Title: Supporting harm reduction through peer support (SHARPS): Testing the feasibility and acceptability of a peer-delivered, relational intervention for people with problem substance use who are homeless to improve health outcomes, quality of life and social functioning, and reduce harms
Funder: Chief Scientist Office, Scotland

Abstract: Design: A mixed-method feasibility study with concurrent process evaluation to explore the feasibility and acceptability of a peer-delivered, relational intervention for homeless people with problem substance use. Settings: Inner-city homeless outreach services in Scotland and Salvation Army hostels in England. Difference between current/planned care pathways: Two standard care settings have been selected that are similar to the intervention sites in key ways but will not have a Peer Navigator located within them. Target population and inclusion/exclusion criteria: People who are homeless/at risk of homelessness with problem substance use and unlikely to achieve abstinence. Inclusion: people who are homeless and self-report alcohol or drug problems. Exclusion: those unable to provide informed consent, those under 18, those who do not use alcohol or drugs, those who do not self-identify as using substances. Health technologies being assessed: Peer-delivered relational intervention drawing on principles of psychologically informed environments, providing holistic health checks and practical and emotional support. Outcomes: Standardised measures of socio-demographic characteristics, housing status/quality (MAP); quality of life (EQ-5D-5L), substance use (SURE), mental health (HADS), and relationship quality (CARE). Outcome data on recruitment rate, engagement, attrition, acceptability, time needed to collect/analyse data, and ethics/equipoise of the intervention to inform a future trial. We will assess suitability of outcome measures and provide a refined intervention manual/staff training resource. Sample size: We aim to recruit 60 people to the intervention with four Peer Navigators. Engagement/attrition will be monitored and a wait list kept so when a participant drops out, a new participant will be invited to engage in the intervention, up to a specified date. Data collection for the process evaluation will be quantitative (from measures with all participants analysed using SPSS) and qualitative (interviews/observational field notes analysed using Framework Method). Purposive sampling will be used to select a sample of 20-25 intervention participants for qualitative interviews at two different time-points. Peer Researchers will be involved in data collection and analysis and wider public and patient involvement is integral to the study. Project timetables: This two year study will be undertaken in three phases. Phase 1: Ethics approvals confirmed, Peer Navigators recruited and trained, intervention and staff training guidance developed using a co-production process. Phase 2: Peer Navigators in sites, recruitment of participants, intervention starts, quantitative/ qualitative data collection and iterative data analysis across intervention/standard care sites. Phase 3: continued analysis and write-up of findings and range of outputs created. Outcomes/outputs: estimates of recruitment and retention of participants; assessment of participant engagement with the intervention and acceptability of intervention to participants /staff; time needed to collect/analyse data; sample size estimates; and fidelity, in order to fully inform a future trial. The specific outcome measures that will be tested for use in a trial are noted above. Using the study findings we will produce a refined intervention manual/staff training resource, a final report that addresses the research questions, and associated academic manuscripts.

Lay abstract: People who are homeless have worse physical and mental health, and higher rates of substance use, than the general population. For some people with severe substance use problems, completely stopping their use is a complex challenge. Many people who end up being homeless have had very difficult lives including traumatic experiences. Harm reduction services can be useful in cutting the risks connected with substance use, for example needle exchange services. Harm reduction aims to support people ‘where they are at’, rather than trying to get people to change before they are ready or able to do so. Harm reduction supports people to improve their quality of life. While harm reduction is suggested for homeless people there is a lack of research on exactly how it should be delivered. We will build on research that has already been done to show that trusting relationships with staff can help people with serious health and social problems. Homeless people need services that suit their specific needs, with staff that are good listeners, caring and understanding. Relationships seem to be most helpful when staff also offer practical help. Our study will involve peer ‘Navigators’ providing practical and emotional support to homeless people who have substance use problems. Peers are people with personal experience of problem substance use who are recovering and have been trained in a range of areas. The word ‘Navigator’ is used to mean that these workers will closely support each person. The Peer Navigators will build trusting relationships to try to help each person improve their quality of life and their health in a safe and supportive environment. As part of the study, a ‘whole person’ health check will be offered. Checks like this can take a while and can be off-putting so we will make sure that it is offered once a trusting relationship has been developed and when the person is comfortable with it. The Peer Navigators will then help the person to find services that can meet their needs, such as healthcare, housing or counselling. They will also go with them to appointments if needed. The practical support offered will include having enough money to travel to appointments and to buy basics such as hot drinks, food and bus fares. We aim to explore whether the Peer Navigator programme can be delivered to people with serious problem substance use in hostel and outreach settings for homeless people. The study will look at whether people want to get involved with the Navigators or not. It will describe how the Peer Navigators and participants worked together. It will also ask staff how they felt about delivering the programme. It will not find out if the programme actually improves people’s lives as that is something that would happen in a later study. To understand how the programme works, Peer Researchers will do interviews with a group of the participants at two different points in time. Interviews will also be done with the Peer Navigators and other staff members working in the homeless services. Peer Researchers will also be involved in making sense of the research findings alongside the research team. People with lived experience have been involved in the design of the Peer Navigator programme and the research study. The most important outcome of the research would be to decide if further research should be carried out to see if the Peer Navigators make a real difference to people’s lives and to their health.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH