Increasing hepatitis C knowledge among homeless adults: results of a community-based, interdisciplinary intervention

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study

Background

There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services.

Objectives

This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated.

Design and setting

The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model.

Participants

People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders.

Results

The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services.

Limitations

There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model.

Conclusions

Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.

A Quality Improvement Project: Implementation of the Centers for Disease Control and Prevention's Hepatitis C Virus Treatment Guidelines at an Addiction Treatment Center

PURPOSE

This quality improvement project was introduced at an addiction treatment center to implement the Centers for Disease Control and Prevention's (CDC's) hepatitis C virus (HCV) treatment guidelines and offer anticraving medications to patients to improve standards of care of patients with substance use disorders.

LITERATURE REVIEW

Patients with opioid use disorders are at the highest risk of contracting HCV. More than 80% of people in the United States with opioid use disorders who use intravenous drugs have contracted HCV. Despite the high prevalence of HCV, patients at treatment centers are being screened only for HCV antibodies (HCV-AB) and are not receiving the CDC's HCV treatment guidelines. The CDC has treatment recommendations of hepatitis panels, full STD testing, and early follow-up care.

METHOD

This quality improvement project utilized the Plan-Do-Study-Act tool. With the application of Plan-Do-Study-Act, for patients identified with HCV-AB, the established CDC HCV treatment guidelines were followed, and the clinical progress of the implementation of the guidelines was monitored. Chart reviews comparing compliance of guidelines before and after the study were implemented.

PARTICIPANTS

A convenience sample of 125 patients were collected, and of these, 32 patients were found to be HCV-AB+.

FINDINGS

The findings revealed that 18.75% of patients followed the CDC's HCV recommendations after the quality improvement project compared with 6.25% of patients before the intervention. The number of HIV testing offered increased by 40.00% as a result of the implementation of the project.

Formal Hepatitis C education increases willingness to receive therapy in an onsite shelter-based HCV model of care in persons experiencing homelessness

Background

To evaluate the effectiveness of formal Hepatitis C (HCV) education on engagement in therapy in persons experiencing homelessness in an onsite shelter-based model of care. As policies to eliminate Medicaid access restrictions to HCV treatment are expanded, patient education is paramount to achieving HCV elimination targets in difficult to engage populations including persons experiencing homelessness.

Methods

This prospective study was conducted at four shelters in San Francisco and Minneapolis from August 2018 to January 2021. Of the 162 HCV Ab positive participants, 150 participated in a 30-minute HCV education session. Post-education changes in knowledge, beliefs, barriers to care and willingness to accept therapy scores were assessed.

Results

Following education, knowledge scores (mean change 4.4 ± 4.4, p<0.001) and willingness to accept therapy (70% to 86% p=0.0002) increased. Perceived barriers to HCV care decreased (mean change -0.8 ± 5.2 p=0.001). Higher baseline knowledge was associated with lesser gain in knowledge following education (coef. -0.7, p<0.001). Post-education knowledge (OR 1.2, p=0.008) was associated with willingness to accept therapy.

Conclusions

An HCV educational intervention successfully increased willingness to engage in HCV therapy in persons experiencing homelessness in an onsite shelter-based HCV model of care.

Clients' perceptions of barriers and facilitators to implementing hepatitis C virus care in homeless shelters

Background

Hepatitis C virus (HCV) is highly prevalent among homeless persons, yet barriers continue to impede HCV testing and treatment in this population. We studied the experiences of homeless individuals related to accessing HCV care to inform the design of a shelter-based HCV prevention and treatment program.

Methods

Homeless shelter clients (10 women and 10 men) of a large shelter in San Francisco participated in gender segregated focus groups. Focus groups followed a semi-structured interview format, which assessed individual, program/system, and societal-level barriers and facilitators to universal HCV testing and linkage to HCV care. Focus group interviews were transcribed, coded, and analyzed using thematic analysis.

Results

We identified key barriers to HCV testing and treatment at the individual level (limited knowledge and misconceptions about HCV infection, mistrust of health care providers, co-morbid conditions of substance use, psychiatric and chronic medical conditions), system level (limited advocacy for HCV services by shelter staff), and social level (stigma of homelessness). Individual, system, and social facilitators to HCV care described by participants included internal motivation, financial incentives, prior experiences with rapid HCV testing, and availability of affordable direct acting antiviral (DAA) treatment, respectively.

