Exploring substance misuse in a prison in Wales: a cross-sectional analysis.

BACKGROUND: Since 2015, the risks of dying due to drug-related causes are higher in prison than in the general population, with opiates and psychoactive substances being the most common substances recorded on death certificates in prison. Many individuals use drugs before entering the prison environment, it is not clear which individuals continue to use drugs while in prison. This study is a first step towards identifying characteristics of those who use drugs in prison, while exploring substances commonly used. METHODS: This retrospective cross-sectional analysis was performed on 299 men (mean age 38 years [SD 11]) in a long-stay UK prison in South Wales who participated in a research study exploring cardiometabolic risk in prison, in which substance misuse was included as a risk variable. All men aged 25 years or older with no previous diagnosis of cardiometabolic illness were eligible to participate. Data were collected between Oct 7 and Oct 23, 2019. Participants were asked details about their substance use before and since entering the prison. Mental wellbeing was assessed using the short Warwick Edinburgh Mental Wellbeing Score and low mental wellbeing calculated as 1 SD below the population mean score. To examine associations between characteristics (age groups, mental wellbeing, exposure to prison environment) and drug use, we used binary logistic regression (adjusted for characteristics such as age group, mental wellbeing, and exposure to prison environment ). FINDINGS: Overall, 195 (65%) of 299 participants reported a history of drug use before entering prison. Since entering prison 49 (16%) participants reported using drugs including methadone, and 24 (8%) reported using drugs excluding methadone. The next leading substances used in prison were spice (11 [4%] participants) and cannabis (six [2%] participants). All those who used drugs in prison had a history of drug use. Individuals more likely to continue using drugs in prison were aged 39 years and younger (adjusted odds ratio [aOR] 4·72, 95% CI 1·88-11·89; p=0·0009), with reported low mental wellbeing (3·38, 1·54-7·41; p=0·002), and had spent collectively more than 2·5 years in the prison environment (4·77, 2·09-10·91; p=0·0002). INTERPRETATION: This study, from a limited sample, describes the characteristics of those who use drugs in prison. Harm reduction interventions targeted to these individuals could reduce the risk of prison drug-related deaths. These findings should be interpreted with some caution, as this is a single site and may not reflect the wider UK prison environment. FUNDING: Public Health Wales.

A 3-year review of deaths in people under community justice supervision in Wales: a cross-sectional analysis.

BACKGROUND: Despite little fluctuation in the numbers of people under community justice supervision in England and Wales, the number of deaths in this population has more than doubled between 2013-14 and 2020-21, from 560 to 1343 deaths. Contributing factors and causes of mortality are somewhat unknown. The aim of this study was to understand the number and the leading causes of people dying while under community justice supervision in Wales, UK, between April 1, 2018, and March 31, 2021. METHODS: Public Health Wales in collaboration with HM Prison and Probation Service in Wales were provided with identifiable data (name, date of birth, date of death, and the Probation Delivery Unit) of 306 individuals (aged ≥18 years) who had died during this time period while under community justice supervision. Following de-duplication and matching of National Health Service (NHS) numbers using the Welsh Demographic System, 266 deaths were linked to the live Office for National Statistics (ONS) Death Registry to obtain the cause of death. Deaths were grouped based on the International Classification of Diseases (ICD)-10 code assigned as their underlying cause of death. FINDINGS: In this cross-sectional study, the mortality rate overall was higher in women than in men (7·5 vs 5·6 deaths per 1000 population), despite the majority of deaths being in men, with less than 40 deaths in women. Mortality rates were nearly double in those aged 50 years and older (9·4 deaths per 1000 population) than in those aged 18-49 years (5·0 deaths per 1000 population). Drugs or alcohol were considered a primary cause of death for just under half of all deaths (n=115; 43%), with opiates being the most commonly named substance (n=63; 24%). 70 drug-related deaths involved poly-drug use. Accidental drug-related deaths were four times higher in those aged 18-49 years than in those aged 50 years and older (2·3 vs 0·6 deaths per 1000 population). Diseases of the circulatory system accounted for 13% (n=34) of all deaths and were 5 times higher in those aged 50 years and older than those aged 18-49 years (2·2 vs 0·4 deaths per 1000 population). INTERPRETATION: This study provides valuable insight into the leading causes of death among this cohort, notably deaths associated with substance misuse in younger age groups and with circulatory disease in older age groups. The increase in substance misuse-related deaths reflects recent national UK trends. Further research is required to understand which of these deaths were preventable. FUNDING: None.

Abundance of undiagnosed cardiometabolic risk within the population of a long-stay prison in the UK.

