“Development and Feasibility Testing of Supported Housing Programme on Independent Living Skills of Homeless Women with Severe Mental Illness: A Prospective Study”

doi:10.21203/rs.3.pex-2024/v1

Method Article

“Development and Feasibility Testing of Supported Housing Programme on Independent Living Skills of Homeless Women with Severe Mental Illness: A Prospective Study”

https://doi.org/10.21203/rs.3.pex-2024/v1

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Homeless

women with severe mental illness

supported housing

Homelessness and mental illness are inextricably linked and this bidirectional phenomenon forms a vicious circle from which an escape seems complicated. One of the most pertinent needs of Homeless Women with Severe Mental Illness (HWSMI) when they recover from mental illness, is to return to their families. However, catering to this need has been challenging due to several reasons. HWSMI, when institutionalized, gets trapped in a system that reduces access to normative resources and solidifies social withdrawal. The existing models of SHP were found to be effective in improving certain areas such as symptom reduction, and re-hospitalization. Still, there is a lack of a holistic need-based model that addresses the independent living of Persons with Mental illness and that includes collaboration with Persons with Mental Illness to the extent of their expected desired/outcome (Walker & Seasons, 2009). It is also found that the impact of housing on outcomes other than those related to residential stability and hospitalization has not been consistently studied (Rogs, 2004). In this context, we aim to develop a supported housing program (SHP) for HWSMI in collaboration with stakeholders such as Homeless Women with Mental Illness and Government facilities & Resources & examine the effect of SHP on their Independent Living Skills.

Methodology: The study will be conducted in two phases and use a mixed methodology. Phase 1 of the study will use an explorative study design - qualitative in nature. In this phase, the experiences, functioning, and needs of HWSMI related to supported housing will be assessed through qualitative interviews with HWSMI. Observational visits will be made to SH facilities for persons with mental illness run by Governmental and Non-Governmental Organizations. Phase 2 of the study will involve a quasi-experimental pre-and post-test design without a control group. In this phase, the HWSMI will be assessed on Quality of Life, Well-being, Self-esteem, and functioning prior to the placement (to Midway/ Independent living) and will be re-assessed at two intervals (3 months and 6 months) after the placement. All HWSMI residing in Institutions with restrictive environments in Bangalore will be the universe and Total enumeration will be used for the study (Both Phase I & II- approximately 20-25

HWSMI in each phase). In Phase II, all HWSMI (during a six-month data collection period) meeting the inclusion and exclusion criteria will be considered as samples.

Tools for Phase I

1. Socio-demographic Datasheet (HWSMI): A Socio-demographic datasheet will be developed by the researcher to collect the demographic details of the HWSMI such as age, religion, educational status, marital status, SES, domicile, languages known, medical history, medication compliance, illness (details of admission, length of stay, and critical incidents during stay), family (details of family, addresses, and reintegration attempts)

2. Socio-demographic Datasheet (MHP): A data sheet will be used to collect the socio-demographic details of the Mental Health Professionals (MHP) involved in the treatment and rehabilitation of the HWSMI. This will include details such as age, gender, educational qualification, areas of specialization, occupation, and working with HWSMI.

3. Qualitative interview schedule for Stakeholders: Stakeholders include HWSMI, Mental Health Professionals involved in the care/treatment of HWSMI, and NGOs working for HWSMI. This will be prepared by the researcher. The interview schedule for HWSMIwill be used to assess and understand the experiences and functioning of the HWSMI and will include questions on current living conditions, willingness to transit, needs, and anticipated challenges related to independent living conditions, education, employment, etc. The interview schedule for MHP/NGOs will include questions on their experiences, practices, challenges, etc. The interviews will also elicit qualitative responses on the needs related to the Supported Housing Program for HWSMI from all stakeholders.

4. Observation checklist: The researcher will develop an observation checklist that will be used during visits to organizations that provide supported housing in India. The checklist would collect details about the supported housing model, its feasibility and implementation, and barriers and challenges experienced.

5. Content Validation: The content validation will be done by 5-7 Mental Health Professionals/ Practitioners (with experience >5 years) involved in the care, treatment, and rehabilitation of Homeless Women with Severe Mental Illness. The researcher will interview the Mental health Professionals using a checklist to quantify the relevance, content, language, and practical application of the developed Supported Housing Program. Based on the results that arrive from the process. The Content Validation ratio (CVR)/ Kappa value will be calculated.

