"When I think about my future, I just see darkness": How youth exiting homelessness navigate the hazy, liminal space between socioeconomic exclusion and inclusion.

OBJECTIVES: The overarching objective of this mixed methods longitudinal study was to understand whether and how rent subsidies and mentorship influenced socioeconomic inclusion outcomes for youth exiting homelessness. The focus of this paper is on the qualitative objectives, which evolved from a primary focus on exploring how study mentorship was working as a facilitator of socioeconomic inclusion to focusing on how participants navigated the hazy, liminal space between socioeconomic exclusion and inclusion. METHODS: This was a convergent mixed methods study scaffolded by community-based participatory action axiology. The quantitative component is reported elsewhere and involved a 2-year pilot randomized controlled trial where 24 participants received rent subsidies and 13 were randomly assigned a study mentor; proxy indicators of socioeconomic inclusion were measured every 6 months for 2.5 years. Qualitative objectives were explored using a qualitative descriptive design and theoretically framed using critical social theory. The lead author interviewed 12 participants every 6 months for 2.5 years. Qualitative interviews were analyzed using reflexive thematic analysis with an emphasis on critical interpretation. RESULTS: Navigating the liminal space between socioeconomic exclusion and inclusion was complex and non-linear, and the way youth navigated that journey was more strongly associated with factors like informal mentorship (naturally occurring "coach-like" mentorship) and identity capital (sense of purpose, control, self-efficacy, and self-esteem), rather than whether or not they were assigned a formal study mentor. CONCLUSION: A holistic approach integrating coaching and attention to identity capital alongside economic supports may be key to helping youth exiting homelessness achieve socioeconomic inclusion.

RéSUMé: OBJECTIFS: L'objectif primordial de cette étude longitudinale à méthodes mixtes était de comprendre si et comment les suppléments au loyer et le mentorat influencent les résultats sur le plan de l'inclusion socioéconomique pour les jeunes qui sortent du sans-abrisme. Notre article porte sur des objectifs qualitatifs; à l'origine, il visait principalement à explorer l'efficacité du mentorat des études comme moyen de faciliter l'inclusion socioéconomique, puis il a évolué en s'attachant à la manière dont les participantes et les participants trouvaient leurs repères dans l'espace liminaire flou entre l'exclusion et l'inclusion socioéconomique. MéTHODE: Cette étude à méthodes mixtes convergentes est échafaudée sur l'axiologie de l'action participative communautaire. L'élément quantitatif, qui fait l'objet d'un autre article, a impliqué un essai pilote comparatif randomisé de deux ans où 24 participantes et participants ont reçu des suppléments au loyer, et 13 ont été jumelés de façon aléatoire à un tuteur ou une tutrice scolaire; des indicateurs approximatifs de l'inclusion socioéconomique ont été mesurés tous les six mois pendant deux ans et demi. Les objectifs qualitatifs ont été explorés à l'aide d'un protocole descriptif qualitatif et encadrés théoriquement par la théorie sociale critique. L'autrice principale a interviewé 12 participantes et participants tous les six mois pendant deux ans et demi. Les entretiens qualitatifs ont été analysés en employant l'analyse thématique réflexive et en mettant l'accent sur l'interprétation critique. RéSULTATS: L'exploration de l'espace liminaire entre l'exclusion et l'inclusion socioéconomique était complexe et non linéaire, et le parcours des jeunes était davantage associé à des facteurs comme le mentorat informel (le mentorat naturel semblable à celui d'un entraîneur ou d'une entraîneuse) et le capital identitaire (le sentiment d'avoir un but, le contrôle, l'auto-efficacité et l'estime de soi) qu'au fait d'avoir ou non été jumelés à un tuteur ou une tutrice dans leurs études. CONCLUSION: Une démarche holistique intégrant l'encadrement et l'attention au capital identitaire, en plus des mesures de soutien économique, pourrait être essentielle pour aider les jeunes qui sortent du sans-abrisme à s'intégrer sur le plan socioéconomique.

