberis S, Messeri P, Drake R, Goering PAS. The pathways housing first fidelity scale for individuals with psychiatric disabilities. Am J Psychiatr Rehabil 2013; 16(4):240-261., and the need for greater understanding of the implementation processes of this type of program in different scenarios is pointed out²²22 Rog DJ, Marshall T, Dougherty RH, George P, Daniels AS, Ghose SS, et al. Permanent supportive housing: Assessing the evidence. Psychiatr Serv 2014; 65(3):287-294..

Breaking with the “first treatment” approach, which requires the beneficiary to show prior skills for housing stability, implies significant changes in PLS care policies, at individual, organizational, and political levels, attaching complexity to the HF and its implementation process²³23 Goering P, Tsemberis S. Housing First and System/Community Transformation. In: Community Psychology and Community Mental Health. New York: Oxford University Press; 2014. p. 278-291.^,2424 Worton SK, Hasford J, Macnaughton E, Nelson G, MacLeod T, Tsemberis S, Stergiopoulos V, Goering P, Aubry T, Distasio J, Richter T. Understanding Systems Change in Early Implementation of Housing First in Canadian Communities: An Examination of Facilitators/Barriers, Training/Technical Assistance, and Points of Leverage. Am J Community Psychol. 2018; 61(1-2):118-130.. Such a proposal for transformation requires involving different interest groups, considering local characteristics, and significantly adapting existing service delivery systems²2 Dorvil H, Morin P, Beaulieu A, Robert D. Housing as a social integration factor for people classified as mentally Ill. Hous Stud 2005; 20(3):497-519. - that is, the so-called contextual factors.

In the global setting of the expanding Housing First as a promising intervention in confronting the PLS situation, it is essential to understand how the model has been implemented and the variables underlying this process. We identified a study that discusses aspects of the implementation of the set of experimental projects developed in Canada²⁶26 Nelson G, Stefancic A, Rae J, Townley G, Tsemberis S, Macnaughton E, et al. Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: A mixed methods approach. Eval Program Plann 2014; 43:16-26.. However, we did not find a critical synthesis about the influence of contextual factors in the implementation of the HF model. Thus, the study proposed to identify and discuss the aspects that facilitate and hinder the implementation of the HF to support the development of the original proposal and address the challenges arising from its adaptation to different contexts, including the Brazilian one.

Methods

The survey of papers was carried out in March 2020, in the PubMed, Scopus, PsychoINFO, Embase, Lilacs, and SciELO databases because they contain a significant number of indexed journals and are a reference in the field of health. We used the word strings “housing first” associated simultaneously with “implementation”, “translation”, “fidelity”, “dissemination”, “variation”, and “application”. The search was performed by cross-referencing subjects, titles, and abstracts. We opted to not filter the publication date to retrieve all works published up to the search date.

The selection followed the following eligibility criteria: empirical study published in a scientific journal in any language or year; intervention defined as Housing First and aimed at PLS, regardless of whether other population groups are included; and evaluation or description of factors related to implementing HF interventions. The elements reported as complicators and facilitators of the implementation process were considered contextual factors in this review.

All publications retrieved from the databases were organized and duplications removed with the Mendeley Reference Manager. Subsequently, the papers were exported to the Rayyan software²⁷27 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5(1):210., where titles and abstracts were analyzed and papers that did not meet the eligibility criteria described above were excluded. The resulting papers were read in full, excluding ineligible ones. Finally, the bibliographic references of the selected papers were manually checked for inclusion of other previously unidentified eligible studies. The process was carried out by two independent researchers with previous experience in housing in mental health. Any disagreement was resolved through a discussion between the two researchers.

Data was extracted from the selected papers by a researcher and verified by another peer throughout the process to ensure accuracy. The following information was extracted: publication data (authorship, country in which the study was carried out, journal subject area, and year of publication); study design (objective, method, research participants, and theoretical framework); characteristics of the intervention and the context (implementation phase, funding agency, related sector policy, organization responsible for management and implementation, institutional arrangement, target audience, housing type, and support services offered); and factors that hampered or facilitated implementation.

The contextual factors extracted from the papers were listed and grouped into four dimensions, based on the Consolidated Framework for Implementation Research (CFIR)²⁵25 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009; 4(1)., an analytical model used in the field of health to identify and understand the contextual factors that influence the implementation process. The similarities between the factors evidenced by the studies were also identified, grouped, and described. Finally, the data were synthesized based on the interpretation of the relationship between contextual factors and the dimensions of Housing First, narrating how the internal and external elements of the intervention influence the process of implementing the model.

