Pilot study investigating an oncofertility program in adults with breast or sarcoma cancers.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e23096-e23096
Author(s):  
Manali A. Bhave ◽  
Fang Fang ◽  
Kelley M. Kidwell ◽  
Gloria Lola Smith ◽  
Rashmi Chugh ◽  
...  
Keyword(s):  
Pilot Study ◽  
Best Practice ◽  
Cancer Survival ◽  
Primary Objective ◽  
Patient Navigator ◽  
Provider Education ◽  
Childbearing Age ◽  
Medical Provider ◽  
Post Intervention ◽  
Patient Reported

e23096 Background: Cancer survival is at an all-time high; however, patients often face long-term consequences including infertility. Loss of fertility can be devastating and lead to long-lasting emotional distress. Despite consensus guidelines encouraging providers to discuss infertility risk and refer for fertility preservation (FP) consultations, fertility counseling and FP occur in only 10-29% of patients of childbearing age. A few identified barriers include lack of provider knowledge on FP, constraints on time and lack of available resources. Methods: This is a prospective pilot study evaluating the efficacy of an oncofertility program in increasing discussions on infertility risk and FP between providers and patients. The oncofertility program includes medical provider education, an electronic medical record (EMR)-based best practice alert with smart order set, patient education pamphlets and a patient navigator through Reproductive Endocrinology and Infertility (REI). Our primary objective was to increase documentation on fertility in the EMR, while our secondary objective was to increase referrals to REI for females and orders for semen cryopreservation for males. Provider and patient-reported outcomes were also obtained. Results: 19 patients with a new diagnosis of breast or sarcoma (7 pre-intervention and 12 post-intervention) were enrolled and 17 providers participated in the study at the University of Michigan. There was no change in documentation on fertility in the EMR and no increase in fertility referrals placed. However, patients reported a statistically significant change in amount of information provided on infertility risk and FP from "too little" to "the right amount." Providers also reported increased confidence in initiating a conversation about FP and a trend towards increased comfort documenting their conversations on FP in the EMR. Conclusions: With an increase in cancers diagnosed in young adults, there is a need to improve counseling on the risk of infertility with cancer treatment and FP options. Through an easily implemented oncofertility program, we were able to improve medical provider confidence in initiating this important conversation, provide patients with education on infertility risk and FP and streamline the process for FP referrals utilizing the EMR.

scholarly journals Protocol for a feasibility study of smoking cessation in the surgical pathway before major lung surgery: Project MURRAY

BMJ Open ◽  
2020 ◽  
Vol 10 (11) ◽  
pp. e036568
Author(s):  
Sebastian T Lugg ◽  
Amy Kerr ◽  
Salma Kadiri ◽  
Alina-Maria Budacan ◽  
Amanda Farley ◽  
...  
Keyword(s):  
Smoking Cessation ◽  
Pilot Study ◽  
Thoracic Surgery ◽  
Elective Surgery ◽  
Primary Objective ◽  
Pulmonary Complications ◽  
University Hospitals ◽  
Patient Reported ◽  
Ethical Approval ◽  
Surgical Pathway

IntroductionSmoking prior to major thoracic surgery is the biggest risk factor for development of postoperative pulmonary complications, with one in five patients continuing to smoke before surgery. Current guidance is that all patients should stop smoking before elective surgery yet very few are offered specialist smoking cessation support. Patients would prefer support within the thoracic surgical pathway. No study has addressed the effectiveness of such an intervention in this setting on cessation. The overall aim is to determine in patients who undergo major elective thoracic surgery whether an intervention integrated (INT) into the surgical pathway improves smoking cessation rates compared with usual care (UC) of standard community/hospital based NHS smoking support. This pilot study will evaluate feasibility of a substantive trial.Methods and analysisProject MURRAY is a trial comparing the effectiveness of INT and UC on smoking cessation. INT is pharmacotherapy and a hybrid of behavioural support delivered by the trained healthcare practitioners (HCPs) in the thoracic surgical pathway and a complimentary web-based application. This pilot study will evaluate the feasibility of a substantive trial and study processes in five adult thoracic centres including the University Hospitals Birmingham NHS Foundation Trust. The primary objective is to establish the proportion of those eligible who agree to participate. Secondary objectives include evaluation of study processes. Analyses of feasibility and patient-reported outcomes will take the form of simple descriptive statistics and where appropriate, point estimates of effects sizes and associated 95% CIs.Ethics and disseminationThe study has obtained ethical approval from NHS Research Ethics Committee (REC number 19/WM/0097). Dissemination plan includes informing patients and HCPs; engaging multidisciplinary professionals to support a proposal of a definitive trial and submission for a full application dependent on the success of the study.Trial registration numberNCT04190966.

