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Competing priorities and second chances - A qualitative exploration of prisoners' journeys through the Hepatitis C continuum of care.

ABSTRACT: High levels of undiagnosed and untreated HCV infection exist in prison populations globally. Prisons are a key location to identify, treat and prevent HCV infection among people who inject drugs (PWID). Understanding prisoners' lived experiences of the HCV continuum of care informs how HCV care can be effectively delivered to this marginalised and high-risk population. This study aimed to explore Irish prisoners' experience of prison and community-based HCV care. We conducted one-to-one interviews with 25 male prisoners with chronic HCV infection. Data collection and analysis was informed by grounded theory. The mean age of participants and first incarceration was 39.5 and 18.3 years respectively. The mean number of incarcerations was eight. The following themes were identified: medical and social factors influencing engagement (fear of treatment and lack of knowledge, HCV relevance and competing priorities), adverse impact of HCV on health and wellness, positive experience of prison life and health care and the transformative clinical and non-clinical changes associated with HCV treatment and cure. Findings suggest that prison release was associated with multiple stressors including homelessness and drug dependence which quickly eroded the health benefits gained during incarceration. The study generated a substantive theory of the need to increase the importance of HCV care among the routine competing priorities associated with the lives of PWID. HCV infected prisoners often lead complex lives and understanding their journeys through the HCV continuum can inform the development of meaningful HCV care pathways. Many challenges exist to optimising HCV treatment uptake in this group and incarceration is an opportunity to successfully engage HCV infected prisoners who underutilise and are underserved by community-based medical services. Support and linkage to care on release is essential to optimising HCV management.

SUBMITTER: Crowley D

PROVIDER: S-EPMC6738615 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Competing priorities and second chances - A qualitative exploration of prisoners' journeys through the Hepatitis C continuum of care.

Crowley Desmond D Cullen Walter W Lambert John S JS Van Hout Marie Claire MC

PloS one 20190911 9

High levels of undiagnosed and untreated HCV infection exist in prison populations globally. Prisons are a key location to identify, treat and prevent HCV infection among people who inject drugs (PWID). Understanding prisoners' lived experiences of the HCV continuum of care informs how HCV care can be effectively delivered to this marginalised and high-risk population. This study aimed to explore Irish prisoners' experience of prison and community-based HCV care. We conducted one-to-one intervie ...[more]

PMID: 31509571

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Project description:BackgroundEarly initiation of antiretroviral therapy (ART) reduces the development of acquired immunodeficiency syndrome (AIDS), non-AIDS related comorbidities and mortality, and prevents transmission. However, the prevalence of delayed ART initiation amongst prisoners in sub-Saharan African countries is high and the contributing factors to this are relatively unknown.MethodsQualitative interviewing was employed to understand the prisoners' lived world with regard to initiating ART and associated barriers and facilitators in the South Ethiopian prison system. We interviewed seven (five male and two female) inmates living with HIV (ILWH) and eleven stakeholders who had a role in human immunodeficiency virus (HIV) care provision for incarcerated people. A phenomenological approach was used to analyse the interview data in which meaning attributed to the lived experiences of the participants was abstracted.ResultsIn this study, participants discussed both barriers to, and facilitators of, early ART initiation during incarceration. The barriers included a lack of access to voluntary counselling and testing (VCT) services, poor linkage to care due to insufficient health staff training, uncooperative prison security systems and loss of privacy regarding disclosure of HIV status. Insufficient health staff training and uncooperative prison security systems both contributed to a loss of patient privacy, ultimately resulting in treatment refusal. Although most participants described the importance of peer education and support for enhancing HIV testing and treatment programs amongst prisoners, there had been a decline in such interventions in the correctional facilities. Service providers suggested opportunities that a prison environment offers for identification and treatment of HIV infected individuals and implementation of peer education programs.ConclusionsOur study identified crucial barriers to and facilitators of early ART initiation amongst prisoners, a key HIV priority population group. Interventions that address the barriers while strengthening the facilitators may enhance a greater utilisation of ART.

