Clinical trial NCT03772522: The Identity Project
Official title: The Identity Project: An Evaluation of an Identity Capital Intervention for Young People Transitioning Out of Homelessness
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Youth
Homelessness
Keywords: Hopelessness
Self Esteem
Social Isolation
Employment Status
Education
Housing Problems
Identity, Social
Self Efficacy
Control Locus
Poverty
Youth
Homelessness
Homeless Youth
Lead sponsor: Unity Health Toronto
Sponsor class: OTHER
Collaborators: name: dk Leadership
name: Covenant House Toronto
name: Ontario Trillium Foundation
First posted: 2018-12-11
Enrollment: 27
Sex: ALL
Minimum age (years): 18
Maximum age (years): 26
Standard ages: ADULT
Accepts healthy volunteers: yes
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Thirty young people (aged 18 - 26 years) who have transitioned out of homelessness within the past three years will be offered scholarships to participate in a six-week intervention that focuses on building identity capital and providing career direction. The intervention will be designed and carried out by dk Leadership - an established, highly successful leadership and counseling centre in Toronto with a track record of significantly improving the life trajectories of teens and adults. Importantly, study participants will be incorporated into the centre's current programming, meaning the intervention will be held at a location not associated with homelessness. All of the participants will be invited to attend two focus groups, which will be conducted immediately post-intervention and at six months post-intervention. Each focus group will contain approximately 8 - 10 youth. Participants in the intervention and delayed intervention will be in separate focus groups.
Primary purpose: TREATMENT

Brief summary: Understanding how to create successful pathways out of homelessness is crucial. Thirty young people (aged 18 - 26 years) who have transitioned out of homelessness within the past three years will be offered scholarships to participate in a six week intervention that focuses on building identity capital (sense of purpose and control, self-efficacy and self-esteem) and providing career direction. The intervention will be designed and carried out by dk Leadership - an established, highly successful leadership and counseling centre in Toronto with a track record of significantly improving the life trajectories of teens and adults. Importantly, study participants will be incorporated into the centre's current programming, meaning the intervention will be held at a location not associated with homelessness. Study participants will be collaboratively recruited by dk Leadership and Covenant House Toronto - Canada's largest agency for street-involved and homeless youth.

This impact and process evaluation aims to address critical gaps in knowledge about transition-related supports by asking whether and how an identity capital intervention delivered outside the social service sector impacts the life-trajectories of formerly homeless young people. Particular attention will be paid to whether this intervention shows promise as an unconventional way to tackle poverty and improve social inclusion.

It is hypothesize that, for the primary quantitative outcome measures of hope, community integration, social connectedness, and self-esteem:

1. Significant improvements in the mean scores of the intervention group compared to the delayed intervention comparison group immediately post-intervention will be observed.
2. Significant improvements in the mean scores of both groups (intervention and delayed intervention) immediately post-intervention will be observed.
3. These significant improvements will be sustained in both groups for at least three months post-intervention.

Detailed description: Young people comprise almost 20% of the homeless population in Canada. It is estimated between 35,000 and 40,000 Canadian youth (aged 13 - 25 years) are homeless at some point during the year and at least 6,000 on any given night. In Toronto, an estimated 1,000 - 2,000 youth find themselves searching for a place to sleep on any given night.

While a great deal is known about the risk factors associated with young people entering and remaining entrenched in street life (e.g., intergenerational poverty, childhood abuse, inadequate education, and limited employment opportunities), less is known much less about how to facilitate and sustain transitions off the streets for youth experiencing homelessness.

The scarcity of evidence on this issue means there are critical gaps in understanding how best to help homeless young people move forward in life after they become housed. For example, results from a recent longitudinal mixed method study of 51 formerly homeless youth living in Toronto and Halifax - led by Dr. Sean Kidd and colleagues and one of the most rigorous investigations to date - showed that obtaining stable housing did not necessarily translate into a sense of belonging or connection to mainstream society. While study participants demonstrated incredible commitment, the structural barriers they experienced during the transition process (e.g., inadequate education and underemployment) led to fragile identities (i.e., self-concept) as they experienced a significant decline in hope and a sense of being 'stuck'. Youth described feeling unprepared for and overwhelmed by the realities associated with the transition process, undermining their sense of belonging and confidence in achieving larger life goals.

Building on the Kidd et al. study, Dr. Naomi Thulien (the lead investigator for this study) spent 10 months following nine young people who had left the shelter system and moved into market rent housing in Toronto. The study - believed to be the first of its kind - captured the crucial role identity plays in the transition away from homelessness. Despite their remarkable determination, study participants lacked sufficient identity capital - conceptualized as a sense of purpose and control, self-efficacy, and self-esteem - to help them press on in the face of significant structural inequities. Thulien asserts that failure to understand and incorporate identity capital into transition-related supports may result in a poor return on investment as these supports are likely to be ineffective, underutilized, or rejected outright.