Tools for phase II

1. Rosenberg Self-Esteem Scale (Rosenberg, 1965): Rosenberg self-esteem scale developed by Rosenberg, consists of ten items to be answered on a four-point Likert scale - strongly agree to strongly disagree, items 2, 5,6,8,9 reverse scoring that is, SA=0, A=1, D=2, SD=3. Sum the scores for the 10 items. The higher the score, the higher the self-esteem.

2. WHO (Five) Well-being Index (WHO-5): The WHO-5, introduced in 1998, is a short self-reported measure of subjective psychological well-being. The index uses only positively phrased questions (World Health Organisation, 1998).

3. Quality of Life: The WHOQOL-BREF is a 26-item instrument consisting of four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items); it also contains QOL and general health items. Each individual item of the WHOQOL-BREF is scored from 1 to 5 on a response scale, which is stipulated as a five-point ordinal scale (Vahedi, 2010).

4. Independent Living Skills Survey (ILSS): Developed by Wallace et al., 2000 is used to assess role functioning in the lifestyles relevant to persons with severe mental illness. The instrument measures personal hygiene. Appearance, care, and clothing, Food preparation, Money management, Transportation, leisure and recreational activities, social interaction, etc. in the time frame of the last 30 days (Wallace et al., 2000). Standardized capacity assessment checklist: Capacity Assessment for Treatment decisions including Admission will be used to assess capacity for decisions regarding mental healthcare (mental healthcare under the Act includes analysis, admission, treatment, and rehabilitation of mental illnesses (Namboodiri, 2019). A Capacity the checklist will be used for screening and documenting decisional capacity in people

participating in different types of clinical research (Jeste et al., 2007)

6. Global Assessment of Functioning Scale: The Global Assessment of Functioning scale (GAF) was introduced in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) in 1987. GAF is a numeric scale with a value range from 0 (most severe) to 100 (least severe) with 10 anchor points at equal intervals (Hall, 1995)

7. Feasibility Checklist: a. The qualitative feasibility of the supported housing program for homeless women

with severe mental illness will be assessed based on Bowen’s eight parameters such Acceptability, Demand, Implementation, Practicality, Adaptation, Integration, Expansion, and Limited-efficacy testing (Bowen et al., 2009) b. The feasibility would also be assessed using the theory of change maxim to detail the Inputs provided at the beginning of the SHP, the Activities conducted to meet the objectives, Outputs observed from activities, and Outcomes as a result of the SHP provided to the HWSMI. This feasibility would mainly be assessed from the qualitative, reflective narrative observed and maintained by the researcher.

8. Case studies: Case studies of HWSMI who have transited from tertiary care institutions to midway homes and/or independent living will be recorded. These case studies would focus on the qualitative outcomes such as the number of productive days, the process of SHP, and the success and challenges experienced by the researcher and HWSMI.

PHASE I: DEVELOPMENT & VALIDATION OF SUPPORTED HOUSING PROGRAM

A. NEEDS ASSESSMENT: In this phase of the study, the researcher will conduct a thorough review of literature on supported housing programmes for women with SMI to understand different models, the needs, trends, and gaps in providing supported housing for women with SMI. The researcher will also visit supported housing facilities for persons with mental illness run by Governmental and Non-Governmental organizations

to understand and learn the best practices and their implications. Interviews will be conducted with Mental Health Professionals involved in the care/treatment of HWSMI and NGOs working for HWSMI to elicit qualitative responses on their experiences of working with HWSMI and the needs of HWSMI related to the Supported Housing Program for HWSMI. Post the review and visit, a qualitative interview schedule prepared

by the researcher will be used to assess and understand the experience and functioning of the women with mental illness in the tertiary care settings and their needs related to the support housing program will also be assessed. (Details of what will be asked in the needs assessment are given in the Tools section).

B. DEVELOPMENT & VALIDATION OF SHP: Based on the above, the supported housing program will be developed. The SHP would provide the content and the guidelines for the pathways, and implementation mechanisms of the supported housing program for HWSMI. The psychosocial interventions to be provided will be drafted, discussed with the research guides, and finalized. The researcher will also identify infrastructures and other facilities required for housing the HWSMI. The ethical and safety SOPs for implementing the SHP will also be delineated in the programme. This developed SHP will be reviewed and validated by 5-7 Mental Health Professionals/ Practitioners (with experience >5 years) involved in the care of homeless women with SMI. The researcher will use the CVR (Lawshe,1975) to validate the content of the SHP.

