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Protocol
Evaluating the Effectiveness of the Housing First for Youth
Intervention for Youth Experiencing Homelessness in Canada:
Protocol for a Multisite, Mixed Methods Randomized Controlled
Trial
Stephen Gaetz1, PhD; Ahmad Bonakdar2, PhD; John Ecker2, PhD; Cora MacDonald2, MA; Sophia Ilyniak3, MA;
Ashley Ward2, PhD; Lauren Kimura4, MPH; Aranie Vijayaratnam5, BA; Emmanuel Banchani6, PhD
1Faculty of Education, York University, Toronto, ON, Canada
2The Canadian Observatory on Homelessness, York University, Toronto, ON, Canada
3York University, Toronto, ON, Canada
4City of Toronto, Toronto, ON, Canada
5University of Toronto, Toronto, ON, Canada
6Faculty of Arts, St. Francis Xavier University, Antigonish, NS, Canada
Corresponding Author:
Ahmad Bonakdar, PhD
The Canadian Observatory on Homelessness, York University
6th Floor Kaneff Tower, 4700 Keele St.
Toronto, ON, M3J 1P3
Canada
Phone: 1 416 736 2100 ext 30208
Email: bonakdar@yorku.ca
Abstract
Background: Emerging evidence at the international level suggests that the Housing First approach could improve the housing
stability of young people experiencing homelessness. However, there is a dearth of literature in Canada on whether the Housing
First intervention for young people experiencing homelessness can improve outcomes including housing stability, health and
well-being, and access to complementary supports. Adapted from the original Housing First model, Housing First for Youth
(HF4Y) was developed in Canada as a rights-based approach tailored specifically for young people aged 16 to 24 years who are
experiencing or are at risk of homelessness.
Objective: The Making the Shift Youth Homelessness Social Innovation Lab is testing the effectiveness of the HF4Y intervention
in Canada. The objective of this study is to determine whether the HF4Y model results in better participant-level outcomes than
treatment-as-usual services for young people experiencing homelessness in 2 urban settings: Ottawa and Toronto, Ontario. Primary
outcomes include housing stability, health and well-being, and complementary supports, and secondary outcomes include
employment and educational attainment and social inclusion.
Methods: The HF4Y study used a multisite, mixed methods, randomized controlled trial research approach for data collection
and analysis. Eligible participants included young people aged 16 to 24 years who were experiencing homelessness or housing
precarity. The participants were randomly assigned to either the treatment-as-usual group or the housing first intervention group.
Survey and interview data in Ottawa and Toronto, Ontario are being collected at multiple time points (3-6 months) over 4 years
to capture a range of outcomes. Analytic strategies for quantitative data will include mixed-effects modeling for repeated measures
and logistic models. A thematic analysis will be used to analyze qualitative data based on participants’narratives and life journeys
through homelessness. Furthermore, program fidelity evaluations are conducted within each HF4Y program. These evaluations
assess how well the intervention aligns with the HF4Y model and identify any areas that may require adjustments or additional
support.
Results: The HF4Y study has received human participant research ethics approval from the Office of Research Ethics at York
University. Recruitment was conducted between February 2018 and March 2020. Data collection is expected to be completed at
both sites by March 2024. A preliminary analysis of the quantitative and qualitative data collected between baseline and 24 months
is underway.
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Conclusions: This pilot randomized controlled trial is the first to test the effectiveness of the HF4Y intervention in Canada.
The findings of this study will enhance our understanding of how to effectively deliver and scale up the HF4Y intervention, with
the aim of continually improving the HF4Y model to promote better outcomes for youth.
Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) ISRCTN10505930;
https://www.isrctn.com/ISRCTN10505930
International Registered Report Identifier (IRRID): DERR1-10.2196/46690
(JMIR Res Protoc 2023;12:e46690) doi: 10.2196/46690
KEYWORDS
youth homelessness; Housing First for Youth; Canada; randomized controlled trial; RCT; Making the Shift
Introduction
Background
Youth homelessness has become a social problem in Canada
that does not lend itself to a straightforward solution. Young
people who experience homelessness (aged 13-24 years) account
for approximately 20% of the total population experiencing
homelessness in Canada, with 6000 to 7000 young people
experiencing homelessness on any given night [1]. Pathways
into youth homelessness are diverse and essentially emerge as
the outcome of a complex and intricate interplay between
individual and relational risk factors (eg, family crises and
trauma), structural circumstances (eg, poverty and the lack of
affordable housing), and systems failures (eg, fragmented service
and program delivery) [2,3]. To effectively reduce and end
youth homelessness, it is necessary to identify best practices
and program interventions that address the unique needs of
developing adolescents and young adults.
To date, studies have mostly focused on evaluating the different
models of housing and support programs that serve adults
experiencing homelessness, particularly those with mental health
and substance use disorders [4]. Among such programs, the
Pathways model known as Housing First gained currency in
the 1990s, largely because of its demonstrated efficacy in
reducing homelessness for individuals experiencing chronic
homelessness and serious mental illness [5]. The underlying
premise of the Pathways model was that individuals
experiencing homelessness should be placed in housing as
quickly as possible without conditions or prerequisites such as
sobriety or medication adherence. The well-established,
evidence-based body of research on the Pathways model lent
further support to its success, with many cities adopting the
model to address homelessness [6-9].
Within the Canadian context, the national At Home/Chez Soi
project initiated in 2008 the largest randomized controlled trial
(RCT) of the Housing First intervention, with many studies
stemming from this research project [10-15]. The Mental Health
Commission of Canada implemented the Housing First model
in 5 cities (Vancouver, Winnipeg, Toronto, Montreal, and
Moncton) with >2200 individuals who were experiencing
homelessness. The 1-year and 2-year findings of the At
Home/Chez Soi project across various sites provided compelling
evidence that the Housing First intervention is an effective
approach that helps individuals experiencing homelessness and
who have serious mental illnesses exit homelessness more
quickly compared with other treatment-as-usual (TAU) services
[11,12,16,17].
