Street Clinic Research Articles

FAMILY AND COMMUNITY MEDICINE AND WORK WITH NEGLECTED POPULATIONS: CHALLENGES AND OPPORTUNITIES IN CARING FOR THE INVISIBLE

Considered specialists in people, Family and Community Medicine has in its constitution of values ​​and principles comprehensive, humanistic and person-centered care, seeking to develop ideas and people with a view to equity and transformation of patients into protagonists. In this context, the specialty works directly with neglected populations, both at the level of primary care in family health units and in street clinics, prisons, assistance to refugee populations, migrants and a comprehensive approach to the LGBT population. This work within the scope of social medicine, beyond a strictly biological view of illness and human beings, dialogues with the pillars of training of the specialty, based on primary care, medical education, humanism, and mainly on the training of leaders. This work seeks to discuss in a reflective way, through a narrative review of the literature, the challenges, opportunities and fields of action of Family and Community Medicine with neglected populations.

Mobile street clinics and harm reduction: pathways to provide care to homeless people in Brazil

Abstract Homeless people (HP) are defined as a heterogeneous group that lives in extreme poverty, with weakened or severed family ties, lacking access to conventional housing, and using public spaces as residence. In terms of health, mental health conditions are prominent as a primary treatment demand, with care aimed at addressing needs arising from the use of alcohol and other drugs being a priority in serving HP. In this context, mobile street clinics (MSC) provide health services directly in street environments, focusing on individuals who use alcohol and other substances through harm reduction approaches. Harm reduction is defined as a set of practices aimed at minimizing the adverse health effects of alcohol and drug use without necessarily eliminating usage. Moreover, it represents an ethical and political direction in care, confronting the logic of criminalization and compulsory abstinence, enhancing access to health care for alcohol and other drug users through strategies that foster autonomy development. In the current study, we conducted an integrative review assessing the facilitators and barriers for HP access to mental health services. Preliminary results indicated that MSC, the connection between healthcare workers and the HP they serve, and the implementation of local street-based actions were the main facilitators of access for individuals who engage in harmful use of alcohol and other drugs to mental health services. Conversely, stigma, services’ lack of adjustment to the lifestyles of homeless people, and excessive bureaucracy were identified as the principal barriers of access. MSC, through their harm reduction activities, have emerged as a potential care technology to facilitate access to health services for homeless people. This research aims to present harm reduction as an ethical and political direction of care through the actions of mobile street clinics, as a way to facilitate access to health services for the homeless people. Key messages • Homeless people require mental health care tailored to the use of alcohol and other drugs, and harm reduction strategies implemented through mobile street clinics prove to be an effective form of care. • Mobile street clinics and harm reduction are important care technologies that enhance access to health services for the homeless population.

Healthcare actions offered to homeless people: state of the art.

The number of homeless people (HP) has been increasing in recent years. Government actions have been implemented to improve the living conditions for this population, especially those focused on health care. This study has as research question: What are the healthcare strategies of services and programs being offered to the homeless population in Brazil? Its objective is to analyze the health care strategies adopted by services and programs offered to the homeless population in Brazil. To achieve this purpose, a search was conducted in the Virtual Health Library (VHL), Latin American and Caribbean Literature in Health Sciences (Lilacs), and Scientific Electronic Library Online (SciELO) databases, resulting in 21 articles. The analysis revealed the scope and challenges of the health care networks, indicating drug use as the main reason for seeking the services, with the Street Clinics (CnaR, Consultório na Rua) being an important service capable of promoting the creation of links between the HP and other sectors. of health. The importance of networking and the complexity of population health care were recurring topics in the discussions, as they deal with actions aimed at vulnerable and stigmatized people, showing needs and singularities in the way of living in society.

