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Journal of Public Health Advance Access originally published online on September 18, 2007
Journal of Public Health 2007 29(4):429-433; doi:10.1093/pubmed/fdm059
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© The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Predictors of hepatitis B vaccination in women prisoners in two prisons in England



E. H. Plugge, Senior Research Scientist1,

P. L. Yudkin, Reader in Medical Statistics2

N. Douglas, Researcher1
1 Department of Public Health, University of Oxford, Old Road Campus, Old Road, Oxford OX3 7LF, UK
2 Department of Primary Care, University of Oxford, Old Road Campus, Old Road, Oxford OX3 7LF, UK

Address correspondence to Emma Plugge, E-mail: emma.plugge{at}dphpc.ox.ac.uk

Background Hepatitis B is an important public health issue, especially in the female prison population. The high prevalence in this population is largely accounted for by the high rates of injecting drug use and the fact that these women are more likely to exchange sex for drugs or money and practice unprotected sex. There is a national programme in English prisons to vaccinate everyone against Hepatitis B. This study aimed to investigate whether women who had been in prison before were more likely to have been vaccinated against hepatitis B and whether contact with community services was more likely to predict hepatitis B vaccination.

Methods A questionnaire survey of new entrants into two women's prisons in England.

Results Four hundred and eighty seven out of 613 women approached completed the questionnaire and gave complete data on hepatitis B vaccination status, giving a response rate of 79.4%. One hundred and thirty three women (27.3%) had received at least three vaccinations against hepatitis B. Previous imprisonment and intravenous drug use were independent predictors of vaccination. Six months or more in prison greatly increased an individual's odds of being immunized [odds ratio 12.01 (95% confidence interval (CI) 5.53–26.10)]. Registration with a general practitioner (GP), contact with drug or alcohol services and exchanging money or goods for sex were not independently associated with vaccination status.

Conclusion Prisons play an important role in the delivery of hepatitis B vaccination. However, this should not prevent providers of health services making greater efforts to engage this marginalized group and to ensure that they receive an appropriate level of healthcare in the community.

Keywords: prisoners, women, hepatitis B, vaccination, prevention


   Background
TOP
 Background
Methods
 Results
 Discussion
 Conclusions
 Acknowledgments
 References
 
Women are an important minority within the prison population. There are now ~4500 imprisoned women in England and Wales, and although they account for <6% of the prison population,1 their numbers are rapidly increasing and they have considerable health needs that are different to and often greater than those of male prisoners. Mental health, drug misuse and infectious diseases are all important health issues for women prisoners.2–4 In 1996, a survey of prisoners in England and Wales showed that rates of blood-borne viruses were higher in the female prisoners than in male prisoners and considerably higher than the general population.5 The prevalence of HIV infection was 0.3% in adult male prisoners and 1.2% in female prisoners; the prevalence of anti-HBc antibodies was 8.2% in males and 12.0% in females and the prevalence of anti-HCV was 8.7% in adult males and 11.0% in females. The high prevalence rates in women prisoners compared with the general population can largely be accounted for by the high rates of injecting drug use in imprisoned women and the fact that they are more likely to exchange sex for drugs or money and practice unprotected sex.6,7

This is not an issue confined to England and Wales; indeed, one of the key strategic objectives of the World Health Organisation's Health in Prisons Project is ‘to reduce the exposure of prisoners to communicable diseases’ and reducing the risk of hepatitis B infection is an important part of this.8 A number of strategies have been used to tackle blood-borne viruses in the prison setting, most notably the introduction of an accelerated hepatitis B vaccination schedule for all prisoners in England and Wales. The accelerated schedule involves three vaccinations being given at 0, 7 and 21 days and a fourth at 12 months if possible as opposed to the standard schedule regimen of vaccinations at 0, 1 and 6 months.9 The accelerated schedule aims to maximize the coverage in a population that is transient and difficult to reach through community vaccination programmes.10–12 Although it was recommended in 1996 that all prisoners should be vaccinated against hepatitis B,9 few prisoners were subsequently offered vaccination. However, over the past 5 years, Prison Health, which leads to the development of health care in prisons nationally, has been actively encouraging the hepatitis B vaccination for all prisoners.13 In addition, the Health Protection Agency monitors vaccination coverage in prisons and publishes monthly statistics.14

Although there is evidence to support the effectiveness of vaccination in prison,11,15 there is little research specifically examining the importance of prison as a setting for the delivery of hepatitis B vaccine. The aim of this study, therefore, was to investigate whether women who had been in prison before were more likely to have been vaccinated against hepatitis B and whether contact with community services was more likely to predict hepatitis B vaccination.


   Methods
TOP
 Background
 Methods
Results
 Discussion
 Conclusions
 Acknowledgments
 References
 
This study took place in two women's closed prisons in England and was approved by the South-East Multi-centre Research Ethics Committee. All women being received into prison on a pre-specified study day during the 6-month recruitment period in 2004 were eligible to participate; those posing a security threat or who were severely mentally ill were excluded. Questions about vaccination against hepatitis B were contained within a questionnaire which the researchers (N.D. and E.P.) gave to participants to complete in private. The questionnaire also contained questions about previous experience of prison, drug use, sexual behaviour and health service use in the community. The researchers were available to administer the questionnaire if the participant requested.

We analysed the information from completed questionnaires using SPSS v13. We compared the data on demographic information for the study sample with the most recent published data for all women prisoners, which were obtained from the Home Office published statistics on Women and the Criminal Justice System for 2003.16 We investigated the relationship between the outcome (three injections of hepatitis B vaccination—a ‘complete course’) and seven individual predictor variables: age, time spent in prison in the last 10 years, intravenous drug use, registration with general practitioner (GP) in the community, use of drug and alcohol services, previous treatment for a sexually transmitted infection and exchange of goods for sex. We used the t-test to compare the means of continuous variables and the chi-squared test to compare the categorical variables. All variables with P < 0.20 in the univariate analysis were entered into a logistic regression analysis to determine the independent predictors of complete vaccination. Women who reported that they were unsure about their vaccination status were considered not to have had a complete course.


   Results
TOP
 Background
 Methods
 Results
Discussion
 Conclusions
 Acknowledgments
 References
 
Five hundred and five out of 613 women approached completed the questionnaire giving a response rate of 82.4%. When compared with all women prisoners in England using Home Office published statistics,16 the study sample appeared broadly comparable in terms of age, ethnicity and educational level. However, women in this sample were less likely to have a dependent child or be employed prior to imprisonment. This information is summarized in Table 1.


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  		Table 1 Demographic information for study sample and all women prisoners in England

 
Of the 505 responders, 487 had complete data on hepatitis B vaccination status, and of those with complete data, 228 (46.8%; 95% CI 42.4–51.3) reported having received one vaccination against hepatitis B at some time and 133 (27.3%, 23.5–31.4) had had at least three injections. Some of these women had missing data as indicated in Table 2.


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  		Table 2 Factors examined for association with ‘complete course’ (three doses) of hepatitis B vaccination: results of univariate analysis

 
Women who had been in prison before, those who had injected drugs, those who were in contact with drug and alcohol services in the community and those who had exchanged goods or money for sex were all more likely to have received three or more vaccinations against hepatitis B (Table 2). Those who were registered with a GP in the community were less likely to have been vaccinated. Previous treatment for a sexually transmitted infection was significantly associated neither with vaccination status nor with age. The mean (SD) age for those with a complete course was 30.7 (7.6) years compared with 31.8 (9.6) years for those not fully vaccinated (P = 0.19).

Intravenous drug users were not only more likely to have been vaccinated but also more likely to have been in prison (84.8 versus 55.0%, P < 0.001), in contact with community drug and alcohol services (70.4 versus 27.2%, P < 0.001) and to have exchanged goods for sex (45.3 versus 15.0%, P < 0.001). They were not significantly less likely to have been registered with a GP (72.7 versus 78.2%, P = 0.20).

Logistic regression analysis was carried out on the 426 women (84.4% of the 505 responders) with complete data. Table 3 shows that previous imprisonment and intravenous drug use were independent predictors of vaccination but registration with a GP, contact with drug or alcohol services and exchanging money or goods for sex were not. Six months or more in prison greatly increased an individual's odds of being immunized.


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  		Table 3 Factors examined for association with ‘complete course’ (three doses) of hepatitis B vaccination: results of multivariate analysis

 

   Discussion
TOP
 Background
 Methods
 Results
 Discussion
Conclusions
 Acknowledgments
 References
 
Main findings of this study
This is the first report to look specifically at predictors of hepatitis B vaccination in imprisoned women in England. These findings show that vaccination is associated with previous imprisonment even for a short period and that the odds of being fully vaccinated against hepatitis B for a woman who has previously been imprisoned for six months or more is 12 times that of women who have not been in prison before. This suggests that prison is an important setting for the delivery of hepatitis B vaccination in this population. Indeed, contact with other community services—GP, sexual health services and drug and alcohol services—did not predict vaccination status. It is of concern that these services have failed to vaccinate these women who will spend more time in the community than in prison. However, the reasons for this are not clear.

Although previous imprisonment and injecting drug use are associated, drug users being more likely to have been in prison before, both these variables were independently associated with having received three doses of vaccine. This may be accounted for by the fact that despite national guidelines to vaccinate all prisoners, until recent years many prisons were continuing to vaccinate selectively, identifying high-risk groups such as injecting drug users (IDUs) only.

