Evaluation of a Health Navigator Pilot Program for Youth in Foster Care

The Health Navigator Program (HNP) was a pilot health mentor intervention program for youth in British Columbia, Canada, with connections to the provincial child welfare system. In this article, youth participants are referred to as “independent youth” as they are independent of traditional familial care. Children and youth in the foster care system face increased prevalence and risk of physical and mental health challenges with lasting implications throughout adulthood. The cumulative effect of childhood trauma, lack of connections to supportive adults, and structural obstacles such as poverty, racism, and sexism all contribute to creating significant barriers for independent youth navigating the health care system. The HNP was created to address these obstacles and facilitate improved health outcomes for independent youth. Youth from 2 program sites were paired with medical student volunteers who provided advocacy and mentorship. A qualitative process evaluation was undertaken to assess the effectiveness of the HNP in achieving the intended program outcomes. Findings revealed that the independent youth participants increased awareness of their own health needs, gained confidence in navigating the health care system, and had improved short-term health outcomes. Relationship building with a caring adult, outside of a paid professional role, was shown to be the most significant factor in achieving these positive outcomes.


Introduction
The Health Navigator Program (HNP) was a health mentor pilot intervention program designed for youth with connections to the provincial child welfare system in British Columbia, Canada.
This group includes young people who are in foster care (youth in care) as well as youth with alternate agreements with the child welfare department who may live on their own but receive social and financial assistance. We refer to these young people throughout this article as "independent youth," meaning that they are independent of care from traditional parental and familial sources. The term "independent youth" was created collaboratively by the youth participants in the HNP after being asked what terminology they would like to use to represent themselves within the community. This article provides an overview of the background, development, implementation, and evaluation of the health navigator pilot program for independent youth. We begin with an overview of the health, social-emotional, and structural barriers impacting independent youth and youth in foster care. Independent youth and youth who have been in foster care have well-established poor health outcomes-including acute and/or chronic physical, mental, and developmental issues (Deutsch & Fortin, 2015)-often due to early adversity, neglect, and unaddressed health care needs (Christian & Schwarz, 2011;Deutsch & Fortin, 2015;Rebbe et al., 2018). It is estimated that nearly all youth who enter foster care have at least one health problem and the majority have multiple problems (Horwitz et al., 2000). However, young people who enter foster care routinely receive less health care than their peers, lack adult support, and are less likely to have a family practitioner (Christian & Schwarz, 2011).

Poor Health Outcomes and the Long-Term Health Impacts for Youth In Care
Increased prevalence and risk for childhood health problems have ongoing implications for physical and mental health in adulthood (Ahrens et al., 2014;Christian & Schwarz, 2011;Zlotnick et al., 2012). Cumulative traumatic childhood events such as maltreatment, family dysfunction, and social isolation are strongly associated with adult physical and mental illness (Christian & Schwarz, 2011). At ages 17 or 18, foster youth are 2 to 4 times more likely to suffer from mental health disorders than youth in the general population (Havlicek et al., 2013).
Independent youth are also less likely to have had their mental health needs adequately addressed in childhood, placing them at increased risk when transitioning out of care and relying on adult mental health services (BC Representative for Children and Youth, 2013).
The Midwest Study, one of the largest longitudinal studies following youth aging out of the foster care system, found that one fourth of the 603 youth who exited foster care reported more emergency room visits and hospitalizations in the 5 years following their exit compared to a nationally representative sample (Courtney et al., 2005). In addition, former foster youth have a higher risk of multiple chronic health conditions even after controlling for economic insecurity (Ahrens et al., 2014), and adults with a history of childhood foster care are consistently found to have poorer health status, with higher reports of asthma, diabetes, hypertension, and epilepsy (Zlotnick et al., 2012).

