The Impact of Fidelity on Behavioral Health Outcomes Among Individuals Experiencing Chronic Homelessness and Co-Occurring Disorders
Main Article Content
Abstract
Background: People with co-occurring substance use and mental health disorders who experience chronic homelessness often have difficulty engaging in both treatment and support services. Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking (MISSION) is a multicomponent wraparound integrated co-occurring substance use and mental health disorders treatment and linkage intervention comprised of three evidence-based components (Critical Time Intervention case management and peer support, Dual Recovery Therapy, and Peer Support). Although prior MISSION studies have demonstrated positive outcomes for this population, and fidelity (i.e., fidelity to the model) has predicted improvements in criminal legal outcomes, the present study builds on these findings by examining to what extent fidelity to the MISSION model improves behavioral health and housing outcomes.
Methods: Individuals with co-occurring substance use and mental health disorders experiencing chronic homelessness (N = 108) completed a comprehensive intake and were offered up to 12-months of MISSION treatment and services. Services received and fidelity to the MISSION model were tracked weekly. Generalized linear mixed models were used to examine whether fidelity to the overall MISSION model and to each component predicted improvements in behavioral health, substance use, and housing stability outcomes.
Results: Among the sample, 70.3% were male, 78.8% were non-Hispanic, 72.3% were White, and were homeless for 8.3 years on average. Fidelity to the overall MISSION model ranged from 0.0 to 296.0%. Generalized linear mixed models demonstrated mixed relationships between fidelity to the MISSION model (and each component) including improvements in behavioral health, reduced overall illicit substance use and alcohol use in the past 6-months, and improvements in housing stability.
Conclusions: This study demonstrated that fidelity to the MISSION model had a direct impact on improving outcomes for individuals with co-occurring substance use and mental health disorders who have experienced chronic homelessness. These findings have important implications for settings that implement MISSION or other multicomponent interventions as fidelity to the model will yield greater behavioral health, substance use, and housing stability improvements.
Keywords:
fidelity, homelessness, co-occurring disorders, mental health, substance use disorders, addiction, behavioral health multicomponent interventions
Article Details
How to Cite
BRUZIOS, Kathryn E. et al.
The Impact of Fidelity on Behavioral Health Outcomes Among Individuals Experiencing Chronic Homelessness and Co-Occurring Disorders.
Medical Research Archives, [S.l.], v. 12, n. 10, oct. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5789>. Date accessed: 22 dec. 2024.
doi: https://doi.org/10.18103/mra.v12i10.5789.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
References:
1. Development USDoHaU. The 2023 Annual Homelessness Assessment Report (AHAR) to Congress. 2023.
2. Caton CL, Wilkins C, Anderson J. People who experience long-term homelessness: Characteristics and interventions. Paper presented at: National symposium on homelessness research2007.
3. Foster S, LeFauve C, Kresky-Wolff M, Rickards LD. Services and supports for individuals with co-occurring disorders and long-term homelessness. The Journal of Behavioral Health Services & Research. 2010;37:239-251.
4. Greenberg GA, Rosenheck RA. Mental health and other risk factors for jail incarceration among male veterans. Psychiatric Quarterly. 2009;80(1):41 -53.
5. Padgett DK, Henwood B, Abrams C, Davis A. Engagement and retention in services among formerly homeless adults with co-occurring mental illness and substance abuse: voices from the margins. Psychiatric rehabilitation journal. 2008;31 (3):226.
6. Schütz C, Choi F, Jae Song M, Wesarg C, Li K, Krausz M. Living with dual diagnosis and homelessness: Marginalized within a marginalized group. Journal of Dual Diagnosis. 2019;15(2):88-94.
7. Stafford A, Wood L. Tackling health disparities for people who are homeless? Start with social determinants. International journal of environmental research and public health. 2017;14(12):1535.
8. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annual review of public health. 2011;32(1):381-398.