One notable identity-based intervention is a randomized controlled trial that targeted 264 eighth graders from high-poverty and high-unemployment neighborhoods in Detroit, Michigan. Participants who attended the seven-week intervention aimed at aligning the students' current identities with achievable positive adult identities, demonstrated improved outcomes on measures pertaining to academics, mood, and behavior, which was sustained through the two-year follow-up. The authors suggest brief identity-based interventions can have significant effects on outcomes. Despite being suggested as a promising approach, the investigators know of no other interventions (nationally or internationally) that are specifically targeting the enhancement of identity capital for formerly homeless young people. Given the limited evidence-based interventions for youth transitioning out of homelessness, the investigators believe there is a critical need for evaluations that compare findings based on different approaches, reflecting the diversity of the population and their corresponding needs.

The proposed intervention is based on two premises: 1) identity is socially constructed and malleable; and 2) people act in identity-congruent ways. Thus, the intervention aims to change socially constructed life trajectories by providing identity-enhancing resources to formerly homeless young people.

This impact and process evaluation aims to address critical gaps in the literature about transition-related supports by asking whether and how an identity capital intervention delivered outside the social service sector impacts the life-trajectories of formerly homeless young people. Particular attention will be paid to whether this intervention shows promise as an unconventional way to tackle poverty and improve social inclusion.

Specifically, this evaluation will investigate and disseminate important new knowledge on the following outcomes

1. The impact of the intervention on measures of hope, community integration, social connectedness, and self-esteem.
2. The effectiveness of the intervention to increase the number of young people in education, employment, or training.
3. Understanding any practical challenges encountered during the intervention implementation and how these challenges were resolved.
4. Understanding what young people found most beneficial about the intervention and their suggestions for how it could be improved.

An impact and process evaluation utilizing a mixed method prospective cohort design with an intervention and delayed intervention comparison group is the most appropriate because it:

1. Addresses the crucial need to understand and disseminate evidence regarding the impact and process of interventions targeting homeless youth - both will help assess and inform questions related to scalability.
2. Provides a more complete and synergistic utilization of data.
3. Balances scientific rigor with the ethical principle of fairness.

This evaluation is a mixed-methods design with a strong qualitative component. Quantitative data collection will occur at six weeks pre-baseline (for the delayed intervention group only), baseline (immediately pre-intervention), immediately post-intervention (one week), three months post-intervention, six months post-intervention, and nine months post-intervention. At each data collection period, participants will be asked whether they are enrolled in education, employment, or training in the questionnaire. They will also be asked about their housing status. Hope, community integration, social connectedness, and self-esteem will be measured quantitatively using scales.

The frequencies, means and standard deviations will be calculated for all evaluation variables. To address the question about the extent to which the outcome variables change over time, independent t-tests will be conducted on the continuous variables (hope, community integration, social connectedness, and self-esteem) and chi-square tests on the categorical variables (education, employment, training, and housing) to report on changes between: 1) baseline and immediately post-intervention; 2) baseline and three months post-intervention; 3) baseline and six months post-intervention; and 4) baseline and nine months post-intervention. To address the question about whether the intervention group demonstrates a statistically significant difference in outcomes compared to no intervention, the outcome variables between the intervention group and the delayed intervention group will be compared six weeks after the baseline questionnaires (i.e., the intervention group will have just completed the dk Leadership program and the delayed intervention group will not have started it yet).

Qualitative measures are an important feature of this evaluation and will consist of: 1) participant observation and 2) focus groups.

Over the six-week intervention period, the co-investigator will attend the weekly meetings as an observer. She will do this with both the intervention and the delayed intervention group. During these meetings, the investigator will take field notes, documenting her perceptions about the way the workshops and group coaching sessions are being run, and how they are being 'taken up' by the young people in the intervention group.

Focus groups, will take place immediately (one week), three months, six months, and 9 months post-intervention. Participants in the intervention and delayed intervention will be in separate focus groups. The questions posed during the focus groups will be guided by the evaluation objectives, but will be conversational and exploratory in nature with particular attention to identity capital, life-trajectories, and social inclusion. It is anticipated that the focus groups will last 60 - 90 minutes. All will be conducted by the co-investigator at locations most convenient for the study participants, and will be audio recorded and transcribed verbatim.

