Protocol of the impact of alternative social assistance disbursement on drug-related harm (TASA) study: a randomized controlled trial to evaluate changes to payment timing and frequency among people who use illicit drugs

Abstract

BackgroundGovernment social assistance payments seek to alleviate poverty and address survival needs, but their monthly disbursement may cue increases in illicit drug use. This cue may be magnified when assistance is disbursed simultaneously across the population. Synchronized payments have been linked to escalations in drug use and unintended but severe drug-related harms, including overdose, as well as spikes in demand for health, social, financial and police services.Methods/designThe TASA study examines whether changing payment timing and frequency can mitigate drug-related harm associated with synchronized social assistance disbursement. The study is a parallel arm multi-group randomized controlled trial in which 273 participants are randomly allocated for six assistance cycles to a control or one of two intervention arms on a 1:1:1 basis. Intervention arm participants receive their payments: (1) monthly; or (2) semi-monthly, in each case on days that are not during the week when cheques are normally issued. The study partners with a community-based credit union that has developed a system to vary social assistance payment timing. The primary outcome is a 40 % increase in drug use during the 3 days beginning with cheque issue day compared to other days of the month. Bi-weekly follow-up interviews collect participant information on this and secondary outcomes of interest, including drug-related harm (e.g. non-fatal overdose), exposure to violence and health service utilization. Self-reported data will be supplemented with participant information from health, financial, police and government administrative databases. A longitudinal, nested, qualitative parallel process evaluation explores participant experiences, and a cost-effectiveness evaluation of different disbursement scenarios will be undertaken. Outcomes will be compared between control and intervention arms to identify the impacts of alternative disbursement schedules on drug-related harm resulting from synchronized income assistance.DiscussionThis structural RCT benefits from strong community partnerships, highly detailed outcome measurement, robust methods of randomization and data triangulation with third party administrative databases. The study will provide evidence regarding the potential importance of social assistance program design as a lever to support population health outcomes and service provision for populations with a high prevalence of substance use.Trial registrationNCT02457949 Registered 13 May 2015.

Integrated knowledge translation to strengthen public policy research: a case study from experimental research on income assistance receipt among people who use drugs

“…In the case of the Cheque Day study, while multiple studies had previously called for a change to the distribution schedule of income assistance, discussion of that change was largely absent from the public sphere, and no scientific evidence had explored the practicalities and potential impacts of implementing such a change. To supplement the Cheque Day Study, which to our knowledge was the first study to experimentally test alternatives to synchronized income assistance payments [ 20 ], an IKT Theory of Change was developed aimed at addressing barriers to the use of evidence. This Theory of Change tested the hypotheses that sustained engagement and access to accessible information would improve understanding and awareness of the research-related issues among knowledge users, in turn leading to increased buy-in and strengthened potential that research results would support policy or programmatic change.…”

“…This IKT project was embedded within a randomized controlled trial entitled: The impact of alternative social assistance disbursement on drug-related harm, known colloquially in the research site as the Cheque Day Study [ 20 ]. In the study context and other jurisdictions, income assistance is commonly distributed once a month to all recipients on the same day.…”

“…This trend has been widely acknowledged in Vancouver, Canada’s Downtown Eastside community, and demonstrated by many years of observational research in Vancouver and across North America [ 22 ]. Research points to intensified and riskier drug use following cheque issue as well as increases in related harm such as fatal and non-fatal overdoses, exposure to violence, emergency department use, police service calls, and treatment or health care interruption [ 20 , 23 – 36 ].…”

“…This field experiment examined whether changing the timing and frequency of income assistance payments would mitigate monthly escalations of drug use and subsequent drug-related harms. Housed within the British Columbia Centre on Substance Use and described in detail elsewhere [ 20 ] briefly, volunteer participants were recipients of income assistance living in Vancouver, British Columbia, who during screening by the research team reported increases in drug use around payment days. In partnership with a community-located and operated branch of a local Credit Union, the study randomly allocated participants to continue receiving income assistance on government cheque issue days (the study control arm) or one of two intervention arms that differed in either (1) the timing (once a month on a day outside of cheque week) or (2) the timing and frequency of payments (twice a month on days outside of cheque week).…”

Drug‐related harm coinciding with income assistance payments: results from a community‐based cohort of people who use drugs

“…This study signals a need for strategies that could mitigate these harms. Programmatic or structural changes, such as desynchronizing or changing the frequency of payments, could reduce the burden of harm for PWUD by dispersing social signals for use [7,12] as well as concentrated service demands for service providers and first responders [73], beneficially impacting payment‐linked cycles of harm. However, such changes may produce unanticipated consequences by disrupting the predictability of money flows and should be approached with caution [74].…”