Article Text

Original research
Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation
  1. Anum Ali1,
  2. Gary Groot2,
  3. Melissa April3,
  4. Maura MacPhee4,
  5. Stephanie Witham3,
  6. Hubert Alimezelli1,
  7. Tracey Carr3
  1. 1 Community Health and Epidemiology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
  2. 2 Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  3. 3 University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  4. 4 The University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Gary Groot; gary.groot{at}usask.ca

Abstract

Background In Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of Saskatchewan.

Objectives The aim of the project was to conduct a resident-oriented realist evaluation of an innovative supportive housing programme, Sanctum, for people living with HIV/AIDS who also face social care issues, such as homelessness. This project took place in Saskatchewan, a province that is seeking innovative approaches to improve quality of life and HIV/AIDS management for its citizens. Our evaluation addressed how and why participants were successful (or not) within the Sanctum programme.

Design and setting Sanctum is a housing programme located in an inner-city location within the province of Saskatchewan. A unique component of this evaluation was the inclusion of an individual with lived experience, a resident partner, as a member of the research team.

Participants 11 recent Sanctum graduates, seven men and four women, were recruited for client partner-led in-depth, semistructured interviews.

Interventions Prior to the evaluation, we developed a realist programme theory with potential causal explanations, known as context-mechanism-outcomes (CMO) configurations. Interview data from the evaluation and ongoing discussions with Sanctum board members and our resident partner were used to test, refine and validate the final programme theory and CMO configurations.

Results CMO configurations at the micro (individual), meso (interpersonal) and macro (community) levels complement the over-arching programme theory. Key findings were the importance of Sanctum’s harm reduction philosophy, accompanied by a non-judgmental and patient-oriented approach. Participants were supported to reduce risky behaviour, improve self-care management and develop healthier relationships within a ‘safe’ home-like setting. Underlying mechanisms that contributed to participants’ success in the programme included: intrinsic motivation, self-worth, belongingness, empowerment and self-efficacy. Evidence-informed recommendations are offered to support Sanctum-like programme development for individuals with holistic health needs related to HIV/AIDS diagnoses and lack of access to necessary social determinants of health.

Conclusions Stigma associated with HIV/AIDS and living circumstances, such as homelessness, were successfully addressed using harm reduction principles and judgement-free approaches within a family-like environment.

  • HIV & AIDS
  • Community-Based Participatory Research
  • Decision Making
  • Health Services Accessibility
  • Health policy

Data availability statement

Data are available upon reasonable request.

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Strengths and limitations of this study

  • A realist evaluation approach generates a deeper understanding of how, why and for whom a programme, such as Sanctum, is successful or not.

  • Engaging a resident partner with lived experience as a research team member enabled academic researchers to establish a shared connection between participants, resulting in transparent conversations and rich data collection.

  • Research training programmes, such as the Saskatchewan Centre for Patient-Oriented Research, are an effective way to engage, train and support non-academic partners with lived experience.

  • Limited record-keeping with lack of contact information and unstable living conditions made it difficult to reach Sanctum individuals who dropped out or were unable to successfully complete the programme. Evaluation findings pertain only to successful Sanctum graduates.

Introduction

Background of HIV in Canada and Saskatchewan

In Canada, the most recent HIV surveillance data from the Public Health Agency reported an 11.3% increase in new HIV cases between 2020 and 2021. There were 5.5 new HIV cases per 100 000 population for men and 2.1 cases for women. The HIV prevalence nationally is projected to rise, although death rates have been decreasing over time.1 Canada is committed to meeting the United Nations Programme on HIV/AIDS (UNAIDS) targets of 95-95-95 by 2030. These targets represent the capacity to diagnose 95% of all HIV-positive individuals, to offer 95% of those diagnosed antiretroviral (ART) therapy and to achieve 95% suppression for individuals being treated with ART.2 These UNAIDS targets have enabled more people living with HIV (PLHIV) to manage their disease with better health outcomes, increased life expectancy and reduced community transmission.1 3 4

