Vulnerable Populations Health Improvement

The evaluation employed a theory of change framework to assess the impact of peer support interventions on vulnerable populations. Data collection involved internal monitoring data from four delivery partners (Basis, Chaplaincy, Leeds GATE, and St. George’s Crypt), interviews with stakeholders and service users, and analysis of two validated questionnaires: the New Directions Team Assessment (NDT) chaos index and the EQ-5D-5L. The study used a mixed-methods approach, combining qualitative and quantitative data to strengthen findings and allow triangulation between different data sources. The 148 service users included in the monitoring data were tracked between July 2018 and February 2019, gathering information on interaction frequency, length, age, gender, GP registration, literacy levels, and place of residence. The NDT index measured engagement with services, multiple exclusion, lifestyle chaos, and negative social outcomes, while the EQ-5D-5L provided a general measure of health across five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Statistical analysis (SPSS v.24) was used, employing both parametric and non-parametric tests to assess pre- and post-intervention changes. The study acknowledged limitations related to sample size and the diversity of interventions across the delivery partners, emphasizing the need for cautious interpretation of findings.

The evaluation focused on addressing health inequalities experienced by highly vulnerable and excluded populations. These groups, identified as experiencing significant social and health disparities, included individuals with histories of drug use, imprisonment, homelessness, and sex work (Luchenski et al., 2018). The study also highlighted the specific health needs and inequalities within the Gypsy and Traveller communities, citing data from the 2011 census indicating a significantly lower proportion (70% compared to 81% of the general population) rating their general health as good (ONS, 2014). The study noted that these populations share common adverse life experiences and risk factors leading to poorer health, multiple morbidity, and early mortality (Aldridge et al., 2017). The challenges faced by the homeless population were specifically detailed, including high rates of multiple chronic conditions such as severe mental illness, depression, and substance misuse, leading to reduced treatment adherence and significantly lower life expectancy (Chambers et al., 2013; Thomas, 2012). These factors underscored the urgent need for targeted interventions to improve healthcare access and outcomes for these marginalized groups.

The evaluation's core findings revealed positive impacts of the peer support interventions across various domains. Analysis of questionnaire data (NDT and EQ-5D-5L) showed statistically significant improvements in mental health, specifically anxiety and depression, as well as improvements in usual activities. The strongest improvements were observed for anxiety/depression (p < .001, r = .473) and usual activities (p < .001, r = .464). Further analysis indicated significant positive changes in housing, stress and anxiety, risk from others, and unintentional self-harm. Improvements in service user engagement were also observed, with a substantial decrease in non-compliance with routine activities. While improvements were noted in social effectiveness and alcohol/drug abuse, these changes lacked statistical significance and required cautious interpretation. Qualitative data from service user interviews highlighted improvements in mental well-being, with participants reporting feeling calmer, less anxious, and better able to cope with difficult situations. The support provided also addressed practical needs, including assistance with housing, benefits, and daily living tasks. Many participants emphasized the value of having an independent, non-judgmental support worker who could provide a new perspective and help break negative cycles of behavior. The interviews indicated increased self-efficacy and confidence in accessing and navigating health services independently. The project’s model, with flexible, non-appointment-led service delivery, proved particularly effective in reaching these often transient populations.

The peer support interventions demonstrated a positive impact on the healthcare system by facilitating more effective use of health services and resources. By improving service users' understanding of appropriate service use and providing advocacy, the project reduced unnecessary emergency room visits. Peer support workers acted as liaisons, coordinating care and advocating for better treatment. GP interviews corroborated the need to address the underlying chaos in the lives of vulnerable individuals to improve healthcare access and outcomes, identifying the inappropriate use of A&E as a key concern. The project's success highlighted the value of a collaborative model integrating third-sector expertise in community engagement with clinical services. The flexibility afforded by commissioners allowed adjustments based on community needs, such as discontinuing routine health checks in favor of more valued opportunities for conversation and connection with healthcare professionals. This adaptive approach emphasized patient-centered care and improved the effectiveness and impact of the interventions, demonstrating a model for future implementation in similar contexts.