Transitioning Out of Care
Each year in British Columbia, approximately 1,000 youth age out of the foster care system at age 19 (Ministry of Child and Family Development, 2020;Vancouver Foundation, 2016). Overall, youth transitioning out of care face multiple barriers and challenges including dropping out of school (Burt & Paysnick, 2012), failure to find employment, lack of income security (Ahrens et al., 2014;Courtney et al., 2005), early pregnancy and parenting (Svoboda et al., 2012), conflict with the law (J. S. , homelessness (BC Representative for Children and Youth, 2013), poor mental health outcomes, and substance abuse (Dewar & Goodman, 2014;Garcia & Courtney, 2011). The challenges during this period relate to an unmet need among independent youth for financial, social, and emotional support.
Youth who are not in foster care commonly receive ongoing familial support as part of a gradual developmental transition towards independence (Greeson et al., 2010). Across socioeconomic groups, families serve as the primary financial buffers during this life stage (C. Lee & Duerr Berrick, 2014;Swartz, 2008). Comparatively, the transition to adulthood for youth in care is driven by rigid policy timelines with few options to extend their transition time or return to care (Mendes & Moslehuddin, 2006;Swartz, 2008).
The sudden separation from caregivers and support systems that occurs when youth age out of care is said to be developmentally premature within contemporary North American contexts (Arnett, 1998;Iglehart & Becerra, 2002). Not only is adult support normative for adolescent development, the presence of a caring adult figure has also been found to be protective (Greeson et al., 2010). Studies examining youth's developmental transition to adulthood have found that for all young people, achievement of adulthood is based more on psychological/social markers (e.g., deciding on personal values and taking responsibility for one's actions) than technical markers (e.g., employment and independent living; Arnett, 1998;Propp et al., 2003). Further, research has identified the importance of helping independent youth to develop supportive relationships with adults during the transition period (Mendes & Moslehuddin, 2006;Nesmith & Christophersen, 2014).
Despite the evidence for the importance of social-emotional development for young people entering adulthood, for independent youth involved with social services, the emphasis is on pragmatic and technical skill building. Teaching independent youth practical skills for independence (e.g., budgeting, finding employment) has been the focus of mainstream policy and intervention programs with this population (C. Lee & Duerr Berrick, 2014). While such skills are necessary and important for any young person to learn, the continued hardship and challenges experienced by youth aging out of care suggests that skills-based approaches alone may be inadequate. Thus, when designing interventions, the focus may need to shift from skills-based approaches that emphasize self-sufficiency towards approaches to transition that emphasize connection, collaboration, and emotional and social support (Propp et al., 2003).

Structural Barriers
In addition to considering independent youth's social-emotional development, the impact of structural factors and institutionalized forms of oppression in preventing independent youth from achieving physical, mental, and social health needs to be considered. Economic inequality is the biggest structural barrier. Poverty is both a cause and a consequence of poor health outcomes (Feinstein, 1993;Mukherjee, 2015). A disproportionate number of youth aging out of care live below the poverty line, exacerbated by low educational attainment, income insecurity, and lack of familial support (Shaffer et al., 2016). Poverty is inextricably linked with housing and food insecurity. Independent youth are at high risk for homelessness and housing instability and almost 60% of homeless youth in Canada report involvement in the child welfare system (Nichols et al., 2017).
An exacerbation of independent youth's poor health status is the historic inability of the social service, child welfare, and health care systems to adequately address their health needs. Social service systems focus on the physical and most immediate needs of independent youth, or the most visible behavioral signs of trauma (such as substance misuse or self-harm). Further, the health care system itself is often ill-equipped to address the complex needs of independent youth as there is generally little training for health care providers on working to effectively support independent youth and the challenges they face (BC Medical Association, 2012;Lopez & Allen, 2007;Vancouver Foundation, 2016;Ziemann, 2019). The cumulative effect of the structural limitations of the health and social service systems is that such youth lack a history of having their health needs adequately addressed, lack awareness as to what their health needs are, and lack support in navigating and developing the competencies required to adequately address their health needs.

The Health Navigator Program Health Navigator Programs
The poor health outcomes, lack of support during the transition from care, and structural barriers confronting independent youth reference unmet or insufficiently addressed primary needs of this population. To address these primary needs, health navigator programs provide a model for interventions that address systemic barriers and situate the challenges of navigating the health care system within the context of relationship building (The Change Foundation, 2013;Pope, 2003). The first documented health navigator programs were implemented to support patients receiving cancer treatment. Subsequently, health navigator programs have been taken up by a variety of health and social service programs, expanding beyond conditionspecific education to address the patients' needs within their social context (Bieling et al., 2013;The Change Foundation, 2013).
Published evaluations and reviews of health navigator programs highlight the following roles of health navigators: improving access to care and addressing health disparities for vulnerable populations (Doolan-Noble et al., 2013;Page-Reeves et al., 2016;Vargas, 2016); facilitating culturally appropriate care (Fraser Health, n.d.;Natale-Pereira et al., 2011); providing patient education and assembling information (Natale-Pereira et al., 2011;Newman et al., 2014;Pope, 2003); improving coordination of health care services, particularly during periods of transition (Bieling et al., 2013;Pope, 2003;The Change Foundation, 2013); addressing distrust in institutions and health care systems (Natale-Pereira et al., 2011;Vargas, 2016); and, offering consistent contact and personal guidance to empower patients to identify routes of service and support (Natale-Pereira et al., 2011;Pope, 2003). Given this evidence, health navigator programs provide an adaptable model to address the challenges facing independent youth.

