Welcome back to the “THIS is” blog series! This month’s installment goes back to the basics of Making the Shift by looking at one of the fundamentals of our research design: the Randomized Controlled Trial.
In developing Making the Shift (MtS), a primary objective has always been to establish a base of sound, scientific evidence for prevention and Housing First for Youth (HF4Y) interventions. We’ve certainly talked about this before! But this evidence base is so fundamental to MtS that it warrants a deeper discussion – in my opinion, anyway. And since I’m the one writing this blog series, I’ve decided to take you all along with me on this exploration of one of the more nuanced and controversial aspects of our work. It’ll be fun (read: informative), I promise!
What is a Randomized Controlled Trial?
Now that I’ve piqued your curiosity with those buzzwords, let’s talk for a minute about Randomized Controlled Trials. Wait, come back! Known among the research community as “RCT,” Randomized Controlled Trial is simply a formal term for a study in which participants are randomly divided into groups of comparable size and defining characteristics. One group is known as the “control” or “treatment as usual” group, which is the standard against which everything else is compared. The other group(s) is the “intervention” in which participants are involved in the field testing of a theory, approach, idea, or condition. Having distinct groups of participants allows us to directly compare participants’ experiences, both individually and as groups, which is enormously helpful in assessing whether or not the proposed intervention had an effect compared to the “treatment as usual” and what exactly the effect was (as it could be positive or negative). Another large-scale example of a RCT that you have probably heard of, currently underway, is the Government of Ontario’s Basic Income Pilot.
So, from a research standpoint, it’s all good – you get controlled data that you can compare and cross-compare. And further, the study can be developed as a mixed methods research design. This kind of design – which we are using for HF4Y – relies on both quantitative and qualitative data to provide a comprehensive idea of how the study is going. Within some research communities, the RCT is regarded as a “gold standard.” The side diagram offers one illustration on how, for some, RCTs measure up to other research methodologies, with the most rigorous options situated near the top and anecdotal evidence comprising the base. From the RCTs’ position in the middle of the pyramid, we can be assured that there is a balance between rigour and flexibility, which is especially important when working with vulnerable populations such as youth.
Busting RCT Myths
There are many opinions out there on the merits and demerits of the RCT design. This is common to any approach to research; as virtually any researcher will tell you, there is no official “right” or “wrong” research methodology. Differing perspectives are to be expected, with specific attention to the subject matter under investigation. However, there are a number of concerns about RCTs, particularly those involving youth, so I thought it would be best to address some of them directly:
RCTs withhold resources from participants in the control group
Participants who are randomized into the “treatment as usual” group receive the services that already exist in the community. Access to service is not in any way withheld from participants. It helps to think of what the participants would do if the RCT didn’t exist – what other resources and services would they be directed to? That’s exactly what the “treatment as usual” group receives.
RCTs are not suitable for youth
There are many other examples of successful RCTs working with young participants. While it’s true that most RCTs are designed for adult participants, RCTs can also be appropriate involving young participants, dependent on their own informed consent – meaning each participant is able to fully understand the scope of the research, what they can expect to happen, the potential risks and rewards of participating, and their role in the study before signing up. The condition under study should, of course, be developmentally appropriate and ethically sound.
RCTs trap participants in interventions they may not want to participate in
Participants in either group are able to withdraw their involvement from a RCT study at any time. They are similarly able to refuse to answer any questions, and withdraw their data and previous input from being used in the study. Of course, participants are encouraged to participate through the entire process but are not obligated to do so. For any time given to research participation, young people receive compensation – even if they choose to withdraw their data or stop participating.
RCTs are unfair
RCTs are regarded in the research community as being one of the fairest methods of allocating new and limited services/resources by randomly dividing participants into groups; participants have an equal chance of being assigned to any group. The randomization process removes all elements of human bias, as the decision is made independent of any emotional factors.
