Service Users’ and Providers’ Experiences and Perceptions of Mental Health Accommodation Services: A Rapid Qualitative Synthesis of International Evidence

Mhlanga, Samantha; Griffiths, Frances; Zharima, Campion; Robertson, Lesley; Abdulla, Saira; Goudge, Jane

doi:https://doi.org/10.1155/2024/7971386

Health & Social Care in the Community

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Abstract Background Methods Results Discussion Conclusions Abbreviations Data Availability Conflicts of Interest Authors’ Contributions Acknowledgments Supplementary Materials References Copyright Related Articles

Review Article | Open Access

Volume 2024 | Article ID 7971386 | https://doi.org/10.1155/2024/7971386

Service Users’ and Providers’ Experiences and Perceptions of Mental Health Accommodation Services: A Rapid Qualitative Synthesis of International Evidence

Samantha Mhlanga,¹Frances Griffiths,^1,2Campion Zharima,¹Lesley Robertson,^3,4Saira Abdulla,¹and Jane Goudge¹

Academic Editor: Kumari Shweta Kalyani

Received13 Oct 2023

Revised14 Mar 2024

Accepted05 Apr 2024

Published13 Apr 2024

Abstract

Background. There is a high prevalence of homeless people with psychotic disorders and supported housing is often required. However, there is little evidence about supported housing services, especially in low-middle income countries. This rapid review synthesizes evidence about the experiences of users and providers of community-based accommodation services for people living with serious mental illness internationally to understand priorities for policy and practice. Methods. PubMed, PsycINFO, Google Scholar, and reference lists were searched to identify 1344 studies. The inclusion criteria specified qualitative studies about users’ and/or providers’ views of the accommodation services for adults aged 18+ years with serious mental illness. Title, abstract, and full-text screening were conducted in duplicate, and quality appraisal was conducted using the standard for reporting qualitative research tool. Data extraction was conducted using both Excel and Word documents, and we used thematic analysis to report findings. Results. Only 43 studies were identified for inclusion. Service users’ and providers’ experiences of accommodation services from high income countries and low-middle income countries were similar. Both the service providers and users appreciated housing, and service providers mentioned it was not a sufficient step towards independent living. Shortage of resources in low-middle income countries made it challenging for some service providers to provide care because they had to choose between buying medicine or food. While service users needed greater availability of service providers, providers were at risk of burnout. Although some service providers were trained to respond to stigmatizing events, some users continued to experience stigma from their family members, society, and service providers. Conclusions. People living with serious mental illness and service providers value the housing provision but globally their experience of this provision is relatively poor compared to mainstream society, suggesting people living with serious mental illness remain disadvantaged. Further research should explore low-cost housing options that will provide quality person-centered care for people living with serious mental illness.

1. Background

Housing is an important social determinant of health [1, 2]. People living with serious mental illness (PLSMI) are at a higher risk of being homeless [3]. Among the homeless, there is a relatively high prevalence of psychosis (estimate 29% in low-middle income countries (LMICs) and 19% in high income countries (HICs) and of post-traumatic stress disorder (estimate 27% globally)) [4, 5]. The World Health Organisation (WHO) suggests countries around the world need to upscale recovery-oriented housing services and promote independent living among PLSMI [6]. The idea of promoting independent living does not mean PLSMI must live without any form of support but rather should be provided with support that enables them to make choices about their own lives [7].

HICs have established policy and legislations that promotes transition to community-based mental health services, including supported accommodation and day-care centers [6, 8]. These accommodation services are funded by the state health and social sectors, donors, and health insurance [6].

However, few LMICs have established policy and legislation on how to improve housing for PLSMI [6]. There is a need for LMICs to upscale mental health accommodation services that deliver recovery-oriented services [9], and yet there is little evidence about how to do this with limited resources.

The experiences of service users and providers are important [10–12] to understand how the needs of PLSMI are met. Krotofil, McPherson, and Killaspy conducted a systematic evidence review of service users’ experiences of mental health-supported accommodation [13]. They synthesized evidence from 50 studies published between 1990 and 2017. They found that the experiences of users are influenced by service characteristics (for example, using a person centered and emphasis to move on approach), social relations, nature of support, and physical environment [13]. However, they did not identify any LMICs studies about the users’ experiences. They also excluded service providers’ experiences to understand how they contribute to the delivery of these services.

We sought to understand the experiences of both service users and providers from HICs and LMICs. We, therefore, decided to conduct a rapid synthesis of international evidence, so it is available for decision-makers attempting to improve the quality of accommodation services for PLSMI including those in LMICs. The review question is “what are the experiences and perception of users and providers of accommodation services for PLSMI?”

1.1. Theoretical Framework for the Review

Maslow’s hierarchy of needs is a psychological theory which states that people are motivated by different hierarchical needs such as physiological, safety, love and belonging, esteem, and self-actualization [14]. Maslow argued that the survival needs which are at the bottom of the hierarchy (physiological and safety) should be satisfied first, and that will enable human beings to fulfil the needs that are higher up the hierarchy (love and belonging, esteem, and self-actualization) [14]. The committee on the rights of persons with disability highlights that people living with disability face barriers when attaining human needs [15]. Therefore, we used Maslow’s theory to understand how accommodation services enable PLSMI to fulfil their needs.

