# Presentation: 096408

## INTERVENING WITH SUBSTANCE USING MEN NEWLY RELEASED FROM JAIL 

- CHALLENGES AND STRATEGIES
- Charles Sperling, MS, NCAC-II 1
- Antonya Pierce, MPH, CHES 1
- Tricia Hall, MPH 1
- James Tomlin 1
- Samantha P. Williams,Ph.D 2
- STAND, Inc.1
- Centers for Disease Control and Prevention 2

**Notes:**
Appreciative of the opportunity to share process, observations, and findings regarding intervening with substance using men newly released from jail
We are pleased to come and share our collective experience and insight a continual effort to improve the relationship between science and community based programs. It is also our hope that this controlled trail can be replicated.

The delivery of an intervention focused on reduction and/or elimination of new case STD’s in the offender population mandates a number of considerations. (e.g.) Drug & Alcohol use, Motivation, Living situations, The difference in working with city jail inmates and prison inmates, participants social milieu (environment) Providing financial stipends for active addicts (ethical issues)

## Background

- There is considerable evidence regarding association between criminal activity and substance use.
- An estimated 7 in 10 local inmates had used drugs regularly or had committed a drug offense (BJS, 2000).
- Two-thirds of convicted jail inmates were actively involved with drugs prior to jail admission (BJS, 2000).
- 55% of convicted jail inmates were using drugs in the month before the offense; 36% at the time of the offense (BJS, 2000)
- Substance use and related activities are likely to continue once the inmate is released and previous behaviors and/or activities are resumed.

## Background

- Consequences of behavioral risk increases with multiple risk:
- Substance use 	 	Negative outcomes
- sexual risk 	     	 	        such as
- criminal activities 	 	          STDs
- Data suggest that prisoners are a high risk population immediately prior to incarceration (an average of three sexual partners in the 30 days prior to detention with 59% of men indicating a female partner at high risk for STDs) as well as upon release.
- Contributors to sexual risk include drug use, which is heavily linked to arrests in approximately 1/3 of parolees and probationers in Georgia
- Given the co-morbidity of these factors, an intervention to reduce STD acquisition and transmission, prior to or upon post release would seem the best strategy for improving sexual health in this population.

## Background

- Goal
- Describe challenges and strategies of working with substance using men newly release from jail
- Context - MISTERS Project
- Multi-session, group intervention study with an intent to reduce sexual risk behaviors in men newly released from jail.

## Suggestions

- Speakers’ time: 10-20 mins each
- Question/Answer: At end of presentations
- Address questions to individual speaker or panel
- Enjoy!

## In the Beginning.....

- Charles Sperling
- Principal Investigator - MISTERS Project
- Executive Director - STAND, Inc.

**Notes:**
Our review of the literature revealed  very little published data concerning a study focused on men newly released from jail, the majority of studies focused on prison releases. Working with men from jail present several very different challenges; (discharge planning) – (survival at release) Prison – usually time for reflection, time to contemplate the appropriateness of their social paradigms (pre-release planning, accountability, parole, probation, etc)
We were able to utilize lessons from the STARR project and some other works funding by CDC Dr. Judith Greenburg “A community support group for sero-positive drug users, published in Aids Care it provided insight on penetrating and follow-up on a similar population.
It was important to involve consumers, representative of this unique population, to that end we facilitated focus groups

## OVERVIEW

- Collaboration
- Intervening
- Intellectual Village
- Study Foundation

## COLLABORATION

- Scientists & Community Based Organizations
- Challenging
- Necessary for effective program development
- Key Collaborators
- Creates a tangible synergistic effect
- Positive outcomes for our participants
- Intellectual Village

