Sampling and recruitment
Case study sites
We aim to recruit 3-4 case study sites across GM and evaluate their approach to delivering primary care for people experiencing homelessness during the pandemic. We will work with three specialist homeless general practices in Manchester and Salford who have already started working with some local hostels and pharmacies to facilitate remote healthcare during the pandemic. We also aim to recruit one or two more case study sites in other areas of GM to compare how they are working with local partners to provide access to primary care.
GPs already collaborating on the study will discuss the study with their colleagues and collect email addresses of anyone willing to be contacted. Potential participants will then be sent a participant information sheet and consent form via email by the University team. If they respond to the email, a time and date will be arranged to contact them via phone. The study and information sheet will be discussed over the phone and if they are still happy to participate, consent will be taken with an encrypted audio recorder. This will saved in a separate file to the research data. All interviews will be audio recorded with an encrypted recorder and anticipate to last between 30-60 mins maximum.
We will conduct audio recorded telephone interviews with GPs, nurses, pharmacists and local partners, such as hostel and charity workers, about their perceptions and experiences of providing and facilitating primary care for people experiencing homelessness since the beginning on the pandemic. We aim to interview 5-10 health professionals and stakeholders from each case study site.
Stakeholders who provide healthcare and support to homeless people will be asked about their perceptions of issues that fall under the umbrella of patient safety, and more specifically about their perspectives on key issues regarding patient safety for homeless people since the pandemic.. We will prompt for general safety concerns as perceived by the participant followed by prompts informed by the patient safety literature.
The topic guide will be developed and with stakeholder involvement (e.g. Urban Medical Practice) and tested prior to formal data collection. Questions will be broad but also informed by the existing literature on homeless health care provision and the key patient safety issues associated with this patient population. Questioning in follow up interviews will also adapt according to prior data collection to utilise findings from the initial interview. The interviews will be audio-recorded and professionally transcribed via a University of Manchester approved transcription service.
GPs and nurses will be asked to keep an audio diary of their experiences of delivering remote consultations. They will be asked to record their views on how the consultation went well/badly, and also any patient safety concerns they may have. This method of data collection has been chosen to minimise the influence of the research team on what health professionals deem important in delivering healthcare remotely for people experiencing homelessness. We plan to ask health professionals to keep an audio diary for a minimum of one month (patient names will not be recorded) and this audio diary will be used to gain insight into any concerns practitioners may experience as they happen. Practitioners will be provided with an encrypted audio recorder and their reflections will be thematically coded in NVIVO.
The results of the audio-diary combined with the concerns and experiences of people experiencing homelessness and other stakeholders will be used to feedback to GPs on how services can be improved. Follow up interviews at the end of study will take place with healthcare professionals and stakeholders to determine how things have progressed and changed during the pandemic.
Follow up interviews with health professionals, including audio- diaries
Health professionals in general practices recruited to the study will be asked to participate in a follow up interview approximately 3-6 months after the baseline interview. During this period, some of the GPs and nurses recruited to the study will be asked to keep a recorded 'diary' of their experiences and any reflections they have on remote consultations. Encrypted audio-recorders will be provided by the University of Manchester for the recordings. The recorders will be collected by the University of Manchester researcher approximately one month after the start date. Participants would need special software on their computers to download the audio recordings themselves and NHS firewall will not allow this software to be uploaded, which is why we will collect the audio recordings rather than ask participants to download the recordings themselves. Healthcare professionals involved will be asked to record no patient personal data and to describe any cases or observations anonymously. Information regarding the recordings will be provided in a SOP for the health professionals involved. GPs often do this as part of their GP training and are therefore used to recording their concerns in this way. These recorded reflections will be listened to and notes taken (by the UOM research team) and used in the follow up interviews to prompt discussion. It will not be compulsory to keep an audio diary to participate in the follow-up interviews. Following the follow up interview, these audio-files will be deleted. Any notes will be saved with a pseudonymised ID and saved on RDS.
Follow up interviews will also be conducted over the phone. A separate information sheet will be provided and consent will be retaken. This will not be guided by an interview schedule as interviews will be based on participant's previous interviews and also audio-diaries (if applicable). Follow up interviews will last between 30-60 minutes.
Follow up interviews with stakeholders
As above, we will gain consent to re-contact stakeholders for a follow up interview. If they agree, they will be re-contacted and sent a follow up interview information sheet via email. Consent will be retaken and interviews will be conducted over the phone. Stakeholders will not be required to keep an audio diary. All interviews will be conducted with an encrypted audio recorder. Interviews will be unstructured as based on previous interviews with participants. Follow up interviews will last between 30-60 minutes.
