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Although the risk factors associated with young people entering and becoming entrenched in street life have been thoroughly investigated, peer-reviewed evidence is scarce to nonexistent for rigorous interventions targeting social integration outcomes for young people who have experienced homelessness. From the limited research that has been done, emerging evidence signals that, although structural supports such as subsidized housing and social service providers are important, these resources alone are insufficient to help young people integrate into the mainstream society.
The overarching aim of this study is to assess whether and how rent subsidies and mentorship influence social integration outcomes for formerly homeless young people living in market rent housing in 3 Canadian cities. The primary outcome measures for this study are community integration (psychological and physical) and self-esteem at 18 months. Secondary outcomes include social connectedness, hope, and academic and vocational participation at 18 months. Exploratory outcomes include income, perceived housing quality, engulfment, psychiatric symptoms, and participant perspectives of intervention barriers and facilitators.
This is a convergent mixed methods, open-label, 2-arm parallel randomized controlled trial (RCT) with 1:1 allocation embedded within a community-based participatory action research (CBPAR) framework. The intervention will provide 24 young people (aged 16-26 years), who have transitioned out of homelessness and into market rent housing within the past year, with rent subsidies for 24 months. Half of the young people will also be randomly assigned an adult mentor who has been recruited and screened by 1 of our 3 community partners. Data collection will occur every 6 months, and participants will be followed for 30 months.
Ethical approval for this study has been obtained from the Providence, St Joseph’s, and St Michael’s Healthcare Research Ethics Board (number 18-251). Enrollment took place from April 2019 to September 2019. Preliminary analysis of the baseline quantitative and qualitative data is underway.
This pilot RCT will be the first to test the impact of economic and social support on meaningful social integration for formerly homeless young people living in market rent housing. We believe that the mixed methods design will illuminate important contextual factors that must be considered if the intervention is to be scaled up and replicated elsewhere. Importantly, the CBPAR framework will incorporate the perspectives of the community, including formerly homeless young people, who are in the best position to determine what might work best in the context of their lives.
Clinicaltrials.gov NCT03779204; https://clinicaltrials.gov/ct2/show/NCT03779204.
DERR1-10.2196/15557
Young people comprise almost 20% of the homeless population in Canada [
Intuitively, it may seem that one important way to improve the life trajectories of young people experiencing homelessness is to provide them with a home. However, from the limited research that has been done in this area, we know that formerly homeless young people continue to experience significant challenges—particularly when it comes to mainstream social integration—even after they are "successfully" housed [
A longitudinal mixed methods study with 51 formerly homeless young people (aged 16-25 years) living in 2 major urban centers in Canada found that, despite living in stable or semistable accommodations (53% lived in subsidized housing), participants continued to face substantial social integration challenges such as poverty-level incomes and limited mainstream social networks [
A subgroup analysis of 156 young people (aged 18-24 years) with mental health challenges who participated in a 24-month randomized controlled trial (RCT) of
In line with the findings from both these studies, a 10-month ethnographic study conducted by the members of our team with 9 formerly homeless young people (aged 18-24 years) living in Canada’s largest city highlighted that, despite the appearance of housing stability in market rent housing, the young people were experiencing significant social integration challenges [
As previously mentioned, little evidence exists for effective interventions that target social integration outcomes for young people who have experienced homelessness. This includes evidence on the impact of mentorship. In fact, for formal mentorship programs in general, meta-analyses have only found small overall positive effect sizes on the psychological, emotional, behavioral, and educational functioning of participating young people [
A systematic review of natural mentoring for youth (aged 13-25 years) transitioning out of foster care showed that the young people benefited from a supportive adult not “tasked with enforcing daily rules and addressing misbehavior” and that this sort of intervention resulted in improved behavioral, psychosocial, and academic outcomes [
From the limited research that has been done with young people transitioning away from homelessness, the emerging evidence signals that, although structural supports such as subsidized housing and social service providers are important, these resources alone are insufficient to help young people integrate into the mainstream society. As it currently stands, the burden for achieving meaningful social integration is on young people, who continue to be marginalized despite achieving stable or semistable housing. Connecting formerly homeless youth with an adult who exhibits the relationship-based components of natural mentoring that young people value most (eg, genuine interest in their well-being and belief in their ability to succeed) may be key to helping young people move forward and integrate into the mainstream.