PHASE II: FEASIBILITY TESTING- IMPLEMENTATION OF SUPPORTED HOUSING PROGRAMME

A. RECRUITMENT AND PRE-ASSESSMENTS: Based on CGI (Guy, 1976) score and Disability score on IDEAS (IPS, 2000), HWSMI who are medically fit (based on a psychiatrist’s assessment) will be recruited for the study. Their capacity for treatment decisions and capacity to give consent will be assessed using a standardized capacity assessment checklist developed at NIMHANS. If the HWSMI can give a written consent, then the HWSMI will be recruited directly for the study. For those HWSMI who have family members, the researcher will work alongside them about the inclusion of the HWSMI into the programme. The following steps will be followed for the recruitment:

A. Identification of HWSMIs who are ‘medically fit in tertiary care institutions (NIMHANS Chronic ward and Govt state home for women). B. Identification of appropriate SHP. C. Debriefing family members of HWSMI (if available). D. Debriefing and orientation to HWSMI, Identified for Discharge. E. Shifting HWSMI to SHP

facilities. F. Monitoring and Follow-up. Pre-Assessments will be done to understand the Independent living skills, Quality of Life, Well-being, Self-esteem, and Functionality of the recruited HWSMI at the Baseline. In this phase, the researcher will sensitize the staff in Midway homes on Mental Health and the Rights of Persons with mental illness. Community-level Interventions such as mental health awareness will be provided to other stakeholders such as employers when the need arises for the same.

B. TRANSITION FROM TERTIARY CARE INSTITUTIONS TO MIDWAY HOMES

(Swaadhar Graha/Nammane): For HWSMI who are eligible and willing to transit from a tertiary institution will first be oriented about the process and challenges. In this phase, the HWSMI will be placed in Nammane and Swadhara Gruha (considered as Midway homes in this study; permission to work with BBMP Nammane and Swadhara Gruha for this study will be obtained). In this facility, psychosocial interventions such as

psychoeducation, independent living skills, social skills training, life skills, behavioral management, and supported employment will be provided based on the needs of the HWSMI. The psychosocial interventions will be provided by the researcher. The HWSMI will also be followed up for a regular psychiatric evaluation at NIMHANS in the respective Adult Psychiatry Units. Assessments will be conducted after 3 months of

placement. At the end of 3 months, HWSMI who are eligible and willing to transition to independent living will be transited.

C. TRANSITION FROM MIDWAY HOMES TO INDEPENDENT LIVING: Based on the choice of the HWSMI and the researcher’s assessment, the HWSMI will either be placed in independent living (Preferably for women who have been placed in a job and are earning a salary would be encouraged to shift to this type of housing. HWSMI transiting to independent living (rented housing), will be oriented about the process and challenges. The process of finding houses for the HWSMI and appointing a health care worker (HWSMI) who will live with the HWSMI in the SH facility will be pursued by the researcher. The advance for the rented accommodation would be facilitated through CSR or NGO funds; however, the monthly rentals of the house and salary of the HCW would be borne by the women from their employment salary (assuming women are working). The HCW will supervise medications and facilitate and monitor Activities of daily living. The researcher will visit them 3 days a week to provide psychosocial interventions such as psychoeducation, independent living skills training, Social skills training, life skills, behavioral management, and supported employment based on the

needs of the HWSMI. The HWSMI will undergo periodic psychiatric evaluation by the DMHP/ NIMHANS. Assessments will be conducted at the end of 3 months. Along with income that comes in through supported employment, disability welfare benefits will be sought for the HWSMI to support aftercare.

D. POST ASSESSMENT & FOLLOW-UP: Post assessments will be conducted at 3 months of placement and a follow-up assessment at 6 months of placement. This is to understand the effect of the SHP on Independent living skills, Quality of Life, Well-being, Self-esteem, and Functionality of HWSMI. The feasibility of the model will also be assessed and reported using Bowen’s eight parameters: Acceptability, Demand, Implementation, Practicality, Adaptation, Integration, Expansion and Limited-efficacy testing.

Expected Outcome: The study will facilitate a supported housing program for HWSMI to live independently in the community with sustainable, dignified, inclusive living options with support services such as social care and facilitation, access to health care, case management, and onsite personal assistance. The major outcome is a need-based supported housing program that will empower HWSMI to make choices about their care and daily living. This will further lead to an improved quality of life and well-being.

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