Homelessness and Readmission of Schizophrenic Patients in Sydney

This study aims to determine the level of adherence to antipsychotic drugs by schizophrenic patients and assess the effect of homelessness to the readmission of schizophrenic patients randomly placed in three different treatment groups including congregate housing first (CHF), Scattered-site housing First (SHF), and Treatment as Usual (TAU). The study will also determine the socio-demographic characteristics of the homeless schizophrenic patients and assess homelessness as a risk factor for schizophrenic relapse leading to readmission of the patients.

Homelessness and Readmission of Schizophrenic patients among 25-80 year old urban citizens
of Sydney, Australia.
Homelessness and Readmission of Schizophrenic patients among 25-80 year
old urban citizens of Sydney, Australia.
Name of the student
Registration No
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Homelessness and Readmission of Schizophrenic patients among 25-80 year old urban citizens
of Sydney, Australia.
Table of content
Contents
1.0 Chapter One: Introduction.....................................................................................................3
1.1Background and rationale....................................................................................................3
1.2 Research Aims......................................................................................................................5
1.3 Justification...........................................................................................................................5
1.4 General Objective.................................................................................................................6
1.4.1 Specific objectives..........................................................................................................6
1.5 Research question.................................................................................................................6
2.0 Chapter Two: Literature Review...........................................................................................7
2.1 Homelessness.........................................................................................................................7
2.2 Chronic diseases among the homeless individuals............................................................8
2.3 Needs of Homeless People....................................................................................................8
2.4 Psychiatric health conditions of the homeless persons......................................................9
3.0 Chapter Three: Materials and Methods..............................................................................10
3.1 Research design..................................................................................................................10
3.1.1 Measurements of sample characteristics...................................................................10
3.1.2 Interventions.................................................................................................................11
3.2 Sampling procedure...........................................................................................................11
3.2.1 Inclusion criteria..........................................................................................................12
3.3 Sample size..........................................................................................................................12
3.4 Data collection tools............................................................................................................12
3.5 Data Analysis method........................................................................................................13
3.6 Ethical Considerations.......................................................................................................13
Appendix 1: Gantt chart..........................................................................................................14
References.................................................................................................................................16
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Homelessness and Readmission of Schizophrenic patients among 25-80 year old urban citizens
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1.0 Chapter One: Introduction
1.1Background and rationale
Treatment and management of homeless individuals with mental disorder such as schizophrenia
is a complex worldwide challenge (Rezansoff et al., 2016a). Therefore, persons who are
homeless and both suffering from psychiatric disorder are a major public health policy focus
internationally (Gaebel et al., 2015; Mechanic et al., 2012). It is estimated that more than
400,000 individuals in Europe are considered to be homeless at any given night, and the situation
has been made worse by the refuges crisis in Europe (Fazel et al., 2014; Solari et al., 2012).
According to Rezansoff et al. (2016), 11% of homeless individuals are schizophrenic. A study
conducted in Sydney Australia, revealed that 36% of homeless persons were positively
diagnosed as schizophrenic (Teesson et al., 2004).
Different Studies have reported reduced antipsychotic drugs adherence among the homeless
person’s resulting to recorded high number of antipsychotic non-adherence cases, increased
period of hospitalization as suggested by (Rezansoff et al., 2016b; Coe et al., 2015; Novick et al.,
2010). According Folsom et al. (2002), there is a strong relationship between homelessness and
suboptimal adherence to prescribed regimes against schizophrenia. Moreover, available
antipsychotic interventions provides limited guidance on how to take care of persons who are
synchronously homeless and schizophrenic.
In countries such as Australia, homelessness and schizophrenia has been prioritized as a public
health policy (Wilkins, 2017; Peterson, 2015a). For example, In Australia, research has revealed
that by the year 2056, for every one elderly individuals there will be only three persons who are
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Homelessness and Readmission of Schizophrenic patients among 25-80 year old urban citizens
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in the working age bracket, this is contrary to the research findings in the year 2007 that placed
elderly citizen to 5 persons within the working age bracket according to (Beer, 2012). Therefore,
homelessness among the elderly as an associated risk factor to the development of Schizophrenic
conditions has been identified as weighty economic matter by the Australian Treasury (Peterson,
2015a; Yates and Bradbury, 2010). In Australia, different studies have associated homelessness
among the low income and elderly citizens to the fact that about 95% of the housing in the
market is controlled by the private sector that has appetite for profit rather than the social benefit
of the entire society (Petersen et al., 2014; Yates and Bradbury, 2010; Minnery and Greenhalgh,
2007). Subsequently, the house prices and rents paid by the tenants is at the mercy of trends that
are dictated by the market equilibriums.