Among the provinces, compared with the national rate of 3.8 new HIV cases per 100 000 population, Saskatchewan had the highest rate of 20.3 new cases per 100 000 population in 2021.5 In Saskatchewan, Indigenous people account for a high rate of 80%6 for new diagnoses despite comprising only 16.3% of the province’s population.7 8 Among various ethnic groups, Indigenous people are disproportionally exposed to HIV/AIDS and make up an increasing percentage of 14% of all Canada’s new HIV-positive reports, while constituting only 4.9% of Canada’s total population.1 A recent systematic review highlighted how ongoing social inequities have increased the risk of ineffective HIV management among Canada’s Indigenous peoples.9 Although new treatments have changed the outlook for PLHIV, social challenges faced by PLHIV create barriers to accessing, managing and sustaining successful and safe treatment; especially in communities challenged by cultural stigma and discrimination with respect to being HIV-positive with Indigenous heritage.

The social determinants of health and housing instability with HIV

The need to understand the role of social determinants of health for PLHIV has become widely accepted in disease prevention efforts.10 Among the challenges facing PLHIV is a lack of safe and stable housing, oftentimes associated with unemployment, socioeconomic challenges and social stigma.4 11–13 Other correlates of residential instability for PLHIV are chronic substance abuse, decreased engagement in care, inconsistent access to healthcare and insurance and poor adherence to medication.4 14–18 As a chronic complex illness, HIV management requires a stable residence where the most basic necessities are provided in order to maintain HIV self-care regimens, healthy eating and medical guidance.19 HIV-positive individuals with unstable housing are more likely to experience higher psychological stress and consequently poorer mental health status, compared with those with stable housing.20–22 Notably, housing insecurity has been linked to HIV progression turning into AIDS and AIDS-related death.19–21 With strong evidence that insecure housing and homelessness can deteriorate physical and mental health outcomes for PLHIV, supportive housing programmes are essential to the well-being of PLHIV.22

In addressing the complex challenges of housing instability in HIV, housing programmes can promote the chances of maintaining stable housing4 23 24 and increase adherence to ART.25 26 Evidence suggests that housing programmes support reductions in individuals’ viral loads, lower the risk of death27 and promote overall improvements in individuals’ physical and mental health.20 24 28 The outcomes of residential housing programmes also directly impact health systems by decreasing emergency room visits and hospital admission rates.20 29 30 Although the benefits of housing programmes have been documented,4 20 23 25 little is known about how and why these programmes can produce such outcomes.

The Sanctum housing programme

To address challenges related to the HIV epidemic, in 2015, Sanctum was established in Saskatoon, Saskatchewan, Canada, as a 10-bed supportive care housing programme targeting PLHIV. In Saskatoon, with a population of 266 141,31 HIV incidence estimated as 17/10 000 people has been one of the highest HIV rates in the province.32 Sanctum offers supportive and palliative care for PLHIV who also face social issues such as homelessness. The majority of Sanctum clients are Indigenous, unstably housed and have other mental and physical health conditions (personal communication, 3 September 2020).

Sanctum implements a harm reduction model of care which emphasises ‘a holistic and person-centred approach for PLHIV’ to ‘minim(ize) their vulnerability and maxim(ize) their control and dignity’.33 The programme offers visits from a family physician, nursing care, support for medical management, opiate-assisted recovery, spiritual care and mental health and addiction outreach services.33 In addition to on-site care and support, Sanctum staff assist residents to achieve stable housing after graduation from the programme, generally after 3 months, by linking them to local community supports. Sanctum also offers peer mentor support from peers with shared experiences, particularly those who have successfully completed the programme. These services are comparable to other similar programmes in Canada that provide services and housing support for PLHIV, such as the Dr Peter Centre34 in Vancouver, British Columbia and Bruce House35 in Ottawa, Ontario.