The project addressed healthcare access barriers by strategically locating services where vulnerable individuals were most likely to encounter them. St. George’s Crypt and Leeds GATE employed an on-site model, placing staff within the service users' daily environments. At St. George’s Crypt, the occupational therapist (OT) interacted with service users during meals or other daily activities and organized weekly social events. The Leeds GATE worker maintained a consistent presence at the Gypsy and Traveller site, allowing for spontaneous interactions and assistance with various needs, including benefit applications (PIPs) and bereavement support. For WYCCP and Basis, offices were established, but flexible arrangements, including home visits and alternative meeting locations, were used to enhance accessibility. Regular, flexible contact through phone or in-person visits, and accompaniment to other services where needed, further enhanced accessibility, emphasizing that the service met the users where they were and adapted to their needs. This approach highlights how service accessibility can be improved by meeting the user at their location of comfort and convenience.

The project directly tackled the issue of stigma within the healthcare system, which frequently hinders access for vulnerable individuals. This was particularly relevant for services employing lone workers, such as District Nurses. A case study detailed a dying patient denied a Night Sitter due to residing in a Gypsy and Traveller camp. The Outreach Nurse successfully advocated for a standard risk assessment to counter discriminatory practices. The project actively promoted inclusivity by working with GP practices. One example highlighted a Practice Manager proactively seeking guidance from Leeds GATE on best practices for supporting the Gypsy and Traveller community. Furthermore, a 'Gypsies and Travellers welcome here' poster was developed to foster a more inclusive environment within GP surgeries. This proactive approach to reducing stigma and advocating for equitable treatment demonstrated the project's commitment to ensuring all service users receive care without bias and highlights the importance of working directly with both providers and users to achieve system level change.

A critical aspect of the project involved improving service users' navigation of and engagement with healthcare systems. Project workers, having a strong understanding of the health system, actively supported service users by accompanying them to appointments and acting as liaisons between various services. They facilitated coordination and advocacy. One example described a support worker helping a service user understand complex medical terminology during a secondary care appointment, demonstrating the value of having an advocate present. This improved the effectiveness and efficiency of interactions. The OT's role further expanded this support by ensuring GP registration, encouraging attendance at appointments, and advocating for service users' needs. This included sharing relevant assessment information with other healthcare providers. The project also addressed challenges related to early hospital discharge among vulnerable individuals, particularly those withdrawing from opiates, advocating for less punitive discharge practices to prevent recurrent infections and other complications. This highlights the vital role of advocacy and coordination in improving both healthcare access and outcomes.

The Outreach Nurse played a significant role in enhancing healthcare access for the Gypsy and Traveller community by bringing mainstream services to their locations, such as roadside encampments. Traditionally, health visitors relied on GP registration and home addresses, rendering Travellers invisible to the system. This initiative demonstrated how tailored outreach services can address unique geographic and social barriers. The Outreach Nurse's efforts extended to building relationships with healthcare providers, facilitating connections with midwives and health visitors and promoting awareness of services. The project also addressed gaps in knowledge about occupational therapy among service users, improving awareness through word-of-mouth within the community. The flexible, non-appointment-based model employed by the OT increased access and enabled opportunistic interactions. This demonstrated how flexible service models can better address the needs of populations whose lives are characterized by transience and immediate needs.

Quantitative data revealed significant positive changes in service users' health and well-being following the interventions. Analysis of the New Directions Team Assessment (NDT) chaos index and the EQ-5D-5L questionnaire demonstrated statistically significant improvements. The most substantial improvements were observed in anxiety/depression (p < .001, with a large effect size of r = .473), and usual activities (p < .001, r = .464). These findings indicated a considerable reduction in the severity of these issues for a majority of participants. Further significant positive changes were found in housing, stress and anxiety, risk from others, and unintentional self-harm (all p < .001, with large effect sizes). Improvements in engagement with services were also evident, showing a marked decrease in non-compliance with routine activities and an increase in appointment attendance. While some areas, such as social effectiveness and alcohol/drug abuse, showed positive trends, these lacked statistical significance, highlighting the need for further investigation and cautious interpretation of these specific findings.