**Notes:**
Synchronizing the development of our cohorts with the local jail release protocols
Coping with an ethical need to provide some case management for those eligible and ineligible.
Addressing the mistrust associated with the word research
Test our theories – incentive protocols, multiple sex partners following release.  We will be able to development program interventions that are based on empirical evidence  increase effectiveness and greater possible opportunity to influence behavior.
Deciding who was key and why – The importance of relationship building
Synergy – public health, combine info from the sessions, ability to gain contact with stability (STAND) proved to positive for some not all – some were in survival mode
Intellectual village – some researchers with preference for qualitative study and those with preference for quantitative study, health dept, corrections created an excellent environment for rich discussion and discovery

## INTERVENING (Research vs. Program)

- The development and delivery of efficacious research initiatives require several critical considerations
- 	Avoiding an impasse
- Examining ethical constructs
- Making research useful to program strategist
- MISTERS Project is an illustration of bridging the gap between research and programs
- Opportunity to gather and synthesize data specific to this population
- Establishes credibility

**Notes:**
Creating the philosophical framework that allows programs and science an opportunity to resolve their ethical issues (creating accountability vs. adherence to protocols)
In this current funding environment evidenced based interventions are required 
It would be great to tie a percentage of research dollars back into program development, based on outcome analysis
It was Allan Leschner who coined the phrase, but it is a perfect way to capture the always daunting delimit science and program working together
Credibility for the program – entry into otherwise unavailable intellectual and funding resources. 
Credibility for science -  addresses the notion that all knowledge begins and ends with science. More access to communities, where these anomilies occur

## INTERVENING  (Research vs. Program)

- Benefits
- Cross Disciplinary participation enhances researchers opportunity to gain access
- Creates an intellectual village
- Impetus for sound program development
- Environment where researchers and program staff can examine their ethical constructs

**Notes:**
Stand’s ability to penetrate social networks
Understanding that some of the principles of research science are:  ????? Which may conflict  with program

## INTERVENING  (Research vs. Program)

- Challenges
-  Bureaucracy
-  Flexibility
-  Funding

**Notes:**
Flexibility – The lack of for programs and the importance of adherence to protocols for researchers

## Study Foundation

- Logistics
- Consultants
- Availability of Technical Assistance
- Staff Competencies

## ASSESSMENT

- Tricia Hall
- Interview Coordinator

**Notes:**
Thank you charles for that wonderful introduction

## SCREENING PROCESS

- Sign In Sheet
- 		How he heard about the project
- Screener
- 		Between 18 and 60		Sexually Active
- 		Substance Use		Read English
- 		Hour Availability		Atlanta Availability
- 		No Sexual Offense		HIV Negative

**Notes:**
The first step for participants is a sign in sheet which we use to verify that they have been released in the past 45 days. Once that has been verified the screening process begins. In addition we call and verify that they have a permanent address and phone number. We don’t take clients who have committed a sexual offense in order to protect the staff. 

## Eligible Participants

- Informed Consent Form
- 		Reason for the study
- 		What will be required
- 		Benefits
- 		Risks/Discomforts
- 		Confidentiality
- Release of Information Form
- 		Authorizes the release of STD results
- Locator Form

## QUESTIONNAIRE

_**Demographic Information**_
- 	Ethnicity
- 	Relationship Status
- 	Housing Arrangements
- 	Education
- 	Work status
_**Knowledge**_
- STDs
- 	Anger Management Skills

**Notes:**
These questions will give u a general overview of the type of questions we ask on our questionnaires. Talk about housing arrangements and STDs what we assume that they know in regards to putting a condom on etc.
Prior to incarceration
Individual or Group

## QUESTIONNAIRE 

_**History**_
- 	Incarceration History
- 	Substance Use History
- 	STD History
**	**_**Sex Partners**_
- Number
- Gender
- Behaviors

## QUESTIONNAIRE

-  _**Associated Factors**_
- Perceived Risk
- Social Networks
- Vaginal, anal, oral sex behaviors
- Condom Use & STD Incidence
- Substance Use
- Health Care Seeking Behaviors

**Notes:**
Questionnaires are modified based on post,3mnth and 6 month assessments. E.g of a question that is not asked in the post is incarceration.

