[Skip to Content]
[Skip to Content Landing]

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

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Do young people exiting homelessness with 24 months of portable rent subsidies and adult mentorship experience more socioeconomic inclusion relative to young people who receive only 24 months of portable rent subsidies?

Findings  In this randomized clinical trial of 24 youths who transitioned out of homelessness and into market-rent housing, all socioeconomic inclusion outcomes were stable or showed nonsignificant improvements at 18 months compared with baseline; however, there were no significant improvements within the group that received mentorship relative to the group that did not receive mentorship.

Meaning  The effectiveness of mentorship for young people exiting homelessness—especially under pandemic-related restrictions—is uncertain; stable socioeconomic inclusion outcomes during the COVID-19 pandemic may be attributable to portable rent subsidies.


Importance  There have been no published randomized clinical trials with a primary outcome of socioeconomic inclusion for young people who have experienced homelessness.

Objective  To explore whether young people exiting homelessness who received rent subsidies and adult mentorship experienced more socioeconomic inclusion relative to young people who received only rent subsidies.

Design, Setting, and Participants  This was a convergent mixed-methods, unblinded, 2-group, parallel randomized clinical trial with 1:1 allocation embedded within a community-based framework in 3 cities in Ontario, Canada. Participants were enrolled between March 1 and September 30, 2019, and were followed up through March 31, 2022.

Interventions  Participants (n = 24) were randomly assigned adult mentors (n = 13) who had been recruited and screened by community partner agencies. All participants received portable rent subsidies (subsidy not tied to a specific location) for 2 years.

Main Outcomes and Measures  Primary quantitative outcomes were self-reported measures of community integration (psychological and physical) and self-esteem—proxy indicators of socioeconomic inclusion. Community integration was measured with the Community Integration Scale, with a score range of 1 to 7 for the physical component and 4 to 20 for the psychological component; higher scores indicate higher integration. Self-esteem was measured with the Rosenberg Self-Esteem Scale, with a score range of 0 to 30; higher scores indicate greater self-esteem. Secondary quantitative outcomes included social connectedness, hopelessness, and academic and vocational participation. All analyses followed the intention-to-treat principle.

Results  A total of 24 youths (12 women [50.0%]; mean [SD] age, 21.8 [2.2] years [range, 18-26 years]; race and ethnicity: 10 White [41.7%], 8 Black [33.3%], 2 Asian [8.3%], 2 Indigenous [8.3%], and 2 different choice [8.3%]) transitioned out of homelessness and into market-rent housing. All youths in the group that received mentorship and in the group that did not receive mentorship had stable or nonsignificant improvements in all study outcomes at the primary end point of 18 months compared with baseline (mean [SD] Community Integration Scale psychological score: mentorship group, 11.3 [2.6] at baseline and 11.2 [3.9] at 18 months; no-mentorship group, 10.8 [4.1] at baseline and 13.2 [2.9] at 18 months; mean [SD] Rosenberg Self-Esteem Scale score: mentorship group, 16.0 [4.6] at baseline and 18.1 [5.2] at 18 months; no-mentorship group, 16.3 [6.1] at baseline and 19.6 [5.7] at 18 months). However, there were no significant differences between the 2 groups in the Community Integration Scale psychological score (adjusted mean difference, −2.0; 95% CI, −5.0 to 1.0; P = .18) and Rosenberg Self-Esteem Scale score (adjusted mean difference, −1.4; 95% CI, −5.0 to 2.3; P = .44) 18 months after randomization. Ancillary analysis suggested that youths with informal mentors (mentors outside the study) at baseline felt more psychologically integrated at 18 months relative to those with no informal mentors at baseline (adjusted mean difference, 3.6; 95% CI, 0.4-6.8; P = .03).

Conclusions and Relevance  In this randomized clinical trial, COVID-19 pandemic–related restrictions made it challenging for mentors and mentees to connect, which may have affected the findings. Steady socioeconomic outcomes—potentially attributable to portable rent subsidies—are noteworthy, given the socioeconomic inequities this population has faced during the COVID-19 pandemic. The possible benefit of informal mentorship warrants further investigation. This small pilot study was designed with the intention of generating data and hypotheses for a full-scale study; findings should be interpreted with caution.