In keeping with the emergent, iterative nature of research using a qualitative design, data analysis and interpretation will begin at the onset of the intervention. The handwritten field notes from the participant observation sessions will be typed into Microsoft Word by the co-investigator immediately after each biweekly meeting. The focus groups will be audio recorded and transcribed verbatim. In order to conduct a more nuanced analysis of the data, the transcriptionist will be instructed to note short responses, uncooperative tones, and literal silence. Prior to each meeting with the participants, the co-investigator will conduct a preliminary data analysis, reading the field notes multiple times, separating the data into coded segments, making analytic memos beside large portions of the field notes or transcripts, identifying emerging themes (and comparing/contrasting these between participants), and complying new questions to ask the participants. Participants will be asked for their perspectives on the emerging interpretations at each visit and these perspectives will play a key role in helping shape the data analysis and help ensure the trustworthiness of the data. The web-based application Dedoose39 will be utilized to assist with sorting and coding the qualitative data.

Study participants may benefit from the opportunity to share with the co-investigator and with each other about whether and how an identity-building intervention delivered outside the social service sector impacts their life-trajectories. Additionally, participants may derive satisfaction from knowing that their contributions will help advance understanding about how best to design interventions that help tackle poverty and improve social inclusion for young people transitioning out of homelessness.

Eligibility criteria: Inclusion Criteria:

* Between 18-26 years of age
* Left homelessness within the last 3 years (youth living in supportive housing contexts (e.g., transitional housing) will be considered to have left homelessness)
* Currently not homeless (youth in supportive or transitional housing are eligible)
* A concerted effort will be made to recruit young people facing additional identity-related challenges like newcomer and racialized youth, Indigenous youth, and youth who belong to the LGBTQ2S community.

Exclusion Criteria:

* Not fluent in English
* Cannot provide informed consent
* Cannot commit to attending two full-day workshops and four half-day group coaching sessions over the course of six weeks (missing more than one workshop and two coaching sessions will disqualify participants from the study)

Primary outcomes:
measure: Mean Change From Baseline in Hopelessness as Measured by the Beck Hopelessness Scale
timeFrame: Assessed at 6 weeks pre-baseline (for the delayed intervention group only), at baseline (immediately pre-intervention), immediately post-intervention, 3 months post-intervention, 6 months post-intervention, and 9 months post-intervention
measure: Mean Change From Baseline in Community Integration (Psychological and Physical) Scores as Measured by the Community Integration Scale (CIS)
timeFrame: Assessed at 6 weeks pre-baseline (for the delayed intervention group only), at baseline (immediately pre-intervention), immediately post-intervention, 3 months post-intervention, 6 months post-intervention, and 9 months post-intervention
measure: Mean Change From Baseline in Social Connectedness Scores as Measured by the Social Connectedness Scale (SCS)
timeFrame: Assessed at 6 weeks pre-baseline (for the delayed intervention group only), at baseline (immediately pre-intervention), immediately post-intervention, 3 months post-intervention, 6 months post-intervention, and 9 months post-intervention
measure: Mean Change From Baseline in Self-esteem Scores as Measured by the Rosenberg Self-Esteem Scale (RSS)
timeFrame: Assessed at 6 weeks pre-baseline (for the delayed intervention group only), at baseline (immediately pre-intervention), immediately post-intervention, 3 months post-intervention, 6 months post-intervention, and 9 months post-intervention
Secondary outcomes:
measure: Change in Vocational Participation/Employment as Assessed by a Questionnaire From Baseline to 9-Months
timeFrame: Assessed at baseline (immediately pre-intervention) and 9 months post-intervention
measure: Change in Academic Participation/Educational Attainment as Assessed by a Questionnaire From Baseline to 9-Months
timeFrame: Assessed at baseline (immediately pre-intervention) and 9 months post-intervention
measure: Number of Themes Related to Change in Career Awareness Informed by Focus Groups With Participants
timeFrame: 60 - 90 minute focus groups at each of the following timepoints: immediately post-intervention, 3 months post-intervention, 6 months post-intervention, and 9 months post-intervention
measure: Number of Themes Related to Change in Knowledge and Use of Soft Skills Informed by Focus Groups With Participants
timeFrame: 60 - 90 minute focus groups at each of the following timepoints: immediately post-intervention, 3 months post-intervention, 6 months post-intervention, and 9 months post-intervention
measure: Number of Themes Related to Participant Perspectives of Intervention Barriers and Facilitators, as Informed by Focus Groups With Participants
timeFrame: 60 - 90 minute focus groups at each of the following timepoints: immediately post-intervention, 3 months post-intervention, 6 months post-intervention, and 9 months post-intervention
Other outcomes:
Locations:
city: Toronto
country: Canada
facility: St. Michael's Hospital
state: Ontario
Study officials:
affiliation: Unity Health Toronto
name: Naomi S Thulien
role: PRINCIPAL_INVESTIGATOR
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