The extent to which non-conditional

housing programs improve housing and

well-being outcomes: a systematic review
Renee O’Donnell, Kostas Hatzikiriakidis, Melissa Savaglio, Dave Vicary, Jennifer Fleming
and Helen Skouteris

Renee O’Donnell, Abstract

Kostas Hatzikiriakidis, and Purpose – To reduce rates of homelessness, recent efforts have been directed toward developing non-
Melissa Savaglio are all conditional supported housing programs that prioritize the delivery of housing support and individual
based at the Health and services, without tenancy conditions (i.e. maintaining sobriety and adhering to mental health treatment).
Social Care Unit, School of As promising as these programs are, findings generally show that while housing stability is improved,
other individual outcomes remain largely unchanged. No review to date has synthesized the collective
Public Health and
evidence base of non-conditional housing programs, rather the focus has been on specific programs of
Preventive Medicine,
delivery (e.g. Housing First) or on specific population groups (e.g. those with mental illness). The purpose
Monash University, of this paper is to evaluate the extent to which non-conditional housing interventions improve housing and
Melbourne, Australia. well-being outcomes for all persons.
Dave Vicary and
Design/methodology/approach – A systematic search of the literature was conducted for randomized
Jennifer Fleming are both controlled studies that evaluated the effectiveness of a non-conditional housing intervention in improving
based at Baptcare, housing and health outcomes among any participant group.
Melbourne, Australia.
Findings – A total of 31 studies were included in this review. Non-conditional supported housing
Helen Skouteris is based at programs were found to be most effective in improving housing stability as compared to health and well-
the Health and Social Care being outcomes. Policymakers should consider this when developing non-conditional supported housing
Unit, School of Public programs and ensure that housing and other health-related outcomes are also mutually supported.
Health and Preventive Originality/value – This is the first review, to the authors’ knowledge, to synthesize the collective impact
Medicine, Monash of all non-conditional supported housing programs. The current findings may inform the (re)design and
University, Melbourne, implementation of supported housing models to prioritize the health and well-being of residents.
Australia and Warwick
Keywords Well-being, Health and social care, Systematic review, Homelessness,
Business School, University Housing, Non-conditional housing
of Warwick, Coventry, UK.
Paper type Literature review

Received 17 September 2021
Revised 21 October 2021
Accepted 9 November 2021
The authors have no conflicts of
interest to declare.
This work was supported and
funded by Baptcare.
Introduction
Homelessness (i.e. living in places that are not designed for human habituation or in
housing that is inadequate, below minimum community standards or lacks secure tenure) is
a persistent health and social care issue, worldwide (Homeless World Cup Foundation,
2019). It is estimated that more than 150 million of the world’s population are homeless (The
Millennium Alliance for Humanity, 2019). Access to stable and adequate housing is an
important determinant of health, and one of the basic human rights (United Nations, 1948).
Compared to those who are housed, people who are homeless (i.e. both individuals and
families) are one of society’s most vulnerable population groups, with significantly worse
outcomes across a myriad of health domains, including as follows: poorer physical health,
increased mental health concerns, impaired social functioning, substance dependence,
higher morbidity, greater use of acute hospital services and reduced life expectancy