2. Methods

To understand the experiences of service users and providers, we have synthesized qualitative evidence [16]. We used a rapid review approach which focuses on producing evidence in a timely manner by simplifying components of a full systematic review [17, 18]. This approach also allowed for systematic precision despite limited resources, including time and personnel available to conduct this review [17, 19]. The protocol for the review is registered on the PROSPERO database: CRD42021270505. Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines were followed in reporting this rapid review [20].

2.1. Eligibility Criteria

Studies were included if they reported on primary qualitative data (from users and providers) about the experiences of mental health accommodation from adults aged (18+) years with serious mental illness. Services were linked to or formed part of the provision of accommodation. We defined serious mental illness (SMI) according to National Institute of Mental Health and included articles where authors said participants primary had mental, behavioral, or emotional disorder resulting in serious functional impairment [21] such as schizophrenia, major depression and anxiety, personality disorder, eating disorder, bipolar, post-traumatic stress disorder (PTSD), and psychotic disorder. All studies written in English and published between 1990 and 2023 were eligible because the Mental Health Atlas indicates that the implementation of community-based accommodation services began in 1990 [22]. Studies were excluded if they reported only quantitative and/or focused on users diagnosed solely with substance abuse, developmental or behavioral disorders (e.g., attention-deficit hyperactivity disorder, autism, and conduct disorder), and neurocognitive disorders such as dementia [21, 23–25].

2.2. Search Strategy

The search strategy is available in Additional file 1. Since this is a rapid review, we restricted the search to two most relevant in the field of mental health [26] (PubMed and PsyINFO) because many databases increase the number of hits with marginal increases in the number of included articles [27]. We supplemented the search using Google Scholar on the 6^th of March 2021, and excluded grey literature. In each database, we combined search and MeSh terms related to the intervention (accommodation services), the population with the condition (adult living with SMI), and the study design (qualitative) using Boolean terms and connectors to search for studies. In addition, we searched reference lists of the included studies. Due to the limited number studies from LMICs, we expanded the search to include mixed-method studies and supplement findings from LMICs. All searches were updated on the 12^th of May 2023.

2.3. Study Selection and Appraisal

We used Zotero reference management software to remove duplicates. We exported all the remaining studies to Covidence software. Initially, the review team (SM, FG, CZ, LR, SA, and JG) screened 7 sets of 10 studies based on title and abstract. We did this to assess and ensure a common application of the screening criteria. The review team discussed and revised the criteria collectively. We used the revised criteria and a team of three reviewers (SM, SA, and CZ) screened in duplicate using the title and abstracts for inclusion. The lead reviewer (SM) conducted full-text screening and discussed the eligibility of studies with coauthors (JG, FG, and LR). The lead reviewer (SM) used the 21-item Standard for Reporting Qualitative Research (SRQR) checklist to appraise the included studies and assess rigor, credibility, and quality of studies. Initially, we (SM, JG, and FG) reviewed the ratings of 5 papers to check for common understanding of how to use the tool. Final ratings were reviewed by coauthors (JG and FG) to ensure rigor and consistency in assessing the quality of the studies.

2.4. Data Extraction and Categorization of Accommodation Types

In this rapid review, SM extracted data onto a predesigned Excel and Word document form. Coauthors (SM, FG, LR, and JG) read how authors of the included studies described the accommodation type and number of years the users stay in that accommodation to categorise the accommodation services. Other extracted data included study characteristics, methods, results, strengths, and weaknesses of the study. We first tested and revised the form using 5 papers with rich data reporting studies from the range of included accommodation types. The lead reviewer discussed the resulting extraction with the coauthors, and the form and extraction were revised as necessary. The final data extraction was conducted by the lead reviewer and checked by the coauthors.

2.5. Thematic Analysis

We used a thematic approach to analyze findings from the included studies. SM created a word document with all the extracted results under the heading results. Themes were generated using a deductive approach with predetermined themes that were informed by Maslow’s hierarchy of needs theory [28, 29]. The coauthors (SM, FG, and JG) conducted a comprehensive manual process of reading, coding, and identifying themes [28]. The resulting themes and subthemes were discussed and revised during meetings until consensus was reached. In the following sections, we present the description of studies that were included and a detailed analysis describing each theme in relation to the users’ and providers’ experiences of accommodation services.

3. Results

3.1. Overview of Included Studies

The database search yielded 1334 records. A total of 223 duplicates were removed and 1101 studies were screened based on title and abstract. Only 256 studies were identified for full-text screening. Of these, only 43 studies met the inclusion criteria and were included for analysis (see Figure 1 for the screening and selection results and Table 1 for summary of the included studies). Out of 43 studies, 30 from HICs and 4 from LMICs were rated as high quality (score of 18–21) because the authors were transparent about most of their standards for reporting qualitative research. 5 from HICs and 2 from LMICs were rated as moderate quality (score of 16-17) because the authors were not transparent about the context in which the study was conducted, study design, and data analysis methods. 2 studies from HICs were rated low quality (score 15 and below) because the authors were not transparent about the research design, sampling strategy, data collection methods, and limitations of the study. Although we did not exclude papers based on the quality appraisal, we took account of the quality during analysis.

