An evaluation of the opt-out approach to Hepatitis C Virus infection testing in prisons

Jack, Kathryn (2020) An evaluation of the opt-out approach to Hepatitis C Virus infection testing in prisons. PhD thesis, University of Nottingham.

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The research in this thesis presents insights into elements of healthcare provided in micro-communities that are hidden from public view; prisons in England. Prisons are a key demographic in NHS England’s drive to eliminate hepatitis C virus infection (HCV) as a major public health threat by 2025. A policy to offer blood borne virus testing, with HCV as the priority, to those entering prisons via an opt-out approach was launched in 2014. This policy was implemented in the East Midlands prison estate, comprising 14 establishments, using dried blood spot tests as the default method of obtaining samples for analysis. The research aimed firstly to measure the impact of the opt-out testing policy on HCV test uptake in the East Midlands prisons and secondly to generate explanatory theories, based on the perspectives of men serving prison sentences, which would underpin future interventions to maximise test uptake in prisons.

Realistic Evaluation methodology and mixed methods informed the conduct of three study phases: 1. Measurements of HCV test uptake pre-and post-policy introduction and prison operational features; 2. Survey of men in a category C prison to establish sentence duration, HCV test uptake, reasons for refusal and risk factors for HCV infection; 3. Semi-structured interviews with men in prison and nurses to elicit data on their perspectives about testing for HCV infection in prisons. In keeping with the Realistic Evaluation methodology programme theories were constructed to explain the test uptake rates observed in phase 1. These were subsequently refined using the novel data generated in phases 2 and 3.

The HCV test uptake fell far short of the targets set by Public Health England and there was evidence of people with risk factors for HCV infection not being tested during their current sentence. The key themes of Fear, Insufficient Knowledge, Stigma, Privacy, Choice and Prison Life emerged as the principal barriers to test uptake. Test Uptake Facilitators were however identified by participants and a positive notion presented of prison healthcare being a Health Farm. In prisons men rarely spoke to each other about HCV and were fearful of catching this infection. Further, if identified as infected social rejection by others in prison was experienced so fears of being found out were high. Moreover, the prison regime which necessarily prioritises security, hampered opportunities for healthcare. Overall most men were accepting of the concept of routine BBV testing on arrival.

The dominant qualitative leitmotif and causative mechanism to emerge from the interviews was Fear. This thesis presents a novel model of prison BBV engagement and interventions to increase test uptake, expressed as a Middle Range Theory comprising context-mechanism-outcome configurations embedded within the wider sociological theory about adaptation to prison life; prisonization.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Irving, Will
Thomson, Brian
Linsley, Paul
Keywords: Hepatitis C, Prisons, Opt-out testing, Realist evaluation, Mixed methods
Subjects: H Social sciences > HV Social pathology. Social and public welfare
R Medicine > RC Internal medicine
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Life Sciences
Item ID: 59842
Depositing User: Jack, Kathryn
Date Deposited: 17 Jul 2020 04:40
Last Modified: 17 Jul 2022 04:30

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