Results

A total of 377 works were identified, from which 68 papers were selected, meeting the eligibility criteria defined in the study (Figure 1).

Characteristics of studies and interventions

The 68 selected papers cover the 2003-2020 period, and most were published between 2014 and 2020 (Chart 1) and in journals classified in the field of Health, which cover 37 publications, underscoring the Mental Health sub-area, with ten papers. Then, the journals in the fields of Housing and Urbanism stand out, with 11 publications; Social and Political Sciences, with eight publications; and Community Psychology, with six publications. Fewer papers (between one and four) can be found in journals in the fields of Social Work and Drugs. The lack of studies before 2003 can be explained by the fact that the use of the term Housing First emerged in scientific publications in 2001⁴4 Tsemberis S, Eisenberg RF. Pathways to housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities. Prim Care Companion J Clin Psychiatry 2001; 3(1):34-35..

Most studies addressed the implementation of HF in the United States and Canada, totaling 85% of the analyzed studies. The European and Australian contexts make up the rest of the studies with six and four papers, respectively. Data produced through qualitative methods (72%), using focus groups and interviews predominate, and three studies were exclusively quantitative²⁸28 Stefancic A, Henwood BF, Melton H, Shin S-M, Lawrence-Gomez R, Tsemberis S, et al. Implementing Housing First in rural areas: Pathways Vermont. Am J Public Health 2013; 103(supl. 2):S206-209.

29 Appel PW, Tsemberis S, Joseph H, Stefancic A, Lambert-Wacey D. Housing first for severely mentally ill homeless methadone patients. J Addict Dis [Internet]. 2012; 31(3):270-277.^-3030 Benjaminsen L. Policy Review Up-date : Results from the Housing First based Danish Homelessness Strategy. Eur J Homelessness 2013; 7(2):109-131.. Most studies had more than one interest group as a source of information, and workers and managers were the most involved (n=43), followed by beneficiaries (n=35).

The papers that explain the methodological designs indicate evaluative approaches (n=11), case study (n=15), ethnography (n=4), and grounded theory (n=7). The 18 studies that provide a theoretical or conceptual framework point to Symbolic Interactionism, Constructivism³¹31 Barrenger SL, Stanhope V, Atterbury K. Discursive Processes Creating Team Culture and Recovery Orientation among Housing First Providers. Am J Psychiatr Rehabil 2015; 18(3):247-264.^,3232 Stanhope V. The ties that bind: Using ethnographic methods to understand service engagement. Qual Soc Work 2012; 11(4):412-430., implementation science frameworks ^30,33-39, change and transformation theories²³23 Goering P, Tsemberis S. Housing First and System/Community Transformation. In: Community Psychology and Community Mental Health. New York: Oxford University Press; 2014. p. 278-291.^,4040 Kertesz SG, Austin EL, Holmes SK, Pollio DE, Schumacher JE, White B, Lukas CV. Making Housing First Happen: Organizational Leadership in VA's Expansion of Permanent Supportive Housing. J Gen Intern Med 2014; 29(4):835-844.

41 Austin EL, Pollio DE, Holmes S, Schumacher J, White B, Lukas CV, Kertesz S. VA's expansion of supportive housing: Successes and challenges on the path toward housing first. Psychiatr Serv 2014; 65(5):641-647.

42 Colombo F, Saruis T. Social innovation and local welfare: A comparative case study on housing first in Italy and Sweden. Journal fur Entwicklungspolitik 2017; 33:85-111.^-4343 Nelson G, Worton SK, Macnaughton E, Tsemberis S, MacLeod T, Hasford J, Goering P, Stergiopoulos V, Aubry T, Distasio J. Systems change in the context of an initiative to scale up Housing First in Canada. J Community Psychol. 2019 1; 47(1):7-20. and Street Level Bureaucracy⁴⁴44 van den Berk-Clark C. The Dilemmas of Frontline Staff Working With the Homeless: Housing First, Discretion, and the Task Environment. Hous Policy Debate 2016; 26(1):105-122.^,4545 Namian D. Governing homelessness through instruments: a critical perspective on housing first's policy instrumentation. Crit Policy Stud 2019; 14(3):303-318..

In general, the implementation was approached based on the binomial of housing structuring and support to residents, and parameters were the quality of the actions carried out and fidelity to the original HF model. A smaller set of papers explored the initial moment of implementation, especially aspects related to planning and local conditions for implementing the intervention. Four papers focused on sustainable interventions⁴⁶46 Anderson-Baron JT, Collins D. Not a "forever model": the curious case of graduation in Housing First. Urban Geogr 2018; 39(4):587-605.