RCT Meets HF4Y
At this point, you might be asking yourself why MtS is using a RCT design, which is absolutely a fair question (and one the top questions we get asked, in fact!). The most straightforward answer is that the At Home/Chez Soi (AH/CS) study on Housing First used the RCT research design; people might not realize that MtS was created as a direct successor to AH/CS, and that MtS is running a mini AH/CS on HF4Y. This is a direct response to the findings from AH/CS, specifically: “We suggest considering modifications of ‘Housing First’ to maintain fidelity to core principles while better meeting the needs of youth”. So, it follows that, like AH/CS, MtS is also implementing a RCT study.
As mentioned, the RCT design is being used to assess the HF4Y intervention for MtS. Youth who are participating in the Ottawa and Toronto HF4Y projects have been randomized into either the “intervention” or “treatment as usual” group, with researchers closely monitoring their outcomes as groups and individuals. In the end, the goal is to understand and support an approach that promotes better outcomes for youth.
The key message to bear in mind is that nothing is guaranteed with the RCT process; and it is indeed a process of evaluating whether or not a proposed intervention works, not an established solution. This is a crucial distinction to make. People might look at a RCT study and think, “Here is an intervention that we know works and it’s cruel to keep it from some participants; why are we doing this?”. I can absolutely sympathize with that perspective, and the concern at its core, but the truth is that we really need strong data to back up our hypotheses.
In the case of MtS, we need to ensure that we are supporting the best option for youth. Strong data establishes “proof of concept” and the aforementioned evidence base that will inform policy and practice shifts concerning youth homelessness. Rigorous research and evaluation techniques – including the RCT design – are how we will get there.
The “THIS is” blog series is a monthly look into the concepts and ideas at the heart of the Making the Shift Youth Homelessness Social Innovation Lab project. This blog is the sixth installment in the blog series; click to read the first, second, third, fourth, and fifth installments.
1 Kozloff et al., (2016) At Home / Chez Soi
Photo credit: University of Canberra Library. Available here
In this bi-weekly blog series, I explore recent research on homelessness, and what it means for the provision of services to prevent or end homelessness. Read the first blog here, and the second blog here.
Housing is foundational to ending homelessness, foundational as a determinant of health, and foundational to community integration. However, housing itself does not guarantee health or integration.
Chris Chamberlain and Guy Johnson explore the question of community integration as outlined in Housing First models. They use the concept of ‘liminality’ to question integration after homelessness, a term referring to being between two worlds.
To address this question, they analyzed 157 interviews with 64 individuals exiting chronic homelessness through a Housing First program. All participants were housed at the final interview, and majority having been housed for over a year. Half of the participants had their first experience of homelessness as youth, three quarters identified as male, and all were receiving government income support.
Chamberlain and Johnson noted a sense of material “liminality” on first becoming housed, based on three challenges:
- Participants lacked resources to furnish their new home and meet basic needs
- Participants felt suddenly lonely in their new spaces
- Participants were either new to or had been some time since managing a home.
However, the research team observed progress over time as participants gained control, acquired possessions, and settled into new autonomy.
Relational 'liminality’ proved more complex. While participants recognized new friendships and casual acquaintances developed in accessing services for people experiencing homelessness, these were often not built on the same bonds and common values of friendships of familial relationships from which they had become disconnected. While many participants disconnected from relationships built during their period of homelessness, they also struggled to reconnect with prior relationships. Familial relationships were often sources of past trauma, so participants were more likely to reconnect with their own children rather than with parents, siblings, or other blood relatives.
Lastly, participants experienced psychological “liminality” which involved carrying the stigma of the experience of homelessness, feeling both “discredited” and “discreditable.” While this sense declined over time, half the participants still felt this stigma by the final interview, despite having been in housing for a year on average.
The authors conclude that while Housing First programs continue to demonstrate good outcomes for rapid re-housing, that community integration needs to be an intentional process of such programs rather than a presumed outcome. While the material components of becoming housed might be more straight-forward to address (such as through furniture bank programs), the relational and stigma components are more complex. They conclude with a call for funding to be focused on community integration.
What is Trauma Informed Care?
