Critical time intervention to prevent homelessness and improve health for people leaving prison: the PHaCT pilot RCT.

内容摘要

People leaving prison face significant barriers to reintegration, often resulting in homelessness, which exacerbates health issues and increases recidivism. Critical time interventions aim to support vulnerable individuals during significant life transitions by providing time-limited, emotional and practical support. While effective in other contexts, the impact of housing-led critical time interventions for people leaving prison in the United Kingdom remains unclear. The PHaCT study was a pilot randomised controlled trial of a housing-led critical time intervention for people leaving prison at risk of homelessness. This study aimed to determine whether a full-scale randomised controlled trial of the critical time intervention model in prison leavers at risk of homelessness was feasible. The pilot was a parallel two-arm, individual-level randomised controlled trial of a pre-existing critical time intervention intervention with an integrated process evaluation and embedded exploratory health economic evaluation. Recruitment occurred in fours male prisons across England and Wales with participants followed up in the communities. Prisons were randomised by site to either receive the critical time intervention or receive usual support, and participants were recruited within 12 weeks of their release. The locations were predetermined by where the intervention was already being delivered by the intervention provider (critical time intervention teams). Critical time intervention included pre-engagement, transition to community, try-out and transfer of care phases, each lasting 3 months. Data collection methods included baseline surveys, follow-up assessments at 3, 6 and 9 months, qualitative interviews, and session observations. Routine data linkage was explored separately to assess feasibility. Progression criteria included recruitment, retention, process evaluation and fidelity. Thirty-four male participants (mean age 38 years) were recruited, with 19 assigned to the intervention and 15 to control. The study achieved a high recruitment rate of 92%, but retention was a significant challenge, with only 18% of participants retained at 9 months follow-up. The process evaluation found critical time intervention was acceptable to staff and participants, but ethical concerns around randomisation and informed consent were raised. Fidelity to the critical time intervention model was generally high, though contextual instability in housing and criminal justice systems posed challenges. Data collection methods for health economics and data linkage were feasible and acceptable. The approval to access prisons was lengthy and support provided by Clinical Research Networks was delayed. Contextual instability within the housing and criminal justice systems, including a lack of social housing, high recall rates, the removal of the requirement to have a probation officer and the emergency early release of people in prison, further complicated the trial. Ethical concerns around randomisation and informed consent affected trial acceptability. The trial methodology faced significant challenges. Low retention rates, ethical concerns by intervention delivery staff around randomisation and contextual instability suggest that a full-scale randomised controlled trial is not feasible. The findings highlight the need for systemic changes within the research support provided to prison-based studies, housing and criminal justice systems to support research in prisons and interventions for people leaving prison. Decision-makers should prioritise policies that increase the availability of affordable housing and provide post-release support. Future research should explore alternative study designs and more intensive recruitment and retention strategies. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR134281. People leaving prison often struggle when returning to the community, leading to homelessness, worse health and higher chances of committing more crimes. Critical time intervention is a structured support model delivered by trained caseworkers to help during this transition. Critical time intervention includes four phases, pre-engagement, transition to community, try-out and transfer of care, each lasting 3 months. Caseworkers support individuals to secure housing, access services and build life skills. From October 2023 to August 2024, 34 men leaving three prisons in England and Wales were recruited for a pilot study. Participants were randomly assigned to either receive critical time intervention or usual support. The study aimed to test whether a full-scale research project could be done to evaluate critical time intervention. We assessed recruitment (did people take part), retention (could we stay in touch), fidelity (was critical time intervention delivered as planned) and acceptability (were the study and intervention acceptable to participants and staff). Data were collected through surveys at baseline and at 3, 6 and 9 months, interviews and session observations. Most people agreed to take part, but it was difficult to maintain contact over time. Critical time intervention was well received by staff and participants, but the research process faced challenges. These included high rates of return to prison, limited housing options, reduced probation contact and emergency early releases. Critical time intervention was valued by those who delivered and received it, but conducting a larger study to evaluate its effects would be difficult. Maintaining contact with participants was challenging, and wider issues in housing and criminal justice systems suggest a full-scale trial may not be feasible. Future work should focus on improving support for prison leavers and adapting research methods to better suit this population.