9. Hossain MM, Sultana A, Tasnim S, et al. Prevalence of mental disorders among people who are homeless: An umbrella review. International Journal of Social Psychiatry. 2020;66(6):528-541.
10. Liu M, Hwang SW. Health care for homeless people. Nature Reviews Disease Primers. 2021;7(1):5.
11. Drake RE, Yovetich NA, Bebout RR, Harris M, McHugo GJ. Integrated treatment for dually diagnosed homeless adults. The Journal of nervous and mental disease. 1997;185(5):298-305.
12. Hwang SW, Burns T. Health interventions for people who are homeless. The Lancet. 2014; 384(9953):1541-1547.
13. Padgett DK, Gulcur L, Tsemberis S. Housing first services for people who are homeless with co-occurring serious mental illness and substance abuse. Research on social work practice. 2006;16(1):74-83.
14. Stefancic A, Tsemberis S. Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. The journal of primary prevention. 2007;28:265-279.
15. Tsemberis S, Gulcur L, Nakae M. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American journal of public health. 2004;94(4):651-656.
16. Herman D, Opler L, Felix A, Valencia E, Wyatt RJ, Susser E. A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms. The Journal of nervous and mental disease. 2000;188(3):135-140.
17. Herman DB, Mandiberg JM. Critical time intervention: Model description and implications for the significance of timing in social work interventions. Research on Social Work Practice. 2010;20(5):502-508.
18. Susser E, Valencia E, Conover S, Felix A, Tsai WY, Wyatt RJ. Preventing recurrent homelessness among mentally ill men: a "critical time" intervention after discharge from a shelter. Am J Public Health. 1997;87(2):256-262.
19. Klein AR, Cnaan RA, Whitecraft J. Significance of peer social support with dually diagnosed clients: Findings from a pilot study. Research on Social Work Practice. 1998;8(5):529-551.
20. Vayshenker B, Mulay AL, Gonzales L, West ML, Brown I, Yanos PT. Participation in peer support services and outcomes related to recovery. Psychiatric rehabilitation journal. 2016;39(3):274.
21. Ziedonis DM, & Stern, R. . Dual recovery therapy for schizophrenia and substance abuse. Psychiatric Annals. 2001;31(4):255.
22. Ziedonis DM. Integrated treatment of co-occurring mental illness and addiction: clinical intervention, program, and system perspectives. CNS Spectr. 2004;9(12):892-904, 925.
23. Chinman M, George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E.. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatric Services. 2014.
24. Smelson D, Kalman, D., Losonczy, M.F., Kline, A., Sambamoorthi, U., Hill L.S., ...& Ziedonis, D. A brief treatment engagement interventions for individuals with co-occurring mental illness and substance use disorders: results of a randomized clinical trial. Community mental health journal. 2012;48(2):127-132.
25. Smelson D, Kline A, Kuhn J, et al. A wraparound treatment engagement intervention for homeless veterans with co-occurring disorders. Psychological Services. 2013;10(2):161-167.
26. Smelson DA, Chinman M, Hannah G, Byrne T, McCarthy S. An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial. BMC health services research. 2018;18(1):332.
27. Smelson DA, Perez CK, Farquhar I, Byrne T, Colegrove A. Permanent Supportive Housing and Specialized Co-Occurring Disorders Wraparound Services for Homeless Individuals. Journal of Dual Diagnosis. 2019:1-10.
28. Shaffer PM, Helm A, Andre M, et al. Rapidly Adapting a Multicomponent Treatment for Persons Experiencing Chronic Homelessness with Comorbid Substance Use and Mental Health Disorders During the Coronavirus Disease 2019 Pandemic. Medical Research Archives. 2023;11(11).
29. Helm AF, Andre MA, Shaffer PM, et al. Multicomponent Co-Occurring Disorders Treatment and Wraparound Services for Individuals Experiencing Chronic Homelessness. Community Mental Health Journal. 2024:1-11.
30. Berkel C, Mauricio AM, Schoenfelder E, Sandler IN. Putting the pieces together: An integrated model of program implementation. Prevention Science. 2011;12:23-33.
