Maritt Kirst

Implementing successful intimate partner violence screening programs in health care settings: Evidence generated from a realist-informed systematic review

We undertook a synthesis of existing studies to re-evaluate the evidence on program mechanisms of intimate partner violence (IPV) universal screening and disclosure within a health care context by addressing how, for whom, and in what circumstances these programs work. Our review is informed by a realist review approach, which focuses on program mechanisms. Systematic, realist reviews can help reveal why and how interventions work and can yield information to inform policies and programs. A review of the scholarly literature from January 1990 to July 2010 identified 5046 articles, 23 of which were included in our study. We identified studies on 17 programs that evaluated IPV screening. We found that programs that took a comprehensive approach (i.e., incorporated multiple program components, including institutional support) were successful in increasing IPV screening and disclosure/identification rates. Four program components appeared to increase provider self-efficacy for screening, including institutional support, effective screening protocols, thorough initial and ongoing training, and immediate access/referrals to onsite and/or offsite support services. These findings support a multi-component comprehensive IPV screening program approach that seeks to build provider self-efficacy for screening. Further implications for IPV screening intervention planning and implementation in health care settings are discussed.

The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness

BACKGROUND There is strong evidence that Housing First interventions are effective in improving housing stability and quality of life among homeless people with mental illness and addictions. However, there is very little evidence on the effectiveness of Housing First in improving substance use-related outcomes in this population. This study uses a randomized control design to examine the effects of scatter-site Housing First on substance use outcomes in a large urban centre. METHODS Substance use outcomes were compared between a Housing First intervention and treatment as usual group in a sample of 575 individuals experiencing homelessness and mental illness, with or without a co-occurring substance use problem, in the At Home/Chez Soi trial in Toronto, Canada. Generalized linear models were used to compare study arms with respect to change in substance use outcomes over time (baseline, 6, 12, 18 and 24 month). RESULTS At 24 months, participants in the Housing First intervention had significantly greater reductions in number of days experiencing alcohol problems and amount of money spent on alcohol than participants in the Treatment as Usual group. No differences between the study arms in illicit drug outcomes were found at 24 months. CONCLUSIONS These findings show that a Housing First intervention can contribute to reductions in alcohol problems over time. However, the lack of effect of the intervention on illicit drug problems suggests that individuals experiencing homelessness, mental illness and drug problems may need additional supports to reduce use. TRIAL REGISTRATION Current controlled trials ISRCTN42520374.

Youth help-Seeking Expectancies and their Relation to help-Seeking Behaviours for Substance use Problems

Objective: To explore how the nature youth expectancies (i.e. their underlying attitudinal and motivational factors) influence help seeking behavioural patterns for Substance Use Problems (SUP). Method: Focus groups were conducted to collect the most important items/issues identified by youth, in their own words. Twenty-four participants were recruited, ranging in ages 14–21 years, 17 males, 7 females, which were formed into four focus groups. Participants were recruited from group homes/shelters, addiction programs, mental health services, general youth programs, and schools in Toronto Canada. The participants had a variety of cultural and social economic status backgrounds. This qualitative data was analyzed by the technique of content analysis. Results: A number of theoretical constructs or themes were elicited from the focus group data. Most constructs supported existing literature, but a number of novel constructs or variations of old ones emerged, regarding first contact with therapy providers, motivation to change, family involvement, forced treatment, and initial and ongoing contact with therapy. Conclusions: The focus group data contained important constructs in regards to help-seeking expectancies and confirms findings from other research in this area. This data has the potential to assist in helping predict outcomes for adolescents with SUP, as well as significantly assist mental health professionals in lowering barriers to help seeking. Understanding these barriers is an initial step toward the development of an evidence-base for treatment program improvements and specialized services that will promote help seeking among this population.