Thirty-seven studies from HICs and four studies from LMICs used a qualitative approach; two from LMICs used the mixed-methods approach. The study designs used by authors were case study, longitudinal, exploratory, explanatory sequential, narrative study design, observational, phenomenological, interpretative and constructionist, grounded theory, and participatory research. Most of the studies were from HICs, i.e., Canada (n-11), Australia (n = 7), United States of America (USA) (n = 10), Sweden (n = 3), Norway (n = 3), Spain (n = 1), Denmark (n = 1), and England (n = 1). Only 6 studies were from LMICs, i.e., Malaysia (n = 1), South Africa (n = 1), India (n = 2), Ghana (n = 1), and Ethiopia (n = 1).

Findings from the studies had either users’ experiences (17 HICs and 4 LMICs) or providers’ experiences (15 HICs only) or both users’ and providers’ experiences (5 HICs and 2 LMICs). Most data were collected using semistructured individual interviews either face-face or telephonic (n = 30), with small numbers using focus group discussions (n = 6), unstructured interviews (n = 2), individual and focus groups (n = 4), and appreciative inquiry conversations (n = 1).

We categorized studies into the following types of accommodation: halfway houses, supported housing, independent living units, and living independently which we describe in the following.

3.2. Categorization of Accommodation Services

3.2.1. Halfway Houses

We defined these as a temporary accommodation for users who have recently been moved from being homeless or discharged from hospital, with onsite staff providing treatment, structured programmes, and psychosocial support [30–33]. Four studies (2 HICs and 2 LMICs) were classified under this category [34–38]. The length of stay ranged from 3 to 24 months [34, 36–38]. Activities described by both the users and providers included group-based psychosocial support and therapeutic programmes (for example the use of cognitive behavioral therapy), structured leisure and physical activities, treatment adherence, abstaining from substance use, and support where needed for activities of daily living [34, 36–38].

3.2.2. Supported Housing

We defined these as shared residential facility offering unlimited length of stay, with 24 hrs onsite staff to provide care, treatment, and psychosocial support (e.g., group homes) [30, 31]. Six studies (4 HICs and 2 LMICs) described the users’ and providers’ views under this category. Length of stay ranged from 2 to over 20 years [39–44]. The services that were described by the users included providing food, assistance with personal care, medication administration, and indoor and community leisure activities [39–44].

3.2.3. Independent Living Units

We defined these as permanent housing specifically for PLSMI with staff available offsite to provide 24 hours care. Twenty studies (19 HICs and 1 LMIC) were under this category. Independent living units were where users are provided with their own keys and have full tenancy rights; rent was paid by the state or users or other forms of funding [45–53]. Some of these permanent housing used the housing first approach (prioritizes the provision of permanent housing before treatment [54]), and the assertive community treatment (ACT) staff were available offsite to deliver care 24 hours [33, 55–57]. Some users were expected to stay for 2-3 years, with possibilities for lease renewal [35, 46–53, 58, 59]. Users have regular contact with mental health staff available offsite to encourage users to do as much as possible for themselves such as personal care, shopping, cooking, domestic chores, and leisure activities [35, 45–53, 58–60]. In 2 studies, users were allowed to choose the service provider, type of treatment, and psychosocial support [61, 62].

Two studies described boarding houses which are occupied by high functioning individuals without 24 hours mental health staff onsite [44, 63]. In the first study, the boarding house was privately owned and provided short- and long-term stays from 1 day to 16 years [63]. Users were provided with 1–3 meals a day, shared cooking facilities and bathrooms. In a second study, all residents had lived in the boarding house for more than 20 years [44]. Users were provided with meals, assistance with cleaning their accommodation and bathing [44]. In both studies, managers occasionally provide practical support and refer for mental health support to case managers outside the boarding house [44, 63].

3.2.4. Living Independently

This was defined as outreach psychosocial support services provided by formal and/or informal mental health staff to users living with family or independently [30, 31]. Outreach services were described as ACT which means assertive community treatment (9 HICs) [64–73], while some were described as floating outreach services (2 HICs and 1 LMIC) [58, 74, 75]. ACT was provided to service users with community treatment court orders and/or history of poor engagement with services [64–72]. In the assertive services, the formal mental health workers visited the users in their own homes to provide intensive services such as treatment (i.e., medication and injections), psychosocial educational groups, social skills programmes, accompanying users to appointment and community activities, providing finance, and housing assistance [64–72]. Floating outreach services involved support workers who visited users in their own home to provide emotional support and assist them to take more responsibility for their daily living tasks such as shopping, cleaning, and cooking [58, 74, 75].

3.3. Results of Thematic Analysis

We present our data analysis according to Maslow’s hierarchy of needs. Table 2 presents the papers reporting results relevant to each theme and for the different categories of accommodation services from both HICs and LMICs.

There is no evidence from Table 2 of differences in attention to different themes by papers reporting on HIC and LMIC settings except “accessible service providers” which only featured in the findings from HICs.

3.4. Physiological and Safety Needs

3.4.1. Housing as a Basic Need

A shelter is an important human basic need and is the basis for the housing first model for PLSMI. Once in accommodation, they then have a base from which to gain access to clinical services, safety, independent, and social relations. Six studies about independent living units (5 HICs and 1 LMIC) described this theme [33, 46, 55, 57, 60, 76]. For example, the service provider stated that “You have to house people before you expect them to work on life-changing things, like becoming sober or getting back together in a relationship or going to see a doctor regularly” [76] (Service provider, USA independent living units). Service providers from India mentioned that “finding a house for residents to live in a community…was an important step” [60] (Service provider, India independent living units). This was from a study which we rated as moderate quality.