PAGE 46 j HOUSING, CARE AND SUPPORT j VOL. 25 NO. 1 2022, pp. 46-60, © Emerald Publishing Limited, ISSN 1460-8790 DOI 10.1108/HCS-09-2021-0025
(Aldridge et al., 2018; Fazel et al., 2014; Perry and Craig, 2015). Given the wide-ranging
ramifications of homelessness, significant efforts have been directed toward intervening
upon homelessness and improving health outcomes.
Efforts to address homelessness have historically adopted a graduated approach (i.e. also
termed conditional housing approach) wherein clients must first display “housing
readiness” by remaining abstinent from alcohol and other drugs, eliminating disruptive
behaviors (e.g. violence or other antisocial behaviors) and/or engaging in mental health
treatment or vocational training before they can access housing (Sahlin, 2005; Tsemberis
et al., 2004). Once housed, residency is dependent on adhering to pre-specified
conditions, such as continued sobriety, psychiatric stability and compliance with mental
health treatment (Kertesz et al., 2009). However, this type of housing approach has been
criticized for not adequately supporting individuals or families who are unable or unwilling to
meet program conditions (Clarke et al., 2019a). For instance, those with complex
psychosocial needs who are not ready to abstain from substances, seek treatment for
mental health issues and/or engage with other support services, tend to be excluded from
such programs, yet these are some of the most vulnerable members of the homeless
community (Clarke et al., 2019b; Tsemberis, 2010). Moreover, research has shown that for
those who can engage in such programs, attrition is often high due to clients being unable
to adhere to the conditions of residency over the long-term. For example, Padgett et al.
(2010) found that 65% of individuals receiving conditional housing support engaged in
substance use during the study period, and thus were exited from the program. Indeed, the
bi-directional relationship between an individual’s health status and housing status is often
not adequately supported by such housing models (Clarke et al., 2019a, 2019b).
In recognizing the limitations of conditional models of housing support, recent efforts have
been directed toward developing and implementing programs that incorporate non-
conditional housing support, such as Housing First (Aubry et al., 2020; Baxter et al., 2019;
Woodhall-Melnik and Dunn, 2015). These programs are distinct from traditional approaches
as they do not impose conditions upon the clients to obtain and retain housing (Clarke et al.,
2019a). Indeed, non-conditional supported housing models are underpinned by the belief
that support needs (i.e. for mental health, substance use) cannot begin to be properly
addressed without the basis of stable, long-term housing (Baxter et al., 2019; Kirst et al.,
2015). For example, the Housing First model offers clients priority access to immediate
accommodation coupled with individualized support. Accommodation typically includes
either: scattered-site independent housing where individuals are provided with their own
private rental unit; or, alternatively, accommodation within congregate facilities such as
apartment buildings where all units are reserved for supported housing clients (Somers
et al., 2017). Following the immediate provision of stable accommodation, individualized
support, such as case management and access to various treatment services, are offered
to address clients’ complex needs (e.g. mental health, substance use, physical health
concerns, vocational needs). Other types of non-conditional housing models include the
provision of rent allowance or housing subsidies without any pre-specified conditions
(Smelson et al., 2018). There are also an increasing number of non-conditional wrap-around
support programs provided to existing tenants of a non-conditional supported housing
arrangement that do not require pre-requisites for engagement, such as case management,
lifestyle interventions, psychosocial assistance or outreach support (Gubits et al., 2018).
The differentiation here is that the specific provision of accommodation is not part of the
intervention; rather, general support is provided once tenants are non-conditionally housed
to ensure ongoing housing stability.
In comparison to conditional housing programs, research suggests that these non-
conditional programs appear to more effectively improve housing access, stability and
program retention (Aubry et al., 2015; Groton, 2013; Stefancic and Tsemberis, 2007).
However, the extent to which they are effective in addressing clients’ individual needs and
improving health and well-being outcomes remains unclear. An illustrative example is

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 evident in a recent meta-analysis of the Housing First program conducted by Baxter et al.
(2019). Across the four studies reviewed, there were no significant improvements in mental
health, quality of life or substance use for those who had received Housing First as
compared to those who did not. Similarly, an earlier review of Housing First by Woodhall-
Melnik and Dunn (2015) yielded positive housing outcomes, but the impacts on health-
related outcomes, such as psychiatric symptoms, substance use and quality of life, were
inconclusive. These findings are concerning given the well-established bidirectional
relationship between health and housing status; poor health status can perpetuate
homelessness, and housing instability can be a predictor for unfavorable health outcomes
(Aldridge et al., 2018; Gadermann et al., 2014). Without addressing clients’ health needs (i.
e. mental, physical, social, financial, vocational and emotional health), housing stability is
threatened, increasing the likelihood of resumed or sustained homelessness (Tsai et al.,
2012).

Current study
The prior literature has predominantly focused on synthesizing the evidence of only Housing
First non-conditional models of support (Baxter et al., 2019; Woodhall-Melnik and Dunn,
2015; Tsai, 2020; Yinan et al., 2020). However, the authors note that some key international
studies evaluating the effectiveness of Housing First, as well as those underpinned by the
Housing First principles, were not included under the scope of these previous reviews
(Baxter et al., 2019; Yinan et al., 2020). Therefore, the current evidence-base is fragmented.
Further, given that the evidence base of non-conditional housing support services extends
beyond Housing First (i.e. rent subsidies, wrap-around programs to retain non-conditional
housing stability), broadening the scope of synthesis is required. In fact, to the authors’
knowledge, no systematic review has been conducted to examine the collective evidence
base of all types of non-conditional models of housing support for all types of population
groups, encompassing single adults, families and people of various diagnoses (i.e. mental
illness, disability, substance abuse concerns, etc.). Particularly, their effect in improving
health and well-being remains unclear and requires synthesis. To provide a comprehensive
contribution to the existing literature, the aim of the current review was to evaluate the extent
to which non-conditional housing interventions improve health and well-being outcomes.

