Denna kunskapsöversikt sammanfattar effekterna av olika boendeinsatser för att motverka hemlöshet. Kunskapsöversikten har tagits fram genom en överenskommelse med Socialstyrelsen. Översikten är en uppdatering av rapporten Boendelösningar för hemlösa personer – en kunskapsöversikt, som Socialstyrelsen publicerade 2009. Underlaget består av 96 vetenskapligt granskade studier publicerade efter 2009, främst från USA och Kanada men med relevans även för svenska förhållanden. Kunskapsöversikten är avgränsad till studier som utvärderar effekter av olika insatser genom kvantitativa effektstudier såsom randomiserade kontrollerade studier (RCT). Det innebär att andra typer av forskning, exempelvis kvalitativa studier, implementeringsstudier eller praktiknära erfarenheter, inte ingår i underlaget. Att en insats saknar evidens i form av effektstudier betyder därför inte nödvändigtvis att den är verkningslös, utan att den ännu inte har prövats med de metoder som krävs för att påvisa vetenskapligt stöd i denna översikt. Evidens implementeras inte i ett vakuum. Den möter befintliga normer, strukturer och marknadsförhållanden.

Bakgrund

Regeringens nationella strategi mot hemlöshet 2022–2026 betonar förebyggande arbete, minskad akut hemlöshet, nationell implementering av Bostad först samt ett stärkt socialt perspektiv i samhällsplaneringen. Hemlöshet beskrivs som både en socialpolitisk och bostadspolitisk utmaning. Den nationella kartläggningen från 2023 visar att drygt 27 000 personer befinner sig i hemlöshet, varav minst 9 400 barn berörs.

Forskningsläget

Studierna i översikten visar att den traditionella svenska boendetrappan saknar evidens och dessutom riskerar att skapa inlåsningseffekter. Merparten av den internationella forskningen fokuserar i stället på modeller där permanent bostad kombineras med flexibelt och individanpassat stöd.

Bostad först

Bostad först har starkast stöd i forskningen. Modellen bygger på principen att en egen bostad ska ges utan krav på behandling eller drogfrihet, och att frivilligt stöd erbjuds parallellt. Effekterna är tydliga:

●    Markant ökad bostadsstabilitet

●    Minskad användning av akuta boenden och sjukhusvård

●    Förbättrad livskvalitet och social integration

●    Minskning av substansbruk över tid

●    Kostnadseffektivitet

Forskningen visar att modellen fungerar för flera målgrupper: personer med samsjuklighet, äldre, unga vuxna och barnfamiljer. Programtrohet är avgörande för resultat.

Evidensen för Bostad först (Housing First) är starkast när det gäller personer i långvarig hemlöshet med samsjuklighet, särskilt samtidig psykisk ohälsa och substansbrukssyndrom. Randomiserade kontrollerade studier i USA och Kanada har visat signifikant högre boendestabilitet jämfört med traditionella trappstegsmodeller. Även långsiktiga uppföljningar indikerar varaktiga effekter avseende boendestabilitet, medan resultaten är mer blandade när det gäller förändringar i psykisk hälsa och substansbruk.

För andra målgrupper, såsom unga vuxna, äldre personer och barnfamiljer, är forskningsunderlaget något mer begränsat och består av kvasi-experimentella studier, implementeringsstudier och systematiska översikter. Studier av unga vuxna tyder på att modellen kan bidra till stabilare boendesituationer och förbättrad social integration, men pekar också på behovet av åldersanpassat stöd. När det gäller barnfamiljer är forskningen mindre omfattande och ofta kontextbunden till nordamerikanska välfärdssystem, men indikerar positiva effekter på boendestabilitet och barns skolnärvaro. För äldre personer är evidensen ännu mer begränsad och fokuserar främst på anpassningar av stödinsatser. Ett lovande exempel är modellen CAPABLE.