Housing was also appreciated by the service users who were housed after being institutionalized. For example a user from a moderate study mentioned that “I used to sleep in the park, I used to sleep on the curb, I used to sleep in abandoned buildings with the rats this size come crawling whack! but, that’s the life I led, you know” [46] (Service user, USA independent living units). Another user reported how important it was for him to receive a new apartment as a first step towards recovery “I offer you an apartment, “I thought, is it God who sent him, or what? But it was a fact. He really had an apartment for me. That was the first step, and I felt it as something exceptional” [65] (Service user, Norway living independently).

3.4.2. Safety and Security

PLSMI need to be housed in a place where they will feel comfortable and safe. Seven [48, 51, 56, 60, 73, 76, 77] independent living units’ studies (6 HICs and 1 LMIC), two [36, 37] halfway houses (1 HIC and 1 LMIC), and one supported housing from LMIC [41] described this theme. For instance, the service providers emphasized “on the need for a safe environment to deliver care and support” [73] (Service providers, Canada independent living unit). Another one highlighted that “having stable housing represented a chance to have a home, a place where they felt safe and secure enough to address other, larger problems in their lives” [56] (Service provider, USA independent living unit). One supported housing and one independent living unit studies from India described how supported housing services gave users a safe long-term home which was comfortable, and service providers observed them feeling at home while taking care of the house [41, 60].

Users’ experiences of safety and security differed between studies. Some users from a high-quality study felt unsafe due to housing conditions and stated “There’s a wall falling. I think it can almost be condemned, an animal can crawl through the wall in the basement, on this side, right into the basement. They’ve got jacks holding the main beams up and stuff like that. You can see cracks in the wall. You can see a bit of light coming through” [48] (Service user, Canada independent living units). Another user from a high quality study stated “where we sleep is also not comfortable, … there is not even light there, some even have bedbugs in their rooms” [37] (Service user, Ghana halfway house).

3.4.3. Food and Clothing

Housing should allow PLSMI have access to food and acceptable clothing. Three studies from halfway house (LMIC) [37], supported housing (HIC) [39], and independent living units (HICs) [44] described this theme. One of the service providers explained how they must choose between medicine and food as follows: “The major problems we have are feeding and drugs. We cannot live with them without giving them medication, so we use the little money we have to buy them medicine” [37] (Service provider, Ghana halfway house). In the same study, the user also mentioned that “Here the feeding is poor… when we talk about feeding, we can eat some kinds of rice” [37] (Service user, Ghana halfway house). Some independent living units users from Australia also complained about the quality of food because service providers bought cheap food, and in some cases, expired food [44].

On the other hand, some service users also complained about clothing in accommodation services. One of the users stated “you got nothing to go out with. Look, if you want to buy a jacket or something like that, a decent jacket could be fifty or a hundred, and its wintertime. In the summer you might be able to just go in a shirt but that’s basically it, but I mean you’ve got to get clothes that match the pants right, and the Salvation Army is kind of a joke. It’s an old man’s clothes. YOU LOOK STUPID!” [39] (User, Canada supported housing). In the same study, users further described how they felt excluded from society due to lack of clothes: “You don’t fit in. You’ve got to go [out] dressed like this, and that’s what you got. You’re conscious of what you look like. You automatically look like a bum. If I didn’t have the [wheelchair], I’d automatically just blend in as a bum” [39].

3.4.4. Accessible Service Providers

Users appreciate the presence of service providers in accommodation services. Five HIC studies from independent living units [53, 56] and living independently [64, 66, 71] described this theme. For instance, “service users felt safe knowing that they have service providers to help and mediate the process of them meeting the housing requirements” [56] (Service provider, Canada independent living units). Even though some service providers promoted safety, workload made it challenging for them to provide care. One study found that users of living independent services reported about the service providers that are not always available to help: “They really don’t respond to your calls all the time. It’s hard getting in touch with them. Sometimes they don’t respond to your calls until the next day” [66] (Service user, USA living independently). Some service providers reported a shortage of clinically trained staff as follows: “There are many clients without a case manager and to me, that means that I or my coordinator must decide about whether [the client] needs extra care or not, and I don’t think that’s good enough. We’re not medically trained; we need a backup” [53] (Service provider, Australia independent living units).

A moderate quality study from Canada about living independently found that the service providers experienced burnout due to human resource shortages: “It’s like a culture of self-sacrifice on my team. The message is, if you really care, you’ll stay late. It’s a recipe for burnout” [71]. These findings were similar to another living independently study from Canada where authors found that service providers also experienced burnout due to workload and the service providers stated “Everybody was feeling a bit burnt because you could only do crisis intervention, there was no time to do anything else, you never got on top of anything” [64]. However, these findings were from a study which we rated as low quality.

3.5. Psychological Needs

3.5.1. Sense of Belonging and Acceptance

Belonging and acceptance are social needs that involve the desire to have interpersonal relationships and feeling part of a group. Two high-quality studies and one moderate study from supported housing (1 HIC [40], 2 LMICs [41, 42]), one high quality study from LMIC about halfway house [34] and one high quality study from HIC about independent living units [45] described this theme. Service providers of a supported housing in India mentioned that “users that stayed in a supported housing felt like they belong to a family when they are with other users and service providers” [41]. This was from a study which we rated as moderate quality. However, some service providers and community members still struggled to understand symptoms of mental illness, and that made some PLSMI to feel like they do not belong to that accommodation. For instance, one halfway house user from South Africa felt excluded by their service providers and the society: “You know it’s difficult when one has a mental illness, it is very difficult to speak about belonging. I mean most people belong somewhere but people with mental illness tend to be displaced, they don’t really fit in anywhere. This belonging, where do you fit in? Who are you? We are all different. So there’s a whole lot of layers” [34].