Method
Design
A systematic review was performed following the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses statement guidelines (Page et al., 2020).

Search strategy
Papers were identified by searching electronic databases, namely, PsycINFO, CINAHL and
Ovid MEDLINE. The following combination of keywords were searched in the title or
abstract of the articles: “housing support” and “evaluation.” The terms used were
purposefully broad so as to be consistent with prior reviews published in this area (Baxter
et al., 2019; Woodhall-Melnik and Dunn, 2015). However, unlike these previous reviews, the
search was inclusive of all non-conditional supported housing programs and not restricted
to Housing First programs. The complete search syntax is presented in the online
Appendix.

Inclusion and exclusion criteria

Study inclusion criteria: randomized controlled trials (RCT) published in English from
January 2001 to May 2021 inclusive; study participants included any population group (i.e.

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adults, families, no limit to diagnosis) who resided in any type of non-conditional supported
housing (e.g. scattered site, lead tenancy, congregate housing); and effectiveness of the
non-conditional supported housing intervention upon individual health and well-being
outcomes was assessed (e.g. physical, mental or social health, such as housing stability,
substance use and community functioning). Study designs were restricted to RCTs to
obtain a synthesis of the most rigorous and robust available research so that strong
inferences could be made (Charrois, 2015). Studies from the past 20 years were sourced to
provide an overview of the most contemporaneous evidence to inform current practice.
Studies, where the intervention was delivered in aged care or residential care, were
excluded, as the housing processes involved in these settings are fundamentally different to
supported housing (Baxter et al., 2019; Sjögren et al., 2017). Studies, where the intervention
was not delivered directly to the tenants themselves (i.e. support staff training), were also
not included.

Study selection and data extraction

Two researchers independently screened and excluded studies based on title and
abstract. For articles that were included, the full-text versions were sourced and assessed
using the inclusion criteria by the same two researchers. The interrater agreement was 0.94.
Disagreements were resolved by a third researcher. Researchers extracted data from
included studies, such as study characteristics, participant characteristics, intervention
description, outcome measures and key findings.

Synthesis
Given the heterogeneity across the studies (i.e. differences in the measures used,
outcomes assessed, type of non-conditional support and intervention delivery period),
meta-analysis was not possible. Therefore, a narrative synthesis was conducted, with the
tabulated findings described qualitatively. Descriptions of study characteristics, including
study design, participant details, program characteristics, and key findings have been
provided in the online Appendix.

Quality assessment
Quality of evidence was assessed independently by two reviewers using the National
Institute of Health (NIH) Quality Assessment Tool for Controlled Studies (14 items), with 30%
cross-checked (in the online Appendix). To meet the assessment criteria, each item was
scored as “yes” if it was described explicitly and present, “no” if the item was absent or
unclearly or inadequately described or “not reported” (NR).

Results
Search yield
As shown in Figure 1, the combined search identified a total of 6,803 potentially relevant
papers. After the removal of 1,229 duplicates, 5,574 papers were screened at the title and
abstract level, of these, 5,423 papers were excluded as they did not meet the inclusion
criteria. In keeping with the methodology proposed by Polanin et al. (2019), the abstract
and title search was conducted independently on all papers by two researchers with a
random 20% of these cross-checked. Any disagreements were discussed by the
researchers. This resulted in 151 potentially relevant papers that were read in their entirety
by the two researchers. During this process, a further 120 papers were excluded. No
additional relevant studies were identified from the reference lists of these included studies.
Therefore, a total of 31 studies were included in this review.