The overarching aim of this mixed methods study is to assess whether and how rent subsidies and mentorship influence social integration outcomes for formerly homeless young people living in market rent housing in 3 urban settings.
The primary objective is to determine whether rent subsidies and mentorship result in better social integration outcomes than only receiving rent subsidies with regard to (1) community integration (psychological and physical) and (2) self-esteem.
The secondary objectives are to determine whether rent subsidies and mentorship result in better social integration outcomes than only receiving rent subsidies with regard to (1) social connectedness, (2) hope, and (3) sustained academic and vocational participation.
The exploratory objectives are to assess whether rent subsidies and mentorship result in better social integration outcomes than only receiving rent subsidies with regard to (1) income, (2) perceived housing quality, (3) sense of engulfment, and (4) psychiatric symptoms.
The qualitative objectives of the study are (1) to explore what the study participants (young people and mentors) found most beneficial about the intervention and how it could be improved and (2) to facilitate a more comprehensive and contextualized understanding of the quantitative data.
This is a convergent mixed methods (ie, quantitative and qualitative data are collected concurrently and the findings, combined), open-label, 2-arm parallel RCT with 1:1 allocation embedded within a community-based participatory action research (CBPAR) framework [
With the goal of reducing health inequities through knowledge and action, CBPAR can be a powerful tool for those working with marginalized populations [
Research participants are viewed as experts in their own lives.
Concerted effort to reduce power imbalances between the researchers and the community.
Equal value placed on academic knowledge and experiential knowledge.
Commitment to producing practical, actionable data to build community capacity and improve the lives of the research participants.
Duty to remain invested with the community beyond the life of the research project.
A total of 24 young people aged between 16 and 26 years, who have experienced homelessness within the past year and are living in market rent housing, will be collaboratively recruited by our research team and our 3 community partners: Covenant House Toronto, Living Rock Ministries (Hamilton), and the Raft (St Catharines). We adopted the Canadian Observatory on Homelessness’ definition of homelessness and defined homelessness to include young people who are unsheltered (eg, sleeping on the streets), emergency sheltered (eg, homeless shelter), or provisionally accommodated (eg, time-limited subsidized housing) [
In addition to the above age and housing inclusion criteria, study participants must be able to provide free and informed consent, fluent in English, planning on staying in or nearby the community in which they were recruited for the duration of the 24-month study, and willing to be matched with an adult mentor who has been screened and recommended by one of our 3 community partners.
Young people will be excluded from the study if they are in imminent danger of losing their housing (eg, facing jail time or impending eviction) and are enrolled in another study with enhanced financial and social support.
Potential participants will be screened for eligibility over the phone by the study coordinator. If a participant meets the eligibility criteria, the study coordinator will arrange a face-to-face meeting between the young person and a member of the research team. During this initial meeting, informed consent will be obtained and the youth will be enrolled in the study. Enrolled participants will be asked to provide baseline quantitative data before being randomized into the intervention (rent subsidies plus mentoring) or the active comparator (rent subsidies only) group.
This pilot study was designed with the intention of generating data and hypotheses for a full-scale study. The sample size was chosen based on the financial resources available to provide substantial rent supplements over a 2-year period, and no formal sample size calculation was performed [
Participants at each of the 3 study sites (Toronto [n=12], Hamilton [n=6], and St Catharines [n=6]) will be randomized using block randomization. Randomization will be balanced by site based on random block sizes of 2 and 4. The advantage of using block randomization is to uniformly distribute participants into treatment groups within each site [
The study biostatistician will generate a unique randomization schedule for each site using SAS software (SAS Institute Inc). A research coordinator at St Michael’s Hospital, who is not affiliated with the study, will be the only person with access to the randomization schedule. She will prepare sealed and sequentially numbered envelopes, separated by site (Toronto, Hamilton, and St Catharines). After each participant has been enrolled and has participated in baseline data collection, a member of the study team will select a randomization envelope from the sequentially ordered randomization envelope file to obtain the participant’s group assignment. The participant’s group allocation will be noted, and all opened randomization envelopes will be returned to the independent research coordinator to check for consistency in participant allocation. Typical of community-based RCTs with psychosocial interventions, blinding of research personnel, community partners, and participants to treatment allocation would not be possible owing to the nature of the intervention [
All study participants (n=24) will receive rent subsidies for 24 months, paid directly to the landlords by our community partners. Given the higher cost of rent in Toronto, youth living in Toronto will receive Can $500/month, whereas youth living in Hamilton and St Catharines will receive Can $400/month.
