HIV and hepatitis prevention in prisons

This thesis comprises three studies that explore the attitudes and beliefs of prison staff and prisoners towards HIV and hepatitis B and C prevention policy in prisons.Analysis of the factors that influence the way prisoners and prison staff view prevention strategies highlighted some important issues from the perspective of the people most closely involved with implementation of prevention policy. The exploration of these issues was complex due to the security, legal, cultural and ethical issues that had to be considered.A case study approach incorporating qualitative and quantitative methods was used to try to embrace the complexity of the research aim. A qualitative foundation for staff and prisoner interviews was used for two reasons; firstly, so that the views of the researcher were not imposed and secondly because there were few prior research studies to base the current study on. In addition, as prisons differ in security category and in the types of prisoners held, it was presumed that developing the research to give a wider representation of the issues would be valuable; this overview was achieved by questionnaire. Data were collected from ten prisons, there were fortyone in-depth staff interviews from three types of prisons; data from 182 questionnaires from 7 prisons and 18 in-depth interviews with prisoners from the three prisons where staff were interviewed.The results show that the predominant concern of staff is that the prevention policies discussed in the study are to do with sex and drug misuse; activities considered illegal within the prison environment. Staff believed that some of the prevention measures concerned with reducing the risk associated with injecting drug use conflict with their discipline and security role and also conflict with the drug strategy policies that focus on eradicating drug use in prisons. Opiate detoxification programmes, abstinence based therapeutic programmes and drug-free areas were viewed most positively by staff and were portrayed as most closely aligned to their security and discipline role and the role of prisons in society. Most staff believed that providing condoms in prisons would also act against their discipline and security role. This is principally because of the potential to conceal or smuggle drugs using condoms and also because the stigma of same sex relationships in prisons may lead to aggression and bullying from other prisoners.Prisoners described a hidden culture of same sex relationships in prisons and generally did not completely welcome policies concerned with improved access to condoms. However, some of the prisoners highlighted a moral imperative to distribute condoms in prisons.Prisoners stated that they would view suspiciously any change in prevention policy concerned with injecting drug use, which ran counter to the current policies of intolerance to illicit drug use in prisons

The characteristics and motivations of online health information seekers : cross-sectional survey and qualitative interview study

Background: Most households in the United Kingdom have Internet access, and health-related Internet use is increasing. The National Health Service (NHS) Direct website is the major UK provider of online health information. Objective: Our objective was to identify the characteristics and motivations of online health information seekers accessing the NHS Direct website, and to examine the benefits and challenges of the health Internet. Methods: We undertook an online questionnaire survey, offered to users of the NHS Direct website. A subsample of survey respondents participated in in-depth, semistructured, qualitative interviews by telephone or instant messaging/email. Questionnaire results were analyzed using chi-square statistics. Thematic coding with constant comparison was used for interview transcript analysis. Results: In total 792 respondents completed some or all of the survey: 71.2% (534/750 with data available) were aged under 45 years, 67.4% (511/758) were female, and 37.7% (286/759) had university-level qualifications. They sought information for themselves (545/781, 69.8%), someone else (172/781, 22.0%), or both (64/781, 8.2%). Women were more likely than men to seek help for someone else or both themselves and someone else (168/509 vs 61/242, χ2 2 = 6.35, P = .04). Prior consultation with a health professional was reported by 44.9% (346/770), although this was less common in younger age groups (<36 years) (χ2 1 = 24.22, P < .001). Participants aged 16 to 75 years (n = 26, 20 female, 6 male) were recruited for interview by telephone (n = 23) and instant messaging/email (n = 3). Four major interview themes were identified: motivations for seeking help online; benefits of seeking help in this way and some of the challenges faced; strategies employed in navigating online health information provision and determining what information to use and to trust; and specific comments regarding the NHS Direct website service. Within the motivation category, four concepts emerged: the desire for reassurance; the desire for a second opinion to challenge other information; the desire for greater understanding to supplement other information; and perceived external barriers to accessing information through traditional sources. The benefits clustered around three theme areas: convenience, coverage, and anonymity. Various challenges were discussed but no prominent theme emerged. Navigating online health information and determining what to trust was regarded as a “common sense” activity, and brand recognition was important. Specific comments about NHS Direct included the perception that the online service was integrated with traditional service provision. Conclusions: This study supports a model of evolutionary rather than revolutionary change in online health information use. Given increasing resource constraints, the health care community needs to seek ways of promoting efficient and appropriate health service use, and should aim to harness the potential benefits of the Internet, informed by an understanding of how and why people go online for health