scholarly journals Accelerometery as a measure of modifiable physical activity in high-risk elderly preoperative patients: a prospective observational pilot study

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e032346 ◽  
Author(s):  
Lisa Grimes ◽  
Joanne G Outtrim ◽  
Simon J Griffin ◽  
Ari Ercole
Keyword(s):  
Physical Activity ◽  
Pilot Study ◽  
High Risk ◽  
Behavioural Change ◽  
The Elderly ◽  
Routine Care ◽  
Major Surgery ◽  
Post Intervention ◽  
Wear Time ◽  
Patient Reported

ObjectivesTo use wrist-worn accelerometers (Axivity AX3) to establish normative physical activity (PA) and acceptability data for the high-risk elderly preoperative population, to assess whether PA could be modified by a prehabilitation intervention as part of routine care, to assess any correlation between accelerometer-measured PA and self-reported PA and to assess the acceptability of wearing wrist-worn accelerometers in this population.Study designProspective, observational, pilot study.SettingSingle National Health Service Hospital.ParticipantsFrail patients≥65 years awaiting major surgery referred to a multidisciplinary preoperative clinic at which they received a routine intervention aimed at improving their PA. 35 patients were recruited. Average age 79.9 years (SD=5.6).Primary outcomesNormative PA data measured as a mean daily Euclidean norm minus one (ENMO) in milli-gravitational units (mg).Secondary outcomesMeasure PA levels (mg) following a routine preoperative intervention. Determine correlation between patient-reported PA (measured using the Physical Activity Scale for the Elderly) and accelerometer-measured PA (mg). Assess acceptability of wearing a wrist-worn accelerometer measured using Visual Analogue Scale (VAS) questionnaire and device wear time (hours).ResultsMedian baseline daily PA was 14.3 mg(IQR 9.75–22.04) with an improvement in PA detected following the intervention (median ENMO post intervention 20.91 mg(IQR 14.83–27.53), p=0.022). There was no significant correlation between accelerometer-measured and self-reported PA (baselineρ=0.162 (p=0.4), post interventionρ=−0.144 (p=0.5)). We found high acceptability ratings (median score of 10/10 on VAS, IQR 8–10) and wear-time compliance (163.2 hours (IQR 150–167.5) preintervention and 166.1 hours (IQR 162.5–167) post intervention).ConclusionsAccelerometery is acceptable to this population and increases in PA levels measured following an unoptimised routine clinical intervention which indicates that health behavioural change interventions may be successful during the preoperative period. Accelerometers may therefore be a useful tool to design and validate interventions for improving PA in this setting.Trial registration numberNCT03737903.

scholarly journals CaRE @ Home: Pilot Study of an Online Multidimensional Cancer Rehabilitation and Exercise Program for Cancer Survivors

2020 ◽  
Vol 9 (10) ◽  
pp. 3092 ◽  
Author(s):  
Anne Marie MacDonald ◽  
Aleksandra Chafranskaia ◽  
Christian J. Lopez ◽  
Manjula Maganti ◽  
Lori J. Bernstein ◽  
...  
Keyword(s):  
Pilot Study ◽  
Cancer Survivors ◽  
Controlled Trial ◽  
Qualitative Interviews ◽  
Care Home ◽  
Exercise Program ◽  
Rehabilitation Program ◽  
Cancer Rehabilitation ◽  
Post Intervention ◽  
Patient Reported