The findings also highlight the low coverage in this high-risk population; less than half (46.8%) had received one vaccination against hepatitis B and only 27.3% had had three injections.

What is already known on this topic
Blood-borne viruses are widely acknowledged as an important public health problem in prison populations.8 It is particularly important that imprisoned women are vaccinated because of the high rates of drug use within this population and because they are more likely than the general population to practice unprotected sex.6,7 Vaccinating offenders when in prison has the potential to confer protection not only on those individuals but other prisoners and also wider society, as they return to the community and continue high-risk behaviours.13,15,17,18

Despite the obvious public health benefits of vaccination, ensuring that female offenders are adequately immunized is a challenge for health services both in prison and in the community. When in the community, these women tend to move around and avoid contact with authority19 and for many women, especially those using drugs, access to health services is not a priority.20 However, vaccinating women in prison is not straightforward either for a variety of reasons and the difficulties vaccinating women in English prisons have been documented elsewhere.13

Previous studies have looked at where IDUs in the community have received their vaccinations against hepatitis B. A study in Scotland found that most had been vaccinated in prison although innovative community medical services for drug users and commercial sex workers were also important settings to deliver hepatitis B vaccine.12 The 2005 Health Protection Agency survey of IDUs in the UK also showed that they were most likely to have been vaccinated against hepatitis B in prison.21

What this study adds
This study shows that despite national policy only a minority of women prisoners (27.3%) have received a full course against hepatitis B. This is clearly unacceptable given the high risk behaviours many of these women practice and the existence of effective prevention.

The findings suggest that prison is an important setting for the delivery of hepatitis B vaccination but health services in the community play little part in vaccinating these women. However, given the poor coverage, health services both in prison and the community should be looking at ways to improve vaccination uptake.

Limitation of this study
There are some methodological issues with the study. The questionnaire survey achieved a reasonable response rate (82.4%) but only 426 women (84.4% of the 505 responders) had data that were sufficiently complete to be entered into the regression model. Unfortunately, no demographic information could be obtained on the non-responders because this would have involved interrogating the prison information system, which the researchers could not access for security reasons. However, analysis of the demographic information on participants, as shown in Table 1, does suggest that this sample is similar to the general population of women prisoners in England and that, therefore, the findings are broadly generalizable. This is despite the fact that the two prisons in which the women were recruited were not wholly representative of women's prisons in England. There are currently 15 women's prisons in England: 11 of these are closed, 2 are open and 2 are semi-open. This study recruited women newly received into prison from the community and therefore only closed prisons could be used, as these are the only type of prison which receives women from the community.

Another important issue was the fact that the study relied upon self-reported data from the women and we were unable to validate their responses using other data sources. Clearly, it would have been preferable to examine their medical records in the prison and in the community as well to verify vaccination status, but this was not possible within the resources of the study. However, there is no clear evidence indicating that prison populations are less reliable informants than the general population, and there is no reason to suppose that bias in recalling vaccination status would be associated with the predictor variables that we examined. Research has shown that the use of self-report questionnaires in the prison population may in fact be better than face-to-face interview22 and that a number of instruments used widely in the general population are also valid for use in prison populations.23–26 Furthermore, as already stated, our findings are in accordance with two studies which looked specifically at IDUs in the community who had been vaccinated against hepatitis B.11,18

This study has only looked at women prisoners in England and Wales. Although the prevalence of hepatitis B in male prisoners is likely to be lower than that in women prisoners, it is still higher than that in the general population5 and is a significant public health issue for the 75 000 male prisoners in England and Wales. Further research is needed to investigate the uptake of hepatitis B vaccination in male prisoners.


   Conclusions
TOP
 Background
 Methods
 Results
 Discussion
 Conclusions
Acknowledgments
 References
 
These findings would support the renewed efforts to ensure all women coming into prison are vaccinated against hepatitis B. However, prisons are often seen as the only opportunity for healthcare services to reach this group who have substantial health needs, and although they clearly have an important role to play in the delivery of health interventions such as hepatitis B vaccination, this should not prevent providers of health services making greater efforts to engage this group and to ensure that they receive an appropriate level of health care in the community.


   Acknowledgments
TOP
 Background
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgments
References
 
We are very grateful to all the women who participated in this study and the prison officers who facilitated access to these women. The study could not have taken place without the support of Steve Tyman or Ray Fitzpatrick. We also thank Eamonn O'Moore and Dick Mayon-White for their helpful comments on previous drafts of this paper. The University of Oxford is grateful to the King's Fund for providing a grant to help with the cost of this study. Any views expressed in this publication are those of the authors and not necessarily those of the King's Fund, which is not responsible for them.


   References
TOP
 Background
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgments
 References
 

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This Article
Right arrow Abstract Freely available
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