Participants in the intervention group (n=12) will be matched with an adult mentor recruited and screened by one of our community partners. Covenant House Toronto has an established mentorship program and will share their comprehensive mentor screening and training resources, which will act as a guide for all sites. Working with established community resources makes practical sense; not only will this facilitate colearning and capacity building between the research team and our community partners but delivering the mentorship intervention under
Our community partners will match all participants with an outreach worker (already employed by each agency and considered standard of care) who will communicate regularly with the research team, help ensure the rent subsidies are being distributed appropriately, maintain an ongoing relationship with the study participants and mentors, and monitor for red flags in participants matched in mentor-mentee relationships (eg, mentee reluctant to meet with their mentor).
Consolidated standards of reporting trials’ diagram of ideal flow of participants through the study. The quantitative measures (QT) completed with all participants will comprise 6 standardized measures to assess community integration, self-esteem, social connectedness, hope, engulfment, and psychiatric symptoms. In addition, participants will complete 2 brief questionnaires pertaining to: (1) education (includes skills training), employment, and income and (2) perceived housing quality. The qualitative measures (QL) will comprise one-on-one semistructured interviews with the same 12 participants. The interview questions will explore the participant’s perspectives of the intervention and provide context to the quantitative responses.
To fully apprehend the complex explanatory pathways of the intervention, we have aligned our key outcome variables (
Key outcome variables.
Variables | Instruments | |
|
||
Community integration (psychological and physical) | Community Integration Scale [ |
|
Self-esteem | Rosenberg Self-Esteem Scale [ |
|
|
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Social connectedness | Social Connectedness Scale–Revised [ |
|
Hope | Beck Hopelessness Scale [ |
|
Enrollment in education (includes skills training) | Composite checklist | |
Employment | Composite checklist | |
|
||
Income | Composite checklist | |
Engulfment | Modified Engulfment Scale [ |
|
Psychiatric symptoms | Modified Colorado Symptom Index [ |
|
Perceived housing quality | Perceived Housing Quality Scale [ |
|
Participant perspectives of barriers and facilitators | Individual semistructured interviews (youth) and focus groups (mentors) and composite checklist (mentor evaluation) |
Participant demographic data will be collected at baseline. Quantitative questionnaires (
Quantitative data collection.
Instrument | Psychometric information |
Beck Hopelessness Scale [ |
This 20-item scale measures motivation, expectations, and feelings about the future (internal consistency alpha=.93) |
Community Integration Scale [ |
This 11-item scale measures behavioral (eg, participation in activities) and psychological (eg, sense of belonging) aspects of community integration. This scale was used extensively in the Chez Soi/At Home study [ |
Education, Employment, and Income Questionnaire | This 13-item questionnaire assesses education, employment, and income. We developed this questionnaire for the study |
Mentor Evaluation Questionnaire | This 10-item questionnaire assesses mentor effectiveness. It will be completed at month 24 by those in the intervention group. We developed this questionnaire for the study in collaboration with our community partners |
Modified Colorado Symptom Index [ |
This 14-item scale measures the presence and frequency of psychiatric symptoms experienced in the past month (internal consistency alpha=.90 to .92) |
Modified Engulfment Scale [ |
This 30-item scale measures the degree to which an individual’s self-concept is defined by their experience of homelessness (internal consistency alpha=.91). We have adapted the scale for this study, substituting |
Perceived Housing Quality [ |
This 7-item scale measures participants’ perception of housing choice and quality. This scale was used extensively in the At Home/Chez Soi study [ |
Rosenberg Self-Esteem Scale [ |
This 10-item scale measures global self-worth (internal consistency alpha=.77 to .88) |
Social Connectedness Scale–Revised [ |
This 20-item scale measures belongingness—the degree to which an individual feels connected to others (internal consistency alpha=.92) |
Qualitative measures are an important feature of this study and will comprise semistructured individual interviews with study participants and focus groups with mentors. A total of 12 participants (6 from Toronto, 3 from Hamilton, and 3 from St Catharines) will be purposively chosen to participate in 6 semistructured individual interviews, which will take place at baseline, month 6, month 12, month 18, month 24, and month 30. We will select 6 participants from the intervention group (rent subsidies plus mentorship) and 6 from the control group (rent subsidies only) for qualitative interviews. All mentors (n=12) will be invited to participate in 2 focus groups, which will take place at month 12 and month 24. The questions posed during the semistructured interviews and focus groups will be conversational and exploratory in nature with particular attention to understanding how mentoring and/or rent subsidies influence social integration outcomes for formerly homeless young people living in market rent housing. To get a better sense of each young person’s living situation and to minimize researcher-participant power imbalance [