Background: Although facility-based cancer rehabilitation and exercise programs exist, patients are often unable to attend due to distance, cost, and other competing obligations. There is a need for scalable remote interventions that can reach and serve a larger population. Methods: We conducted a mixed methods pilot study to assess the feasibility, acceptability and impact of CaRE@Home: an 8-week online multidimensional cancer rehabilitation and exercise program. Feasibility and acceptability data were captured by attendance and adherence metrics and through qualitative interviews. Preliminary estimates of the effects of CaRE@Home on patient-reported and physically measured outcomes were calculated. Results: A total of n = 35 participated in the study. Recruitment (64%), retention (83%), and adherence (80%) rates, along with qualitative findings, support the feasibility of the CaRE@Home intervention. Acceptability was also high, and participants provided useful feedback for program improvements. Disability (WHODAS 2.0) scores significantly decreased from baseline (T1) to immediately post-intervention (T2) and three months post-intervention (T3) (p = 0.03 and p = 0.008). Physical activity (GSLTPAQ) levels significantly increased for both Total LSI (p = 0.007 and p = 0.0002) and moderate to strenuous LSI (p = 0.003 and p = 0.002) from baseline to T2 and T3. Work productivity (iPCQ) increased from T1 to T3 (p = 0.026). There was a significant increase in six minute walk distance from baseline to T2 and T3 (p < 0.001 and p = 0.010) and in grip strength from baseline to T2 and T3 (p = 0.003 and p < 0.001). Conclusions: Results indicate that the CaRE@Home program is a feasible and acceptable cancer rehabilitation program that may help cancer survivors regain functional ability and decrease disability. In order to confirm these findings, a controlled trial is required.

scholarly journals Improving Compliance with Best Practice Standards for Patients at Risk for Opioid Use Disorder

2020 ◽  
Author(s):  
Casey Williams
Keyword(s):  
Best Practice ◽  
Opioid Use Disorder ◽  
Evidence Based ◽  
Provider Education ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Post Intervention ◽  
Improvement Project ◽  
Care Plans ◽  
Opioid Use Disorders

Background: Available literature suggests that provider adherence to best practice guidelines regarding the prescribing and management of opioid therapies is low. Documentation of patient screening for present or future opioid use disorder is inconsistent. Provider incorporation of evidence-based guidelines into routine patient care is essential to optimizing outcomes related to opioid use disorders. Purpose/Specific Aims: The purpose of this scholarly project was to facilitate recognition of patients at high risk for opioid use disorders and facilitate best evidence based practices in the care of this population. Specific aims were to achieve provider compliance with: patient risk screening, PDMP review, completion of signed care plans, and reduction of inappropriate opioid prescriptions. Methods: A quasi-experimental design was used for this quality improvement project. The sample included patients receiving treatment for acute or chronic pain, or who were identified as having a substance use disorder. The project was conducted at an internal medicine practice in the northeast region. The intervention included an educational program addressing the ASAM guidelines and ORT utilization with implementation of a SmartPhrase in Epic. Baseline data was collected for the two-month period preceding the intervention and post-intervention data was collected for the three-month period following the intervention. Differences in pre- and post- intervention results were analyzed using chi square. Results: This project resulted in improved compliance with the implementation of urine toxicology screening, PDMP review, and completion of a controlled substance agreement. Compliance with ORT was not achieved. Conclusion: This project led to an increase in compliance with best opioid prescribing practices. The ORT was not consistently implemented; however, the number of new opioid prescriptions remained negligible. Additional efforts will be necessary to maintain the progress achieved in this project including attention to continued provider education. Real-time auditing and feedback will also be incorporated, and opportunities to involve office staff will be explored.

