Implementation and Engagement in Programs for Youth Experiencing Homelessness: A Meta-Synthesis of the Qualitative Evidence

Background and Purpose: Despite increased awareness about the needs of youth facing homelessness, the level of evidence regarding effectiveness of programs intended to address these needs remains limited and mixed. Further, to date there has not been a systematic review of the evidence concerning factors that contribute to the level of participant engagement and quality of implementation for these youth. Thus, in this qualitative meta-synthesis, we explore the following research questions: 1) What are common programmatic or contextual factors that researchers and/or practitioners identify as contributing to the successful implementation of an intervention for homeless and unstably housed youth? and 2) What programmatic or contextual factors do youth and practitioners identify as hindering implementation of an intervention for these youth?

Methods: Through searches of academic databases, websites, professional outreach, and hand-searching reference lists of relevant articles published between 2008 and 2018, we screened 1,560 studies through two levels of blind review. Ultimately, 47 articles met our inclusion criteria. These articles were rated for quality using the Critical Appraisal Skills Programme Tool. We then engaged in the process of qualitative synthesis, involving integrating multiple original qualitative study findings and interpreting and comparing concepts and findings to create new understanding of the topic. Two researchers coded each study for pre-determined study characteristics, including type of program, urbanicity, sample size, and whether attention was given to racial/LGBTQ equity. Two other researchers then engaged in thematic analysis of the full text, involving inductive coding to arrive at analytical themes regarding implementation and engagement in these programs.

Results: The majority of the studies included took place in urban settings, were based on programs located in the United States, and the most common type of intervention in which factors influencing implementation took place were behavioral health treatment and case management. Only 3 out of the 47 studies explicitly focused on racial/LGBTQ equity. Two primary themes regarding factors that support implementation and engagement included: 1) Organizational policies impact implementation and engagement, and 2) Staff behaviors and training are paramount. Appropriate organizational policies involve a developmentally appropriate balance between structure and flexibility; considerations to access including low-barrier options when appropriate; concerns to the physical space of the program; and coordination with other agencies, particularly for effective referrals. Staff behaviors and training were also found to be crucial. The most common problematic staff dynamic included falling into "power struggles" with youth. Engagement with youth experiencing homelessness requires a "flexible, nonjudgmental orientation,” that allows youth a substantial level of independence, and self-determination, in their life-choices.

Conclusions and Implications: Given our findings regarding the importance of organizational factors and staff behaviors when interacting with youth and implementing programs, this review supports services that emphasize empowerment and anti-paternalism, and increased attention to racial/LGBTQ equity. For example, “zero tolerance” policies” can unintentionally reinforce paternalistic staff behaviors, while low-barrier approaches, attention to the ways in which physical space are attuned to youth needs, and integration of harm reduction, trauma-informed practice, and empowerment may facilitate quality youth engagement and strengthen program implementation.