En viktig skillnad mellan målgrupperna rör hur de definieras. Personer med samsjuklighet kategoriseras utifrån medicinska och psykiatriska diagnoser, medan unga vuxna, äldre och barnfamiljer definieras utifrån livsfas eller familjesituation. Detta påverkar stödbehovens karaktär: i den första gruppen är vård- och behandlingsinsatser ofta centrala, medan stöd till de senare grupperna i högre grad rör utbildning, arbetsmarknadsintegration, föräldraskap eller åldersrelaterad omsorg.

Samtidigt finns gemensamma strukturella drag. Samtliga grupper kännetecknas av en utsatt position på bostadsmarknaden, ofta i kombination med ekonomisk marginalisering och bristande tillgång till ordinarie välfärdssystem. Forskningen indikerar att det är den omedelbara tillgången till permanent bostad, kombinerad med frivilligt och individuellt anpassat stöd, som är avgörande för positiva resultat snarare än målgruppens specifika problemprofil.

Programtrohet framstår därmed som en avgörande förklaringsfaktor. Studier visar att avvikelser från modellens kärnprinciper, exempelvis villkorad nykterhet, tidsbegränsade kontrakt eller koppling mellan boende och behandlingskrav, tenderar att minska effekterna på boendestabilitet. Skillnaderna mellan grupperna handlar därför mindre om huruvida modellen fungerar och mer om hur stödet behöver anpassas och utformas inom ramen för bibehållen programtrohet.

Stödinsatser: ACT och ICM

Metoderna Assertive Community Treatment (ACT) och Intensive Case Management (ICM) visar goda resultat, särskilt när de kombineras med stabilt boende. Båda modellerna stärker förmågan att bo kvar och minskar behovet av institutionsvård. ACT fungerar särskilt väl för personer med allvarlig psykisk ohälsa och hög vårdkonsumtion.

Andra modeller

Ecologically Based Treatment (EBT) har lovande resultat för unga mödrar.IPS (Individual Placement and Support) ökar möjligheten till en integrering i arbetslivet och förstärker bostadsstabilitet när det kombineras med Bostad först. Permanent supportive housing har visat starka effekter på boendestabilitet för ensamstående vuxna i långvarig hemlöshet med samsjuklighet, och forskningen indikerar att liknande positiva effekter kan uppnås även för barnfamiljer.

Svensk kontext

Trots att många studier är genomförda i andra välfärdssystem bedöms resultaten vara relevanta för Sverige. Allmännyttans förändrade roll och bostadsbristens ökade strukturella karaktär påverkar dock kommunernas handlingsutrymme. Det framgår tydligt att tillgången till långsiktiga och stabila bostäder är en nyckelfaktor, oavsett individernas bakomliggande problematik.

Slutsats

Utifrån resultaten av översikten är vår slutsats att det mest effektiva sättet att motverka hemlöshet är att erbjuda permanenta bostäder i kombination med flexibelt, långsiktigt och individanpassat stöd. Traditionella boendetrappor bör betraktas som ineffektiva och riskabla. Bostad först och integrerade stödmodeller har den starkaste evidensen och bör utgöra grunden för fortsatt utveckling av hemlöshetsarbetet i Sverige i kombination med förebyggande arbete.

BACKGROUND: Implementing the evidence-based Individual Placement and Support (IPS) model in welfare states like Sweden faces contextual challenges that often necessitate local adaptations to enhance fit and effectiveness. While fidelity assessments aim to ensure effective outcomes, adaptations may lead to unintended drift from core components. The Model for Adaptation Design and Impact (MADI) help analyse the characteristics of adaptations and their ripple effects. This study explores the interplay between implementation, adaptations and fidelity in mental health services using the MADI framework.

METHODS: An embedded case study design was used, involving five mental health services in a major Swedish city. Data from 26 key informants, field notes, and meeting protocols were analysed using content analysis and interpreted through the MADI framework.

RESULTS: The adaptations were both planned and unplanned, some adaptations supported the integration of IPS and others negatively impacted core components, revealing unintended impacts on implementation and intervention outcomes.

