According to the 2015 Ontario Student Drug Use and Health Survey (OSDUHS), there has been a significant increase in the number of secondary school youth who use poly-substances. Not all youth have the same risk for problematic substance use. Health literature documents a high level of comorbidity between mental health and substance use, which is exacerbated in homeless youth populations. Therefore, the proposed study will focus on understanding poly-substance use among at-risk homeless school youth. As seen in substance use research and the PROMPT (2016) study (Participatory Research in Ottawa: Management and Point-of-Care for Tobacco Dependence, PI: Dr. Smita Pakhale), reduction and quitting of one substance (tobacco smoking) can lead to the reduction and quitting of other poly-substance use. A Community-Based Participatory Action Research (CBPAR) approach can help at-risk youth feel safe and comfortable enough to provide personal information about their poly-substance use and engagement with treatment or harm reduction programs. This project will be a first step in increasing health equity among at-risk homeless youth in Downtown Ottawa. The investigators aim to follow a group of at-risk youth to while providing an appropriately modified PROMPT intervention, including peers support and a licensed mental health and substance use nurse.

Part 1: Youth and Polysubstance Use This study aims to expand the reach of the existing PROMPT intervention operationalized at the Bridge for vulnerable polysubstance using youth who smoke tobacco. The peer-led PROMPT intervention aims to reduce rates of tobacco smoking and poly-substances use among populations who are homeless or at-risk for homelessness.

Research Objectives:

Understand the positive and negative experiences of cannabis use, the effect of cannabis use on mental health, and recognize the patterns of cannabis use between different generations among marginalized populations with a disproportionate burden of mental illness. Additionally, use meaningful qualitative methods to encourage storytelling and authentic sharing of individual experiences of cannabis use and mental health.

Sub-objectives: 1) Identify trends in tobacco and poly-substance use among at-risk youth in Ottawa. Surveys and interview guides have been created with the intention of understanding the root cause of tobacco and poly-substance use among at-risk youth who attend alternative schooling, their perception of tobacco/drug use, types of tobacco and drug use that are most prevalent among these youth, and where youth access tobacco and other substances.

2) Appropriately modify and implement the peer-led PROMPT intervention for 20 youth recruited into the program. The peer-led intervention includes free access to nurse counselling and support on homelessness, addictions, and mental health. You will also access a safe and non-judgemental space for one-to-one peer support. Modifications to this intervention will be dependent on the findings from data collected in the first phase of the study (sub-objective 1).

3) Upon completion of the research project, a manuscript will be submitted for publication in a peer-reviewed, open access journal, and various knowledge translation initiatives (e.g., infographics, seminars, etc.) will be undertaken to ensure that study findings are meaningfully available to organizations that serve at-risk youth who smoke tobacco and/or use poly-substances.

4) Compare healthcare utilization (ER visits and hospitalizations) over one year after the study by linking the trial data to health administrative data available at the Institute for Clinical and Evaluative Sciences (ICES).

Part 2: Tobacco, Cannabis, and Mental Health Marginalized groups, such as polysubstance using street-involved, homeless, and/or racialized individuals, have been overlooked by studies that investigated the causal relationship between cannabis and mental health. As a result, a paucity of data exists on the motives and reasons that influence cannabis use in these populations, and their potential impact on mental health. This knowledge gap is concerning as marginalized groups experience disproportionate rates of mental illness, and due to social and structural inequities are more likely to abuse drugs, including cannabis, relative to the general population. Therefore, the unique experiences of this population should be investigated to further our understanding on the relationship between polysubstance use, cannabis, and mental health.

In marginalized communities, patterns of cannabis use, including type, duration, and frequency of use, may mediate the mental health effects of cannabis. While recreational cannabis is legal in Canada, marginalized populations may have limited access to Ontario's legal cannabis retailers. As a result, individuals may seek illegal or 'street' cannabis, which may be combined with other illicit drugs and/or tobacco that could influence mental health. Therefore, patterns of cannabis consumption, and the source of cannabis, should be evaluated in relation to mental health.

In light of the above, we propose the use of mixed methods to investigate the lived experience of people with mental illness, risk for cardiovascular disease, and current or past history of cannabis use. Cannabis use is a modifiable risk factor for poor mental health and cardiovascular disease. Using a qualitative focus group approach, we will prospectively explore patterns of cannabis use, tobacco use/other substance use, and their impact on mental health (e.g., depression, anxiety) and physical health (risk factors for cardiovascular disease). Using a quantitative survey, we will quantify the substance use (cannabis and other substance use), physical and mental health, and the prevalence of cardiovascular disease risk factors. The study will be carried out in conjunction with The Bridge Engagement Centre (The Bridge), which has over six years of Community Based Participatory Research (CBPR) experience with marginalized communities, including: people experiencing homeless or at-risk of homelessness, People Who Use Drugs (PWUD), racialized populations, and Indigenous peoples.

