Permanent Supportive Housing Design Characteristics Associated with the Mental Health of Formerly Homeless Adults in the U.S. and Canada: An Integrative Review
Abstract
:1. Introduction
2. Background
2.1. Chronic Homelessness in the U.S. and Canada
2.2. Homelessness and Mental Health
2.3. Permanent Supportive Housing (PSH) and Service Models
2.4. Architecture, Design, the Built Environment, and Mental Health
3. Methods
3.1. Review Aims and Design
3.2. Literature Search Strategy and Inclusion Criteria
3.3. Literature Evaluation and Analysis
4. Results
4.1. Overview of the Included Literature
4.1.1. Research Design, Participants, and Rigor
4.1.2. Housing Type, Service Model, and Spatial Scale
4.1.3. Built Environment (BE) Relevance
4.1.4. Built Environment Findings, Properties, Place Attributes, and Integrative Domains
4.2. A Home Is More Than Housing
4.2.1. Sense of Home and Ontological Security
4.2.2. Safe Haven
4.2.3. Trauma Sensitivity, Trauma-Informed Care, and Trauma-Informed Design
4.3. Dwelling as a Vessel for Autonomous Daily Life
4.3.1. Having One’s Own Space, Single Occupancy, and an Apartment versus a Room
4.3.2. Preferences for Not Sharing a Bathroom
4.3.3. Safety and Security
4.3.4. Housing (and Location) Quality
4.3.5. Access to Storage, Facilities, and Nearby Amenities
4.4. Shared Common Space and Sociality within Single-Site PSH
4.4.1. Setting Facilitates Community
4.4.2. Promising and Contested Shared Common Spaces
4.4.3. Sociality and Trauma Sensitivity
4.4.4. Sociality by Design
5. Discussion
5.1. Interpretation and Implications of Findings
5.2. Strengths and Limitations
5.3. Directions for Future PSH Research
5.3.1. Increasing the Quantity and Quality of Research
5.3.2. Topics for Future Research
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Appendix A
Extracted Data | Categories and Definitions |
---|---|
Housing type (Table 3) | Permanent supportive housing (PSH) provides affordable, safe, and stable housing to people experiencing homelessness, mental and substance use disorders, and/or disability (see Background). |
Service model (Table 3) | Housing First (HF) offers immediate housing and supportive services to individuals regardless of substance use and psychiatric treatment status; individuals are encouraged to define their own recovery-oriented goals [1,24]. Treatment First (TF), also referred to as Sober Living, Sober Living Housing, and Treatment as Usual, offers temporary housing to individuals experiencing homelessness, mental illness, and/or substance use issues with the requirement that they receive treatment and progress through a hierarchy of housing options based on “housing readiness” [1]. |
Site approach [1] (Table 3) | Single site (SS) refers to one dedicated site (through new purpose-built construction, purchase of an existing building, or a master lease of an existing building) that primarily serves formerly homeless individuals with service needs. Dwelling units can be located within the same building, block, or neighborhood, and supportive services are usually available on site. Dwelling units can be independent apartments, shared independent apartments, shared rooms, or SROs with shared bathrooms kitchens. Scattered site (Scat) refers to private market apartments or general affordable housing dispersed throughout the community and leased by residents who are no longer experiencing homelessness via rental subsidies. Supportive staff may visit dwellings or provide services off-site. |
Dwelling unit type (Table 3 and Table S1a,b) | Independent apartments: A dwelling unit with a lockable entry door, full bathroom, kitchen with refrigeration and cooking capability, and living/sleeping areas (e.g., a studio/one-bedroom apartment). Shared independent apartment: An independent apartment that is shared by two or more individuals. Congregate housing: Clustered arrangements of individual sleeping rooms with shared bathroom and kitchen facilities for each cluster of several residents. Rooms can be shared or single-occupancy. SRO (single-room occupancy): A single-occupancy dwelling unit with a bed that may or may not have a sink or small refrigerator. An SRO usually does not have its own bathroom or cooking facilities; instead, common bathrooms and cooking areas are shared. |