CONCLUSIONS: To understand adaptations and its pathways when implementing IPS in mental health services, and other stakeholders, the MADI framework is valuable. Excessive adaptations can compromise core values and fidelity assessments must account for adaptations and their consequences. To ensure IPS remains effective, some practices within mental health services and other organisations may need to be revised or adapt to the method itself to support IPS implementation and outcomes. The findings offer valuable insights for professionals and user organisations adopting evidence-based practices in mental health services.

Imminent crises and the much-needed transition to a sustainable society bring knowledge about de-implementation to the fore. Using case studies with inspiration from process tracing, and with tools from Charles Tilly's theory on Durable inequality, we identify mechanisms that generate inequality and counteract the implementation of recovery - and strength-based practices. Our case studies of social work with homelessness in Swedish municipalities, the prospective implementation of Housing First (HF) and the early implementation of Individual Placement and Support (IPS), show that there are recurring similarities in implementation barriers, despite differences in focus of methods and context. They generate knowledge of importance to an emerging critical framework for de-implementation. Such de-implementation knowledge has a strong potential as a practical tool in transforming social and mental health work.

The aim of this chapter is to discuss the strengths of the Housing First approach in tackling homelessness. The Housing First model emphasizes providing immediate access to housing without preconditions, allowing individuals to make choices about their living situation and services. This approach aligns with strength-based practices, which focus on empowering individuals by recognizing and building on their strengths and capabilities. The chapter highlights the importance of situating the person-in-context, identifying enabling and entrapping social niches, and fostering social ties and community involvement. By prioritizing the needs and preferences of the individual, Housing First offers holistic support that addresses various aspects of a person's life, leading to better outcomes in terms of housing stability, health, and overall quality of life.

Background: Employment is a vital source for experiencing well-being and lowering the risk of long-term social marginalisation and poverty. For persons with alcohol and drug addiction, it may also improve sobriety. However, the unemployment situation for this group reflects the knowledge gap in effective interventions to support employment. While Individual Placement and Support (IPS) is recognised as evidence-based supported employment for those with serious mental health problems, no scientific evidence for the target group of addiction exists to date. The aim of the present IPS for Alcohol and Drug Addiction in Sweden (IPS-ADAS) trial is to study whether IPS has an effect on gaining employment for this group. Methods: The IPS-ADAS trial is a multisite, pragmatic, parallel, and single-blinded, superiority randomised controlled trial (RCT). Participants (N = 330) will be randomly assigned (1:1) and participate in IPS plus treatment as usual within Addiction Services (IPS + TAU) or Traditional Vocational Rehabilitation (TVR) available plus TAU (TVR + TAU) for 12 months. The principle of intention-to-treat (ITT) will be applied. The hypothesis is that a significantly larger proportion of IPS + TAU participants will be employed for > 1 day (primary outcome), reach employment sooner, work more hours and longer periods of time, and have a higher income as compared to TVR + TAU participants at 18-month follow-up. We further anticipate that those who benefit from IPS + TAU will use less alcohol and drugs, experience better health, and use less care and support, including support from the justice system, in comparison to TVR + TAU participants, at 6, 12, and 18 months. A supplementary process evaluation, using the IPS Fidelity Scale (25 items) and adhered interviews will address delivery and receipt of the IPS as well as contextual hinders and barriers for coproduction and implementation. Working age (18-65), willingness to work, unemployment, participation in an information meeting about the RCT, treatment for addiction diagnosis, and being financially supported by welfare, constitute eligible criteria. Discussion: A primary study on the effectiveness of IPS on employment for the new target group of addictions will add to the international IPS knowledge base and inform national policy to include the underrepresented group in working life.

