Relationships Matter: Social Capital Theory and Hepatitis C Treatment Uptake among Men in Prison

Social capital is a valuable social resource that has the potential to influence health outcomes at both the individual and community level. The mechanisms upon which this occurs are extensive and are explored within this thesis. Hepatitis C is highly prevalent in the prison setting, with an estimated HCV-antibody prevalence of 26% among the global prison population. Although HCV treatment is available in the prison setting, a number of barriers exist resulting in low treatment uptake. This PhD thesis explores the social capital of men in prison living with hepatitis C. Chapter 1 of this thesis provides an overview of social capital, presents prisoner demographics in the Australian setting, and outlines hepatitis C prevalence among the prisoner population, risk factors for hepatitis C, and changes in the hepatitis C treatment landscape. Chapter 2 (published in Health & Justice) is a systematic literature review of social capital in the prison setting. Chapter 3 (published in Health & Justice) draws on thirty qualitative interviews completed with male inmates living with hepatitis C to identify social capital dimensions in the prison setting (e.g., trust and safety, reciprocity, agency, formal and informal networks). Chapter 4 (published in Social Science & Medicine) explores contextual differences of social capital between Aboriginal and non-Aboriginal inmates living with hepatitis C. The fifth chapter (published in the Journal of Viral Hepatitis) explores social capital (specifically, bonding and linking social capital) and its influence on hepatitis C education and treatment access in the prison setting. Following on from the qualitative interviews, the Inmate Social Capital Questionnaire – HCV (ISCQ-HCV) was developed for use with male inmates. Chapter 6 reports on the piloting of the ISCQ-HCV (to be submitted for publication). Chapter 7 provides discussion of the overall work within this thesis and includes suggestions and recommendations for practical changes within the prison setting to improve HCV treatment uptake among those incarcerated. Findings from this PhD research show that social capital theory is a useful strategy for exploring HCV treatment uptake among men in prison. It is anticipated that the results of this study are transferable to other health interventions among those incarcerated

Barriers and facilitators to HIV and syphilis rapid diagnostic testing in antenatal care settings in low-income and middle-income countries: a systematic review.

BACKGROUND: Testing and treatment during pregnancy is a well-established and cost-effective prevention strategy, which relies largely on use of rapid diagnostic tests (RDTs). Yet, in many low-income and-middle-income countries, the uptake of RDTs is suboptimal. A qualitative meta-synthesis was conducted to identify the barriers and enablers to use of HIV and syphilis RDTs among pregnant women in low-income and middle-income countries. METHODS: This review was conducted using PRISMA guidelines. Eligible studies included peer-reviewed publications, which used qualitative methods to explore HIV and syphilis RDT in antenatal care clinics in low-income and middle-income countries. Studies focusing on perspectives of pregnant women, healthcare workers and/or stakeholders were included. We used an inductive approach informed by a modified socioecological model to synthesise the data. RESULTS: 62 manuscripts met the eligibility criteria. For pregnant women, initial acceptance of the RDT and continuation in antenatal care depends on the perception that engaging in testing will be a beneficial experience for their baby and themselves, often influenced by the provision of services that are gender-sensitive, confidential, respectful, flexible and considers their well-being into the future. Local sociocultural beliefs about pregnancy and diseases, awareness of diseases and gender roles in society also influenced RDT acceptability among pregnant women. For healthcare workers, the ability to provide high-quality RDT care required ongoing training, accurate and easy to use tests, support from supervisors and communities, sufficient resources and staffing to provide services, and reliable salary. At the stakeholder level, well-developed guidelines and health system infrastructures were imperative to the delivery of RDT in antenatal clinics. CONCLUSION: Our findings highlight clear gaps to the provision of sustainable and culturally acceptable maternal HIV and/or syphilis screening using RDTs. In addition, greater attention needs to be paid to community stakeholders in promoting the uptake of RDT in antenatal clinics. PROSPERO REGISTRATION NUMBER: CRD42018112190

Perceptions of COVID-19 Vaccines: Lessons from Selected Populations Who Experience Discrimination in the Australian Healthcare System