Young people's use of NHS Direct: a national study of symptoms and outcome of calls for children aged 0-15

Objectives National Health Service (NHS) Direct provides 24/7 expert telephone-based healthcare information and advice to the public in England. However, limited research has explored the reasons to why calls are made on behalf of young people, as such this study aimed to examine call rate (CR) patterns in younger people to enable a better understanding of the needs of this population in England. Setting NHS Direct, England, UK. Participants and methods CRs (expressed as calls/100 persons/annum) were calculated for all calls (N=358 503) made to NHS Direct by, or on behalf of, children aged 0–15 during the combined four ‘1-month’ periods within a year (July 2010, October 2010, January 2011 and April 2011). χ² Analysis was used to determine the differences between symptom, outcome and date/time of call. Results For infants aged <1, highest CRs were found for ‘crying’ for male (n=14, 440, CR=13.61) and female (n=13 654, CR=13.46) babies, which is used as a universal assessment applied to all babies. High CRs were also found for symptoms relating to ‘skin/hair/nails’ and ‘colds/flu/sickness’ for all age groups, whereby NHS Direct was able to support patients to self-manage and provide health information for these symptoms for 59.7% and 51.4% of all cases, respectively. Variations in CRs were found for time and age, with highest peaks found for children aged 4–15 in the 15:00–23:00 period and in children aged <1 in the 7:00–15:00 period. Conclusions This is the first study to examine the symptoms and outcome of calls made to NHS Direct for and on behalf of young children. The findings revealed how NHS Direct has supported a range of symptoms through the provision of health information and self-care support which provides important information about service planning and support for similar telephone-based services

The impact of location of the uptake of telephone based healthcare

Telephone healthcare systems have been put forward as a key strategy to overcome geographical disadvantage, however, evidence has suggested that usage decreases with increasing rurality. This research aimed to identify geographical high and low areas of usage of NHS Direct, a leading telephone healthcare provider worldwide to determine if usage is influenced by rurality. National call data was collected (January, 2011) from the NHS Direct Clinical Assessment System for all 0845 4647 calls in England, UK (N=360,137). Data extracted for analysis included; unit postcode of patient, type of call, date of call, time of call and final disposition. Calls were mapped using GIS mapping software using full postcode, aggregated by population estimate by local authority to determine confidence intervals across two thresholds by call rate. Uptake rate Output Area Classification (OAC) group profiles was performed using the chi-square goodness of fit. The majority of calls were ‘symptomatic’ (N=280,055; 74.8%) i.e. calls that were triaged by an expert nurse, with the remaining 25.2% of calls health/ medicine information only (N=94,430). NHS Direct were able to manage through self-care advice and health information 43.5 of all calls made (N=99,367) with no onward referral needed. Geographical pattern of calls were highest for more urbanised areas with significant higher call usage found in larger cities. Lower observed usage was found in areas that are more rural of which were characterised by above average older populations. This was supported by geo-segmentation, which highlighted that rural and older communities had the lowest expected uptake rate. There is a variation of usage of NHS Direct relating to rurality, which suggests that this type of service has not been successful in reducing accessible barriers. However, geographical variations are likely to be influenced by age. There is a need for exploratory to determine the underlying factors that contribute to variation in uptake of these services particularly older people who reside in rural communities. This will have worldwide implications as to how telephone based healthcare is introduced

A Study on Marketing Behaviour of Rural Youth Entrepreneurs among Seven Different Ventures

The study was conducted among 210 rural youth entrepreneurs of seven different ventures in Krishnagiri district to assess their marketing behaviour. The entrepreneurial ventures selected for the study were Sericulture, Mushroom Production, Hi-tech nurseries (Polyhouse), Fruit and flower nursery, Fisheries, Poultry farming and Value addition (Tamarind processing and Millet based cookies).