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 Figure 1 Flowchart illustrating the study selection process

Quality of evidence
The quality assessment of the 31 RCT studies is presented in the online Appendix. In
total, 13 studies (42%) did not adequately describe their method of randomization
used, which increases the risk of selection bias. Nonetheless, groups were similar at
baseline in all studies except one, suggesting that randomization was adequate. Only
one study (3%) blinded participants and intervention providers to treatment allocation
while nine studies (29%) blinded outcome assessors. The lack of blinding across
studies suggests that there is a high risk of bias that could occur as a result of
participants’ expectations, such as influencing self-report outcomes, as well as
observer bias from outcome assessors. In total, 21 studies (67%) reported an attrition
rate lower than 20%, and 21 studies (67%) reported that the differential drop-out rate
between the intervention and control group was less than 15%. As such, the overall risk
of attrition having biased the estimated treatment effects was low. Only 10 studies
(32%) reported high adherence to the intervention protocol for treatment groups.
Furthermore, only seven studies (23%) reported having a sample size that was large
enough to detect a significant difference between groups; hence, the majority of
studies lacked sufficient power. Finally, all studies pre-specified outcomes, which were
assessed using valid and reliable measures, and participants were analyzed in the
groups that they were assigned. Therefore overall, the studies included in this review
are of fair quality, as there is some moderate risk of bias.

Study design and sample

A summary of each study’s design, participants and intervention is presented in the online
Appendix. The majority of studies were conducted in the USA (n = 16) while the remaining
studies were conducted in Canada (n = 11), Sweden (n = 3) and France (n = 1). Most
studies used a parallel-groups RCT design (22/31) while the remaining studies used a
clustered RCT design (9/31). Two of the studies examined the impact of non-conditional

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supported housing for families with at least one child 15 years of age or under (Gewirtz
et al., 2015; Gubits et al., 2018). The remaining studies examined single adults. Participants
in 25 studies were diagnosed with either a severe mental illness, substance misuse or both.
The mean total sample size was 499 (SD = 639), ranging from 41 to 2,282. The mean age of
participants was 44.61 years (SD = 13.63) and 66% of participants were male.

Types of supported housing interventions

Across the 31 studies, two broad types of programs were identified: non-conditional
supported housing programs that aimed to provide homeless individuals with stable
accommodation alongside access to support, such as intensive case management (ICM)
and assertive community treatment (ACT) (n = 21); and interventions that were delivered to
individuals who were already residing in non-conditional supported housing to ensure
ongoing stability (n = 10).
The majority of the studies (21/31) included in this review evaluated non-conditional
supported housing programs. In total, 18 of these 21 studies evaluated programs that were
based on the Housing First model. These programs provided housing support (e.g.
immediate access to housing – most commonly scattered-site housing) that was affordable,
with no requirements regarding treatment compliance or substance abstinence. These
programs also included the provision of ACT or ICM, depending on the needs of each
person. ACT was most often delivered to high-need participants, which involved intensive,
recovery-oriented support from a multidisciplinary team of clinicians (i.e. social worker,
psychiatrist, nurse, doctor and peer worker). ICM was delivered to moderate-need
participants by individual case managers to connect participants to various community
resources. Two of the remaining studies examined the Housing and Urban Development-
Veterans Affairs Supported Housing (HUD-VASH) program, which provided housing
subsidies and case management specifically to veterans who were homeless (O’Connell
et al., 2008, 2017). The final study assessed the impact of priority access to long-term rent
subsidies as a form of non-conditional housing for homeless families (Gubits et al., 2018).
In contrast, the 10 remaining studies delivered interventions to people who were already
residing in some type of non-conditional supported housing arrangement. Participants were
made aware that these wrap-around support programs were voluntary, with no conditions
for tenants to participate (i.e. sobriety) and that their decision to not partake would not
impact their housing arrangement (i.e. would not result in eviction). Two of these studies
examined the delivery of a healthy living intervention which consisted of educational classes
regarding the importance of healthy eating and maintaining a balanced diet (Forsberg
et al., 2010a, 2010b). Two studies delivered Tai Chi classes to older adults (Manor et al.,
2014; Lipsitz et al., 2019) while Gyllensten and Forsberg (2016) delivered interactive
computer games focused on body movements to residents. Two studies evaluated
psychological interventions, including motivational interviewing to reduce substance use
(Kennedy et al., 2018) and cognitive training (Medalia et al., 2017), which included
computerized, therapist-led activities to improve cognitive skills. Smelson et al. (2018)
evaluated the MISSION-Vet program which provided case management, peer support,
vocational and educational support to veterans. Gewirtz et al. (2015) examined the Early
Risers program, which delivered an educational curriculum and activities to families in
supported housing. Finally, Illness Management and Recovery was delivered to help adults
effectively manage their mental illness through a recovery-oriented and goal-focused
approach to self-management skills training (Levitt et al., 2009).