47 Barrenger SL, Stanhope V, Atterbury K. Discursive Processes Creating Team Culture and Recovery Orientation among Housing First Providers. Am J Psychiatr Rehabil 2015; 18(3):247-264.

48 Brothers S, Lin J, Schonberg J, Drew C, Auerswald C. Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention. Soc Sci Med 2020; 245:112724.^-4949 Bullen J, Baldry E. "I waited 12 months": how does a lack of access to housing undermine Housing First? Int J Hous Policy 2019; 19(1):120-130..

Almost a third or 21 studies analyzed HF pilot interventions, 18 of which stemmed from the Canadian project At Home Chez Soi⁶6 Goering P, Veldhuizen S, Watson A, Adair C, Kopp B, Latimer E, Nelson G, Macnaughton E, Streiner D, Aubry T. National at Home/Chez Soi Final Report. Calgary; 2014 [cited 2020 ago 25]. Available from: www.mentalhealthcommission.ca/English/at-home#national
www.mentalhealthcommission.ca/English/at... , the largest HF experimental study ever developed¹²12 Padgett DK, Stanhope V, Henwood BF, Stefancic A. Substance use outcomes among homeless clients with serious mental illness: Comparing housing first with treatment first programs. Community Ment Health J 2011; 47(2):227-232., which evaluated the results and the process of implementing the model in five cities in the country and attended to approximately 2,000 PLS with mental health problems. Also in the Canadian context, we identified studies that examined interventions linked to another initiative financed by the Federal Government to expand the HF - the Homelessness Partnering Strategy (HPS)⁴³43 Nelson G, Worton SK, Macnaughton E, Tsemberis S, MacLeod T, Hasford J, Goering P, Stergiopoulos V, Aubry T, Distasio J. Systems change in the context of an initiative to scale up Housing First in Canada. J Community Psychol. 2019 1; 47(1):7-20.. In U.S. research, studies of programs derived from the Full-Service Partnerships (FSPs)¹²12 Padgett DK, Stanhope V, Henwood BF, Stefancic A. Substance use outcomes among homeless clients with serious mental illness: Comparing housing first with treatment first programs. Community Ment Health J 2011; 47(2):227-232. project, financed by a mental health service fund of the State of California (Mental Health Services Fund - MHSF) and the initiative signed between the federal housing and urbanism sector - US Department of Housing and Urban Development (HUD), and supported housing services for veterans - VA’s Supportive Housing Services (VASH)⁴³43 Nelson G, Worton SK, Macnaughton E, Tsemberis S, MacLeod T, Hasford J, Goering P, Stergiopoulos V, Aubry T, Distasio J. Systems change in the context of an initiative to scale up Housing First in Canada. J Community Psychol. 2019 1; 47(1):7-20.. The Housing First Europe⁷7 Busch-Geertsema V. Housing First Europe-Results of a European Social Experimentation Project. Eur J Homelessness 2014; 8(1). pilot project and the Inner-City Integrated Services Coalitions⁴³43 Nelson G, Worton SK, Macnaughton E, Tsemberis S, MacLeod T, Hasford J, Goering P, Stergiopoulos V, Aubry T, Distasio J. Systems change in the context of an initiative to scale up Housing First in Canada. J Community Psychol. 2019 1; 47(1):7-20. initiative stand out among European and Australian studies.

Most studies did not inform the legal nature of the organization responsible for the (public or private) intervention, the funding source and the management model adopted. Among those that did, the following stand out: mental health and housing as the sectors responsible for the intervention; federal government sources as the main funding source; and NGOs, such as the institutions providing the services underpinning the interventions.

The studies essentially addressed HF programs implemented in urban areas and three surveys included initiatives developed in rural areas⁵⁰50 Jetté J, Aubry T, Cherner R, Ecker J, Yamin S, Bourque J. The implementation of a Housing First intervention in Canadian rural region . Can J Community Ment Heal 2015; 33(4):41-59.

