Table 5.

List of all determinants to implementation of the Cepheid GeneXpert in HMP Perth identified in semi-structured staff interviews (n=70)

Domain	Barriers (n=41)
Inner setting	Leadership staff felt individual custody trumped healthcare in the prison, hindering improvements to care.
	Laboratory staff did not prioritise uploading GeneXpert results as they did not perform the test.
	Laboratory staff did not prioritise reporting GeneXpert results because it was a pilot project.
	Leadership staff felt that, as the nurses were not present for the majority of admissions, in-reach was limited.
	Leadership staff felt a lack of freedom to operate in the prison hindered the design of the pathway.
	Clinical staff felt the lack of physical space and clinic rooms adversely affected how and when the GeneXpert could be used.
	Clinical staff were limited to using the GeneXpert and obtaining samples for testing in specific locations in the prison.
	Clinical staff found it difficult to transit individuals from residential areas of the prison the health centre due to the need for intermediary ‘runners’.
	Clinical staff felt pressured by SPS staff (‘runners’) to finish clinic appointments quickly.
	Clinical staff found it difficult to implement healthcare initiatives as it was perceived as secondary to the regimental running of the prison/security.
	Clinical staff found it difficult to engage colleagues outside their direct team in HCV testing due to perceived lack of integrated care.
	The GeneXpert was seen as difficult to implement in the long-term due to high staff turnover in the prison.
	Laboratory staff found it difficult to log results in a timely manner due to staff turnover and training issues.
Outer setting	Laboratory staff felt uncertainty around whether reporting tasks could be delegated to administrative staff due to professional regulations.
	Laboratory staff found it difficult to manage the reporting workflow due to the pressures of the Covid-19 pandemic.
Characteristics of Individuals	Leadership staff felt a lack of awareness of HCV among people in prison and prison staff hindered improvements to prison care.
	Laboratory staff did not see administration of GeneXpert results as part of their job/in line with their skillset.
	Laboratory staff felt uncertain about the value of their role in the reporting process.
	Clinical staff felt cynical about whether SPS staff ‘runners’ actually approached individuals to inform them their attendance at the health centre was required.
	Clinical staff indicated a preference to obtain a venous sample to fingerprick sample due to their self-perceived proficiency at obtaining venous bloods.
	Clinical staff viewed fingerprick sampling method as slower than obtaining venous samples.
	Clinical staff often wanted to know antibody status of an individual, meaning at times they may not have prioritised PCR testing with GeneXpert.
	Clinical staff felt obtaining fingerpick samples using the minivette introduced infection control concerns.
	Laboratory staff felt unsure about the value of their role in the result reporting process.
Intervention characteristics	Leadership staff felt the need to return to device to check result after 1 hour made it difficult to plan work for a clinic when they had competing priorities for their time.
	Performing a GeneXpert test was perceived as more work than obtaining conventional samples and sending them for lab analysis, by leadership staff.
	Transporting GeneXpert test assays in the prison caused anxiety for clinical staff due to the sensitivity of the rear fin on the cartridge.
	Clinical staff felt the dexterity required to correctly insert the sample into the cartridge caused errors in results.
	Laboratory and clinical staff found it challenging to interpret the viral load quantification output (scientific notation) from the device.
Process	Laboratory staff felt the lack of an IT link raised concerns about accurate result reporting.
	Laboratory staff found it difficult to plan/implement an SOP for reporting results, as they were unsure what to expect in terms of volume of tests.
	Clinical staff had difficulty conceptualising how the device would be used due to a lack of a plan on who to target for testing and how to do so.
	Clinical staff found it difficult to plan a ‘1 day’ test/treat pathway due to safety concerns with the frontline medication used.
	Clinical staff found it difficult to transit individuals to the prison health centre due to the provision of OAT at concurrent time to BBV clinics.
	The GeneXpert process was viewed as time-consuming and difficult to implement systematically due to unpredictable nurse workload.
