{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T19:25:29Z","timestamp":1764617129233,"version":"3.46.0"},"reference-count":59,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T00:00:00Z","timestamp":1764547200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100030692","name":"Intramural Research Program, National Institute on Drug Abuse","doi-asserted-by":"publisher","award":["R01DA057655"],"award-info":[{"award-number":["R01DA057655"]}],"id":[{"id":"10.13039\/100030692","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>The opioid overdose crisis has continued to affect women who use drugs (WWUD), particularly in urban cities such as Baltimore, Maryland, where fatal overdose rates rank among the highest in the nation. Despite evidence demonstrating the impact of mobile health services in serving underserved populations, few interventions are specifically tailored to meet the unique needs of WWUD. The Sustained Harm Reduction OUTreach (SHOUT) study evaluates the effectiveness and implementation of a harm reduction\u2013based mobile outreach service operated by a community-based organization serving WWUD in Southwest Baltimore. The \u201cintervention group\u201d consists of WWUD recruited within the organization\u2019s catchment area, while the \u201ccontrol group\u201d comprises those recruited from neighborhoods outside of the organization\u2019s catchment area. The study\u2019s three aims are: (1) to conduct in-depth interviews with WWUD (N=12) to assess the feasibility of using a modified respondent-driven sampling (RDS) method; (2) to conduct a prospective cohort study comparing intervention (N=250) and control (N=150) groups over 18 months to assess nonfatal overdose and healthcare access outcomes; and (3) to evaluate intervention implementation using the RE-AIM framework. The study is guided by Andersen\u2019s Behavioral Model for Vulnerable Populations and Rhodes\u2019s Risk Environment Framework. Preliminary findings suggest that a modified RDS approach is both feasible and acceptable among WWUD. Aim 2 will examine the effect of mobile services on reducing nonfatal overdoses by promoting harm reduction practices within participants\u2019 social and physical environments. Aim 3 will incorporate qualitative and cost-effectiveness analyses to contextualize the program\u2019s impact and sustainability. This study addresses critical service gaps for WWUD by integrating and providing low-barrier harm reduction services offered on an accessible mobile van. Findings will inform scalable, community-driven strategies to reduce overdose mortality and improve health equity among structurally vulnerable populations. Strengths, limitations, and plans for results dissemination are discussed.<\/jats:p>","DOI":"10.1371\/journal.pone.0336607","type":"journal-article","created":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T18:23:40Z","timestamp":1764613420000},"page":"e0336607","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["A study protocol to explore the effectiveness and implementation of mobile community outreach services for women who use drugs in Baltimore, Maryland: The SHOUT Study"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-3786-5385","authenticated-orcid":true,"given":"Sewika","family":"Sulpe","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2622-5518","authenticated-orcid":true,"given":"Catherine","family":"Tomko","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emily","family":"Clouse","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrea L.","family":"Wirtz","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brian","family":"Weir","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nouran","family":"El-Ashry","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susan G.","family":"Sherman","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,12,1]]},"reference":[{"key":"pone.0336607.ref001","volume-title":"Provisional drug overdose death counts","author":"FB CJ Ahmad","year":"2025"},{"key":"pone.0336607.ref002","volume-title":"Drug overdose deaths in the United States, 2002-2022","author":"MR Spencer","year":"2024"},{"issue":"2","key":"pone.0336607.ref003","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1177\/0033354920968806","article-title":"Differences in opioid overdose mortality rates among middle-aged adults by race\/ethnicity and sex, 1999-2018","volume":"136","author":"RA Hoopsick","year":"2021","journal-title":"Public