31. Nelson G, Stefancic A, Rae J, et al. Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: a mixed methods approach. Evaluation and program planning. 2014;43:16-26.
32. Dates B, Young MS, Bennett-Clark F, et al. Assertive Community Treatment fidelity in programs serving persons who are homeless with co-occurring mental and addictive disorders. Journal of Dual Diagnosis. 2009;5(3-4):264-286.
33. Durlak JA, DuPre EP. Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American journal of community psychology. 2008;41:327-350.
34. Shaffer PM, Rodriguez CP, Gaba A, et al. Engaging vulnerable populations in drug treatment court: Six month outcomes from a co-occurring disorder wraparound intervention. International Journal of Law and Psychiatry. 2021;76:101700.
35. Marques L, Valentine SE, Kaysen D, et al. Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. Journal of consulting and clinical psychology. 2019;87(4):357.
36. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.
37. Smelson DA, Sawh L, Harter J, Ziedonis D. The MISSION Participant Workbook: Second Edition. Worcester, MA: University of Massachusetts Medical School,; 2014.
38. Smelson D, Kline A, Hills S, Ziedonis D. The MISSION treatment manual: Second Edition. Worcester, MA: University of Massachusetts Medical School; 2014.
39. Moynihan DP. The new federal performance system: Implementing the GPRA Modernization Act. Improving performance. 2013.
40. Administration SAaMHS. CSAT GPRA Modernization Act Data Collection Tools. In:2015.
41. Weathers FW, Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P. The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at www.ptsd.va.gov. Published 2013. Accessed.
42. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. Journal of traumatic stress. 2015;28(6):489-498.
43. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of biomedical informatics. 2009;42(2):377-381.
44. Eisen SV, Wilcox M, Leff HS, Schaefer E, Culhane MA. Assessing behavioral health outcomes in outpatient programs: Reliability and validity of the BASIS-32. The Journal of Behavioral Health Services & Research. 1999;26:5-17.
45. McLellan AT, Grissom GR, Zanis D, Randall M, Brill P, O'brien CP. Problem-service'matching'in addiction treatment: A prospective study in 4 programs. Archives of General Psychiatry. 1997; 54(8):730-735.
46. Breslow NE, Clayton DG. Approximate inference in generalized linear mixed models. Journal of the American statistical Association. 1993;88(4 21):9-25.
47. SAS Institute I. SAS/STAT® 15.3 user’s guide. In: SAS Institute, Inc.; 2023.
48. Corp. I. IBM SPSS Statistics for Windows, Version 29.0.2.0. In. Armonk, NY: IBM; 2023.
49. StataCorp. Stata Statistical Software: Release 18. In. College Station, TX: StataCorp LLC.; 2023.
50. McHugo GJ, Drake RE, Teague GB, Xie H. Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Services. 1999;50(6):818-824.
51. Chinman M, McCarthy S, Mitchell-Miland C, Daniels K, Youk A, Edelen M. Early stages of development of a peer specialist fidelity measure. Psychiatric rehabilitation journal. 2016;39(3):256.
52. Pauly B, Reist D, Belle-Isle L, Schactman C. Housing and harm reduction: What is the role of harm reduction in addressing homelessness? International Journal of Drug Policy. 2013;24(4): 284-290.
53. Gillard S, Banach N, Barlow E, et al. Developing and testing a principle-based fidelity index for peer support in mental health services. Social Psychiatry and Psychiatric Epidemiology. 2021;56(10):1903-1911.
54. Barker SL, Maguire N. Experts by Experience: Peer Support and its Use with the Homeless. Community Mental Health Journal. 2017;53(5):59 8-612.
55. Barker SL, Maguire N, Bishop FL, Stopa L. Peer support critical elements and experiences in supporting the homeless: a qualitative study. Journal of Community & Applied Social Psychology. 2018; 28(4):213-229.