Effect of Portable Rent Subsidies and Mentorship on Socioeconomic Inclusion for Young People Exiting Homelessness: A Community-Based Pilot Randomized Clinical Trial.

Importance: There have been no published randomized clinical trials with a primary outcome of socioeconomic inclusion for young people who have experienced homelessness. Objective: To explore whether young people exiting homelessness who received rent subsidies and adult mentorship experienced more socioeconomic inclusion relative to young people who received only rent subsidies. Design, Setting, and Participants: This was a convergent mixed-methods, unblinded, 2-group, parallel randomized clinical trial with 1:1 allocation embedded within a community-based framework in 3 cities in Ontario, Canada. Participants were enrolled between March 1 and September 30, 2019, and were followed up through March 31, 2022. Interventions: Participants (n = 24) were randomly assigned adult mentors (n = 13) who had been recruited and screened by community partner agencies. All participants received portable rent subsidies (subsidy not tied to a specific location) for 2 years. Main Outcomes and Measures: Primary quantitative outcomes were self-reported measures of community integration (psychological and physical) and self-esteem-proxy indicators of socioeconomic inclusion. Community integration was measured with the Community Integration Scale, with a score range of 1 to 7 for the physical component and 4 to 20 for the psychological component; higher scores indicate higher integration. Self-esteem was measured with the Rosenberg Self-Esteem Scale, with a score range of 0 to 30; higher scores indicate greater self-esteem. Secondary quantitative outcomes included social connectedness, hopelessness, and academic and vocational participation. All analyses followed the intention-to-treat principle. Results: A total of 24 youths (12 women [50.0%]; mean [SD] age, 21.8 [2.2] years [range, 18-26 years]; race and ethnicity: 10 White [41.7%], 8 Black [33.3%], 2 Asian [8.3%], 2 Indigenous [8.3%], and 2 different choice [8.3%]) transitioned out of homelessness and into market-rent housing. All youths in the group that received mentorship and in the group that did not receive mentorship had stable or nonsignificant improvements in all study outcomes at the primary end point of 18 months compared with baseline (mean [SD] Community Integration Scale psychological score: mentorship group, 11.3 [2.6] at baseline and 11.2 [3.9] at 18 months; no-mentorship group, 10.8 [4.1] at baseline and 13.2 [2.9] at 18 months; mean [SD] Rosenberg Self-Esteem Scale score: mentorship group, 16.0 [4.6] at baseline and 18.1 [5.2] at 18 months; no-mentorship group, 16.3 [6.1] at baseline and 19.6 [5.7] at 18 months). However, there were no significant differences between the 2 groups in the Community Integration Scale psychological score (adjusted mean difference, -2.0; 95% CI, -5.0 to 1.0; P = .18) and Rosenberg Self-Esteem Scale score (adjusted mean difference, -1.4; 95% CI, -5.0 to 2.3; P = .44) 18 months after randomization. Ancillary analysis suggested that youths with informal mentors (mentors outside the study) at baseline felt more psychologically integrated at 18 months relative to those with no informal mentors at baseline (adjusted mean difference, 3.6; 95% CI, 0.4-6.8; P = .03). Conclusions and Relevance: In this randomized clinical trial, COVID-19 pandemic-related restrictions made it challenging for mentors and mentees to connect, which may have affected the findings. Steady socioeconomic outcomes-potentially attributable to portable rent subsidies-are noteworthy, given the socioeconomic inequities this population has faced during the COVID-19 pandemic. The possible benefit of informal mentorship warrants further investigation. This small pilot study was designed with the intention of generating data and hypotheses for a full-scale study; findings should be interpreted with caution. Trial Registration: ClinicalTrials.gov Identifier: NCT03779204.

Tackling exclusion: A pilot mixed method quasi-experimental identity capital intervention for young people exiting homelessness.