Trial Registration  ClinicalTrials.gov Identifier: NCT03779204

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: September 12, 2022.

Published: October 27, 2022. doi:10.1001/jamanetworkopen.2022.38670

Correction: This article was corrected on January 13, 2023, to fix an error in a table note.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Thulien NS et al. JAMA Network Open.

Corresponding Author: Naomi S. Thulien, NP-PHC, PhD, MAP Centre for Urban Health Solutions, 30 Bond St, Toronto, ON M5B 1W8, Canada (naomi.thulien@unityhealth.to).

Author Contributions: Dr Thulien had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Thulien, Hwang, Kozloff, Nisenbaum.

Acquisition, analysis, or interpretation of data: Thulien, Amiri, Kozloff, Wang, Akdikmen, Roglich, Nisenbaum.

Drafting of the manuscript: Thulien, Amiri, Roglich, Nisenbaum.

Critical revision of the manuscript for important intellectual content: Thulien, Hwang, Kozloff, Wang, Akdikmen, Nisenbaum.

Statistical analysis: Amiri, Roglich, Nisenbaum.

Obtained funding: Thulien, Hwang.

Administrative, technical, or material support: Hwang, Wang.

Supervision: Hwang, Kozloff, Nisenbaum.

Conflict of Interest Disclosures: Dr Thulien reported receiving grants from St Michael’s Hospital Foundation and the Canadian Institutes of Health Research (CIHR) during the conduct of the study; and personal fees from Covenant House Toronto; and being employed part-time at Covenant House Toronto, a community partner on the project, outside the submitted work. Ms Amiri reported receiving grants from St Michael’s Hospital Foundation and the CIHR during the conduct of the study. Dr Hwang reported receiving grants from the CIHR during the conduct of the study. Mr Akdikmen reported receiving grants from St Michael’s Hospital Foundation and the CIHR during the conduct of the study. Ms Roglich reported receiving grants from the CIHR and St Michael’s Hospital Foundation during the conduct of the study. Dr Nisenbaum reported receiving grants from CIHR and the St Michael’s Hospital Foundation during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was supported by CIHR Foundation grant FDN-167263: Interventions Research in Homelessness, Housing, and Health (primary grant holder, Dr Hwang) and by the St Michael’s Hospital Foundation.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this publication are the views of the authors and do not necessarily reflect those of the funders.

Data Sharing Statement: See Supplement 2.

Additional Contributions: Thank you to Elizabeth McCay, RN, PhD, Toronto Metropolitan University, who participated as a coinvestigator on this study until her retirement—your thoughtful insights continue to shape this work (note: Dr McCay did not receive financial compensation from the study funder). Special thanks to our 3 community partners: Covenant House Toronto, The RAFT, and Living Rock Ministries—this study would not have been possible without your collaboration. Thank you to the 24 young people who participated in this study and patiently answered our questions every 6 months—we are inspired by your wisdom and hope these findings help deepen understanding of the supports you need as you transition away from homelessness.