BACKGROUND: The health of people in prisons is a public health issue. It is well known that those in prison experience poorer health outcomes than those in the general community. One such example is the burden of non-communicable diseases, more specifically cardiovascular disease (CVD), stroke and type 2 diabetes (T2DM). However, there is limited evidence research on the extent of cardiometabolic risk factors in the prison environment in Wales, the wider UK or globally. METHODS: Risk assessments were performed on a representative sample of 299 men at HMP Parc, Bridgend. The risk assessments were 30 min in duration and men aged 25-84 years old and free from pre-existing CVD and T2DM were eligible. During the risk assessment, a number of demographic, anthropometric and clinical markers were obtained. The 10-year risk of CVD and T2DM was predicted using the QRISK2 algorithm and Diabetes UK Risk Score, respectively. RESULTS: The majority of the men was found to be either overweight (43.5%) or obese (37.5%) and/or demonstrated evidence of central obesity (40.1%). Cardiometabolic risk factors including systolic hypertension (25.1%), high cholesterol (29.8%), low HDL cholesterol (56.2%) and elevated total cholesterol: HDL ratios (23.1%) were observed in a considerable number of men. Ultimately, 15.4% were calculated at increased risk of CVD, and 31.8% predicted at moderate or high risk of T2DM. CONCLUSIONS: Overall, a substantial prevalence of previously undiagnosed cardiometabolic risk factors was observed and men in prison are at elevated risk of cardiometabolic disease at a younger age than current screening guidelines.

Investigating the prevalence of latent Tuberculosis infection in a UK remand prison.

BACKGROUND: Tuberculosis (TB) remains a major global public health issue and in low-incidence countries guidance identifies the need to screen for and treat latent tuberculosis infection (LTBI) with the prison environment recommended as a setting to perform LTBI screening. This study describes the findings of a LTBI screening programme which took place on entry to a remand prison in the UK. METHODS: Testing for LTBI was undertaken alongside screening for blood borne viruses in 567 men. During the screening process, information was collected on demographic variables and also specific risk factors based on World Health Organization recommendations. LTBI analysis was performed using Interferon-Gamma Release Assay (IGRA) technique. RESULTS: In total, 40 men returned an IGRA positive result (7.1%). However, irrespective of IGRA/LTBI status there was a substantial burden of risk factors present including previous prison stay, history of substance misuse and no BCG vaccination. Non-White ethnicity, a history of substance misuse and age over 34 years were the most significant factors in identifying individuals who would require treatment for LTBI (Positive IGRA result). CONCLUSIONS: The study further demonstrates that the prevalence of LTBI remains increased within the prison environment and is a setting that still requires effective LTBI management.

Prevalence of HCV in prisons in Wales, UK and the impact of moving to opt-out HCV testing.

BACKGROUND: Viral hepatitis is a leading cause of death worldwide. The World Health Organisation introduced a target to reduce hepatitis C virus (HCV) as a public health threat by 2030. Testing and treatment of those at elevated risk of infection in prison is key to achieving disease elimination. An opt-out testing policy for those in prison was introduced in Wales, UK, in 2016. METHODS: We analysed all Wales laboratory data where the testing site was a prison. We analysed numbers tested and positivity for a 14-month period before and after the introduction of opt-out testing policy. RESULTS: Between September 2015 and December 2017, 6949 HCV tests were from prison settings in Wales, equating to 29% of admissions to prison (P < 0.001). All but one prison increased testing following the introduction of opt-out policy. Percentage positivity for HCV remained at 11% before and after opt-out policy (P = 0.572). Short-stay prisons saw higher rates of HCV positivity than long stay. CONCLUSION: Data suggest implementation of opt-out policy improved uptake and diagnosis of HCV amongst those in prison; however, further effort is required to fully embed screening for all. Positivity remains high amongst those in prison, particularly in short-stay prisons. Laboratory data can support audit of opt-out policy.

"A journey towards acceptance": The process of adapting to life with HIV in Greece. A Qualitative study.

Aim To identify the experiences related to adaptation for people living with HIV in Greece and to explore different adaptation stages as well as their individual reactions. BACKGROUND: Receiving an HIV positive diagnosis leads to major changes in an individual's life and it can trigger an array of emotions including fear, despair and loss of control. As the profile of the disease has changed due to its transition into a chronic disease and extended life expectancy, adaptation to life and coping with uncertain events is of paramount importance. METHOD: Interpretative phenomenological research design was used to guide data collection and analysis. A purposive sampling technique was used. Ethical procedures were taken into account and nine individuals who were diagnosed with HIV took part in the study using semi-structured interviews. RESULTS: Data analysis revealed the different stages of adaptation that the participants experienced after an HIV positive diagnosis. A superordinate theme identified as 'a journey towards acceptance' while five subthemes were formed, namely, 'Communicating the bad news, Conscious loneliness, Getting information, Receiving Support, and Moving on with hope'. CONCLUSION: An HIV positive diagnosis can affect the very core of the individual as the essence of -self- is targeted and in need of reform. Education, empathy, family and social support can help the individual make small steps towards a greater journey, that of acceptance.