Study objective

The aim of this project was to conduct a realist evaluation of the Sanctum housing programme to better determine how and why a supportive housing programme produces successful/unsuccessful programme outcomes for PLHIV. Building on a study protocol36 where an initial realist programme theory (IRPT) was developed, the goal of this study was to test and validate the IRPT through qualitative interviews with Sanctum residents. Our realist evaluation questions were: (a) what are the contextual factors associated with better outcomes for Sanctum residents? and (b) what are underlying mechanisms or psychological factors that link contextual factors to outcomes?

Methods and analysis

A realist evaluation

Our study used a realist evaluation approach36 whereby the evaluator operates under the assumption that an intervention does not act alone and is not, in itself, what produces an outcome.23 Instead, specific contextual factors (C) trigger underlying mechanisms (M) that result in intended or unintended programme outcomes (O). The context (C) is the setting and conditions in which the programme is implemented, the mechanisms (M) represent the drivers of individuals’ decisions to act or not to act on available Sanctum and community services and the outcomes (O) are intended short or long term of what works or does not work.37 38

The C-M-O (CMO) configurations generated through secondary data (realist synthesis of literature) are similar to causal explanations that are tested, refined and validated using primary evaluation data.37 As a theory-driven approach, realist evaluation typically encompasses three phases: (1) eliciting the IRPT, (2) testing the IRPT through data collection and (3) refining the final programme theory (RPT).39–42 Our protocol paper36 documents the development of the IRPT. This evaluation followed the reporting standards for realist evaluations.43

Resident and public involvement

A resident partner, who was a graduate of the Sanctum programme, was hired as a member of the research team and was involved in each stage of the study. The resident partner had considerable experience with the Sanctum housing programme, its services and the population. The resident partner co-developed the interview guide, recruited and interviewed participants, analysed data and disseminated findings. Resident partner engagement was crucial in our study, as they informed the research team about appropriate interview approaches, particularly language use (eg, avoiding triggering words/questions) as well as helping to build trust between researchers and the participants. Prior to data collection, the resident partner was trained in realist evaluation by the research team44 and attended the Saskatchewan Centre for Patient-Oriented Research training courses.45

Realist programme theory testing and refinement

Given the large number of Indigenous residents at Sanctum, the research design had included Indigenous sharing circules with elder participation during data collection. Due to COVID-19 restrictions, the resident partner conducted virtual qualitative interviews with Sanctum graduates. Although Sanctum mainly serves Indigenous residents, qualitative interviews were open to graduates with any ethnic identity.

Data collection

Data collection for phases 1–3 took place between May 2020 and December 2021, and qualitative interviews were conducted between September and October 2021. Using convenience sampling, participants were recruited from a list of residents who had gone through the programme at least once: some residents attended the programme more than once due to living circumstances in the community. The resident partner initiated contact with all eligible graduates via email and/or phone based on available contact information through Sanctum. If potential participants expressed interest, the research partner sent them ethics-approved information about the study, interview guide topics and informed consent forms via email or mail. Further contact with potential participants via phone or email was used to answer questions and to organise interviews via Zoom by phone or computer. Interviewees also provided consent for the researchers to view their Sanctum records, which contained participant dates for first entry to the programme, programme graduation and 3 months after graduation.

The resident partner led the virtual (Zoom) interviews by introducing themselves, obtaining oral consent and asking questions from the interview guide based on a realist evaluation teacher-learner approach (see online supplemental file 1).46 The questions and prompts were designed and piloted by the resident partner to inquire about participants’ personal journeys of recovery while in Sanctum, as well as their encounters with programme facilitators and barriers. The interviews were audio recorded and transcribed, and participants were offered an honorarium for participation.