BACKGROUND: Longitudinal studies examining the life trajectories of young people after they have exited homelessness have identified concerns with persistent social and economic exclusion, struggles to shake off identities of homelessness, and housing instability. This pilot study sought to explore the feasibility of improving socioeconomic inclusion outcomes by bolstering identity capital (sense of purpose and control, self-efficacy and self-esteem) among young people who had experienced homelessness. METHODS: Nineteen individuals (aged 18-26) who had transitioned out of homelessness within the past three years participated in a six-week, six-session program focused on building identity capital. The study employed a mixed method prospective cohort hybrid design with an intervention group (Group One) and a delayed intervention comparison group (Group Two). Participants were interviewed every three months until nine months post-intervention. RESULTS: None of the youth who began the intervention dropped out of the program, with the exception of one participant who moved across the country and was unable to continue. Immediately after participating in the intervention, Group One had statistically significant improvements (p < .05) and large to very large effect sizes in self-esteem (d = 1.16) and physical community integration (d = 1.79) compared to changes in Group Two over the same period, which had not yet begun the intervention. In the pooled analysis, small to moderate effect sizes in hopelessness, physical community integration, and self-esteem were observed at all post-intervention time points. Notably, at six- and nine-months post-intervention, statistically significant improvements (p < .05) and moderate effect sizes in hopelessness (d = -0.73 and d = -0.60 respectively) and self-esteem (d = 0.71 and d = 0.53 respectively) were observed. Youth shared they appreciated the normalizing (vs. pathologizing) of strategies they needed to learn and spoke of the importance of framing new skills as something one needs "to have a better life" vs. "to get better." CONCLUSIONS: These early findings signal that targeting identity capital is feasible and may be a promising approach to incorporate into a more complex intervention that includes housing, education, and employment supports to help youth transition out of homelessness. Future research could build on these findings through a sufficiently powered randomized controlled trial.

Evaluating the Effects of a Rent Subsidy and Mentoring Intervention for Youth Transitioning Out of Homelessness: Protocol for a Mixed Methods, Community-Based Pilot Randomized Controlled Trial.

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TRIAL REGISTRATION: Clinicaltrials.gov NCT03779204; https://clinicaltrials.gov/ct2/show/NCT03779204. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15557.

The elusive goal of social integration: A critical examination of the socio-economic and psychosocial consequences experienced by homeless young people who obtain housing.

OBJECTIVES: The objective of this study was to provide an insider perspective on the experiences of nine formerly homeless young people as they transitioned into independent (market rent) housing and attempted to achieve meaningful social integration. METHODS: The study was conducted in Toronto, Canada, and guided by the conceptual framework developed for the World Health Organization by the Commission on Social Determinants of Health. A critical ethnographic methodology was used. Over the course of 10 months, the lead author met every other week with nine formerly homeless young people who had moved into their own homes within 30 days prior to study recruitment. RESULTS: Unaffordable housing, limited education, inadequate employment opportunities, poverty-level income, and limited social capital made it remarkably challenging for the young people to move forward. As the study progressed, the participants' ability to formulate long-range plans was impeded as they were forced to focus on day-to-day existence. Over time, living in a perpetual state of poverty led to feelings of "outsiderness," viewing life as a game of chance, and isolation. CONCLUSION: Rather than a secure, linear path from the streets to the mainstream, study participants were forced to take a precarious path full of structural gaps that left them stuck, spinning, and exhausted by the day-to-day struggle to meet basic needs. Despite their remarkable agency, it was almost impossible for the participants to achieve meaningful social integration given the structural inequities inherent in society. These observations have implications for practice, policy, and research.

Innovative approaches to cervical cancer screening for sex trade workers: an international scoping review.