A stepped wedge cluster randomized control trial of dried blood spot testing to improve the uptake of hepatitis C antibody testing within UK prisons.

BACKGROUND: The prevalence of hepatitis C (HCV) is elevated within prison populations, yet diagnosis in prisons remains low. Dried blood spot testing (DBST) is a simple procedure for the detection of HCV antibodies; its impact on testing in the prison context is unknown. METHODS: We carried out a stepped-wedge cluster-randomized control trial of DBST for HCV among prisoners within five male prisons and one female prison. Each prison was a separate cluster. The order in which the intervention (training in use of DBST for HCV testing and logistic support) was introduced was randomized across clusters. The outcome measure was the HCV testing rate by prison. Imputation analysis was carried out to account for missing data. Planned and actual intervention times differed in some prisons; data were thus analysed by intention to treat (ITT) and by observed step times. RESULTS: There was insufficient evidence of an effect of the intervention on testing rate using either the ITT intervention time (OR: 0.84; 95% CI: 0.68-1.03; P = 0.088) or using the actual intervention time (OR: 0.86; 95% CI: 0.71-1.06; P = 0.153). This was confirmed by the pooled results of five imputed data sets. CONCLUSIONS: DBST as a stand-alone intervention was insufficient to increase HCV diagnosis within the UK prison setting. Factors such as staff training and allocation of staff time for regular clinics are key to improving service delivery. We demonstrate that prisons can conduct rigorous studies of new interventions, but data collection can be problematic. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number Register (ISRCTN number ISRCTN05628482).

Raising public awareness of hepatitis B and C through a testing road show.

Over the past decade, as the profile of hepatitis B and C has been raised, a range of nurse-led services has been developed among substance misuse services, prisons and homeless services to reach those at the highest risk of infection. In the UK, it is estimated that up to two-thirds of people with hepatitis C are unaware of their infection (Cornberg et al, 2011). These patients represent those at the highest risk of developing cirrhosis and liver cancer, and many are unlikely to be in contact with services that offer routine testing. To help address this, the Welsh Hepatitis Nurse Forum (WHNF) carried out two road shows aimed at raising awareness of hepatitis B and C among the general public and offering testing. This paper describes the process, results and evaluation of the road shows that took place in 2011 and 2012. The road show is a unique way in which nurses can reach those who may not have regular contact with health services, and has proved useful for generally raising awareness. Further work is needed to evaluate the cost-effectiveness of the road shows.

Evaluating the impact of a prison smoking ban on the cardiovascular health of men in a UK prison.

PURPOSE: Smoking rates are known to be higher amongst those committed to prison than the general population. Those in prison suffer from high rates of comorbidities that are likely to increase their risk of cardiovascular disease (CVD), making it more difficult to manage. In 2016, a tobacco ban began to be implemented across prisons in England and Wales, UK. This study aims to measure the effect of the tobacco ban on predicted cardiovascular risk for those quitting smoking on admission to prison. DESIGN/METHODOLOGY/APPROACH: Using data from a prevalence study of CVD in prisons, the authors have assessed the effect of the tobacco ban on cardiovascular risk, using predicted age to CVD event, ten-year CVD risk and heart age, for those who previously smoked and gave up on admission to prison. FINDINGS: The results demonstrate measurable health gains across all age groups with the greatest gains found in those aged 50 years and older and who had been heavy smokers. Quitting smoking on admission to prison led to a reduced heart age of between two and seven years for all participants. ORIGINALITY/VALUE: The data supports tobacco bans in prisons as a public health measure to reduce risk of CVD. Interventions are needed to encourage maintenance of smoking cessation on release from prison for the full health benefits to be realised.

Prisoner health: assessing a nurse-led hepatitis C testing clinic.

Prisons provide an ideal setting in which to carry out blood-borne virus testing among a high-risk population. This paper describes a nurse-led testing programme offered to all prisoners within the substance misuse unit at a local prison in South Wales over a 4-year period. Challenges to organizing such a clinic within the prison setting are discussed. Between April 2006 and April 2010, approximately 4500 prisoners were admitted through the substance misuse unit. Blood-borne virus testing took place among 176 prisoners, of which 24 were hepatitis C seropositive, 19 were confirmed as virus-positive, and eight were referred to specialist teams to consider treatment. Among prison populations blood-borne virus testing needs to be encouraged and improved. Offering testing provides opportunities for harm minimization, education and referrals for treatment. Such provisions are needed to benefit the health of individuals, their families and the wider public health.

