Outreach with street-involved youth: a quantitative and qualitative review of the literature

Program logic of a mental health outreach service for socially anxious youth

Youth mental health is a major concern both in Australia and internationally. Identifying at-risk young people is a core service priority. This report describes a "Youth Social Inclusion Program" developed in Australia to assist young people identified as having social difficulties that prevent them linking into formal mental health services. This report describes the Australian service context and uses the "program explication" methodology to document: the program activities, therapeutic processes, and underpinning evidence for the benefits of this service. Program explication is a consulting method designed to assist services to identify and review implicit program logic assumptions against evaluation literature. We demonstrate the application of this method in exploring the assumptions and evidence for the Youth Social Inclusion Program, targeting outreach to socially anxious young people in Australia. The Youth Social Inclusion Program involved seven logically consistent activities. Our literature search revealed moderate evidence for the expected benefits of the activities. This practice-based design drew on several theoretical perspectives. Given that the program logic has been established, we outline a proposal for further evaluation.

Outreach programs to improve life circumstances and prevent further adverse developmental trajectories of at-risk youth in OECD countries: A systematic review

BACKGROUND

At-risk youth may be defined as a diverse group of young people in unstable life circumstances, who are currently experiencing or are at risk of developing one or more serious problems. At-risk youth are often very unlikely to seek out help for themselves within the established venues, as their adverse developmental trajectories have installed a lack of trust in authorities such as child protection agencies and social workers. To help this population, a number of outreach programmes have been established seeking to help the young people on an ad hoc basis, meaning that the interventions are designed to fit the individual needs of each young person rather than as a one-size-fits-all treatment model. The intervention in this review is targeted outreach work which may be (but does not have to be) multicomponent programmes in which outreach may be combined with other services.

OBJECTIVES

The main objective of this review was to answer the following research questions: What are the effects of outreach programmes on problem/high-risk behaviour of young people between 8 and 25 years of age living in OECD countries? Are they less likely to experience an adverse outcome such as school failure or drop-out, runaway and homelessness, substance and/or alcohol abuse, unemployment, long-term poverty, delinquency and more serious criminal behaviour?

SEARCH METHODS

We identified relevant studies through electronic searches of bibliographic databases, governmental and grey literature repositories, hand search in specific targeted journals, citation tracking, and Internet search engines. The database searches were carried out in September 2020 and other resources were searched in October and November 2021. We searched to identify both published and unpublished literature, and reference lists of included studies and relevant reviews were searched.

SELECTION CRITERIA

The intervention was targeted outreach work which may have been combined with other services. Young people between 8 and 25 years of age living in OECD countries, who either have experienced or is at-risk of experiencing an adverse outcome were eligible. Our primary focus was on measures of problem/high-risk behaviour and a secondary focus was on social and emotional outcomes. All study designs that used a well-defined control group were eligible for inclusion. Studies that utilised qualitative approaches were not included.

DATA COLLECTION AND ANALYSIS

The total number of potentially relevant studies constituted 17,659 hits. A total of 16 studies (17 different interventions) met the inclusion criteria. Only five studies could be used in the data synthesis. Eight studies could not be used in the data synthesis as they were judged to have critical risk of bias and, in accordance with the protocol, were excluded from the meta-analysis on the basis that they would be more likely to mislead than inform. Two studies (three interventions) did not provide enough information enabling us to calculate an effect size and standard error, and one study did not provide enough information to assess risk of bias. Meta-analysis of all outcomes were conducted on each conceptual outcome separately. All analyses were inverse variance weighted using random effects statistical models incorporating both the sampling variance and between study variance components into the study level weights. Random effects weighted mean effect sizes were calculated using 95% confidence intervals. Too few studies were included to carry out any sensitivity analyses.

MAIN RESULTS

Four of the five studies used for meta analysis were from the USA and one was from Canada. The timespan in which included studies were carried out was 32 years, from 1985 to 2017; on average the intervention year was 2005. The average number of participants in the analysed interventions was 116, ranging from 30 to 346 and the average number of controls was 81, ranging from 32 to 321. At most, the results from two studies could be pooled in a single meta-analysis. It was only possible to pool the outcomes drug (other than marijuana) use, marijuana use and alcohol use each at two different time points (one and 3 months follow up). At 1 month follow up the weighted averages varied between zero and 0.05 and at 3 months follow up between -0.17 and 0.07. None of them were statistically significant. In addition, a number of other outcomes were reported in a single study only.