Program Design
The Health Navigator Program (HNP) was created to address the poor health outcomes confronting independent youth, as well as the structural barriers they face and their vulnerability within the health care system. The HNP was designed by an interdisciplinary research team including health practitioners and researchers in collaboration with two community agencies providing services to independent youth. The HNP paired independent youth with adult mentors who served as health navigators. Health navigators were five, 2 nd -year medical student volunteers who received university credit from their medical school program for their participation in the HNP. All of the health navigators identified as cisgender women. Their ages ranged from 23 to 25. Ethnically, four of the navigators identified as White and one person identified as Indo-Canadian.
The HNP began with 20 hours of training for the medical students, divided across 4 weeks, prior to any contact with youth participants (see Health Navigator Training). Ongoing support to the health navigators throughout the duration of the program was provided by a sociologist who acted as the program coordinator (first author), the adolescent pediatrician program director (third author), and a physician staff member. The health navigators as a group, met twice a month with the program coordinator. This was an opportunity to debrief about their experiences with their youth mentees, share ideas, and plan next steps for future activities. The navigators also submitted weekly written reflections to the program coordinator. These reflections detailed what the navigator did that week with their mentees as well as a reflection on their experiences with their mentee and as a health navigator. The navigators had access to the staff physician via telephone or e-mail and would contact them on their own to discuss any medical-related issues that arose with their mentees.

Health Navigator Training
Prior to engaging with youth, the medical students participated in a total of 20 hours of training across 4 weeks. The training followed a youth mentorship, positive youth development framework (PYD). PYD is a philosophy and an approach towards youth programming that adopts a holistic and strengths-based perspective with youth in contrast to the traditional deficit/medical model of adolescent development (Lerner et al., 2005;Overton, 2010).
Traditional psychological/deficit models of adolescent development focus on the absence of problems as an indication of healthy development, and promote one, universal pathway towards health/growth. PYD emphasizes the diversity of paths towards and meanings of a successful adulthood (Overton, 2010). Research has shown that mentoring that occurs within the context of a PYD framework is associated with the capacity for youth to engage in highquality social relationships, to have greater academic achievement, and to view their futures more positively (Rhodes et al., 2006). Each of these capacities is in support of the underlying needs of independent youth and the objectives of this intervention.
Health navigator training began with an overview of PYD and an explanation of how to develop a structural perspective on youth in contrast to the traditional deficit/medical model of adolescent development. Navigators learned about the health and social issues impacting youth in foster care and independent youth, community resources available for marginalized youth, and trauma-informed care. Another portion of the training involved developing mentoring and relational skills for engaging with independent youth. This consisted of roles and responsibilities, communication skills, relationship building, boundary setting, and ethical considerations. The medical students also visited each of the two research sites and met with the site staff.

Research Sites
The HNP took place at two established community-based organizations that serve independent youth: Vista Education Center and the Mom and Baby Group at Roberta's House, a non-profit organization. Vista Education Center is a partnership between the Vancouver School Board 1 and the provincial child welfare system for youth aged 15 to 18 completing grades 11 and/or 12. It is a self-paced alternative education program, with a maximum enrolment of 20 students who are referred by government social workers, by an Aboriginal designated agency, or by a probation officer. In addition to academic education and post-secondary/vocational planning, there is a focus on offering social and emotional support based on the students' individual needs.
Roberta's House provides supported housing, education, employment training, and coaching on essential life skills for youth in foster care as they transition to independence. One of their primary objectives is to prevent young mothers in need from losing custody of their children.
The Mom and Baby Group is a support and resource drop-in group that meets weekly for young mothers. Approximately 12 to 15 mothers and their children attended the group each week.
The youth who attend Vista have experienced multiple barriers to completing their high school education. These barriers include their status as a youth in care, housing instability, lack of financial support, and the absence of supportive adult care providers. In addition, many of the students have learning disabilities, mental health diagnoses, and substance misuse or addiction experience. Many youth at both locations have experienced trauma such as physical and sexual abuse, witnessing violence, and institutional trauma from racism, classism, heterosexism or transphobia, and sexism.
Ethnically, the majority of the young people at both locations identified as Indigenous (they often used the term "First Nations") or White. The remaining youth identified as Chinese Canadian, South Asian, Filipina, and "mixed race" (Black and White). Gender and sexuality diversity was present at Vista, while all of the youth in the Mom and Baby Group identified as cisgender heterosexual girls or women (see Table 1 for demographic information).
Three medical students self-selected to be placed at the Vista Education Center, and two students chose to go to Roberta's House. As part of the program requirement, health navigators were expected to spend 4 hours per week engaging with their youth mentees. This time included in-person meetings with their mentees as well as planning activities or contacting resources on behalf of their mentee. The health navigators met with their assigned youth approximately once per week. They assisted their mentees to establish health-related goals, attended medical appointments, and provided them with health resources. One of the primary objectives was for the navigators to develop a relationship with their mentee and to support them as they worked towards addressing their health goals. At the conclusion of the program, eight youth from Vista had connected with a health navigator, reflecting a 40% participation rate. The health navigators informally connected with even more youth. Eight young mothers from Roberta's House connected with a health navigator, reflecting a 53% participation rate, while informal assistance was offered to 10 other young parents (see Table 1). Note. This table presents data on youth who formally participated in the Health Navigator Program (HNP).
Additional youth regularly informally engaged with health navigators at weekly meetings (drop-in groups or mealtimes) at each research site. Gender and sexuality categories include categories participants used to selfidentify.

