Jasmine Singh
Born and raised in Liverpool, Jasmine Singh is a UNSW PhD candidate at CHETRE (ICFHS/SWSLHD), committed to advancing healthcare equity for people experiencing homelessness in her local community. She holds a Bachelor of Science and Bachelor of Advanced Studies (Honours Class I) from the University of Sydney, where she was a Dalyell Scholar. Her research uses realist methodology and linked data to inform implementation of the SWSLHD Homelessness Strategy. It examines how fragmented services can be transformed into a more integrated healthcare system, addressing the revolving-door cycle in which people experiencing homelessness repeatedly access Emergency Departments without receiving the sustained care and support needed to improve their health and wellbeing.
Session
Homelessness is not produced or resolved by a single service. It is shaped by the interactions of health, housing, social care and community systems, yet policy and evaluation often treat implementation as if it occurs in a stable environment. This creates a methodological problem: how can research explain not only whether a homelessness policy works, but how, why, for whom and under what changing conditions it produces system-level effects?
This abstract reports an applied complex realist methodology examining how health, housing and community systems generate coordinated or fragmented responses to people experiencing homelessness. While realist review are scarce and often treated as the endpoint of evidence synthesis, in this project, it is the first cycle of an applied, longitudinal methodology: explanatory theory is generated from the literature, translated into health-system development, and then tested and refined as implementation unfolds. Its initial programme theory identifies two competing pathways. In the enabling and integrated pathway, stable and flexible funding, intersectoral collaboration, explicit accountability and a non-judgemental, person-centred culture activate mechanisms including staff security, trust, knowledge sharing, cross-sector collaboration and flexible care. These mechanisms are expected to support engagement, accessible and responsive services, continuity of care, reduced emergency department use and improved health and wellbeing.
In contrast, the fragmented and unaccountable pathway is associated with short-term funding, siloed services, absent shared accountability and stigma. These contexts generate staff insecurity, organisational workarounds, poor information-sharing and responsibility-shifting. The resulting mechanisms contribute to inconsistent care, disengagement, repeated emergency department presentations and the persistence of homelessness-related health inequities. Presenting these pathways together makes visible how the same broad policy objective—improving responses to people experiencing homelessness—may produce different outcomes depending on the conditions in which it is implemented. Cross-cutting mediators were also identified, including population subgroup, frequency and duration of service contact, and digital interventions. These factors may influence how mechanisms are triggered and how outcomes develop across different groups and points of contact with services. Foundational capacities include housing and wraparound support, workforce development, data learning and knowledge transfer. System accountability and continuous learning are theorised as feedback loops capable of reinforcing either the enabling and integrated pathway or the fragmented and unaccountable pathway.
These findings have already been fed into the development stage of the South Western Sydney Local Health District Homelessness Plan, demonstrating the review's purpose to not only to synthesise existing evidence, but support the development of a health-system response grounded in an explicit account of context, mechanism and outcome. Evidently, realist methodology can move between evidence, policy and practice while maintaining a focus on how and why system change occurs. Critically, the initial programme theory will guide a Theory of Change, participatory systems mapping, documentary analysis, ethnographic observation in Liverpool Hospital Emergency Department, stakeholder interviews and later longitudinal analysis of changing governance and service responses. The methodological contribution is a theory-to-practice-and-back-again model in which realist synthesis is both explanatory and formative, and findings are visible and assessable. It demonstrates how realist findings can shape policy development while creating a structured basis for examining whether, how and under what conditions system change occurs over time. By linking realist review to the development and subsequent study of the SWSLHD Homelessness Plan, the project offers a practical approach for investigating homelessness as a systems problem and for connecting evidence synthesis, policy development and longitudinal inquiry.