However, as discussed by Goering et al [10], it remains
unknown whether the Housing First intervention is effective
and can be replicated among young adolescents with diverse
racial and sociodemographic backgrounds, particularly within
the Canadian context where Indigenous youth experiencing
homelessness are overrepresented [3]. In addition, although
Kozloff et al [14] presented promising results that the Housing
First model can be “a viable intervention to promote housing
stability in homeless youth with mental illness,” they suggested
that modifications be made to the model to better meet the needs
of youth, as their findings indicated that the application of the
model to young people did not significantly improve other
primary outcomes in the treatment group (eg, community
integration and substance use).
With these considerations in mind, Housing First for Youth
(HF4Y) was developed in Canada as an adaptation of the
original Housing First model and is based on the understanding
that the causes and conditions of youth homelessness are distinct
from those affecting adults; therefore, the solutions must
likewise be youth focused [18-22]. This means that HF4Y is
designed specifically to meet the needs of young adults who
are at risk of or experience homelessness by providing them
with age-appropriate supports including housing. As a
rights-based approach, HF4Y rests on the philosophy that “all
people deserve housing and that adequate housing is a
precondition for recovery” [23]. The core principles of the HF4Y
model provide a framework for developing the interventions
that are needed to help young people successfully transition to
adulthood in a safe and planned way. These core principles are
as follows [20]:
1. A right to housing with no preconditions: as a rights-based
and youth-centric approach, HF4Y does not require youth
to fulfill any precondition, such as sobriety or abstinence,
to qualify for receiving housing support.
2. Youth choice, youth voice, and self-determination: this
principle speaks to providing opportunities for youth to be
in control of their own lives and encouraging them to make
informed decisions when it comes to deciding where they
want to live, rather than having this imposed on them (in
real-world practice, eg, if a young person cannot live in
cooperative housing with shared rooms, case workers need
to discuss and work on a solution to accommodate the youth
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living on their own by finding a place that is suitable for
the young person and within their budget).
3. Positive youth development and wellness orientation: as a
strength-based approach, the HF4Y model extends beyond
assessing risk and vulnerability by recognizing the assets
and strengths of young individuals to build self-esteem and
a positive sense of self.
4. Individualized, client-driven supports with no time limits:
as youth have diverse pathways into homelessness, the
program model is client-driven to ensure culturally
appropriate services are offered to youth that also
accommodate the spectrum of sexual orientation and gender
identities with no time limits.
5. Social inclusion and community integration: HF4Y
promotes social inclusion by building youth’s life skills
and strengthening their existing relationships or by
providing opportunities for them to meaningfully participate
in community activities and engage with school and the
labor market.
There is emerging evidence on the effectiveness of HF4Y at
the international level [24-26]; however, little is known about
the effectiveness of the HF4Y model in Canada, particularly
considering that interventions and programs based on the HF4Y
model must strictly adhere to the model’s core values and
principles to qualify as an HF4Y intervention [20]. This paper
describes the research protocol of a 4-year comprehensive study
that will contribute to the evidence base on the effectiveness of
HF4Y through a rigorous program of developmental and
outcomes evaluations. This will enhance our understanding of
how to effectively deliver the HF4Y intervention and what
outcomes are likely to be expected, with the aim of continually
improving the HF4Y model to promote better outcomes for
youth.
Making the Shift Youth Homelessness Social
Innovation Lab
A key challenge in addressing youth homelessness is to
determine what works, for whom it works, and in what context
[27]; thus, how we frame “youth homelessness” is of paramount
importance. In the Canadian context, youth homelessness refers
to “the situation and experience of young people between the
ages of 13 and 24 who are living independently of parents and/or
caregivers, but do not have the means or ability to acquire a
stable, safe, or consistent residence” [3]. The youth population
experiencing homelessness is diverse, with Indigenous,
2SLGBTQA+ (2-spirit, lesbian, gay, bisexual, transgender,
queer [or questioning], asexual, and additional groups), and
Black youth being overrepresented, meaning that our
interventions need to be implemented with a focus on equity,
diversity, and inclusion [3].
Focusing specifically on the prevention of youth homelessness
(ie, reducing inflow into homelessness and returns to
homelessness), the Making the Shift (MtS) Youth Homelessness
Social Innovation Lab is coled by A Way Home Canada and
the Canadian Observatory on Homelessness, which is housed
at York University. MtS supports the facilitation of sustainable
exits from homelessness by identifying, developing, prototyping,
testing, evaluating, and mobilizing innovations in policy and
practice through the implementation of demonstration projects.
Blending experimental program delivery with research and
evaluation, the demonstration projects include 15 sites across
Canada in 12 communities in Alberta, British Columbia,
Newfoundland and Labrador, and Ontario. These projects are
intended to expand the knowledge and understanding of
innovative approaches to preventing and ending youth
homelessness by using design thinking and producing scientific
evidence to truly meet the needs of those served. The
demonstration projects also help determine how and whether a
proposed policy or intervention works—known as establishing
“proof of concept”—which can later be used to inform policy
and provide knowledge for “scaling” successful models beyond
the original communities.
As part of the MtS Youth Homelessness Social Innovation Lab,
3 demonstration projects on HF4Y are currently being
implemented by community agencies in Ottawa, Toronto, and
Hamilton in Ontario, Canada. In each of the cities, agencies that
work with youth experiencing homelessness are implementing
and operating the HF4Y program, consistent with the model
developed by Gaetz et al [21]. Each testing site focuses on
specific populations of young people experiencing homelessness.
Although Ottawa focuses on youth currently experiencing
homelessness, Toronto focuses on youth exiting the child
welfare system as a preventive intervention.
In Hamilton, an RCT design is not being used as it does not
align with the values of Indigenous knowledge and traditions.
Instead, a hybrid model is being implemented; it is called
Endaayaang and combines the core principles of HF4Y with
Indigenous ways of knowing and cultural practices. In Canada,
Indigenous youth include 3 distinct cultural groups, that is, First
Nations, Metis, and Inuit. Youth from these communities are
overrepresented in the population of youth experiencing
homelessness because of the history of colonialism (including
practices aimed at eradicating Indigenous cultural traditions
such as residential schools and the 1960s Scoop); involvement
with child protection services; and the presence of intersecting
forms of oppression, intergenerational trauma, and
marginalization [28-30]. The adaptation of the HF4Y program
necessitates the inclusion of Indigenous leadership in the
program for it to succeed. Therefore, an Indigenous-led
methodology that adopts a hybrid approach combining Western
and Indigenous methodologies and ways of knowing is being
used [31]. This approach combines elements from the
settler-developed HF4Y model with Indigenous ways of
knowing and cultural practices, rooted in the understanding that
Indigenous youth must experience a sense of belonging within
their community and have access to cultural and spiritual
guidance from Elders and Traditional Knowledge Keepers to
achieve positive outcomes.
The demonstration projects intend to help build an evidence
base for youth homelessness prevention in Canada and to inform
work on youth homelessness internationally. The research
protocol described in this paper focuses on the models being
implemented at the HF4Y sites in Toronto and Ottawa. The
Endaayaang program model, which incorporates Indigenous
epistemology, vernacular knowledge, and Indigenous-led
research methodologies, will be described separately.
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Study Objectives
The HF4Y study seeks to engage relevant stakeholders and
communities in a collaborative research and knowledge
translation process throughout all stages of the project. The
stakeholders include young people with lived experiences of
homelessness, Indigenous communities, the agencies engaged
in the homelessness sector and delivering interventions, and the
broader network of service providers for youth experiencing
homelessness in each city. On the basis of an equity lens, this
study also intends to address the intersectional needs of
racialized, Indigenous, and 2SLGBTQA+ youth populations as
well as youth with disabilities. Together, this collaboration aims
to achieve the following objectives:
1. To determine whether the HF4Y model results in better
participant-level outcomes than TAU services for young
people experiencing homelessness in 2 urban settings
(Ottawa and Toronto) with respect to (1) housing stability;
(2) health and well-being; (3) complementary supports such
as social functioning and life skills (4) engagement in
education, training, and employment; and (5) social
inclusion.
2. To identify the critical components of the HF4Y model and
what modifications are needed to effectively serve particular
communities and subpopulations (eg, youth exiting the
child welfare system, Indigenous youth, and 2SLGBTQA+
youth).
3. To identify the main pathways into youth homelessness or
precarious housing situations and understand the key
challenges young people experience in terms of recovery,
the ability to thrive, and housing precarity. This will allow
policies, practices, and program interventions to be
improved to better serve the needs of youth experiencing
homelessness.
It should be noted that the relationship between these objectives
can be framed in a complementary manner, which helps improve
the HF4Y program to better respond to the needs of youth
experiencing homelessness.
Methods
Study Design
The HF4Y study uses a longitudinal, multisite, mixed methods
RCT research approach for data collection and analysis. The
choice of using an RCT design was consistent with the relevant
body of clinical trials at the intersection of homelessness, social
policy, and health [16,32,33], particularly the At Home/Chez
Soi national project [10]. RCT studies are widely regarded as
the highest standard for studying causal relationships between
interventions and outcomes [34,35]. Despite their limitations,
such as population availability, missing data, and participant
dropouts [36], RCTs can successfully minimize a substantial
portion of the inherent biases commonly observed in other study
designs.
There is a growing recognition of the importance of integrating
qualitative approaches in RCTs [37]. The choice of incorporating
a qualitative inquiry in this study was intended to gain insights
from youth participants during the implementation phase to
better understand the effects of the HF4Y interventions and how
they are experienced by recipients. Therefore, the results of the
qualitative inquiry and RCT can be integrated to draw
meaningful conclusions about the efficacy of the HF4Y
intervention.
Each of the 2 site-specific HF4Y demonstration projects was
tailored to reflect the needs of the target population as well as
the unique local environments and cultural contexts at hand. At
both the Ottawa and Toronto sites, 2 groups were created: an
intervention group that received housing first (HF intervention)
and a control group that received TAU services. At both sites,
the participants randomized to the HF intervention group receive
housing and support, consistent with the HF4Y program model
[20,21], including the provision of a housing subsidy for the
duration of the study (4 years). Youth participants are offered
a range of housing options with no treatment preconditions (eg,
in-place crisis, transitional, supportive, or scatter-site housing
with mobile supports), and they receive an array of case
management services related to housing retention, well-being,
income and employment, education, and social inclusion as
well as complementary supports. Participants randomized to
the TAU group do not receive the HF intervention but generally
have access to supports and regular housing programs in the
community that are available for young people, potentially
including income support, drop-ins, physical and mental health
clinics, emergency shelters, and transitional housing or
longer-term housing. Participants in this group are provided
with an information package about both housing and supports
and are invited to use the field office or participating service
agency as a resource.
