Determinants of effective interventions for HIV prevention, treatment, and care to address inequitable HIV outcomes among Black Women of African Descent (BWAD) in High-Income Countries: Systematic review protocol.

BACKGROUND: In High-Income Countries (HICs) HIV/AIDS continues to disproportionally affect Black Women of African Descent (BWAD) and other racialized groups and is now a major public health concern. Despite the multiple efforts, evidence is limited on the effectiveness of HIV interventions to address the HIV outcomes inequalities among BWAD. This protocol outlines the methodological process of a systematic review that will gather quantitative and qualitative data to examine existing determinants of effective HIV prevention, treatment, and care interventions to address the HIV outcomes disparities and inequities among BWAD in HICs. METHODS: A systematic review of eligible articles will be conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive search of the literature will be made in MEDLINE(R) ALL (Ovid), Embase (Ovid), CINAHL (EBSCO Host), and Global Health (Ovid). Peer-reviewed studies involving the experience of BWAD in HICs; different HIV prevention, treatment, and care interventions both in the community and in a clinical setting; studies that report on the experience of BWAD on HIV intervention/ service including different levels of barriers and facilitators; reports of original research and peer-reviewed articles based on qualitative, quantitative, and mixed study designs published in English from 1980 onwards in HICs will be included. A narrative synthesis, thematic synthesis, and descriptive quantitative analysis of both extracted qualitative and quantitative data will be undertaken. CONCLUSION: Substantial changes including tailored interventions are needed to address the inequities in HIV outcomes that disproportionally impact BWAD in HICs. Understanding the determinants of the effectiveness of BWAD-focused HIV interventions is critical to stemming the HIV epidemic and reducing the burden of the disease and poor health outcomes experienced by BWAD in HICs Our study finding will inform the multi level and multisectoral stakeholder including public health, community-based organizations and nongovernmental civil society organization engaged in BWAD HIV and health policy and practice in HICs. Findings from this review will be used to guide effective response to HIV/AIDS using an equity-driven policy and practice framework. TRIAL REGISTRATION: PROSPERO registration number: CRD42023458938.

Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study.

INTRODUCTION: In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system. METHODS: We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation. RESULTS: The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges. CONCLUSION: This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

Determinants of community health workers effectiveness for delivery of maternal and child health in Sub Saharan Africa: A Systematic review protocol.

BACKGROUND: Countries in sub-Sahara African continue to have the highest maternal and under- five child death occurrences in the world and this has become a key health challenge in the region and persists as global public health agenda. Although Community Health Workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in reducing health disparity, evidence is limited on perspective of community health workers. The objective of this protocol is to outline the methodological process of a systematic review that will gather qualitative data to examine determinants of community health workers effectiveness for delivery of maternal and child health in Sub Saharan Africa. Synthesizing the perspectives of community health workers' perceived experience is crucial to inform decision makers, policy makers, and practitioners to address barriers to and scaleup facilitators of CHWs program to ensure maternal and child health equity and a resilience community health system. METHODS: The protocol has been registered in the PROSPERO (CRD42020206874). We will systematically conduct a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Eligible studies will be reports of original research, peer reviewed articles having a qualitative component (i.e., qualitative, mixed, or multi-method studies) on empowerment of CHWs associated with maternal and child health in the sub-Saharan Africa. Eligibility will be restricted to studies published in English. Two reviewers will independently screen all included abstracts and full-text articles. The primary outcome will be CHWs' perceived barriers to and facilitators of effectiveness of community health workers in maternal and child health in sub-Saharan Africa. Study methodological quality (or bias) will be appraised using appropriate tools. Narrative analysis will be conducted, and narrative summary of findings will be presented. We will use the 'best fit' framework method as a systematic approach to analyzing the qualitative data. DISCUSSION: This study will systematically and comprehensively search literature and integrate evidence on perceived barriers to and facilitators of effectiveness of community health workers led maternal and child health program in sub-Saharan Africa. Our findings will inform policy and practice on maternal and child health equity and a resilient communities health system. The resulting manuscript will be disseminated in a peer-reviewed journal and at international and national conferences.

Sex differences in HIV testing among elders in Sub-Saharan Africa: a systematic review protocol.

