Title: NIHR Global Health Research Group on homelessness and severe mental illness in Africa (HOPE)
Funder: Department of Health and Social Care

Abstract: Co-occurrence of homelessness and severe mental illness (SMI) is a health and social emergency affecting an estimated 28-36 million people in low- and lower-middle-income countries (LLMICs)[6]. SMI includes disabling psychotic and affective disorders, often co-morbid with substance abuse. Homeless persons with SMI are at high risk of human rights violations, premature mortality and social exclusion. Absence of evidence on effective interventions is a potent barrier to global action. Research Question: How can unmet needs of homeless persons with SMI in LLMICs be addressed effectively in ways that are rights-based, contextually grounded, scalable and sustainable? Aim: To establish a new partnership of stakeholders across Ethiopia, Ghana and Kenya who are equipped to lead action research to improve the lives of homeless persons with SMI. Methods: To improve understanding of diverse contexts and ensure wider applicability of findings, we will work in a capital city in Ethiopia, a regional city in Ghana and a rural county in Kenya. We will build foundations for participatory working, equipping all stakeholders for inclusive work and empowering people with lived experience. Formative phase (Months 3-15): Formative work will include synthesis of global evidence (scoping & grey literature reviews) and experience (Delphi exercise). In the study sites we will map the context (documentary analysis, geography of homelessness, key actors & existing resources); a rapid ethnographic study to understand lived experience; survey of homeless persons (n=700 each in Ethiopia & Ghana; n=350 in Kenya) for prevalence of SMI, co-morbidity and prioritised unmet needs; and in-depth interviews and focus group discussions with key stakeholders to identify experiences, challenges and opportunities for intervention. This global and local evidence will lead to serial Theory of Change workshops to agree valued primary outcomes, map pathways to impact and inform selection of interventions and implementation strategies. Intervention co-production and piloting (Months 16-24): Intervention packages to address prioritised needs will be co-produced, piloted with 10-15 homeless persons with SMI for proof-of-concept, and optimised for feasibility and acceptability using participatory action research. A cornerstone of intervention is peer support. We will draw on experience with rights-based approaches and community-based care to ensure sustainability as an integrated service. Implementation and evaluation (Months 25-42): Implementation of the interventions will be phased to allow controlled evaluation up to 3 months and a pre-post intervention study over 6 months. We will recruit 1050 homeless persons with SMI and assess impact on the selected primary outcome, change in unmet needs, social inclusion, human rights abuses, home status, physical health, family reintegration, survival and societal costs. We will conduct a mixed methods evaluation of implementation processes and outcomes. Realist evaluation will analyse how contextual variation affects mechanisms and outcomes for global application. Impacts: (1) Evidence-supported interventions for homeless persons with SMI; (2) WHO manual on how to adapt & implement the programme in different LLMIC settings; (3) Innovative methods and ethical approaches; (4) Greater policy prioritisation; (5) 3 PhD/post-doc fellows and 3 peer researchers trained; (6) Strong partnerships and platforms for ongoing high-quality research at scale.

Lay abstract: We will develop and test community-based interventions to address the needs of homeless people with severe mental illness (SMI) in Ethiopia, Ghana and Kenya. SMI includes schizophrenia, bipolar disorder and severe depression, causes substantial disability and may be complicated by substance abuse. People with SMI are over-represented in homeless populations globally, but this is a major concern in low- and lower middle-income countries (LLMICs). Our previous work showed that 2 in 5 homeless people assessed in Addis Ababa had SMI and that 1 in 3 people with SMI in a rural district in Ethiopia had slept unsheltered. Despite the scale of the problem, there is no high-quality evidence to show which interventions are effective in LLMICs. There is a clear need to develop partnerships and capacity for Africa-led research to tackle this complex problem. _x000D_ This project will create a new partnership of researchers, policy makers, community members and people with lived experience of SMI and homelessness. We will work in a capital city (Addis Ababa) in Ethiopia, a regional city (Tamale) in Ghana, and a rural county (Makueni) in Kenya to understand the different approaches needed across varied settings. _x000D_ Phase 1: We will:_x000D_ • Map existing supports and policy contexts,_x000D_ • Survey homeless persons to identify unmet needs of those with SMI,_x000D_ • Conduct an ethnographic study in which researchers spend time with people with SMI who are homeless to develop understanding of their lived experience, needs and priorities,_x000D_ • Interview key stakeholders,_x000D_ • Synthesise what is already known about initiatives for homeless persons with SMI in LMICs,_x000D_ • Prioritise potential interventions by asking global stakeholders operating in similar contexts. _x000D_ Phase 2: We will select and co-produce intervention packages. We will conduct proof-of-concept testing to optimise feasibility and acceptability. This process will be guided by local and global findings and will involve all people with a stake in the intervention. Specifically, we will support and empower people with lived experience of SMI and homelessness. The intervention package will seek to address a range of needs, from basic needs for safety, food and water, shelter and sanitation, to mental and physical health, family support, livelihoods and social inclusion. A cornerstone of the approach will be peer support. We will draw on our experience with rights-based approaches and community-based care to ensure sustainability as an integrated service. _x000D_ Phase 3 We will: _x000D_ • Test the intervention package in specific geographic areas to reach 350 homeless people with SMI per site, _x000D_ • Track what happens to homeless persons with SMI participating in the programme over six months to see whether they benefit in terms of their physical and mental health, experience of discrimination and abuse, housing status, family reintegration, functioning and social inclusion, _x000D_ • Identify ways to implement at scale and ensure sustainability. _x000D_ Project end: We will have: (1) developed evidence-supported interventions to improve the lives of homeless persons with SMI in LLMICs; (2) collaborated with WHO to produce a manual on how to adapt and implement the programme in different settings; (3) developed methods and the capacity of early career researchers and other stakeholders in LLMICs; (4) built a strong collaboration of multi-sector partners to sustain in-country work and longer-term high-quality future research on this neglected topic.

Research activity codes: 5.6 PSYCHOLOGICAL AND BEHAVIOURAL;6.6 PSYCHOLOGICAL AND BEHAVIOURAL;7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH;GENERIC HEALTH RELEVANCE