Research Objectives:

Objective 1: To understand perceptions, beliefs, cultural practices, and factors that influence cannabis use among marginalized populations with a disproportionate burden of mental illness.

Objective 2: To explore positive and negative experiences of cannabis use in marginalized populations with a disproportionate burden of mental illness.

Objective 3: To understand patterns of cannabis use from adolescence to adulthood and its perceived relationship to mental health in marginalized populations with mental illness.

Objective 4: To understand patterns of cannabis use and its effect on mental health in marginalized populations.

Objective 5: To understand different patterns of cannabis use and its effect on mental health in marginalized populations, specifically looking at youth and adult experiences simultaneously.

Objective 6: To use qualitative methods to encourage storytelling and authentic sharing of individual experiences of mental health and cannabis use among youth populations.

Objective 7: To quantify the prevalence of cardiovascular risk factors among marginalized populations with a cannabis use disorder and poor mental health.

Objective 8: To co-produce knowledge on cardiovascular disease prevention strategies for marginalized populations that use cannabis and report poor mental health.

Study Design:

Phase 1: will involve gathering information on the root causes or facilitators of poly-substance use among at-risk youth, the types of drug use that is most prevalent among at-risk youth, and the early and ongoing points of access to licit and illicit substances.

Phase 2: will involve a single arm prospective cohort study looking to tackle poly-substance use in marginalized youth by providing an individualized, youth-tailored (i.e. based on qualitative results obtained in phase I), social-based intervention with optional access to a licensed mental health and substance use nurse counselling.

A team of community-based (peer) researchers will enroll 20 youth and 500 adult and youth (16 years and older) participants from Operation Come Home and the Bridge, respectively using iPads for the proposed TCAY-Ottawa study. Participants will be eligible if they: 1) are currently living in Ottawa for at least 3 months prior to enrolment, 2) are homeless or insecurely housed (from Operation Come Home and the Bridge), 3) 16 years or older, 4) have used drugs in the past year, 5) have smoked tobacco in the past 7 days, currently co-use or have a past history of cannabis use, and/or 6) self-report a mental illness. Participation will be entirely voluntary. Community-based researchers will conduct recruitment by working with Operation Come Home and Bridge staff to assess youth and/or adults, who meet the eligibility criteria, and have an interest in participating upon receiving relevant study information (i.e. risks, benefits, remuneration, etc.), which will be provided verbally by the peer researchers or in written form on a study consent document. Upon enrolment, peer researchers will then provide an appointment time for Phase 1 study data collection. All those who are enrolled to participate in the study will be provided with consent forms to assent their own participation.

Peer researchers will administer a one-time questionnaire about their cannabis use and how it relates to their physical and mental health. Some of those participants that co-use tobacco and marijuana and self-report a mental health illness will be invited to participate in a semi-structured interview to collect further data about their smoking and drug use (type of use, frequency of use, etc.), place of access, and facilitators and barriers to use. Participants will receive a $50 cash honorarium as compensation for their participation. Qualitative data will also be collected informally from social support workers and other key informants at Operation Come Home to gain a better understanding of tobacco/drug use patterns among youth, their progress upon joining Operation Come Home, drivers to join the program, and how the issue of addiction(s) affects the youth and their education/job status, mental health, social networks, quality of life, etc.

Understanding specific details from this phase about youth and adult smoking and concurrent illicit drug use will allow peer researchers to develop a more accurate hypothesis and potentially modify qualitative interview questions (from the PROMPT project) that will be asked on a monthly basis during the intervention.

Recruited participants can partake in the two following optional methods:

• Photovoice: 20 recruited participants will be trained on how to use Photovoice.
• Duoethnographic Dialogue: Ten interested Photovoice participants will be invited to be paired one-on-one with an adult-aged (aged 27+) participant of the MHCC OCM project.

Setting: 1) The Bridge Engagement Centre, Ottawa; and 2) Operation Come Home, Ottawa

Expertise: The PI is well versed in community-based research. Dr. Pakhale led the PROMPT project, a community-based smoking cessation project engaging a similar target population. Partnering with Operation Come Home and Ms. Elspeth McKay, the Executive Director of Operation Come Home, provides the PI with expert experience in engaging this marginalized youth population. Together, the team is very experienced in substance dependence and the target population. The investigators collective expertise with links to the target community will support the implementation of the trial.

Outcomes: Community-based participatory and peer-led research holds a tremendous potential in investigating solutions 'for the people, by and with the people'. Outcomes of this trial will aid policy makers in designing and implementing effective programs to treat substance dependence in marginalized youth populations.

Inclusion criteria:

• Are currently living in Ottawa for at least 3 months prior to enrolment.
• Are homeless or insecurely housed (from OCH and the Bridge).
• 16 years or older.
• currently use or have a past history of cannabis use
• Self-report a mental illness.

Exclusion criteria:

• Not meeting inclusion criteria

20 youth and 500 adult participants