Methods
A qualitative process evaluation was undertaken to assess implementation of the HNP based on the participants' views and experiences throughout the pilot program. Qualitative process evaluation ensures a deep understanding of the experiences and perspectives of program participants, generating rich data about the social realities of participants (Al-HadiHasan et al., 2017;Broughton, 1991). An interpretive framework was used to identify independent youths' needs in order to assess the effectiveness of the HNP. Three primary health-related needs were identified in the literature and reflected in the experiences of the independent youth in our study: (a) poor health outcomes, (b) lack of support during the transition from care, and (c) structural barriers faced by independent youth when navigating the health care system. This framework was then used to guide data analysis in order to identify the key process issues (or underlying needs) underpinning the participants' primary needs.
For the purposes of program evaluation, the underlying needs identified in the literature informed the development of program objectives or intended outcomes following each independent youth's participation in the HNP. The program outcomes were then used to evaluate the HNP's overall effectiveness. The program outcomes were as follows: (a) developing agency for one's own health, (b) empowerment to respond to discrimination in the health care system (c) increased agency navigating the health care system, and (e) relationship building with a trusting adult (see Figure 1).

Data Collection and Analysis
Data were collected in order to assess the degree to which the program outcomes were achieved following the youths' participation in the HNP. Multiple qualitative methods were used.
These include open-ended in-depth interviews with the youth participants (Rubin & Rubin, 2012a, 2012b, open-ended in-depth interviews with staff at Vista Education Center, a focus group with the youth participants at the end of the program (Gibson, 2007), a focus group with the health navigators at the end of the program, and participant observation throughout the duration of the program at both research sites (Maxwell, 2013). Examples of interview prompts with the youth participants are as follows: "Please describe your experience participating in the HNP."; "What were the health goals that you established with your health navigator?"; "In what ways did you address your health goals?"; and "In what ways did you not address your health goals?" Another source of data was weekly written reflections by the health navigators describing their experiences with their mentees.
The program outcomes formed an interpretive framework used to analyze the data and evaluate the HNP's overall effectiveness. In each instance the data took the form of written text either from transcribed interviews or field notes from participant observations. All data were entered into HyperRESEARCH qualitative data analysis software. Thematic analysis was used (Burawoy, 1998) in a two-stage coding process involving open coding and focused coding to identify themes appearing across all data (Esterberg, 2002).

Results
Results are presented according to the intended program outcome (see Figure 1 for program outcomes; see Table 2 for a summary of themes). Themes in the data related to and interacted with multiple underlying needs and program outcomes. Overall, each of the program outcomes was achieved in some way by the youth who participated in the HNP. A central component of Note. Primary Needs: primary health-related needs as identified in the literature and verified in the data from project participants; used as an analytical frame to identify underlying needs. Underlying Needs: contextual factors understood as contributing to primary needs; used to develop program outcomes. Outcomes: program outcomes used for evaluation of the pilot program.
the program design was supporting youth participants to identify their subjective health needs and establish their own individualized goals (see Developing Health Goals). Rather than evaluating whether youth participants met or did not meet a predefined program outcome based on fixed criteria, qualitative process evaluation facilitated analyzing and identifying themes that emerged through the iterative, youth-centered process in which youth defined and worked towards their individualized health goals with the support of their health navigator.
While youth who chose to participate in the program may not have experienced the same outcomes quantitatively, common themes in their experiences emerged related to agency, empowerment, and relationship building. Thus, the program outcomes were met for each individual in some capacity through the process of their participation and learning. Please note that pseudonyms have been used for health navigators and independent youth participants.

Facilitating Health Care Utilization
Through the process of becoming aware of their health needs, writing down their health goals, and then learning how to address those goals, the youth took proactive steps to improve their health. One of the ways that this became evident was through making and going to medical appointments. All the health navigators spent time with the youth to seek medical services. This included medical, dental, and mental health appointments, pharmacy visits, and emergency services. John (age 19) stated: "I need a root canal. My navigator is helping me take small steps towards it," which reflects his perception of the multiple steps required to working towards meeting a health need, and the role of the navigator in being present throughout this process. Riley (age 17) also reflected on the significance of having a health navigator to support them with completing health-related tasks: "She is really helpful in getting medical stuff done.
Like making appointments, picking up prescriptions and that kind of thing as needed." These steps facilitating health care utilization can be understood as part of a longer process with the potential to contribute to improved health outcomes by increasing access to care. What is important to stress here is the background work related to self-reflection and self-awareness among the youth that is needed before their immediate health needs can be met. This relates to the next finding from the study, the youths' increased agency to respond to discrimination within the health care system.