The street as a space for care production: the singular therapeutic project and tuberculosis management in people experiencing homelessness during the Covid-19 pandemic in the city of Rio de Janeiro

From the theoretical perspective of the cartography of the micropolitics of living labor in action, the objective was to analyze the work process of the "street clinic" team based in a primary care unit in the city of Rio de Janeiro, Brazil, in the management of tuberculosis cases in the context of the Covid-19 pandemic. This is an exploratory qualitative research. Between May and December 2021, seven professionals from the street clinic team were interviewed, and participant observation was conducted with field diary records. Three thematic axes emerged from the interviews related to people experiencing homelessness in the context of the Covid -19 pandemic: 1) Challenges, potentialities, and weaknesses of tuberculosis care; 2) Building intersectoral care networks for monitoring individuals with tuberculosis; and 3) The street as a space for care production: the work process of the street clinic in tuberculosis management. It is concluded that caring for people experiencing homelessness with tuberculosis in the context of the Covid -19 pandemic requires not only managing clinical protocols but also building shared work with the intra and intersectoral network. In addition to the task of being in the territory, the outpatient service in the territory must also be a street outpatient service, especially regarding tuberculosis treatment.

The symbolic value of drug use for ill-housed people: drug that kills and nourishes

Drugs have been consumed since ancient times, and their taboo has generated segregation and hindered the proper confrontation of harmful use. This study investigated the real and symbolic values of drug use for ill-housed people beyond pathologization, seeking to understand factors that hinder giving them up, even with intense losses and suffering. It also aimed to understand its implications for health care. This is a phenomenological qualitative research based on participant observation of ill-housed people care provided by the Street Clinic, interviews with ill-housed people and focus group with professionals from the Health Care Network in Rio de Janeiro city, Brazil, between March 2017 and July 2019. Results showed that "drug use" interacted with the research categories as follows: drugs are the main reason for living and staying on the streets; drugs motivate having financial activity; drugs cause abandonment of health treatment; drugs soothe and cause depression, suffering and hunger; drugs make them seek shelter and religion to "escape" using, but without adequate treatment hope leads to relapse and low self-esteem - which one want to get rid of, but few successes undermine hope. As expected, it is the reason for divergences among professionals regarding the type of care and support for ill-housed people. Given the results, how can we face abusive use that relieves hunger, loneliness, suffering and depression? How to take care of a use that generates hunger, depression, affective, health and self-esteem losses? A cyclical story told by people in situations of extreme vulnerability. Unveiling the symbolic plurality of drug use enables reflections and new ways of caring for ill-housed people.

Health promotion of Street Clinic workers: convergent care research.

To develop a health promotion action for Street Clinic workers. Qualitative research which used the Convergent Care Research methodology. The data collection was conducted through participant observation and convergence groups, from May to October 2021, with 39 workers from six teams of the Street Clinic. Data analysis followed the stages of apprehension, synthesis, theorization, and transfer. Some integrativepractices such as, stretching, group dynamics, dance, music, massage and cinema were suggested as interventions to be implemented. Given the need, Reichian stretching was developed as an intervention which favored body awareness, promoting the well-being of workers. The workers presented a conception of health promotion related to access to services and guarantee of rights. Reichian stretching provided a space for care and reflection on caring and respecting limits, favoring the body awareness and promoting relaxation.

Atenção à Saúde para quem (con)vive nas sombras

Abstract This study aimed to analyze the implementation of Street Clinic teams, co-financed by the Ministry of Health, in the national territory from 2018 to 2023, focusing on the perspective of equity and the scope of healthcare provided to Brazilian people living on the streets. This quantitative, exploratory study employed spatial distribution techniques based on secondary data from implemented Street Clinic teams. The data analysis on the implementation of eCR showed significant developments toward democratizing access to health services. An increase of 21,73% in the number of teams co-financed by the Ministry of Health was observed from 2018 to 2023.