Research shows that resistance to change might occur in organisations that implement new evidence-based practices (EBP). Formal and informal structures may work to retain traditional interventions, potentially counteracting the implementation process. Little is known about the de-implementation of traditional practices to leave room for and enhance the implementation of EBPs. This study uses implementation structures as a theoretical framework with the aim of analysing implementation and de-implementation factors among Swedish municipalities that provide support to vulnerable clients through the Housing First (HF) or Individual Placement and Support (IPS) interventional programmes. This cross-sectional study is based on a digital survey and collects descriptive and qualitative data from three organisational levels in each responding municipality in Sweden. The descriptive statistics and qualitative texts were analysed using content analysis. The results show the incidence of HF and IPS, if and to what extent the interventions are going to be developed further, and partially, describe the organisational settings of HF and IPS. Organisational factors shown to have a negative impact on the implementation of HF and IPS were identified. The mapping of professional experiences from the intersection between HF or IPS and organisations such as the Swedish Health Insurance Office, the social services, and other similar welfare organisations, indicates that the realisation of HF and IPS requires expanded collaboration, which raises the consideration as to whether it is necessary to de-implement broader frameworks and guidelines in these organisations to provide the prerequisites that enable the implementation of EBPs.

In recent decades, Sweden has seen extensive change in its housing policy, with emphasis shifting from "good housing for all" to marketisation and the supposed benefits of private ownership (Bengtsson, 2013; Grander, 2018). Consequently, Swedish society is now facing increasing homelessness rates, including whole new groups of social service clients due to housing shortages and people's difficulties accessing the housing market. This article examines the complexities emerging from diverging institutional frames and points specifically to a dividing line between those who can access housing independently and those who need support from the social services. The article describes how such a categorical division/dividing line is institutionalised in the organisation of the social services' work with homelessness and points to causes and effects of this situation. The case study is based on interviews and documents. The interviewees are staff from the municipal social services and the municipal public housing company. Our theoretical point of departure is Tilly's (1999) "categorical inequality," using exploitation, opportunity hoarding, emulation, and adaptation to explain how homelessness is (created and) maintained in our case study. The results show the dependency of social services on external actors and demonstrate the problematic consequences both for those referred to social services and for the practical work within them, including a requirement to stringently control clients. The results further show how it is possible for the social services to maintain collaboration with (public) housing companies at the same time as the most vulnerable clients are permanently denied housing.

The aim of this article is to develop theory and generate knowledge about the challenges and possibilities of co-producing change in a social housing programme. The purpose of the project was to implement the Housing First philosophy in the social housing programme in the city of Helsingborg, Sweden. The aim was also to create opportunities for service user involvement. Several innovative measures were implemented in order for these changes to occur from autumn 2016 to summer 2017. The social services commissioned a university course on which social workers and their clients studied together on equal terms to create project plans for the further development of their own workplace. A "Future" workshop was held by the researchers with representatives from all the different housing options (the shelter, transitional housing, category housing, Housing First apartments), both clients and social workers. Repeated dialogue meetings were conducted at the different housing options to discuss how service user involvement could be developed and to discover new ways of participation. This article is based on a strengths-based perspective using the theoretical discussions on social traps, as well as the concepts of enabling and entrapping niches. We show the importance of social workers identifying and supporting missing heroes-service users who want to participate and be involved in co-producing change. We also show that if an organisation is not prepared for the initiated changes, there is a risk of disappointment due to awakened expectations that are not fulfilled. Building trust is also an important component to emerge from the material, but we also found that change processes can be initiated that continue and have impact beyond the initial project's goals.

The aim of this study was to analyze the influence of some personal characteristics, health variables, and social support on the self-rated health of people in housing exclusion in Spain. For that purpose, we used the FOESSA Survey of Social Integration and Needs database, with a final sample of 1574 households. Being more educated and reporting a good life satisfaction stood out as the main factors preventing worse health status. Furthermore, results showed that being female, experiencing poverty-related food insecurity, not having health insurance, experiencing widowhood or partner bereavement, and having caring responsibilities for others or having a disabled person in the household are associated with increased reporting of regular or poor health. On the other hand, being young, having a diagnosed/long-term illness, and a big household size are preventive factors for good health. These results allowed identifying risk and prevention factors to inform interventions to improve the health of those living in housing exclusion. Promoting better education levels, social support, and overall life satisfaction could be important to improve health in this population. Developing social support policies for caring responsibilities and food insecurity must be a priority to improve the health of people living in housing exclusion.