BACKGROUND: Elders (age 50+) HIV demographic (age and sex) data are essential to better understand their HIV service utilization and develop appropriate evidence-based responses and policies. Despite a significant prevalence rate of HIV and growing numbers of this population group, data are still scarce, and studies have neglected them in Sub-Saharan Africa. The aim of this protocol is to outline the methodological process of a systematic review that will gather qualitative and quantitative data to critically examine sex differences in HIV testing among elders (age 50+) in Sub-Saharan Africa. METHODS: This protocol adheres to the PRISMA-P reporting guidelines. We will conduct a systematic database search to retrieve all observational and qualitative studies. Electronic search strategies will be developed for MEDLINE, EMBASE, Web of Science, Global Health, and CINAHL for studies reporting HIV data. Two reviewers will independently screen all citations, full-text articles, and abstract data. The search strategy will consist of free-text and Medical Subject Headings (MeSH) terms. Search terms for elders (50+) will include the following: "elders", "older adults", "aged", "geriatric" and "seniors". The primary outcome of interest is sex differences in the uptake of HIV counselling and testing (HCT). The study methodological quality (or bias) will be appraised using appropriate tools. Screening, data extraction, and assessments of risk of bias will be performed independently by two reviewers. Narrative synthesis will be conducted with studies that are compatible based on population and outcome. As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval. DISCUSSION: The systematic review will present key evidence on sex differences in HIV testing among elders in Sub-Saharan Africa. The findings will be used to inform program developers, policymakers, and other stakeholders to enhance sex disaggregated HIV data to improve access to HIV counselling and testing service for elders in Sub-Saharan Africa. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42020172737 .

Community perspectives on addressing and responding to HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) among African, Caribbean and Black (ACB) people in Ontario, Canada.

BACKGROUND: The African, Caribbean, and Black (ACB) population of Ontario, Canada is comprised of individuals with diverse ethnic, cultural and linguistic backgrounds and experiences; some of whom have resided in Canada for many generations, and others who have migrated in recent decades. Even though the ACB population represents less than 3.5% of the Canadian population, this group accounts for 21.7% of all new HIV infections. It is well-documented that ACB populations, compared to the general population, experience multi-level barriers to accessing appropriate and responsive HIV services. In this paper, we present qualitative findings on the ACB population's experiences with HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) and obtain their perspectives on how to improve access. METHODS: We conducted twelve Focus Group Discussions (FGDs), within a two-day World Café event and used socio-ecological framework and community-based participatory research (CBPR) approaches to guide this work. We meaningfully engaged ACB community members in discussions to identify barriers and facilitators to HIV testing, PEP and PrEP and how these may be addressed. The FGDs were transcribed verbatim and thematic analysis guided data interpretation. Credibility of data was established through data validation strategies such as external audit and peer-debriefing. RESULTS: Our analyses revealed multi-level barriers that explain why ACB community members do not access HIV testing, PEP and PrEP. Fear, health beliefs, stigma and lack of information, were among the most frequently cited individual- and community-level barriers to care. Health system barriers included lack of provider awareness, issues related to cultural sensitivity and confidentiality, cost, and racism in the health care system. Participants identified multi-level strategies to address the HIV needs including community-based educational, health system and innovative inter-sectoral strategies. CONCLUSION: CBPR, co-led by community members, is an important strategy for identifying the multi-level individual, interpersonal, community, institutional and structural factors that increase HIV vulnerability in ACB communities, notably anti-Black systemic racism. Study findings suggest the need for targeted community-based strategies and strategies aimed at reducing health system barriers to testing and care.

Barriers and facilitators to access mental health services among refugee women in high-income countries: a systematic review.

BACKGROUND: Based on the Global Trends report from the United Nations High Commissioner for Refugee, in high-income countries, there are 2.7 refuges per 1000 national population, girls and women account for nearly 50% of this refuge population. In these high-income countries, compared with the general population refuge women have higher prevalence of mental illness. Thus, this review was conducted to examine the barriers to and facilitators of access to mental health services for refugee women in high-income countries for refugee resettlement. METHODS: We searched MEDLINE, EMBASE, PsycINFO, and CINAHL databases for research articles written in English with qualitative component. The last search date was on March 14, 2020. A narrative synthesis was conducted to gather key synthesis evidence. Refugee women (aged 18 and older) that could receive mental health services were included. Men and women under non-refugee migrant legal status were excluded. Studies were evaluated studies using the Critical Appraisal Skills Programme (CASP) qualitative checklist. RESULTS: Of the four databases searched, 1258 studies were identified with 12 meeting the inclusion criteria. Three studies were cross-sectional by design, eight studies used a qualitative approach and one studies used mixed approach. The major barriers identified were language barriers, stigmatization, and the need for culturally sensitive practices to encourage accessing mental health care within a religious and cultural context. There were several studies that indicated how gender roles and biological factors played a role in challenges relating to accessing mental health services. The major facilitators identified were service availability and awareness in resettlement countries, social support, and the resilience of refugee women to gain access to mental health services. CONCLUSION: This review revealed that socio-economic factors contributed to barriers and facilitators to accessing mental health among women refugees and asylum seekers. Addressing those social determinants of health can reduce barriers and enhance facilitators of access to mental health care for vulnerable populations like refugee women. A key limitation of the evidence in this review is that some data may be underreported or misreported due to the sensitive and highly stigmatizing nature of mental health issues among refugee populations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020180369.