51 Nolin D, Jetté J. Specific features of urban and rural areas: A comparative study on the results of the At Home/Chez Soi project in New Brunswick . Can J Community Ment Heal 2015; 33(4):125-140.^-5252 Stergiopoulos V, O'Campo P, Gozdzik A, Jeyaratnam J, Corneau S, Sarang A, Hwang SW. Moving from rhetoric to reality: adapting Housing First for homeless individuals with mental illness from ethno-racial groups. BMC Health Serv Res 2012; 12(1):345.. Of the papers that specified the characteristics of the beneficiaries of the interventions, PLS with mental health problems or drug use was the predominant target audience. Some programs assisted PLS in specific situations: young people⁵³53 Brothers S, Lin J, Schonberg J, Drew C, Auerswald C. Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention. Soc Sci Med 2020; 245., black people with mental health problems⁵⁴54 Stergiopoulos V, O'Campo P, Gozdzik A, Jeyaratnam J, Corneau S, Sarang A, Hwang SW. Moving from rhetoric to reality: Adapting Housing First for homeless individuals with mental illness from ethno-racial groups. BMC Health Serv Res 2012; 12(1)., women with children⁴²42 Colombo F, Saruis T. Social innovation and local welfare: A comparative case study on housing first in Italy and Sweden. Journal fur Entwicklungspolitik 2017; 33:85-111., people assisted in penal system services⁵⁵55 Kriegel LS, Henwood BF, Gilmer TP. Implementation and Outcomes of Forensic Housing First Programs. Community Ment Health J 2016; 52(1):46-55., and war veterans⁴⁰40 Kertesz SG, Austin EL, Holmes SK, Pollio DE, Schumacher JE, White B, Lukas CV. Making Housing First Happen: Organizational Leadership in VA's Expansion of Permanent Supportive Housing. J Gen Intern Med 2014; 29(4):835-844.^,4141 Austin EL, Pollio DE, Holmes S, Schumacher J, White B, Lukas CV, Kertesz S. VA's expansion of supportive housing: Successes and challenges on the path toward housing first. Psychiatr Serv 2014; 65(5):641-647..

The type of housing and support services offered by the programs is not specified in all studies. We identified programs that used dispersed individual apartments, congregated units in which the participants lived with other beneficiaries in the same building, and finally those that adopted the two housing options.

Support services are predominantly offered through Case Management or integrating Case Management and Assertive Community Treatment (ACT). Both are community-based care models indicated by the HF as a proposal to operationalize the support offered to residents. The ACT is most often used for people with great need for mental health support and Case Management for those with moderate needs⁵⁶56 Tsemberis S. Housing First: The Pathways Model to end homelessness for people with mental illness and adiction. Minnesota: Hazelden; 2015.. Studies that addressed programs that used only the ACT appear less prominently²⁹29 Appel PW, Tsemberis S, Joseph H, Stefancic A, Lambert-Wacey D. Housing first for severely mentally ill homeless methadone patients. J Addict Dis [Internet]. 2012; 31(3):270-277.^,4747 Barrenger SL, Stanhope V, Atterbury K. Discursive Processes Creating Team Culture and Recovery Orientation among Housing First Providers. Am J Psychiatr Rehabil 2015; 18(3):247-264.^,5050 Jetté J, Aubry T, Cherner R, Ecker J, Yamin S, Bourque J. The implementation of a Housing First intervention in Canadian rural region . Can J Community Ment Heal 2015; 33(4):41-59.^,5757 Ecker J, Aubry T, Cherner R, Jetté J. Implementation evaluation of a housing first program in a small Canadian City. Can J Community Ment Heal 2014; 33(4):23 40.

58 Nicholls CM, Atherton I. Housing First: Considering components for successful resettlement of homeless people with multiple needs. Hous Stud 2011; 26(5):767 777.^-5959 Tiderington E, Stanhope V, Henwood BF. A qualitative analysis of case managers' use of harm reduction in practice. J Subst Abuse Treat 2013; 44(1):71-77..

Factors that influence the implementation of the HF

The difficulties and facilities faced in the HF implementation process are analyzed here based on four dimensions: characteristics of the proposal, context in which the intervention was introduced (beneficiaries, network of local services, and community), institutional aspects (values, attitudes, competencies, resources, and coordination of program actions) and the process of implementing the proposal (selection of participants, housing structuring, and offering support to beneficiaries). In Chart 2, the factors are grouped as they represent barriers or facilitators and the respective sources indicated according to the numbering of the studies established in Chart 1.