Different western countries have developed different approaches to mitigate the effects of
homelessness as a risk factor to mental illness such as schizophrenia. For example, Housing first,
which is a public health housing based-intervention approach that has been adopted across the
USA, Europe countries, and Canada. The intervention policy involves prioritizing rapid re-
housing for individuals who are constantly homeless and who are suffering serious psychiatric
illness such as schizophrenia (Somers et al., 2016; Tsemberis et al., 2000).
There is limited information on the demographic characteristics of persons who are homeless in
Sydney, Australia (Nielssen et al., 2018). Moreover, for the studies that have attempted to
research on this area touching on the homelessness and its association to schizophrenia they have
not dwelt so much on homelessness as a risk factor for schizophrenic relapse leading to the
readmission of the patients (Rezansoff et al., 2016; Canavan et al., 2012; Fazel et al., 2008).
Furthermore, the available research findings have not attempted to evaluate the impact of the
First housing intervention to access the rate of the readmission of patients suffering from
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schizophrenia by comparing the significant differences in the three treatment groups. Moreover,
there is limited information on the number of the homeless Australian citizens according to
different demographics. The challenges and barriers to accessing affordable housing has not been
well studied in the Australian context, this can be attributed to the fact that most studies have
focused on the gender without factoring ethnicity.
Therefore, in this study I propose to determine the level of adherence to antipsychotic drugs by
schizophrenic patients and assess the effect of homelessness to the readmission of schizophrenic
patients randomly placed in three different treatment groups including congregate housing first
(CHF), Scattered-site housing First (SHF), and Treatment as Usual (TAU). I propose a null
hypothesis that, there is no association between the format of housing first and the number of
readmission and adherence to antipsychotic drugs by schizophrenic patients.
1.2 Research Aims
The main aim of this research will be to apprehend and elucidate the demographic characteristics
of the homeless, and understand the effect of homelessness as a risk factor for the relapse of
schizophrenia among the residence of Sydney, Australia aged between 25-80 years old.
Furthermore, this study is intended to evaluate the impact of either congregate Housing First
(CHF) or Scattered-site Housing First (SHF) models compared to Treatment as usual (TAU) on
the adherence to antipsychotic among the homeless who are diagnosed by schizophrenia.
1.3 Justification
The outcomes generated out of this research will go a long way to seek answers for the gaps that
exists on the current studies including information on the demographic characteristics of the
affected homeless persons with confirmed cases of schizophrenia. At the same time, study results
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Homelessness and Readmission of Schizophrenic patients among 25-80 year old urban citizens
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will identify challenges and barriers experienced by the homeless individuals in accessing a
fordable houses. The findings from the intervention policies regarding housing first will help the
government to come up with better mitigation methods of schizophrenia treatment and
management. The conclusion and recommendations from this research will enable the public
health policy makers in Australia come up with mitigation measures on how to reduce number of
cases among the homeless individuals.
1.4 General Objective
To assess whether homelessness contributes to non-adherence to antipsychotic drugs and a risk
factor for schizophrenic relapse, leading to readmission of schizophrenic patients.
1.4.1 Specific objectives
1. To determine socio-demographic characteristics of the homeless schizophrenic patients
2. To determine the level of adherence to antipsychotic drugs by homeless schizophrenic
patients placed in different housing first intervention models
3. To assess homelessness as a risk factors that contribute to schizophrenic relapse leading
to readmission of the patients.
1.5 Research question
What are the socio-demographic characteristics of the homeless schizophrenic patients?
What is the level of adherence to antipsychotic drugs among the homeless schizophrenic patients
placed in different models of Hosing first models?
Does homelessness contribute to schizophrenic relapse leading to readmission of the patients?
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2.0 Chapter Two: Literature Review
2.1 Homelessness
According to Fazel et al. (2015), homelessness has been defined differently globally. Different
countries have attempted to adopt a uniform definition of homelessness in an attempt to define
eligibility criteria for services and tacking of progress in reduction of number of persons without
proper home. For example, in the USA, Homeless Emergency Assistance and Rapid Transition
to Housing (HEARTH) act of 2012, have based their definition mainly the McKinney-Vento
Act.2. However, people at looming risk of getting into situation of being homelessness have been
included by providing a formalized definition of chronic homelessness (Busch et al., 2010;
Culhane and Metraux, 2008; Echenberg and Jensen, 2008).