	Laboratory staff did not prioritise uploading test results to electronic systems because they did not perform the test themselves.
	The paper reporting process was felt to introduce potential for result reporting/transcription errors.
	Laboratory staff found it difficult to adapt to the paper/manual reporting workflow as it was unfamiliar to them.
	Laboratory staff felt there was poor communication between themselves and clinical staff implementing the testing.
	Clinical staff found it difficult to verify patients’ CHI numbers as they are not routinely used in the prison system.
	Clinical staff were anxious about the paper reporting process because it placed a high degree of responsibility on them not to make reporting errors.
	Facilitators (n=29)
Inner setting	Laboratory staff were open to challenge on results incorrectly uploaded due to their perceived professional responsibility to ensure accuracy.
	Clinical staff found it easier to plan engagement with testing by co-designing awareness materials with people in prison.
	Clinical staff found it easier to implement the GeneXpert pathway because of previous testing undertaken in the prison for diabetes by another team.
	Clinical staff found it easier to navigate the prison environment for testing after being ‘key trained’.
	The prison BBV nursing team’s openness to change and credibility with prison staff was perceived as helpful to implementation, by leadership staff.
	Clinical staff found it easier to engage patients due to the ethos of their team which values individual relationships.
Outer setting	The local HCV elimination strategy was seen as facilitative of improving care by leadership staff.
	MCN infrastructure and inter-organisational working was seen as facilitative of improving prison BBV care by leadership staff.
	GeneXpert was viewed as preferable for sampling in patients with difficult venous access by clinical staff.
	Some people in prison indicated a preference to clinical staff to be tested using the GeneXpert due to the non-invasive sampling.
	Clinical staff found it easier to implement the GeneXpert pathway as the virology team were perceived as supportive.
Characteristics of Individuals	Laboratory staff felt prior experience with reference result reporting and prior PoC pilots for influenza were helpful in implementing the result reporting workflow for the GeneXpert.
	Laboratory staff appreciated the unique testing challenges in the prison environment.
	Laboratory staff perceived GeneXpert testing in the prison as innovative.
	Wider knowledge of GeneXpert testing in other UK cities among laboratory staff and individual advocacy among those staff facilitated the decision to support the project.
	Clinical staff trusted the results from the GeneXpert due to an awareness other teams were using them.
	Clinical staff perceived the GeneXpert as making their job easier.
	New staff in the prison health centre were perceived as being open to change by existing clinical staff.
	Clinical staff perceived the GeneXpert as enabling quicker transition from diagnosis to treatment.
Intervention characteristics	Leadership staff felt the strong existing evidence base on the clinical effectiveness of the GeneXpert and benefits of HCV treatment for PWID facilitated implementation.
	Laboratory staff found it easier to integrate the GeneXpert as there were no financial implications to do so.
	Clinical staff found it easier plan their use of the GeneXpert as it was mobile (on trolley).
	Clinical staff could plan afternoon clinics/more flexible clinic times as the GeneXpert made the 12.30 bloods cut-off inapplicable for PCRs.
	Leadership staff felt that GeneXpert delivered quick, actionable, results and was easy to use.
	GeneXpert was perceived as preferable to conventional testing due to the speed of the results by leadership staff.
Process	Laboratory staff felt existing lab systems could be easily amended to integrate the GeneXpert test platform.
	Clinical staff found it easier to engage people in prison into testing by building rapport with and disseminating HCV information via ‘pass men’.
	Laboratory staff felt integrating the GeneXpert process as a whole was minimally disruptive to their usual work.
	Laboratory staff felt it was an easier process compared with conventional testing as they did not have to process the samples themselves.

BBV, blood-borne virus; CHI, community health index; HCV, hepatitis C virus infection; HMP, His Majesty’s Prison Service; IT, information technology; MCN, managed care network; OAT, opioid agonist therapy; PCR, polymerase chain reaction; PoC, point-of-care; PWID, people who inject drugs; SOP, standard operating procedure; SPS, Scottish Prison Service.