Peer support and homelessness

Those who have been socially excluded face extreme consequences—such as a higher chance of premature death (Aldridge et al., 2018). Homelessness services utilise peers to engage this population in the UK, but with little evidence. Current definitions are too broad and lack differentiation between types of peer support. Therefore, there is a need to clarify underlying concepts within peer interventions to influence practice and for future research. This thesis aims to identify and define the underlying change mechanisms involved in peer interventions for those who are homeless and the feasibility of testing the effectiveness of this intervention. Using the Medical Research Council guidance on developing complex interventions, two literature reviews and three empirical studies were completed. Chapter 3 reports a review of the literature exploring the effectiveness of peer interventions and evaluates included articles for potential common elements in peer interventions, from 13 articles. Chapter 4 describes qualitative interviews with 29 participants providing and/or receiving this support to understand potential change mechanisms. Interestingly, it was found that participants were describing a mentorship-type of peer support, suggesting further clarification is needed. Therefore, a second literature review was conducted, in Chapter 5. This realist review focused on the mentorship-type of peer support, terming it intentional, unidirectional peer support (IUPS). The iterative literature search resulted in 71 articles from several sources (e.g. empirical and theoretical literature). Chapter 5 provides a detailed description of IUPS from multiple health areas and suggests change mechanisms that can transcend contexts. To test these concepts in a homeless context, Chapter 6 reports a Q Sort study; a mixed methods design that has never been used within this topic, where a by-person approach to factor analysis is used to generate understanding of shared viewpoints. Forty participants (20 peers and 20 professionals) involved in the delivery and/or facilitation of peer interventions for a homeless population were recruited. Peers and professionals ranked general statements describing peer interventions. Results found support for the developed change mechanisms in Chapter 5 and further evidence the need for peer interventions to be clearly defined in practice and research. To aid this, Chapter 7 reports IUPS as an evidence-based intervention that can be used to inform practice and future research. Additionally, this intervention definition was utilised in the final empirical study in Chapter 8, where the feasibility of testing IUPS across multiple homeless organisations through a controlled cohort study was conducted. Five organisations (two in treatment group and three in control group) participated. Through qualitative interviews and quantitative data, a number of recommendations are suggested to ensure the success of future research. The work in this thesis provides an identification of emerging issues within peer interventions that are worthy of investigation, creating new understanding of a previously poorly defined peer intervention. The main contribution of knowledge that this thesis provides is the clarity on types of peer interventions, and illuminates new avenues to further our understanding of this important topic.