Supplemental material

Data analysis

A social-ecological approach47 was used to understand the CMOs operating at the individual, interpersonal and community levels for the RPT. The social-ecological approach considers factors or ‘systems’ that surround an individual, including interpersonal interactions, community settings and society at a broader scale.48–50 This model has been applied in public health prevention frameworks50 to understand the social determinants of health that contribute to inequities, including determinants related to HIV and substance use.10 51

Interview data were coded for CMOs according to these three levels using NVivo V.12. A deductive-inductive coding approach was used. Based on the IRPT, a deductive coding framework was developed with key concepts or coding buckets.36 Inductive coding was used to code divergent data or background data into an ‘Other’ bucket for later consideration. Although inductive and deductive reasoning are well-known in qualitative/quantitative approaches, realist methods use a variety of analytic reasoning processes including induction, deduction, abduction and retroduction. Abductive reasoning is where patterns in data result in ‘draft’ explanations of what is reasonably happening: abductive reasoning was used throughout the development of the IRPT and initial CMO configurations. Retroductive reasoning uses inferential explanations from the other types of reasoning to formulate more refined explanations for the RPT and CMO configurations.52 An iterative process was used throughout the analysis process to check all the interview data within the coding buckets, to ensure a ‘fit’ between the final CMO configurations and the primary data. Since the IRPT and initial CMO configurations were based on preliminary abductive reasoning and secondary data, we expected changes after an in-depth analysis of primary data. The RPT and CMO configurations with exemplar quotes from the interviews were presented to the Sanctum board and staff for validation. Interview quotes (anonymised) were selected by the research partner and team that best demonstrated the richness and relevance of Cs-Ms and Os in the final CMOs. Richness and relevance refer to ‘contextual thickness’ and explanatory power of the primary data findings, respectively.53 Rigour describes the credibility of the data: for example, in this study, the interviewees gave similar explanations for why Sanctum was an effective housing programme for them. Realist evaluations, therefore, rely on exemplar quotes (and online supplemental file 1 of additional data) to lend transparency to their analytic methods.53

A final consideration with realist methods is the use of existing, mid-range theories to explain underlying mechanisms in the CMO configurations.41 Retroduction is used to identify hidden mechanisms or causal forces that are drivers for people’s decisions and actions.54 Mechanisms are linked to social and psychological theories at a mid-range level of abstraction; where they are broad enough to propose relationships among relevant key concepts, while being concrete enough (vs abstract, grand theory) to apply and test in ‘real-life’ settings.41

Patient and public involvement

This is a POR project; as such patients and a resident-research partner were involved throughout different stages of the project (design conception, data collection, data analysis, dissemination).

Results

Of the 18 potential participants contacted, 11 participants (61%), including seven men and four women, were recruited for individual interviews. Six eligible participants did not respond, and one was unavailable. Based on the approved ethics recruitment protocol, potential participants were contacted by phone or email using Sanctum information. For non-respondents, repeat attempts were made via phone or email without success. The high non-response rate may have been due to ongoing COVID-19 restrictions. Interviews ranged from 10 min to 32 min with an average of 20 min in duration. Table 1 shows the admission data for the individuals recruited for the interviews. Table 2 represents the trends in housing and financial status for the residents at admission, closure and 3-month follow-up. These data show that residents reported improved financial and housing status after being a resident at Sanctum and maintained it 3 months after leaving the programme.

Table 1

Participant characteristics at admission (n=11)

Table 2

Participant housing and financial status from admission to follow-up (n=11)

After testing the IRPT through interviews with Sanctum residents and the Sanctum board of staff, we refined the IRPT and developed a final RPT. The final RPT is as stated: when housing-insecure individuals with HIV/AIDS require a place to stay to rehabilitate and to learn how to manage their health and social care needs (eg, housing and employment), housing programmes that offer a person-centred, harm reduction philosophy with education and support in medication management promote successful transition to healthier, self-care management in the community.

Accompanying CMO configurations with representative quotes are presented in table 3 for each socioecological level (ie, micro, meso, macro). Table 4 is a bulleted version of Cs-Ms-Os with mid-range theories associated with each mechanism.