56. Erangey J, Marvin C, Littman DM, et al. How peer support specialists uniquely initiate and build connection with young people experiencing homelessness. Children and Youth Services Review. 2020;119:105668.
57. Ross J, Teesson M, Darke S, et al. The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS). Drug and alcohol review. 2005;24(5): 411-418.
58. Breitenstein SM, Gross D, Garvey CA, Hill C, Fogg L, Resnick B. Implementation fidelity in community‐based interventions. Research in nursing & health. 2010;33(2):164-173.
59. Berkel C, Mauricio AM, Sandler IN, Wolchik SA, Gallo CG, Brown CH. The cascading effects of multiple dimensions of implementation on program outcomes: A test of a theoretical model. Prevention Science. 2018;19:782-794.
60. Leadbeater BJ, Thompson K, Sukhawathanakul P. Enhancing social responsibility and prosocial leadership to prevent aggression, peer victimization, and emotional problems in elementary school children. American journal of community psychology. 2016;58(3-4):365-376.
61. Padgett DK. Homelessness, housing instability and mental health: making the connections. BJPsych Bulletin. 2020;44(5):197-201.
62. Zerger S, Strehlow AJ, Gundlapalli AV. Homeless young adults and behavioral health: An overview. American behavioral scientist. 2008;51 (6):824-841.
1. Development USDoHaU. The 2023 Annual Homelessness Assessment Report (AHAR) to Congress. 2023.
2. Caton CL, Wilkins C, Anderson J. People who experience long-term homelessness: Characteristics and interventions. Paper presented at: National symposium on homelessness research2007.
3. Foster S, LeFauve C, Kresky-Wolff M, Rickards LD. Services and supports for individuals with co-occurring disorders and long-term homelessness. The Journal of Behavioral Health Services & Research. 2010;37:239-251.
4. Greenberg GA, Rosenheck RA. Mental health and other risk factors for jail incarceration among male veterans. Psychiatric Quarterly. 2009;80(1):41 -53.
5. Padgett DK, Henwood B, Abrams C, Davis A. Engagement and retention in services among formerly homeless adults with co-occurring mental illness and substance abuse: voices from the margins. Psychiatric rehabilitation journal. 2008;31 (3):226.
6. Schütz C, Choi F, Jae Song M, Wesarg C, Li K, Krausz M. Living with dual diagnosis and homelessness: Marginalized within a marginalized group. Journal of Dual Diagnosis. 2019;15(2):88-94.
7. Stafford A, Wood L. Tackling health disparities for people who are homeless? Start with social determinants. International journal of environmental research and public health. 2017;14(12):1535.
8. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annual review of public health. 2011;32(1):381-398.
9. Hossain MM, Sultana A, Tasnim S, et al. Prevalence of mental disorders among people who are homeless: An umbrella review. International Journal of Social Psychiatry. 2020;66(6):528-541.
10. Liu M, Hwang SW. Health care for homeless people. Nature Reviews Disease Primers. 2021;7(1):5.
11. Drake RE, Yovetich NA, Bebout RR, Harris M, McHugo GJ. Integrated treatment for dually diagnosed homeless adults. The Journal of nervous and mental disease. 1997;185(5):298-305.
12. Hwang SW, Burns T. Health interventions for people who are homeless. The Lancet. 2014; 384(9953):1541-1547.
13. Padgett DK, Gulcur L, Tsemberis S. Housing first services for people who are homeless with co-occurring serious mental illness and substance abuse. Research on social work practice. 2006;16(1):74-83.
14. Stefancic A, Tsemberis S. Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. The journal of primary prevention. 2007;28:265-279.
15. Tsemberis S, Gulcur L, Nakae M. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American journal of public health. 2004;94(4):651-656.
16. Herman D, Opler L, Felix A, Valencia E, Wyatt RJ, Susser E. A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms. The Journal of nervous and mental disease. 2000;188(3):135-140.
17. Herman DB, Mandiberg JM. Critical time intervention: Model description and implications for the significance of timing in social work interventions. Research on Social Work Practice. 2010;20(5):502-508.
