Service Use, Physical Function, and Community Integration for People Who Were Once Homeless: a Geographic Information Systems (GIS) Approach

Research Article

Austin J Psychiatry Behav Sci. 2014;1(6): 1027.

Service Use, Physical Function, and Community Integration for People Who Were Once Homeless: a Geographic Information Systems (GIS) Approach

Chan DV1

1Department of Allied Health, University of North Carolina, USA

*Corresponding author: Chan DV, Department of Allied Health, Division of Rehabilitation Counseling and Psychology, The University of North Carolina at Chapel Hill, Campus Box 7205, Chapel Hill, NC 27599-7205, USA

Received: June 02, 2014; Accepted: July 04, 2014; Published: July 08, 2014


The impact and prevalence of mental illness within the homeless community is often difficult to measure but estimated at 30-45% [1,2]. It is well established that people who are homeless have significant unmet physical and mental health needs [3-6]. For individuals who are homeless and have a psychiatric disability, disproportionately poorer health outcomes include increased mortality, premature death, increased use of emergency services due to advanced illness, and higher risk of communicable disease [7].

Despite the established prevalence of physical and mental health conditions while homeless, the theory of competing priorities, which identifies a hierarchy of needs by examining the needs that go unmet, suggests that meeting basic needs of food, temporary shelter, and clothing is what is most important to individuals while homeless rather than health and treatment services [4,6,8,9]. Once in housing, health outcomes research comparing individuals pre- and post-housing show housing is associated with better physical and mental health [10-12] and decreased health care utilization [13,14]. It would seem that improved health outcomes lead to improved community functioning, but individuals transitioning to permanent housing continue to struggle with social isolation, meaningful role involvement, and limited community integration.

Housing and community integration

Community integration is considered a concrete, measurable, observable manifestation of recovery [15]. Successful integration has been linked to greater self-confidence, hope, self-determination, and subjective well-being [15-17]. Wong and Solomon [18] present a conceptual framework for understanding multiple dimensions of community integration, including physical, social, and psychological integration. Physical integration considers time spent in the community, resources used, and participation in activities. Social integration includes the amount and quality of social interactions and support. Psychological integration comprises feeling connected to the community and a sense of belonging.

Community integration has received increasing attention as an ongoing challenge for individuals transitioning from homelessness into permanent housing. For example, in their first year of independent housing, people with a mental illness fostered either a sense of belonging and gains in psychological integration, or social isolation, loneliness, and limited social integration [12]. Longitudinal research also shows little change in social integration with supported housing [19]. To date, there are minimal findings related to length of time housed, specific treatment interventions, clinical symptoms, or life satisfaction associated with gains in social or psychological integration [13,20,21]. In addition, demographics of ethnic match with neighbors, and factors of age, education and length of time homeless are not significantly associated with community integration [22].

Environment and person factors affecting community integration

There is support, however, for both person and environment factors impacting integration. For example, access to public transportation and living in a higher quality neighborhood is associated with greater participation in community activities [23- 25].Similarly, level of function, symptomology, and perseveration of homeless behaviors can affect one's participation, social interactions, and affinity with the neighborhood and community. Because physical and psychosocial level of function can impact all three dimensions of community integration, disability experience must be incorporated into measures of participation and sense of community [26]. In research on community living for people with a mental illness, disability factors were significantly related to neighborhood relations, isolation, psychiatric distress, and adaptive functioning in predicting community integration outcomes, with greater psychological symptoms associated with decreased integration [27,28]. However, overall there are mixed findings related to the impact of psychiatric symptoms on integration outcomes [29,30].

If the presence of physical or psychiatric symptoms can augment physical, social and psychological integration, it is possible that treatment or service use may positively impact integration efforts [28,31]. In contrast to relying on emergency services while homeless, housing is associated with increased access to planned health care services [32]. Improved access specifically to mental health treatment with housing could mitigate psychiatric symptoms that can interfere with integration. Contingency based housing models that require treatment first, however, demonstrate poor housing stability rates compared to Housing First program models that provide individuals who are homeless immediate housing without requirements of sobriety or involvement in treatment, although substance abuse and mental health services are readily available if the person chooses to seek treatment [7,12,28]. Housing First programs are associated with decreased urgent health care utilization and decreased social service and health care expenditures, but have limited findings related to gains in community integration to date [19,33-35].

Difficulty measuring community integration

Because of the complexity of the integration process, research strategies that can obtain valid assessments of the community integration processes and the effectiveness of interventions from a multi-dimensional approach are needed [25,36]. There is also a call for individual determinants of how "community" is defined and measured [28], particularly as many meaningful activities often occur outside the boundaries of one's neighborhood [37,38]. One such method uses participatory mapping, where individuals identify places in the community that are important to them through drawing personal maps, in conjunction with Geographic Information Systems (GIS), which plots these locations on a geographic map [17]. Combining information from participatory mapping and GIS to create an individual's "activity space" shows promise in mixed methods research to meet the methodological challenges of measuring multiple aspects of re-integration. Activity space is the subset of all locations within which an individual has direct contact as a result of day-to-day activities, such as work, shopping, and interacting with friends and family [39]. Activity space size can be compared by area and related to other measures of community integration or function.

A study using GIS and participatory mapping techniques to measure community integration for people who have a serious mental illness, but not previously homeless, found those with larger activity spaces had greater life satisfaction, but less sense of community compared to those with smaller activity spaces [17]. Previous research replicating these methods with individuals with disabilities who were formerly homeless did not find that community integration outcomes varied by measures of spatial presence in the community, but rather that larger activity spaces were associated with greater use of homeless services that were geographically spread throughout the city [40]. Level of function, however, was not included in the analysis, which could impact integration efforts.

The purpose of this exploratory study was to extend the prior research by completing a secondary analysis to examine differences in GIS measures of community integration related to service use and health function in adults with disabilities who were previously homeless. The research was guided by five questions: 1) What types of services are individuals using after housing? 2) Does treatment use correspond to better community integration outcomes? 3) Are there specific services associated with better community integration outcomes? 4) Is there a significant difference in community integration for individuals with the presence of a psychiatric disorder? 5) What is the relationship between physical function and community integration? It was hypothesized that better function and use of more treatment services would be associated with better community integration, using multiple measures of integration

Materials and Methods


Data was collected from 37 individuals with a history of homelessness who now had permanent housing in Boston, MA, USA. All participants self-reported a physical or psychiatric disability, with 62% reporting both. Participants were recruited from one of two housing programs that consisted of either scatter site housing (40.5%) or single room occupancy in congregate housing (59.5%). Demographics for the sample are included in Table 1. All participants were recruited from a larger ongoing study teaching Life Skills in Food and Nutrition Management, Home and Self-Care, Safe Community Participation, and Money Management in a group setting [41-44].