Spatial scales (Table 3 and Table S4) | Room scale: Interior spaces that were divided into two subscales. Dwelling units referred to individual or shared rooms and apartments where residents lived. Shared common spaces referred to areas such as community rooms, kitchens, media rooms, laundry facilities, and outdoor spaces. Building scale: The building scale included factors such as the overall floor plan layout, adjacencies and arrangements of spaces, and the number of units. Location scale: Factors related to PSH location including access to transportation, amenities, and services; condition; and safety. |
Built environment properties [68] (Table S2) | Ambient properties: Environmental conditions relating to the senses, also often included in measures of indoor environmental quality, such as lighting, sound, odor, temperature, humidity and ventilation. Physical properties: Built or natural elements that create and are contained within space such as the structure and enclosure (floors, walls, roof, windows), environmental control systems (heating and cooling, plumbing, electric, security), furnishings, fixtures, equipment, materials, and finishes. This paper included single and aggregated measures of quality (housing, environmental, and physical) and condition in this category. Spatial properties: Quantifiable spatial characteristics within and between physical spaces such as size, shape, proportion, volume, spatial and social densities, adjacency, proximity, layout, and arrangement. |
Place Attribute | Definition | Reference |
---|---|---|
Safety and security | A state in which hazards and environmental conditions leading to physical, psychological, and material harm are controlled in order to preserve individual and group well-being. Security is the process and equipment that protects safety and well-being. Alternate definitions of security referring to maintaining consistent possession of personal items and housing were not coded as place attributes. | [109] |
Control | The extent to which an environment facilitates personalization and territorial claims to a space, as well as the ability to alter one’s physical environment or regulate exposure to surroundings. | [68,69] |
Choice | The provision of options in the physical environment, such as the ability to select a space or pathway (spatial choice), that leads to positive outcomes. | [110] |
Privacy | The process of regulating the flow of visual and auditory information to and from others. When regulatory processes (e.g., territoriality, personal space) fail, social isolation and withdrawal can occur. Social isolation is the absence of positive social relationships resulting from restriction of contact with most or all other people (and/or activity, services, programs, stimulation) and is imposed by others. Social withdrawal is the restriction of contact with most or all other people (and/or activity, services, programs, stimulation) and is self-imposed due to, for example, over-stimulation or fear of harm (e.g., violence, substance abuse influences). | [68,94,95,111] |
Territoriality | A boundary-regulation mechanism used to achieve desired levels of privacy that involves personalization or marking of a place or object and communicating that the place or object is “owned” by a person or group. | [94] |
Sociality | The degree to which an environment facilitates or inhibits social interaction among people. | [68] |
Sense of community | The feelings of belonging or affiliation to a group, that individual members matter to each other and the group, and that members’ needs will be met via commitment to that group. | [112,113] |
Sense of “home” | A place for refuge, protection, security, safety, and centering described by comfort, privacy, familiarity, multiple layers of meaning, and a sense of self-expression, identity, responsibility, ownership, and being “at one” within the setting; the absence of mistreatment, alienation, and discomfort. | [70,85] |
Comfort | The extent to which an environment provides both sensory and mobility fit and facilitates task performance. | [68] |
Legibility | The ease with which people can conceptualize key spatial relationships within an environment. | [68] |
Wayfinding | How people orient themselves and navigate to destinations in spaces within rooms, buildings, and cities. | [68] |
Accessibility | The ease in locomotion through and use of an environment or space by users of varying abilities; addressed by ADA, universal, inclusive, and barrier-free design. | [68] |
Adaptability | The ease with which an environment or space and its components can be reorganized to accommodate different patterns of use. | [68] |
Sensory stimulation | The quality and quantity of information in a setting or object that impinges upon human users as experienced by the various senses. | [68,69] |