Oncology boot camp: A preparatory curriculum for advanced pharmacy practice experience students

2021 ◽  
pp. 107815522110191
Author(s):  
Bethannee Horn ◽  
Lyn Wells ◽  
Zachery Halford
Keyword(s):  
Student Perceptions ◽  
Pharmacy Practice ◽  
Boot Camp ◽  
Primary Objective ◽  
Comfort Level ◽  
Post Intervention ◽  
Student Knowledge ◽  
Survey Tool ◽  
Practice Experience ◽  
Drug Knowledge

Introduction The primary objective of this study was to evaluate the effectiveness of an autonomous oncology boot camp on Advanced Pharmacy Practice Experience (APPE) student knowledge. Secondary objectives included assessing student perception of the virtual learning experience and overall comfort level with the material. Methods APPE students rotating through our institution between November 2019 and March 2020 were voluntarily enrolled in a 4-hour oncology-focused boot camp, which included five PlayPosit (Denver, CO, USA) interactive video lectures embedded with case-based application questions followed by one comprehensive web-based Quandary (Victoria, BC, Canada) action-maze case. Student learning was measured by a pre- and post-intervention exam. A web survey tool (Qualtrics, Provo, UT, USA) collected student perceptions evaluating their comfort with oncology-specific drug knowledge and APPE rotations tasks. Results Fifty students enrolled in the oncology boot camp, with 100% completing the pre- and post-intervention assessments. Overall, pre-intervention exam scores (mean: 55.4%, SD: 21.8%) improved by 23.2% following the boot camp (mean: 78.6%, SD: 19.2%; p < 0.001). Students performed better on all 10 exam questions, with 6 questions showing a statistically significant improvement (p < 0.05). Forty-five students (90%) completed the perception surveys. Of those, 93% agreed that it effectively reinforced important oncology knowledge, 91% supported the autonomous design, and 82% would recommend the oncology boot camp for future students. Conclusion The boot camp proved to be a beneficial educational tool that enhanced student knowledge and confidence in navigating common oncology concepts. Students valued the ability to independently complete the activities and supported its continuation.

The Surprise Question and Serious Illness Conversations: A pilot study

2021 ◽  
pp. 096973302098339
Author(s):  
Kathy Le ◽  
Jenny Lee ◽  
Sameer Desai ◽  
Anita Ho ◽  
Holly van Heukelom
Keyword(s):  
Pilot Study ◽  
Healthcare Professionals ◽  
Post Intervention ◽  
Acute Medicine ◽  
Serious Illness ◽  
Patient Goals ◽  
Ethical Approval ◽  
Seriously Ill Patients ◽  
Surprise Question ◽  
Seriously Ill

Background: Serious Illness Conversations aim to discuss patient goals. However, on acute medicine units, seriously ill patients may undergo distressing interventions until death. Objectives: To investigate the feasibility of using the Surprise Question, “Would you be surprised if this patient died within the next year?” to identify patients who would benefit from early Serious Illness Conversations and study any changes in the interdisciplinary team’s beliefs, confidence, and engagement as a result of asking the Surprise Question. Design: A prospective cohort pilot study with two Plan-Do-Study-Act cycles. Participants/context: Fifty-eight healthcare professionals working on Acute Medicine Units participated in pre- and post-intervention questionnaires. The intervention involved asking participants the Surprise Question for each patient. Patient charts were reviewed for Serious Illness Conversation documentation. Ethical considerations: Ethical approval was granted by the institutions involved. Findings: Equivocal overall changes in the beliefs, confidence, and engagement of healthcare professionals were observed. Six out of 23 patients were indicated as needing a Serious Illness Conversation; chart review provided some evidence that these patients had more Serious Illness Conversation documentation compared with the 17 patients not flagged for a Serious Illness Conversation. Issues were identified in equating the Surprise Question to a Serious Illness Conversation. Discussion: Appropriate support for seriously ill patients is both a nursing professional and ethical duty. Flagging patients for conversations may act as a filtering process, allowing healthcare professionals to focus on conversations with patients who need them most. There are ethical and practical issues as to what constitutes a “serious illness” and if answering “no” to the Surprise Question always equates to a conversation. Conclusion: The barriers of time constraints and lack of training call for institutional change in order to prioritise the moral obligation of Serious Illness Conversations.

scholarly journals Malignant Pleural Effusions Impact on Fatigue (IMPE-F): A Prospective Observational Cohort Pilot Study