In Europe a consensus has not been reached on a shared definition of homelessness (Canavan et
al., 2012). Even though, there is an agreement that persons who are unsheltered, persons living
with family members, and individuals accommodated in transitional shelters are recognized as
homeless (Busch et al., 2010; Minnery et al., 2007). In Australia, homeless persons are
individuals without regular accommodation, persons living in shelters, temporarily living with
family or friend (Grenier et al., 2013; Greenberg et al., 2010). According to Grenier (2016),
individuals can be termed as being in the risk of becoming homeless when their housing
condition doesn’t meet the criteria for public health safety standards. Mott et al. (2012),
characterizes homeless individuals as ones living in the government provided shelters and
streets.
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2.2 Chronic diseases among the homeless individuals
Studies have revealed an increase in the number of non-communicable diseases that are
attributed to the ageing among the homeless populations including schizophrenia and cognitive
impairment (Marek, 2017; Brown et al., 2012; Mott, 2012; Morrison, 2009; Ploeg et al., 2008;
Garibaldi et al., 2005). Persons who are above the age of 50 years and are homeless have a risk
of developing age related chronic diseases as compared to the general population according the
findings by (Canavan et al., 2012; Ploeg et al., 2008; Shinn et al., 2007). A cohort study
conducted in Boston, USA, where the average age of the study participants had mean age of 56
years revealed that 30 percent of the respondents reported at least one age related condition
leading to functional impairment, whereas about 24 percent of the study participants reported
cognitive impairment (Brown et al., 2012). Therefore, from different studies it has been
concluded that homeless individuals tend to suffer from age related chronic conditions early in
life as compared to the general population (Gonyea, 2010; McDonald et al., 2009; Cloke and
May, 2005). The explanation given by different researchers include but no limited to increased
rate of alcohol consumptions, increased tobacco usage, among other factors.
2.3 Needs of Homeless People
There is shared need among the elderly and younger homeless persons globally, such needs
include the basic human needs such as good shelter, Food, access to health care services, and
economical self-reliance through proper income (Grenier, 2016). However, older homeless
persons have exceptional need that is connected to access to social services and healthcare
services offered by their governments (Morris et al., 2012). This is due to the fact that elderly
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homeless individuals have high risk of suffering from psychiatric related conditions (Marek,
2017), hence, they need specialized healthcare services that is not readily available in the shelters
according to (Minnery and Greenhalgh, 2007). Some of the challenges and barriers experienced
by the elderly in their quest to access health care services include stigmatization and
discrimination emerging from the service providers within the health facilities, hence there is an
urgent need for sensitization and awareness among the medical staff (Morris et al., 2012;
Lipmann, 2009).For example, in Canada, lack of relevance psychiatric services within the
government shelters have been cited as a major barrier to homeless persons with schizophrenia
accessing the services (Latimer et al., 2017; McDonald et al., 2009)
2.4 Psychiatric health conditions of the homeless persons
Research have established that individuals without homes suffers worst mental illnesses such as
schizophrenia as compared to the general population (Fazel et al., 2014). Multifactorial reasons
including risk factors that increases individuals risks of homelessness have been associated with
poor health outcomes such mental illness. At the same time, substance abuse, poor nutrition, and
exposure to communicable diseases are other identified factors (Baggett et al., 2011; Sprake et
al., 2014). The major factors that contribute to homelessness include lack of low-cost housing,
lack of employment opportunities for workers with low-skills (Burt et al., 2001).
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3.0 Chapter Three: Materials and Methods
According to Carter and Little (2007), methodology is the chronology of events and processes
involved during the research period. The objectives and research question should be coherent
with the research design.
3.1 Research design
In this study both qualitative and quantitative research design will adopted. A semi structured
questionnaire will be used to get information from the respondents. At the same time, Home care
owners will be interviewed. The Study participants will be Australian citizens who permanently
reside in Sydney, but are schizophrenic and homeless. 3 arm Housing First including ACT vs
CHF plus support vs TAU models will be used in a randomized control trial that will involve
homeless individuals with diagnosed cases of schizophrenia. The randomization will be carried
out using centralized computer generated procedure. Based on the baseline interviews, eligible
study participants will be randomly placed to CHF, SHF, and TAU. Thereafter, they will be
directed to appropriate service representative. Independent variable in the study will be
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Homelessness while dependents variable will be readmission of schizophrenic patients and
adherence to antipsychotic drugs by the schizophrenic patients will be out come measurement.