Qualitative data gathered from service user interviews further supported the positive impacts of the peer support interventions. A recurring theme was improved mental health, with participants reporting reduced anxiety, worry, and feelings of depression. Many attributed their improved mental well-being to the support workers' ability to provide a sense of calm, stability, and encouragement. The provision of practical and emotional support was also crucial. Examples included access to hot meals and drinks, assistance with appointments, social activities, and help with literacy. The independence and non-judgmental nature of the support workers were repeatedly highlighted as key factors in fostering trust and open communication. Crucially, several participants described how the support helped them gain new perspectives, break negative behavioral cycles, and re-evaluate their lives, indicating far-reaching effects that extend beyond immediate health concerns. This holistic approach to support fostered positive changes in self-perception, leading to improvements in daily life and self-management of health issues.

The positive impacts extended beyond improvements in mental and physical health, encompassing wider determinants of health and overall quality of life. The support workers provided substantial assistance with practical needs, directly addressing social and economic factors that significantly influence health. Examples included help with housing, benefits, budgeting, and accessing essential services like transportation. In several cases, the interventions played a pivotal role in securing housing, obtaining disability allowances, and making essential home adaptations. The ability to connect service users with other services, such as domestic violence support or drug and alcohol services, highlighted the integrated nature of the support provided. These practical interventions were pivotal in establishing more stable living situations and access to resources, which in turn contributed to improved overall health and well-being. Participants' enhanced confidence in seeking help and accessing various services indicated that the support extended beyond immediate needs, empowering individuals to manage their health and well-being in the long term. The success of the project underscores the interconnectedness of health, social, and economic well-being, highlighting the importance of addressing these factors holistically.

The peer support intervention demonstrated a positive impact on healthcare resource utilization and efficiency. By enhancing service users' understanding of appropriate service use and providing effective advocacy, the project demonstrably reduced unnecessary emergency room visits. The support workers, possessing a strong understanding of the healthcare system, acted as crucial liaisons between service users and various healthcare providers, effectively coordinating care and advocating for better treatment. This coordination minimized duplicated effort and streamlined access to needed services. The ability of the peer support workers to navigate the complexities of the healthcare system on behalf of service users facilitated more efficient and effective utilization of resources, reducing the burden on emergency services and other healthcare providers. This intervention highlights the potential of peer support to contribute to a more sustainable and efficient healthcare system, particularly when working with vulnerable populations who often face significant barriers to accessing services.

The project directly addressed a significant concern expressed by GPs: the inappropriate use of Accident and Emergency (A&E) services by vulnerable individuals. The interventions actively worked to reduce this by improving service users' knowledge of available healthcare options and providing support to navigate the healthcare system effectively. The project recognized that resolving the underlying chaos in people's lives is fundamental to achieving more stable lives and consistent healthcare access. By addressing these root causes, the intervention aimed to create a system where individuals could access appropriate care without resorting to A&E for non-urgent needs. The observation that early discharge from hospitals is a common occurrence among vulnerable populations, often due to self-discharge or non-compliance with behavioral rules, highlights the importance of ongoing support and advocacy. The project aimed to address such issues by providing comprehensive and holistic support that enhances their capacity for self-management and promotes better engagement with healthcare services.

The project significantly highlighted the crucial role of advocacy and multi-agency collaboration in improving healthcare outcomes for vulnerable populations. The peer support workers actively advocated on behalf of service users, addressing prejudice and judgments from healthcare professionals. This included intervention in cases where individuals faced discrimination or unfair treatment based on their backgrounds or circumstances. The support workers also facilitated better communication between service users and clinicians by clarifying complex medical information and acting as liaisons between various services. The active participation in multi-agency meetings contributed to better coordination of care and a more holistic approach to addressing the multiple needs of these individuals. The collaborative nature of the approach demonstrated the importance of partnership working across the healthcare system and community organizations in effectively supporting vulnerable populations, showcasing how community based advocacy can help ensure appropriate and equitable healthcare access.