Some users felt the need to be accepted with their mental illness “humanity means acceptance and understanding the sick person, that they are human like anybody else, they want to be loved and treated and handled with care” [40] (Service user, Canada supported housing). This was similar to users who described their desire to experience a sense of acceptance through contact with the society: “Main thing is, don’t shun us. I think we can be normal; we want to get back to society” [42] (Service user, Malaysia supported housing). For some users, inner acceptance was important before being accepted by the society: “I have begun to understand that I should accept and be accepted for who I am, as I am, but at the same time I want to be like everybody else. But what is “normal” anyway?” [45] (Service user, Sweden independent living unit).

3.5.2. Relationship with Family

When users are provided with housing, it becomes easier for them to have social relations. Four studies about independent living units in HICs [39, 52, 56, 77], four studies about supported housing (1 HIC [43] and 3 LMICs [41, 42, 60]), two studies about living independently (1 HIC [66] and 1 LMIC [75]), and two studies about halfway houses in LMICs [34, 37] described this theme. In Canada, service providers stated that “some users complained about being lonely in independent living units, some appreciated connecting with their family members” [77]. Similarly, service providers from USA also mentioned that “independent living units gave users a chance to reunite with their children” [56]. The supported housing service providers allowed users to visit their relatives which strengthened their relationship with family. One service user stated that “I have many relatives in Bangalore, and I visit them often. Whenever I visit them, I have a good time” [41] (Service user, India supported housing). Similarly, in Ghana, “users and providers expect halfway house services to help users reunite with their family members and make meaning contributions” [37]. Another user from an independent living unit in Canada showed determination to maintain social relations with family as follows: “I try to go to visit my mother once a month …it’s three-o-five [$3.05] but one way or another I try and get there. I put money aside and try to see her because she lives alone” [39].

Some users longed for social relations with their family members. For example, a user stated “I have very little contact with my family, having contact with my sister makes me feel close to my family” [52] (Service user, Denmark independent living units). Some users felt abandoned and forgotten by their family members who never visited them, “My two siblings have not contacted me since I am here for nearly 6 years. I feel very sad that it ended this way. How can they be so busy to the extent that they just can’t give me a call?” [42] (Service user, Malaysia supported housing). This was similar to a South African study where halfway house users felt unsupported by their family members [34].

The living independently users from a USA study stated that “service providers help them stay in touch with their family members by providing phone access to call them” [66]. Service providers also play a role in promoting social relations between the users and their family members. For example, authors from supported housing studies conducted in Spain and India said service providers mediated between the users and their family members to stimulate the culture of social relations [43, 60]. This was also found in a living independently study from Ethiopia where service providers act as mediators in family conflicts: “[the man with schizophrenia] was expelled from home because he kicked his mother. He was roaming the streets and was unable to stay at home because of his illness, But the family relationship improved significantly after I gave them the lesson from the module about interpersonal relationships in the family, he asked for her forgiveness and they started living together happily” [75].

3.5.3. Relationship with Other Residents and Service Providers

Not only do users want to have social relationships with their family but also with other service users and providers of accommodation services. Seven studies about independent living units from HICs [46, 48, 50, 52, 56, 58, 77] and 2 studies about living independently (1 HIC [65] and 1 LMIC [75]) described this theme. Some users from independent living units in USA had a family relationship with other residents: “It really is an extended family, so I love it. I think that this is the best thing that ever happened to me” [46]. Authors from a studies conducted in Canada [77] and USA [56] found that independent living units allowed users to have intimate relationships with other residents, and one user stated “I’m trying to build acquaintances into friendships, which I’ve had a really hard time with. I’m surprised I have a girlfriend now... because, [with] what I’ve gone through, I find it hard to get close to people” [77] (Service user, Canada independent living units). On the other hand, relationship with other users created the feeling of safety and support. Independent living unit users from an England study felt safe and comfortable to share similar experiences with other residents: “Yeah, I’m not very good at living alone. If anything goes wrong for me, I’ve got the support, yeah residents as well actually. But I’ve lived in supported accommodation because having other people around helps really” [58]. Even service provider from an England study observed how users living independently supported each other: “And I think, just from taking these ladies to the coffee mornings they have, you know it’s not for everybody but, you know you can see that they’ve made friends, they’ve interacted with people, they’ve shared stories and also I think it’s empowering really because you can help each other and sort of give each other tips on how you cope with your mental health” [58].

In contrast, some users were happy to create social relations with their service providers. Users had family relationship with their service providers who kept them in treatment while enabling them to imagine the future, and the user stated “Most people are concerned with how things are with family and friends. That’s how it is, and for me living independent services function as a kind of family, making phone calls and taking care of things. It contributes to believing in the future” [65] (Service user, Norway living independently).

