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- Understanding the legislative and policy framework
- Understanding the prison environment
- The prisoner population
- Understanding the existing hepatitis C testing and treatment services
- Engaging stakeholders and formulating the plan
- Correctional authority – planning
- Health services – planning
Correctional authority - planning
Correctional authorities are critical stakeholders in facilitating the scale-up of hepatitis C testing and treatment. It is important to ensure that the correctional authority is willing to support the project throughout its lifecycle and is potentially conducive to change.
All necessary approvals and support should be gained in the planning phase to ensure the scale-up plan and subsequent implementation strategies are feasible.
Workforce and other resource requirements
Scale-up of hepatitis C testing and treatment requires movement of large numbers of prisoners to the health clinic (or permitted alternate locations) within the prison.
Alternatively, permission for healthcare staff to provide care in prison wings may be considered to ease logistical constraints. If a correctional officer escort is required for such movements or to supervise health-related interactions outside the clinic, workforce planning should consider: the projected need for additional allocation of correctional officer(s) based on the expected throughput of prisoners for testing and treatment, and whether the existing pool of officers on the roster can accommodate this need, or recruitment of new staff is needed.
Large scale movements of prisoners
The workload for correctional officers scheduled to escort large numbers of prisoners to the health clinic for hepatitis C testing and treatment was not feasible on top of their existing role demands. Also, in some prisons hepatitis C testing was conducted in alternate locations, where there were no correctional officers available.
The employment of a dedicated correctional officer or a small pool of officers on a roster who were dedicated to the task of escorting prisoners for hepatitis C testing and treatment was very effective. This required commitment and funding approval from the correctional authority.
“It works well with a dedicated officer to get the inmates, because then you’re not taking away from somebody else who has extra stuff lobbed on them”.
A specific budget allocation to facilitate scale-up is recommended. The primary budget consideration for the correctional authority is the workforce allocation to facilitate prisoner movements.
Other potential budget implications include the physical infrastructure costs associated with use of a suitable room for prisoner appointments, and any associated structural or equipment modification required; the cost of implementing or upgrading information systems, and preparation of the correctional data needed for monitoring and evaluation which may exceed routine data collection and reporting.
The costs associated with the participation by correctional personnel in the scale-up planning and project management committees should also be considered. Prisoners engaged in paid work whilst in prison may be disinclined to attend appointments for hepatitis C testing or treatment during work time. If possible, the correctional authority should absorb these losses within the prison industries budget.
Relatively cheap incentives for prisoners to participate in testing and treatment (such as barbecues for the prisoners on one wing – contingent upon participation) are very effective, along with incentives for correctional officers (such as a cake at morning tea) to gain their support for prisoner participation. Please refer to Resources page for examples of SToP-C incentives for prisoners.
“Because the dedicated officer doesn’t take away from our security budget….it does make it easier that it’s funded from that because otherwise you’re going to restrict things.”
Prison Manager of Security
Data collection and information systems
Access to custodial data is critical for planning effective scale-up of treatment, including a regular record of the total population in the centre(s), as well as entry/exit dates.
When combined with testing and treatment datasets from the health service, this information allows regular review of the coverage (i.e. the number and proportion of all prisoners being tested, as well as the number and proportion of all prisoners diagnosed with chronic hepatitis C being treated). If possible this data is best obtained at the individual level with coding to link corrections and health datasets, within jurisdictional privacy regulations.
Information regarding the number of prisoners that can feasibly be brought to the clinic per day should be sought to facilitate workforce and resource planning. The number of prisoners able to be seen may be impacted by various factors such as frequency of lock-downs (stay in cell periods), timing of let-go (release from the cells into communal areas) and access windows (periods in which prisoners are available for health care visits), the frequency of staff meetings or training days, and the availability of health clinic space.
A reduced prisoner flow resulting from such constraints will limit the potential for scale-up of testing and treatment. Information gaps or issues with access to data should be identified during the planning phase so that the potential to upgrade information systems and processes can be considered and costed.
Access to data
Testing and treatment scale-up requires regularly updated data regarding the number of individuals incarcerated within each centre (e.g. weekly or monthly) and movements between centres, as well as to/from the community. The most feasible method to collect and access this data should be considered during planning. Requests for site specific data from local centre management (e.g. general managers and managers of security) in the selected SToP-C prisons was unsuccessful.
These data were ultimately provided by the centralised data management unit for the corrective service as a whole, after provision of one-off funding from the SToP-C project to cover the costs incurred in setting up automated regular reports from the correctional database
Considerations for communication, education and special populations
A communication plan should be developed as part of the overall scale-up plan. This should include updates about scale-up implementation and progress to correctional staff, correctional authorities, policymakers, community organisations, and managing release of information to the general community (where applicable).
Regular communications with correctional authorities by the project team should be followed by endorsement and dissemination of progress toward targets to all correctional staff by the prison governor or other senior personnel. Methods of dissemination may include newsletters, emails, or announcements during staff meetings, including introducing personnel acting as staff champions.
“I just think information is the key….if you’re going to educate staff first and bring along whatever you’ve done in other centres to bolster that information, people are more palatable to a change that way.”
Correctional Manager of Security
Knowledge, attitudes and stigma
Correctional staff have widely varied levels of awareness of hepatitis C and the highly effective DAA treatments, as well as the important role of the prison sector in regional and national elimination. Further there are widely varied attitudes towards the merits of hepatitis C testing and treatment of prisoners, amongst the correctional workforce.
Stigma attached to hepatitis C may prevent prisoners coming forward for testing and treatment thereby impeding scale-up. This may include punitive action taken by correctional authorities as a result of a prisoner being recognised to have hepatitis C, and therefore notionally associated with ongoing injecting drug use.
These knowledge gaps and attitudinal barriers may be overcome by provision of hepatitis C education to the correctional workforce. In addition, identifying strong champions within the correctional staff is very effective, as well as engaging supportive officer(s) who are dedicated to the scale-up project.
Stigma should be considered in planning communications with targeted messaging to correct misinformation, emphasise the prison-specific reduction in risks from needle-stick injuries associated with scale-up, the community-wide public health benefits, and the right of prisoners of healthcare equivalent to community standards. In addition, it remains important to maintain systems to ensure confidentiality of the hepatitis C status of individual prisoners, from correctional officers as well as other prisoners, when planning scale-up. Please refer to Resources page for examples of staff education and training materials, as well as SToP-C educational resources for prisoners.
“To be honest I don’t care either way about prisoners getting hepatitis treatment, but I thought it was great when I heard that this program might stop me getting hep C from a jab when I am doing a cell search”.
“If they’re like smoking bupe or something and they’re using somebody else’s tube and that person’s got hep C, it can easily be passed on through saliva…but is it faecal matter as well?”
The characteristics of particular prisoner sub-populations may impact on the several aspects of planning the logistics of scale-up of hepatitis C testing and treatment, including those with a higher prevalence of risk behaviours such as injecting drug use, cultural sensitivities or stigma within ethnic minorities about hepatitis C infection, and restricted movement of prisoners in protection programs.