Multilevel determinants of community health workers for an effective maternal and child health programme in sub-Saharan Africa: a systematic review.

BACKGROUND: Countries in sub-Saharan Africa (SSA) continue to have the highest maternal and under-five child deaths in the world. The ongoing COVID-19 pandemic is amplifying the problems and overwhelming already fragile health systems. Community health workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in improving maternal and child health (MCH). However, evidence is limited on multilevel determinants of an effective CHWs programme using CHWs' perspective. The objective of this systematic review is to examine perceived barriers to and enablers of different levels of the determinants of the CHWs' engagement to enhance MCH equity and a resilient community health system in SSA. METHODS: We systematically conducted a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Qualitative studies that presented information on perceived barriers to and facilitators of effectiveness of CHWs in SSA were eligible for inclusion. Quality appraisal was conducted according to the Critical Appraisal Skills Programme qualitative study checklist. We used a framework analysis to identify key findings. FINDINGS: From the database search, 1561 articles were identified. Nine articles met the inclusion criteria and were included in the final review. Using socio-ecological framework, we identified the determinants of CHWs' effectiveness at 4 levels: individual/CHWs, interpersonal, community and health system logistics. Under each level, we identified themes of perceived barriers such as competency gaps, lack of collaboration, fragmentation of empowerment programmes. In terms of facilitators, we identified themes such as CHW empowerment, interpersonal effectiveness, community trust, integration of CHWs into health systems and technology. CONCLUSION: Evidence from this review revealed that effectiveness of CHW/MCH programme is determined by multilevel contextual factors. The socio-ecological framework can provide a lens of understanding diverse context that impedes or enhances CHWs' engagement and effectiveness at different levels. Hence, there is a need for health programme policy makers and practitioners to adopt a multilevel CHW/MCH programme guided by the socio-ecological framework to transform CHW programmes. The framework can help to address the barriers and scale up the facilitators to ensuring MCH equity and a resilient community health system in SSA.

De-problematizing masculinity among heterosexual African, Caribbean, and Black male youth and men.

OBJECTIVES: The dominant discourse in literature often constructs heterosexual African, Caribbean, and Black (ACB) masculinity as inherently problematic and in need of "correction, repair, or rescue." This discourse privileges hegemonic male standards and conceals the power relations that shape racialized masculinities. Our study of self-identified heterosexual ACB men and male youth examines how performative and perceptual attenuations of hegemonic masculinity can moderate social and behavioural vulnerabilities in the context of HIV prevention, transmission, and survival. METHODS: We used descriptive qualitative methods informed by community-based participatory research. Individual in-depth interviews and focus group discussions were conducted with 63 ACB men and male youth (aged 16 and above) residing in Ottawa, Canada, including community leaders, HIV service providers, and decision makers. The interviews were transcribed verbatim, and thematically analyzed with NVivo software. Member-checking, peer debriefing, and external audit ensured trustworthiness of data. RESULTS: ACB men and male youth define masculinity by their ability to provide for, protect, love, and lead their families. Within ACB cultures, men demonstrate their masculinity through their traditional role as family breadwinners, and are expected to be strong, bold, and responsible. This positive view of masculinity is potentially beneficial to the well-being of ACB men and male youth, and challenges mainstream notions of Black masculinity as uncontrolled, risky, toxic, or even predatory. CONCLUSION: A positive view of masculinity among ACB heterosexual men and youth could support future practice and policy interventions aimed at strengthening community responses to HIV and health.