Without social relations in accommodation, users feel lonely and disconnected from everyone. In a Canadian study, independent living unit users without social relations had this to say, “I like it here, but I don’t. It’s very lonely here. I feel lonely because I don’t have much companionship with other people. I feel a lot of disconnection from the community, you know, but I just wish I had more company, If there were someone sharing the apartment, I would feel much better, someone that I could trust so, companionship is the main thing I’m missing” [50]. This was similar to an Ethiopian study about a user living independently who also wanted social relations to avoid being lonely: “I have to start a social life, no one invites me because I am living alone, and I don’t have social life. I am lonely” [75]

3.6. Esteem Needs

3.6.1. Developing and Promoting Independent Living Skills

Accommodation services help users develop independent living skills. Some PLSMI receive support to help them move and live independently while other users receive support in their permanent houses so that they can live independently. Six studies about independent living units (5 HIC [45, 47, 50, 59, 63] and 1 LMIC [60]), two studies about halfway houses (1 HIC [36] and 1 LMIC [37]), and 1 study about living independently in HIC [58] described this theme. Independent living units users from India were free to participate in housing chores that helped them develop independent living skills [60]. Some users struggled with room maintenance and hygiene as a service provider highlighted, “You’d give him clean sheets to make his bed, and they would not get put on, you’d take his sheets off, and he would not make his bed. So, I found I had to go in and make his bed. There were dirty cups and plates all through the room. I’d just, in the end, go in and grab them” [63] (Service provider, Australia independent living units). This was from a study which we rated as moderate quality.

For some users, independent living was associated with the way services were provided. Independent living unit users in Norway and USA studies had keys to their permanent apartment which made them feel independent [47, 59], some independent living units users from Canada independently made choices about their home environment: “Home is where I park my books and I can decide where to put my bookshelves. I do have those choices. I don’t have to negotiate where I put the furniture [laughs]. If I want to do something like hanging a hammock in my bedroom, I don’t have to worry about dealing with what other people think. I can be in my own space again, it’s a good thing” [50]. Similarly, independent living unit users from Sweden study also made choices about their apartments: “It was fun to think through how I wanted it and how I would spend my money to make it just the way I wanted it. Now I think I have created my own personal style here” [45].

Service providers of accommodation services aimed to deliver services in a way that promotes independent living. For example, in a halfway house study from USA, the service providers mentioned that “they endorsed the importance of developing independent living skills as giving people life tools, which will keep them in housing” [76]. Service providers from Australia described halfway house as a place for users to learn independent living skills, “This is only their transition base they are going to go to the community to live either on an independent accommodation or a supported accommodation. They are going to go one step forward from where they were this is a transition period for them to learn some of the skills to live in the community, and depending upon how much they learn and how much the interest they have, depending upon the recovery goal” [36]. Similarly, in LMICs, some service providers also viewed independent living as an end outcome of accommodation services. For instance, in a study from Ghana about halfway houses, service providers expect users to gain independent living skills before discharge, the service provider stated “We expect that they can work for themselves, and they will never depend on somebody. We are expecting that, after the rehabilitation, they can use the things that they learn from here to go out there to manage their lives without depending on somebody” [37]. On the other hand, a living independent study found that the service providers from England help build users’ capacity to live independently and maintain their home, and the service provider stated “We don’t treat people, but we are more like life coaches now. We have kind of our main role is to help people to maintain their independence, maintain their tenancies, stay in their own home basically” [58].

3.6.2. Freedom and Choice within Accommodation Services

Service users have a right to freedom and choice when they are in accommodation services. Six independent living unit studies from HICs [33, 46, 47, 50, 56, 68], 2 halfway house studies (1 HIC [36] and 1 LMIC [37]), and one supported housing study from HIC [44] described this theme. In USA, independent living unit users appreciated the freedom to come and go as they liked. For example, one user said, “I like the idea that, you know, you can come and go as you want. If you want to spend nights out with family or friends or whatever, you know, you can just come and go and the staff here has never really had a lot of restrictions on us for anything”. Some users appreciated being able to eat what they like, “you can cook whatever you want. You can cook hamburgers or chicken and chips or whatever” and to organize their social life: “Yeah, we’re like free. I have a friend coming. She can come and eat with me. Then we talk and go out together” [50] (Service user, Canada independent living unit). Such freedom allows users to feel like they are in control of their life and improves the quality of life. In halfway houses from Ghana, the service providers allowed users to be involved in their treatment plan, “users contributed to their service plan and reported to service providers if they experienced side effects from the medication” [37]. This was not the case for other users in USA-supported housing where authors described how their freedom was limited because they had to report everything to service providers [56]. On the other hand, halfway house service providers from an Australian study described how allowing users to live freely led to better relationships with the users: “I think that, taking them away from being so restricted and putting them into an environment, where they’ve got, more rights, so much more freedom, I think automatically they just relate to you so much better, it’s easier to establish a rapport cause you’re not trying to take anything away from them, they can come and go as they please” [38]. Although freedom is important in independent living units some service providers from Canada were complaining about negative behavior associated with having freedom, such as drug use and dealing, excessive noise, and damaging apartments [33].

In contrast, living independent users from an Australian study reported limitations on their choices of activities, for example, “Harry had been encouraged to attend the weekly cooking class despite informing his case manager and the researcher that he already knew how to cook” [68]. Similarly, in a South African study, halfway house users experienced pressure to attend group sessions which they found difficult, “My illness made me very solitary in the sense that I like being on my own, you know, and what they do is, you’re kind of contained, so you must do it. You can’t sit back and say no I don’t want to do this. You must participate in the programme, you know. So, it’s hectically interactive because you’re in groups all the time” [36]. Supported housing users from another Australian study experienced restrictive practices that limited their freedom of movement, “If you are not there for your meals then you get nothing. They generally lock the kitchen around 6 p.m” [44].