Conclusions

Interrelated individual- and social-level factors were the predominant barriers affecting homeless persons’ decisions to engage in HCV prevention and treatment. Integrated models of care for homeless persons at risk for or living with HCV address many of these factors, and should include interventions to improve patient knowledge of HCV and the availability of effective treatments.

Care2Cure: A randomized controlled trial protocol for evaluating nurse case management to improve the hepatitis C care continuum within HIV primary care

Co-infection with HIV and hepatitis C virus (HCV) results in a threefold increase in relative risk of progression to end stage liver disease and cirrhosis compared to HCV alone. Although curative treatments exist, less than one quarter of people with HCV are linked to care, and even fewer have received treatment. The Care2Cure study is a single-blinded, randomized controlled trial to improve the HCV care continuum among people co-infected with HIV. This ongoing study was designed to test whether a nurse case management intervention can (i) improve linkage to HCV care and (ii) decrease time to HCV treatment initiation among 70 adults co-infected with HIV who are not engaged in HCV care. The intervention is informed by the Andersen Behavioral Model of Health Services Use and consists of nurse-initiated referral, strengths-based education, patient navigation, appointment reminders, and care coordination for drug-drug interactions in the setting of HIV primary care. Validated instruments are used to measure participant characteristics including HCV knowledge, substance use, and depression. The primary outcome is linkage to HCV care (yes/no) within 60 days. In this protocol paper, we describe the first clinical trial to examine the effects of a nurse case management intervention to improve the HCV care continuum among people co-infected with HIV/HCV in the era of all-oral HCV treatment. We describe our work in progress, challenges encountered, and strategies to engage this hard-to-reach population.

A systematic review of interventions by healthcare professionals to improve management of non-communicable diseases and communicable diseases requiring long-term care in adults who are homeless

OBJECTIVE

Identify, describe and appraise trials of interventions delivered by healthcare professionals to manage non-communicable diseases (NCDs) and communicable diseases that require long-term care or treatment (LT-CDs), excluding mental health and substance use disorders, in homeless adults.

DESIGN

Systematic review of randomised controlled trials (RCTs), non-RCTs and controlled before-after studies. Interventions characterised using Effective Practice and Organisation of Care (EPOC) taxonomy. Quality assessed using EPOC risk of bias criteria.

DATA SOURCES

Database searches (MEDLINE, Embase, PsycINFO, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA) and Cochrane Central Register of Controlled Trials), hand searching reference lists, citation searches, grey literature and contact with study authors.

SETTING

Community.

PARTICIPANTS

Adults (≥18 years) fulfilling European Typology of Homelessness criteria.

INTERVENTION

Delivered by healthcare professionals managing NCD and LT-CDs.

OUTCOMES

Primary outcome: unscheduled healthcare utilisation.

SECONDARY OUTCOMES

mortality, biological markers of disease control, adherence to treatment, engagement in care, patient satisfaction, knowledge, self-efficacy, quality of life and cost-effectiveness.

RESULTS

11 studies were included (8 RCTs, 2 quasi-experimental and 1 feasibility) involving 9-520 participants (67%-94% male, median age 37-49 years). Ten from USA and one from UK. Studies included various NCDs (n=3); or focused on latent tuberculosis (n=4); HIV (n=2); hepatitis C (n=1) or type 2 diabetes (n=1). All interventions were complex with multiple components. Four described theories underpinning intervention. Three assessed unscheduled healthcare utilisation: none showed consistent reduction in hospitalisation or emergency department attendance. Six assessed adherence to specific treatments, of which four showed improved adherence to latent tuberculosis therapy. Three concerned education case management, all of which improved disease-specific knowledge. No improvements in biological markers of disease (two studies) and none assessed mortality.

CONCLUSIONS

Evidence for management of NCD and LT-CDs in homeless adults is sparse. Educational case-management interventions may improve knowledge and medication adherence. Large trials of theory-based interventions are needed, assessing healthcare utilisation and outcomes as well as assessment of biological outcomes and cost-effectiveness.