Rua na rede: a device for care in the context of the Street Clinic

O presente relato de experiência objetiva apresentar o dispositivo Rua na Rede, criado pela equipe de Consultório na Rua (eCR) de Florianópolis, SC , como estratégia de construção da integralidade e longitudinalidade do cuidado do usuário da eCR, especialmente no momento de internação hospitalar e pós-alta. Para isso, analisou-se a experiência vivida pelos autores, operando o dispositivo por meio do diário de campo e em diálogo com a literatura científica sobre o tema. O relato aponta que o Rua na Rede é orientado pelo paradigma da redução de danos e enfrenta um importante desafio para o Sistema Único de Saúde: a articulação entre Atenção Básica e atenção hospitalar, ponto nodal para a integralidade e a longitudinalidade do cuidado da pessoa em situação de rua.

Protection of gender health and fight against gender violence during the COVID-19 pandemic: the experience of our street clinic in a disadvantaged suburb of Rome Metropolitan City

ObjectIn this study, we evaluated health, social inequalities and risk to gender violence of women living in a disadvantaged degraded suburb of Rome Metropolitan City, during COVID-19 pandemic.Methods The study included 779 women referring to primary care services of Medicina Solidale Institute for gynecological/breast examinations (209), medical and support aid for the children (383) and COVID-19 test execution (187).Results The data show that most women (68%) were unemployed or had an irregular job. The request of support varied depending on the ethnicity: while healthcare support was requested mostly by African female community, the COVID-19 test, mandatory for public transportation and work, was a need of the east-european community. Both these communities referred to Medical Solidale primary care service for the healthcare and food/clothing support for their children.It is interesting to note that the requests from the Italian women community was elevated in terms of personal healthcare, support for the children and COVID-19 test execution.The access to the national health system (NHS) resulted a complex administrative procedure despite the original social-ethnic communities. The vast majority of women lacked awareness of their crucial role for supporting the family entity, while inadequacy was commonly reported.Conclusions This study confirms a critical condition for women living in disadvantaged neighborhoods, whose vulnerability is further worsened by the limited access to primary care assistance with serious consequences for health and quality of life. Prevention and treatment, especially for the most vulnerable subjects, should be a priority for the public health system.

Nursing care for the Warao people: an experience report based on transcultural theory.

To report on the experience of nurses from the Street Clinic in caring for the Indigenous Venezuelan population of the Warao ethnic group in Maceió/AL based on Madeleine Leininger's Transcultural Theory. A descriptive study, of the experience report type, based on the care of the Warao Indigenous population in the light of Madeleine Leininger's Transcultural Theory, carried out during the year 2022. Light technologies were used to form bonds and understand the cultural universe of the Warao people. The concepts of preservation, accommodation and cultural restructuring of care from Leininger's transcultural theory helped to elucidate the practice. Comprehensive care was offered in accordance with the programs recommended by the Ministry of Health, with transcultural care, including respect for refusal of care. The language barrier and health beliefs represented challenges in the context of singular care. The experience of nurses from the Street Clinic in caring for the Indigenous population favored significant social interaction and expanded the possibilities for achieving comprehensive health care. The application of Transcultural Theory proved to be an effective and congruent device for health care.

Street Clinics and the Healthcare of Vulnerable Homeless Communities in Brazil: A Qualitative Study.

(1) Background: homeless people are characterized by serious social vulnerability and difficulty in accessing health services worldwide. In Brazil, this population is supported by the Street Clinic teams who are challenged to establish intersectoral networks to expand access and promote unique and humanized care from the perspective of harm reduction. The study aimed to analyze the practices of professionals working at the Street Clinic in a city in the interior of São Paulo, Brazil, to tackle the vulnerabilities of the homeless population and expand access to the health care network. (2) Methods: a qualitative study was conducted with a social approach in which we interviewed eight workers from the Street Clinic. Data were analyzed using the thematic content analysis tool. (3) Results: three nuclei of meaning were built: stigma and prejudice as the main barriers to accessing services, harm reduction as a humanized care practice and valuing autonomy, and Street Clinic as a gateway to the health system and main interlocutor with other services. (4) Conclusions: the articulation with network services is marked by contradictory relationships, of conflict and trust, signaling the need for greater investment in educational qualifications and working conditions for professionals at all levels of care to expand access to health care.