3.6.3. Respect

PLSMI feel happy when they are respected for who they are rather than being judged because of their illness. Three independent living unit studies from HIC and 2 supported housing studies from both HIC and LMIC described this theme. For some users, having a job made them stand up for themselves and feel respected: “I think that having a job made me stand up for myself more, get respect from people, or show respect to people” [32] (Service user, USA Independent living unit). Some users appreciated being respected “being respected as a person [means] you’re a human being, called by your own name and not being called crazy” [40] (Service user, Canada supported housing). In USA, independent living unit users felt respected by their service providers: “Yes [they respect my privacy] … They’ll call and let me know. And plus I be here every day, so they tell me when they going’ to my apartment to check” [58]. Independent living units users in a Swedish study reported how service providers respected their personal integrity and privacy: “It’s good that our own personal space at home is respected by the coaches they don’t just walk in uninvited” [45].

In contrast, one service user from Malaysia did not like how they were treated by the service providers in supported housing. Users described how they were exploited and bullied by the services: “We need staff who are humble, who can treat us with respect. The center should hire knowledgeable staff who will not judge us” [42].

3.6.4. Stigma and Discrimination

PLSMI experienced stigma and discrimination from family and community. Four independent living unit studies (3 HICs [32, 57, 77], 1 LMIC [60]), two supported housing (LMIC [42], HIC [40]) and one living independent study from HIC [69] described this theme. Users of supported housing in Malaysian felt humiliated and threatened by their family because of their mental illness, one user quoted the words from her mother who threatened her: “You want to go to dinner, you cannot talk, once you open your mouth people will know you are abnormal, so I just sit quietly even though I like to talk” [42]. Some users from independent living units in USA were scared to work because of negative judgements from the community: “what if I’m working somewhere and someone finds out that I have a mental illness? That scares me because people outside of the mental health community, you know, when they think of mental illness, they think of really dangerous people, like serial killers for example. You know people who are evil and dangerous, and out to hurt them” [32]. Some people have a stigmatizing attitude that PLSMI should not have housing provided. In India, “the manager of a supported housing project experienced challenges before finding a house for residents to live in a community because the property owners stigmatized PLSMI” [60]. Similarly, users of supported housing in Canada also felt vulnerable, excluded, and alienated by society: “A lot of people around town think that I should not have my own room here [and] that I should be in a mental hospital” [40]. However, some users stated that “living in quality independent living units helped reduced the stigma they experienced from the community” [77] (Service user, Canada independent living unit).

Some mental health accommodation services also contribute to PLSMI experiencing stigma from the community. Users from a moderate study conducted in Canada mentioned how living independent services continued to identify them as people in need of mental health services, and the delivery of services contributed to stigma: “Someone knocking at your door, one, twice, three times a day, four people with keys, its odd, it’s a strange feeling. And those white carers just come coming in and out. So, lots of people who live in the building already know you are psychiatric patients. Nurses don’t even conceal the medication. It does take away your independence” [69]. Yet in USA, the service providers of independent living units were trained to give users the benefit of the doubt in response to stigmatizing triggering events” [57].

3.7. Self-Fulfilment Needs

3.7.1. Recovery or Reaching Full Potential

Recovery is when accommodation services help PLSMI reach their full potential despite the presence of a mental illness. Three independent living unit studies from HICs, three halfway houses studies (2 LMICs and 1 HIC), and two living independent studies from HICs described this theme. In Ghana, users and providers mentioned that “halfway house services aim to achieve recovery by promoting independent living, managing of illness, social inclusion and economic empowerment” [37]. Recovery is also linked to community integration, “users appreciated the opportunity to work which provided them with a sense of accomplishment and made them feel like contributing members of the society” [32] (Service provider, USA independent living unit).

Some living independent services from USA helped users recover from the symptoms of mental illness, “Recovery is very important to me because I don’t want to get sick anymore. Because that’s the worst thing in my life that happened. So, recovery is good. Nobody wants to walk around here being sick. If you could only be in my shoes and walk around, being sick like that, nobody would want to go through that. So recovery is a very good thing” [68]. Similarly, halfway house services in South Africa “helped users with clinical recovery but limited their personal recovery by protecting them from learning how to reintegrate into the community” [34].

One user from living independent services in Australia hoped that accommodation services will help them gain their physical energy: “Recovery for me is about energy and having the physical energy to get out of the house, exercise and hopefully one day play tennis. I like the idea of going swimming with my nephews in the future” [68]. In Canada, independent living unit service providers stated that “allowing users to be responsible for organizing their own social life contributed to their recovery” [50].

To achieve recovery, service providers of accommodation services need to work together with PLSMI. For example, halfway house service providers from an Australian study described recovery as a collaborative process where service providers actively listen to the users’ needs and take them seriously: “It’s all about collaborative partnership and this is something I talk to clients [consumers] about all the time, there’s no point in me telling you what I want you to do if it doesn’t fit your interests and your values. I need to know what you want to do so then I can support you in identifying ways of achieving what it is that you’d like for yourself” [38]. Some halfway house service providers from another Australian study defined recovery as a process influenced by the user’s mindset and how they engage with the services provided: “well the recovery is what happens to the client. They have that; the recovery is not only from the recovery from the mental health/mental illness situation. It is the recovery from their mindset, their insight and their ability, their confidence, their self-esteem; everything is getting recovered. The whole thing, the whole setup itself, from the beginning all the way up to there, what will we do. The whole thing is a rehabilitation process” [36].