Trauma Informed Care (TIC) is an approach that embraces an understanding of trauma at every step of service delivery. This model requires a compassionate and understanding attitude, in order to address the intersecting effects that trauma can have on people’s lives. It seeks to create a culture of nonviolence, learning, and collaboration in all aspects of treatment, while also recognizing the physical, psychological and emotional importance of clients’ and providers’ safety.
Trauma Informed Care does not have to be directly focused on delivering trauma-related services or treatments. Rather, it is an approach that is incorporated into the structure of a variety of practices, including housing, primary care, mental health, and addictions services. The aim is to provide services in ways that are appropriate and welcoming for those who may have been affected by trauma.
While the effects of trauma frequently have an impact on services and organizations, trauma often goes undetected. Thus, interfering with their recovery and healing, individuals may be re-traumatized by the services and organizations that they interact with.
Many people experiencing homelessness have faced traumatic events, such as being exposed to violence, experiencing losses, and dealing with severed relationships. The experience of homelessness itself is traumatic, as it involves a lack of stability, a loss of safety and the disconnection from one’s community at large.
Research has found that a large proportion of mothers (79%) who accessed emergency shelters, transitional housing and permanent supportive housing programs, experienced traumatic events during their childhoods. Most commonly, mothers reported past experiences of interpersonal violence, physical assaults, and sexual abuse. Many also met the criteria for Post Traumatic Stress Disorder (PTSD). Furthermore, intergenerational trauma affects Indigenous communities, which have been gravely impacted by colonial practices, such as: the destruction of Indigenous institutions, disruption of traditions (including Indigenous systems of governance), linguicide, and the implementation of the reserve system, to name a few. Interwoven in many Indigenous experiences of homelessness are the impacts of individual and community traumas, often leading to high levels of mental, cognitive, behavioural, social and physical challenges.
Trauma, depression and substance abuse tend to occur simultaneously, and also have the potential to impact the ability of mothers to form healthy relationships, work consistently and parent effectively.
The effects of trauma have serious health outcomes for individuals, families and communities, and services must recognize the role they play in creating supportive and welcoming environments. As there are many different types of trauma affecting people of all ages, and across all socioeconomic backgrounds in society, a trauma informed care approach should be an essential component for all services and organizations.
Traditionally, responses to homelessness in Canada have placed a great deal of emphasis on emergency services, such as shelters and temporary housing. However, since the challenges that many people experiencing homelessness face are complex, the necessity for different approaches to address their needs have become clear. One example of this includes the integration of trauma informed care (TIC) practices into service delivery and housing programs.
Adopting a TIC approach as a service provider, organization or system involves:
- Recognizing the wide-spread nature of trauma and its effects
- Understanding the potential avenues for recovery and healing
- Being able to identify signs and symptoms of trauma in staff, clients, patients, residents and other members of the system
- A complete integration of trauma-related knowledge and information into policies, settings, practices and procedures
In addition to providing permanent supportive housing for trauma survivors, individuals with serious mental illnesses (SMI) need programs that directly address their mental health needs. One suggestion involves the developmental assessment of children, and mental health assessments for all members of families. Mental health services that address the needs of both mothers and their children are a recommendation for trauma informed care approaches. As research has indicated the experiences of trauma in early childhood are different from trauma experienced later on in life, trauma informed care takes into account age-appropriate service delivery. For mothers, these services may include dealing with major depression and Post-traumatic Stress Disorder (PTSD). For children, services should include therapy or supportive services to address their learning and emotional needs, a safe and supportive environment, and the presence of continuous and nurturing caregivers.
Furthermore, case management should address both individual, short-term needs along with the long-term needs of clients. Some examples of short term needs include: income, education, and employment, whereas long-term needs may involve addressing histories of trauma, health/ mental health, and emotional difficulties.