Estimating the burden of type 2 diabetes in the UK prison environment for the next decade.

Although limited, global evidence suggests that the cardiometabolic health of those in prison is poorer than their community peers. Type 2 diabetes (T2DM) is a public health challenge and community rates are continuing to rise. Given that cardiometabolic risk factors are prevalent amongst younger individuals within the prison population, it is reasonable to assume that the prison environment will also experience an increase in new cases of T2DM. Therefore, the aim of this study was, to predict in a current prison population, how many potential new cases of T2DM could develop in the next 10 years. This study used health data collected from a prison sample (n = 299) aged 25-84 years in HMP Parc, UK, and the Diabetes UK Risk Score was used to predict T2DM risk. In terms of projecting new cases, it was estimated that in the next decade 6.4 individuals per 100 would develop T2DM, and this value increased to 16.4 individuals per 100 in those aged 50 years and older. The development of new cases across all age groups is a concern, and it appears that the prison community are a 'target population' for prevention opportunities.

Exploring HIV infection in a UK vulnerable prisoner population in response to newly identified cases.

PURPOSE: Prison populations are considered at elevated risk of blood borne virus (BBV) transmission. Between December 2015 and February 2016, four new cases of HIV infection were diagnosed across two male vulnerable prisoner (VP) custodial units in Wales, UK. Cases were identified through routine BBV testing. The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH: As a result of identifying four new HIV cases, targeted BBV testing across the VP units using dried blood spot testing for HIV, Hepatitis C (HCV) and Hepatitis B was undertaken. FINDINGS: A total of 617 men were offered testing, 256 (41 per cent) were tested. No further cases of HIV were identified. Eight men were identified as HCV antibody positive. There was no evidence to suggest the four original cases of HIV were linked. PRACTICAL IMPLICATIONS: Embedding universal BBV screening within prison health provision will ensure timely identification of cases. Further research is needed to better understand BBV transmission risks within subsets of the prison population such as the VP and sex offending groups. ORIGINALITY/VALUE: Little is known about the prevalence of BBVs in vulnerable prison populations. The findings add to the knowledge available for practitioners in the field.

Hepatitis B vaccine coverage in short and long stay prisons in Wales, UK 2013-2017 and the impact of the global vaccine shortage.

Data on hepatitis B vaccination coverage across prisons in Wales 2013-2017 were analysed to describe coverage of one dose, and the full hepatitis B vaccine course for men in prison. Whilst vaccination coverage increased in both short and long stay prisons, annual coverage was consistently lower in short stay prisons compared to long-stay prisons, despite short-stay prisons delivering a higher numbers of vaccine doses. The exception of this pattern was in 2017, at a time of global vaccine shortage. The data demonstrate the need for all prisons to work together to ensure men in prison can receive the full hepatitis B vaccine course. Collaborative working will be required to recover from the vaccine shortage and to achieve higher coverage than the plateau in 2016.

Exploring health and wellbeing in prison: a peer research approach.

PURPOSE: Those in prison have expert knowledge of issues affecting their health and wellbeing. The purpose of this paper is to report on work undertaken with male prisoners. This paper presents learning and findings from the process of engaging imprisoned men as peer researchers. DESIGN/METHODOLOGY/APPROACH: The peer researcher approach offers an emic perspective to understand the experience of being in prison. The authors established the peer research role as an educational initiative at a long-stay prison in Wales, UK to determine the feasibility of engaging imprisoned men as peer researchers. Focus groups, interviews and questionnaires were used by the peer researchers to identify the health and wellbeing concerns of men in prison. FINDINGS: The project positively demonstrated the feasibility of engaging imprisoned men as peer researchers. Four recurring themes affecting health and wellbeing for men in a prison vulnerable persons unit were identified: communication, safety, respect and emotional needs. Themes were inextricably linked demonstrating the complex relationships between prison and health. ORIGINALITY/VALUE: This was the first prison peer-research project to take place in Wales, UK. It demonstrates the value men in prison can play in developing the evidence base around health and wellbeing in prison, contributing to changes within the prison to improve health and wellbeing for all.

Review of Roy adaptation model-based qualitative research.