Restoration | An environment’s ability to provide relief and recovery from mental fatigue often resulting from overstimulation and stress. | [102] |
Crowding | The psychological response to high density based on perceptions of spatial restriction due to too little space (spatial density) or too many people present in a space (social density). | [114] |
Meaning | The extent to which an environment holds individual or collective significance for people (e.g., attachment, challenge, beauty). | [68] |
Appendix B
Citation | Housing Quality Measure (Data Collection Methods) | Subscales (# items) | Measure Reference | Outcomes Related to Mental Health |
---|---|---|---|---|
Adair et al., 2016 [38] | Observer-Rated Housing Quality Scale (Observations, interview questions, publicly available data) Perceived Housing Quality Scale (Participant-rated Likert scales) | Dwelling unit (18) Building (7) Neighborhood (9) Comfort, Safety, Privacy, Spaciousness, Overall Quality, Proximity (24) | Adair, 2014 [115] Tsemberis et al., 2003 [116] Toro et al., 1997 [117] | Housing stability |
Brown et al., 2015 [72] | Housing Environment Survey (Participant-rated Likert scales and 5 semi-open-ended questions) | Physical quality (11) Neigh. quality (9) Neigh. social climate (10) Neigh. safety (8) Neighbor relationships (7) Landlord relationship (6) Roommate relationship (6) * | Kloos and Shah, 2009 [118] | Housing satisfaction |
Nelson et al., 2007 [74] | Housing Quality Assessment ** (Participants rated 4-point scales for their previous residence and residences at baseline and follow-up) | Comfort, Safety, Privacy, Spaciousness, Overall Quality (5) | Toro, 1997 [117] | Self-reported quality of life, adaptation to community living |
Tsai 2010 [75] | Housing Environment Survey-Physical Quality Scale (Participant-rated Likert scale) | Physical Quality (14) | Wright and Kloos, 2007 [119] | Housing satisfaction, residential satisfaction, social support |
SAMSHA Housing Satisfaction Scale (Participant-rated Likert scales) | Choice, Safety, Privacy, Proximity (19) | Tsemberis et al., 2003 [116] | ||
Tsai 2012 [76] | SAMSHA Housing Satisfaction Scale (Participant-rated Likert scales) | Choice, Safety, Privacy, Proximity (19) | Tsemberis et al., 2003 [116] | Housing satisfaction, self-reported quality of life, mental health, social support, psychological distress |
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Search Concepts | Search Terms 1 |
---|---|
Supportive(ed) Housing 2 | Housing, residential |
Mental Health | Mental health, mental illness/es, mental disorder/s, mental well-being, psychological illness/es, behavioral health, psychiatric disabilities, loneliness, trauma, psychological health |
Architecture/Design | Built environment, interior design, architecture, physical environment, environmental design, environment design, design attributes, design features, architectural, spatial characteristics, design characteristics, safety, security, surveillance, wayfinding, territoriality, crowding, privacy, housing quality, environment quality, environmental quality |
Excluded | Children, older adults, later life, elderly, aged, disabled, older people, care facilities, board home, care home, nursing home, nursing homes, city, cities, urban, eating disorder, eating disorders, mental retardation, prison, prisons, jail, jails, HIV, AIDS, refugee, refugees, asylum, youth, adolescent, adolescents, workplace, workplaces, COVID-19 |
a. Built Environment Relevance | b. Methodological Rigor Ratings [60] |
---|---|
Design driven (DD): Studies contained independent and/or dependent variables addressing built environment factors associated with design (e.g., size, location, adjacency); study aims included evaluating and/or informing architectural design. Built environment focused (BE): Studies included BE independent and/or dependent variables (e.g., housing quality), without aims to evaluate or inform architectural design. Inductive (IN): Qualitative studies that indirectly addressed built environment factors in research questions (e.g., aspects of “home”) and yielded findings or responses relevant to design. Mentions (ME): Qualitative studies that did not include the built environment in the research design, but findings (i.e., participant responses) frequently “mentioned” built environment factors consistent with studies in the other three relevance categories. | Quantitative: Rigor was rated on a three-point scale (high, medium, or low) based on research design (e.g., longitudinal or cross-sectional, control or comparison group), sampling technique (random,, purposeful, or convenience) and size, data collection methods and measures (e.g., single or multiple, self-reported and/or objective, tested or newly created) including reported psychometrics (e.g., reliability and validity), and analysis methods (advanced statistical analysis vs. descriptive statistics) and reported measures of effect size with results. Qualitative: Rigor was rated on a three-point scale (high, medium, or low) based on the research design (cross-sectional, repeated measures, or longitudinal), sampling technique (purposeful or convenience), data collection methods and measures (e.g., cited instrument, accuracy check), and coding and analysis techniques (e.g., iterative, multiple coders, cited method, end-stage validation). Mixed Methods: After rating the quantitative and qualitative components of mixed-methods studies according to the rigor definitions, an overall rigor rating was discussed by researchers based on whether the study was primarily quantitative or qualitative. Review: Rigor was assessed based on reported search processes and analyses procedures (neither were reported in the single review). |
Citation Location | Purpose 1 | Research Design 2 STUDY TYPE (Research Design)
| Rigor | Housing 3
| Scale 4 Dwelling, Room, Building, Location | |||
---|---|---|---|---|---|---|---|---|
D | R | B | L | |||||
Relevance: Design Driven (2) | ||||||||
McLane et al., 2020 [27] U.S. (Tallahassee); UK (Southampton) | Recorded and explored socio-spatial and design factors, policies and programming, and resident perceptions of shared community gathering space location, design, and use in two PSH facilities with the aim of presenting new analysis methods and improving future shared spaces. | MIXED (Dual case study; CS)
| Medium QUAN-Low QUAL-Med |
| • | • | ||
Wittman et al., 2017 [71] U.S. (review article) | Provided an overview of Housing First (HF) and Sober Living Housing (SLH) models and recommendations for practice based on an approach to architectural planning that emphasized the interaction between settings and operations on resident experiences. | REVIEW (not specified)
| Low |
| • | • | • | • |
Relevance: BE Focus (8) | ||||||||
Adair et al., 2016 [38] Canada (Moncton, Montreal, Toronto, Winnipeg, Vancouver) | Assessed housing quality in Housing First (HF) and Treatment as Usual (TAU) facilities, examined differences between participants in each group, and studied associations between housing quality and housing stability. | QUANTITATIVE (Quasi-Experimental, Longitudinal—2 yrs)
| High |
| • | • | • | |
Brown et al., 2015 [72] U.S. (Seattle) | Explored perceptions of housing and neighborhood environments and associations with satisfaction (high/low desire to stay) among single-site Housing First residents via the Housing Environment Survey. | MIXED (2-group comparison, CS)
| Low QUAN-Med QUAL-Low |
| • | • | • | |
Hsu et al., 2016 [73] U.S. (Los Angeles) | Examined perceptions of safety and security among residents living in and surrounding the Skid Row area of Los Angeles and how those perceptions correlated with objective measures of neighborhood environment. | MIXED (Explanatory sequential; CS)
| Low QUAN-Low QUAL-Med |
| • | • | • | |
Huffman, 2018 [26] U.S. (Los Angeles) | Investigated the connection between PSH social spaces, participation, and community based on resident experiences in a housing organization on Skid Row in Los Angeles, California. | QUALITATIVE (Case study, CS)
| High |
| • | |||
Knight et al., 2014 [36] U.S. (San Francisco) | Explored how SROs can operate as “mental health risk environments” in which macro-structural factors (housing policies shaping the built environment) interact with meso-level factors (social relations within SROs) and micro-level, behavioral coping strategies to affect women’s mental health. | QUALITATIVE (Longitudinal, Ethnography—4 yrs) #
| High |
| • | • | ||
Nelson et al., 2007 [74] Canada (Toronto, Hamilton, Ottawa) | Examined whether consumer choice and control over housing, support, and housing quality contributed to self-reported quality of life and adaptation to community living among people with mental illness, and whether individual apartments provided more choice and control than group living arrangements. | QUANTITATIVE (Repeated measures, CS) *
| Med |
| • | • | ||