Table 3

CMO configurations for each socioecological level

Table 4

Context, mechanisms and outcomes for Sanctum with mechanism mid-range theories

At the micro level (individual level), participants learnt how to manage their medications, improve their self-care and decrease risky behaviours. Participants also learnt that HIV/AIDS is a manageable, chronic illness, which gave them an opportunity to feel more in control of their health. In addition, the residents had opportunities for spiritual care, cultural connection and meaningful activities, which lowered risky behaviours because of increased pride in themselves (self-worth).

At the meso level (interpersonal), the presence of paid peer mentors provided an opportunity for participants to share their personal experiences with someone with similar life challenges and successful sobriety, creating a sense of trust in the mentor’s advice and support. Peer mentorship was valued by many participants, who recommended increasing Sanctum’s mentor supports. A common suggestion from participants was to use previous graduates of the Sanctum programme. Sanctum board members and staff tempered this suggestion by highlighting the need for on-site training and formal preparation in harm reduction approaches and management of emotionally charged situations. The Board and staff also commented on the need for more hired staff supports, such as opportunities for debriefing, easing the emotional burden, creating more collaborative teamwork and preventing staff burnout.

Sanctum’s hired staff (eg, nurses, social workers, counsellors) promoted a harm reduction philosophy that contributed to participants’ intrinsic motivation by helping them to learn how to make better health decisions and manage their own health and social care needs. Individuals were treated with respect and dignity; they were not labelled or stigmatised, which created a sense of belonging among participants. A person-centred approach promoted self-care management and participants’ capacity to make their own decisions so they could feel in control (empowerment and self-efficacy). Participants noted how recreational activities helped keep them productively occupied, and they recommended more culturally sensitive activities to connect them to their Indigenous roots. The presence of Elders and spiritual counsellors was an important component of Indigenous participants’ healing process.

At the macro level (community), the Sanctum programme helped participants to have the necessary resources and contacts in place before transitioning back to the community, although this was not always the case where gaps were still present for the community to fill. This gradual transition process helped participants succeed on their own and enhanced feelings of self-efficacy. The Board recommended building closer partnerships with the local community and organisations close to Sanctum to provide more sustainability and assist with seamless transition for residents. Although there may be a variety of supports within a community, they are not necessarily well-connected or easy to access, especially for marginalised populations.

Discussion

The aim of this realist evaluation was to find out from Sanctum residents what characteristics of the housing programme were most effective/ineffective for them, and to identify potential, underlying mechanisms linking key contextual characteristics to intended outcomes. This realist evaluation includes an over-arching RPT with accompanying, testable causal explanations or CMOs. The RPT and the CMOs provide potential explanations of what works (and why) for a vulnerable population of HIV/AIDS Sanctum residents, many residents doubly stigmatised by a long history of Indigenous colonisation in Canada. For this evaluation, we used primary data from interviews conducted by a research partner with lived experience to better connect with former Sanctum residents. Subsequent validation of the RPT and CMOs was conducted with the Sanctum Board and staff. Our findings illustrate the benefits of a harm-reduction philosophy and a non-judgmental and family-like environment with respect to positive, sustainable changes for Sanctum residents. The Sanctum professional staff and peer mentors improved outcomes for participants/Sanctum residents by providing education, medical guidance, meaningful and culturally relevant activities and transition-to-community supports.

This study found that participants reported greater feelings of intrinsic motivation, which was identified as a mechanism that helped residents engage less in risky behaviour and more in self-care. According to self-determination theory,55–57 sustainable behaviour change depends on individuals’ opportunities to have increased autonomy over their lifestyle decisions and to have positive experiences with the development and application of new skill sets related to their health and well-being. Over time, individuals internalise new values and skills that act as drivers for the decisions they make (ie, intrinsic motivation). Self-determination theory is a general theory of motivation that helps explain how contextual factors within treatment environments, such as Sanctum, can influence increased self-care activities and eventual self-management of health and social care needs.