Characteristics of control groups

In total, 20 out of the 31 studies included treatment as usual (TAU) as the control group,
where participants only had access to the usual case management, support and housing
services that were already available in their community. The control groups in the remaining

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 11 studies received some additional support that was either at a lesser intensity or varied in
content in comparison to the intervention group. Examples of these control groups included
a health education program (compared to Tai Chi program; Manor et al., 2014; Lipsitz et al.,
2019), weekly classes teaching artistic techniques (compared to a healthy living
intervention; Forsberg et al., 2010a, 2010b), TV games controlled using a remote
(compared to body movements;Gyllensten and Forsberg, 2016), a general computer skills
educational program (compared to targeted cognitive training; Medalia et al., 2017),
waitlist-control to illness management and recovery (Levitt et al., 2009) and conditional
housing support (as opposed to non-conditional support; Tsemberis et al., 2004; Gulcur
et al., 2003; McHugo et al., 2004; Tinland et al., 2020).

Summary of findings
The following outcomes were evaluated in the 31 studies: Housing Stability (i.e. percentage
of the time housed; n = 13), Substance Use Severity (n = 13), Mental Health (n = 13),
Quality of Life (n = 10), Physical Health (n = 9), Community Functioning (n = 6), Service
Utilization (n = 9) and other Psychosocial Functioning outcomes (n = 6). Some studies
assessed more than one outcome. The majority of studies predominantly relied on self-
report measures for all outcomes. However, three studies also accessed administrative
records to report hospitalizations (Sadowski et al., 2009), emergency department visits
(Raven et al., 2020), and justice involvement (Luong et al., 2021). A summary of the
outcomes upon the final follow-up assessment for each study is presented in the online
Appendix.
Housing stability. In total, 13 out of the 31 studies evaluated the extent to which the non-
conditional housing program improved housing stability, which was defined in all studies as
the percentage of the time housed, most often measured using the Residential Timeline
Follow Back Inventory (Aubry et al., 2016, 2015; Chung et al., 2017; Gubits et al., 2018;
Gulcur et al., 2003;Kerman et al., 2020; McHugo et al., 2004; O’Connell et al., 2008;Raven
et al., 2020; Stefancic and Tsemberis, 2007; Stergiopoulos et al., 2015; Tinland et al., 2020;
Tsemberis et al., 2004). In total, 11 of these 13 studies found that the housing stability of
participants in the intervention group at follow-up was greater in comparison to the control
group (Aubry et al., 2016, 2015; Gubits et al., 2018;Gulcur et al., 2003;Kerman et al., 2020;
O’Connell et al., 2008;Raven et al., 2020; Stefancic and Tsemberis, 2007; Stergiopoulos
et al., 2015; Tinland et al., 2020; Tsemberis et al., 2004). Specifically, adults who received
the Housing First model of support (i.e. immediate access to housing alongside case
management support) were adequately housed for a significantly longer period of time in
the prior three to six months, compared to those who did not receive such support (Tinland
et al., 2020).
Substance use. In total, 13 studies examined substance use severity, which was most
commonly measured using either the Global Appraisal of Individual Needs – Short Screener
Substance Problem Scale (n = 5) or the Addiction Severity Index (n = 4). Five of these 13
studies examined general substance use severity (Aubry et al., 2016; Chung et al., 2017;
Gubits et al., 2018;Kerman et al., 2020; Stergiopoulos et al., 2015) while the other eight
studies examined alcohol and other drug use severity separately (Kennedy et al., 2018;
Kirst et al., 2015; Levitt et al., 2009; McHugo et al., 2004; O’Connell et al., 2008; Smelson
et al., 2018; Tsemberis et al., 2004; Tinland et al., 2020). None of the five studies that
examined overall substance use found any significant differences between the intervention
and control group at follow-up. Three of eight studies reported that alcohol use severity was
significantly lower for those in the supported housing program as compared to the control
group (Kennedy et al., 2018; Kirst et al., 2015; O’Connell et al., 2008) while only one of these
eight studies reported that drug use severity was significantly lower for veterans in the HUD-
VASH program as compared to the control group (O’Connell et al., 2008).