COVID-19 vaccination is particularly challenging among populations who have experienced discrimination in healthcare settings. This paper presents qualitative findings from in-depth interviews about COVID-19 vaccination conducted in Australia between October 2020 and November 2021. Data from four different studies are presented; each population has unique experiences of discrimination within the healthcare system: Aboriginal people; people who inject drugs (PWID); people living with HIV (PLHIV); and gay and bisexual men (GBM). Analyses were guided by the behavioural and social determinants model that forms the basis of the World Health Organization’s “data for action: achieving high uptake of COVID-19 vaccines” interim guidance. All populations viewed vaccination as necessary for community protection, although narratives of community care were most common among Aboriginal people. Concerns about vaccine safety were expressed by all participant groups, although participants living with HIV and GBM were more trusting of vaccines possibly because of their ongoing and usually positive past experiences with biomedical technologies for HIV management and sexual health. Aboriginal participants reported distrust of mainstream government and participants who inject drugs expressed a more generalised suspicion about COVID-19 and its origins. Practical problems related to transport, booking appointments for vaccination and so forth, were more common among participants living with HIV and GBM, possibly because these specific interviews were conducted throughout 2021 when vaccines were more available, whereas data for the other populations were collected before the vaccine rollout. Findings show that vaccine willingness is shaped by past experiences of discrimination in healthcare setting, but different histories of discrimination can differently impact vaccine willingness. Promotional messaging and delivery must take account of these important differences so to not treat these populations homogenously

The ‘missing’ in the ‘endgame’ of hepatitis C elimination: A qualitative study in New South Wales, Australia

Introduction: After a promising start in Australia, elimination efforts for hepatitis C are not on track. Following the global campaign to ‘find the missing’ in hepatitis C response, this qualitative study explores stakeholder perspectives on the ‘missing’ in the ‘endgame’ of hepatitis elimination in the state of New South Wales, Australia. Method: Twenty-eight key informants working in New South Wales, elsewhere in Australia and internationally in high income countries participated in a semi-structured qualitative interview. Analysis examined key informant accounts of the ‘missing’ in efforts to eliminate hepatitis C. Results: Participants' accounts framed the missing in relation to epidemiological knowledge, making-up four population categories ‘missing’ or ‘missed’ in hepatitis C response. In turn, accounts situated the missing in relation to where and how individuals were presumed to connect, or not, with existing health-care infrastructures. This gave rise to concerns about the capacity of health services to be made available for those at risk or in need, with systems said to create opportunities for people to ‘miss out’ on hepatitis C services. Discussion and Conclusions: The ‘missing’ in the ‘endgame’ of hepatitis C elimination effort is not simply a function of who—populations missed—but of where and how, that is, situation and context. Our findings encourage a focus on how services, systems and contexts may create situations in which people become missed or are ‘made missing’ from care. We therefore advocate for a systemic, and not only population-based, approach in the final push towards hepatitis C's elimination

A policy analysis exploring hepatitis C risk, prevention, testing, treatment and reinfection within Australia’s prisons

Abstract Background Hepatitis C (HCV) is a global public health concern. There is a global prevalence of 15% among the world’s prisoner population, suggesting the need for priority HCV treatment among this population group. New highly efficacious therapies with low side effects, known as directing-acting antivirals, became available under Australia’s universal healthcare scheme on 1 March 2016. This creates an opportune time to trial treatment as prevention as an elimination strategy for HCV in prison settings. This paper examines whether policies in Australian jurisdictions support treatment scale-up to achieve elimination among this priority population. Methods A comprehensive search was conducted using Google and other web-based search functions to locate all publicly available policies in each Australian state and territory related to HCV health and HCV-related prison health. Ministers (corrections and health) were contacted from each jurisdiction to identify any additional policies. Inductive and deductive analyses were conducted for each jurisdiction, with documents being assessed against a set of four a priori criteria. Documents included in the analysis were current at 1 September 2017, or 18 months following treatment availability. Results A total of 18 documents were located, including both health (n = 12) and corrections/prison health (n = 6) documents relevant to HCV. Jurisdictions ranged in their commitments for delivering HCV harm reduction strategies and treatment availability within the prison setting. Conclusion Few jurisdictions have updated or published HCV-related health or prisoner health policies following availability of directing-acting antivirals. Current policies do not provide effective support for implementing treatment scale-up that could be possible under universal access to HCV treatment among this priority population

Social capital strategies to enhance hepatitis C treatment awareness and uptake among men in prison