4. Discussion

In this rapid review, we synthesized 43 international studies to explore the service users’ and providers’ experiences of accommodation services. Only 6 studies were from LMICs indicating limited evidence about accommodation services for PLSMI compared to HICs. There are many more studies on independent living units and living independently in HICs. Studies from both HICs and LMICs reported on all the needs except for accessible service providers which only featured in the findings from HICs. In essence, the experiences of users and providers about accommodation services for PLSMI were strikingly similar across the globe despite limited evidence from LMICs. This was not surprising given that mental healthcare services are low on government health expenditure in both HICs and LMICs [6, 78].

Shortage of resources made it challenging for some service providers to provide care because they had to choose between buying medicine or food. Service users complained about the quality of food and clothing. While service users needed greater availability of service providers, providers were at risk of burnout. Service providers valued promoting independent living skills, and users appreciated having freedom of choice. Service providers and users also mentioned that housing promoted social relations and service providers were trained to respond to stigmatizing events. However, some users continued to experience stigma from their family members, society, and service providers.

There was evidence in both HIC and LMIC of trying to deliver services according to the WHO guidance on community mental health services [6]. The WHO housing and health guidelines [2] are consistent with PLSMI experiences of housing as a primary need for themselves; housing helps them meet other essential needs that are connected to health such as safety, food, and access to healthcare. Housing PLSMI also means providing them with a place where they will be able to live independent, be supported to make their own decisions about treatment and care, and be encouraged to participate in community activities and have social relations rather than only focusing on reduction of mental health symptoms [6].

The WHO recommends healthy housing should have sufficient space, comfortable temperatures, safe drinking water, adequate sanitation, electricity, and protection from pollution and harmful hazards [2]. PLSMI experiences indicate the importance of these quality issues. Sustainable housing is an issue for a larger percentage of the global population where low-cost yet efficient and long lasting housing is needed [79, 80]. This applies to PLSMI too.

Our findings show that users have different accommodation service needs, and service providers understand that the services should be individualized and user centered. Existing evidence suggests that it is possible for service providers to deliver user-centered services and for mental health users to achieve recovery [81, 82]. This can be achieved only if the service providers focus on the users’ strengths, provide with resources and give them the opportunity to be in control of their lives [82].

4.1. Implications for Practice, Policy, and Research

Our review of these experiences provides evidence for service providers and policymakers to work towards housing PLSMI to promote independent living, safety, and social relations. Research evidence suggests that housing PLSMI helps promote the stable use of mental health clinical services and lower the inpatient hospitalization rates [83–85] and so reducing burden on health services. In LMICs where there is a shortage of resources, a safe home or accommodation of reasonable quality may need to be considered in these situations to house PLSMI.

The WHO guidance on community mental health services [6] included relatively little research evidence on existing services in LMICs; our review found only 6 articles about the experiences of users and providers of accommodation services in LMICs. An expansion of this research literature would more clearly bring the user and provider voice into the development service quality assessments [86, 87] and evidence-based policy.

4.2. Strengths and Limitations

We included studies of both user and provider perspectives and relevant studies from LMICs. Using Maslow’s hierarchy of needs enabled a comparison regardless of the country’s policies or legislation because it is generic to all human beings. However, our inclusion criteria meant that we exclude experiences of those who are homeless with serious mental illness, and they are no longer receiving accommodation services. This could mean that we missed their views about why accommodation services did not work for them. There is also a possibility that we missed papers where accommodation was taken as a given such as countries with strong social housing programmes.

5. Conclusions

Globally, PLSMI and service providers value the provision of accommodation services, but their experiences of this provision are relatively poor compared to mainstream society suggesting PLSMI remain disadvantaged. Further research should explore low-cost housing options that will provide quality person-centered care for PLSMI [88, 89].

Abbreviations

HICs:	High income countries
LMICs:	Low-middle income countries
NGO:	Nongovernmental organizations
PLSMI:	People living with serious mental illness
SMI:	Serious mental illness
WHO:	World Health Organisation.

Data Availability

We have included search strategy as additional file 1. All other supporting documents which informed the development of this review (data extraction, quality appraisal, and SRQR guidelines) are freely available on request.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

SM conducted the search, screening, data extraction quality appraisal, and analysis and wrote the entire review. FG, LR, and JG supervised the whole project by being involved in the design of the research protocol and manuscript, provided input at all stages of the review, reviewed, and revised the manuscript. CZ and SA were involved in title and abstract screening, read, and provided input in the draft version of the manuscript. All the authors have read and approved the final version of the manuscript.

Acknowledgments

The review is part of a PhD project funded by the South African Research Chairs Initiative (SARChI) under the Department of Science and Technology (DST) and National Research Foundation (NRF), reference number MND210619613383. Open access funding was enabled and organized by SANLiC Gold.

Supplementary Materials

Additional file 1: search strategy. (Supplementary Materials)

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Copyright © 2024 Samantha Mhlanga et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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