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Mental health. In total, 13 of the 31 studies evaluated mental health outcomes, including
self-reported mental health status and psychiatric symptom severity. Mental health was
most often measured using the 12-item Short-Form Health Survey – Mental Health
Component. Only 6 of the 13 studies observed significant improvements in general mental
health symptom severity among participants who engaged in the non-conditional housing
support program compared to the control group at follow-up (Aubry et al., 2016; Chung
et al., 2017; Gubits et al., 2018; Levitt et al., 2009; Medalia et al., 2017; Tinland et al., 2020).
Particularly, supported housing accompanied by therapeutic support that specifically
focused on effectively managing their mental health (e.g. cognitive training or illness
management and recovery) yielded significant improvements among adults’ psychiatric
symptoms (Levitt et al., 2009; Medalia et al., 2017).
Quality of life. Ten of the 31 studies examined participants’ overall quality of life, which was
predominantly measured by the Quality of Life Inventory or Lehman’s Quality of Life
Interview (Aubry et al., 2016, 2015; Chung et al., 2017; Forsberg et al., 2010b;Gyllensten
and Forsberg, 2016; Levitt et al., 2009; McHugo et al., 2004; O’Connell et al., 2008;
Stergiopoulos et al., 2015; Tinland et al., 2020). Only two studies found significant
improvements in overall quality of life among participants who received supported housing
alongside Illness Management and Recovery (Levitt et al., 2009) and among Housing First
participants (Aubry et al., 2015) after one-year follow-up in comparison to those in the
control group.
Physical health. Nine studies evaluated participants’ physical health and functioning, which
was most often measured by the 12-item Short-Form Health Survey – Physical Health
Component (Chung et al., 2017; Forsberg et al., 2010a, 2010b; Gubits et al., 2018; Lipsitz
et al., 2019; Manor et al., 2014; Sadowski et al., 2009; Stergiopoulos et al., 2015; Tinland
et al., 2020). Only one of these nine studies found significant improvements in physical
functioning, specifically mobility, balance and walking speed, among older adults in
supported housing who received Thai Chi training in comparison to those in the control
group (Manor et al., 2014).
Community functioning. In total, 6 of the 31 studies examined outcomes related to
community functioning, which was assessed by the Multnomah Community Ability Scale
(Aubry et al., 2015, 2016; Chung et al., 2017;Kerman et al., 2020; Patterson et al., 2013;
Stergiopoulos et al., 2015). Community functioning encompassed physical community
integration (i.e. involvement in community activities) and psychological community
integration (i.e. sense of belonging within the community, including social relationships).
Only two of the six studies found a significant improvement in community functioning among
the intervention group who received support aligned with the Housing First principles in
comparison to control participants (Aubry et al., 2016;Kerman et al., 2020).
Service utilization. In total, 9 of the 31 studies assessed participants’ engagement and
utilization of health, social and justice services, including emergency department visits,
psychiatric hospitalizations, primary care or jail (Aubry et al., 2015;Gulcur et al., 2003;
Kerman et al., 2020; Luong et al., 2021;Raven et al., 2020; Sadowski et al., 2009;Smelson
et al., 2018; Stergiopoulos et al., 2015; Whisler et al., 2021). Only three of these nine studies
accessed administrative records to measure such outcomes (Luong et al., 2021;Raven
et al., 2020; Sadowski et al., 2009) while the remaining six studies relied on self-report. Non-
conditional housing support programs had no significant impact on reducing the likelihood
of incarceration (Luong et al., 2021;Raven et al., 2020), emergency department visits (Aubry
et al., 2015;Kerman et al., 2020;Raven et al., 2020;Smelson et al., 2018; Stergiopoulos et al.,
2015), psychiatric hospitalizations (Sadowski et al., 2009;Smelson et al., 2018); or
increasing primary care engagement (Whisler et al., 2021). Nonetheless, non-conditional
housing support was associated with a reduced length of psychiatric inpatient stays, with
less number of days spent in hospital at follow-up among intervention participants
compared to the control group (Gulcur et al., 2003; Sadowski et al., 2009).

