Background
Methods
Term | Definition |
---|---|
Realist review | A theory-driven approach to synthesising secondary research (including quantitative, qualitative, or mixed methods research). It aims to develop an explanatory model for how a programme (or different programmes) bring about a recorded change, why, for whom, and under what circumstances. It does this by developing realist programme theory, expressed as Context + Mechanism (Resource/Response) = Outcome. |
Rapid-realist review (RRR) | An adapted form of realist review, which provides a truncated method for the development of realist programme theory, whilst preserving the core elements of realist methodology. It relies more explicitly on stakeholders to focus and expedite the review process. |
Programme theory | An explanation for how a programme works. Realist reviews and RRRs attempt to develop and test programme theory. |
Provisional programme theory | A hypothesised explanation for how a programme is expected to work. Realist reviews and RRR usually start by developing a provisional programme theory to be tested using the literature. |
Refined programme theory | The product of a realist review or RRR. An explanation for how a programme works in practice, based on empirical data identified by the review. |
Context-mechanism-outcome (CMO) configuration | A heuristic used in realist reviews or RRRs to structure an explanation for how a programme, or part of a programme, works. CMO configurations act as the building blocks for programme theory. |
Context | Covers the programme context and the broader contextual backdrop that the programme is situated within, which modify the expression of mechanisms [22]. |
Mechanism | The “underlying entities, processes or social structures, which operate in particular contexts to generate outcomes of interest” [18]. This review focused on the individual reasoning and preference construction, which occurred in response to resources implemented by the opt-out testing programme [79]. |
Outcome | Both the intended and unintended consequences of the opt-out testing programme. Outcomes can be proximal, intermediate, or final [22]. |
Nudge Theory | Nudge is a “substantive theory” (i.e. a theory that exists within a discipline, which can be used to help understand the way a programme works). Utilised in the fields of behavioural science and economics, it describes various quirks of human behaviour and decision-making and suggests ways these can be used to encourage certain actions. |
Default Effect | A theory within Nudge, which suggests that for any choice or action, there is a tendency for the majority of individuals to stick with the default option. |
Review process
Phase one
Phase two
Population | Location | Exposure |
---|---|---|
• Prisoner* • Offender* • Convict* • Detainee* • Inmate* • Incarcerated | • Prison* • Gaol* • Jail* • Penal institution* • Correction* or penal or remand* or detention or custody) adj2 (centre or department or facility* or system*) • Penitent* | • Mass screen* • (Mandatory or systematic or routine or compulsory or obligatory) adj (test* or screen* or diagnos* or identif* or assess) • Opt-out • Opt* out |
Phase three
Results
First author, year | Country | Prison | Disease | Study design | Data collection | Aims | Dimensions of relevance | Strength of relevance | Quality score |
---|---|---|---|---|---|---|---|---|---|
Kavasery, 2009 [43] | U.S. | Urban men’s jail – New Haven Connecticut | HIV | Prospective controlled trial | Quantitative data capture | Determine the optimal timing of opt-out HIV testing for newly incarcerated jail detainees. | Red Orange Green | 9 |
d
|
Beckwith, 2011 [41] | U.S. | Rhode Island Jail | HIV | Mixed-methods: sequential explanatory | Routine data and interviews/FGD | Introduce rapid opt-out HIV testing to Rhode Island Jail. | Red Orange Green | 8 |
d
|
Public Health England, 2015 [5] | U.K. | Mixture of phase 1 “pathfinder” prisons | HIV, HCV, and HBV | Project evaluation | Questionnaire | Evaluation of opt-out testing for blood borne viruses, implemented throughout pilot English prisons. | Red Orange | 4 | N/A |