Who uses NHS Direct? Investigating the impact of ethnicity on the uptake of telephone based healthcare

Introduction NHS Direct, a leading telephone healthcare provider worldwide, provided 24/7 health care advice and information to the public in England and Wales (1998-2014). The fundamental aim of this service was to increase accessibility, however, research has suggested a disparity in the utilisation of this service related to ethnicity. This research presents the first national study to determine how the diverse population in England have engaged with this service. Methods NHS Direct call data from the combined months of July, 2010 October, 2010, January 2011 and April, 2011 was analysed (N?=?1,342, 245) for all 0845 4647 NHS Direct core service calls in England. Expected usage of NHS Direct was determined for each ethnic group of the population by age and gender and compared by actual usage using Chi-square analysis. A one-way analysis of variance (ANOVA) was used to determine variations of uptake by ethnic group and Index for Multiple Deprivation (IMD) 2010 rank. Results Results confirmed that all mixed ethnic groups (White and Black Caribbean, White and Black African, White and Asian) had a higher than expected uptake of NHS Direct which held consistent across all age groups. Lower than expected uptake was found for Black (African/Caribbean) and Asian (Bangladeshi/Indian/Chinese) ethnic group which held consistent by age and gender. For the Pakistani ethnic group usage was higher than expected in adults aged 40 years and older although was lower than expected in younger age groups (0¿39). Conclusion Findings support previous research suggesting a variation in usage of NHS Direct influenced by ethnicity, which is evidenced on a national level. Further research is now required to examine the underlying barriers that contribute to the ethnic variation in uptake of this service

Telehealth for patients at high risk of cardiovascular disease: pragmatic randomised controlled trial

Objective: To assess whether non-clinical staff can effectively manage people at high risk of cardiovascular disease using digital health technologies. Design: Pragmatic, multicentre, randomised controlled trial. Setting: 42 general practices in three areas of England. Participants: Between 3 December 2012 and 23 July 2013 we recruited 641 adults aged 40 to 74 years with a 10 year cardiovascular disease risk of 20% or more, no previous cardiovascular event, at least one modifiable risk factor (systolic blood pressure ≥140 mm Hg, body mass index ≥30, current smoker), and access to a telephone, the internet, and email. Participants were individually allocated to intervention (n=325) or control (n=316) groups using automated randomisation stratified by site, minimised by practice and baseline risk score. Interventions: Intervention was the Healthlines service (alongside usual care), comprising regular telephone calls from trained lay health advisors following scripts generated by interactive software. Advisors facilitated self-management by supporting participants to use online resources to reduce risk factors, and sought to optimise drug use, improve treatment adherence, and encourage healthier lifestyles. The control group comprised usual care alone. Main outcome measures: The primary outcome was the proportion of participants responding to treatment, defined as maintaining or reducing their cardiovascular risk after 12 months. Outcomes were collected six and 12 months after randomisation and analysed masked. Participants were not masked. Results: 50% (148/295) of participants in the intervention group responded to treatment compared with 43% (124/291) in the control group (adjusted odds ratio 1.3, 95% confidence interval 1.0 to 1.9; number needed to treat=13); a difference possibly due to chance (P=0.08). The intervention was associated with reductions in blood pressure (difference in mean systolic −2.7 mm Hg (95% confidence interval −4.7 to −0.6 mm Hg), mean diastolic −2.8 (−4.0 to −1.6 mm Hg); weight −1.0 kg (−1.8 to −0.3 kg), and body mass index −0.4 (−0.6 to −0.1) but not cholesterol −0.1 (−0.2 to 0.0), smoking status (adjusted odds ratio 0.4, 0.2 to 1.0), or overall cardiovascular risk as a continuous measure (−0.4, −1.2 to 0.3)). The intervention was associated with improvements in diet, physical activity, drug adherence, and satisfaction with access to care, treatment received, and care coordination. One serious related adverse event occurred, when a participant was admitted to hospital with low blood pressure. Conclusions: This evidence based telehealth approach was associated with small clinical benefits for a minority of people with high cardiovascular risk, and there was no overall improvement in average risk. The Healthlines service was, however, associated with improvements in some risk behaviours, and in perceptions of support and access to care

Reassuring and managing patients with concerns about swine flu: Qualitative interviews with callers to NHS Direct

<p>Abstract</p> <p>Background</p> <p>During the early stages of the 2009 swine flu (influenza H1N1) outbreak, the large majority of patients who contacted the health services about the illness did not have it. In the UK, the NHS Direct telephone service was used by many of these patients. We used qualitative interviews to identify the main reasons why people approached NHS Direct with concerns about swine flu and to identify aspects of their contact which were reassuring, using a framework approach.</p> <p>Methods</p> <p>33 patients participated in semi-structured interviews. All patients had telephoned NHS Direct between 11 and 14 May with concerns about swine flu and had been assessed as being unlikely to have the illness.</p> <p>Results</p> <p>Reasons for seeking advice about swine flu included: the presence of unexpectedly severe flu-like symptoms; uncertainties about how one can catch swine flu; concern about giving it to others; pressure from friends or employers; and seeking 'peace of mind.' Most participants found speaking to NHS Direct reassuring or useful. Helpful aspects included: having swine flu ruled out; receiving an alternative explanation for symptoms; clarification on how swine flu is transmitted; and the perceived credibility of NHS Direct. No-one reported anything that had increased their anxiety and only one participant subsequently sought additional advice about swine flu from elsewhere.</p> <p>Conclusions</p> <p>Future major incidents involving other forms of chemical, biological or radiological hazards may also cause large numbers of unexposed people to seek health advice. Our data suggest that providing telephone triage and information is helpful in such instances, particularly where advice can be given via a trusted, pre-existing service.</p

