Design overview
Miracle Messages, the nonprofit that delivers the Miracle Friends and Miracle Money interventions, is headquartered in the San Francisco Bay Area but expanded to have staff members in Los Angeles for this study. Through partnerships with homeless services agencies or direct street outreach, Miracle Messages staff members engaged unhoused individuals to explain the Miracle Friends intervention, which requires having a phone, and signed up anyone who expressed interest in a phone buddy. Those who signed up also learned about a study to evaluate the Miracle Friends intervention, and those who expressed interest were referred to a study team affiliated with the University of Southern California. For those who agreed and provided written informed consent to participate in the study, a random number generator was used to determine sequentially whether a study participant would be offered the Miracle Friends intervention or put on a waitlist. Participants had a two-thirds chance to be offered Miracle Friends. More specifically, as depicted in Fig. 1, participants were randomized to one of three groups: (a) a group offered the Miracle Friends intervention; (b) a group offered Miracle Friends and considered for eligibility to receive guaranteed income through Miracle Money; and (c) a waitlist group. Study team members interacting with participants for recruitment purposes were informed by a single study administrator via telephone just prior to enrollment about whether a participant had been been randomized to receive Miracle Friends or put on a waitlist, but were blinded to whether they would also be considered for Miracle Money. Once enrolled, the single study administrator provided Miracle Messages staff the group assignment of each participant in order to determine whether Miracle Friends should be offered and if a person was elgibily to receive guaranteed income.
The possibility of receiving guaranteed income was only disclosed to participants randomized to the second group and eligible for Miracle Money through having engaged in the Miracle Friends intervention. Nondisclosure of the Miracle Money program, a form of deception, was deemed necessary to avoid: (a) unduly influencing people to participate in the research and (b) biasing results such that people might have engaged in the Miracle Friends program only because they were interested in guaranteed income. Because revealing that a participant may have been eligible for but was not selected to receive basic income could potentially cause more distress than the deception, the study team will not debrief participants at the conclusion of the study about the complete study design, which is consistent with the Code of Federal Regulations on the protection of human subjects [45].
Regardless of group assignment, all participants who are identified by a unique study identification number to preserve confidentiality have been asked to complete a baseline survey and five subsequent quarterly surveys; participants will receive a $30 gift card incentive for each completed survey. Qualitative interviews with a subset of 20 participants receiving basic income have and will be conducted shortly after receipt of the first of 12 monthly payments with another follow-up qualitative interview scheduled around the time of the last payment. A single qualitative interview will be conducted with 20 volunteers serving as a phone buddy for at least 6 months to understand their experience of delivering the Miracle Friends intervention. Participants will receive a $30 incentive at the end of each qualitative interview. This human subjects’ research is being performed in accordance with the Declaration of Helsinki with protocols approved by the first author’s Institutional Review Board. Reporting of study protocols follows the SPIRIT guidelines [46], which include a schedule of enrollment, interventions, and assessments as depicted in Fig. 2.
Interventions
Miracle Friends. Miracle Messages program staff members have recruited volunteers who want to serve as a phone buddy and unhoused individuals who express an interest in being matched with a phone buddy. Recruitment of volunteers has occurred primarily through people who learned about the program through media coverage, word of mouth, social media, or internet searches about helping people experiencing homelessness, with most volunteers signing up on the Miracle Messages website. Volunteers are required to complete an application listing any preferences for a friend (e.g., gender, language, shared interests, text or calls preferred) and attend a 30-minute training call offered once a week synchronously. A recording of the training call is available as needed to those with significant scheduling conflicts. Volunteers receive a program handbook that outlines expectations for logging into an online platform to record any contact or attempted contact with an unhoused friend. After completing a waiver of liability, volunteers receive a phone number through Dialpad or similar service (which allows the volunteers to avoid divulging their personal phone numbers if they wish) and subsequently matched with an unhoused friend, usually in a few weeks. Weekly support calls are offered to all volunteers, in addition to one-on-one support provided upon request based on completing the contact logs.
Recruitment of unhoused individuals has happened primarily through: (a) site visits at local partner sites, including shelters, transitional housing facilities (e.g., tiny homes), converted hotels or motels for unhoused individuals, etc.; (b) referrals from case workers and social workers who work at these partner sites; and (c) limited direct outreach on the streets in and around partner sites or at events designed to address the needs of people experiencing homelessness (e.g., food pantries, homeless connect events). Miracle Friends program staff members explain the intervention and sign up anyone who expresses an interest in a phone buddy.