The promise of recovery: narratives of hope among homeless individuals with mental illness participating in a Housing First randomised controlled trial in Toronto, Canada

Objectives Hope is widely embraced as an important factor in the recovery process. The role of housing in inspiring hope and facilitating recovery has been explored with homeless populations but is not well understood. This study explores perspectives on hopes for recovery and the role of housing on these hopes from the perspective of homeless adults experiencing mental illness participating in a multisite Housing First randomised controlled trial in Canada. The study draws on data from in-depth qualitative interviews with participants from the Toronto, Ontario site of the ‘At Home/Chez Soi’ Project. Design In-depth interviews were conducted with a subsample of participants from a larger Housing First randomised controlled trial. Setting The research took place in Toronto, Canada. Participants 60 participants in the larger trial (36 from the Housing First group and 24 from the Treatment as Usual group) took part in in-depth interviews. Method Participants for the in-depth interviews were purposively selected from the larger trial sample in Toronto and participated in an interview at the beginning of the study (baseline). Data from the baseline interviews were analysed using the constant comparative method derived from grounded theory methods. Results Participants’ narratives show clear visualisation of goals for recovery, and emphasise that housing is an integral factor that can facilitate hope and support dimensions of recovery. However, some participants had difficulty adjusting to housing, and were concerned about feeling socially isolated, which could have negative implications for hopefulness and recovery. Conclusions Housing First interventions should explicitly incorporate hope-inspiring, recovery-oriented approaches and support participants while adjusting to housing in order to sustain hopefulness.

Referral to Health and Social Services for Intimate Partner Violence in Health Care Settings: A Realist Scoping Review

Efficient and coordinated health care responses to intimate partner violence (IPV) are essential, given that health care settings are a major entry point for abused women who seek professional services. However, there is a lack of evidence on how IPV referrals are effectively made within health care settings. In order to help program planners and providers across sectors to address the complex and chronic issue of IPV, a greater understanding of the post-IPV identification referral process is essential. A scoping review of the evidence on IPV referral programs and processes in health care settings was undertaken to provide an overview of the state of evidence and identify pertinent gaps in existing research. The scoping review identified 13 evaluative studies and 6 qualitative, primarily nonevaluative studies that examined IPV referral programs and processes. Evaluative studies involved a variety of designs and IPV referral outcomes. Rich descriptions of barriers and facilitators to seeking referrals by victims and making referrals by health care providers emerged from the evaluative and qualitative studies, but were explored more in depth in the qualitative studies. This scoping review provides guidance on what is currently known about IPV referral programs in health care settings and provides a starting point for further research on effectiveness of referral processes.

Co-responding Police-Mental Health Programs: A Review

Co-responding police-mental health programs are increasingly used to respond to ‘Emotionally Disturbed Persons’ in the community; however, there is limited understanding of program effectiveness and the mechanisms that promote program success. The academic and gray literature on co-responding police-mental health programs was reviewed. This review synthesized evidence of outcomes along seven dimensions, and the available evidence was further reviewed to identify potential mechanisms of program success. Co-responding police-mental health programs were found to have strong linkages with community services and reduce pressure on the justice system, but there is limited evidence on other impacts. The relevance of these findings for practitioners and the major challenges of this program model are discussed, and future research directions are identified.

Public awareness of income-related health inequalities in Ontario, Canada

IntroductionContinued action is needed to tackle health inequalities in Canada, as those of lower income continue to be at higher risk for a range of negative health outcomes. There is arguably a lack of political will to implement policy change in this respect. As a result, we investigated public awareness of income-related health inequalities in a generally representative sample of Ontarians in late 2010.MethodsData were collected from 2,006 Ontario adults using a telephone survey. The survey asked participants to agree or disagree with various statements asserting that there are or are not health inequalities in general and by income in Ontario, including questions pertaining to nine specific conditions for which inequalities have been described in Ontario. A multi-stage process using binary logistic regression determined whether awareness of health inequalities differed between participant subgroups.ResultsAlmost 73% of this sample of Ontarians agreed with the general premise that not all people are equally healthy in Ontario, but fewer participants were aware of health inequalities between the rich and the poor (53%–64%, depending on the framing of the question). Awareness of income-related inequalities in specific outcomes was considerably lower, ranging from 18% for accidents to 35% for obesity.ConclusionsThis is the first province-wide study in Canada, and the first in Ontario, to explore public awareness on health inequalities. Given that political will is shaped by public awareness and opinion, these results suggest that greater awareness may be required to move the health equity agenda forward in Ontario. There is a need for health equity advocates, physicians and researchers to increase the effectiveness of knowledge translation activities for studies that identify and explore health inequalities.