Elkington, 2016 [59] | U.S. | Mixed | HIV | Literature review | Systematic search | To review the effectiveness of HIV testing and linkage programmes and review barriers and facilitators to these programmes in the correctional setting. | Red Orange | 4 | N/A |
Rosen, 2016 [52] | U.S. | North Carolina | HIV | Before and after study | Routine data | Assess the impact of routine opt-out testing in terms of case detection. | Red | 5 |
d
|
Rice, 2011 [44] | U.S. | Wayne County Jail | HIV | Thesis | Multiple | Design, implement, and evaluate a jail-based HIV testing program. | Red Orange Green | 10 | N/A |
Spaulding, 2015 [38] | U.S. | Fulton County Jail | HIV | Mixed-methods: sequential explanatory | Routine data and questionnaire | To establish a rapid opt-out HIV testing program, led by the jail-based nursing team. | Red Orange Green | 6 |
c
|
Lucas, 2016 [39] | U.S. | Eight prison reception centres (California) | HIV | Quantitative descriptive evaluation | Routine data | Conduct an evaluation of routine HIV services, implemented throughout California. | Red | 4 |
c
|
Rosen, 2007 [63] | U.S. | 8 intake prisons in North Carolina | HIV | Thesis | Routine data | Evaluation of a large southern state opt-out HIV testing programme. | Red Orange Green | 5 | N/A |
Schoenbachler, 2016 [55] | U.S. | Durham County Jail, Florence Detention, Orangeburg Jail, Marion Jail and Darlington Jail | HCV | Quantitative descriptive evaluation | Routine data | Evaluate an HCV testing and linkage-to-care post release program among detainees of small-to-medium sized jails. | Red Orange | 5 |
b
|
Grinstead, 2003 [64] | U.S. | Mixed | HIV, HCV, HBV, and other sexually transmitted infections | Qualitative exploration | Interviews | Explore providers’ experiences regarding HIV, hepatitis, and other sexually transmitted infection testing services within prison. | Red Orange | 7 |
c
|
Centres for Disease Control, 2011 [49] | U.S. | Washington State Department of Corrections (12 male facilities) | HIV | Quantitative descriptive evaluation | Routine data | To assess the rate of testing under three different testing strategies: on-request, routine opt-in, and routine opt-out. | Red Orange Green | 5 |
c
|
Centres for Disease Control, 2009 [11] | U.S. | N/A | HIV | Opt-out testing programme guidance | N/A | To guide the implementation of opt-out HIV testing in the correctional setting by highlighting suggested common components and tenants of such a testing programme. | Red Orange | 6 | N/A |
Peter, 2009 [45] | U.S. | Orleans Parish Prison, Jefferson Parish Correctional Centre | HIV | Thesis | Routine data | Look at the effectiveness of opt-out and opt-in approaches to HIV testing in jail populations. | Red Orange | 7 | N/A |
Muessig, 2016 [57] | U.S. | North Carolina State Prison System | HIV | Qualitative | Interviews – 76 incarcerated men and women | Exploring issues of HIV stigma within an opt-out testing programme. | Red Orange Green | 10 |
c
|
Walker, 2005 [54] | U.S. | N/A | HIV | Letter(s) | N/A | Discusses the ethical concerns surrounding routine opt-out HIV testing within the prison setting. | Red | 4 | N/A |
Beckwith, 2010 [67] | U.S. | N/A | HIV | Literature review | Search | Provide a review of the current state of delivering HIV testing, prevention, treatment and transition services to incarcerated populations. | Red Orange | 4 | N/A |
Rosen, 2015 [8] | U.S. | North Carolina State Prison System | HIV | Quantitative cross-sectional survey | Quantitative survey and routine data | To explore prisoners understanding of the voluntary nature of routine opt-out testing. | Red Orange | 8 |
c
|
Grodensky, 2016 [48] | U.S. | North Carolina Prison System | HIV | Quantitative cross-sectional survey | Quantitative survey and routine data | Estimate the proportion unaware of being tested and the proportion of people tested who did not want a test. | Red Orange Green | 9 |
c
|
Cole, 2014 [46] | U.S. | Cook County Jail | Chlamydia trachomatis & Neisseria gonorrhoeae | Retrospective analysis | Routine data | Evaluate the impact of opt-out testing on rates of testing and diagnosis of infection among incarcerated women, assess the proportion of infections successfully treated, and evaluate factors associated with receipt of treatment. | Red Orange Green | 8 |