Partnership and Public Involvement
The HF4Y research study actively engaged community partners
and youth with a lived experience of homelessness throughout
the design and implementation process. Forming a partnership
with key stakeholders, including community agencies, was
pivotal to advancing the goals of the study while allowing for
a more meaningful collaboration between researchers and
service providers. It was important that the study be delivered
in partnership with local agencies, as the ultimate aim was to
build practical knowledge and an evidence base for the HF4Y
intervention. Combining on-the-ground knowledge with insights
provided by a large body of stakeholders, including service
providers, policy makers, researchers, and youth with lived
experience, was an underlying ethos that undergirded the
development of the original HF4Y program model guide [20].
The collaboration between researchers and 2 key organizations,
namely, the Street Youth Planning Collaborative (Hamilton)
and the National Learning Community on Youth Homelessness,
played a central role in shaping and executing this study. In
particular, the input from young individuals with lived
experience was crucial and highly valued during this
collaborative process. The findings of this study will also be
shared with the youth participants and community partners who
actively participated in the research.
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Ethical Considerations
The study’s human participant research protocol was approved
by the Office of Research Ethics at York University (2017-382).
The eligible participants are provided with informed consent
forms that contain information about the study, participants’
rights, expectations, potential risks and benefits, the amount of
compensation, and the resources and services available for them
during the study. Informed consent is also solicited from
participants for each follow-up survey or interview. Participants
are compensated for their participation in the research depending
on the length of the sessions they attend. For the intervention
group, 90-minute appointments are being remunerated with
CAD $50 (US $37) per session, and shorter appointments of
30 minutes are being remunerated with CAD $25 (US $18.5)
per session. For the TAU group, 90-minute appointments are
being remunerated with CAD $60 (US $44.4) per session, and
shorter appointments of 30 minutes are being remunerated with
CAD $35 (US $25.9) per session. Qualitative interviews last
approximately 60 to 90 minutes, and participants in both the
intervention and control groups receive CAD $50 (US $37) per
interview.
The privacy and confidentiality of participants will strictly be
followed to the fullest extent possible by the law. All identifying
information collected will be treated as strictly confidential.
The names of the participants will not be used to identify the
data at any stage of the research. Each participant will instead
be identified by a number code on every survey, recording, and
transcript to ensure privacy. The participants ID list, linking the
participants’ names with their unique identifiers, will be kept
electronically on a password-protected computer in the locked
office of the principal investigator at the Canadian Observatory
on Homelessness at York University. This participants ID list
will be kept separate from all other data and will only be
accessible to the research team enlisted in the study’s human
participant research protocol. The participants ID list will be
kept in the event that any participant wishes to withdraw from
the study following data collection. In terms of data analysis,
the research team will only be working with deidentified data,
and all findings will be presented at the aggregate level. For the
purpose of research dissemination, no identifying information
about the participants themselves or the names of participating
agencies and organizations will be shared in publications or
presentations.
Participants’ Recruitment
The recruitment process began by identifying eligible youth
across the demonstration sites, which included young people
aged 16 to 24 years who were experiencing homelessness or
housing precarity consistent with the Canadian definition of
youth homelessness [3]. However, because of concerns over
participants not reaching the age of majority to be able to
participate in the HF4Y research study, the age range was set
between 16 and 24 years. Owing to different operational
procedures, each community agency included additional criteria
in terms of recruiting participants.
Potential study participants came from the pool of young people
who accessed homelessness services and associated sectors (eg,
child protection services, youth mental health or addictions
services, law enforcement, or corrections). Each site determined
additional inclusion criteria to address existing gaps in local
service delivery as well as individualized recruitment strategies
based on local prioritization processes and budgeting limitations.
For example, the Ottawa site recruited youth aged 18 to 24 years
who were experiencing homelessness, including young people
living in a shelter, couch surfing, or sleeping outdoors. The
Toronto site recruited youth experiencing homelessness (or at
risk of experiencing homelessness) aged 17 to 24 years who
had been in or were transitioning out of the provincial child
welfare system.
To identify eligible participants to be recruited for the study,
outreach activities began with local agencies and providers who
were in contact with young people experiencing homelessness
in Ottawa. Community representatives from each site developed
a strategy to work with potential referral sources and inform
them about the study. Strategies to ensure adequate participation
in the study included seeking referrals from a wide range of
services accessed by each site population. In Ottawa, these
included local youth shelters, drop-in centers, city prioritization
lists (ie, by-names list), and other local service agencies
delivering programs for youth experiencing homelessness. In
Toronto, youth were primarily referred by Youth in Transition
workers who work with youth exiting the child welfare system,
in addition to the types of referral sources used in Ottawa.
Researchers and service delivery teams followed site-specific
strategies for informing referral agencies (eg, outreach, posters,
and meetings with key staff), identifying prospective
participants, making contact to ascertain participant interest,
and carrying out screening processes.
Recruitment for the study started in February 2018 in Ottawa
and was completed in November 2019, with 86 participants
enrolled in the study. In Toronto, the first participants were
recruited in June 2018, and the final group of youth was
admitted to the study in March 2020, with 62 youth participants
in total. At the initial interview, participants were guided through
an informed consent process and then asked to complete a
baseline evaluation (interview and survey) before receiving a
notification of the group assignment.
Data Collection and Randomization
Survey and interview data in Ottawa and Toronto are being
collected at multiple time points over the course of 4 years to
capture a range of outcomes, as listed in Table 1. Data collection
is expected to be completed at both sites by March 2024. The
data collection procedures follow a sequential, mixed methods
design [38], which involves a 2-phase process starting with the
quantitative data collection, followed by a qualitative phase to
help provide a deeper understanding of the survey responses
and quantitative results based on participants’personal narratives
and life journeys through homelessness.
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Table 1. Core outcome areas, domains, measures, and interval schedule.