Tsai et al., 2010 [75] U.S. (Chicago) | Examined whether housing preferences differed between substance abuse treatment stages, whether dual-diagnoses consumers who prefer certain housing types preferred certain characteristics, and whether consumers residing in different housing types reported differences in choice, social support, and housing satisfaction. | QUANTITATIVE (Group comparison, CS)
| Med |
| • | • | • | |
Tsai et al., 2012 [76] U.S. (11 sites, locations not specified) | Identified primary domains of housing satisfaction (HS), tracked HS over time, and assessed relations between HS and subjective and functional outcomes. | QUANTITATIVE (Longitudinal: quarterly for 2 yrs)
| High |
| • | • | ||
Relevance: Inductive (6) | ||||||||
Anucha, 2005 [77] Canada (Toronto) | Explored the needs of the formerly homeless, from their perspective, and how housing, neighborhood, and community can meet their needs more effectively to avoid a return to homelessness. | QUALITATIVE (Exploratory, CS)
| Low |
| • | • | • | |
Burns et al., 2020 [78] Canada (Montreal) | Explored everyday experiences of formerly homeless older men residing in single-site PSH based on the concepts of home and social exclusion. | QUALITATIVE (Const. grounded theory, CS)
| High |
| • | • | ||
Chan, 2020 [79] U.S. (Boston, Cambridge) | Explored what makes supportive housing feel like “home” for individuals who were once homeless related to constructing new, non-homeless identities, social isolation, and community integration. | QUALITATIVE (Repeated measures, CS)
| Med |
| • | • | • | |
Henwood et al., 2018a [80] U.S. (Los Angeles) | Considered how contextual factors generate or reduce risk for substance use among adults who recently moved into PSH. | QUALITATIVE (Case summary matrix, CS)
| Med |
| • | • | ||
Henwood et al., 2018b [81] U.S. (Los Angeles) | Used ontological security (well-being rooted in a sense of constancy in the social and material environment) as a sensitizing framework to examine the perspectives and experiences of young adult PSH residents. | QUALITATIVE (Grounded theory, CS)
| Med |
| • | |||
Padgett, 2007 [82] U.S. (New York City) | Explored how study participants who obtained independent housing experience, enact and describe having a “home” and to what extent their experiences reflect markers of ontological security. | QUALITATIVE (Grounded theory, CS)
| High |
| • | • | • | |
Relevance: Mentions (1) | ||||||||
Adame et al., 2020 [83] U.S. (Seattle) | Interviewed residents of a Housing First organization about their experiences of community and gathered suggestions for improving community building efforts. | QUALITATIVE (Exploratory, CS)
| Med |
| • | • | ||
Table Notes and Abbreviations * = Psychometrics were reported for the quantitative measure(s) used to collect independent and/or dependent variables. # = Qualitative methods included procedures that addressed rigor in data collection, coding, and/or analysis. 1 = “Purpose” column: HF = Housing First; HQ = housing quality; PSH = permanent supportive housing; TF = Treatment First; SLH = Sober Living Housing; TAU = Treatment as Usual | 2 = “Research Design” column: MIXED= mixed methods; CS= cross-sectional 3 = “Housing” column: Type/Program: PSH= permanent supportive housing; HF = Housing First; TF = Treatment First; TAU = Treatment as Usual; SL = Sober Living Site approach: SS = single site; Scat = scattered site; Priv Mkt = private market Dwelling type: SRO = single-room occupancy; Cong = congregate housing; Apt = apartment; Ind = independent; Shrd = shared 4 = “Spatial Scale” column: D = dwelling unit; R = room (shared common area); B = building; L = location |
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Rollings, K.A.; Bollo, C.S. Permanent Supportive Housing Design Characteristics Associated with the Mental Health of Formerly Homeless Adults in the U.S. and Canada: An Integrative Review. Int. J. Environ. Res. Public Health 2021, 18, 9588. https://doi.org/10.3390/ijerph18189588
Rollings KA, Bollo CS. Permanent Supportive Housing Design Characteristics Associated with the Mental Health of Formerly Homeless Adults in the U.S. and Canada: An Integrative Review. International Journal of Environmental Research and Public Health. 2021; 18(18):9588. https://doi.org/10.3390/ijerph18189588
Chicago/Turabian StyleRollings, Kimberly A., and Christina S. Bollo. 2021. "Permanent Supportive Housing Design Characteristics Associated with the Mental Health of Formerly Homeless Adults in the U.S. and Canada: An Integrative Review" International Journal of Environmental Research and Public Health 18, no. 18: 9588. https://doi.org/10.3390/ijerph18189588