Effective self-care practices are associated with better quality of life outcomes, such as lower morbidity and mortality.58 59 Self-care is defined as health maintenance through illness management and health promotion practices. Contextual factors that are particularly important for self-care are the provision of relevant information about medication practices, for instance, that give control and choice to the individual. The presence of peer mentors and staff using a harm reduction philosophy reinforces individual choice versus external pressure to change. When individuals are ‘volitionally engaged’ they are more likely to learn and to apply new self-care activities.57 (p.3) Intrinsic motivation, therefore, is based on contextual factors that ensure autonomy and acknowledgement of growing competence over self-care management.

Participants reported greater feelings of self-worth and self-efficacy that also contributed to improved self-care management and decreased risky behaviours. An individual’s capacity to monitor their thoughts and emotions and compare their own against others’ standards and environmental circumstances is described by Bandura’s theory of self-regulation.60 61 Self-regulation is also influenced by how an individual values themselves, known as self-worth.62 63 Residents have experienced emotional trauma for various reasons (ie, their ethnicity, culture, gender, sexual orientation),64 65 which can adversely influence individuals’ sense of self-worth, lower self-esteem and create a belief that they cannot succeed in society.66 Acknowledging residents’ cultural, ethnic and gender-based identities is an important aspect of Sanctum’s trauma-informed care. As such, culturally-adapted treatment programmes have had successful outcomes, such as reinstating a sense of self-worth in residents, especially for Indigenous members of Sanctum.67 Sanctum provides an environment where individuals can learn to monitor their thoughts and emotions against others in a psychologically safe space to help their transition into the community.68

Sanctum aims to counter feelings of stigmatisation so that individuals can share common lived experiences and collectively create a new, validating narrative for themselves.69 70 Using a harm-reduction approach encourages feelings of trust and belongingness while reducing social stigma. Trust and belongingness were identified in our study as underlying mechanisms that encouraged self-disclosure, the development of healthy relationships and decreased risky behaviours. When individuals are stigmatised, the capacity to control negative impulses through self-regulation is diminished.71 Subjective alienation theory is used to describe an individual’s inability to establish healthy social contacts that can influence their trust in others.72 73 Alternatively, a harm-reduction approach provides education and support for individuals to make better life choices and gradually establish a new sense of social belongingness.74 Developing a sense of belonging in a supportive community, such as Sanctum, furthers the sense of internalising new values and competencies.75

Lastly, we found that empowerment was an underlying mechanism that drove improvements in residents’ self-care management. Empowerment denotes individuals’ capacity to take control of their lives.76 When working with disadvantaged individuals who often come from chaotic and dangerous communities, empowerment must be considered at multiple levels—the individuals and the community. Empowerment is often achieved by gradually increasing individuals’ mastery over their own lives. Zimmerman proposed three types of individual empowerment: intrapersonal, interpersonal and behavioural. Intrapersonal empowerment is often manifested as perceived competence or self-efficacy.77 Interpersonal empowerment refers to individuals’ sense of connecting or belonging to a community of like-minded people with shared common goals and behavioural empowerment translates as actual engagement in healthy activities, such as self-care activities and activities with others that achieve a sense of greater good. In one systematic review on interventions to address HIV/AIDS stigma, the ‘empowerment approach’ was shown to improve psychological well-being in people with HIV. An effective empowerment approach was the sharing of lived experiences among people with HIV, including discussions of how to engage in meaningful social and family relationships. The negative impact of HIV/AIDS self-stigma can be ameliorated by empowering individuals to establish positive self-image and resilience through programmes such as Sanctum.78

Rather than return to chaotic neighbourhoods where illicit drug use is rampant, Sanctum provides ‘in-house’ resources and supports where individuals are empowered to regulate their own lives and make their own decisions. Sanctum acts as a bridge to community empowerment by ensuring individuals have access to necessary resources and supports before they leave their Sanctum ‘home’. Social psychologists argue that empowerment across systems levels is critical to sustainability. In the case of Sanctum, individual empowerment is nurtured in a non-judgmental environment based on harm reduction philosophy that carries over to the community level (ie, community empowerment).