18. Susser E, Valencia E, Conover S, Felix A, Tsai WY, Wyatt RJ. Preventing recurrent homelessness among mentally ill men: a "critical time" intervention after discharge from a shelter. Am J Public Health. 1997;87(2):256-262.
19. Klein AR, Cnaan RA, Whitecraft J. Significance of peer social support with dually diagnosed clients: Findings from a pilot study. Research on Social Work Practice. 1998;8(5):529-551.
20. Vayshenker B, Mulay AL, Gonzales L, West ML, Brown I, Yanos PT. Participation in peer support services and outcomes related to recovery. Psychiatric rehabilitation journal. 2016;39(3):274.
21. Ziedonis DM, & Stern, R. . Dual recovery therapy for schizophrenia and substance abuse. Psychiatric Annals. 2001;31(4):255.
22. Ziedonis DM. Integrated treatment of co-occurring mental illness and addiction: clinical intervention, program, and system perspectives. CNS Spectr. 2004;9(12):892-904, 925.
23. Chinman M, George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E.. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatric Services. 2014.
24. Smelson D, Kalman, D., Losonczy, M.F., Kline, A., Sambamoorthi, U., Hill L.S., ...& Ziedonis, D. A brief treatment engagement interventions for individuals with co-occurring mental illness and substance use disorders: results of a randomized clinical trial. Community mental health journal. 2012;48(2):127-132.
25. Smelson D, Kline A, Kuhn J, et al. A wraparound treatment engagement intervention for homeless veterans with co-occurring disorders. Psychological Services. 2013;10(2):161-167.
26. Smelson DA, Chinman M, Hannah G, Byrne T, McCarthy S. An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial. BMC health services research. 2018;18(1):332.
27. Smelson DA, Perez CK, Farquhar I, Byrne T, Colegrove A. Permanent Supportive Housing and Specialized Co-Occurring Disorders Wraparound Services for Homeless Individuals. Journal of Dual Diagnosis. 2019:1-10.
28. Shaffer PM, Helm A, Andre M, et al. Rapidly Adapting a Multicomponent Treatment for Persons Experiencing Chronic Homelessness with Comorbid Substance Use and Mental Health Disorders During the Coronavirus Disease 2019 Pandemic. Medical Research Archives. 2023;11(11).
29. Helm AF, Andre MA, Shaffer PM, et al. Multicomponent Co-Occurring Disorders Treatment and Wraparound Services for Individuals Experiencing Chronic Homelessness. Community Mental Health Journal. 2024:1-11.
30. Berkel C, Mauricio AM, Schoenfelder E, Sandler IN. Putting the pieces together: An integrated model of program implementation. Prevention Science. 2011;12:23-33.
31. Nelson G, Stefancic A, Rae J, et al. Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: a mixed methods approach. Evaluation and program planning. 2014;43:16-26.
32. Dates B, Young MS, Bennett-Clark F, et al. Assertive Community Treatment fidelity in programs serving persons who are homeless with co-occurring mental and addictive disorders. Journal of Dual Diagnosis. 2009;5(3-4):264-286.
33. Durlak JA, DuPre EP. Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American journal of community psychology. 2008;41:327-350.
34. Shaffer PM, Rodriguez CP, Gaba A, et al. Engaging vulnerable populations in drug treatment court: Six month outcomes from a co-occurring disorder wraparound intervention. International Journal of Law and Psychiatry. 2021;76:101700.
35. Marques L, Valentine SE, Kaysen D, et al. Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. Journal of consulting and clinical psychology. 2019;87(4):357.
36. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.
37. Smelson DA, Sawh L, Harter J, Ziedonis D. The MISSION Participant Workbook: Second Edition. Worcester, MA: University of Massachusetts Medical School,; 2014.
38. Smelson D, Kline A, Hills S, Ziedonis D. The MISSION treatment manual: Second Edition. Worcester, MA: University of Massachusetts Medical School; 2014.