Recruiting participants with lived experience of homelessness
We will aim for a purposive sample to represent a diverse range of participants according to age, gender, ethnicity, types of health problems (including long-term mental and physical health problems). We will also include people who are either currently homeless or people with recent experience of homelessness during the pandemic. By homelessness we are referring to people who are street homeless, live in temporary accommodation or are ‘sofa surfing.’ This definition also includes homeless families
The mixed sample will allow for recent reflections on patient safety issues experienced by those who are no longer homeless who may have greater capacity to compare and contrast receiving health care in the varying scenarios as well as those experiencing any patient safety issues as a result of their current homelessness. In total we will aim to recruit 5-10 people with lived experience of homelessness per site.
The University of Manchester is working with a homeless charity called Groundswell that will also conduct interviews with people experiencing homelessness. These interviews will not be conducted by staff at the University of Manchester, but the University will work with Groundswell to co-analyse the transcripts. All interviews conducted by Groundswell will be conducted with an encrypted audio recorder. All interviews, including follow up interviews will last approximately 30 minutes.
As it is important to interview a wide range of homeless people regarding their experiences, we will engage with local stakeholders, such as hostels and day centres to act as gatekeepers to recruit people experiencing homelessness to the study. Gatekeepers will approach eligible participants about the study and give them a participant information sheet so they can make an informed choice about participating and if they are interested, they will be asked for consent to pass their phone number to a researcher from Groundswell. Due to social distancing measures, all interviews will take place over the phone. If they do not have a telephone, the Gatekeeper will arrange a time for the Groundswell researcher to call the hostel/key worker to speak to the participant. When the researcher from Groundswell calls the participant, they will discuss the content of the information and if they are still interested, audio- recorded consent will be taken over the phone. Posters will also be displayed in hostels so that individuals can contact Groundswell and express their interest directly.
Semi- structured interviews
Interviews with participants experiencing homelessness will be undertaken by a researcher from Groundswell who has lived experience of homelessness. Demographic data (age, gender and ethnic origin) will be taken. Participants will be given an ID number and this ID number will also be used to save the audio-recordings and transcripts. Consent forms will be saved under an anonymous ID so it cannot be linked to research data. The pseudonymised ID number will also be recorded on the participant's contact information spreadsheet. Contact information will be deleted at the end of the study.
Interviews will also be audio-recorded with an encrypted recorder and topics will include questions about previous and current health problems and health care needs, as well as who they seek help from when they have health problems and what has changed during the pandemic. Prompts will be used to elicit specific examples of perceived safety issues and their views about the quality and safety of care
Specific questions about their experience of remote consultations and how it compares to their previous experience of receiving care will also be asked. Participants will also be asked if they would be willing to participate in a follow up interview 3-6 months after the initial interview to discuss how their experiences have changed.
Follow up interviews
We also aim to conduct some follow up interviews with people experiencing homelessness if possible regarding their experiences over the next 3-6 months. This interview will not be compulsory and may not always be possible due to the transient nature of this population. Participants who consent to the initial interview and also consent to be re-contacted, will be telephoned/emailed to discuss the follow up interview. If possible, a follow up PIS will be emailed to participants and read out over the phone. Consent will also be retaken. Interviews will be unstructured as based on previous interviews with participants.
Interviews will be recorded digitally and transcribed ensuring that the data are anonymised. Initial notes and reflections will be made by researchers (both UoM and Groundswell) immediately following interviews to reflect on the processes, key issues raised in discussion, and any contextual issues that would not be reflected in transcripts. The qualitative data will be analysed using a framework method. This method produces a matrix of summarised data and provides a structure to analyse and summarise data within key themes. It is particularly suited to informing intervention design as well as enabling analysis effectively within teams of multiple researchers, and is highly suited to policy related research (37, 38).The approach allows for analysis according to predefined themes and themes that emerge more inductively from the data (37). Our initial analytical framework will be structured by some of the main aspects of experience reflected in the literature on homelessness and patient safety. This framework will be used as a starting point for coding initial transcripts, and the framework will be extended as new codes emerge inductively from the data. For these processes the Research Associate and the core research team based at University of Manchester will work closely with the Research Lead and Peer Researchers from Groundswell (MB and team) to do all stages of coding and thematic analysis. Members of the UoM team and the Groundswell team will conduct initial reading and coding of the transcripts and will chart and summarise these within the framework structure. The team will hold regular meetings in order to discuss emerging themes, and to develop and refine the final themes. This process will continue until no new themes emerge. The findings from this initial round of focus groups and interviews will feed into development of a number of possible ‘solutions’ in the form of potential interventions for discussion at follow-up workshops in phase 2.
Patient and Public Involvement & Engagement
The Groundswell charity is a lead partner organisation for this project and will be co-producing this work with the UoM team. Groundswell will work with Shelter in Manchester in order to establish a public involvement advisory group made up of people with lived experience of homelessness who can meet at regular intervals throughout the development and conduct of the research. They will advise on key stages of the research and all information for participants, as well as providing input in developing appropriate material for dissemination of the research.