Matching of unhoused individuals and volunteers has been primarily based on preferences and shared interests, as indicated on the enrollment application. Once a match is determined, volunteers receive the phone number of their assigned unhoused friend and asked to make contact as soon as possible. The program has no time limit, and the development of friendships is expected to occur naturally over time. If a lack of fit occurs or communication is not maintained between the two individuals, the program will offer to rematch the unhoused individual, volunteer, or both. If a volunteer or Miracle Messages staff members cannot contact an unhoused person after five attempts by the volunteer and one attempt by the staff, the person will be removed from the list of people needing to be matched—effectively a discharge from the program. However, participants can reenroll at any time. Once matched, volunteers are expected to attempt weekly phone voice or text contact. Volunteers log their efforts on the program’s online platform after each attempt, helping the program monitor the progression of friendships and address any issues. Based on volunteer responses, the Miracle Friends program can provide referrals to the unhoused person if there is a more urgent need or contact a formal service provider if authorized by the unhoused individual.
Miracle Money. Whereas the Miracle Money proof-of-concept provided $500 for 6 consecutive months, for this study, funds were raised so that Miracle Messages could provide up to 110 individuals with $750 per month for 12 months. This was based on pilot work that suggested that $500 per month meaningfully changed lives [41] but recognizing a living wage income in these cities would be much higher [47]. As noted, Miracle Money is not advertised to those interested in the Miracle Friends intervention; unhoused individuals were only notified about the possibility of receiving basic income after they qualify by having participated in the Miracle Friends interventions, defined as having had at least two meaningful contacts with a matched volunteer in a 1-month period. Volunteers are notified when the person with whom they have been matched with becomes eligible for Miracle Money so that the volunteer can be present during the phone call in which the study participant is offered Miracle Money. Those who qualify and decide to move forward with receiving basic income payments are asked to complete an application for a cash transfer technology company known as AidKit, which has been contracted to process monthly payments sent via a debit card or direct deposit. Although we do not expect many people turning down Miracle Money, we envision that some may decide against receiving income payments based on how it may affect other benefits that depend on income (e.g., Supplemental Security Income, Supplemental Nutrition Assistance Program, etc.), although the intent of guaranteed basic income is to supplement rather than replace existing resources.
Recruitment and enrollment
As noted, study recruitment has occurred via the Miracle Messages program, which notifies the study team about unhoused individuals interested in participating in an evaluation of the Miracle Friends intervention. This has occurred in person when the study team accompanied Miracle Messages staff members to outreach events or through a shared online referral document that provided the study team the contact information of individuals interested in Miracle Friends and the evaluation study. Once the study team confirmed that an individual met the inclusion criteria—which included: (a) being 18 years old or older; (b) speaking English or Spanish; (c) currently experiencing homelessness; and (d) expressed interest in the Miracle Friends phone buddy intervention—enrollment into the study occurred in person with signed informed consent or over the phone with informed consent, requiring an electronic signature completed via email using the REDCap platform [48, 49]. The informed consent process ensures that individuals understand that participation in the study may result in being assigned to a waitlist where they would be ineligible to participate in Miracle Friends for 15 months unless they withdrew from the study. Once enrolled in the study, participants complete a baseline survey and learn whether they have been randomly assigned to the waitlist or Miracle Friends. Surveyors are blinded to whether a participant is assigned to the group that will be offered Miracle Friends only or the group that will be considered for Miracle Money. The Miracle Messages administrative staff is notified to which of the three groups a participant has been assigned to determine whether someone should be matched to a phone buddy and monitor which individuals become eligible for Miracle Money based on participation in Miracle Friends.
Quantitative data collection procedures
Upon enrollment in the study and regardless of group assignment, the participants complete a baseline survey that takes approximately 45 minutes and includes questions about demographic characteristics, homelessness history, physical and mental health status, health service utilization, employment, substance use, socioeconomic status, and income. Participants are also asked to provide an email address and collateral contact information for one or more people to ensure that the study team can reconnect with them when it is time to complete a shorter survey five more times, one every 3 months (i.e., quarterly) until 15 months. The quarterly survey asks about similar topics and takes approximately 25 minutes. Surveys can be completed in person or over the phone, with responses recorded by a surveyor directly into the REDCap data management platform [48, 49] that is also used to support data visualization to monitor data quality and study retention. Upon request, participants also receive a link to self-administer the survey available in English or Spanish. Table 1 describes all study measures.