IntervalMeasures and instrumentsCore outcome areas, variables, and domains
Housing stabilitya
3 monthsc
Residential timeline follow-back [39]b
Obtaining and maintaining housing with reduced stays in emer-
gency shelters
6 monthsCasey-Ansell Youth Life Skills Assessment (adapted) [40]Knowledge and skills regarding housing and independent living
Health and well-beinga
6 monthsWorld Health Organization Quality of Life-Brief Form [41]Perceptions of health and well-being
6 monthsGlobal Appraisal of Individual Needs–Short Screener [42]Behavioral health
6 monthsFood Security Survey [43]Food security
6 monthsBrief Symptom Inventory [44]Psychological functioning
6 monthsOntario Student Drug Use and Health Survey [45]Substance use patterns
6 monthsGeneral Self-Efficacy Scale [46]Self-efficacy
Complementary supportsa
6 monthsCasey-Ansell Youth Life Skills Assessment (Adapted) [40]Life skills
6 monthsDiagnostic interviewAccess to necessary nonmedical services
6 monthsHerth Hope Index [47]Hope for the future
6 monthsDiagnostic interviewLegal and justice issues
6 monthsThe Resilience Scale-14 [48]Resilience
Education and employment
3 months
VTLFBdand education [13]
Participation in education and training
24 monthsDiagnostic interviewEducational achievement
3 monthsVTLFB and employmentParticipation in the labor force
3 monthsVTLFB and incomeFinancial security
Social inclusion
6 monthsMultidimensional Screener of Perceived Social SupportFamily and natural supports
6 monthsPsychological Community Integration Scale [49]Sense of belonging to the community
6 monthsPhysical Community Integration Scale [50]Engagement in cultural and meaningful activities
aPrimary outcomes domains.
bThe residential timeline follow-back (RTLFB) is designed to assess various aspects of housing status and stability. In this study, it serves to incorporate
point-in-time assessments and longitudinal evaluations of participants’ housing stays and transitions. It allows building a chronological record of each
respondent's residential history between successive interviews. In addition, the RTLFB collects information about the type of residence, the individuals
the participants are living with, and the reasons for moving in and moving out during the specified period. The records obtained from the RTLFB will
be analyzed to gain insights into the specific places where young people stayed during the study, as well as the reasons for their moves in and out of
different residences. This information will contribute to a comprehensive assessment of the effectiveness and impact of the HF4Y intervention on their
housing stability and overall well-being.
cThe measures and intervals listed will be used at the interval indicated to collect data over 48 months (eg, the residential timeline follow-back is being
used every 3 months for 48 months).
dVTLFB: vocational timeline follow-back.
It was expected that baseline differences would exist across
sites, reflecting the diverse demographic, socioeconomic, and
ethnoracial background of participants based on regional
characteristics. To achieve representativeness in the RCT
sample, homogeneous sampling was used [38], which targeted
several shared characteristics including age range (youth aged
16-24 years) and those who were experiencing homelessness
or were at risk of homelessness. For each site, a minimum of
63 participants needed to be recruited for the study to be able
to detect an effect size of 0.5 between the TAU group and the
intervention group for the primary outcome domains, given
α=.05 and β=.20. However, the total number of participants
recruited was 148 to account for an attrition rate of 25%,
following similar RCT-designed studies [11,17].
The participants were assigned through strict randomization to
either the TAU or HF intervention groups. Research assistants
sealed assignments in envelopes ordered by participant
identification number according to a randomization sequence
generated through a web-based random sequence generator.
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Once the baseline interview was completed, the participants
received a notification of the group assignment in a sealed
envelope along with an information sheet. In Ottawa, 44 youths
were assigned to the HF intervention group and 42 were
assigned to TAU group. In Toronto, the number of participants
in the HF intervention and TAU groups was equal (n=31; Figure
1). After group assignment, research assistants connected the
participants assigned to the HF intervention group to the
program service provider. Participants randomized to the TAU
group were informed about the available services in the
community. All participants were informed of the schedule of
research follow-up appointments and were invited to use the
research field office or the participating service agency as a
resource center. All participants were provided with a pamphlet
on existing services in the community.
Figure 1. Housing First for Youth randomized controlled trial study design HF: housing first; TAU: treatment-as-usual.
Housing and Supports Services
Participants randomized to the HF intervention group receive
housing and support in accordance with the HF4Y model’s
framework and core principles [20,21]. The program staff were
extensively trained on the intervention requirements to ensure
fidelity to the model. Supports offered include the provision of
a housing subsidy, such that participants spend ≤30% of their
income on housing based on the private rental market.
Participants may also live in social, supported, or alternative
housing with no treatment preconditions (eg, in-place crisis,
transitional, supportive, or scatter-site housing with mobile
support), in which case the rent supplement is not required. The
provision of support services is not bound by any preconditions
(eg, housing readiness, sobriety, and engagement in other
treatment), although participants agree to be visited in their unit
a minimum of once per week by program staff for a length of
time that is appropriate to their level of need.
It is important to note that although a range of housing options
is available in both Ottawa and Toronto, the immediate access
to specific options may vary. Factors such as demand, capacity,
and funding influence the availability of each option. Resource
limitations or eligibility criteria may result in some options
being more readily available than others.
The intervention services young people receive within the HF4Y
model, including a housing rent subsidy and a range of supports
delivered via housing-based case managers, are designed to
bridge the financial gap and enhance young people’s ability to
secure suitable housing, such as private market rentals, which
they may not be able to afford on their own. In addition,
housing-based case managers provide support in navigating
housing processes while ensuring that young people are aware
of their housing prospects. These supports include providing
young people with comprehensive information about the various
housing options available in the community as well as
facilitating discussions with youth on the advantages and
disadvantages of each option, including any potential constraints
in accessing their preferred types of housing. Through these
conversations, young people actively participate in the
decision-making process, enabling them to select the type of
housing, neighborhood, and level of services that best align
with their individual needs and preferences. This means that
young people can also reassess their needs and make adjustments
to their housing options as required. This approach empowers
young individuals, promotes informed decision-making, and
supports their personal growth and development.