RéSUMé: OBJECTIFS: Le discours dominant dans la littérature spécialisée construit souvent la masculinité hétérosexuelle africaine, caribéenne et noire (ACN) comme étant problématique en soi et nécessitant « correction, réparation ou sauvetage ¼. Ce discours privilégie les normes masculines hégémoniques et cache les relations de pouvoir qui façonnent des masculinités racisées. Notre étude auprès d'hommes ACN adultes et plus jeunes s'identifiant comme étant hétérosexuels cherche à déterminer si des atténuations performatives et perceptuelles de la masculinité hégémonique peuvent modérer les vulnérabilités sociales et comportementales dans le contexte de la prévention du VIH, de la transmission du virus et de la survie. MéTHODE: Nous avons utilisé des méthodes qualitatives descriptives éclairées par la recherche participative communautaire. Des entretiens individuels en profondeur et des groupes de discussion ont été menés avec 63 hommes ACN adultes et plus jeunes (16 ans et plus) vivant à Ottawa, au Canada, dont des responsables locaux, des dispensateurs de services en matière de VIH et des décideurs. Les entretiens ont été transcrits mot à mot, puis analysés par thème à l'aide du logiciel NVivo. Une vérification des membres, une séance-bilan avec des pairs et un audit externe ont assuré la fiabilité des données. RéSULTATS: Les hommes ACN adultes et plus jeunes définissent la masculinité selon leur capacité de protéger, d'aimer et de diriger leur famille et de subvenir à ses besoins. Dans les cultures ACN, les hommes prouvent leur masculinité en jouant le rôle traditionnel de soutiens de famille et sont censés être forts, audacieux et responsables. Cette image positive de la masculinité, potentiellement favorable au bien-être des hommes ACN adultes et plus jeunes, remet en question la notion de la masculinité noire comme étant incontrôlable, risquée, toxique ou même prédatrice. CONCLUSION: Une image positive de la masculinité chez les hommes hétérosexuels ACN adultes et plus jeunes pourrait appuyer de futures interventions axées sur les pratiques et les politiques visant à renforcer la riposte communautaire au VIH et la santé.

Gender differences in survival among low birthweight newborns and infants in sub-Saharan Africa: a systematic review.

In sub-Saharan Africa, low birthweight (LBW) accounts for three-quarters of under-five mortality and morbidity. However, gender differences in survival among LBW newborns and infants have not yet been systematically examined. This review examines gender differences in survival among LBW newborns and infants in the region. Ovid Medline, Embase, CINAHL, Scopus and Global Health databases were searched for qualitative, quantitative and mixed methods studies. Studies that presented information on differences in mortality or in morbidity between LBW male and female newborns or infants were eligible for inclusion. The database search yielded 4124 articles, of which 11 were eligible for inclusion. A narrative synthesis method was used to summarize the findings of the included studies. Seven studies reported more LBW male deaths, three studies reported more LBW female deaths and one study did not disaggregate the deaths by gender. Nine of the 11 studies that examined gender differences in mortality did not find significant evidence of gender differences in mortality among LBW newborns and infants. Likewise, no significant differences were found for gender differences in morbidity among this population. The review findings suggest a need for further research on this topic given the potential significance on child health and developmental goals.

Sex Differences in HIV Testing among Older Adults in Sub-Saharan Africa: A Systematic Review.

BACKGROUND: Despite being sexually active and engaging in risky sexual behaviours similar to young adults, older adults (50 years or older) are less likely to receive HIV testing, and disaggregated data are still scarce about HIV prevention and treatment in this vulnerable population in sub-Saharan Africa (SSA). This systematic review is aimed at examining sex differences in HIV testing and counseling (HTC) among older adults in SSA. METHODS: A systematic search of four databases, namely, MEDLINE (Ovid), EMBASE (Ovid), Web of Science, and Global Health, was conducted from 2000 to January 2020. The primary outcome of interest for this study was gender differences in HTC among older adults in SSA. Observational studies including cross-sectional, retrospective, and prospective cohort studies were included. Eligible studies must have reported sex differences in HIV testing uptake in a standard HTC service among older adults in SSA. RESULTS: From the database search, 4143 articles were identified. Five studies were ultimately included in the final review. Of the 1189 participants, 606 (51.1%) and 580 (48.9%) were female and male, respectively. The review findings suggested that both men and women preferred HTC providers that are the same sex as them with women additionally preferring a provider who is also of a similar age. Men and women differed in their pathways to getting tested for HIV. The review documented mixed results with regard to the associations between sex of older adults and uptake of HTC. Older adult HTC uptake data are limited in scope and coverage in sub-Saharan Africa. CONCLUSION: This review revealed shortage of evidence to evaluate optimum HTC utilization among older adults. Few studies examined sex differences in HIV testing among older adults in the region. There is a need for stakeholders working in the area of HIV prevention and treatment to focus on older adult health utilization evidence organization, disaggregated by age and sex. Hence, high-quality research designs are needed on the topic in order to generate good quality evidence for targeted interventions to improve HTC among older adults in sub-Saharan Africa.

Barriers and facilitators to access mental health services among refugee women in high-income countries: study protocol for a systematic review.