Health Rep"},{"key":"pone.0336607.ref004","volume-title":"Baltimore\u2019s unprecedented overdose crisis: 5 takeaways. The Baltimore Banner","author":"Alissa Zhu NTaJG","year":"2024"},{"key":"pone.0336607.ref005","volume-title":"Nonfatal Surveillance Data","year":"2025"},{"key":"pone.0336607.ref006","article-title":"Baltimore dubbed \u201coverdose capital\u201d amid drug-related deaths","author":"J Babb","year":"2024","journal-title":"Fox News Baltimore"},{"key":"pone.0336607.ref007","author":"Maryland Department of Health Data Office","year":"2025"},{"key":"pone.0336607.ref008","article-title":"In Baltimore\u2019s senior homes, overdoses plague a forgotten generation","author":"NTZaJ Gallagher","year":"2024","journal-title":"The New York Times"},{"issue":"1","key":"pone.0336607.ref009","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.mm6801a1","article-title":"Drug overdose deaths among women aged 30-64 years - United States, 1999-2017","volume":"68","author":"JP Van Houten","year":"2019","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"1","key":"pone.0336607.ref010","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1001\/jama.2021.8012","article-title":"Mortality from drug overdoses, homicides, unintentional injuries, motor vehicle crashes, and suicides during the pandemic, March-August 2020","volume":"326","author":"JS Faust","year":"2021","journal-title":"JAMA"},{"issue":"11","key":"pone.0336607.ref011","doi-asserted-by":"crossref","first-page":"3058","DOI":"10.1007\/s10461-019-02643-0","article-title":"Severe food insecurity, gender-based violence, homelessness, and HIV risk among street-based female sex workers in Baltimore, Maryland","volume":"23","author":"S Lim","year":"2019","journal-title":"AIDS Behav"},{"key":"pone.0336607.ref012","doi-asserted-by":"crossref","first-page":"10383","DOI":"10.1177\/0886260519884694","article-title":"Cumulative violence and PTSD symptom severity among urban street-based female sex workers","volume":"36","author":"JN Park","year":"2021","journal-title":"J Interpers Violence"},{"key":"pone.0336607.ref013","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.drugalcdep.2019.03.026","article-title":"Patterns of polysubstance use and overdose among people who inject drugs in Baltimore, Maryland: a latent class analysis","volume":"201","author":"KE Schneider","year":"2019","journal-title":"Drug Alcohol Depend"},{"key":"pone.0336607.ref014","article-title":"Incidence and predictors of violence from clients, intimate partners and police in a prospective US-based cohort of women in sex work","author":"M Decker","year":"2020","journal-title":"Occup Environ Med"},{"issue":"5","key":"pone.0336607.ref015","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1097\/QAI.0000000000001959","article-title":"Drivers of HIV infection among cisgender and transgender female sex worker populations in Baltimore City: results from the SAPPHIRE study","volume":"80","author":"SG Sherman","year":"2019","journal-title":"J Acquir Immune Defic Syndr"},{"key":"pone.0336607.ref016","doi-asserted-by":"crossref","first-page":"107215","DOI":"10.1016\/j.addbeh.2021.107215","article-title":"Identifying pathways to recent non-fatal overdose among people who use opioids non-medically: How do psychological pain and unmet mental health need contribute to overdose risk?","volume":"127","author":"C Tomko","year":"2022","journal-title":"Addict Behav"},{"key":"pone.0336607.ref017","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/j.drugalcdep.2017.12.037","article-title":"Opioid use and stigma: the role of gender, language and precipitating events","volume":"185","author":"K Goodyear","year":"2018","journal-title":"Drug Alcohol Depend"},{"issue":"1","key":"pone.0336607.ref018","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1111\/j.1360-0443.2011.03601.x","article-title":"The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review","volume":"107","author":"JD Livingston","year":"2012","journal-title":"Addiction"},{"issue":"6","key":"pone.0336607.ref019","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1080\/00224499.2020.1755821","article-title":"Confirmatory factor analysis and construct validity of the internalized sex work stigma scale among a cohort of cisgender female sex workers in Baltimore, Maryland, United States","volume":"58","author":"C Tomko","year":"2021","journal-title":"J Sex