c
|
Public Health England, 2016 [70] | U.K. | Pentonville Prison | HIV, HBV, and HCV | Pilot evaluation | Routine data | Report results from provisional data analysis for the pilot blood-borne virus care pathway trialled within Pentonville prison. | Red Orange | 5 | N/A |
Jack, 2016 [51] | U.K. | East Midlands Category B male prison | HCV | Qualitative phenomenology | Interviews (prison officers) | To explore the views of prison officers about people in prison being tested and treated for HCV. | Red Orange | 6 |
d
|
Beckwith, 2012 [53] | U.S. | Baltimore Department of Corrections, Philadelphia Prison System, District of Columbia Department of Corrections | HIV | Quantitative descriptive evaluation | Routine data | To assess the feasibility of implementing large scale rapid and routine opt-out testing programmes for HIV in large urban jails. | Red Orange Green | 6 |
d
|
Centres for Disease Control, 2013 [37] | U.S. | Fulton County Jail | HIV | Quantitative descriptive evaluation | Routine Data | Evaluate a routine opt-out testing programme in a large county jail. | Red Orange Green | 5 |
c
|
Centre for Disease Control, 2010 [77] | U.S. | Rhode Island Jail | HIV | Quantitative descriptive evaluation | Routine Data | Review of Rhode Island Jail’s testing records. | Red Orange | 4 |
c
|
Kavasery, 2009 [42] | U.S. | York Correctional Institution, Connecticut | HIV | Prospective controlled trial | Quantitative data capture | Evaluate the optimal time to conduct routine opt-out HIV testing of newly incarcerated jail inmates in a manner that maximises the number of individuals capable of consenting and wiling to be tested. | Red Orange Green | 9 |
d
|
Newlan, 2016 [40] | Indonesia | Banceuy Prison | HIV, HBV, and HCV | Natural experiment | Routine data | To compare the efficacy of two different testing strategies (routine or targeted). | Red Orange Green | 5 |
b
|
Rumble, 2015 [13] | Mixed | Mixed | HIV, HBV, and HCV | Systematic review | Systematic literature search | Describe components of routine HIV, HBV, and HCV testing policies in prisons and quantify testing acceptance, coverage, result notification, and diagnosis. | Red Orange Green | 7 |
d
|
Gagnon, 2012 [61] | N/A | N/A | HIV | Literature review | Search | Provide a sociological critique of mandatory testing in light of other testing approaches, including opt-out. | Red Orange | 7 | N/A |
Process theory and contextual framework
Provisional programme theory
Refined programme theory
Proportion offered testing
CMOc 1: Delayed test offer
In a prison that has a rapid population turn-over (C), a programme mandated delay in engaging intake with an opt-out test offer (MR) reduces the proportion of intake offered a test (O), as some individuals have already been released or transferred (C).
CMOc 2: Early testing and capacity to consent
A higher proportion of prisoner’s lack capacity to consent on the first night (e.g. undergoing substance abuse withdrawal) (C). As opt-out testing requires informed consent (C), health workers that identify this lack of capacity (MR) and view it as important (MRE) will not offer testing (O).
CMOc 3: Prioritisation of security and prison processes
Prison officers have a challenging role, particularly when budget cuts have strained the workforce (C). Opt-out testing often requires prison officers to collect prisoners, bring them to clinic, and supervise them (MR). Officers prioritise security and prison processes over escorting and monitoring prisoners at clinic (MRE), meaning prisoners frequently do not arrive, or are not allowed to be at the clinic, to be offered testing (O).
CMOc 4: Provider capacity to run clinics
Prisons are a demanding place to work (high burden of mental illness, physical morbidity, and regular medical emergencies) (C) and budget deficits result in health staff cuts (C). These working conditions reduce the capacity of health staff (MR), forcing them to prioritise certain activities (MRE), such as dealing with urgent conditions or emergencies, resulting in testing clinics being delayed or cancelled and prisoners not offered a test (O).