AUTHORS' CONCLUSIONS

Overall, there were too few studies included in any of the meta-analyses in order for us to draw any conclusion concerning the effectiveness of outreach. The vast majority of studies were undertaken in the USA. The dominance of the USA as the main country in which outreach interventions meeting our inclusion criteria have been evaluated using rigorous methods and within our specific parameters clearly limits the generalisability of the findings. None of the studies, however, was considered to be of overall high quality in our risk of bias assessment and the process of excluding studies with critical risk of bias from the meta-analysis applied in this review left us with only five of a total of 16 possible studies to synthesise. Further, because too few studies reported results on the same type of outcome at most two studies could be combined in a particular meta-analysis. Given the limited number of rigorous studies available from countries other than the USA, it would be natural to consider conducting a series of randomised controlled trials evaluating the effectiveness of outreach for at-risk youth in countries outside the USA. The trial(s) should be designed, conducted and reported according to methodological criteria for rigour in respect of internal and external validity to achieve robust results and preferably reporting a larger number of outcomes.

Predictors of Treatment Engagement Among Suicidal Youth Experiencing Homelessness

Homeless youth experience high rates of suicidal ideation and attempts, yet limited research has examined predictors of treatment engagement among this population. Suicidal homeless youth (N = 150) between the ages of 18 and 24 years were recruited from a drop-in center in Columbus, Ohio. Participants were randomly assigned to Cognitive Therapy for Suicide Prevention + treatment as usual through a local drop-in center (CTSP + TAU) (N = 75) or TAU alone (N = 75), and treatment attendance among those assigned to CTSP + TAU was examined in this study. As expected, among youth engaged in CTSP + TAU, those with a history of intimate partner violence (IPV) showed decreased odds of treatment attendance. Additionally, youth randomized into CTSP + TAU with higher acquired capability for suicide (ACS) scores and those identifying as Black were more likely to attend treatment sessions. Findings suggest that effective treatment implementation must consider youth's trauma history, demographics and severity of suicidal ideation and behaviors.

Service needs of young people affected by adverse childhood experiences (ACEs): A systematic review of UK qualitative evidence

BACKGROUND

Adverse Childhood Experiences (ACEs) such as, physical and sexual abuse, neglect, or living in a household with domestic violence or substance misuse, can have negative impacts on mental and physical health across the lifecourse. A deeper understanding of the kinds of services that people affected by ACEs feel they need to overcome these negative impacts is required.

REVIEW QUESTION

How do people affected by ACEs between the ages of 3 to 18 experience support and services in the UK? What are their needs relating to services and support?

METHODS

Systematic review of qualitative evidence. We harvested relevant studies from existing systematic reviews of qualitative evidence located through a search of 18 databases. Included studies needed to be published in or after 2008, conducted in the UK, and report the views of people exposed to ACEs relating to their service needs. We included studies with participants who were affected by ACEs between 3 and 18 years old with no restriction on the age at which they accessed services.

RESULTS

We identified 71 reviews from which we harvested 238 references on title and abstract screening. Following full text screening and quality and relevance appraisal we included 20 studies. Each of the included studies focussed on a specific ACE population. Almost half focused on young people who were fostered, looked-after or leaving care. No studies focussed on parental incarceration or divorce. Young people value emotional and practical support. Service providers were most valued for displaying empathy, being non-judgemental, and being active listeners. Supportive relationships, especially with adults, are a key factor in feeling understood.

CONCLUSIONS

People affected by ACEs describe the importance of stability and continuity in the support they receive. These factors are important for allowing necessary time to overcome obstacles and build up trust. Research often frames response to ACE in terms of short term individual psychological outcomes but these findings highlight the importance of focussing on wider social factors to encourage meaningful engagement with services.

An Intersectional Content Analysis of Inclusive Language and Imagery Among Sex Trafficking-Related Services

The extent to which services are available for and inclusive of diverse survivors of sex trafficking remains understudied. This content analysis in a U.S. Midwestern region designated as a hub explores the availability of sex trafficking-specific organizations and perceived inclusivity of organizations regarding diverse identities (including Lesbian, Gay, Bisexual, Trans, or Queer [LGBTQ]+ and racial/ethnic groups). 186 regional organizations were analyzed, of which only 7 were trafficking specific. Of nontrafficking organizations (n = 179), less than 12% (n = 21) stated that they provided services to individuals who identify as LGBTQ+, 6% (n = 10) included LGBTQ+ symbols/language, 36% (n = 65) featured perceived People of Color (POC). Lack of inclusive language, photos, and symbols may contribute to trafficking survivors who identify as POC, English language learners, or as LGBTQ+ feeling as though services do not apply to them. Implications are discussed.

