IntroductionPoor health of sex workers continues to be a source of international concern. Sex work is frequently linked with problematic drug use and drug-dependent sex workers typically work on the street, experiencing the greatest risks to health compared with the general population. Street sex workers (SSWs) are much more likely to have experienced incidences of physical and sexual assault, increasing their risk of developing post-traumatic stress disorder (PTSD). We have developed a novel complex intervention designed to reduce illicit drug use in drug-dependent female SSWs which involves: female SSW drug treatment groups (provided by a specialist charity) in a female SSW setting (female sex worker charity premises) provided by female-only staff, PTSD care with eye movement desensitisation and reprocessing (EMDR) therapy provided by female staff from National Health Service (NHS) mental health services.Methods and analysisA mixed methods study investigating the feasibility and acceptability of this intervention to inform the design of a future randomised controlled trial. The study aims to recruit up to 30 participants from November 2017 to March 2018 at a single site, with the intervention being delivered until December 2018. It will gather quantitative data using questionnaires and group attendance. Drug treatment group observations and in-depth interviews undertaken with up to 20 service users and 15 service providers to examine experiences and acceptability of the intervention. Study feasibility will be assessed by evaluating the recruitment and retention of participants to the intervention; the feasibility of NHS and third sector organisations working closely to coordinate care for a SSW population; the potential for specialist NHS mental health services to screen and provide EMDR therapy for drug-dependent SSWs and potential costs of implementing the intervention.Ethics and disseminationThis study was approved by South West–Frenchay Research Ethics Committee (REC reference: 17/SW/0033; IRAS ID: 220631) and the Health Research Authority (HRA). Findings will be disseminated through research conferences and peer-reviewed journals.
The importance of behavioural science in advancing health in low-and middle-income countries (LMICs) was highlighted in a journal funded by the US Agency for International Development (Global Health Science and Practice). [1] In particular, the authors outlined six domains of behaviour change that were building blocks of global health. One of these domains was 'provider behaviour' and included understanding healthcare workers' capabilities, opportunities and motivations to provide high-quality care. We propose that understanding provider behaviour is most urgent in the areas of healthcare that have been shown to impact greatly on patient mortality and morbidity, e.g. management of the critically ill patient. Management of the deteriorating and critically ill patient is a key activity in acute healthcare facilities. Firth and Ttendo [2] emphasised the need for recognition, assessment and management of the critically ill in Uganda and other low-income countries. This need is great because many patients present to hospital in a critical state owing to certain factors, including underlying health issues (e.g. malnutrition); present to hospital at a late stage owing to the time taken to travel to hospital; and seek help at a late stage of an illness because of the need to pay fees. A systematic review of critical care in LMICs found that many health professional students had limited training in the assessment and management of acutely ill patients. [3] It is clear, therefore, that there is a need to educate and train staff in the management of acute illness in LMICs. There are many courses that teach the recognition and management of acutely ill people. Examples are the 1-day Acute Illness Management (AIM) Background. Understanding the drivers of 'provider behaviour' has been highlighted as one of the six domains of behaviour change in strengthening healthcare systems. Objectives. To assess changes in healthcare provider behaviour, i.e. use of the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach in acute illness management, after participating in a 1-day course on the assessment and management of acutely ill patients. We aimed to assess whether changes in psychological determinants of the ABCDE approach were associated with changes in the use of the approach. Methods. We used a pre-post design to study self-reported change in behaviour after a 1-day training course from pre-course to follow-up 1 month later. We also measured psychological determinants of behaviour immediately before and after and at 1-month follow-up. We explored if changes in psychological determinants were associated with change in practice 1 month later. Results. We found the following: firstly, use of the ABCDE approach increased at 1 month post-course from a median use of 50-90%. Secondly, the increase in the ABCDE approach was associated with a positive change in only one of the determinants of practice from pre-to post-course: perception of environmental determinants (r=0.323; p<0.05). Finally, there were no other significa...
Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.
Little is known about the social and medical characteristics of people who regularly sleep rough, or whether medical care can be targeted at these people. In 1987 a mobile surgery was used to provide primary health care at two sites in central London where many single homeless people sleep outdoors. One hundred and forty six patients were seen with illnesses ranging from scabies to osteomyelitis and tuberculosis. Sociodemographic data showed the patients to be generally an isolated group with deprived and unstable backgrounds, often compounded by alcohol abuse. Over a third of the patients from one site attended a drop in surgery for homeless people in Soho within a month after seeing a doctor in the mobile surgery. This suggests that the project can be a first step in integrating this isolated group with health care facilities.
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