It has also been suggested that organizations make a number of changes to their overall service delivery structure, in order to incorporate a Trauma Informed Care approach. Organizations should include written statements and policy implementation that express their commitment to delivering Trauma Informed Care, such as:
- Adopting a strengths-based, optimistic, evidence-informed model of service delivery
- The allocation of time and resources to staff, to deliver TIC services
- Encouragement of clients, patients and residents to provide feedback and ideas
- Clearly defined point of responsibility for implementing trauma-informed services
Overall, housing that quickly stabilizes families while also ensuring that the individual needs of those accessing services have better outcomes for the long-term stability of families; that includes taking the affordability of the placement into consideration.
Ontario is gearing up for a provincial election on June 7th, and Quebec isn’t far behind. While some people may already know who they plan to vote for this time around, others may still be feeling unsure of how (or if) they will vote on Election Day.
For those of us in youth-serving sectors and related fields, and for young people with lived experience of homelessness, A Way Home Canada and Eva’s Initiatives for Homeless Youth in Toronto have collaborated to create an overview of how to navigate the provincial political landscape around election time and to inform your decision making process.
Who can vote?
If you’re a Canadian citizen, resident of the province where the election is being held, and are 18 or older, you can vote. If you’re under 18 or currently not eligible to vote, this information is still valuable and can help you make decisions both now and in the future. There have also been public discussions about lowering the voting age, which is something to think about for young people who want to have a say.
Whom or what am I voting for?
There are three orders of government, each with its own areas of responsibility: municipal, provincial, and federal. The issues surrounding youth homelessness are complex and each order of government addresses them in multiple ways.
In June, residents of Ontario will be voting for their provincial government. Individuals don’t vote for the party’s leader directly, but instead choose whom they would like to be their Member of Provincial Parliament (MPP)1, the representative in your area of the province or “riding”. However, in Canada’s electoral system, your vote also indicates that you are in favour of your chosen candidate’s party.
Each party has its own priorities that are put into a ‘platform’. The platform explains what the party might do if it were to lead the government. It can tell you what its supporters value, whose interests it represents, and how it plans to will achieve its goals 2. Looking at a party’s platform, the goal is to figure out what it all means to you, your family, or your community.
What matters to me?
Putting government and politics aside for a moment, think about the issues or challenges that affect you and your community on a regular basis. When it’s functioning well, the government should reflect and try to address the issues that matter to its communities and constituents (that’s you!). When it comes to youth homelessness, there are a number of policy areas in the provincial jurisdiction3 to pay attention to in each party’s platform or when hearing from your local candidates. Below are some key areas Eva’s came up with that are important to think about in upcoming elections, which we expand on with some questions to help inform your thinking.
Mental Health: Homelessness has direct impacts on developing adolescents’ mental health and wellbeing, requiring specialized supports to equip them with healthy coping mechanisms and tools for success.
- What will your candidate/party commit to around ensuring youth have access to mental health and addictions/substance use supports?
Colonization and Discrimination: Many young people are at higher risk of homelessness, including Indigenous youth, racialized youth, and trans youth. The impacts of intergenerational trauma from colonization continue to be a barrier to young Indigenous people in Canada. Racism, both overt and systemic, put Indigenous, Black and newcomer youth, in particular, at significant disadvantage to their non-racialized peers, requiring culturally appropriate and specialized supports to help them thrive. Trans youth face discrimination and transphobia and need safe and accepting spaces to go for help.
- What steps will your candidate/party take to implement the Calls to Acton from the Truth and Reconciliation Commission, address social discrimination, promote equitable treatment, and provide specialized supports for young people who face higher risk of homelessness?
Child Protection: In Canada’s first national survey on youth homelessness, Without A Home, 57.8% of young people experiencing homelessness had been involved with child protective services to some degree in their lifetime4. Child protective services can be a first line of support for young people and their families to do early intervention and prevention work to keep families together, where safe and appropriate. This requires adequate funding, standards, and policies to support programs, such as kinship care, that focus on family reunification and healing and reduce the number of young people entering the system. For those young people who are in the child protection system, we need to ensure they are supported to make healthy and safe transitions out of care and toward adulthood.