Program Outcome: Empowerment to Respond to Discrimination Negative Experiences With the Health Care System
The young people in the HNP shared with their health navigators many problems and challenges they had encountered interacting with the health care system. Even once they had access to health care, their experiences were frequently unpleasant, discriminatory, dismissive, and at times ineffective. "They [the youth] seem to have some hesitancy around the health care system (acquiring prescription medications for example) and have mentioned negative experiences with a past family doctor that they felt didn't listen to them," (Amy, Health Navigator). Lea, a health navigator, described her perception of her mentee's frustrations as follows: The mom seemed like she wanted to talk about her previous experience of trauma and coping, she expressed that she felt as though she hadn't gotten adequate support and counselling in discussing and healing. She expressed her frustration at having wanted to talk about her experience of violence with her counsellor during her time of receiving detox but that it was deemed to not be in the role of an addictions counsellor to discuss that information.
The lack of culturally appropriate health care services also emerged as a need for the youth as Amy, a health navigator, reveals: My mentee also shared with me some of their views on the health care system.
They mentioned an Elder in their school program had shared some knowledge about traditional, Indigenous approaches to medicine, and that seemed to be important to them. They also had some fears and apprehension around engaging with the medical system.
This interaction suggests fear related to engaging with the medical system, as well as a desire to engage with Indigenous approaches to health that appear to not be recognized or provided.
Such negative and biased experiences with health care itself is important to stress, as often the poor health status of independent youth and youth in care is presented as a result of their lack of familial support, familial abuse, and unstable living arrangements. However, for the young people who participated in the HNP, even after they had access to care their health needs were still not being met. This reveals the institutionalized discrimination present in the health care system.

Negative Experiences With Doctors
All the youth shared negative experiences with past doctors. For some youth it was an experience of not being heard or listened to: She does not like her current family doctor so she almost never goes to see her.
I asked her why and she said she does not feel like she listens to her or explains anything to her during the visits. One time she saw a substitute doctor who told her that what her doctor had given her was wrong and changed the medications.
(Jessica, Health Navigator) For other youth it was an experience of outright discrimination because of their age, life circumstances, or their sexuality. Lea, a health navigator, discussed how the two mothers she worked with expressed feeling discriminated against because they were young mothers: For both mothers, the health of their children was most important. They had encountered many doctors who ignored them, didn't take them seriously, or didn't believe them when they said something was wrong with their children.
They both wanted to find health care providers that better addressed the needs of their children.
Additionally, finding a queer-friendly doctor was a prominent health goal for the queer-identified youth in the program: "Some health goals that we discussed were that she is looking for a family doctor that is queer-friendly" (Jessica, Health Navigator).
The ability of the youth in the HNP to articulate their negative experiences with the health care system to their health navigator, reveals the trust they were developing with this new adult in their life. It also suggests the beginning of the youths' acknowledgment that their negative experiences were not of their own making. It demonstrated a recognition of the institutionalized discrimination present in the health care system and hence, recognition of their own personal empowerment to challenge this discrimination.

Program Outcome: Increased Agency Navigating the Health Care System
Knowledge of the Health Care System The health navigators spent a great deal of time acquiring information on resources for the youth in response to their health goals. The youth learned about available resources in the community and how to access them. Knowledge sharing contributed to fostering the youth's self-awareness about their health needs. Knowledge acquisition increased the youths' ability to navigate the health care system and hence their agency within it.
Accountability. Accountability emerged as an important theme that connected knowledge of the health-care system to motivation and behavioral change. If it were just knowledge of available resources that propelled young people to then use those resources, independent youth and youth in care would not have the low rates of health care participation that they do. Through the one-on-one support provided to the youth by their health navigator, youths' knowledge acquisition translated into motivation to use those resources to address their health goals.
Paramount to this process was the accountability provided by the health navigators. Having a trusting adult to be accountable to and who is following up with you is critical in the lives of young people who have been mistreated and let down by their familial caregivers. John (age 19), describes his view on accountability by stating, "It's nice to have someone that is on top of you about getting stuff done." Kayla, a health navigator, also reflected on the impact of accountability in the HNP: "My mentee has said when I have asked how they think that this program is working that they do think that having me there is helpful, not only to help search for resources, but also to have someone to be accountable to for completing some tasks on their own." Being accountable to someone else is also a key factor toward improving the young people's health outcomes. One clear example of this is the high number of medical appointments that youth made and subsequently attended with their health navigators. Another example is how frequently finding a general practitioner was featured as a goal for youth in the program.

