Effectiveness and cost-effectiveness of a peer-delivered, relational, harm reduction intervention to improve mental health, quality of life, and related outcomes, for people experiencing homelessness and substance use problems: protocol for the 'SHARPS' cluster randomised controlled trial.

BACKGROUND: Those experiencing homelessness and problem substance use find it challenging to access the healthcare and treatment they need. The Supporting Harm Reduction through Peer Support (SHARPS) feasibility study demonstrated that Peer Navigators can help these individuals to improve their service engagement, increase access to opioid substitution therapy, and lead to reductions in drug use and risky injection practices. Specifically, participants indicated that the lived experience of Peer Navigators was particularly helpful by enabling the development of trusting relationships. A cluster randomised controlled trial (cRCT) will now assess the effectiveness and cost-effectiveness of a Peer Navigator intervention with this population.

METHODS: A two-arm, pragmatic, cRCT will be conducted with embedded cost-effectiveness and mixed methods process evaluations. Individuals will be recruited who are as follows: over the age of 18 years; experiencing/at risk of homelessness and self-report problem substance use; and attending The Salvation Army (TSA) homelessness services across 20 included clusters (towns/cities). Each cluster will be randomised (1:1) to either the intervention or control arm using covariate-constrained allocation based on area-level characteristics. The target sample size is 550 participants in total. A co-produced peer-delivered harm reduction, relational intervention lasting 12 months will be delivered to those in the intervention arm. Usual care will be social care via TSA Support Workers delivered within homelessness services. The co-primary outcomes will be mental health and quality of life, with harmful substance use, risk taking behaviours, social functioning, physical health, social outcomes, housing status, therapeutic alliance/accessibility, service utilisation, and relational empathy chosen as secondary outcomes. Data collection points are baseline, 6 and 12 months, for all measures. The primary timepoint of interest is 12 months after baseline measurement. Economic outcomes will be incremental cost per quality-adjusted life year (QALY) and per year in full capability (YFC) gained with the intervention versus standard homelessness service care, inclusive of costs to the NHS, local government and criminal justice, and the third-sector host organisation. The EQ-5D-5L and ICECAP-A will be used to calculate QALYs and YFC respectively. We will also conduct a cost-consequence analysis.

DISCUSSION: The results of this trial will be used to inform whether the SHARPS intervention has a positive impact on those experiencing homelessness and problem substance use and if it is cost-effective to roll it out across social care services.

TRIAL REGISTRATION: ISRCTN11094645 ( https://doi.org/10.1186/ISRCTN11094645 , registered April 5, 2024).