The York Street General Practice in Leeds serves as a compelling example of an innovative approach to providing care for homeless individuals, ex-offenders, and sex workers. The integrated model, offering multiple services under one roof, eliminates the need for patients to navigate multiple locations for different healthcare needs, enhancing access for this particularly vulnerable population. The practice's unique features, including a lack of ID or address requirements for registration, and its street medicine program utilizing an access bus, illustrate how innovative healthcare delivery can be adapted to reach the most marginalized. This approach not only demonstrates a commitment to providing accessible and comprehensive services but also highlights the importance of adapting healthcare structures to better suit the needs of vulnerable populations. The successful integration of specialized drug treatment programs further strengthens the holistic approach toward addressing the complex needs of this population.

St. George’s Crypt focused its peer support services on a population of 81 predominantly homeless service users. The average number of appointments per user was approximately 5, ranging from a single visit to 29 visits. The age range was largely concentrated between 25-44 years (59%) and 46-64 years (28%), with smaller proportions of younger (10%) and older (4%) individuals. The sample leaned heavily towards male users (79%). The majority (90%) were registered with a GP, indicating a degree of engagement with mainstream healthcare. Literacy levels varied, with approximately 44% having good literacy skills, 22% having some literacy, and 32% unsure. The high percentage of unsure participants regarding literacy is a relevant factor for intervention planning. A significant portion (75%) of the service users were homeless, highlighting the challenges faced by this group. The remaining service users resided in supported housing or with family. This demographic information provides context for the specific interventions and challenges faced by this subset of the study population.

The Leeds GATE project concentrated on providing peer support to the Gypsy and Traveller community. A key feature of their approach was the on-site presence of project workers, facilitating interactions with community members at their locations of choice. This approach allowed for both proactive outreach, such as approaching individuals when upset, and reactive support, responding to requests for assistance with various issues (e.g., benefit applications or bereavement). This approach addressed the unique challenges of this highly mobile population who historically have limited access to formal healthcare services, given the traditional reliance of outreach services on a fixed address. The initiative highlights the importance of adapting service delivery models to suit the needs of specific communities. The success of the on-site model highlights the value of establishing trust and building relationships. The report highlights a successful example of improving health visitor access via the Outreach Nurse. This strategy directly addresses the invisibility and access issues faced by the Gypsy and Traveller community within the existing health system.

The West Yorkshire Community Chaplaincy Project (WYCCP) focused its peer support on ex-offenders. Operating as a self-referral service, WYCCP offered open-ended support, maintaining contact with individuals even years after their release. This approach acknowledges the long-term needs of this vulnerable population, addressing ongoing challenges far beyond the immediate post-release period. The program emphasized the development of trusting relationships through close collaboration, beginning well before release from prison. The program's unique nature, which contrasted with standard service provision, underscores the critical need for tailored support for this extremely vulnerable group, who are often lost or overlooked by existing support systems. A significant challenge noted within this population was low literacy levels. The program adapted to address the health needs of this population and incorporated strategies to improve access to essential healthcare services, including assistance with registration with healthcare providers and attending medical appointments.

Basis provided a women-only peer support model tailored to the specific needs of women involved in sex work who often have experienced significant trauma and abuse. The women-only environment prioritized creating a safe and non-judgmental space for open communication, particularly concerning intimate details and sexual health issues. This approach aimed to overcome barriers often encountered by women in accessing mainstream healthcare services due to fear of judgment. The project actively addressed systemic barriers by working with healthcare professionals to raise awareness about the unique challenges faced by these women, including those relating to stigma and judgment encountered within healthcare settings. Assertive outreach and proactive engagement with healthcare professionals were employed to address subconscious biases and improve the sensitivity and quality of care provided. The data suggests that a non-judgmental approach improved the engagement of service users by focusing on reducing risk behaviors versus punitive responses. This model provides insight into the development of services for highly stigmatized populations, and the need for tailored approaches to effectively engage with and support such service users.