The HF4Y model offers a wide array of support services related
to housing retention, well-being, income and employment,
education, and social inclusion as well as complementary
supports such as peer support that are offered by providers who
are based off-site. These support services are individualized and
tailored specifically to participants’ needs, preferences, and
cultural backgrounds. Adapted from the Pathways model [5],
the support services are provided in the home or community,
using mostly intensive case management, which is appropriate
for individuals with moderate mental health needs and linked
them primarily to 1 case manager rather than a team. In the
HF4Y program model [20-22], an intensive case management
model should be established in the range of 7 to 10 youths per
case manager, with 7 being the ideal number to produce the
most desired, optimal outcomes for youth. Case managers work
with participants to obtain and maintain housing and to navigate
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referrals to external services (eg, mental health support and
medical services).
Compared with the HF intervention group, no active intervention
is introduced to the TAU group. However, participants may
continue to access existing supports and housing available in
each community, including income support, drop-ins, physical
and mental health clinics, emergency shelters, transitional
housing, and longer-term housing. As both Ottawa and Toronto
are urban centers with agencies that deliver housing services
targeted to young people, it is recognized that some individuals
in the TAU group may over time, through new or existing
programs, access some of the same services being offered to
the HF intervention group. It is also likely that the usual care
service patterns will differ between cities.
Participant Retention
Participation retention is a major concern, particularly in RCT
studies where receiving maximum response rates and
compliance with the research protocol is pivotal to their success.
In this longitudinal study, enrolling young people experiencing
homelessness and housing precarity was a particularly difficult
task because of their involvement in a variety of competing
activities, such as school and meeting their basic needs. In
addition, barriers such as unstable housing and frequent
transitions have made it difficult for youth to maintain a
consistent mode of communication over time. The COVID-19
pandemic in February 2020 compounded these challenges, as
it disrupted the efforts made to establish and maintain contact
with youth.
Existing literature suggests strategies to minimize participant
attrition, which broadly include baseline tracking procedures
such as collecting detailed information on the participant’s
location and follow-up procedures, including sending reminders
to conduct follow-up interviews [51-53]. Consistent with the
literature, this study uses an array of techniques to maintain
contact with hard-to-reach participants, which include building
rapport, supplementing traditional tracking methods (eg, phone,
email, social media, and known associates) with new
technologies, and offering financial incentives. More
importantly, as data collection is still underway, a key factor is
cultivating an appreciation of the contribution of the respondents
as experts. Such a “participant-centered” approach [54] ensures
that participants are aware of the impact of their participation
in the outcomes and success of the study, thereby increasing
the likelihood that they will continue to be engaged in the study.
Although the existing body of research suggests varying rates
of retention depending on the types of strategies used, ranging
from 65% to 85% [53], this study aims to keep approximately
75% of the participants engaged in the study over 4 years.
Outcome Areas and Measures
Building on the existing body of research including the At
Home/Chez Soi national study, primary outcomes were selected
to reflect the unique characteristics of youth experiencing
homelessness and to measure the effectiveness of the HF4Y
program interventions that are consistent with the program’s
core principles and the detailed service delivery model
[20,21,55]. In evaluating complex interventions, there are a
range of factors that likely have an impact on housing
stabilization, including sufficient and stable income, health and
well-being, involvement with the justice system, involvement
in education and employment, and social inclusion [56,57]. The
core primary outcomes are thus selected to assess the
effectiveness of HF4Y interventions on housing stability (as
defined by a joint function of the number of days housed and
the number of moves), health and well-being (mental and
physical health status), and access to complementary supports,
with secondary outcomes consisting of participation in education
and employment and social functioning, as listed in Table 1
[55]. Multimedia Appendix 1 provides a comprehensive
description of the measures.
In Ottawa and Toronto, interviews and surveys designed to
collect quantitative data were administered at baseline, and each
follow-up takes place at specific time points (3-6 months) over
4 years. At entry into the study (baseline), youth participants
were interviewed using a range of questions aimed at collecting
demographic data, physical health conditions, access to care,
housing retention (using residential timeline follow-back), and
employment (using vocational timeline follow-back; refer to
Multimedia Appendix 1 for a detailed description of the
interview measures). Following the interview, the participants
were administered a battery of survey measures for physical
and mental health and well-being, social inclusion, self-esteem
and self-efficacy, resilience, hope, quality of life, and a measure
reflecting complementary skills that impact the various domains
(Table 1). In-person and phone-based follow-up quantitative
interviews are being conducted at 3- or 6-month intervals
depending on the instrument used. Since the onset of the
COVID-19 pandemic, interviews and surveys with youth
participants have been conducted remotely via Zoom (Zoom
Video Communications) or phone. The number and timing of
interview sessions were decided based on two factors: (1) the
intention to evaluate longer-term outcomes and trajectories of
change for each participant and (2) the recognition that
participants may miss appointments owing to the nature of their
situation and issues. This may be even more pronounced in the
TAU group that has no interaction with the intervention, and,
therefore, a potentially weaker incentive to attend appointments
as scheduled.
The collection of primary data is mostly achieved through
interviews conducted via Zoom or phone, with a mixture of
both paper- and computer-based survey methods. Each interview
appointment takes approximately 30 to 60 minutes to complete,
and the participants are compensated for their time.
