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Testing behind bars: A mixed-methods realist evaluation of opt-out blood-borne virus testing and associated pathways of care within London prisons

Francis-Graham, Seth; (2020) Testing behind bars: A mixed-methods realist evaluation of opt-out blood-borne virus testing and associated pathways of care within London prisons. Doctoral thesis (Ph.D), UCL (University College London). Green open access

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Abstract

Background: The elimination of viral hepatitis C by 2025, hepatitis B by 2030, and the control of the human immunodeficiency virus is predicated on the diagnosis and treatment of these infections in high prevalence settings. In response to historic low testing rates, opt-out blood-borne virus testing has been implemented and linked with treatment pathways throughout the English prison estate. The aim of my PhD was to evaluate this initiative in London. Methods: Guided by realist methodology, a mixed-methods evaluation was performed. I began by conducting a pilot assessment of a hepatitis C care pathway implemented within one London prison. From this, I decided to focus on the testing stage of the implemented pathways. I analysed routine data to assess outcomes from opt-out testing across the London estate. I then conducted a rapid-realist review to begin developing an explanatory framework for the outcomes reported. Theories developed during the review were used to guide a qualitative comparative case-study, which explored the variation in performance between a higher and low performing local London prison. Results: The pilot evaluation highlighted significant attrition throughout every stage of the hepatitis C care pathway. Analysis of test outcomes revealed that healthcare teams operating within local prisons struggled to test people, whilst also reporting the highest test positivity for hepatitis C exposure. The review flagged a range of potential drivers of poor performance, including access issues and incentives for prisoners to refuse testing. Results from the qualitative comparative case study suggested that differences in the numbers of new prisoners tested, between two local London prisons, primarily stemmed from access issues, rather than test acceptability. Conclusion: The implementation of opt-out blood-borne virus testing has occurred at a difficult time for the prison service. The ability of healthcare staff to deliver testing and treatment pathways for blood-borne viruses is dependent on prison staff providing access to prisoners. Although small-scale pathway adaptation may help improve programme performance, better resourcing of prisons and systemic change that places healthcare at the centre of the rehabilitative mandate of the English prison service should be considered.

Type: Thesis (Doctoral)
Qualification: Ph.D
Title: Testing behind bars: A mixed-methods realist evaluation of opt-out blood-borne virus testing and associated pathways of care within London prisons
Event: UCL (University College London)
Open access status: An open access version is available from UCL Discovery
Language: English
Additional information: Copyright © The Author 2020. Original content in this thesis is licensed under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0) Licence (https://creativecommons.org/licenses/by/4.0/). Any third-party copyright material present remains the property of its respective owner(s) and is licensed under its existing terms. Access may initially be restricted at the author’s request.
UCL classification: UCL
UCL > Provost and Vice Provost Offices
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > Institute for Global Health
URI: https://discovery.ucl.ac.uk/id/eprint/10104792
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