Improving support and education of low-income baby boomers diagnosed with chronic hepatitis C virus infection through universal screening

AIMS AND OBJECTIVES

To identify support needs of low-income baby boomers recently diagnosed with chronic hepatitis C virus infection.

BACKGROUND

The U.S. Preventive Services Task Force has endorsed one-time screening of all baby boomers (born 1945-1965) for hepatitis C because 75% of the estimated 2-3 million persons with chronic infection are in this age range. We hypothesised that persons diagnosed by routine screening would have significant psycho-emotional, cognitive and healthcare challenges that need to be met by collaborative care and services from nurses and other healthcare personnel.

DESIGN

Qualitative descriptive study of data from three focus groups with predominantly minority participants (N = 16). Data were analysed using qualitative content analysis, and transcribed data were categorised by three domains in a previously developed model and a new domain identified in this study. Frequencies of unique participants' comments about each theme were calculated.

RESULTS

Elucidated domains were as follows: (i) psycho-emotional effects due to social stigma, shame, fear and dealing with risky behaviours; (ii) social effects due to concerns about infecting others; and (iii) cognitive deficits because of poor understanding about hepatitis C virus infection and its care. A new domain related to health care emerged reflecting the following themes: poor access to care, barriers to costly treatment, and navigating complex care for comorbidities. Despite these challenges, participants strongly endorsed universal baby boomer hepatitis C virus screening.

CONCLUSIONS

This study describes psycho-emotional and social challenges of people dealing with a hepatitis C diagnosis which are compounded by poor knowledge and barriers to supportive care.

RELEVANCE TO CLINICAL PRACTICE

Nursing and other allied health personnel require structured support programmes to assist older persons diagnosed with hepatitis C with addressing these common challenges with the ultimate goal of achieving a cure.

Comparison of Rapid Point-of-Care Tests for Detection of Antibodies to Hepatitis C Virus

OraSure had the highest sensitivity at 92.7% followed closely by Chembio's three blood tests. False results were associated with HIV, and hepatitis B core antibody. The OraSure and Chembio blood tests have good performance characteristics.

Background. Hepatitis C is one of the most prevalent blood-borne diseases in the United States. Despite the benefits of early screening, among 3.2 million Americans who are infected with hepatitis C virus (HCV), 50%–70% are unaware of their infection status.

Methods. Data were collected between 2011 and 2014, from 1048 clients who were in the following groups: (1) injection drug users, (2) women at sexual risk, (3) gay and bisexual men, and (4) transgender individuals. The sensitivity and specificity of point-of-care tests included (1) the MedMira rapid human immunodeficiency virus (HIV)/HCV antibody test, (2) MedMira hepatitis B (HBV)/HIV/HCV antibody test, (3) Chembio HCV Screen Assay used with both whole blood and (4) oral specimens, (5) Chembio HIV-HCV Assay also used with both whole blood and (6) oral specimens, (7) Chembio HIV-HCV-Syphilis Assay, and (8) OraSure HCV Rapid Antibody Test used with whole blood. The gold standard for the HCV tests were HCV enzyme immunoassay (EIA) 2.0.

Results. OraSure had the highest sensitivity at 92.7% (95% confidence interval [CI] = 88.8%–96.5%) followed closely by Chembio's 3 blood tests at 92.1% (95% CI = 87.7%–96.4%), 91.5% (95% CI = 87.2%–95.7%), and 92.3% (95% CI = 88.4%–96.2%). The sensitivities of MedMira HIV/HCV and MedMira HIV/HCV/HBV tests were the lowest, at 79.1% (95% CI = 72.6%–85.5%), and 81.5% (95% CI = 75.2%–87.8%), respectively. Specificity for the OraSure was 99.8% (95% CI = 99.4%–100%); specificity for the Chembio blood tests was 99.2% (95% CI = 98.6%–99.9%), 99.4% (95% CI = 98.8%–99.9%), and 99.3% (95% CI = 98.8%–99.9%); and specificity for the MedMira was100% and 100%. False-negative results were associated with HIV and hepatitis B core antibody serostatus.

Conclusions. The OraSure and Chembio blood tests (including those multiplexed with HIV and syphilis) appear to good performance characteristics. This study has identified potential limitations of rapid testing in those testing positive for HIV and HBcAb. There should be discussion of updates to the 2013 CDC guidance.