Finding a General Practitioner
The majority of the young people who participated in the HNP did not have a general practitioner (GP) or a family physician with whom they consistently visited at the start of the program. For those youth who did have a GP, they expressed dislike and at times abhorrence of their practitioner. Riley, age 17, shared this sentiment: "Yeah, I was seeing a family doctor, but not anymore. I had bad experiences with them." The young mothers in the Mom and Baby Group were the most likely to already have a GP due to pregnancy and childbirth. However, they too expressed concern that they did not like their current GP and did not think they were addressing their needs. Lea, a health navigator, described this situation in one of her weekly reflections: "She wanted a stable GP that her daughter and future children can grow up with. She also stated she wanted a GP that listened to her needs, had reasonable wait times, and helped with patient education." Finding a GP, thus, became a health goal for all the participants in the HNP and a goal that was achieved by nearly everyone.
The acquisition of a GP was one of the key positive outcomes of the youths' participation in the HNP that will lead to improved health outcomes. Given the high level of health needs of these youth, obtaining a medical home with a GP can improve their health outcomes into adulthood (Christian & Schwarz, 2011). Further, for youth who are transitioning out of care, a consistent GP provides a continuity from childhood to adulthood when there is little other permanency during this transition period (Lopez & Allen, 2007).

Confidence in Advocating for Oneself
Increased knowledge about available resources and how to use them, and inquiry into or the acquisition of a GP, ultimately contributed to the young people's confidence in advocating for themselves. Part of this self-assurance emerged as the youth and their navigators engaged in problem solving together. Lea, a health navigator, described an interaction with her mentee that focused on building the mentee's confidence and readiness to engage with a health professional: "She had a doctor's appointment the day following [my visit at] Roberta's House, so we went over questions she can ask such as 'How to ensure the baby is okay with the formula and adjusting?' and 'Why is there pain in my nipple/breast area?'" Jessica, a health navigator, described this interaction with a youth: "We talked about what they look for in a pharmacy or physician, for example, wait times, location." Working collaboratively to set objectives for appointments and to practice advocating for oneself by asking questions enabled the youth to gain confidence and a sense of readiness to engage with health professionals.

Youth Empowerment
Related to this increased confidence in the youths' own abilities was the experience of having their needs met. As the health navigators assisted the youth in addressing their health needs, this translated into a feeling of empowerment, that is, independent youths' subjective sense that they could gain the ability to navigate the health care system and advocate for themselves.
This attentiveness is reflected in a quote by Lea, a health navigator: "With one of my mentees who is seeking answers for getting a FAS [Fetal Alcohol Spectrum Disorder] diagnostic assessment, I scheduled an appointment with her to go to her family doctor's office with her on December 5 th and will get to see her then and work through anything else that she would like." In this quote, Lea describes responding to her mentee's needs by being available to connect and provide support on any topic her mentee chooses, as well as the tangible contribution of scheduling and attending an appointment with her mentee. The participant's decision to pursue a FASD assessment demonstrated her willingness to initiate a complicated interaction with the medical system. Several health navigators reported helping youth complete complex tasks that they had previously avoided for various reasons. For example, Kayla, a health navigator, described supporting her mentee in their engagement with a government institution: "My mentee mentioned that they were trying to request documents regarding their adoption and together, next time we meet, we are planning to mail those documents to the Ministry of Children and Families." As the program progressed, youth appeared to demonstrate an increased sense of empowerment by undertaking difficult tasks to address their health goals and previously unmet needs.

Program Outcome: Relationship Building With a Trusting Adult Interpersonal Connections
Perhaps the most significant loss for independent youth and youth in care is the absence of supportive, reliable, and nurturing adult care in their lives. All the youth who participated in the HNP were connected to many professionals for support (i.e., social workers, doctors, teachers, youth and family workers). Yet what they did not have was an adult mentor, someone who was not in a specific paid role, with whom they could connect. This kind of relationship formed between the youth and their health navigator, and it is what made the HNP unique. The youth in the program were at an age where they were likely too old for other mentoring programs geared towards younger youth (like Big Brothers/Big Sisters).
This individual human connection in the HNP was an important factor in producing the positive outcomes. The evidence for this came from the youth themselves. They talked about how they liked having someone to talk to even if they didn't "do" anything specific. One of the youth,

Riley
, remarked that what they liked most about having a navigator was that there was someone to help them with mundane, everyday tasks like going to the grocery store or helping them plan out their week. Amy, one of the health navigators, thought she was not being useful anymore towards the end of the program because she and her mentee had addressed all his health goals. When the youth Amy was working with was asked if he wanted to keep seeing her, he said definitively, "Yes. Absolutely." John, a youth participant, described the importance of having regular contact with his health navigator: "The best thing about this [the HNP] program is that there is someone to talk to. . . . It feels like amateur therapy hour. We talk about what's going on, break down the week." Statements like these provide clear examples of the importance of social and emotional support offered in a less structured setting than traditional skills-based programming for independent youth.
Building a positive relationship with a young adult who is not a paid professional provided the youth in the HNP with the experience of defining the terms of a positive, healthy relationship with an adult outside of the context of institutionalized social services. These relationships were not formed with the intention of addressing problems or issues that had been identified by outsiders-health navigators were not there to "fix" problems that someone else had identified in the youth's life or behavior-but rather youth were given opportunities to identify their own health goals. Thus, the youth experienced increased agency as they defined for themselves what they needed to be healthy. This is something that independent youth have little familiarity with as they have frequently been at the mercy of adults' actions and behaviors. Providing opportunities to connect with a caring adult within a strengths-based, youth-led context was one of the most important elements of the HNP.