Abramovich  IA .  No safe place to go—LGBTQ youth homelessness in Canada: reviewing the literature.   CJFY. 2012;4(1):29-51. doi:10.29173/cjfy16579 Google ScholarCrossref
Centrepoint. Gathering data: understanding youth homelessness. Accessed March 11, 2022. https://centrepoint.org.uk/databank/
Gaetz  S , O’Grady  B , Kidd  S , Schwan  K . Without a home: the National Youth Homelessness Survey. Toronto: Canadian Observatory on Homelessness Press. Published 2016. Accessed March 11, 2022. https://www.homelesshub.ca/sites/default/files/attachments/WithoutAHome-final.pdf
Kulik  DM , Gaetz  S , Crowe  C , Ford-Jones  EL .  Homeless youth’s overwhelming health burden: a review of the literature.   Paediatr Child Health. 2011;16(6):e43-e47. doi:10.1093/pch/16.6.e43 PubMedGoogle ScholarCrossref
Morton  MH , Dworsky  A , Matjasko  JL ,  et al.  Prevalence and correlates of youth homelessness in the United States.   J Adolesc Health. 2018;62(1):14-21. doi:10.1016/j.jadohealth.2017.10.006 PubMedGoogle ScholarCrossref
Samuels  GM , Cerven  C , Curry  S , Robinson  SR , Patel  S . Missed opportunities in youth pathways through homelessness. Chapin Hall at the University of Chicago. Published June 2019. Accessed March 11, 2022. https://www.chapinhall.org/wp-content/uploads/ChapinHall_VoYC_Youth-Pathways-FINAL.pdf
Brueckner  M , Green  M , Saggers  S .  The trappings of home: young homeless people’s transitions towards independent living.   Housing Stud. 2011;26(1):1-16. doi:10.1080/02673037.2010.512751 Google ScholarCrossref
Thulien  NS , Gastaldo  D , Hwang  SW , McCay  E .  The elusive goal of social integration: a critical examination of the socio-economic and psychosocial consequences experienced by homeless young people who obtain housing.   Can J Public Health. 2018;109(1):89-98. doi:10.17269/s41997-018-0029-6 PubMedGoogle ScholarCrossref
Kidd  SA , Frederick  T , Karabanow  J , Hughes  J , Naylor  T , Barbic  S .  A mixed methods study of recently homeless youth efforts to sustain housing and stability.   Child Adolesc Social Work J. 2016;33:207-218. doi:10.1007/s10560-015-0424-2 Google ScholarCrossref
Kozloff  N , Adair  CE , Palma Lazgare  LI ,  et al.  “Housing first” for homeless youth with mental illness.   Pediatrics. 2016;138(4):e20161514. doi:10.1542/peds.2016-1514 PubMedGoogle ScholarCrossref
Mayock  P , O’Sullivan  E , Corr  ML .  Young people exiting homelessness: an exploration of process, meaning and definition.   Housing Stud. 2011;26(6):803-826. doi:10.1080/02673037.2011.593131 Google ScholarCrossref
Chamberlain  C , Johnson  G .  From long-term homelessness to stable housing: investigating “liminality”.   Housing Stud. 2018;33(8):1246-1263. doi:10.1080/02673037.2018.1424806 Google ScholarCrossref
Luchenski  S , Maguire  N , Aldridge  RW ,  et al.  What works in inclusion health: overview of effective interventions for marginalised and excluded populations.   Lancet. 2018;391(10117):266-280. doi:10.1016/S0140-6736(17)31959-1 PubMedGoogle ScholarCrossref
Quilgars  D , Pleace  N .  Housing first and social integration: a realistic aim?   Soc Incl (Lisboa). 2016;4(4):5-15. doi:10.17645/si.v4i4.672 Google ScholarCrossref
Solar  O , Irwin  A . A conceptual framework for action on the social determinants of health: social determinants of health discussion paper 2 (policy and practice). World Health Organization Press. Published July 13, 2010. Accessed March 11, 2022. https://apps.who.int/iris/handle/10665/44489
Thulien  NS , Kozloff  N , McCay  E , Nisenbaum  R , Wang  A , Hwang  SW .  Evaluating the effects of a rent subsidy and mentoring intervention for youth transitioning out of homelessness: protocol for a mixed methods, community-based pilot randomized controlled trial.   JMIR Res Protoc. 2019;8(12):e15557. doi:10.2196/15557 PubMedGoogle ScholarCrossref
Wallerstein  N , Duran  B , Oetzel  JG , Minkler  M , eds.  Community-Based Participatory Research for Health: Advancing Social and Health Equity. 3rd ed. Jossey-Bass; 2018.