The aim of this paper is to examine the role of qualitative research in the development of the Roy adaptation model. An exploration of the findings from qualitative research using Roy's adaptation model from 1995 to 2005 is compared with the findings and recommendations from a previous review over a 25-year period (1970-1995). The usefulness of qualitative methods in furthering nursing theory is highlighted. Findings from both reviews support the assumptions of the model while generating new information and demonstrating the valuable place of qualitative research in promoting nursing science.

Evaluation of an e-learning package to improve understanding of blood-borne viruses amongst prison staff in Wales, UK.

PURPOSE: The purpose of this paper is to provide education on blood-borne viruses (BBVs) to prison staff to help reduce stigma within the prisons, improve the care prisoners receive and reduce the risk of occupational transmission. DESIGN/METHODOLOGY/APPROACH: An e-module was used to improve staff understanding of hepatitis B (HBV), hepatitis C (HCV) and HIV at a prison in Wales, UK. An assessment was used to gather data on prison staff understanding of BBVs prior to undertaking the e-module. FINDINGS: In total, 530/697 (76 per cent) prison staff completed the BBV e-module. Average pre- and post-course assessment scores were 8.6/11 and 10.85/11, respectively. Most staff understood the modes of hepatitis transmission, however, gaps in understanding were highlighted. In total, 22 per cent of staff believed HBV and HCV were airborne, 9 per cent believed transmission occurred through sharing cutlery. In total, 31 per cent of staff believed prisoners with hepatitis should declare their status to the prison. Practical implications: The e-module significantly improved staff understanding of BBVs and should be incorporated into future prison training packages. Future education should include how BBVs are not transmitted with an emphasis on casual contact. Medical confidentiality in prisons should also be addressed. Improving understanding will help reduce the stigma of BBVs within prison and improve the multidisciplinary care the prisoner receives. ORIGINALITY/VALUE: To the authors knowledge this is the first published evaluation of a BBV learning package for custodial staff. Evaluation of this educational package demonstrates a unique and valuable insight into the general understanding of BBVs by prison staff in Wales, UK.

A Roy model study of adapting to being HIV positive.

Roy's adaptation model outlines a generic process of adaptation useful to nurses in any situation where a patient is facing change. To advance nursing practice, nursing theories and frameworks must be constantly tested and developed through research. This article describes how the results of a qualitative grounded theory study have been used to test components of the Roy adaptation model. A framework for "negotiating uncertainty" was the result of a grounded theory study exploring adaptation to HIV. This framework has been compared to the Roy adaptation model, strengthening concepts such as focal and contextual stimuli, Roy's definition of adaptation and her description of adaptive modes, while suggesting areas for further development including the role of perception. The comparison described in this article demonstrates the usefulness of qualitative research in developing nursing models, specifically highlighting opportunities to continue refining Roy's work.

Developing blood borne virus services across prisons in Wales, UK.

PURPOSE: This paper aims to describe the strategies being put in place to develop blood borne virus (BBV) services across prisons in Wales, UK, in response to the recommendations for prisons within the Welsh Government's Blood Borne Viral Hepatitis Action Plan for Wales. DESIGN/METHODOLOGY/APPROACH: A task and finish group was established to ensure multidisciplinary engagement between healthcare and custody staff. A service improvement package was developed focusing on awareness raising and/or development of clinical services for prisoners, prison officers and prison healthcare staff. FINDINGS: Prison healthcare staff have undergone training in BBVs and are being supported to deliver clinical services to prisoners. Training has been delivered in pre/post test discussion and dried blood spot testing; care pathways have been established between prison and community specialists for treatment referrals. An e-learning module is being rolled out to raise awareness amongst custody staff and encourage occupational hepatitis B vaccination. Literature on "liver health" has been produced to be given to every prisoner across Wales. SOCIAL IMPLICATIONS: It is envisaged that BBV services will become a routine part of prison care in Wales. Data on activity are being collected for evaluation and it is hoped that tackling BBVs in prisons will help reduce rates of infection both within prisons and in the wider community. ORIGINALITY/VALUE: This paper describes new initiatives that have been established to tackle BBVs across Welsh prisons and will be relevant to any prison healthcare staff looking to develop similar services.

Negotiating uncertainty: the transitional process of adapting to life with HIV.

Glaser's (1978) grounded-theory method was used to investigate the transitional process of adapting to life with HIV. Semistructured interviews took place with 8 male HIV-infected participants recruited from a clinic in South Wales, United Kingdom. Data analysis used open, substantive, and theoretical coding. Adapting to a life with HIV infection emerged as a process of adapting to uncertainty with "negotiating uncertainty" as a core concept. Seven subcategories represented movements between bipolar opposites labeled "anticipating hopelessness" and "regaining optimism." This work progresses the theoretical concepts of transitions, uncertainty, and adaptation in relation to the HIV experience.