Discussion

Transposing an intervention proposal to concrete situations finds support and resistance in the local context⁶⁰60 Champagne F, Brousselle A, Hartz Z, Contandriopoulos A-P, Denis J-L. A Análise da Implantação. In: Brousselle A, Champagne F, Contandriopoulos A-P, Hartz Z, editors. Avaliação: conceitos e métodos. 2ª ed. Rio de Janeiro: Fiocruz; 2011. p. 217-238.^,6161 Hasford J, Nelson G, Worton SK, Macnaughton E, MacLeod T, Piat M, Tsemberis S, Stergiopoulos V, Distasio J, Aubry T, Goering P. Knowledge translation and implementation of housing first in Canada: A qualitative assessment of capacity building needs for an evidence-based program. Eval Program Plann 2019; 75:1-9.. In the specific case of Housing First, it appears that the set of evidence available on the effectiveness of the intervention confers legitimacy to the model, favoring its perception as a more effective solution than other interventions in addressing the problem of the homeless situation⁶²62 Nelson G, Macnaughton E, Goering P, Dudley M, O'Campo P, Patterson M, Piat M, Prévost N, Strehlau V, Vallée C. Planning a Multi-site, Complex Intervention for Homeless People with Mental Illness: The Relationships Between the National Team and Local Sites in Canada's At Home/Chez Soi Project. Am J Community Psychol 2013; 51(3-4):347-358.. However, since the proposal is externally conceived, implementing agents may perceive that the local capacities are not properly considered in the planning and implementation of the intervention and that the model carries low permeability for adaptations³⁴34 Fleury M-J, Grenier G, Vallée C. Evaluation of the implementation of the Montreal at home/chez soi project. BMC Health Serv Res 2014; 14(1).^,6262 Nelson G, Macnaughton E, Goering P, Dudley M, O'Campo P, Patterson M, Piat M, Prévost N, Strehlau V, Vallée C. Planning a Multi-site, Complex Intervention for Homeless People with Mental Illness: The Relationships Between the National Team and Local Sites in Canada's At Home/Chez Soi Project. Am J Community Psychol 2013; 51(3-4):347-358..

Still regarding the characteristics of the proposal that challenge implementation, the HF model can be perceived as complex due to the level of change in attitude required from implementers, the need for interaction between agents and institutions with different cultures and institutional practices, besides the lack of program operational clarity. It should also be noted that, when the opportunity for implementation takes place through pilot projects, after the demonstration period, the uncertainty about the sustainability of the intervention also seems to influence the lack of engagement⁶²62 Nelson G, Macnaughton E, Goering P, Dudley M, O'Campo P, Patterson M, Piat M, Prévost N, Strehlau V, Vallée C. Planning a Multi-site, Complex Intervention for Homeless People with Mental Illness: The Relationships Between the National Team and Local Sites in Canada's At Home/Chez Soi Project. Am J Community Psychol 2013; 51(3-4):347-358.^,6363 Volk JS, Yamin S, Jetté J, Aubry T, Bourque J. The at home / Chez Soi project: Community partners' perspectives on the implementation of housing first in Moncton. Can J Community Ment Heal 2015; 33(4):77-90..

Attitudes that deviate from the fundamentals established in the HF³⁵35 Kumar N, Plenert E, Hwang SW, O'Campo P, Stergiopoulos V. Sustaining housing first after a successful research demonstration trial: Lessons learned in a large urban center. Psychiatr Serv 2017; 68(7):739-742.^,4646 Anderson-Baron JT, Collins D. Not a "forever model": the curious case of graduation in Housing First. Urban Geogr 2018; 39(4):587-605.^,6464 Johnsen S, Teixeira L. "Doing it Already?": Stakeholder Perceptions of Housing First in the UK. Int J Hous Policy 2012; 12(2):183-203.^,6565 Fenwick K, Henwood B, Lengnick-Hall R, Stefancic A, Gilmer T. Exploring Variation in Housing First Implementation: The Role of Fit. Hum Serv Organ Manag Leadersh Gov 2019; 43(5):392-406., especially with regard to focusing the program on people with more complex needs (such as those who make heavy use of drugs and have low adherence to health treatments), compromise critically the implementation of the model. For example, the establishment of criteria and time limits for the permanence of participants in the program⁴⁴44 van den Berk-Clark C. The Dilemmas of Frontline Staff Working With the Homeless: Housing First, Discretion, and the Task Environment. Hous Policy Debate 2016; 26(1):105-122.^,6666 Gilmer TP, Ojeda VD, Hiller S, Stefancic A, Tsemberis S, Palinkas LA, et al. Variations in full service partnerships and fidelity to the housing first model. Am J Psychiatr Rehabil 2013; 16(4):313-328.^,6767 Bullen J, Fisher KR. Is Housing First for Mental Health Community Support Possible During a Housing Shortage? Soc Policy Adm 2015; 49(7):928-945. threatens the model’s assumption of housing stability and reduces the capacity to interrupt the logic of temporary housing, marked by the alternation between life on the streets, public institutions, and poor housing.