## CONDOM SKILL ASSESSMENTS

_**Demo of condom skills**_
- Condom Selection
- Latex vs. lambskin
- Not expired vs. Expired
- Open package
- Roll on outside
- Hold the tip
- Unroll to base pf penis
- When to remove penis
- Type of Lubrication
- Oil vs. Water base
- How many times can use one condom

**Notes:**
Condom application
Penis Model
Selection
	- Latex condom expired
	- Lamb skin
	- Latex condom NOT expired

Assess their condom application
using a model participants demonstrate the proper way to select and put on a male  condom
*Pick latex condom * latex condom not expired * carefully open/remove package 
*Roll on outside * hold the tip * “right away” “Right after ejaculation” * Lubricant
 * how many times use condom

## COMMUNICATION SKILL ASSESSMENTS

_**Role plays**_
- Listening Actively
- Speaks about himself
- States Feelings
- Specific Needs

**Notes:**
Are assessed by asking men to participate in tape recorded role plays.

## RANDOMIZATION

- • Colored ball selection
- 	- Intervention group
-    - Control group
- Groups are separated
- 	- What is required
- 	- Intervention begins that night

**Notes:**
Approximately half of the men will be randomized into the intervention or the comparison group via selection of a colored ball in a bag. The intervention starts the same night of randomization and the control group is talked to about their continued commitment to the project and are asked to come back the following week for a follow up. Follow up appointment cards and calls are made to participants.

## BIOLOGICAL SPECIMENS

_**Urine**_
- Chlamydia & Gonorrhea
_**Blood**_
- Syphilis & HIV

**Notes:**
In collaboration with the health department a urine sample which is tested for ct and gc and a blood sample which is tested for HIV and syphilis is collected from each participant that arrives on the night of randomization.

## ASSESSMENT SCHEDULE

|  |  Interview | Skills | STD Screening |
| --- | --- | --- | --- |
| Baseline
30 days prior to arrest | √ | √ | √ |
| Post
Since joining | √ | √ | -- |
|   3 month
   30 days prior | √ | √ | √ |
| 6 month
30 days prior | √ | √ | √ |

**Notes:**
Baseline time period is prior to incarceration. Post is since joining the MISTERS project. 3month and 6 month assessments are within the last 30 days.

## RECRUITMENT  

- RECRUITMENT
- &
-  INTERVENTION
- James C. Tomlin
- Intervention Coordinator

## RECRUITMENT STRATEGIES 

- In Jail Presentation (3x per week)
-  IRB approved script
-  STAND, Inc.  Services
-  Walk-ins and word of mouth by  participants
-  Flyers, business cards, and other materials
- Expanding, to other Locations

## INTERVENTION DEVELOPMENT

- Theory – Based (Fisher & Fisher,1992)
-  Motivation & Behavioral  Skills
-  Piloted Focus Groups
- Target population sample

## INTERVENTION SESSION 

- Ice Breaker
- Five Nightly Session
- Two Hours
- Days of Week
- Closure

## INTERVENTION SESSIONS 

- Session 1: STD Knowledge
- Session 2: Condom & Negotiation Skills
- Session 3: Avoiding triggers for drug use
- Session 4: Anger Management
- Session 5: Life Skills/Community Resources

## QUALITY ASSURANCES

- Evaluator
- Manual
- Facilitators
- Feedback

##  MISTERS GROUP CHALLENGES 

-  Substance use
-  Relationship Issues
-  Family Issues
-  Probation/Parole
-  Work Schedules
-  Weather

## RETENTION

- SUGGESTIONS / RECOMMENDATONS FOR FUTURE RESEARCH
- Antonya Pierce
- MISTERS Project Coordinator

## RETENTION

- “First Impression = Lasting Impression”
- Personable Service
- Locator Form
- Baseline	        Randomization	         Follow Up