2021 ◽  
Vol 1 (2) ◽  
pp. 98-104
Author(s):  
Avinash Aujayeb ◽  
Donna Wakefield
Keyword(s):  
Pilot Study ◽  
Health Research ◽  
Patient Reported Outcome ◽  
Pleural Effusions ◽  
Inclusion Criteria ◽  
Malignant Pleural Effusions ◽  
Cancer Related Fatigue ◽  
Patient Reported ◽  
Observational Cohort ◽  
Respondent Fatigue

Introduction: Cancer-related fatigue is well described. Fatigue in patients with a malignant pleural effusion (MPE) has not been directly studied. Methods: A prospective observational cohort pilot study ‘Do Interventions for Malignant Pleural Effusions (MPE) impact on patient reported fatigue levels (IMPE-F study)’ is planned to determine whether pleural interventions reduce fatigue in MPE. Fatigue will be assessed with a validated patient reported outcome measure, FACIT-F. Discussion: MPE-F has funding from Rocket Medical Plc, and is part of a Masters in Clinical Research at Newcastle University. Respondent fatigue will be addressed by the investigators going through the questionnaire with the participants. Inclusion criteria are all patients above 18 years of age with a presumed MPE undergoing a procedure and able to consent. The expected number of participants is 50. Trial registration: The IMPE-F study has Research Ethics Committee (REC) [20/YH/0224] and Health Research Authority (HRA) and Health and Care Research Wales (HCRW) approvals [IRAS project ID: 276451]. The study has been adopted on National Institute for Health Research portfolio [CPMS ID 46430].

scholarly journals 83 A Medication Self-Management Intervention to Improve Medication Adherence For Older People with Multimorbidity: A Pilot Study

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
C Yang ◽  
Z Hui ◽  
S Zhu ◽  
X Wang ◽  
G Tang ◽  
...  
Keyword(s):  
Medication Adherence ◽  
Pilot Study ◽  
Older People ◽  
Intervention Group ◽  
Self Management ◽  
Control Group ◽  
Medication Knowledge ◽  
Management Intervention ◽  
Patient Reported

Abstract Introduction Medication self-management support has been recognised as an essential element in primary health care to promote medication adherence and health outcomes for older people with chronic conditions. A patient-centred intervention empowering patients and supporting medication self-management activities could benefit older people. This pilot study tested a newly developed medication self-management intervention for improving medication adherence among older people with multimorbidity. Method This was a two-arm randomised controlled trial. Older people with multimorbidity were recruited from a community healthcare centre in Changsha, China. Participants were randomly allocated to either a control group receiving usual care (n = 14), or to an intervention group receiving three face-to-face medication self-management sessions and two follow-up phone calls over six weeks, targeting behavioural determinants of adherence from the Information-Motivation-Behavioural skills model (n = 14). Feasibility was assessed through recruitment and retention rates, outcome measures collection, and intervention implementation. Follow-up data were measured at six weeks after baseline using patient-reported outcomes including medication adherence, medication self-management capabilities, treatment experiences, and quality of life. Preliminary effectiveness of the intervention was explored using generalised estimating equations. Results Of the 72 approached participants, 28 (38.89%) were eligible for study participation. In the intervention group, 13 participants (92.86%) completed follow-up and 10 (71.42%) completed all intervention sessions. Ten participants (71.42%) in the control group completed follow-up. The intervention was found to be acceptable by participants and the intervention nurse. Comparing with the control group, participants in the intervention group showed significant improvements in medication adherence (β = 0.26, 95%CI 0.12, 0.40, P &lt; 0.001), medication knowledge (β = 4.43, 95%CI 1.11, 7.75, P = 0.009), and perceived necessity of medications (β = −2.84, 95%CI -5.67, −0.01, P = 0.049) at follow-up. Conclusions The nurse-led medication self-management intervention is feasible and acceptable among older people with multimorbidity. Preliminary results showed that the intervention may improve patients’ medication knowledge and beliefs and thus lead to improved adherence.

scholarly journals Safety and efficacy of faecal microbiota transplantation by Anaerobic Cultivated Human Intestinal Microbiome (ACHIM) in patients with systemic sclerosis: study protocol for the randomised controlled phase II ReSScue trial