Effectiveness and cost-effectiveness of a telehealth intervention to support the management of long-term conditions: study protocol for two linked randomized controlled trials

Background: As the population ages, more people are suffering from long-term health conditions (LTCs). Health services around the world are exploring new ways of supporting people with LTCs and there is great interest in the use of telehealth: technologies such as the Internet, telephone and home self-monitoring. Methods/Design: This study aims to evaluate the effectiveness and cost-effectiveness of a telehealth intervention delivered by NHS Direct to support patients with LTCs. Two randomized controlled trials will be conducted in parallel, recruiting patients with two exemplar LTCs: depression or raised cardiovascular disease (CVD) risk. A total of 1,200 patients will be recruited from approximately 42 general practices near Bristol, Sheffield and Southampton, UK. Participants will be randomly allocated to either usual care (control group) or usual care plus the NHS Direct Healthlines Service (intervention group). The intervention is based on a conceptual model incorporating promotion of self-management, optimisation of treatment, coordination of care and engagement of patients and general practitioners. Participants will be provided with tailored help, combining telephone advice from health information advisors with support to use a range of online resources. Participants will access the service for 12 months. Outcomes will be collected at baseline, four, eight and 12 months for the depression trial and baseline, six and 12 months for the CVD risk trial. The primary outcome will be the proportion of patients responding to treatment, defined in the depression trial as a PHQ-9 score <10 and an absolute reduction in PHQ-9 ≥5 after 4 months, and in the CVD risk trial as maintenance or reduction of 10-year CVD risk after 12 months. The study will also assess whether the intervention is cost-effective from the perspective of the NHS and personal social services. An embedded qualitative interview study will explore healthcare professionals’ and patients’ views of the intervention. Discussion: This study evaluates a complex telehealth intervention which combines evidence-based components and is delivered by an established healthcare organisation. The study will also analyse health economic information. In doing so, the study hopes to address some of the limitations of previous research by demonstrating the effectiveness and cost-effectiveness of a real world telehealth interventio

Tracking the spatial diffusion of influenza and norovirus using telehealth data: A spatiotemporal analysis of syndromic data

Background: Telehealth systems have a large potential for informing public health authorities in an early stage of outbreaks of communicable disease. Influenza and norovirus are common viruses that cause significant respiratory and gastrointestinal disease worldwide. Data about these viruses are not routinely mapped for surveillance purposes in the UK, so the spatial diffusion of national outbreaks and epidemics is not known as such incidents occur. We aim to describe the geographical origin and diffusion of rises in fever and vomiting calls to a national telehealth system, and consider the usefulness of these findings for influenza and norovirus surveillance. Methods: Data about fever calls (5- to 14-year-old age group) and vomiting calls (≥ 5-year-old age group) in school-age children, proxies for influenza and norovirus, respectively, were extracted from the NHS Direct national telehealth database for the period June 2005 to May 2006. The SaTScan space-time permutation model was used to retrospectively detect statistically significant clusters of calls on a week-by-week basis. These syndromic results were validated against existing laboratory and clinical surveillance data. Results: We identified two distinct periods of elevated fever calls. The first originated in the North-West of England during November 2005 and spread in a south-east direction, the second began in Central England during January 2006 and moved southwards. The timing, geographical location, and age structure of these rises in fever calls were similar to a national influenza B outbreak that occurred during winter 2005–2006. We also identified significantly elevated levels of vomiting calls in South-East England during winter 2005–2006. Conclusion: Spatiotemporal analyses of telehealth data, specifically fever calls, provided a timely and unique description of the evolution of a national influenza outbreak. In a similar way the tool may be useful for tracking norovirus, although the lack of consistent comparison data makes this more difficult to assess. In interpreting these results, care must be taken to consider other infectious and non-infectious causes of fever and vomiting. The scan statistic should be considered for spatial analyses of telehealth data elsewhere and will be used to initiate prospective geographical surveillance of influenza in England.