Title: Frailty in People Experiencing Homelessness: quantifying the extent of the problem and exploring barriers and facilitators to interventions to prevent and manage frailty
Funder: Department of Health and Social Care

Abstract: Research questions What are the prevalence, severity, risk factors for, and impact of, frailty amongst PEH? What are the perceived facilitators, barriers and potential adaptation of existing interventions that could prevent and treat frailty amongst PEH?Background Frailty is an accumulation of physical, psychological, and social deficits, associated with vulnerability and reduced resilience against health challenges, which increase risks of adverse outcomes and health service usage. In the general population, 10% of people >65 years are estimated to be frail. Research suggests prevalence of frailty amongst PEH ranges between 16 and 55%, often presenting at a younger age. Physiotherapists hold an important role in identification and management of frailty. Aims To inform the development of interventions to prevent, identify and manage frailty in PEH. Objectives Understand prevalence and risk factors for frailty in PEH in high income countries. Identify approaches previously used to measure frailty in PEH. Determine prevalence, severity, risk factors and impact of frailty in PEH in the UK. Understand perceived facilitators, barriers and potential adaptation of existing interventions that could prevent or treat frailty among PEH and explore potential new models of care.Methods This mixed-methods research comprises three work packages (WP), informed by public and patient involvement (PPI) with PEH and homeless healthcare providers. WP1: Systematic review of literature, to identify prevalence, risk factors and measurement tools of frailty in PEH. PPI groups will advise suitability of measures and adaptation. WP2: A cross-sectional study of prevalence, risk factors and impact of frailty in PEH. A systematic sample of 270 PEH (135 street-dweller and 135 hostel-dwellers) will be identified though NHS 'Find and Treat'. Data collection comprises gold-standard tools to measure frailty in PEH (informed by WP1, PPI, frailty researcher consultation and feasibility testing with PEH) and a health questionnaire. Descriptive analyses will report frailty prevalence and severity across groups. Logistic regression models will explore frailty risk factors and associations with social support and healthcare usage. WP3: Qualitative interview study, exploring perceived facilitators, barriers and potential adaptation of existing interventions that could prevent or treat frailty among PEH. 20 PEH and 10 homeless support staff will be interviewed using topic guides informed by WP1 and WP2. Interviews will be audio-recorded, transcribed, and analysed using Thematic Analysis (NVivo software). Peer-researchers will collaborate on analysis.Timeline Year 1: WP1 systematic review, write up, PPI activities, ethical approval, site set-up WP2 and 3, piloting WP2 Year 2: WP2 data collection, PPI, develop interview schedule, start WP3 data collection Year 3: WP2 analysis, write up, finish WP3 data collection Year 4: WP3 analysis, thesis completion, disseminationAnticipated impact and dissemination Improved understanding of frailty in PEH and how to address it, aiming to reduce frailty in PEH, increase resilience and reduce healthcare need. This research must inform public/political understanding of the health consequences of homelessness, reaching PEH, commissioners, charities, health/social staff working with PEH. Outputs: accessible publications (e.g. The Big Issue), training resources, publication in journals, conference presentations (Pathway, Street Medicine), All Party Parliamentary Groups and social/ mainstream media reporting.

Lay abstract: Background Frailty and homelessness Despite government attempts to tackle homelessness, it remains a significant problem. Research shows that as well as being more likely to die young, People Experiencing Homelessness (PEH) are more likely to develop frailty at a young age. People described as 'frail' are not physically strong, which affects their health, activities, ability to work, and need for long-term health and social care. Homelessness can increase frailty, and frailty may reduce resilience, making it harder to escape homelessness. We need better evidence of the size and impact of the problem, and to seek views of PEH and service providers about how to address it. Exercise, food, mood, smoking, alcohol, and social support can affect frailty in older adults. We do not know how important these, and other factors are amongst PEH. We need to understand the impact of frailty on the health and lives of PEH. I will work with PEH and people who support them to understand what initiatives and support could prevent and address frailty. Aims This research aims to provide the information needed to help to prevent and address frailty in PEH by: a) measuring how common frailty is in PEH, who is most affected and the impact on their lives. b) talking to PEH and people who provide services to understand how approaches that have been used to prevent and manage frailty in older adults might be adapted for PEH.Design and methods Understanding frailty in PEH I will systematically search, review, and summarise existing research about levels, risks and the impact frailty has on PEH. I will also explore how frailty can be reliably measured in PEH. Establishing how frailty affects PEH We need to understand how common frailty is in PEH, who is most likely to become frail and how it affects them. This is essential so those most at risk can be identified, receive appropriate care and new models of care can be developed to help those at risk of frailty or who are frail. By working with NHS outreach services used by PEH, I will reach people for my research. I will measure how frail they are and learn about their health and lifestyle. Preventing and treating frailty in PEH I will work with PEH and staff who support them, to discuss how to prevent and treat frailty. 'Peer-researchers' (PEH trained in researcher skills) will help, by speaking to PEH. I have worked in homeless health services, and I will speak to health, social and support staff. Using people with shared experiences for interviews helps to get the most useful information from that conversation. Patient, carer and public involvement I have talked to PEH and people who provide support services relevant to my research. They have helped me make my research relevant to them and plan the best ways to ensure PEH find it easy to take part. I will continue to involve PEH in planning my research. Impact and dissemination Frailty is preventable and reversible. My research will help to understand frailty in PEH and work out what to do to prevent and reduce it. My research will help improve the health and resilience of PEH and reduce their need for hospital care. Who needs to hear about this? PEH and their families People and charities who support PEH Those planning, commissioning and delivering health and social care services for PEH. The general public and politiciansHow I will communicate Pavement magazine, The Big Issue Charities working with PEH Staff training resources Scientific journals Conferences (Pathway, Street Medicine) Social/ mainstream media All Party Parliamentary Groups for Ending Homelessness

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: GENERIC HEALTH RELEVANCE