Employment and Other Income Sources Among Homeless Youth

Homeless youth report high rates of unemployment. While homeless serving agencies usually offer employment services, most homeless youth are disengaged from homeless service agencies, and a limited number of studies have examined employment and other income sources among service disconnected youth. Our study examined income sources and change in income among service disconnected youth, all of whom received Strengths-Based Outreach and Advocacy (SBOA, N = 79). Findings revealed that over time employment and legal income from non-survival behaviors increased (e.g., governmental assistance and receiving income from friends and relatives), while income from survival behaviors decreased (e.g., prostitution, stealing, selling possessions, selling blood or plasma). Although unemployment among these youth remained high (62%), income from survival behaviors reduced most drastically. Findings also suggest that employment is linked to housing stability and mental health, as is substance use and income, which suggests that mental health, housing, and substance use treatment services are important components in income stabilization for homeless youth.

Utilization and Perceptions of Drop-in Center Services Among Youth Experiencing Homelessness

Drop-in centers offer a range of services to assist unaccompanied youth experiencing homelessness, but little is known about their perceptions of drop-in centers or use of different services. A random sample of 273 youth experiencing homelessness in the Los Angeles area who had ever used a drop-in center was surveyed. Most youth heard about local drop-in centers from peers (65.1%). They generally reported positive perceptions of the drop-in center environment, staff, and clients; overall, 57.8% were "very" or "extremely" satisfied with the services they had received. Nearly all youth cited basic services (e.g., food, showers, clothes) as a reason they went to drop-in centers; far fewer reported going to obtain higher-level services (e.g., case management). Perceptions and utilization did not differ by sexual orientation; however, non-white youth were more likely than Whites to use drop-in centers for certain higher-level services. Strategies for engaging youth in drop-in center services are discussed.

Reductions in Hard Drug Use Among Homeless Youth Receiving a Strength-Based Outreach Intervention: Comparing the Long-Term Effects of Shelter Linkage Versus Drop-in Center Linkage

OBJECTIVES

The current study sought to test hard drug use outcomes for youth receiving a strengths-based outreach and advocacy intervention that linked youth to either a shelter or a drop-in center.

METHODS

Homeless youth (14-24 years old) were engaged by research assistants (RAs) at soup kitchens, parks, libraries, and other locations that homeless youth were known to frequent. Youth were randomly assigned to receive six months of advocacy that focused on linking youth to a drop-in center (n = 40) or to a crisis shelter (n = 39). Follow-up assessments were conducted at 3, 6, and 9 months post-baseline. Hard drug use over time was the main outcome. Intervention condition and service connection were used as predictors for the baseline level and the slope of change in hard drug use over time. Data analysis was conducted with Bernoulli Hierarchical Generalized Linear Modeling in HLM7.

RESULTS

The current study found that those who were in the drop-in linkage condition exhibited a greater reduction in their odds of using hard drugs during the follow-up points than their counterparts in the shelter linkage condition. And finally, those who utilized services more often during the follow-ups were those who exhibited less hard drug use at baseline and less reduction in their odds of using hard drugs.

CONCLUSIONS

This study suggests that drop-in centers, which are often characterized by low-demand programming and few behavioral restrictions, are effective for addressing hard drug use among homeless youth.

Design strategies from sexual exploitation and sex work studies among women and girls: Methodological considerations in a hidden and vulnerable population

The study of sex trafficking, prostitution, sex work, and sexual exploitation is associated with many methodological issues and challenges. Researchers' study designs must consider the many safety issues related to this vulnerable and hidden population. Community advisory boards and key stakeholder involvement are essential to study design to increase safety of participants, usefulness of study aims, and meaningfulness of conclusions. Nonrandomized sampling strategies are most often utilized when studying exploited women and girls, which have the capacity to provide rich data and require complex sampling and recruitment methods. This article reviews the current methodological issues when studying this marginalized population as well as strategies to address challenges while working with the community in order to bring about social change. The authors also discuss their own experiences in collaborating with community organizations to conduct research in this field.

Predictors of Outreach Meetings Among Substance Using Homeless Youth

Homeless youth have high rates of substance use and often lack connection to social services. Outreach is critical for connecting youth to services, but factors influencing their outreach engagement are unknown. This study examined predictors of meetings with outreach workers among 79 non-service connected, substance using homeless youth between 14 and 24 years of age. Results provide direction to service providers in that older age, higher levels of depressive symptoms, fewer drug-related problems, and no use of hard drugs within the prior 30 days predicted higher meeting attendance. Future research is needed testing strategies that overcome barriers to outreach engagement.

Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street-connected children and young people

BACKGROUND

Millions of street-connected children and young people worldwide live or work in street environments. They are vulnerable to many risks, whether or not they remain connected to families of origin, and despite many strengths and resiliencies, they are excluded from mainstream social structures and opportunities.