O acadêmico de Medicina frente à população em situação de rua: Trabalho Colaborativo como ferramenta

ABSTRACT This is the experience report of a medical academic from Federal University Fluminense, intern of the Education Program for Work for Health/Interprofessionality, working as part of the Street Clinic of Niterói/RJ, Brazil between April 2019 and March 2020. Aiming at the recognition of challenges, limits and potential of Interprofessional Education and Collaborative Work, the narrative constructed through 44 reports sent to the Program’s preceptors and tutors was used as a methodological tool, being shared not only what the practical field as a physical space brought to light, but also what came to life through intersubjectivity in the encounter with different characters. The opportunity to follow the strategy allowed the student to know more about this essential service to ensure equity in the health of the homeless population, leading to the improvement/development of skills/tools that will compose a work centered on the formation of positive bonds with service users, in the provision of comprehensive care and collabora- tive health practices. It was concluded that, despite the numerous barriers, Interprofessional Education and Collaborative Work are important instruments in academic training, standing out in the production of high quality health services, especially in offering comprehensive care to people in vulnerability.

Rising rates of recent preexposure prophylaxis exposure among men having sex with men newly diagnosed with HIV: antiviral resistance patterns and treatment outcomes.

Introduction:Preexposure prophylaxis (PrEP) is contributing to achieve a reduction in HIV diagnoses in men having sex with men (MSM). Albeit infrequent, HIV infections in the context of recent PrEP exposure represent a clinical challenge.Methods:Data on recent PrEP use and possible reasons leading to HIV infection were analysed in individuals newly diagnosed with HIV at 56 Dean Street clinic in 2016–2020. Demographics, immune-virological parameters, genotypic resistance test results and treatment management in this group were compared with those not reporting recent PrEP exposure using Mann–Whitney U test and Fisher's exact test.Results:Fifty-two of 1030 (5%) individuals reported recent PrEP exposure at HIV diagnosis; 98% were MSM, median age 34 years (interquartile range [IQR] 28–42), 65% of white ethnicity, 65% non-UK-born. 35% reported PrEP intake the day before testing HIV positive, 46% reported sub-optimal PrEP adherence since their last negative HIV test result. Thirty-three of 52 (63%) were self-sourcing PrEP and 9/52 (17%) reported issues with its supply. Recent PrEP use was associated to lower HIV viral load and higher CD4+ cell count at baseline than in counterparts non-recently exposed to PrEP (P < 0.01). M184V mutation was harboured more commonly in the recent PrEP use group (30% vs. 1%, P < 0.01). The proportion of individuals recently exposed to PrEP among those diagnosed with HIV rose sharply, reaching 21% in the first semester of 2020. Viral suppression was achieved by all patients intensified from PrEP to antiretroviral treatment (ART) who remained in care at week 24.Discussion:Rapid PrEP intensification to ART allowed to achieve high rates of HIV viral suppression despite significant rates of M184V mutation harboured in those newly diagnosed with HIV and reporting recent PrEP exposure.

A Study on the Efficacy of a Naloxone Training Program.