Res"},{"issue":"5","key":"pone.0336607.ref020","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1080\/09540121.2010.525606","article-title":"Measuring perceived stigma in female sex workers in Chennai, India","volume":"23","author":"S-H Liu","year":"2011","journal-title":"AIDS Care"},{"issue":"6","key":"pone.0336607.ref021","doi-asserted-by":"crossref","first-page":"2093","DOI":"10.1111\/j.1475-6773.2009.01017.x","article-title":"Mistrust of health care organizations is associated with underutilization of health services","volume":"44","author":"TA LaVeist","year":"2009","journal-title":"Health Serv Res"},{"issue":"5","key":"pone.0336607.ref022","doi-asserted-by":"crossref","first-page":"381","DOI":"10.1176\/appi.ajp.20230917","article-title":"Understanding and addressing widening racial inequalities in drug overdose","volume":"181","author":"JR Friedman","year":"2024","journal-title":"Am J Psychiatry"},{"key":"pone.0336607.ref023","doi-asserted-by":"crossref","first-page":"100550","DOI":"10.1016\/j.puhip.2024.100550","article-title":"Mobile health clinics for distribution of vaccinations to underserved communities during health emergencies: A COVID-19 case study","volume":"8","author":"L Rennert","year":"2024","journal-title":"Public Health Pract (Oxf)"},{"issue":"1","key":"pone.0336607.ref024","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1186\/s12939-020-01175-7","article-title":"Mobile health clinic model in the COVID-19 pandemic: lessons learned and opportunities for policy changes and innovation","volume":"19","author":"S Attipoe-Dorcoo","year":"2020","journal-title":"Int J Equity Health"},{"issue":"1","key":"pone.0336607.ref025","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1136\/sextrans-2017-053104","article-title":"HIV seroconversion among Baltimore City residents tested at a mobile van programme","volume":"94","author":"S Puryear","year":"2018","journal-title":"Sex Transm Infect"},{"issue":"5","key":"pone.0336607.ref026","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1080\/09540121.2013.845280","article-title":"Comparison of strategies to increase HIV testing among African-American gay, bisexual, and other men who have sex with men in Washington, DC","volume":"26","author":"C Baytop","year":"2014","journal-title":"AIDS Care"},{"issue":"2","key":"pone.0336607.ref027","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1093\/jurban\/79.2.257","article-title":"Risk-taking behaviors among injecting drug users who obtain syringes from pharmacies, fixed sites, and mobile van needle exchanges","volume":"79","author":"CL Miller","year":"2002","journal-title":"J Urban Health"},{"issue":"1","key":"pone.0336607.ref028","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1186\/s12954-018-0212-3","article-title":"Scoping out the literature on mobile needle and syringe programs-review of service delivery and client characteristics, operation, utilization, referrals, and impact","volume":"15","author":"C Strike","year":"2018","journal-title":"Harm Reduct J"},{"key":"pone.0336607.ref029","doi-asserted-by":"crossref","first-page":"1407522","DOI":"10.3389\/fpubh.2024.1407522","article-title":"Mobile addiction treatment and harm reduction services as tools to address health inequities: a community case study of the Brockton Neighborhood Health Center mobile unit","volume":"12","author":"A Pinkhover","year":"2024","journal-title":"Front Public Health"},{"key":"pone.0336607.ref030","article-title":"Drug overdose deaths are dropping. The reasons are not perfectly clear","author":"W N","year":"2024","journal-title":"The New York Times"},{"issue":"1","key":"pone.0336607.ref031","doi-asserted-by":"crossref","first-page":"3541","DOI":"10.1186\/s12889-024-21104-5","article-title":"Multiple material need insecurities and severity of psychological distress during the COVID-19 pandemic among women who use drugs","volume":"24","author":"C Tomko","year":"2024","journal-title":"BMC Public Health"},{"key":"pone.0336607.ref032","doi-asserted-by":"crossref","first-page":"102859","DOI":"10.1016\/j.drugpo.2020.102859","article-title":"Conceptualizing overdose trauma: The relationships between experiencing and witnessing overdoses with PTSD symptoms among street-recruited female sex workers in Baltimore, Maryland","volume":"92","author":"KE Schneider","year":"2021","journal-title":"Int J Drug Policy"},{"issue":"3","key":"pone.0336607.ref033","doi-asserted-by":"crossref","first-page":"1584","DOI":"10.1353\/hpu.2021.0151","article-title":"Characterizing