3.1.1 Measurements of sample characteristics
Some of the sample characteristics will be achieved through respondents self-rating or through
observations of mental health indicators including ever admitted to hospital for schizophrenic
conditions (1/0). Schizophrenic patient’s clinical history and medication will be obtained from
the data that will be provided by the health facilities purposively selected during the study.
Guidelines from the experts will define our acceptable level of adherence to the antipsychotic
drugs, medication possession ratio (MPR) will be calculated using a number of days the drugs
were prescribed within the follow up period as the numerator, and the denominator will be the
total number of drugs prescribed after randomization the protocol will be adopted from
(Rezansoff et al., 2016). The study participants will be observed for adherence to antipsychotic
drugs and episodes of relapse will be recorded. The observation period will consist of length of
time between the patient’s randomization and the study end date or date which patient has died.
The follow uptime will vary among the patients.
3.1.2 Interventions
In this study the two housing first interventions (SHF and CHF) will be compared to TAU. The
SHF will give the patients opportunity to occupy market based apartments all over the Sydney,
and the services will be provided by multidisciplinary psychiatrist team. The CHF conditions
will be conducted in a shelter which was previously a hotel, all the patients will be given their
own rooms. CHF condition will provide recreational activities, communal meal. The patients
will have an all-round support from multidisciplinary team, and a medical facility will be
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situated on site. The patients randomly placed to the TAU conditions will not receive any
housing support and services during the study period, but they will be followed in the same
manner as other study participants in the two other intervention conditions.
3.2 Sampling procedure
The study participants will be purposively selected. Community agencies and health facilities
providing services to the homeless schizophrenic individuals will be involved during this process
of recruitment. Eligibility of the study participants include homeless schizophrenic Australian
citizens who permanently reside in Sydney. Moreover, the persons eligible for recruitment in the
study should be eligible for government financial benefits, free healthcare and prescription
intervention programs from the government.
3.2.1 Inclusion criteria
1. Persons between the ages of 25 to 80 years
2. Australian citizen permanently residing in Sydney.
3. The person should meet the criteria of homellesness and positively diagnosed with
schizophrenia
4. The study participants or their legal representatives agreeing to sign consent.
3.3 Sample size
The study is designed to detect differences between the intervention groups on the primary
outcome variable. For example, previously conducted similar studies using MPR as a measure of
adherence to antipsychotic drugs and readmission rates in comparable different interventions
have reported SD of 0.29 (Rezansoff et al., 2016; Valenstein et al., 2013). However, for this
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study it is anticipated that there will be moderate effect with Cohen’s d = 0.6 (17% difference)
and alpha level of 0.05, this will be clinically have real world meaning.
Therefore, I propose to recruit 45 eligible study participants in each of the 3 treatment arm, this
would be sufficient to yield about 80% statistical power to reject the null hypothesis.
3.4 Data collection tools
I propose to use structured questionnaire, interview notes, and tape recording to obtain the
necessary data from the study participants.
3.5 Data Analysis method
For the statistical Analysis of the variables about the demographics such as age of the study
participants (Continuous Variables), I propose to use descriptive statistics such as mean with
standard deviation (SD). Counts and proportions (%) will be used to present Categorical
variables including Age and ethnic status of the study participants. The independent sample t
tests will be used to test for statistical significance difference between the continuous variable,
whereas Pearson chi-square test will be used to compare categorical variables between groups. A
single factor ANOVA will be used to test for statistical significant difference in number of
readmission and drugs adherence between the schizophrenic patients who will be randomly
placed in three different housing condition (SHF, CHF, and TAU). The data obtained will be
entered into IBM SPSS Statistics software version 22.047, cleaned and all analyses will be
conducted.
3.6 Ethical Considerations
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The eligible recruited study participants will be required to sign a consent form before being
allowed to answer questions from study enumerators. The information given by the respondents
during the course of this study will be treated with outmost confidentiality and respondents will
be informed of that. The recordings from the conducted interviews during this study will be
transcribed and de-identified late after getting answers from the study participants. Ethical
clearance certificate will be sought from the Australian ethical review board, and in case of any
change in the study methodology the ethical review board will be informed.
Appendix 1: Gantt chart
Year
2018
Year
2019
Year
2020
Project
component
Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3
Recruitment
of staff
Ethical
approval
Collection of
available
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data
Meeting with
key
informants
Data
collection on
socio-
demographic
Data
collection on
drug
adherence
Data
cleaning and
Analysis
Report
writing
Dessiminatio
n of research
findings
Publication
of research
finding to
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peer review
journal
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