Table 1
Study measures and scales
Measure | Description |
Primary outcomes | |
Housing status | Housing status is measured using questions from the Los Angeles County Homeless Count demographic survey [49]. Participants are asked, “In the past 30 days, please indicate all places where you have slept for at least one night.” Response options include: 1. My own apartment or home; 2. Someone else’s apartment or home; 3. In a shelter, emergency, temporary housing; 4. Hotel/motel provided by an agency; 5. Outside on the street, park, or beach; 6. Tent or makeshift shelter; 7. In a bus station, train station, airport; Abandoned building; 8. In a vehicle (car, van, RV, truck); 10. An institution, hospital, or facility. A follow-up question could include, “If you stayed in more than one place, where did you stay the most?” Participants are also asked up to three possible questions with “yes” or “no” as response options. These include: Do you currently have a case worker who can help you with housing assistance? Do you currently have a housing assistance voucher? Are you on a waitlist for housing assistance? |
Loneliness | UCLA Loneliness Short Version is a validated instrument [50] that measures three dimensions of loneliness: relational connectedness, social connectedness, and self-perceived isolation. Participants are asked three questions: (1) How often do you feel that you lack companionship? (2) How often do you feel left out? (3) How often do you feel isolated from others? Response options include: Hardly ever; Some of the time; Often. |
Social support | The Oslo Social Support Scale is a 3-item self-report measure of the level of social support [51]. Participants are asked three questions with different response options. The first is: “How many people are so close to you that you can count on them if you have great personal problems?” with response options of: None; 1–2; 3–5; or 5+. The second is: “How much interest and concern do people show in what you do?” with response options of: None; Little; Uncertain; Some, or A lot. The third is: “How easy is it to get practical help from neighbors if you should need it?” with response options of: Very difficult; Difficult; Possible; Easy; or Very easy. |
Other covariates | |
Demographic and historic information (baseline only) | The baseline survey includes questions about the following demographic and historic information taken from previous research studies related to homelessness: age, sex, gender, sexual orientation, race and ethnicity, country of origin, relationship status, children, level of education, military service, health insurance, public benefits, employment, monthly income, criminal justice involvement, homeless history, housing preferences, and health conditions. |
Employment status | Employment status is measured using questions from the Los Angeles County Homeless Count demographic survey [49]. Participants are asked, “What is your employment status?” with the following response options: Employed, full-time (35 hours a week or more); Employed, part-time; Unemployed, looking for work; Unemployed, not looking for work; Retired, receiving retirement benefits; and Retired, not receiving benefits. Participants are also asked to indicate their total monthly income. |
Financial well-being | Adapted questions from the Consumer Finance Protection Bureau’s abbreviated 5-item measure are used. Questions include: “Usually, do you have enough money to meet your needs?” with response options: Completely; Mostly; Moderately, A little; Not at all. “How often (always, often, sometimes, rarely, never) does this statement apply to you? 1) I have money left over at the end of the month; and 2) My finances control my life.” “How well (completely, very well, somewhat, very little, not at all) do the following statements describe you or your situation? 1) Because of my money situation, I feel like I will never have the things I want in life; 2) I am just getting by financially; and 3) I am concerned that the money I have or will save won’t last.” Participants are also asked if and what health insurance they have; monthly benefits that they receive (e.g., general relief, social security disability income or Supplemental Security Income; Supplemental Nutritional Assistance, etc.); if they have a bank account; and whether they were able to pay all bills last month. |
Food security | Two items taken from United States Department of Agriculture Household Food Security Survey ask about how often it is usually true for the particiant (“often,” “sometimes,” “never,” or “I don’t know”) in the past 30 days: “I worry whether my food will run out before I get money to buy more” and “The food I bought just doesn’t last and I don’t have money to get more.” |
Life satisfaction | General life satisfaction is assessed using a 7-item validated measure from the World Health Organization Quality of Life toolkit [52]. Questions include: In general, how satisfied are you with your life? How satisfied are you with your ability to perform your daily living activities? How satisfied are you with your personal relationships? How satisfied are you with the support you get from your friends and family? How satisfied are you with your ability to provide for or support others? How satisfied are you with the way you spend your time? How would you rate your quality of life? Response options for all questions are: Very satisfied; Satisfied; Neither satisfied nor dissatisfied; Dissatisfied; Very dissatisfied. |
Physical health | The PROMIS Global Health Scale Version 1.2 (2 items, self-rated physical health and activities) is used: “In general, how would you rate your physical health?” Response options: Excellent; Very good; Good; Fair; Poor. “To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?” Response options: Completely; Mostly, Moderately; A little; Not at all. |