Project description:BACKGROUND:Despite ample clinical evidence that gaining excess weight in pregnancy results in negative health outcomes for women and infants, more than half of women in Western industrialized nations gain in excess of national guidelines. The influence of socio-demographic factors and weight gain is well-established but not causal; the influence of psychological factors may explain some of this variation. METHODS:This is the qualitative portion of an explanatory sequential mixed-methods study designed to identify predictive psychological factors of excess gestational weight gain (QUAN) and then explain the relevance of those factors (qual). For this portion of the study, we used a qualitative descriptive approach to elicit 39 pregnant women's perspectives of gestational weight gain, specifically inquiring about factors determined as relevant to excess gestational weight gain by our previous predictive study. Women were interviewed in the latter half of their third trimester. Data were analyzed using a combination of unconstrained deductive content analysis to describe the findings relevant to the predictive factors and a staged inductive content analytic approach to examine the data without a focus on the predictive factors. RESULTS:Very few participants consistently made deliberate choices relevant to weight gain; most behaviour relevant to weight gain happened with in-the-moment decisions. These in-the-moment decisions were influenced by priorities, hunger, a consideration of the consequence of the decision, and accommodation of pregnancy-related discomfort. They were informed by the foundational information a woman had available to her, including previous experience and interactions with health care providers. The foundational information women used to make these decisions was often incomplete. While women were aware of the guidelines related to gestational weight gain, they consistently mis-applied them due to incorrect understanding of their own BMI. Only one woman was aware that weight gain was linked to maternal and infant health outcomes. CONCLUSIONS:There is an important role for prenatal providers to provide the foundational information to positively influence in-the-moment decisions. Understanding how weight gain guidelines apply to one's own pre-pregnancy BMI and comprehending the well-established link between gestational weight gain and health outcomes may help women prioritize healthy weight gain amongst many competing factors.

Project description:Oversight of clinical quality is only one of physical therapy managers' multiple responsibilities. With the move to value-based care, organizations need sound management to navigate this evolving reimbursement landscape. Previous research has not explored how competing priorities affect physical therapy managers' oversight of clinical quality. The purpose of this study was to create a preliminary model of the competing priorities, motivations, and responsibilities of managers while overseeing clinical quality. This qualitative study used the Rapid Qualitative Inquiry method. A purposive sample of 40 physical therapy managers and corporate leaders was recruited. A research team performed semi-structured interviews and observations in outpatient practices. The team used a grounded theory-based immersion/crystallization analysis approach. Identified themes delineated the competing priorities and workflows these managers use in their administrative duties. Six primary themes were identified that illustrate how managers: (1) balance managerial and professional priorities; (2) are susceptible to stakeholder influences; (3) experience internal conflict; (4) struggle to measure and define quality objectively; (5) are influenced by the culture and structure of their respective organizations; and (6) have professional needs apart from the needs of their clinics. Generally, managers' focus on clinical quality is notably less comprehensive than their focus on clinical operations. Additionally, the complex role of hybrid clinician-manager leaves limited time beyond direct patient care for administrative duties. Managers in organizations that hold them accountable to quality-based metrics have more systematic clinical quality oversight processes. This study gives physical therapy organizations a framework of factors that can be influenced to better facilitate managers' effective oversight of clinical quality. Organizations offering support for those managerial responsibilities will be well positioned to thrive in the new fee-for-value care structure.

Project description:BackgroundAchieving quality improvement in primary care is a challenge worldwide, with substantial gaps between best practice and actual practice. Within the context of Australia, Aboriginal and Torres Strait Primary Health Care (PHC) services have great variation across settings, structures and context. Research has highlighted how these contextual differences can critically influence the success of Quality Improvement (QI) interventions and outcomes. Less understood is the interaction between local context and other factors, which may impact the implementation of QI interventions. This paper aims to explore the strengths and challenges in QI for Aboriginal and Torres Strait Islander PHC services and their priorities for improvement.MethodsA multiple case study design was adopted, working with eight Aboriginal and Torres Strait Islander PHC services in Northern Territory, Queensland and Western Australia. Data were collected via a health service survey, semi-structured interviews with health service staff and service users and researcher observations, to explore QI and perceptions of care quality at the service level. Data reported here were analysed using an iterative thematic technique, within-case and across-case.ResultsA total of 135 interviews were conducted with health service staff, service users and community members. Participants emphasised the centrality of resilient community, committed workforce and valued Aboriginal and Torres Strait Islander team members in delivering care. A shared purpose around improving the health of community was a significant driver. Key challenges included staff turnover and shortages, a complex and overwhelming acute and chronic care workload, building relationships and trust between health services and the community. Service-suggested priority areas for improvement were categorised into five themes: i) cultural safety (community driving health and planning for culturally safe services); ii) community engagement (through clinical activities in the community); iii) shared ownership and a team approach around QI; iv) strengthening systems and consistent ways of doing things in the health service; and v) strengthening local workforce (and resources for a culturally safe workforce).ConclusionsThese findings advance understandings of relational, community and cultural factors which are identified priorities for the delivery of quality care in Aboriginal and Torres Strait Islander PHC services across varied contexts.