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 Other psychosocial outcomes. Six included studies examined additional psychosocial
outcomes that did not fit within the categories discussed previously. First, families engaged
in the Early Risers multicomponent family support program exhibited higher parenting self-
efficacy and reduced depressive symptoms among children compared to the control
group, but there were no differences in parenting practices or externalizing behaviors
among children (Gewirtz et al., 2015). Similarly, families engaged in the Family Options
Study (i.e. received priority access to long-term rent subsidies) experienced significant
improvements in their child’s behavior and an increase in school engagement compared to
children from families who received usual care (46). Of the two studies that assessed
medication adherence (Rezansoff et al., 2016; Tinland et al., 2020), only one observed
higher compliance among Housing First residents in comparison to individuals receiving
usual care (Rezansoff et al., 2016). Further, Housing First did not significantly improve
income or odds of obtaining employment among intervention participants compared to
controls (Poremski et al., 2016). Finally, O’Connell et al. (2017) found that veterans from the
HUD-VASH program reported significant improvements across several social support
outcomes (e.g. number of close and supportive relationships, satisfaction with
relationships) as compared to the control group.

Discussion
To the authors’ knowledge, this is the first review to synthesize the collective evidence base
of non-conditional supported housing programs. Given that previous reviews have
restricted their evaluation to specific types of non-conditional housing programs or
participant group, this review is novel in that it evaluated the collective characteristics and
impact of any program that delivered non-conditional housing support on health and well-
being outcomes, using an RCT evaluation. Two types of non-conditional supported housing
programs were identified as follows: programs that delivered individualized support in
tandem with supported housing; and programs that delivered support to individuals already
residing in some type of supported housing arrangement.
Housing stability was only assessed by less than half of the studies included in this review
(13/31). This may be because many programs were delivered to participants who were
already living in supported housing. Nonetheless, the majority of these 13 studies identified
the intervention as effective in significantly improving housing stability and reducing the risk
of homelessness. Previous reviews have also reported that non-conditional supported
housing programs (i.e. Housing First) are effective in achieving housing stability (Aubry
et al., 2020; Baxter et al., 2019; Woodhall-Melnik and Dunn, 2015). The findings of the
current study are consistent with these reviews and reiterate the success of non-conditional
housing programs in reducing the incidence of homelessness through the provision of
immediate accommodation.
Interestingly, the findings of this systematic review revealed that supported housing
programs are less effective in improving participants’ health and well-being outcomes. Only
a small proportion of studies found significant improvements in such outcomes, including
substance use severity, mental health symptomology, physical health, quality of life,
community functioning and service utilization. These findings are consistent with previous
reviews that found a lack of improvements in the physical and mental health of supported
housing residents (Baxter et al., 2019; Woodhall-Melnik and Dunn, 2015). Further, while
broadly examining all non-conditional supported housing programs may have conflated the
different models of support, there were no significant patterns in effectiveness depending
on the type of intervention or type of participant group. That is, there were consistent
improvements in housing stability and less significant changes in other well-being
outcomes, regardless of participant or intervention type. It seems that while these programs
are satisfying people’s most basic primary need of affordable and stable housing, other
related health and psychosocial needs are not being adequately addressed.

