Delivering positive youth sexual health services: a realist evaluation

International and English scholars, youth advocates, policy makers and young people call for sexual health services which take a positive, holistic, comprehensive approach to support young people achieve sexual wellbeing. The enduring model of youth sexual health services is, however, orientated towards reducing the negative impacts of sexual activity. There is limited evidence and theory to facilitate the widespread transformation of services to support sexual wellbeing. Specifically, current policy and academic outputs lack programme theory which describes how such a transformation might be realised. The current study aims to contribute to this gap by addressing the question - what works to deliver positive youth sexual health services, when, under what circumstances and why? A realist evaluation was used to address the research question. Programme theory, providing specific ideas for local buy-in to positive services, was developed iteratively over four research cycles. This comprised theory building and refinement using data from two literature reviews, a comparative case study of three organisations where positive services have been attempted and thorough engagement with realist and existing formal theories of behaviour, organisation and social change. Analysis demonstrated that local buy-in to positive services could be led by the following factors: clarity regarding what positive services are, and what one's individual role is in implementing it; conviction that the approach is the best way to bring support young people and cultural and structural coherence with local policy and practice. The results illuminated occasions when structural, cultural and agential entities were aligned to bring about positive changes. The thesis illustrates a method for conducting a realist evaluation of a large scale, messy intervention which systematically utilises multiple existing formal theories and engages closely with mechanisms operating between cultural, structural and agential layers of society. This thesis contributes new programme theory for local buy-in to positive services, a critical step towards delivering positive youth sexual health services. It also provides detailed recommendations for policy makers, commissioners and practitioners. Wider lessons may also be drawn by those engaged with culture and structural change within public sector organisations, particularly where the new practice is emerging and may be culturally sensitive.