Title: A mixed-method impact, economic and process evaluation of how a peer advocacy intervention for people experiencing homelessness in London facilitates access to health care and enables well-being
Funder: Department of Health and Social Care

Abstract: People experiencing homelessness suffer extreme health inequalities. The average age of death is 47 years for homeless people and even lower for women (43 years), they are between 5-7 times more likely to die prematurely than the general population. Homeless people are more vulnerable to tuberculosis, hepatitis C and HIV, injury and chronic physical and poor mental health that result from limited access to health care and harsh living conditions. Access to health services is hindered by organisational challenges, fear of stigma and difficulties reconciling daily demands of being homeless with prioritising care. As a result, presentation at health care is delayed until it is urgent and use of accident and emergency services and hospitals is high; this represents potentially avoidable ill-health and distress, but also significant health system costs. The health care costs of homeless people are estimated to be 8 times higher than the general population._x000D_ _x000D_ Groundswell, a third sector organisation, have pioneered Homeless Health Peer Advocacy (HHPA) among homeless populations in London, a model that is being adapted by others. Peer advocates who themselves have experience of homelessness provide one-to-one support to attend health care appointments. The availability of a trusted advocate, with similar experience, to guide health care encounters; overcome logistical, structural and psychosocial challenges; and enhance individual and community understanding could be an acceptable, effective and cost-efficient intervention. There is limited evidence showing the impact of peer advocates on health service utilisation and other health and social outcomes, nor the mechanisms through which the intervention works. Further evidence would facilitate development and scale-up of the intervention among homeless and other vulnerable populations in London and elsewhere._x000D_ _x000D_ This research will evaluate how and to what extent the intervention changes the way homeless populations use outpatient and emergency services and how it shapes other health and social outcomes (e.g. mental health, drug use and access to drug and alcohol or mental health services). Qualitative research methods (interviews and observation) will also be used to understand how peer advocacy works and on what health and social outcomes. We will compare how engagement with peer advocates affects homeless peoples’ use of health services and their health through a survey of 600 people who are currently homeless, some who work with peer advocates and some who do not and linking individuals to routinely recorded electronic health records. We will look at how much the intervention costs, and is cost saving, compared to no intervention in relation to increasing planned use of health services and decreasing use of emergency services and hospital care. The research team has extensive multi-disciplinary experience of research with homeless and excluded populations. We will involve peers and the homeless in the study both as researchers and on the advisory group. The study will be overseen by an advisory group consisting of people with experience of homelessness, agencies providing specialist services for homeless populations, policy makers and researchers. Findings will be disseminated at workshops for: 1) community groups for people currently or previously homeless; 2) policy makers and service providers; and 3) agencies employing peer advocates to integrate findings into existing interventions.

Lay abstract: People experiencing homelessness suffer extreme health inequalities and barriers to accessing health care, resulting in health crises and frequent acute care usage. The Homeless Health Peer Advocacy (HHPA) intervention implemented by Groundswell, a third sector organisation working across London, seeks to empower people currently homeless to overcome barriers to accessing health care through the provision of peer advocates, all of whom have experience of homelessness themselves. Peer advocates accompany individuals to health services, providing support, assisting with communication and encouraging people to attend to their health through facilitating engagement with health services. Although emerging evidence suggests peer advocacy can increase primary and outpatient health care attendance and reduce emergency health care costs, evidence from impact evaluations has been mixed and there has been little research into the mechanisms through which it achieves its’ effects. There is a need to measure the range of health and social outcomes peer advocacy achieves, and how, to support the further development of peer advocacy programmes for homeless and other vulnerable populations and address the vast inequalities in health experienced. _x000D_ _x000D_ The project aim is to evaluate the impact, cost-efficacy and process through which HHPA improves health care attendance and health and social outcomes among homeless people in London. Specific objectives include: 1.) To explore the mechanisms, contexts and outcomes for HHPA and how they interplay with social and structural factors that shape health and social welfare and refine our working ‘theory of change’ model. 2) To define and prioritise the range of social and health outcomes the peer support programme brings to the peers themselves, and the mechanisms and contexts for this. 3) To measure the effect of engagement with HHPA on the utilisation of health services (planned outpatient appointments, use of emergency services and hospital admissions). 4) To measure how rates of utilisation of health services change before and following engagement with peer advocates. 5) To measure associations between (non)engagement with peer advocacy on health and social outcomes and access to health services, including the mediating effect of other macro-structural, community and individual factors (based on our theory of change).6) To estimate the costs and cost-effectiveness of the HHPA compared to no provision on attendance at health services and the health and social welfare of homeless populations. 7) To assess the fidelity, acceptability and reach of the intervention._x000D_ _x000D_ We will use a mixed-method quasi-experimental design drawing on participatory approaches comprising 3 linked components (A-C). A) We will collect qualitative data with homeless people, peer advocates and other stakeholders to understand the process and define the range of outcomes on which it works. B) We will conduct a cross-sectional survey of 600 people currently homeless with and without peer advocate support and compare a range of health and social outcomes. Data linkage to Hospital Episode Statistics held by NHS digital will be used to measure differences in health service utilisation (planned use of outpatient services and use of emergency services) through prospective follow-up. C) These data will be used to assess the cost-effectiveness of the peer advocacy intervention through a cost-consequence analysis.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: GENERIC HEALTH RELEVANCE