One major critique of mixed methods RCTs is that, typically, there is no true integration (ie,
All analyses will be performed using the intention-to-treat principle. Baseline characteristics of the intervention and control groups will be summarized using mean, standard deviation, median, and interquartile range for continuous variables and frequencies and proportions for categorical variables. Differences in group trajectories from baseline to 30 months follow-up will be explored using scatterplots and box plots. Group mean differences with 95% confidence intervals in continuous outcomes at 18 months (psychological community integration, self-esteem, social connectedness, hope, perceived housing quality, sense of engulfment, and psychiatric symptoms) will be estimated using analysis of covariance, including an indicator of intervention group and the baseline value of the outcome. We will perform regression diagnostics and will repeat analyses using the nonparametric Wilcoxon rank sum test if there are extreme outliers or influential observations. For the count outcome of physical community integration, groups will be compared at 18 months using graphical tools and the nonparametric Wilcoxon rank sum test. For binary outcomes at 18 months, such as sustained academic and vocational participation, and income above low income cut-off, differences in proportions with 95% confidence intervals will be estimated and tested using the chi-square or Fisher exact test. If there are high rates of attrition or missing interviews, we will consider performing multiple imputation.
In keeping with the emergent, iterative nature of research using a qualitative design [
We worked closely with our community partners to design this study and amended the design based on their feedback. For example, we initially proposed a study design where only half the young people would receive rent subsidies with the other half receiving
All data collected will be kept in strict confidence. Although the participants’ names will appear on the consent forms, pseudonyms (created by the participants) will be used in place of their real names on all documents related to data generation, including the audio recordings and interview transcripts. All electronic data will be stored on a secure server at the MAP Centre for Urban Health Solutions at St Michael’s Hospital and will be accessible only to select members of the research team. The audio recordings from the individual interviews and focus groups will be deleted once the transcripts have been stored on the secure server and entered into the Dedoose application. Paper copies of the data (eg, consent forms and standardized quantitative measures) will be stored in a locked filing cabinet at the MAP Centre for Urban Health Solutions—an area accessible only to those with electronic key access. All paper and electronic files will be retained for a period of up to 5 years from study closure.
In keeping with our CBPAR methodology, we are committed to disseminating evidence
Ethical approval for this study (protocol version January 13, 2019) was obtained in November 2018 from the Providence, St Joseph’s, and St Michael’s Research Ethics Board (REB; number 18-251). Any amendments to the study protocol will be reviewed by our community partners and approved by the Providence St Joseph’s and St Michael’s Healthcare REB before implementation. Enrollment took place from April 2019 to September 2019. We have enrolled 24 young people in the study. Preliminary analysis of the baseline quantitative and qualitative data is underway.
This pilot RCT will be the first to test the impact of economic and social support on meaningful social integration for formerly homeless young people living in market rent housing. We believe the mixed methods design will illuminate important contextual factors that must be considered if the intervention is to be scaled up and replicated elsewhere. Importantly, the CBPAR framework will incorporate the perspectives of the community, including formerly homeless young people, who are in the best position to determine what might work best in the context of their lives.
Young people recruited for this pilot study will be a small sample of youth connected to urban-based social service providers in the province of Ontario, Canada. Thus, the findings may not be generalizable to formerly homeless young people living in other contexts and/or not connected to social service agencies.
community-based participatory action research
Research Ethics Board
randomized controlled trial
This study is being conducted in collaboration with the authors’ 3 community partners: Covenant House Toronto, Living Rock Ministries, and the RAFT.
This work is being supported by the St Michael’s Hospital Foundation. The funding source had no role in the design of this study and will not have a role in its execution, analyses, interpretation of the data, or decision to submit results.
NT conceived the study. RN provided statistical expertise. All authors contributed substantially to the refinement of the study protocol and approved the final manuscript.
None declared.