39. Moynihan DP. The new federal performance system: Implementing the GPRA Modernization Act. Improving performance. 2013.
40. Administration SAaMHS. CSAT GPRA Modernization Act Data Collection Tools. In:2015.
41. Weathers FW, Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P. The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at www.ptsd.va.gov. Published 2013. Accessed.
42. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. Journal of traumatic stress. 2015;28(6):489-498.
43. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of biomedical informatics. 2009;42(2):377-381.
44. Eisen SV, Wilcox M, Leff HS, Schaefer E, Culhane MA. Assessing behavioral health outcomes in outpatient programs: Reliability and validity of the BASIS-32. The Journal of Behavioral Health Services & Research. 1999;26:5-17.
45. McLellan AT, Grissom GR, Zanis D, Randall M, Brill P, O'brien CP. Problem-service'matching'in addiction treatment: A prospective study in 4 programs. Archives of General Psychiatry. 1997; 54(8):730-735.
46. Breslow NE, Clayton DG. Approximate inference in generalized linear mixed models. Journal of the American statistical Association. 1993;88(4 21):9-25.
47. SAS Institute I. SAS/STAT® 15.3 user’s guide. In: SAS Institute, Inc.; 2023.
48. Corp. I. IBM SPSS Statistics for Windows, Version 29.0.2.0. In. Armonk, NY: IBM; 2023.
49. StataCorp. Stata Statistical Software: Release 18. In. College Station, TX: StataCorp LLC.; 2023.
50. McHugo GJ, Drake RE, Teague GB, Xie H. Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Services. 1999;50(6):818-824.
51. Chinman M, McCarthy S, Mitchell-Miland C, Daniels K, Youk A, Edelen M. Early stages of development of a peer specialist fidelity measure. Psychiatric rehabilitation journal. 2016;39(3):256.
52. Pauly B, Reist D, Belle-Isle L, Schactman C. Housing and harm reduction: What is the role of harm reduction in addressing homelessness? International Journal of Drug Policy. 2013;24(4): 284-290.
53. Gillard S, Banach N, Barlow E, et al. Developing and testing a principle-based fidelity index for peer support in mental health services. Social Psychiatry and Psychiatric Epidemiology. 2021;56(10):1903-1911.
54. Barker SL, Maguire N. Experts by Experience: Peer Support and its Use with the Homeless. Community Mental Health Journal. 2017;53(5):59 8-612.
55. Barker SL, Maguire N, Bishop FL, Stopa L. Peer support critical elements and experiences in supporting the homeless: a qualitative study. Journal of Community & Applied Social Psychology. 2018; 28(4):213-229.
56. Erangey J, Marvin C, Littman DM, et al. How peer support specialists uniquely initiate and build connection with young people experiencing homelessness. Children and Youth Services Review. 2020;119:105668.
57. Ross J, Teesson M, Darke S, et al. The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS). Drug and alcohol review. 2005;24(5): 411-418.
58. Breitenstein SM, Gross D, Garvey CA, Hill C, Fogg L, Resnick B. Implementation fidelity in community‐based interventions. Research in nursing & health. 2010;33(2):164-173.
59. Berkel C, Mauricio AM, Sandler IN, Wolchik SA, Gallo CG, Brown CH. The cascading effects of multiple dimensions of implementation on program outcomes: A test of a theoretical model. Prevention Science. 2018;19:782-794.
60. Leadbeater BJ, Thompson K, Sukhawathanakul P. Enhancing social responsibility and prosocial leadership to prevent aggression, peer victimization, and emotional problems in elementary school children. American journal of community psychology. 2016;58(3-4):365-376.
61. Padgett DK. Homelessness, housing instability and mental health: making the connections. BJPsych Bulletin. 2020;44(5):197-201.
62. Zerger S, Strehlow AJ, Gundlapalli AV. Homeless young adults and behavioral health: An overview. American behavioral scientist. 2008;51 (6):824-841.