Mental health | PROMIS is also used to assess mental health (2 items, self-rated mental health, frequency bothered by symptoms): “In general, how would you rate your mental health, including your mood and your ability to think?” Response options: Excellent; Very good; Good; Fair; Poor. “In the past 7 days, how often have you been bothered by emotional problems such as feeling anxious, depressed, or irritable?” Response options: None at all; A little; A moderate amount; Very much; An extreme amount. |
Social health | PROMIS is used to assess social health (1 item, self-rated satisfaction with social activities and relationships): “In general, please rate how well you carry out your usual social activities and roles (this includes activities at home, at work, and in your community, and your responsibilities as a parent, child, spouse, employee, friend, etc.).” Response options: Excellent; Very good; Good; Fair; Poor. |
Substance use | Participants are asked: In the last month, how often did you: 1) have a drink containing alcohol? 2) take substances like cannabis/marijuana, meth, cocaine, fentanyl, heroin, prescription opioids, etc.? Response options include: Never; once or twice; Once a week; 2 to 3 times a week; 4 to 6 times a week; Daily; Prefer not to answer. Participants are also asked if they are currently receiving treatment for substance use (including alcohol) and how much money in the past month that they have spent on 1) Cigarettes and 2) drugs and alcohol. |
Sleep | Sleep disturbance is measured using two questions from the WHO Quality Of Life Scale [52]: Do you have any difficulties with sleeping? How much do sleep problems worry you? Response options: None, A little, A moderate amount; Very much; An extreme amount. |
Psychological distress | Via the Kessler Psychological Distress Scale, participants are asked how often over the past month that they have had certain feelings on a scale of: None of the time; A little of the time; Some of the time; Most of the time; All of the time. Feelings include: Tired out for no good reason; Nervous; So nervous that nothing could calm you down; Hopeless; Restless or fidgety; So restless you could not sit still; Depressed; That everything was an effort; So sad that nothing could cheer you up; and Worthless. |
Health care utilization | Participants are asked how many times they have seen a doctor or health care provider for nonemergency care in the past 30 days. |
Criminal justice involvement | Participants were asked: In the past 3 months, have you had contact with the police? In the past 3 months, how many times have you been arrested? Did a new arrest lead to new charges pending against you? During the past 3 months, did you stay one or more nights in prison or jail? |
Perceived discrimination | A short version of the daily discrimination subscale includes six items and attributions for why a person experienced discrimination. Items regarding discrimination include: You are treated with less courtesy than other people; You receive poorer service than other people at restaurants or stores; People act as if they think you are not smart; People act as if they are afraid of you; You are followed around in stores; You are threatened or harassed. Response options are: Often; Sometimes; Rarely; Never. Participants who have perceive discrimination are asked, “What do you think is the main reasons for these experiences?” and can check all that apply: 1. Your ancestry or national origins; 2. Your gender; 3. Your race; 4. Your religion; 5. Your weight/height; 6. Some other aspect of your physical appearance; 7. Your sexual orientation; 8. Your education or income level; 9. Your housing status. |
At the end of each survey, participants are asked the following two open-ended questions: (1) Looking back over the last 3 months, what do you think was the most significant change to your quality of life? (2) Tell me in a sentence or two, what are your most important goals in life right now? If the survey is administered by a surveyor, responses are entered verbatim as much as possible; if self-administered, participants enter their responses directly. All surveyors complete a training on best practices for trauma-informed interviewing.
Qualitative data collection procedures
Miracle Money recipients. Qualitative interviews will be conducted in English with a subset of 20 participants who receive basic income—shortly after receipt of the first of 12 monthly payments and again around the time of their last payment. During the first quarterly survey, participants who received monthly income will be purposively sampled and asked if they would be interested in participating in an additional in-depth qualitative interview to learn more about their experience with the program. Maximum variation sampling will be used to ensure differences in race, ethnicity, and gender in our qualitative subsample. Those who are interested and agree to participate will be contacted by a research team member who has been trained in conducting qualitative interviews. Interviewers will schedule a convenient time and place to meet unless participants request a phone interview. Once an addendum consent is completed, semistructured interviews will last between 30 and 60 minutes and include questions about how participants view their lives, general experiences with the Miracle Friends program, and the Miracle Money program, including how they use the money and any difference it has made in their lives. Interviews will be audio recorded and transcribed verbatim.