These and other practices that would account for the model’s assumptions may be associated with broader reproduction of social inequalities⁶⁸68 Brodkin EZ, Majmundar M. Administrative exclusion: Organizations and the hidden costs of welfare claiming. J Public Adm Res Theory 2010; 20(4):827-848.^,6969 DeVerteuil G. Homeless Mobility, Institutional Settings, and the New Poverty Management. Environ Plan A Econ Sp 2003; 35(2):361-379., which may represent a greater challenge when the implementation occurs in settings of such unequal social relationships, as in the Brazilian case⁷⁰70 Pires R. Implementando desigualdades: reprodução de desigualdades na implementação de políticas públicas. Rio de Janeiro: IPEA; 2019.. This debate has been addressed in the public policy literature on discretion, including a Brazilian study in the field of care related to drug use⁷¹71 Dutra R, Arenari B. Implementação de políticas públicas e inclusão social: a atuação de organizações implementadoras com populações de rua usuárias de drogas e reprodução de desigualdades. Boletim de Análise Político-Institucional 2017; 13(9):29-36..

Overcoming barriers to accessing housing while ensuring intensive support to residents is the central process for implementing the HF, a robust mission that requires technical, organizational and governance capacity. While the HF model admits that professionals from the two areas of the program (housing and clinical) work both separately and in the same team⁵⁶56 Tsemberis S. Housing First: The Pathways Model to end homelessness for people with mental illness and adiction. Minnesota: Hazelden; 2015., differences in these arrangements directly impact the regularity and intensity of monitoring residents²⁶26 Nelson G, Stefancic A, Rae J, Townley G, Tsemberis S, Macnaughton E, et al. Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: A mixed methods approach. Eval Program Plann 2014; 43:16-26.^,6363 Volk JS, Yamin S, Jetté J, Aubry T, Bourque J. The at home / Chez Soi project: Community partners' perspectives on the implementation of housing first in Moncton. Can J Community Ment Heal 2015; 33(4):77-90.^,7272 Collins SE, Clifasefi SL, Andrasik MP, Dana EA, Stahl N, Kirouac M, Welbaum C, King M, Malone DK.. Exploring transitions within a project-based housing first setting: Qualitative evaluation and practice implications. J Health Care Poor Underserved 2012; 23(4):1678-1697.

73 Greenberg B, Korb S, Cronon K, Anderson R. Supportive housing best practices in a mid-sized US urban community. Housing, Care Support 2013; 16(1):6-15.

74 Kertesz SG, Austin EL, Holmes SK, DeRussy AJ, Van Deusen Lukas C, Pollio DE. Housing first on a large scale: Fidelity strengths and challenges in the VA's HUD-VASH program. Psychol Serv 2017; 14(2):118-128.^-7575 Henwood BF, Stanhope V, Padgett DK. The role of housing: a comparison of front-line provider views in housing first and traditional programs. Adm Policy Ment Heal Ment Heal Serv Res 2011; 38(2):77-85.. Obstacles to the adequacy of clinical support predominate in different contexts, even in the Canadian experience⁷⁶76 Macnaughton E, Stefancic A, Nelson G, Caplan R, Townley G, Aubry T, McCullough S, Patterson M, Stergiopoulos V, Vallée C, Tsemberis S, Fleury MJ, Piat M, Goering P. Implementing Housing First Across Sites and Over Time: Later Fidelity and Implementation Evaluation of a Pan-Canadian Multi-site Housing First Program for Homeless People with Mental Illness. Am J Community Psychol 2015; 55(3-4):279-291., considered the most consistent with the original HF model. These limitations may partially explain the interventions that fail to achieve improvements in the health status of residents⁷⁴74 Kertesz SG, Austin EL, Holmes SK, DeRussy AJ, Van Deusen Lukas C, Pollio DE. Housing first on a large scale: Fidelity strengths and challenges in the VA's HUD-VASH program. Psychol Serv 2017; 14(2):118-128.^,7777 Appel PW, Tsemberis S, Joseph H, Stefancic A, Lambert-Wacey D. Housing first for severely mentally ill homeless methadone patients. J Addict Dis 2012; 31(3):270-277.. It is noteworthy that factors of other dimensions, such as housing far from the teams’ base and turnover of professionals, also interact, disfavoring the quality of monitoring residents.

