Background Access to housing is an important determinant of health, with homeless people having substantially increased morbidity and mortality compared to the housed population. Conventional ‘Treatment First’ (TF) models for tackling homelessness provide temporary accommodation conditional on adherence to services to address health needs, particularly substance use. A new policy approach aiming to end homelessness across Europe and North America, the ‘Housing First’ (HF) model, provides rapid housing, not conditional on abstinence from substance use. This has been noted by other reviewers as improving housing stability, but at the potential cost of removing incentives to use health services and abstain from harmful substances. Conversely, increased housing stability may lead to health improvements. We aimed to systematically review the evidence from randomised controlled trials to evaluate the effects of HF on health and well-being.
Method We searched seven databases for randomised controlled trials of interventions providing rapid access to non-abstinence-contingent, permanent housing. We extracted data for the following primary outcomes: mental health; self-reported health and quality of life; substance use; non-routine use of healthcare services. Data recording housing stability was extracted as a secondary outcome. We assessed risk of bias and calculated standardised effect sizes.
Results We included four studies, all with ‘high’ risk of bias. The impact of HF on most short-term health outcomes was imprecisely estimated, with varying effect directions. No clear difference in substance use was seen. Intervention groups experienced fewer emergency department visits (incidence rate ratio (IRR)=0.63; 95% CI 0.48 to 0.82), fewer hospitalisations (IRR=0.76; 95% CI 0.70 to 0.83) and less time spent hospitalised (standardised mean difference (SMD)=−0.14; 95% CI −0.41 to 0.14) than control groups. In all studies intervention participants spent more days housed (SMD=1.24; 95% CI 0.86 to 1.62) and were more likely to be housed at 18–24 months (risk ratio=2.46; 95% CI 1.58 to 3.84).
Conclusion HF approaches successfully improve housing stability and may improve some aspects of health. Implementation of HF would likely reduce homelessness and non-routine health service use without an increase in problematic substance use. Impacts on long-term health outcomes require further investigation.
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