Program Challenges
Several challenges were encountered during the process of program implementation and evaluation. Addressing challenges as they arose was essential in supporting the success of youth participants and health navigators. The first challenge was youth participation. A key consideration in designing the HNP was accessibility for independent youth and providing greater flexibility and choice in their participation than they are often offered in other institutionalized settings. Program participation was voluntary, and for youth who did choose to participate in the program, their level of involvement (e.g., frequency and duration of meetings with health navigators, types of activities) was also individualized. Defining the terms of their relationship with their health navigator was a learning opportunity unto itself for both independent youth and the navigators, as this required youth to take initiative in communicating their needs, and for health navigators to be flexible and adapt to youth's often challenging and changing circumstances. Navigating the challenges involved in the relationshipbuilding process together was a vital element of the HNP and contributed to the program outcome of relationship building and interpersonal connections.
While the HNP was designed to be accessible to youth by partnering with established community organizations, this approach excluded independent youth who were not involved with these organizations. Finding ways to reach marginalized and vulnerable youth to provide relationship-building opportunities is an important consideration for future programming (see As demonstrated in the results, youth frequently shared negative past experiences within the health care system and with health care providers. For some youth, these negative experiences may have contributed to choosing not to participate in a program involving medical students.
To address this potential issue, health navigators at Roberta's House made themselves available to all youth accessing services at existing drop-in groups-some youth chose to participate fully in one-to-one mentorship relationships, while others engaged in less intensive ways through informal conversations and more gradual relationship building. While the youth who did not formally participate were not involved in interviews for program evaluation, it is possible that creating opportunities to connect with health navigators in an unstructured way may contribute to choosing to participate in the future.
Other reasons for choosing not to participate may include focusing on other areas of life, or not feeling interested or ready to set health goals. While we did not interview or survey youth who did not participate in the program, reasons for not participating and barriers to involvement should be considered in future programs and studies. Of note, none of the youth who participated in the program chose to withdraw or cease their relationship with their health navigator. All youth participants maintained regular contact with their health navigator, with varied frequency (e.g., the youth spoke and/or met with their health navigator every week, while some met in person less frequently). The health navigators' ongoing willingness to meet with youth and flexibility in responding to youths' changing circumstances can be understood as facilitating accessibility and involvement for youth.
The second challenge was supporting the health navigators in adapting to the method of program delivery, which was more flexible and less structured relative to much of their previous training. For the health navigators, the iterative nature of relationship building and supporting youth as they established individual health goals was sometimes challenging. Rather than a more structured education program where meetings were scheduled at the same time each week (as is often the case in community health programs that involve delivering educational workshops, or hosting drop-in clinics), the HNP aimed to encourage youth's self-advocacy and developing agency by creating opportunities for youth to engage in relationship building and take on increasing responsibility for identifying and addressing their health needs. The flexibility required from health navigators appeared to contrast the regular structure of their medical training, and their training in positive youth development as well as ongoing support from program staff were essential in helping the health navigators learn to work effectively with this vulnerable population.
For example, in one situation a youth participant shared with their health navigator that they would like to work on improving their nutrition. The health navigator's initial response was to research scientific journal articles on nutrition and print the articles to share with their youth mentee. This strategy may be effective in some instances, but in this particular mentorship relationship the health navigator found that their mentee did not seem to engage with the articles. With help from the program coordinator, the health navigator reflected on issues of accessibility, communicated with their mentee, and adjusted their approach to make a plan to practice meal planning and go grocery shopping together. This interaction illustrates the impact of the HNP on changing medical students' understanding of health education, knowledge translation, and developing skills to work with diverse populations. This particular interaction could be indicative of the stage of training of the health navigators and their experience working outside of university contexts, as the strategies they were most likely to employ involved relying on academic skills. Applying problem-based learning in real-world contexts with support to help them reflect and adjust their approach was important in addressing challenges as they arose.
Another issue related to the health navigators that should be noted was the demographic characteristics of the health navigators. They were all women and all but one of them were White, while in contrast, the majority of the youth participants were racialized youth. We do not know if there would have been more youth participation in the program from boys if there had been health navigators who were men. Still, this lack of diversity was not necessarily negative for the HNP. None of the youth participants commented on the gender or ethnicity of the navigators. Rather, the lack of diversity among the health navigators is reflective of the lack of diversity among medical students and ultimately the lack of diversity among physicians.
Additionally, medical students are in a relatively privileged position in relation to independent youth. In this way, the youth participants were able to form connections with young adults who are outside of their social and economic circles but are reflective of the dominant institutions with which they come in contact on a daily basis.