Life Changes Among Homeless Persons With Mental Illness: A Longitudinal Study of Housing First and Usual Treatment

OBJECTIVE This study compared the life changes of homeless people with mental illness participating in Housing First or treatment as usual and examined factors related to various changes. METHODS Semistructured narrative interviews were conducted with 219 participants in five Canadian cities at baseline; 197 were interviewed again at 18 months after random assignment to Housing First (N=119) or treatment as usual (N=78). Interviews were coded across 13 life domains, and each participant was categorized as reporting positive, mixed-neutral, or negative changes. Housing First and treatment as usual participants were compared with respect to change patterns. Thematic analysis was used to examine factors related to various changes. RESULTS The percentage of participants in Housing First reporting positive changes was more than double that for participants in treatment as usual, and treatment as usual participants were four times more likely than Housing First participants to report negative changes. Factors related to positive changes included having stable good-quality housing, increased control over substance use, positive relationships and social support, and valued social roles. Factors related to negative changes included precarious housing, negative social contacts, isolation, heavy substance use, and hopelessness. Factors related to mixed-neutral changes were similar to those for participants reporting negative changes but were less intense. CONCLUSIONS Housing First with intensive support was related to more positive changes among homeless adults with mental illness across five Canadian cities. Those with poor housing or support, more common in treatment as usual, continued to struggle. These findings are relevant for services and social change to benefit this population.

Community-based Participatory Research: Development of an Emergency Department–based Youth Violence Intervention Using Concept Mapping

OBJECTIVES Emergency departments (EDs) see a high number of youths injured by violence. In Ontario, the most common cause of injury for youths visiting EDs is assault. Secondary prevention strategies using the teachable moment (i.e., events that can lead individuals to make positive changes in their lives) are ideal for use by clinicians. An opportunity exists to take advantage of the teachable moment in the ED in an effort to prevent future occurrences of injury in at-risk youths. However, little is known about perceptions of youths, parents, and community organizations about such interventions in EDs. The aims of this study were to engage youths, parents, and frontline community workers in conceptualizing a hospital-based violence prevention intervention and to identify outcomes relevant to the community. METHODS Concept mapping is an innovative, mixed-method research approach. It combines structured qualitative processes such as brainstorming and group sorting, with various statistical analyses such as multidimensional scaling and hierarchical clustering, to develop a conceptual framework, and allows for an objective presentation of qualitative data. Concept mapping involves multiple structured steps: 1) brainstorming, 2) sorting, 3) rating, and 4) interpretation. For this study, the first three steps occurred online, and the fourth step occurred during a community meeting. RESULTS Over 90 participants were involved, including youths, parents, and community youth workers. A two-dimensional point map was created and clusters formed to create a visual display of participant ideas on an ED-based youth violence prevention intervention. Issues related to youth violence prevention that were rated of highest importance and most realistic for hospital involvement included mentorship, the development of youth support groups in the hospital, training doctors and nurses to ask questions about the violent event, and treating youth with respect. Small-group discussions on the various clusters developed job descriptions, a list of essential services, and suggestions on ways to create a more youth-friendly environment in the hospital. A large-group discussion revealed outcomes that participants felt should be measured to determine the success of an intervention program. CONCLUSIONS This study has been the springboard for the development of an ED-based youth violence intervention that is supported by the community and affected youth. Using information generated by youth that is grounded in their experience through participatory research methods is feasible for the development of successful and meaningful youth violence prevention interventions.

Predictors of Substance Use Among Young Adults Transitioning Away from High School: A Narrative Review

Background: Young adulthood has been shown to be a time of increased substance use. Yet, not enough is known about which factors contribute to initiation and progression of substance use among young adults specifically during the transition year away from high school. Objectives: A narrative review was undertaken to increase understanding of the predictors of changes in use of tobacco, alcohol, cannabis, other illicit drugs, and mental health problems among young adults during the transition period after high school. Methods: A review of academic literature examining predictors of the use of tobacco, alcohol and cannabis, and co-morbidities (e.g., co-occurring substance use and/or mental health issues) among young adults transitioning from high school to post-secondary education or the workforce. Results: Twenty six studies were included in the review. The majority of the studies (19) examined substance use during the transition from high school to post-secondary settings. Seven studies examined substance use in post-secondary settings. The studies consistently found that substance use increases among young adults as they transition away from high school. During the transition away from high school, common predictors of substance use include substance use in high school, and peer influence. Common predictors of substance use in post-secondary education include previous substance use, peer influence, psychological factors and mental health issues. Conclusions/Importance: Further research on social contextual influences on substance use, mental health issues, gender differences and availability of substances during the transition period is needed to inform the development of new preventive interventions for this age group.