Perspectives on Sexual and Reproductive Health Screening Conversations Between Healthcare Providers and Women Experiencing Homelessness

Purpose: Women experiencing homelessness are at a heightened risk of sexually transmitted infections (STI) and unintended pregnancy. While the healthcare setting may be an ideal venue to assess the reproductive health needs of women experiencing homelessness, it is unknown how consistently this may be occurring for a population with competing health and social demands. This study aimed to assess healthcare providers' and women experiencing homelessness' perspectives of reproductive health discussions during healthcare visits. Methods: Semi-structured interviews were conducted with healthcare providers (n=6) and women experiencing homelessness (n=19) between December 2019 and November 2020 in Fort Worth, TX. Interviews were conducted as part of a larger systemwide study examining preferences for, facilitators of, and barriers to contraception for women experiencing homelessness. Participants were recruited through convenience and snowball sampling from local community and healthcare organizations serving the target population. Interviews assessed perceptions regarding need and implementation of women's health exams, birth control counseling, STI testing, and sexual health screening. Coding achieved consensus and thematic analysis was conducted. This study was reviewed and approved by the North Texas Regional Institutional Review Board. Results: Several themes emerged regarding the timing of healthcare appointments, sexual and reproductive health conversations, and perceptions of these conversations among women experiencing homelessness and healthcare providers. Only about half of the healthcare appointments occurred in the last year, within the recommended timeframe for annual health exams. In recalling STI and birth control conversations, women recounted inconsistency in the occurrence of these conversations and screenings. When these conversations occurred, women reflected on both positive (e.g., friendly, comfortable) and negative (e.g., awkward) experiences with their healthcare providers. Finally, healthcare providers described the importance of having sexual and reproductive health conversations. However, healthcare providers acknowledged a bias as they perceive a lack of initiation of these conversations by women experiencing homelessness as disinterest in contraception and sexual healthcare. When aiming to prioritize these conversations, healthcare providers note conflicting priorities, including finding stable shelter, access to food, substance abuse, and healthy relationships with partners among women experiencing homelessness, as additional barriers that hinder the initiation of the conversations. Conclusion: This study identified potential inconsistencies in the frequency and quality of reproductive and sexual health conversations, STI screening, and birth control discussions between healthcare providers and women experiencing homelessness. Assumptions by healthcare providers that interested women will initiate sexual and reproductive health conversations puts the onus on women experiencing homelessness to be knowledgeable about, self-screen for sexually risky behaviors, and advocate for their sexual health needs. These findings, coupled with potentially extended periods of time between healthcare appointments, may highlight an opportunity for enhanced reproductive healthcare for this population. Future interventions can focus on improved sexual and reproductive health screening tools, patient intake forms, and clinical practice guidelines for healthcare providers, which can help achieve sexual and reproductive health equity for vulnerable populations.