Miracle Friend volunteers. A single qualitative interview will be conducted with 20 volunteers who served as a phone buddy for at least 6 month to understand their experience of Miracle Friends. Any volunteer who has been engaged in the intervention for at least 6 months will receive an email from the Miracle Messages program that informs them of the study and refers them to the study team if they are interested in speaking about their personal experience with the program. Thirty-three volunteers have indicated that they would be interested; 20 have been purposively sampled to include volunteers who had participants in the Miracle Friends program and Miracle Money program. Phone or videoconferencing interviews have been conducted using a semistructured interview guide that included questions about how and why participants became a volunteer, experiences with the program, and whether they felt that they had an impact on their unhoused friend or if their friend has affected their life. Questions about how the program could be improved were also included. Interviews have typically lasted between 25 and 35 minutes and were audio recorded and transcribed verbatim. Written informed consent has been waived by IRB oversight for volunteer interviews.
Quantitative data analysis
Social isolation outcomes. To evaluate the efficacy of the Miracle Friends intervention on social isolation and social support, responses to the Oslo Support Scale (OSS), Kessler Psychological Distress Scale (KPD), and UCLA Loneliness Scale at the final survey (Quarter 5) will be summed, with each sum score modeled as a function of treatment group (1 = Miracle Friends or Miracle Money group members who participated in at least one phone buddy intervention, 0 = waitlist group), covariates including demographic characterstics, physical and mental health, and substance use and a random intercept for city in linear mixed models. Logistic regression with a random intercept will be used to model dichotomized summed scores at the final survey (1 = UCLA Loneliness Scale sum score ≥ 6 as indicative of high loneliness, 0 = otherwise; 1 = OSS sum score < 9 as indicative of poor social support, 0 = otherwise; 1 = KPD sum score > 25 as indicative of high psychological distress, 0 = otherwise) as functions of treatment group, covariates, and random intercept.
Housing outcomes. The association of Miracle Friends with housing outcomes will be evaluated using logistic regression with a random intercept, modeling the dichotomized outcome of exited homelessness (1 = individual responded “My own apartment or home” or “Someone else’s apartment or home,” 0 = otherwise) as a function of treatment (1 = Miracle Friends group members who participated in at least one phone buddy intervention, 0 = waitlist group), with the same covariates and random intercept.
Differences in treatment effect based on race. To evaluate if outcomes differed by race, all models will be run with the addition of an interaction between race and treatment.
Statistical power. Recruitment efforts yielded about 200 individuals in each treatment group, resulting in statistical power exceeding 95% to detect the hypothesized 50% difference in the proportion of people exiting homelessness between the Miracle Money and waitlist groups and exceeding 80% to detect the hypothesized 15% difference in the proportion of people exiting homelessness between the Miracle Friends and Waitlist groups at p < .05 each using a one-sided test. For the continuous outcomes (i.e., summed OSS, KPD, and UCLA Loneliness Scale), the minimum detectable difference between the two treatment groups will be an effect size of .28 with at least 200 individuals per group. For subgroup analysis focused on race, we expect to have 97% power to detect the difference between Miracle Money compared to the waitlist group, given we expect to have close to 65 African Americans in each group. To explore the heterogeneity of treatment effect, we could determine statistical significance in the difference of proportions of Cohen’s h = .43.
Qualitative data analysis
In keeping with qualitative analytic procedures, each interview has been transcribed verbatim by the research team member who conducted the interview. Transcripts have been distributed and shared with the larger team for review. A team approach will occur in data analyses, where instruction in coding will be supplemented with test cases in which two researchers read and code a transcript and then meet to discuss discrepancies and arrive at consensus. Given the focused nature of the inquiry, the resulting codebook will be a reflection of the questions that were asked. At the same time, interviewees often have shared greater depth or alternative descriptions that will “earn their way” into the analyses and interpretation [53]. In the final stage of analysis, broader interpretation will be sought to identify recurrent themes agreed on by consensus and recorded as memos.