The use of mixed care arrangements⁷⁸78 Stefancic A, Henwood BF, Melton H, Shin SM, Lawrence-Gomez R, Tsemberis S. Implementing Housing First in rural areas: Pathways Vermont. Am J Public Health 2013; 103(Supl. 2):S206-209. that ensure attention to the diversity and complexity of residents’ needs and clearly defined roles are strategies that can reduce conflicts between professionals with different institutional cultures and promote greater implementation capacity. However, more robust governance structures are required to ensure the coordination of services in cases where housing and clinical support modalities are provided by different institutions or belong to different systems. Regardless of the arrangement adopted, there is a concern that those responsible for clinical monitoring are not burdened with solving problems of structuring and maintaining homes and end up adopting a passive posture vis-à-vis investing in psychosocial rehabilitation⁷³73 Greenberg B, Korb S, Cronon K, Anderson R. Supportive housing best practices in a mid-sized US urban community. Housing, Care Support 2013; 16(1):6-15.^,7979 Tiderington E. "We Always Think You're Here Permanently": The Paradox of "Permanent" Housing and Other Barriers to Recovery-Oriented Practice in Supportive Housing Services. Adm Policy Ment Heal Ment Heal Serv Res 201:103-114..

Specific difficulties in putting into practice the Harm Reduction proposal are attributed to the lack of conceptual and operational clarity of this approach within the HF, besides the agents’ lack of a practical repertoire of skills essential to its implementation, emphasizing motivational interview techniques, user-centered planning and clinical management of crisis situations⁵²52 Stergiopoulos V, O'Campo P, Gozdzik A, Jeyaratnam J, Corneau S, Sarang A, Hwang SW. Moving from rhetoric to reality: adapting Housing First for homeless individuals with mental illness from ethno-racial groups. BMC Health Serv Res 2012; 12(1):345.^,6363 Volk JS, Yamin S, Jetté J, Aubry T, Bourque J. The at home / Chez Soi project: Community partners' perspectives on the implementation of housing first in Moncton. Can J Community Ment Heal 2015; 33(4):77-90.^,6565 Fenwick K, Henwood B, Lengnick-Hall R, Stefancic A, Gilmer T. Exploring Variation in Housing First Implementation: The Role of Fit. Hum Serv Organ Manag Leadersh Gov 2019; 43(5):392-406.^,8080 Collins SE, Malone DK, Larimer ME. Motivation to change and treatment attendance as predictors of alcohol-use outcomes among project-based Housing First residents. Addictive Behaviors 2012; 37:931-939.. On the other hand, the quantity and quality of interaction between the team and users are a determining factor for the construction of positive relationships that favor the practice of Harm Reduction and Recovery⁵⁹59 Tiderington E, Stanhope V, Henwood BF. A qualitative analysis of case managers' use of harm reduction in practice. J Subst Abuse Treat 2013; 44(1):71-77.^,8181 Andvig ES, Sælør KT, Ogundipe E. Harm reduction in a Norwegian housing first project: a qualitative study of the treatment providers' practice. Adv Dual Diagn 2018; 11(1):4-15., and the offer of support geared to addressing the economic insufficiency of the residents⁸¹81 Andvig ES, Sælør KT, Ogundipe E. Harm reduction in a Norwegian housing first project: a qualitative study of the treatment providers' practice. Adv Dual Diagn 2018; 11(1):4-15.. Managers and teams with values, attitudes, and technical skills aligned with the HF principles, and offering continuing education, are the driving elements of the implementation process.

Limitations of existing community services, which act complementarily to the HF to meet the multiple needs of residents, indicate that the barriers historically faced by this public to access basic goods and services (health, minimum income subsidies, public transport, and communication means) require stronger local partnerships and agreements to overcome them. Failure to meet these needs adversely affects implementation, albeit in other ways. For example, the lack of transport and telephone hinders maintaining bonds with family and friends, participating in city life, and scheduling follow-up visits, which are factors associated with the residents’ feelings of isolation and loneliness⁸²82 Macnaughton E, Stefancic A, Nelson G, Caplan R, Townley G, Aubry T, McCullough S, Patterson M, Stergiopoulos V, Vallée C, Tsemberis S, Fleury MJ, Piat M, Goering P. Implementing Housing First Across Sites and Over Time: Later Fidelity and Implementation Evaluation of a Pan-Canadian Multi-site Housing First Program for Homeless People with Mental Illness. Am J Community Psychol 2015; 55(3-4):279-291.. The same can be said for their lack of engagement and adherence to the program, which can be influenced by negative experiences in similar programs, lack of transportation to attend services, and irregular offer of services in the network.