- How will your candidate/party support families, children, and youth to prevent them from becoming involved with child protection, adequately fund the child protective services that are needed, and provide ongoing supports to youth that are exiting or have left the system?
Housing and Income: Affordable, safe, and appropriate housing for young people and families is a crucial foundation for success, but is increasingly difficult come by, and costs of living are rising. Young people are also discriminated against when they try to access rental housing. Shelters are not long-term solutions, and we need to do a better job of preventing young people from becoming homeless in the first place. Young people need housing options that match their unique stage in life and the care and supports to maintain their housing. They should be able to stay in the communities they know and feel safe in, not pushed further to the margins of society to access housing, jobs and services.
- What measures will your candidate/party take to alleviate poverty, and ensure that there is adequate affordable housing supply to meet the demand (e.g. Incentives for developers; Matching federal rent supplements; social procurement; Inclusionary zoning; etc.)?
Education: The 2016 Without A Home Study found that 65% of young people that experience homelessness are have not completed high school. Today’s job market increasingly requires higher education in order to secure a sustainable income and future, however the cost of post-secondary schooling is rising. Additional challenges such as learning disabilities and previous experiences of being bullied in school can limit young people’s educational achievements without proper supports in place.
- What will your candidate/party do to ensure young people with all levels of income and backgrounds have access and supports to pursue and complete secondary and post-secondary studies without a high burden of debt?
Of course, this list is just to get you started. There are many other topics and issues surrounding youth homelessness that aren’t on this list and you’ll likely come up with more as you start working through party platforms and thinking for yourself. For example, public transportation infrastructure and accessibility, and crime prevention and restorative justice can enhance young people’s resilience and/or impact their risk of homelessness. You may also want to know whether these issues could be impacted by funding cuts if your candidate’s party comes into power.
Where else can I look for information?
Party platforms are a good starting point, but they don’t necessarily list all issues the party cares about or that your candidates may have an opinion on. Particularly if your candidate has been your riding’s representative before, you can do some online research and look into their track-record on a particular subject or issue.
When internet searches fail, it doesn’t hurt to reach out and ask candidates about the topics that are important to you! Call, email, or contact them through social media with your questions. How (or if) they respond to you may give you a hint about how responsive they’ll be if elected.
If you’re concerned that a candidate might not connect with or fully understand your issue, take a look at what they are campaigning on. Do they say they support families? Mental health? Education? Try re-framing your message from these perspectives. Showing how your issue relates directly to their campaign, may make your candidate more inclined to be responsive and champion that issue when elected.
Don’t candidates just say what they think I want to hear?
For the most part, absolutely - candidates want your vote, after all! However, when you talk to your candidates you can get a sense of whether someone really hears what you’re saying and shows interest in pursuing further conversations and information. Your candidate may not be an expert on youth homelessness, but if they show genuine interest in learning more and doing something about it, that’s an attitude you can work with!
Candidates have a lot to learn during the campaign and after the election. Once elected, we can continue to build relationships with our representatives by reaching out and having conversations to help them understand the issues that affect their community (what we call ‘Politicking’).
I don’t want to/cannot vote. What can I do instead?
Some people are not eligible to vote. Others decide not to vote, and that’s a valid choice. Those that do not vote may feel that none of the candidates represent them, or that they’ve been failed by the political system and don’t want to participate. Regardless of why an individual doesn’t or cannot vote, there are many other ways to be involved in the political process and have your voice heard. You can join political conversations in person and online, sign petitions, participate in public demonstrations/protests, and volunteer, to name a few options.
For those of us who can and do want to vote, we can show solidarity by challenging our candidates to address the concerns of those that feel left behind or unheard by our political system - these may be the communities that are the most marginalized. It’s our duty as allies to show our candidates that the issues that matter to those communities, matter to all of us.
After the election, is there anything else I can do?