CMOc 5: Refusal to attend clinic
When testing is conducted concurrently with other prison activities (C), attendance at clinic becomes an opportunity cost for the prisoner (MR). If health is a lower priority, relative to the other activity (MRE), the prisoner will not attend clinic (O).
CMOc 6: Rebooking prisoners
Budget deficits have led to health staff cuts (C). Stretched health workers (C) that are required to re-book prisoners (MR), prioritise medical emergencies and conducting other tasks that require immediate attention (MRE), further delaying the test offer (O). Overworked health staff (C) may also forget to rebook a prisoner (MRE), delaying the realisation of the test offer (O).In high-turnover prison settings (C), a failure to rapidly rebook a prisoner (MR), reduces the proportion of people offered testing (O), as individuals may be released or transferred by the time they are rebooked (C).
Test uptake
CMOc 1: Confidentiality and stigma (loss aversion)
BBVs are stigmatised within the prison context (C). Maintenance of confidentiality (MR) is therefore crucial, as prisoners will feel safe (MRE) to share personal information (O). If a prisoner distrusts prison healthcare’s ability to maintain confidentiality (MR), they may fear stigma (MRE), encouraging opt-out (O).
CMOc 2: Coping with a positive diagnosis (loss aversion)
BBVs are a situational concern for many people within prison (C). The provision of supportive information (e.g. treatment options, dispelling myths around prognosis, and psychosocial support) (MR), reassures a prisoner about coping if they test positive (MRE), encouraging test uptake (O).Failure to provide supportive information (MR) can leave people in prison feeling unable to cope with the perceived burden associated with a positive diagnosis (treatment, stigma, psychological distress, lifestyle changes) (MRE), encouraging opt-out (O).
CMOc 3: Fear of an invasive procedure (loss aversion)
A proportion of prisoner’s fear needles (C). When testing is conducted using a venous sample method (MR), prisoners that are uncomfortable with the method of blood acquisition (MRE) may opt-out (O).
CMOc 4: Institutional recommendations and trust (loss aversion/recommendation)
Recommendations to test in circumstances of trust (C) provide an institutional social pressure (MR) that encourages an individual to comply with the perceived positive action (MRE), encouraging test uptake (O). However, institutional distrust is prevalent in prison (C). Institutional social pressure (MR) can be perceived as a coercive process of surveillance, triggering resistance from the individual (MRE) and encouraging opt-out (O) [59, 64, 67].
CMOc 5: Personal interpretation of risk (loss aversion)
Misconceptions around BBVs are common amongst prisoners (C). Prisoners that have been informed about modes of transmission and symptoms of the disease (MR) are empowered (MRE) to accurately interpret their risk of infection (O).For prisoners that self-identify as “at risk” (C), testing can be an opportunity to confirm serostatus (MR), allowing the individual to either confront infection (MRE) or be reassured by a negative result (MRE), encouraging test uptake (O).
Prisoners that interpret themselves as low risk (C), but that face no other barriers to testing (MR), may still seek reassurance (MRE), encouraging test uptake (O). Prisoners that face other barriers to test uptake (e.g. fears around confidentiality or dislike of test method) (MR), may view testing as an unnecessary burden (MRE) and opt-out of testing (O).
CMOc 6: Defaults and capacity to consent (cognitive effort)
New prisoners frequently lack capacity to provide informed consent (C). If the health worker fails to identify this and proceeds with an opt-out test offer (MR), these individuals may misunderstand what is taking place (MRE) or be unable to make an active decision to opt-out (MRE), instead appearing to comply with testing (O).
CMOc 7: Opt-out fidelity
If programme implementers misinterpret how to deliver an opt-out test (C), training and scripts provided to health workers (MR) will encourage them to comply (MRE) with the delivery of either an opt-in (O) or mandatory (O) test offer.An opt-out test offer is not the norm (C). When health workers have little training, and no standard script (MR), the meaning of opt-out may be misinterpreted (MRE) resulting in either opt-in (O) or mandatory (O) test offers. The way testing is offered, when there is no standard script (MR), can also morph with each encounter, with rapport (C), situational distractions (C) and fatigue (C) all potentially influencing test delivery (O).