Access to healthcare for street sex workers in the UK:perspectives and best practice guidance from a national cross-sectional survey of frontline workers

BACKGROUND: Street sex workers (SSWs) are a highly marginalised and stigmatised group who carry an extremely high burden of unmet health need. They experience multiple and interdependent health and social problems and extreme health inequality. Despite high levels of chronic physical and mental ill-health, there is little evidence of effective healthcare provision for this group. They are often considered ‘hard to reach’, but many individuals and organisations have extensive experience of working with this group. METHODS: We conducted a cross-sectional survey of professionals who work with SSWs in the UK on their perspectives on their access to primary care, mental health, sexual health and drug and alcohol services, how well these services met the needs of SSWs and suggestions of best practice. RESULTS: 50 professionals mostly from England, responded. Mainstream general practice and mental health services were found to be largely inaccessible to SSWs. Sexual health, drug and alcohol services and homeless health services better met their needs; this was mostly attributed to flexible services and collaborations with organisations who work closely with SSWs. The main challenges in providing healthcare to SSWs were services being inflexible, under-resourced services and services not being trauma-informed. Best practice in providing healthcare to SSWs includes- seamless partnership working between agencies with case worker support; peer-involvement in service development and engagement, a range of health provision including outreach, presence in community spaces and fast-track access into mainstream services; trauma-informed, gender-sensitive health services in a welcoming environment with flexible, responsive appointment and drop-in systems and consistent clinicians with specialist knowledge of substance misuse, mental health, domestic violence and homelessness. CONCLUSIONS: Access to healthcare for SSWs in the UK is highly variable but largely inadequate with regards to primary care and mental health provision. The examples of positive healthcare provision and partnership working presented here demonstrate the feasibility of accessible healthcare that meets the needs of SSWs. These need to be systematically implemented and evaluated to understand their impact and implications. As we build back from COVID-19 there is an urgent need to make accessible healthcare provision for marginalised groups the norm, not the exception. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-022-07581-7

A discursive approach to narrative accounts of hearing voices and recovery

Substantive objective: To research the range of discursive constructions ‘recovered’ voice hearers employ to describe hearing voices and the implications for positioning and subjectivity (what can be thought and felt) using each construction. Methodological objective and method: To explore a ‘sympathetic’ application of Foucauldian discourse analysis, adapting Willig’s (2008 Willig, C. 2008. Introducing Qualitative Research in Psychology, Maidenhead: Open University Press. ) method, analysing two published accounts. Results and conclusions: Heterogeneous discursive constructions for talking about hearing voices were identified, including: ‘many-’selves’’, ‘taking-the-lead-in-your-own-recovery’, ‘voices-as-an-’imagined-world’’ and ‘voices-as-a-coping-strategy-for-dealing-with-trauma’. The discourse of the biomedical model was not prominent, suggesting alternate discursive constructions may create subjects with a greater capacity for ‘living with voices’ and create a subjectivity from which vantage point the experience holds meaning and value and can be integrated into life experiences. This research may have useful clinical applications for mental health services aiming to collaboratively explore service users’ ways of understanding hearing voices

Behavioral Coping Phenotypes and Associated Psychosocial Outcomes of Pregnant and Postpartum Women During the COVID-19 Pandemic

The impact of COVID-19-related stress on perinatal women is of heightened public health concern given the established intergenerational impact of maternal stress-exposure on infants and fetuses. There is urgent need to characterize the coping styles associated with adverse psychosocial outcomes in perinatal women during the COVID-19 pandemic to help mitigate the potential for lasting sequelae on both mothers and infants. This study uses a data-driven approach to identify the patterns of behavioral coping strategies that associate with maternal psychosocial distress during the COVID-19 pandemic in a large multicenter sample of pregnant women (N = 2876) and postpartum women (N = 1536). Data was collected from 9 states across the United States from March to October 2020. Women reported behaviors they were engaging in to manage pandemic-related stress, symptoms of depression, anxiety and global psychological distress, as well as changes in energy levels, sleep quality and stress levels. Using latent profile analysis, we identified four behavioral phenotypes of coping strategies. Critically, phenotypes with high levels of passive coping strategies (increased screen time, social media, and intake of comfort foods) were associated with elevated symptoms of depression, anxiety, and global psychological distress, as well as worsening stress and energy levels, relative to other coping phenotypes. In contrast, phenotypes with high levels of active coping strategies (social support, and self-care) were associated with greater resiliency relative to other phenotypes. The identification of these widespread coping phenotypes reveals novel behavioral patterns associated with risk and resiliency to pandemic-related stress in perinatal women. These findings may contribute to early identification of women at risk for poor long-term outcomes and indicate malleable targets for interventions aimed at mitigating lasting sequelae on women and children during the COVID-19 pandemic

Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial

Background Phenytoin is the recommended second-line intravenous anticonvulsant for treatment of paediatric convulsive status epilepticus in the UK; however, some evidence suggests that levetiracetam could be an effective and safer alternative. This trial compared the efficacy and safety of phenytoin and levetiracetam for second-line management of paediatric convulsive status epilepticus.Methods This open-label, randomised clinical trial was undertaken at 30 UK emergency departments at secondary and tertiary care centres. Participants aged 6 months to under 18 years, with convulsive status epilepticus requiring second-line treatment, were randomly assigned (1:1) using a computer-generated randomisation schedule to receive levetiracetam (40 mg/kg over 5 min) or phenytoin (20 mg/kg over at least 20 min), stratified by centre. The primary outcome was time from randomisation to cessation of convulsive status epilepticus, analysed in the modified intention-to-treat population (excluding those who did not require second-line treatment after randomisation and those who did not provide consent). This trial is registered with ISRCTN, number ISRCTN22567894.Findings Between July 17, 2015, and April 7, 2018, 1432 patients were assessed for eligibility. After exclusion of ineligible patients, 404 patients were randomly assigned. After exclusion of those who did not require second-line treatment and those who did not consent, 286 randomised participants were treated and had available data: 152 allocated to levetiracetam, and 134 to phenytoin. Convulsive status epilepticus was terminated in 106 (70%) children in the levetiracetam group and in 86 (64%) in the phenytoin group. Median time from randomisation to cessation of convulsive status epilepticus was 35 min (IQR 20 to not assessable) in the levetiracetam group and 45 min (24 to not assessable) in the phenytoin group (hazard ratio 1·20, 95% CI 0·91–1·60; p=0·20). One participant who received levetiracetam followed by phenytoin died as a result of catastrophic cerebral oedema unrelated to either treatment. One participant who received phenytoin had serious adverse reactions related to study treatment (hypotension considered to be immediately life-threatening [a serious adverse reaction] and increased focal seizures and decreased consciousness considered to be medically significant [a suspected unexpected serious adverse reaction]). Interpretation Although levetiracetam was not significantly superior to phenytoin, the results, together with previously reported safety profiles and comparative ease of administration of levetiracetam, suggest it could be an appropriate alternative to phenytoin as the first-choice, second-line anticonvulsant in the treatment of paediatric convulsive status epilepticus

Clinical outcomes and response to treatment of patients receiving topical treatments for pyoderma gangrenosum: a prospective cohort study

Background: pyoderma gangrenosum (PG) is an uncommon dermatosis with a limited evidence base for treatment. Objective: to estimate the effectiveness of topical therapies in the treatment of PG. Methods: prospective cohort study of UK secondary care patients with a clinical diagnosis of PG suitable for topical treatment (recruited July 2009 to June 2012). Participants received topical therapy following normal clinical practice (mainly Class I-III topical corticosteroids, tacrolimus 0.03% or 0.1%). Primary outcome: speed of healing at 6 weeks. Secondary outcomes: proportion healed by 6 months; time to healing; global assessment; inflammation; pain; quality-of-life; treatment failure and recurrence. Results: Sixty-six patients (22 to 85 years) were enrolled. Clobetasol propionate 0.05% was the most commonly prescribed therapy. Overall, 28/66 (43.8%) of ulcers healed by 6 months. Median time-to-healing was 145 days (95% CI: 96 days, ∞). Initial ulcer size was a significant predictor of time-to-healing (hazard ratio 0.94 (0.88;80 1.00); p = 0.043). Four patients (15%) had a recurrence. Limitations: No randomised comparator Conclusion: Topical therapy is potentially an effective first-line treatment for PG that avoids possible side effects associated with systemic therapy. It remains unclear whether more severe disease will respond adequately to topical therapy alone