Introduction: The use of naloxone to reverse a potentially fatal opioid overdose is a harm reduction strategy that reduces mortality and increases the potential for referral to substance use treatment for affected individuals. In the setting of outreach performed by a street medicine team, we aimed to determine the effectiveness of an educational intervention involving distribution of naloxone accompanied by a brief instructive session about opioids, opioid overdose, and medication administration.Methods: Our street medicine outreach team distributed 200 naloxone kits to clinicians and volunteers involved in caring for patients on ‘street rounds,’ as well as in shelters, soup kitchens, and street medicine clinic settings. Those receiving a naloxone kit engaged in a peer-reviewed presentation on how to safely use the medication to reverse a potentially fatal opioid overdose. The study team developed and administered a pre- and post-survey of 10 multiple choice questions on material covered in the educational training. The pre- and post-survey scores were compared to assess the effectiveness of implementing this training. Results were stratified by participant gender and age group.Results: Out of the 200 participants, six were excluded from the analysis due to completely missing data from one or both surveys. The mean age of participants was 40.2±12.5 years; 120 (65.6%) were female, 62 (33.9%) were male, and 1 (0.6%) identified as nonbinary. Every survey question had an increase in correct responses from pre-survey to post-survey (identified by an increase in the percentage of correct responses). The mean survey total score increased from 5.5±1.6 to 7.5±1.3. Within the sample of 194, the mean difference in scores from pre-survey to post-survey was 2.02 points (95% CI [1.77, 2.26]), p<0.0001. Males had a mean increase in the total score from 5.6±1.8 to 7.4±1.1. Females had a mean increase in the total score from 5.5±1.5 to 7.5±1.3. The difference in total scores in males was 1.89 points (95% CI [1.42, 2.35]), p<0.0001, and in females was 2.02 points (95% CI [1.71, 2.32]), p<0.0001. Post-test scores improved in all age groups.Conclusion: The educational training on opioids, opioid overdose, and the use of naloxone was an effective adjunct to naloxone kit distribution to volunteers and clinicians caring for people experiencing homelessness.

Street Clinic Nursing for coping with vulnerabilities

Objective: to unveil the perceptions of the Street Clinic nursing staff about coping with vulnerabilities. Methods: qualitative study, carried out by means of participant observation of the team’s activities, recording in a field diary and semi-structured interviews with the nursing team, totaling 17 participants. Results: situations experienced by people living on the streets that deepen health inequities by violating rights were revealed. Among the nursing work tools, the potential of collaborative work, listening, and welcoming technologies stand out as mediators of a more humanized care. There is a need for specific strategies to guide nursing care on the streets. Conclusion: nursing has great potential for addressing the vulnerabilities of the homeless population using soft and soft-hard technologies.

A Nurse Case Management HIV Prevention Intervention (Come As You Are) for Youth Experiencing Homelessness: Protocol for a Randomized Wait-list Controlled Trial.

BackgroundYouth experiencing homelessness are more likely than housed youth to experience premature death, suicide, drug overdose, pregnancy, substance use, and mental illness. Yet while youth experiencing homelessness are 6 to 12 times more likely to become infected with HIV than housed youth, with HIV prevalence as high as 16%, many do not access the prevention services they need. Despite adversities, youth experiencing homelessness are interested in health promotion programs, can be recruited and retained in interventions and research studies, and demonstrate improved outcomes when programs are tailored and relevant to them.ObjectiveThe study aims to compare the efficacy of a nurse case management HIV prevention and care intervention, titled Come As You Are, with that of usual care among youth experiencing homelessness aged 16 to 25 years.MethodsThe study is designed as a 2-armed randomized wait-list controlled trial. Participants (n=450) will be recruited and followed up for 9 months after the intervention for a total study period of 12 months. Come As You Are combines nurse case management with a smartphone-based daily ecological momentary assessment to develop participant-driven HIV prevention behavioral goals that can be monitored in real-time. Youth in the city of Houston, Texas will be recruited from drop-in centers, shelters, street outreach programs, youth-serving organizations, and clinics.ResultsInstitutional review board approval (Committee for the Protection of Human Subjects, University of Texas Health Science Center at Houston) was obtained in November 2018. The first participant was enrolled in November 2019. Data collection is ongoing. To date, 123 participants have consented to participate in the study, 89 have been enrolled, and 15 have completed their final follow-up.ConclusionsThere is a paucity of HIV prevention research regarding youth experiencing homelessness. Novel and scalable interventions that address the full continuum of behavioral and biomedical HIV prevention are needed. This study will determine whether a personalized and mobile HIV prevention approach can reduce HIV risk among a hard-to-reach, transient population of youth at high risk.International Registered Report Identifier (IRRID)DERR1-10.2196/26716