Discussion
This study evaluated a pilot Health Navigator Program (HNP) for independent youth-youth with connections to the provincial child welfare system. The objectives of the HNP were to (a) address the poor health outcomes of independent youth in the short term, (b) address the difficulties that independent youth face in navigating the health care system, and (c) foster a trusting relationship with an adult outside of a formal institutionalized role.
Results from this study reveal that each of the intended objectives or outcomes of the HNP were addressed in some way. In the short term, independent youths' health outcomes were improved by receiving support and guidance towards understanding and identifying their health needs, setting health goals, and taking steps towards achieving these goals. The results also provide evidence that the young people in the HNP increased their ability to navigate the health care system. This change occurred through increased knowledge of the health care system and acquired confidence in advocating for oneself with health care providers.
Importantly, these outcomes were achieved through the youth building meaningful connections with a health navigator-an adult mentor outside of a professional role. Establishing trust between the youth and their health navigator provided vital social and emotional support for the youth that was missing from other social service programs. These relationships empowered the youth to voice their health concerns and needs. All of this increased the youth's sense of agency in regard to their own health. This approach addresses a key gap identified within the literature on health outcomes for youth in care, by supporting youth's social-emotional development rather than focusing only on hard skills and prioritizing and centering youth's experiences within all stages of program design and implementation. Importantly, the HNP expanded the definition of health beyond physical or biological indicators of disease. The youth identified and defined what health meant to them, incorporating physical, mental, emotional, spiritual, and cultural dimensions. Creating space for youth to reflect on and identify their needs helped to address previous gaps in care. Importantly, providing training and ongoing support for medical students facilitated a shift in perspective away from a deficit model towards a collaborative understanding of individual health, grounded in principles of relationship building.
There are a few important limitations to note. Firstly, we did not collect longitudinal data on independent youths' experiences after their involvement in the HNP. While the goals of the program evaluation were to understand the experiences during the program, the absence of follow-up data limits our understanding of the long-term impact or lasting changes related to youths' involvement. As previously stated, indicators of youths' increased willingness to engage in complex institutional processes and increased motivation to take independent action in identifying and meeting their health needs provide evidence supporting an increased sense of agency and empowerment, with potential lasting impact. Future studies should investigate youths' experiences following their involvement, to better understand the lasting impact of the health navigator relationship on future health experiences. Additionally, finding ways to improve accessibility and reach additional youth is an important consideration for future studies.

Considerations for Program Implementation
Accessibility and participation were key considerations in developing the HNP. Working in partnership with organizations that had established relationships with independent youth was an important aspect of the program. The youth were already gathering regularly at the program sites and there was an existing level of trust between youth and program staff which supported their participation in the HNP. Furthermore, staff at both partner organizations provided important direction and feedback, and health navigators could observe and follow the lead of professionals who had experience working with independent youth.
Bringing the HNP to existing meeting spaces did not ensure 100% accessibility, however.
Attendance at both program sites was variable, as youth were dealing with daily challenges like poverty, homelessness, and trauma. The authors believe that one of the reasons the program sites have been able to develop long-term relationships with independent youth is that they are accommodating of intermittent attendance and try and reduce barriers to returning to program activities. The health navigators adopted this low-barrier approach by being flexible and accommodating of youths' sometimes unpredictable life circumstances that might affect attendance. Further, health navigators attended existing gatherings at each program site in order to engage youth who may not have been able to commit to regular participation in the HNP. It is important to note that while engaging youth through partner organizations made programming more accessible for these youth, it necessarily meant that we were not engaging youth outside of these organizations. Youth who are not engaged in alternative education or support programs could stand to benefit from one-on-one mentorship relationships. Finding additional ways to reach independent youth is a consideration for future health navigator programs.
Another key to the success of the HNP was engaging medical students as health navigators.
Partnering with a university medical school provided valuable infrastructure to support the health navigators as well as offered them course credit for their participation. Additionally, health navigators received 20 hours of training in youth development, the foster care system, and adolescent health all from a structural and positive youth development framework. This perspective challenges the victim-blaming and deficit orientation of many interventions targeting independent youth. It also challenges the dominant ideology around youth and appeared to reframe both the medical student's perspective and the youth's perception of themselves within the health care system. This kind of training around institutionalized inequality and direct community experience for future health professionals is key to addressing the structural challenges that independent youth face in the health care system.

Conclusion
The HNP reveals the importance of understanding relationship building and social-emotional development as part of a healthy transition to adulthood and emphasizes the need to create opportunities for this type of support for independent youth outside of relationships with paid service providers. While youth participants demonstrated observable changes in skills, attitudes, and behaviors related to their health, they reported that developing a relationship with their health navigator was what they valued most. Social and emotional support can be understood as an essential component of addressing independent youth's health needs, as it was through the development of a relationship with a trusting adult that youth were able to identify and work towards their health goals.