Difficulty in accessing adequate and sufficient housing and housing subsidies, reported in more than half of the studies analyzed and found in all countries represented in the review, appears as a persistent factor inhibiting the materialization of the other central component of the HF proposal: facilitated access to permanent housing, respecting the choice of the participants. Besides the housing system’s local conditions, which include limitations of the social housing policies and the private real estate market, the unavailability of housing is also associated with the stigma and prejudice of property owners towards applicants for tenancy, which hampers structuring of dwellings in the desired time and place and implies recurrent relocation of participants as a result of conflicts and evictions. As the housing system is one of the biggest challenges not only to the HF implantation process, but also to the proposal’s scaled and sustainable development, the debate on its implementation must consider the globally experienced housing crisis and its regional and local particularities⁸³83 Molina I, Czischke D, Rolnik R. Housing policy issues in contemporary South America: an introduction. Intern J Housing Policy 2019; 19:277-287..

The systematization of contextual factors in the proposed dimensions and in the difficulties and facilities categories was an important exploratory instrument to identify relevant issues in the experience of implementing the HF, and the different levels at which they operate (individual, institutional and social). However, this division must be relativized, since the aspects underlying the context are related to each other and are seen as barriers or facilities in different degrees of importance and intensity, depending, for example, on the stage of implementation of the HF.

It is noteworthy that there is no consensus in the literature about the boundaries that delimit the context and that, for some evaluators, the dimensions considered in this study, for example the design of the proposal, can be external to the context and restricted to the intervention⁶⁰60 Champagne F, Brousselle A, Hartz Z, Contandriopoulos A-P, Denis J-L. A Análise da Implantação. In: Brousselle A, Champagne F, Contandriopoulos A-P, Hartz Z, editors. Avaliação: conceitos e métodos. 2ª ed. Rio de Janeiro: Fiocruz; 2011. p. 217-238.. On this issue, we believe that, in our case, the adoption of a comprehensive concept of context was advantageous as it resulted in an overview of factors that subsidized perspectives for future in-depth research and potentially included realities of several contexts. On the other hand, the selection criteria adopted for this review, especially the set of words and the type of publication - which was restricted to empirical studies published in scientific journals - potentially limited the identification of a greater number of factors.

The significant number of papers, almost a third of the total analyzed, addressing the same Canadian pilot study - At Home/Chez Soi, and the prevalence of a group of seven researchers who are authors in more than a quarter of the publications, are two very relevant aspects. From the perspective of the characteristics of the analyzed studies, we should emphasize that most of the selected studies do not sufficiently characterize the local conditions of the health, social assistance, and housing social policies in which HF programs are developed, which reduces the ability to analyze which strategies can be adopted in particular circumstances of public policy outside the North American, European, and Australian contexts. In this sense, the reading of the factors systematized here, in dialogue with an in-depth description of the political context and the social protection system of the countries in which the HF was consolidated, can contribute to better adapting the model to the Latin American needs.

Since the object of intervention of the HF, at least in Brazil, is located in the field of public policy (meeting the need for social protection of PLS people who use drugs or have mental health issues), the understandings and proposals formulated on the adaptation of the model nationally should consider the modes of production of Health and Social Assistance services and their existing work processes, and the political disputes surrounding mental health public care. Dimensions related to living in the Brazilian reality, for example, the ideal of home ownership and the high presence of informality in property leasing processes, must also be considered.

Conclusion

This study aimed to understand the challenges and opportunities for implementing this intervention through a literature review. We presented a set of factors relevant to the implementation process of this type of intervention, organized into four dimensions: intervention characteristics, implementation context, institutional aspects, and implementation process. We found that the unavailability of housing, the lack of coordination of the services required by residents and the resistance of implementing agents to the HF principles are the main factors that hinder the implementation. In turn, agents with values, attitudes, and skills converging with the model and continuing education are facilitating elements.

We believe that the study of the literature carried out achieved its objective, providing a set of relevant elements in the analysis, formulation, and improvement of interventions that aim to guarantee the right to housing for people with mental health support needs, besides pointing out aspects relevant to the Housing First expansion process itself. The scope of the contextual dimensions considered provided an opportunity for a broad understanding of the implementation process at structural and relational levels, which can be analyzed in-depth from theoretical frameworks and delimited references.

We point out the relevance of producing new knowledge that favors the integration of HF interventions to existing social protection systems, a decisive process for their implementation and sustainability within the scope of public policy.

Acknowledgments

We are grateful to Wagner Oda for his contribution in the paper selection stage.

References

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