P23\u2005Fragile success: findings from a realist process evaluation of opt-out blood borne virus testing

Abstract

The elimination of viral hepatitis C in England by 2025, is predicated on the diagnosis of blood-borne virus (BBV) infections in high prevalence settings, such as prison. In response to historic low testing rates, opt-out BBV testing has been implemented across the English estate. As part of a wider realist process evaluation, a high and low performing prison in London were selected for qualitative data generation, with the aim of unpicking conditions that facilitate or hinder programme performance. Data were used to test context-mechanism-outcome theories. Four months were spent within each prison. Documentary analysis and unstructured observation captured aspects of the broader social and physical context. Semi-structured observation focused on the sequence of events that constitute opt-out testing, which was supplemented using realist interviews, conducted with prison officers, health workers, and patients. Support from the Governor was crucial to ensure scarce resources were directed towards programme enablement. The testing was spearheaded by a single health worker and differences in personal motivation, experience, and confidence were salient. However, stress from pushing the programme, in an environment where healthcare was not prioritised, risked burnout. Within the poor performing prison, a lack of officers precipitated a ‘dangerous environment’, where safety concerns constrained patient access. Within the high performing prison, clinic set-up fostered interaction between health workers and officers. Social relationships developed, with staff occupying a liminal space, facilitating the development of informal strategies that maximised testing. The success reported by some London prisons is a vulnerable one. Until wider structural pressures are addressed and opt-out testing securely embedded, staff change risks programme disintegration. Results suggest there is opportunity for innovation within the liminal space between the prison and healthcare, but formalisation of roles within this space is recommended. Further work is required to ensure London prisons are on track to facilitate elimination targets.