OBJECTIVES

Primary research objectivesTo evaluate and summarise the effectiveness of interventions for street-connected children and young people that aim to:• promote inclusion and reintegration;• increase literacy and numeracy;• facilitate access to education and employment;• promote mental health, including self esteem;• reduce harms associated with early sexual activity and substance misuse. Secondary research objectives• To explore whether effects of interventions differ within and between populations, and whether an equity gradient influences these effects, by extrapolating from all findings relevance for low- and middle-income countries (LMICs) (Peters 2004).• To describe other health, educational, psychosocial and behavioural effects, when appropriate outcomes are reported.• To explore the influence of context in design, delivery and outcomes of interventions.• To explore the relationship between numbers of components and duration and effects of interventions.• To highlight implications of these findings for further research and research methods to improve evidence in relation to the primary research objective.• To consider adverse or unintended outcomes.

SEARCH METHODS

We searched the following bibliographic databases, searched for the original review, from inception to 2012, and various relevant non-governmental and organisational websites: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE and Pre-MEDLINE; EMBASE and EMBASE Classic; Cumulative Index to Nursing and Allied Health Literature (CINAHL); PsycINFO; Education Resource Information Center (ERIC); Sociological Abstracts; Social Services Abstracts; Social Work Abstracts; Healthstar; Latin American Caribbean Health Sciences Literature (LILACS); System for Grey literature in Europe (OpenGrey); ProQuest Dissertations and Theses; EconLit; IDEAS Economics and Finance Research; JOLIS Library Catalog of the holdings of the World Bank Group and International Monetary Fund (IMF) Libraries; British Library for Development Studies (BLDS); Google and Google Scholar. We updated the search in April 2015 for the review update, using the same methods.

SELECTION CRITERIA

This review includes data from harm reduction or reintegration intervention studies that used a comparison group study design; all were randomised or quasi-randomised studies. Studies were included if they evaluated interventions provided for street-connected children and young people, from birth to 24 years, in all contexts.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias and other factors presented in the Discussion and Summary quality assessment (Grades of Recommendation, Assessment, Development and Evaluation (GRADE)). We extracted data on intervention delivery, context, process factors, equity and outcomes, and grouped outcomes into psychosocial outcomes, risky sexual behaviours or substance use. We conducted meta-analyses for outcomes where the outcome measures were sufficiently similar. We evaluated other outcomes narratively.

MAIN RESULTS

We included 13 studies evaluating 19 interventions from high-income countries (HICs). We found no sufficiently robust evaluations conducted in low- and middle-income countries (LMICs). Study quality overall was low and measurements used by studies variable. Participants were classified as drop-in and shelter-based. No studies measured the primary outcome of reintegration and none reported on adverse effects.We found no consistent results on a range of relevant outcomes within domains of psychosocial health, substance misuse and sexually risky behaviours . Interventions evaluated consisted of time-limited therapeutically based programmes that proved no more effective than standard shelter or drop-in services and other control interventions used for most outcomes in most studies. Favourable changes from baseline were reported for outcomes for most participants following therapy interventions and standard services. We noted considerable heterogeneity between studies and inconsistent reporting of equity data. No studies measured the primary outcome of reintegration or reported on adverse effects.

AUTHORS' CONCLUSIONS

Analysis revealed no consistently significant benefit for focused therapeutic interventions compared with standard services such as drop-in centres, case management and other comparable interventions for street-connected children and young people. Commonly available services, however, were not rigorously evaluated. Robust evaluation of interventions, including comparison with no intervention, would establish a more reliable evidence base to inform service implementation. More robust research is needed in LMICs to examine interventions for street-connected children and young people with different backgrounds and service needs.

Psychometric properties of the consumer quality index to assess shelter and community care services

BACKGROUND

Our aim was to design a valid and reliable consumer quality index (CQI) specifically suited to assess the experiences that homeless people, homeless youth, and abused women have with shelter and community care services.

METHODS

A pilot CQI questionnaire was constructed on the basis of literature study, focus group discussions with clients, concept mapping by clients and shelter workers, and a pre-pilot study. The pilot questionnaire was completed by 762 clients using shelter facilities for homeless people, homeless youth or abused women. Psychometric and multilevel analyses were performed to optimize the instrument and determine its validity, reliability and discriminative power.

RESULTS

The preparatory research had revealed seven primary focus topics, all of which were incorporated into the pilot questionnaire. Psychometric analyses resulted in four reliable scales, one of which applied only to clients in residential, day or night shelter programs. The final instrument consisted of 42 items for community care clients and 52 for clients using residential facilities, and day and night shelters; 32 and 42 such items pertained to client experiences.

CONCLUSION

The consumer quality index for shelter and community care services (CQI-SCCS) is a valid, reliable instrument for assessing the quality of these services. It provides guidance to facilities in quality maintenance and improvement, and it is useful in determining quality differences in facilities for homeless people and homeless youth.