BACKGROUND: According to the United Nation High Commissioner for Refugee Global Trends report in 2019, on average, there are 2.7 refugees per 1000 national population in high-income countries, where girls and women attributed to 48% of the refugee population. Evidence shows high prevalence of mental health disorder among women refugees in comparison to the general population. To our knowledge, no systematic reviews have addressed access to mental health services for refugee women. The aim of this study will be to examine existing barriers and facilitators to accessing mental health services for refugee women in leading high-income countries for refugee resettlement. METHODS: We designed and registered a study protocol for a systematic review. We will conduct a literature search (from inception onwards) in MEDLINE, EMBASE, PsycINFO, and CINAHL. Research articles having a qualitative component (i.e., qualitative, mixed, or multi-method) will be eligible. Study populations of interest will be refugee women at any age that can receive mental health services in leading high-income countries for refugee resettlement (e.g., 14 countries from North America, Europe, and Oceania). Eligibility will be restricted to studies published in English. The primary outcome will be all barriers and facilitators related to accessing mental health services. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or bias) will be appraised using appropriate tools. Reporting will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. A narrative synthesis will be conducted, and summary of findings tables will be produced. As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval. DISCUSSION: The systematic review will present key evidence on barriers and facilitators to access mental health services among refugee women in leading resettlement countries. The findings will be used to inform program developers, policymakers, and other stakeholders to enhance mental health services for refugee women. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020180369.

Systematic review protocol examining sex differences in survival among low birthweight newborns and infants in sub-Saharan Africa.

INTRODUCTION: In sub-Saharan African countries, low birthweight (LBW) accounts for three-quarters of under-five mortality and morbidity. However, there is no systematic evidence of sex differences in LBW survival risk. The aim of this protocol is to outline the methodological process of a systematic review that will gather qualitative and quantitative data on sex differences in survival among LBW newborns and infants in sub-Saharan Africa. METHODS: This protocol adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols reporting guidelines. We will conduct a systematic review to retrieve all qualitative and quantitative studies. Electronic search strategies are being finalised on 24 February 2020 for Ovid Medline and EMBASE, and on 28 February 2020 for CINAHL, Scopus and Global Health in collaboration with a Health Sciences librarian. The primary outcome of interest is indicating sex differences in survival among LBW newborns and infants. Secondary outcomes are sex-disaggregated differences in morbidity among LBW newborns and infants. Screening, data extraction and assessments of risk of bias will be performed independently. Narrative synthesis and a meta-analysis will be conducted with studies that are compatible based on population and outcome. The systematic review is focused on the analysis of secondary data and does not require ethics approval. ETHICS AND DISSEMINATION: As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval. The systematic review will present key evidence of sex-disaggregated differences in mortality and morbidity among LBW newborns and infants in sub-Saharan Africa. Programme managers, policy-makers and researchers can use the findings to evaluate LBW health outcomes in different sexes. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42020163470.

Common trust and personal safety issues: A systematic review on the acceptability of health and social interventions for persons with lived experience of homelessness.

BACKGROUND: Persons experiencing homelessness and vulnerable housing or those with lived experience of homelessness have worse health outcomes than individuals who are stably housed. Structural violence can dramatically affect their acceptance of interventions. We carried out a systematic review to understand the factors that influence the acceptability of social and health interventions among persons with lived experience of homelessness. METHODS: We searched through eight bibliographic databases and selected grey literature sources for articles that were published between 1994 and 2019. We selected primary studies that reported on the experiences of homeless populations interacting with practitioners and service providers working in permanent supportive housing, case management, interventions for substance use, income assistance, and women- and youth-specific interventions. Each study was independently assessed for its methodological quality. We used a framework analysis to identify key findings and used the GRADE-CERQual approach to assess confidence in the key findings. FINDINGS: Our search identified 11,017 citations of which 35 primary studies met our inclusion criteria. Our synthesis highlighted that individuals were marginalized, dehumanized and excluded by their lived homelessness experience. As a result, trust and personal safety were highly valued within human interactions. Lived experience of homelessness influenced attitudes toward health and social service professionals and sometimes led to reluctance to accept interventions. Physical and structural violence intersected with low self-esteem, depression and homeless-related stigma. Positive self-identity facilitated links to long-term and integrated services, peer support, and patient-centred engagement. CONCLUSIONS: Individuals with lived experience of homelessness face considerable marginalization, dehumanization and structural violence. Practitioners and social service providers should consider anti-oppressive approaches and provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care. Accepting and respecting others as they are, without judgment, may help practitioners navigate barriers to inclusiveness, equitability, and effectiveness for primary care that targets this marginalized population.