Prisoner populations are characterized by high rates of hepatitis C (HCV), up to thirty times that of the general population in Australia. Within Australian prisons, less than 1% of eligible inmates access treatment. Public health strategies informed by social capital could be important in addressing this inequality in access to HCV treatment. Twenty-eight male inmates participated in qualitative interviews across three correctional centres in New South Wales, Australia. All participants had recently tested as HCV RNA positive or were receiving HCV treatment. Analysis was conducted with participants including men with experiences of HCV treatment (n=10) (including those currently accessing treatment and those with a history of treatment) and those who were treatment naïve (n=18). Social capital was a resourceful commodity for inmates considering and undergoing treatment while in custody. Inmates were a valuable resource for information regarding HCV treatment, including personal accounts and reassurance (bonding social capital), while nurses a resource for the provision of information and care (linking social capital). Although linking social capital between inmates and nurses appeared influential in HCV treatment access, there remained opportunities for increasing linking social capital within the prison setting (such as nurse-led engagement within the prisons). Bonding and linking social capital can be valuable resources in promoting HCV treatment awareness, uptake and adherence. Peer-based programmes are likely to be influential in promoting HCV outcomes in the prison setting. Engagement in prisons, outside of the clinics, would enhance opportunities for linking social capital to influence HCV treatment outcomes.The first author (LL) is a recipient of a National Health & Medical Research Council Scholarship (Grant No. 1075727). The Centre for Social Research in Health is supported by a grant from the Australian Government Department of Health

Violence and hepatitis C transmission in prison-A modified social ecological model.

BackgroundTransmission of hepatitis C virus (HCV) among the prisoner population is most frequently associated with sharing of non-sterile injecting equipment. Other blood-to-blood contacts such as tattooing and physical violence are also common in the prison environment, and have been associated with HCV transmission. The context of such non-injecting risk behaviours, particularly violence, is poorly studied. The modified social-ecological model (MSEM) was used to examine HCV transmission risk and violence in the prison setting considering individual, network, community and policy factors.MethodsThe Australian Hepatitis C Incidence and Transmission Study in prisons (HITS-p) cohort enrolled HCV uninfected prisoners with injecting and non-injecting risk behaviours, who were followed up for HCV infection from 2004-2014. Qualitative interviews were conducted within 23 participants; of whom 13 had become HCV infected. Deductive analysis was undertaken to identify violence as risk within prisons among individual, network, community, and public policy levels.ResultsThe risk context for violence and HCV exposure varied across the MSEM. At the individual level, participants were concerned about blood contact during fights, given limited scope to use gloves to prevent blood contamination. At the network level, drug debt and informing on others to correctional authorities, were risk factors for violence and potential HCV transmission. At the community level, racial influence, social groupings, and socially maligned crimes like sexual assault of children were identified as possible triggers for violence. At the policy level, rules and regulations by prison authority influenced the concerns and occurrence of violence and potential HCV transmission.ConclusionContextual concerns regarding violence and HCV transmission were evident at each level of the MSEM. Further evidence-based interventions targeted across the MSEM may reduce prison violence, provide opportunities for HCV prevention when violence occurs and subsequent HCV exposure

Vulnerability and antimicrobial resistance

It is now well-recognised that antimicrobial resistance (AMR), or the ability of organisms to resist currently available antibiotics and other antimicrobial drugs, represents one of the greatest dangers to human health in the 21st Century. As of 2022, AMR is a top-10 global public health threat. Various national and transnational initiatives have been implemented to address accelerating AMR, and the pressure to find local and global solutions is increasing. Despite this urgency, surprisingly limited progress is being made in rolling back or even slowing resistance. A multitude of perspectives exist regarding why this is the case. Key concerns include an enduring dependency on market-driven drug development, the lacklustre governance and habitual over-prescribing of remaining antimicrobial resources, and rampant short-termism across societies. While rarely presented in such terms, these disparate concerns all speak to the social production of vulnerability. Yet vulnerability is rarely discussed in the AMR literature, except in terms of ‘disproportionate effects’ of AMR. In this paper, we therefore present an analysis of vulnerability as manifest in the AMR scene, showing that vulnerability is both a predictable consequence of AMR and, critically, productive of AMR to begin with. We underline why this matters for international efforts to combat resistance

Sex, drugs and superbugs: The rise of drug resistant STIs

Antimicrobial resistance (AMR) presents a swiftly advancing challenge to a wide range of healthcare and health promotion practices. While rising rates of AMR share some dimensions across contexts, the specificities of field, practice, place and population shape – and at times hinder attempts to stem – the rising tide of this health threat. Sexually transmitted infections (STIs) are one area of healthcare where the threat of AMR has traditionally been met with lethargy. In this paper, we draw on a range of stakeholder perspectives across practice, innovation and regulatory systems in Australia, the US and the UK to understand and examine the evolving nexus of STIs and AMR, including the roles of cultural reception, professional practice and political traction. We argue for a critical sociology of the nexus of sexual health and evolving resistance, which will be instructive for comprehending inaction and informing future developments. We also note that part of this critical sociology must involve challenging stigma concerning sexual practices and people/groups, and recognising the role of communities in driving positive change