To our knowledge, this is the first realist evaluation of a residential programme for PLHIV in Canada. A realist evaluation that employed multiple analytic reasoning approaches allowed for a deeper understanding of the contexts and mechanisms that contributed to successful programme outcomes. Engaging a previous Sanctum resident as a resident partner in the research established trust between the researchers and participants, enabled more open dialogue in the qualitative interviews, provided an opportunity to incorporate the partner’s lived experiences and engaged a non-academic partner in research skills training. Additionally, the evaluation team members contributed their backgrounds in community health and epidemiology, nursing, evaluation and psychology, which created a diverse team environment. Our resident-oriented approach to a realist evaluation can be used as a model for other harm-reduction programmes that seek to understand what works and does not, for whom and under what circumstances. Other literature describes the benefits of co-producing research with members of disadvantaged populations.79 80

Our study was limited by COVID-19 restrictions that required interviews to be conducted on Zoom. Some potential participants lacked internet access and therefore could not be interviewed. Virtual interviews may have acted as a barrier between the resident partner and interviewees: conducting the interviews in person may have enhanced relationship-building and ongoing recruitment. There was a high non-response rate of 61% despite multiple efforts to contact individuals via Sanctum contact information (ie, phones, email). Finally, we did not have access to contact information for non-graduates and programme drop-outs, limiting our study findings to successful programme graduates.

Conclusions

Our study emphasised the effectiveness of a harm-reduction residential programme and how a resident-oriented approach is valuable to programme evaluation. The study also reinforced the intrinsic link between unstable housing, stigma and poor health outcomes for PLHIV,3 28 81 82 and how residential housing programmes for PLHIV can increase adherence to antiretroviral therapy,25 26 and improve overall physical and mental health.20 24 28 The mechanisms identified in this study complement each other through classic theories on motivation, self-regulation, self-esteem/self-worth and theories associated with the negative influences of growing up in marginalised communities where individuals become alienated, socially excluded, mistrustful of others and disempowered at multiple levels. The Sanctum environment provides knowledge, skills and resources to learn new life skills and bridges successfully to mainstream/community living—a new life based on a better sense of self. Future research may include interviews with other key stakeholders, such as staff and paid peer mentors; longitudinal tracking and follow-up of all programme attendees beyond the first 3 months; and investigation of how links to community supports can forge healthier, sustainable self-care management beyond the borders of residential care programmes.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This project was reviewed and approved by the research ethics board of the University of Saskatchewan Behavioural Research Ethics Board (Beh-1595) on 2 July 2020.

Acknowledgments

Our team would like to thank Sanctum Care Group staff and clients for working closely with us to establish a realist evaluation plan for Sanctum 1.0. As well, we are extremely grateful for the time, knowledge and insight provided by our resident partner, MA, and Sanctum Care Group’s executive director, Katelyn Roberts.

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • Contributors AA coordinated patient-oriented research training, collected data, co-conducted data analysis, engaged with the resident partner and prepared initial drafts of the manuscript. GG, as principal investigator of the grant proposal, provided overall supervision and reviewed and edited the manuscript. MA was involved in the grant application, collected data and co-conducted analysis. MM was engaged with data collection, writing initial drafts of the manuscript and reviewed and edited the final draft. SW assisted with manuscript writing and provided edits on the final draft. HA reviewed and edited the manuscript. TC assisted with the development of the grant proposal, co-supervised the project and reviewed and edited the manuscript.

  • Funding The present study is funded by Canadian Institutes of Health Research Catalyst grant #PAO-169390.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.