Computer-based surveys administered through the Qualtrics
survey platform are entered into a secure central database using
wireless technology. Hard-copy data are stored securely
following double-lock procedures at each site, and electronic
backups are stored on cloud-based, secure, institutional
network–based storage. Several strategies are being used to
ensure optimal data quality: (1) using validated and reliable
tools for susceptible youth populations; (2) using a cross-site
protocol for data management, data entry, quality checking, and
cleaning; (3) practicing common data-checking routines at each
site through monthly multisite data quality committee meetings;
(4) training interviewers for face-to-face and web conferencing
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interaction with participants; and (5) fielding interviewer
questions centrally and making decisions where necessary across
both RCT sites.
Following a sequential mixed methods approach [38], a subset
of 20 youths per group at each RCT site was randomly selected
(10 participants from the HF intervention group and 10 from
the TAU group) to participate in a narrative interview, once at
6 months and later at 18 months. Demographic data of
participants successfully recruited into the qualitative study
were then assessed to ensure balance in demographic variables
including age, gender identity, and ethnoracial background.
The purpose of this qualitative research inquiry is (1) to
supplement the quantitative data collected with respect to the
effectiveness of the HF4Y program and (2) to help identify areas
that need improvement for future scaling of the HF4Y program.
This qualitative approach is also intended to allow us to
understand the lived and living experiences of study participants
in their own words through life story (or “narrative”) interviews.
For the large majority of youth participants, homelessness is
not the product of a single event, but it is seen as a journey in
which individual agency and life decisions take center stage.
The qualitative interviews follow a semistructured format and
include questions that are mapped onto the quantitative outcome
domains. The follow-up interviews help understand how youths’
lives have changed during the RCT and what things may have
contributed to those changes. These interviews specifically
inquire about the types of services within and outside the HF4Y
program that participants are currently receiving. They also
explore the types of services participants require but are not
currently receiving as well as their perspectives on the
helpfulness or limitations of the services they are accessing.
Analytical Procedures
HF intervention and TAU groups will be compared within each
RCT site; although if it is determined that no significant
differences exist between the 2 sites in terms of
sociodemographic characteristics and outcome measures
collected at baseline, the TAU and intervention groups will be
combined accordingly across sites to increase the power of the
study. There will be an interim analysis using 2-year quantitative
data, with the final analyses based on the 4-year data. It is
expected that certain participants might not adhere to the
protocol or could discontinue their involvement owing to health
issues or fatigue arising from repeated assessments. As
deviations from the protocol are inevitable and likely to occur
in real-time practice [58-60], there exist a number of approaches
that can preserve the integrity of the randomization process
including an intention-to-treat analysis, which considers all
participants initially randomized in the study.
In addition, certain participants may be more likely not to
respond to surveys, or certain questions might be more likely
to have missing responses. With respect to missing data, 3
common mechanisms can be observed: missing completely at
random, missing at random, and missing not at random [61,62].
For data missing completely at random, single imputation
methods can be used to address the missing values, albeit with
a tendency to provide conservative estimates of the treatment
effect; for example, missing values can be replaced with the
last observed values or the mean values. For data missing at
random and missing not at random, multiple imputation can be
used, which produces a more accurate and less biased estimate
of the treatment effect [63].
For continuous outcome measures, differences between the
intervention and control groups will be examined by using
mixed-effects modeling for repeated measures. For binary
outcomes, logistic models will be used, and negative binomial
modeling will be used for all count outcome measures to account
for any possible overdispersion in the data. Sociodemographic
characteristics collected at baseline will be entered into the
models as covariates, and the interaction between time and
intervention will be considered to capture the interaction effects.
All quantitative analyses will be conducted in SPSS (IBM Corp)
and R studio (Posit) software packages with power set at 80%
(α=.05 and β=.20) to detect an effect size of 0.5 between the
TAU and intervention groups for the primary outcome domains.
Qualitative data will be assessed through thematic analyses to
identify common themes related to outcomes and to analyze
the underlying intervention process, consistent with the
approaches suggested by Miles et al [64] and Saldaña [65]. The
qualitative data provide a rich source of the narratives regarding
young people’s experiences with homelessness, housing
instability, and interaction with the HF4Y program itself.
Interviews will be transcribed and imported into NVivo (QSR
International) software for analysis. Rather than focusing on
preexisting theoretical constructs using an a priori method, an
emergent, bottom-up approach will be used for coding [64].
The process of coding will shift back and forth from the key
narratives provided by the participants to the researcher’s
interpretation of the meaning of those narratives, which will be
documented through the researcher’s analytic memos. Recurring
patterns gleaned from the codes will be grouped as themes and
will be thematically classified under broader themes. The final
set of themes will be summarized and presented in a table, where
representative quotes from transcripts will be paired with themes
as textual evidence.
In addition to the quantitative and qualitative analyses, each
agency is responsible for completing monthly reports that
provide important metrics for all participating youth, including
demographic information and key indicators such as the number
of youth housed during the month and the number of youth who
exit a program. Furthermore, program fidelity evaluations are
conducted within each HF4Y program. These evaluations assess
how well the intervention aligns with the HF4Y model and
identify any areas that may require adjustments or additional
support.
Data Access
Quantitative data are entered directly into laptops configured
specifically for the project and are stored using a contracted
service provider who will manage data storage for the study on
an off-site, centralized server with high levels of physical
network security. No data are stored on the hard drive, and after
entry, the hard copies are kept in secure storage at each site.
Access to the data is limited to authorized users only, using a
multilevel permission protocol.