health care access among cisgender female sex workers with substance use histories in Baltimore, Maryland","volume":"32","author":"C Tomko","year":"2021","journal-title":"J Health Care Poor Underserved"},{"issue":"48","key":"pone.0336607.ref034","doi-asserted-by":"crossref","first-page":"1337","DOI":"10.15585\/mmwr.mm6448a3","article-title":"Syringe service programs for persons who inject drugs in urban, suburban, and rural areas - United States, 2013","volume":"64","author":"DC Des Jarlais","year":"2015","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"6","key":"pone.0336607.ref035","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1097\/OLQ.0000000000001781","article-title":"Impact of a community empowerment intervention on sexually transmitted infections among female sex workers in Baltimore, Maryland","volume":"50","author":"SG Sherman","year":"2023","journal-title":"Sex Transm Dis"},{"issue":"2","key":"pone.0336607.ref036","doi-asserted-by":"crossref","first-page":"174","DOI":"10.2307\/3096941","article-title":"Respondent-driven sampling: a new approach to the study of hidden populations","volume":"44","author":"DD Heckathorn","year":"1997","journal-title":"Social Problems"},{"issue":"5","key":"pone.0336607.ref037","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25694","article-title":"An evaluation of assumptions underlying respondent-driven sampling and the social contexts of sexual and gender minority youth participating in HIV clinical trials in the United States","volume":"24","author":"AL Wirtz","year":"2021","journal-title":"J Int AIDS Soc"},{"key":"pone.0336607.ref038","doi-asserted-by":"crossref","DOI":"10.1016\/j.jadohealth.2014.07.021","article-title":"Respondent-driven sampling for an adolescent health study in vulnerable urban settings: a multi-country study","volume":"55","author":"MR Decker","year":"2014","journal-title":"J Adolesc Health"},{"issue":"9","key":"pone.0336607.ref039","doi-asserted-by":"crossref","DOI":"10.2196\/17269","article-title":"Providing unique support for health study among young black and latinx men who have sex with men and young black and latinx transgender women living in 3 urban cities in the united states: protocol for a coach-based mobile-enhanced randomized control trial","volume":"9","author":"R Arrington-Sanders","year":"2020","journal-title":"JMIR Res Protoc"},{"issue":"3","key":"pone.0336607.ref040","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1080\/15332640.2016.1196629","article-title":"Sociodemographic and access-related correlates of health-care utilization among African American injection drug users: The BESURE study","volume":"16","author":"AC Maragh-Bass","year":"2017","journal-title":"J Ethn Subst Abuse"},{"key":"pone.0336607.ref041","doi-asserted-by":"crossref","DOI":"10.1016\/j.jadohealth.2014.08.024","article-title":"Predictors of substance use among vulnerable adolescents in five cities: findings from the well-being of adolescents in vulnerable environments study","volume":"55","author":"AO Olumide","year":"2014","journal-title":"J Adolesc Health"},{"key":"pone.0336607.ref042","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1016\/j.drugpo.2018.12.005","article-title":"Police violence among people who inject drugs in Baltimore, Maryland","volume":"64","author":"JN Park","year":"2019","journal-title":"Int J Drug Policy"},{"issue":"10","key":"pone.0336607.ref043","doi-asserted-by":"crossref","first-page":"1273","DOI":"10.1080\/09540121.2018.1447078","article-title":"Correlates of exchange sex among a population-based sample of low-income women who have heterosexual sex in Baltimore","volume":"30","author":"SG Sherman","year":"2018","journal-title":"AIDS Care"},{"issue":"11","key":"pone.0336607.ref044","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0259983","article-title":"Using large-scale respondent driven sampling to monitor the end of an HIV epidemic among persons who inject drugs in Hai Phong, Viet Nam","volume":"16","author":"DC Des Jarlais","year":"2021","journal-title":"PLoS One"},{"issue":"3","key":"pone.0336607.ref045","doi-asserted-by":"crossref","first-page":"250","DOI":"10.4103\/ijph.IJPH_572_20","article-title":"Characteristics of substance abusing female sex workers and identifying the changing trends in sex work dynamics in Imphal, Northeast India: A mixed-method study","volume":"65","author":"OK Khaba","year":"2021","journal-title":"Indian J Public