Street Legal Clinic: Development of Legal Learning Methods Based On Clinical Education in Law Education Institutions

Clinical Legal Education is an interesting subject to be developed at the Faculty of Legal, Universitas Udayana. Unlike other subjects, clinical legal education participants get an education in the classroom and go directly to the field (community) to increase students' knowledge and practical abilities in solving problems in society. The purpose of writing this journal is to find out how the form of clinical education-based learning, especially in the form of Street Legal Clinic at the Faculty of Law, Universitas Udayana, and to find a model for developing learning methods based on clinical legal education in the form of street legal clinic that can answer legal problems that develop in society. More optimally, the author uses normative legal research methods with the statutory approach and conceptual approach. The results showed that the form of the clinical legal education which is implemented at the Faculty of Law of Universitas Udayana consisted of three stages of the process, namely the planning component, the experiential component, and the reflection component with the learning models that had been used so far, namely In House Clinic, Out House Clinic, Combination and Street Legal Clinic. The development model suggested in implementing the Street Legal Clinic is to be more optimal in answering problems in the community, namely by accommodating several stages in its implementation, namely the pre-implementation, implementation, and evaluation stages into a single unit that is packaged creatively and comprehensively in collaboration with Clinical Partners.

Ways of governing street life during the pandemic: discourses, technologies, and practices

Drawing on multiple sources, this article presents an analysis of a national survey implemented by Street Clinic teams in Brazil on the homeless population and the COVID-19 pandemic. Through the lens of certain ethical-political principles and methodological decisions, we focus our analysis on discourses about who lives and works on the streets during the pandemic, connecting discourse with experience. From the perspective of governmentality and biopolitics, we seek to shed light on power relations that reveal modes of government embodied at the street level - mainly related to isolation measures and social distancing - to create tensions surrounding the emergence of the notion of the homeless population in the midst of the pandemic. We conclude with a discussion of the precariousness that circumscribes life on the streets as a shared condition, and search for ways to comprehend forms of resistance and the right to exist.

Sistematização da assistência de enfermagem aplicada nas equipes de consultórios de rua

The aim was to describe the activities performed by nurses in the Street Clinic. Due to the constant disruption of the bonds established between users and professionals of the Street Clinic teams, there is great difficulty in carrying out and developing the work, especially for nurses, who would benefit from the adoption of the Systematization of Nursing Care, in order to organize and document their practices and service delivery. However, there are several difficulties in implementing this work tool in health services, in addition to the lack of preparation of many nurses about its applicability, making it even more difficult to use it in Street Clinics. Thus, the many activities performed by nurses end up linking them to technical practices, distancing them from their functions and contributing even more to the devaluation of the Systematization of Nursing Care. Despite the SUS guaranteeing Universality, Integrality and Equity in its principles, homeless individuals still face difficulties in accessing public health networks. Due to the difficulties of immediate responses to these individuals' health problems, many abandon the treatment offered by the professionals at the Street Clinic, which breaks down the bonds between professionals and patients, which are so important for nursing care.

Ações de promoção da saúde com a equipe do consultório na rua de Florianópolis

Objetiva-se promover ações de cuidado e saúde às pessoas em situação de rua através da parceria com a equipe do Consultório na Rua. As atividades são realizadas in loco, compartilhadas e integradas às Unidades Básicas de Saúde e com as equipes dos Centros de Atenção Psicossocial, serviços de Urgência e Emergência e outros serviços, de acordo com as necessidades do usuário. O processo de coleta de dados ocorreu em oito etapas, desde o princípio do projeto até os dias atuais. Este projeto de extensão tem sido desenvolvido entre março de 2018 até o presente momento. Consideramos fundamental ao aluno esta vivência, cujo interesse visa aprimorar o trabalho e a sua formação na graduação em enfermagem, tendo como perspectiva a qualificação da atenção e a inserção das necessidades dos sujeitos como fonte de produção de conhecimento e pesquisa nas instituições de ensino superior em consonância com o SUS.