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There are two reasons which may explain why for the majority of studies, health and well-
being outcomes were not significantly improved. First, the aim of the majority of programs
reviewed were primarily focused on improving housing stability as opposed to well-being
outcomes, such as mental health and substance use. Indeed, several studies described
housing stability as the primary outcome of focus and other aspects of health and well-
being were defined as either secondary or exploratory outcomes (Aubry et al., 2015;
Stergiopoulos et al., 2015; O’Connell et al., 2008). Despite offering additional support, such
as case management and mental health treatment, these programs invested the majority of
their resources into providing participants with stable accommodation. Yet, it has been well
established that housing and these other well-being factors are interconnected (Narendorf,
2017). Several recent systematic reviews that aimed to examine the psychosocial factors
associated with homelessness found that individuals who experience poor mental and
physical health, a lack of social support and substance dependency, have an increased
likelihood of losing or lacking stable accommodation and experiencing homelessness
(Schreiter et al., 2017; Tsai and Huang, 2018; Tsai and Rosenheck, 2015). Likewise,
housing instability can be a predictor for poor health status (Henwood et al., 2018).
However, it is inherently difficult to fully differentiate support that promotes housing stability
from the support that is intended to improve other aspects of health and well-being. The
programs that were clearly more holistic in their approach, aiming to address each tenant’s
unique needs to enhance various aspects of their health and well-being, yielded better
outcomes. Therefore, the current findings confirm that effective holistic treatment and wrap-
around psychosocial support to address health-related factors associated with
homelessness is required, for all types of non-conditional supported housing arrangements.
As such, it is imperative that those experiencing homelessness receive adequate
multidisciplinary holistic support to mutually address their housing and other health-related
needs.
Second, given that the housing programs reviewed herein are non-conditional, those who
participated in these studies may have declined the offer for additional support, beyond
housing support, which could explain the lack of improvement in their health and well-being
outcomes. Although participants assigned to intervention groups were provided with secure
housing, the majority of studies either did not report on engagement with additional
individual supports or their assessments of fidelity were inadequate. For example, although
Stergiopoulos et al. (2015) acknowledged that fidelity was high, they also recognized that
assessments of treatment service use were dependent on self-report, which has been well
established as an assessment method that is vulnerable to recall error (Khare and Vedel,
2019; Walentynowicsz et al., 2018). This highlights a significant limitation of the literature
that has imposed a difficulty in associating changes in well-being with different aspects of
program engagement. Future research may benefit from evaluating the outcomes of
individuals who accept the offer for additional support, compared to those who decline the
offer and only receive housing support. Furthermore, future research may also benefit from
examinations of administrative data which has consistently been found to be more accurate
than self-report measures in assessing treatment engagement (Khare and Vedel, 2019;
Short et al., 2009).

Limitations
While the synthesis of this literature has led to a more thorough understanding of the impact
of non-conditional housing programs on individual health outcomes, limitations are noted.
First, a large number of studies included an active control group that delivered some kind of
care, as opposed to TAU. Indeed, the active control group often included treatment
components that were different from what was delivered in the intervention itself. This may
have contributed to a lack of significant differences observed between groups. Given that
using an active control helps to reduce the impact of the placebo effect, coupled with the
ethical issues in randomizing patients to an organic control group where no care is

VOL. 25 NO. 1 2022 j HOUSING, CARE AND SUPPORT j PAGE 55

 delivered (Boot et al., 2013), it is recommended that more consideration is applied to
the delivery of the control group when evaluating such programs. Indeed, ensuring that the
control group and the intervention group are as matched as possible will help to separate
the individual contribution that the intervention is making, above and beyond the control
group.
Further, the lack of reporting on adherence and fidelity to interventions among the included
studies reflects a significant limitation of this literature and impacts the quality of evidence
presented. The majority of studies (21/31) either reported low fidelity or did not assess
adherence at all; hence, it was not possible to extrapolate whether the intervention was
implemented as intended. This shows that not only is the notion of implementation
overlooked within this area of literature but also within the intervention delivery itself. It is well
established that if participants do not receive an intervention as intended, it can have a
significant impact on the effectiveness of the intervention (Handley et al., 2018). This may
explain the lack of significant improvements observed across key health and well-being
outcomes as perhaps the support programs were not implemented as intended. It is
recommended that future research in this area is dedicated to assessing the
implementation and fidelity of non-conditional supported housing programs more broadly,
to ensure that they are being delivered as close to as intended as possible.

Conclusion
The findings of this review indicate that non-conditional supported housing programs are
effective in improving housing stability among individuals who experience homelessness.
However, the effectiveness of these programs and interventions in improving health and
well-being outcomes appears to be poor. Policymakers should consider investing more
resources into the development of supported housing programs that are focused on
improving the health outcomes of their residents. Given the bi-directional influence that
health status and housing stability have upon one another and the fact that those residing in
such housing are among the most disadvantaged and vulnerable population groups with
significant health concerns and complex psychosocial needs, improving both outcomes
equally will seek to provide more effective holistic care. Therefore, the current findings may
be useful and informative in the (re)design, development and implementation of non-
conditional supported housing models that seek to provide more comprehensive or holistic
individual support to prioritize and improve the health and well-being of their residents.

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Online Appendix
HCS-09–2021-0025.R1 Appendix

Corresponding author
Helen Skouteris can be contacted at: helen.skouteris@monash.edu

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