BMJ Open ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. e048541
Author(s):  
Anna-Maria Hoffmann-Vold ◽  
Håvard H Fretheim ◽  
Vikas K Sarna ◽  
Imon Barua ◽  
Maylen N Carstens ◽  
...  
Keyword(s):  
Systemic Sclerosis ◽  
Pilot Study ◽  
Phase Ii ◽  
Intestinal Microbiome ◽  
Induction Phase ◽  
Inflammatory Disorder ◽  
Faecal Microbiota ◽  
Safety And Efficacy ◽  
Faecal Microbiota Transplantation ◽  
Patient Reported

IntroductionIn the multisystem inflammatory disorder systemic sclerosis (SSc), gastrointestinal tract (GIT) affliction is highly prevalent. There are no known disease modifying therapies and the negative impact is substantial. Aiming for a new therapeutic principle, and inspired by recent work showing associations between gut microbiota changes and GIT symptoms in SSc, we performed a pilot study on faecal microbiota transplantation (FMT) with the single-donor bacterial culture ‘Anaerobic Cultivated Human Intestinal Microbiome (ACHIM)’. Motivated by positive pilot study signals, we designed the ReSScue trial as a phase II multicentre, placebo-controlled, randomised 20-week trial to evaluate safety and efficacy on lower GIT symptoms of FMT by ACHIM in SSc.Methods and analysesWe aim to include 70 SSc participants with moderate to severe lower GIT symptoms, defined by the validated patient-reported University of California Los Angeles Scleroderma Clinical Trial Consortium GIT 2.0 2.0 questionnaire. The trial includes three parts. In part A1 (induction phase) lasting from week 0 to week 12, participants will be randomised 1:1 to repeat infusions of 30 mL ACHIM or placebo at week 0 and 2 by gastroduodenoscopy. In part A2, which is an 8-week subsequent maintenance phase, all study participants will receive 30 mL ACHIM at week 12 and followed until week 20 on continued blind. In part B, which will last until the last participant completes part A2, the participants will be followed through a maximum 16-week extended monitoring period, for longer-term data on safety and intervention effects. Primary endpoint is change from baseline to week 12 in UCLA GIT subscale scores of diarrhoea or bloating, depending on the worst symptom at baseline evaluated separately for each patient. Secondary endpoints are safety measures and changes in UCLA GIT scores (total, diarrhoea and bloating).Ethics and disseminationThis protocol was approved by the Northern Norwegian Committee for Medical Ethics. Study findings will be published.Trial registration numberNCT04300426; Pre-results.Protocol versionV.3.1.

scholarly journals Prenatal Provider Breastfeeding Toolkit: Results of a Pilot to Increase Women’s Prenatal Breastfeeding Support, Intentions, and Outcomes

2021 ◽  
pp. 089033442110087
Author(s):  
Casey Rosen-Carole ◽  
Jill Halterman ◽  
Constance D. Baldwin ◽  
Hayley Martin ◽  
Nicolas P. N. Goldstein ◽  
...  
Keyword(s):  
New York ◽  
Breastfeeding Initiation ◽  
Provider Education ◽  
Breastfeeding Support ◽  
Post Intervention ◽  
Peer Counselors ◽  
Breastfeeding Intention ◽  
Healthy People 2020 ◽  
Peer Counselor ◽  
Publicly Insured

Background Breastfeeding rates for United States women with lower incomes fall below the government’s Healthy People 2020 Goals. Breastfeeding recommendations combined with support from providers and peer counselors help women decide to begin and sustain breastfeeding, but peer counselor uptake is low. Research Aim To evaluate changes in referrals to Women, Infants, and Children’s Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention. Method In this pre-post intervention study (2015–2016; upstate New York), providers implemented a Toolkit to discuss infant feeding recommendations and initiate peer counselor referral. We surveyed women pre- and post-implementation (after delivery; 1 month postpartum) about prenatal breastfeeding intentions, provider support, and breastfeeding outcomes. Analyses controlled for secular trends. Results Pre-intervention ( n = 71) and post-intervention ( n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding support. Conclusions Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants’ breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

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