OBJECTIVE: Female sex trade workers are among those at highest risk for developing and dying of cervical cancer, and yet many-particularly the most marginalized-are less likely than other women to be screened. This review summarizes global findings on innovative approaches to cervical cancer screening for female sex trade workers, highlights current gaps in the delivery of cervical cancer screening for female sex trade workers globally, and suggests areas for future research and policy development. DATA SOURCES: A scoping review of peer-reviewed publications and grey literature was conducted. Medline (OVID), PubMed, EMBASE, and SCOPUS were searched for relevant studies written in English. There were no limitations placed on dates. Grey literature was identified by hand searching and through discussion with health care providers and community outreach workers currently working with sex trade workers. STUDY SELECTION: Twenty-five articles were deemed suitable for review. Articles detailing innovative ways for female sex trade workers to access cervical cancer screening were included. Articles about screening for sexually transmitted infections were also included if the findings could be generalized to screening for cervical cancer. Articles limited to exploring risk factors, knowledge, awareness, education, prevalence, and incidence of cervical cancer among sex trade workers were excluded from the review. DATA EXTRACTION AND SYNTHESIS: Successful screening initiatives identified in the studies reviewed had unconventional hours of operation, understood the difference between street-based and venue-based sex trade workers, and/or used peers for outreach. CONCLUSION: Two significant gaps in health care service delivery were highlighted in this review: the limited use of unorthodox hours and the nearly exclusive practice of providing sexually transmitted infection screening for female sex trade workers without cervical cancer screening. In addition, although street-based (as opposed to venue-based) sex trade workers are likely at higher risk for developing cervical cancer, they are much less likely than other eligible women to participate in screening programs, meaning traditional outreach methods are unlikely to be successful.

Objectif : Les travailleuses du sexe font partie des femmes qui sont exposées aux risques les plus élevés de connaître un cancer du col utérin et d'en mourir, et pourtant, un bon nombre d'entre elles (particulièrement celles qui sont les plus marginalisées) sont moins susceptibles de faire l'objet d'un dépistage que les autres femmes. Cette analyse résume les constatations globales quant aux approches novatrices envers le dépistage du cancer du col utérin pour ce qui est des travailleuses du sexe, souligne les lacunes actuelles en ce qui concerne l'offre de services de dépistage du cancer du col utérin à l'ensemble des travailleuses du sexe et suggère des voies à explorer pour la tenue de futures recherches et l'élaboration de politiques. Sources de données : Une analyse d'orientation des publications soumises à l'examen collégial et de la littérature grise a été menée. Des recherches ont été menées dans Medline (OVID), PubMed, EMBASE et SCOPUS en vue d'en tirer les études pertinentes rédigées en anglais. Aucune limite n'a été imposée en matière de dates. La littérature grise a été identifiée par recherche manuelle et par l'intermédiaire de discussions avec des fournisseurs de soins et des travailleurs de proximité communautaires qui œuvraient auprès de travailleuses du sexe. Sélection des études : Vingt-cinq articles ont été considérés comme répondant aux critères de l'analyse. Les articles détaillant des façons novatrices de permettre aux travailleuses du sexe d'obtenir accès à des services de dépistage du cancer du col utérin ont été inclus. Les articles traitant du dépistage des infections transmissibles sexuellement ont également été inclus, lorsque les constatations y étant faites pouvaient être généralisées au dépistage du cancer du col utérin. Les articles se limitant à l'exploration des facteurs de risque, des connaissances, de la sensibilisation, de l'éducation, de la prévalence et de l'incidence pour ce qui est du cancer du col utérin chez les travailleuses du sexe ont été exclus de l'analyse. Extraction et synthèse des données : Les initiatives réussies de dépistage qui ont été identifiées dans les études analysées comptaient des heures d'exploitation non conventionnelles, comprenaient la différence entre les travailleuses œuvrant dans la rue et celles qui travaillent en maison close, et/ou faisaient appel à des pairs pour la mise en œuvre de services d'approche. Conclusion : Deux lacunes considérables en ce qui concerne l'offre de services de santé ont été soulignées dans le cadre de cette analyse : l'utilisation limitée d'heures irrégulières et l'offre pratiquement exclusive de services de dépistage des infections transmissibles sexuellement excluant le dépistage du cancer du col utérin aux travailleuses du sexe. De plus, bien que les travailleuses du sexe œuvrant dans la rue (par comparaison avec celles qui travaillent en maison close) soient probablement exposées à des risques accrus de voir apparaître un cancer du col utérin, elles sont beaucoup moins susceptibles que les autres femmes admissibles de participer à des programmes de dépistage, ce qui signifie que le recours aux modes d'approche traditionnels a peu de chances de donner des résultats satisfaisants.