Health"},{"key":"pone.0336607.ref046","first-page":"100337","article-title":"Assessment of a psychiatric intervention at community level for people who inject drugs in a low-middle income country: the DRIVE-Mind cohort study in Hai Phong, Viet Nam","volume":"18","author":"L Michel","year":"2021","journal-title":"Lancet Reg Health West Pac"},{"issue":"1","key":"pone.0336607.ref047","doi-asserted-by":"crossref","first-page":"1549","DOI":"10.1186\/s12889-021-11373-9","article-title":"Rapid situational assessment of people who inject drugs (PWID) in Nairobi and coastal regions of Kenya: a respondent driven sampling survey","volume":"21","author":"FO Oguya","year":"2021","journal-title":"BMC Public Health"},{"issue":"3","key":"pone.0336607.ref048","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1080\/13691058.2017.1346201","article-title":"Structural risk and limits on agency among exotic dancers: HIV risk practices in the exotic dance club","volume":"20","author":"KHA Footer","year":"2018","journal-title":"Cult Health Sex"},{"issue":"1","key":"pone.0336607.ref049","first-page":"79","article-title":"Probability based estimation theory for respondent driven sampling","volume":"24","author":"EVaDD Heckathorn","year":"2008","journal-title":"J Official Stat"},{"key":"pone.0336607.ref050"},{"issue":"1","key":"pone.0336607.ref051","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1186\/s12954-017-0153-2","article-title":"Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility","volume":"14","author":"A Irwin","year":"2017","journal-title":"Harm Reduct J"},{"issue":"6","key":"pone.0336607.ref052","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1016\/j.amepre.2016.01.011","article-title":"Cost effectiveness of HIV prevention interventions in the U.S","volume":"50","author":"F Lin","year":"2016","journal-title":"Am J Prev Med"},{"key":"pone.0336607.ref053","doi-asserted-by":"crossref","first-page":"47","DOI":"10.3109\/10826080902864712","article-title":"The development and psychometric properties of a new measure of perceived stigma toward substance users","volume":"45","author":"JB Luoma","year":"2010","journal-title":"Subst Use Misuse"},{"key":"pone.0336607.ref054","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1016\/j.drugalcdep.2006.10.014","article-title":"Stigma, discrimination and the health of illicit drug users","volume":"88","author":"J Ahern","year":"2007","journal-title":"Drug Alcohol Depend"},{"issue":"6","key":"pone.0336607.ref055","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1007\/s11606-008-0575-3","article-title":"Development of a revised health care system distrust scale","volume":"23","author":"JA Shea","year":"2008","journal-title":"J Gen Intern Med"},{"issue":"1","key":"pone.0336607.ref056","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1186\/s12889-020-08723-4","article-title":"Barriers and facilitators to retaining a cohort of street-based cisgender female sex workers recruited in Baltimore, Maryland, USA: results from the SAPPHIRE study","volume":"20","author":"BE Silberzahn","year":"2020","journal-title":"BMC Public Health"},{"issue":"1","key":"pone.0336607.ref057","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1214\/09-STS313","article-title":"Matching methods for causal inference: a review and a look forward","volume":"25","author":"EA Stuart","year":"2010","journal-title":"Stat Sci"},{"issue":"19","key":"pone.0336607.ref058","doi-asserted-by":"crossref","first-page":"3373","DOI":"10.1002\/sim.5786","article-title":"Propensity score weighting with multilevel data","volume":"32","author":"F Li","year":"2013","journal-title":"Stat Med"},{"issue":"10","key":"pone.0336607.ref059","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1001\/jama.2016.12195","article-title":"Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine","volume":"316","author":"GD Sanders","year":"2016","journal-title":"JAMA"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0336607","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T18:23:49Z","timestamp":1764613429000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0336607"}},"subtitle":[],"editor":[{"given":"Katherine Demi","family":"Kokkinias","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2025,12,1]]},"references-count":59,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12,1]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0336607","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,1]]}}}