What works and doesn't work in sexual health interventions for the homeless community: early findings of a realist review
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Background: People experiencing homelessness (PEH) face persistent sexual health inequities due to intersecting structural barriers including housing instability, stigma, discrimination, and inadequate access to healthcare. While sexual and reproductive health (SRH) interventions—ranging from drop-in services to incentive-based care—have been developed for this population, their success varies greatly depending on how they are implemented and whom they serve. A realist approach helps identify how these interventions work, for whom, in what contexts, and through which mechanisms. Methods: Following Pawson’s six-step realist synthesis approach, we developed an initial programme theory and are iteratively refining it through a systematic review of peer-reviewed and grey literature. Context–Mechanism–Outcome Configurations (CMOCs) are being developed and tested to explain how SRH interventions function across varied settings. Data extraction focuses on identifying patterns of resources, reasoning, and outcomes across subgroups and delivery models. Preliminary Findings: Early synthesis suggests that SRH interventions are most effective when they provide stability (e.g., food, hygiene, shelter), foster trust, and are culturally and contextually aligned. Mechanisms such as perceived recognition, cultural affirmation, and safety are frequently triggered when interventions prioritise low-barrier access, trauma-informed care, and client autonomy. Constraints include procedural inaccessibility, confidentiality concerns, and lack of cultural relevance. Conclusion: Emerging findings support the need for holistic, flexible, and equity-focused SRH interventions that acknowledge the realities of homelessness. The review will offer transferable insights to inform more context-sensitive policies and practices.
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