Project description:BackgroundWhile challenging to provide, prisoners are entitled to healthcare equivalent to community patients. This typically involves them travelling to hospitals for secondary care, whilst adhering to the prison's operational security constraints. Better understanding of equivalence issues this raises may help hospitals and prisons consider how to make services more inclusive and accessible to prisoners. We used prisoners' accounts of secondary care experiences to understand how these relate to the principle of healthcare equivalence.MethodsWe undertook a qualitative interview (n = 17) and focus group (n = 5) study in the English prison estate. Prisoners who had visited acute hospitals for consultations were eligible for participation. They were recruited by peer researchers. 45 people (21 female, 24 male, average age 41) took part across five prisons. Participants were purposively recruited for diversity in gender, age and ethnicity.FindingsExperiences of hospital healthcare were analysed for themes relating to the principle of 'equivalence of care' using Framework Analysis. Participants described five experiences challenging 'equivalence of care' for prisoners: (1) Security overriding healthcare need or experience (2) Security creating public humiliation and fear (3) Difficulties relating to prison officer's role in medical consultations (4) Delayed access due to prison regime and transport requirements and (5) Patient autonomy restricted in management of their own healthcare.InterpretationAchieving equivalence of care for prisoners is undermined by fear, stigma, reduced autonomy and security requirements. It requires co-ordinated action from commissioners, managers, and providers of prison and healthcare systems to address these barriers. There is a need for frontline prison and healthcare staff to address stigma and ensure they understand common issues faced by prisoners seeking to access healthcare, while developing strategies which empower the autonomy of prisoners' healthcare decisions.

Project description:BACKGROUND:A new movement towards improved postpartum care calls for restructuring how that care is provided. As professional guidelines evolve, understanding how providers prioritize and practice postpartum care can offer insights about elements of care that may be currently performed more routinely than providers deem a priority to do so, as well as those that may warrant more routine practice. METHODS:We surveyed 600 randomly-sampled U.S. postpartum care providers about their priorities for and the frequency with which specific elements of care are provided, as well as the feasibility of remote delivery of postpartum care provision (i.e., telemedicine). RESULTS:The survey response rate was 43% across medical specialties. Providers reported an average of only 24.4 ± 11.7 min available to spend on the postpartum visit. Certain types of postpartum care were highly prioritized and routinely performed, such as depression screening. Yet, there were also noted discrepancies between prioritized and performed care, revealing competing demands on providers' time. For example, pelvic exams were performed more often than similarly prioritized care, whereas screening for intimate partner violence and substance use were performed less often than similarly-prioritized care. Certain types of care were identified as important that are not explicitly addressed by national practice guidelines (e.g. transitioning to parenthood). Approximately 25% of respondents regarded telemedicine as a feasible remote care delivery alternative to much of the care currently provided in-person. CONCLUSIONS:The time providers have available to offer comprehensive postpartum care is constrained. Understanding how certain elements of care may be competing with one another at a single postpartum visit highlights those elements of care, which may be currently underperformed, as well as those elements of care that may warrant evaluation for future inclusion in standard care. For some providers experiencing time constraints, complementary remote care represents a potentially viable approach to implementing recommendations for transitioning the traditional visit to a more frequent, ongoing postpartum care process. In calling for a new approach to postpartum care delivery, professional organizations should consider the practices and priorities of their constituency as they revise guidelines and shape future research about the value of specific postpartum services.

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Competing priorities and second chances - A qualitative exploration of prisoners' journeys through the Hepatitis C continuum of care.

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Competing priorities and second chances - A qualitative exploration of prisoners' journeys through the Hepatitis C continuum of care.

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