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Results
The HF4Y study has been registered with the International
Standard Randomized Controlled Trial Number
(ISRCTN10505930). Human participant research ethics approval
has been obtained from the Office of Research Ethics at York
University. Recruitment was conducted between February 2018
and March 2020. Data collection is expected to be completed
at both sites by March 2024, and preliminary analysis of data
collected between baseline and 24 months is underway. The
preliminary findings of the study will be published through
public-facing reports at 24 months, and these results will be
generated from deidentified and aggregate-level data (final
results will be reported at 48 months). These reports will be
made publicly available for the broader network of community
partners and all levels of government (federal, provincial, and
municipal), and they will be hosted virtually for a larger
readership. Furthermore, several peer-reviewed, scholarly
publications will be published based on the study’s findings in
top-tier journal outlets with an open-access option. During the
course of the study, research vignettes and blog posts will
highlight the ongoing progress of the research project and
discuss the lessons learned, and this will be followed by a
number of webinars and presentations at major national and
international conferences. In addition, as part of the MtS project
and in the context of what we have learned from implementation
science [66-70], a robust training and technical assistance
capacity has been developed to enable the spread and scaling
of the HF4Y program. In particular, an iterative interaction
between research and practice enhances service design and
contributes to the continuous quality improvement of training
and technical assistance.
Discussion
Strengths and Limitations
As the first pilot RCT to test the effectiveness of the HF4Y
intervention in Canada, this study’s strength lies in its approach
to engaging participants and community partners in the study
design while using a sequential, mixed methods design during
the quantitative phase, followed by a qualitative phase. However,
this study has some limitations. A larger sample size would
make the study’s findings more robust in terms of
aggregate-level analyses. The current sample size could
potentially limit the generalizability of our results. Participant
dropouts, missed intervals, and noncompliance between the HF
intervention and TAU groups could also affect the outcomes.
Furthermore, RCT studies have limitations including issues
related to low sample sizes, external validity, and missing data,
which are applicable to this study.
Public Health Implications
The findings of this study will help build an evidence base on
the impact of HF4Y through a rigorous program of
developmental and outcomes evaluations. The findings will
have potential public health implications for youth experiencing
homelessness or housing precarity, as housing stability is central
to preventing homelessness and addressing the range of physical
and mental health issues resulting from housing instability [55].
Consistent with the emerging evidence at the international level
[24,26], we anticipate an increase in housing stability and a
reduction in homelessness, followed by longer periods of
housing retention in the HF4Y intervention groups compared
with the TAU group. This could lead to enhanced physical and
mental well-being, improved social functioning, and increased
community integration while allowing participants to
meaningfully engage in education and employment
opportunities. In addition, improved housing quality and
increased housing stability are likely to lead to a reduction in
the use of hospitals and emergency services as well as improved
clinical outcomes, such as psychiatric symptoms and substance
use, and reduced involvement in the criminal justice system.
Conclusions
Although there is emerging evidence on the efficacy of HF4Y
globally [24-26], there is limited knowledge about its
effectiveness specifically in Canada. This knowledge gap is
significant because the HF4Y interventions and programs in
Canada must adhere closely to the model’s core values and
principles to be recognized as true HF4Y interventions. This
study will contribute to our understanding of how to effectively
deliver and scale up the HF4Y intervention, with the aim of
continually improving the HF4Y model and promoting better
outcomes for youth.
The HF4Y pilot study will provide an evidence base for
transforming policy and program interventions to address youth
homelessness. This requires a shift away from solely managing
the crisis and toward prioritizing prevention, which entails
supporting those who are experiencing or at risk of homelessness
to regain stable housing. By empowering individuals to sustain
their housing, the HF4Y demonstration project actively seeks
to engage youth in education and cultivate their sense of
inclusion in the community, thereby creating a foundation for
long-term health and well-being.
Acknowledgments
Funding for this study is provided by the Government of Canada through the Youth Employment and Skills Strategy Program
of the Department of Employment and Social Development, Canada. The funding is being implemented through a partnership
between A Way Home Canada, the Canadian Observatory on Homelessness, and local partner agencies.
The views expressed herein solely represent those of the authors.
The authors would like to thank the editorial team and the 2 anonymous reviewers for their comments on the earlier version of
this manuscript. The authors would like to acknowledge the invaluable work of Cedar Michel for copyediting the earlier version
of this manuscript.
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Data Availability
The data sets generated and analyzed during this study are available upon request. External researchers must make a formal
request to use the data sets and agree to the policies and procedures set forth by the Making the Shift. Inquiries and requests can
be sent to the corresponding author.
Conflicts of Interest
None declared.
Multimedia Appendix 1
Psychometric descriptions of the measures used in the randomized controlled trial study.
[DOCX File , 28 KB-Multimedia Appendix 1]
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Abbreviations
2SLGBTQA+: 2-spirit, lesbian, gay, bisexual, transgender, queer (or questioning), asexual, and additional groups
HF: housing first
HF4Y: Housing First for Youth
MtS: Making the Shift
RCT: randomized controlled trial
TAU: treatment-as-usual
Edited by A Mavragani; submitted 21.02.23; peer-reviewed by S Gabrellian, B Henwood; comments to author 04.04.23; revised
version received 11.07.23; accepted 07.08.23; published 19.09.23
Please cite as:
Gaetz S, Bonakdar A, Ecker J, MacDonald C, Ilyniak S, Ward A, Kimura L, Vijayaratnam A, Banchani E
Evaluating the Effectiveness of the Housing First for Youth Intervention for Youth Experiencing Homelessness in Canada: Protocol
for a Multisite, Mixed Methods Randomized Controlled Trial
JMIR Res Protoc 2023;12:e46690
URL: https://www.researchprotocols.org/2023/1/e46690
doi: 10.2196/46690
PMID:
©Stephen Gaetz, Ahmad Bonakdar, John Ecker, Cora MacDonald, Sophia Ilyniak, Ashley Ward, Lauren Kimura, Aranie
Vijayaratnam, Emmanuel Banchani. Originally published in JMIR Research Protocols (https://www.researchprotocols.org),
19.09.2023. This is an open-access article distributed under the terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information,
a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be
included.
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