Beck  AT , Weissman  A , Lester  D , Trexler  L .  The measurement of pessimism: the Hopelessness Scale.   J Consult Clin Psychol. 1974;42(6):861-865. doi:10.1037/h0037562 PubMedGoogle ScholarCrossref
Kerman  N , Sylvestre  J , Aubry  T , Distasio  J , Schütz  CG .  Predictors of mental health recovery in homeless adults with mental illness.   Community Ment Health J. 2019;55(4):631-640. doi:10.1007/s10597-018-0356-3 PubMedGoogle ScholarCrossref
Stergiopoulos  V , Gozdzik  A , O’Campo  P , Holtby  AR , Jeyaratnam  J , Tsemberis  S .  Housing First: exploring participants’ early support needs.   BMC Health Serv Res. 2014;14:167. doi:10.1186/1472-6963-14-167 PubMedGoogle ScholarCrossref
Ciarolo  JA , Edwards  DW , Kiresuk  TJ ,  et al.  Colorado Symptom Index. National Institute of Mental Health; 1981.
McCay  EA , Seeman  MV .  A scale to measure the impact of a schizophrenic illness on an individual’s self-concept.   Arch Psychiatr Nurs. 1998;12(1):41-49. doi:10.1016/S0883-9417(98)80007-1 PubMedGoogle ScholarCrossref
Toro  PA , Passero Rabideau  JM , Bellavia  CW ,  et al.  Evaluating an intervention for homeless persons: results of a field experiment.   J Consult Clin Psychol. 1997;65(3):476-484. doi:10.1037/0022-006X.65.3.476 PubMedGoogle ScholarCrossref
Goering  PN , Streiner  DL , Adair  C ,  et al.  The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities.   BMJ Open. 2011;1(2):e000323. doi:10.1136/bmjopen-2011-000323 PubMedGoogle ScholarCrossref
Rosenberg  M .  Society and The Adolescent Self-Image. Princeton University Press; 1965. doi:10.1515/9781400876136
Lee  RM , Robbins  SB .  Measuring belongingness: the Social Connectedness and the Social Assurance scales.   J Couns Psychol. 1995;42(2):232-241. doi:10.1037/0022-0167.42.2.232 Google ScholarCrossref
Slesnick  N , Zhang  J , Brakenhoff  B .  Personal control and service connection as paths to improved mental health and exiting homelessness among severely marginalized homeless youth.   Child Youth Serv Rev. 2017;73:121-127. doi:10.1016/j.childyouth.2016.11.033 PubMedGoogle ScholarCrossref
Thulien  NS , Gastaldo  D , McCay  E , Hwang  SW .  “I want to be able to show everyone that it is possible to go from being nothing in the world to being something”: identity as a determinant of social integration.   Child Youth Serv Rev. 2019;96:118-126. doi:10.1016/j.childyouth.2018.11.005 Google ScholarCrossref
Thulien  NS , Wang  A , Mathewson  C , Wang  R , Hwang  SW .  Tackling exclusion: a pilot mixed method quasi-experimental identity capital intervention for young people exiting homelessness.   PLoS One. 2021;16(8):e0256288. doi:10.1371/journal.pone.0256288 PubMedGoogle ScholarCrossref
ACES Aware. Adverse childhood experience questionnaire for adults. Published May 5, 2020. Accessed March 11, 2022. https://www.acesaware.org/wp-content/uploads/2022/07/ACE-Questionnaire-for-Adults-Identified-English-rev.7.26.22.pdf
Solomon  P , Cavanaugh  MM , Draine  J . Randomized Controlled Trials: Design and Implementation for Community-Based Psychosocial Interventions. Oxford University Press, Inc; 2009.
Ministry of Children, Community and Social Services, Government of Ontario. Social assistance. Published November 1, 2020. Updated April 4, 2022. Accessed March 11, 2022. https://www.ontario.ca/page/social-assistance
Abramovich  A , Pang  N , Moss  A ,  et al.  Investigating the impacts of COVID-19 among LGBTQ2S youth experiencing homelessness.   PLoS One. 2021;16(9):e0257693. doi:10.1371/journal.pone.0257693 PubMedGoogle ScholarCrossref
Gewirtz O’Brien  JR , Auerswald  C , English  A ,  et al.  Youth experiencing homelessness during the COVID-19 pandemic: unique needs and practical strategies from international perspectives.   J Adolesc Health. 2021;68(2):236-240. doi:10.1016/j.jadohealth.2020.11.005 PubMedGoogle ScholarCrossref