When the polls are closed and the new government is announced, your work is just beginning! Your newly-elected MPP will be going to the legislature to represent you and should be accountable to you. If they or their party don’t seem to be acting in the interests of young people at risk of or experiencing homelessness, you can reach out to voice your concerns. If there’s a bill or piece of policy that you hope they will support, contact them and let them know why it matters to their community5.
The government puts tax dollars toward programs and services you and your neighbours use every single day, from hospitals, to schools, to transportation systems, and beyond. When we don’t invest in proactive solutions to prevent issues like youth homelessness, not only does it have a human cost of suffering and unmet potential, but the financial cost of managing the issue only grows larger. We have to ask our political leaders to have the vision and sense of urgency to help our province and the people in it to thrive both now and in the future.
We hope that over the coming months and beyond the election date you are able to meaningfully engage with your local candidates in order to determine whom will best represent you, your community, and the young people that need our support!
Have other ideas on how to engage with the provincial political system leading up to and beyond election season? Or perhaps you or your organization are helping youth at-risk of and/or experiencing homelessness to engage with their local candidates and the political system? We’d love to hear what you’re doing! Please comment below or on social media - we may follow-up for more information in order to enhance this body of knowledge for other individuals and communities.
2. In Canada, the mandate of political parties is put to the test by government bureaucrats. Bureaucrats are unelected professionals who try to put the government’s priorities into action. Bureaucrats have policy and research expertise, and sometimes, what the party wants to do looks good on paper, but is a lot harder to put into action. That’s part of the reason why not everything in a party’s platform becomes a reality when that party comes into power.
3. The Canadian Constitution Act, 1867 sets out the Division of Powers for the Federal and Provincial governments. This indicates what is within the jurisdiction of each order of government. Note that municipalities are not a constitutionally mandated entity, but are developed under the purview of provincial governments (often referred to as ‘creatures’ of the provinces). Read more about the Division of Powers here: https://www.canada.ca/en/intergovernmental-affairs/services/federation/distribution-legislative-powers.html
4. Take a look at A Way Home Canada’s Child Welfare Policy Brief for more analysis and recommendations.
5. If you are a non-profit organization, or acting on behalf of one, there may be more constraints around advocacy for particular pieces of policy. Be sure to be clear on what activities are allowable, and what are considered advocacy or lobbying activities in your province and at the federal level (they are different).
In this bi-weekly blog series, I explore recent research on homelessness, and what it means for the provision of services to prevent or end homelessness. Read the first blog here.
It has been stated that “political will follows public will.” And those who work in fundraising will tell you that a hopeful story generates more funds than a story of distress. Within these two issues lie a challenge for us in solving homelessness: if the general public feels that homelessness is a hopeless situation, there will be limited will to do anything about it. And if the public sees no benefit in taking action on homelessness, then there is less motivation for governments to act.
“We asked ourselves – how might we talk about homelessness in a way that deepens public understanding and builds demand for change?” she asks.
To do this analysis, they conducted 15 interviews with topic experts, 50 interviews with the general public using different methods to glean understanding, and analysis of 333 materials about homelessness put out by the media or homeless-serving organizations.
A number of key points came from this study are:
- Raising awareness alone is not enough to create change, and can actually have unintended negative impacts (such as enhancing hopelessness)
- The public is too much locked into a single understanding of homelessness as the “middle-aged, chronically homeless man”
- We need to push the discussion away from individual causes of homelessness to societal causes
- We need to be explicit on what homelessness prevention means, what it looks like, and how it works
- We need to speak of homelessness as a solvable problem
Dr. Teixeira, consistent with the message within her research of focusing on hopefulness, is hopeful when looking at how we communicate about homelessness in order to win the hearts and minds of the general public and policy-makers.
She points out that these recommendations for improving communication are relatively straightforward and easy to adopt, and that many organizations and individuals in the sector are already communicating in this way (see, for example, the Urban Institute in the U.S.). As she concludes, communicating more effectively won’t solve homelessness by itself; but neither can we, if communities and governments do not believe in the cause.
Content on this site is licensed under a Creative Commons Attribution Non-Commercial No Derivatives License
The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.