Rew  L , Yeargain  O , Peretz  C , Croce  E .  “I’m losing everything all over again”: responses from youth experiencing homelessness during the COVID-19 pandemic.   Arch Psychiatr Nurs. 2021;35(6):653-657. doi:10.1016/j.apnu.2021.08.002 PubMedGoogle ScholarCrossref
Schwan  K , Dej  E , Versteegh  A .  Girls, homelessness, and COVID-19: the urgent need for research and action.   Girlhood Stud. 2020;13(3):151-168. doi:10.3167/ghs.2020.130311 Google ScholarCrossref
Silliman Cohen  RI , Bosk  EA .  Vulnerable youth and the COVID-19 pandemic.   Pediatrics. 2020;146(1):e20201306. doi:10.1542/peds.2020-1306 PubMedGoogle ScholarCrossref
Thulien  NS , Noble  A , Akdikmen  A ,  et al. Youth homelessness: mental health and substance use during the COVID-19 pandemic: pandemic proof: synthesizing real-world knowledge of promising mental health and substance use practices utilized during the COVID19 pandemic with young people who are experiencing or have experienced homelessness. Canadian Observatory on Homelessness Press. Published November 2020. Accessed March 11, 2022. https://covid19mentalhealthresearch.ca/wp-content/uploads/2021/01/THULIEN-CMH-FINAL-knowledge-synthesis-MentalHealthSubstanceUseDuringCovid-Nov-24-2020.pdf
Tucker  JS , D’Amico  EJ , Pedersen  ER , Garvey  R , Rodriguez  A , Klein  DJ .  Behavioral health and service usage during the COVID-19 pandemic among emerging adults currently or recently experiencing homelessness.   J Adolesc Health. 2020;67(4):603-605. doi:10.1016/j.jadohealth.2020.07.013 PubMedGoogle ScholarCrossref
Dang  MT , Miller  E .  Characteristics of natural mentoring relationships from the perspectives of homeless youth.   J Child Adolesc Psychiatr Nurs. 2013;26(4):246-253. doi:10.1111/jcap.12038 PubMedGoogle ScholarCrossref
Thompson  AE , Greeson  JKP , Brunsink  AM .  Natural mentoring among older youth in and aging out of foster care: a systematic review.   Child Youth Serv Rev. 2016;61:40-50. doi:10.1016/j.childyouth.2015.12.006 Google ScholarCrossref
Van Dam  L , Smit  D , Wildschut  B ,  et al.  Does natural mentoring matter? a multilevel meta-analysis on the association between natural mentoring and youth outcomes.   Am J Community Psychol. 2018;62(1-2):203-220. doi:10.1002/ajcp.12248 PubMedGoogle ScholarCrossref
Thulien N. Searching for Home: A Companion Documentary to the Transitioning Youth Out of Homelessness Study. MAP Centre for Urban Health Solutions. Accessed October 5, 2022. https://www.searchingforhome.ca/
Castleberry  JJ . Recovery from homelessness: choice, mastery, and relatedness. Dissertation. Georgia State University; 2020. Accessed March 11, 2022. https://scholarworks.gsu.edu/cps_diss/141/
Barnes  AJ , Gower  AL , Sajady  M , Lingras  KA .  Health and adverse childhood experiences among homeless youth.   BMC Pediatr. 2021;21(1):164. doi:10.1186/s12887-021-02620-4 PubMedGoogle ScholarCrossref
Liu  M , Luong  L , Lachaud  J , Edalati  H , Reeves  A , Hwang  SW .  Adverse childhood experiences and related outcomes among adults experiencing homelessness: a systematic review and meta-analysis.   Lancet Public Health. 2021;6(11):e836-e847. doi:10.1016/S2468-2667(21)00189-4 PubMedGoogle ScholarCrossref
City of Toronto. Final report: COVID-19 interim shelter recovery strategy: advice from the Homelessness Service System. Published September 2020. Accessed March 11, 2022. https://www.toronto.ca/legdocs/mmis/2020/ph/bgrd/backgroundfile-156419.pdf
Mental Health Commission of Canada. Guidelines for recovery-oriented practice: hope, dignity, inclusion. Ottawa: Mental Health Commission of Canada. Published July 19, 2016. Accessed March 11, 2022. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/MHCC_RecoveryGuidelines_ENG_0.pdf
Cumming  J , Whiting  R , Parry  BJ ,  et al.  The My Strengths Training for Life™ program: rationale, logic model, and description of a strengths-based intervention for young people experiencing homelessness.   Eval Program Plann. 2022;91:102045. doi:10.1016/j.evalprogplan.2021.102045 PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.