**Notes:**
We know the saying first impressions are lasting impressions.... Because this is a 6 month follow up study , retention is extremely important and begins for the MISTERS project begins the moment the potential participant arrives at the STAND office. 
The participants receive personable service...the staff understands the emotional ramifications as well  as the stereotypes that the participants may think the staff has. We help the participants understand that their participation is voluntary, not tied to any law enforcement agency and confidential.
Along with this personable service, the participants once enrolled are asked to complete a very extensive locator form. This from includes not only the obvious participants name, address, and phone, but also includes places they may hang out or frequent, and phone number of at least 3 friend or relatives.
This information is necessary because we understand that this population is a high risk mobile population,in which drug use, unstable employment and housing are all factors.
Again, retention efforts begin at baseline and continue through randomization, 3 and 6 month follow up

## TRACKERS

- DIS Trained
- 15+ years combined experience
- Familiar with population and city
- Face to face recognition
- Follow up throughout 6 months

**Notes:**
Retention is a team effort.  However, is effectively driven and successful because of the trackers involved in the project....
This project has 2 DIS trained trackers that have a combined experience of over 15 years. The trackers are familiar with the Metro Atlanta area and high risk populations such as drug users and HIV positive individuals.
The trackers are present the night of randomization, in which they obtain an opportunity to meet the participants face-to-face in order to gain face recognition and familiarize themselves with the participants.
Interestingly enough, there have been instance where the trackers have had prior relationship with the participants from street intercepts or other jail related projects.
The trackers  are assigned to individual participants and follow up with the participants through out the 6 months. The trackers make contact with the participants through out  the 6 months. The trackers make contact with the participants through telephone calls, site visits, and street intercepts. 

## PROJECT ADHERENCE

- Housing
- Employment
- Physical
- Legal Recidivism
- Children / Partners
- Substance Use

**Notes:**
Since beginning the MISTERS project, we have found that there is direct relationship between project adherence and reality...there was an underestimate of the extent of these social issues and the impact THAT these social issues would have on adherence to the project.
These social issues include but are not limited to...........

Housing issues turned out to be a major issue which may affect adherence. Because some of the men may have been incarcerated for 3 month or more, they may no longer have the housing arrangements they had before incarceration. Additionally, some men may have been arrested for domestic violence and are no longer allowed to return to their homes. Thus housing and the lack of became factors that would lead to a lack interest or ability to attend and adhere to the project requirements.

Additionally, many of the men are seeking employment in order to reconstruct their lives pre-incarceration and adhering the project is not a viable outlook, but rather they feel a hindrance in seeking employment.
Participants physical health and ability to return to the office has also been noted as an inableler.

Some men are heavily engaged in criminal activity and have re-arrested before they are scheduled to return to randomized, and during the 3 and 6 month follow up periods.  Similarly, reporting appointment to probation and parole officers, during the same hour and day of their scheduled appointment in our office.  

Lack of childcare availability as sited by some participants make it difficult to return for the scheduled appointments.  In many instances,the female partners are employed and rely on the unemployed male counterparts to care for their children.
Surprisingly, significant others play an important role in adherence.  In some cases, partners have influenced participants to believe that participation in the intervention sessions is not important.  Many of them felt that because they are in monogamous relationships that the safe sex messages and condom neogation skills are irrelevant to their relationship.

Keeping in mind that all of the participants have used drugs and alcohol prior to arrest...Substance use would be the greatest factor in adherence and successfully complying to the project.  However, the level of substance use is a confounding factor.  There are some participants that when they arrive have extreme addiction to drugs and alcohol and have not yet arrived in the stages of change model.

## Maslow’s Theory

- Physiological

- Safety

- Social

- Esteem

- Self-
- actualization

**Hierarchy of Needs**

**Notes:**
Under closer examination, Maslow’s theory of hierarch of needs is essential to understand...
According to Maslow’s theory, his belief is that basic needs must be met in order for an individual to function successfully in society.   
Many of the participants are lacking Maslow’s essential needs thus creating an inability to successfully comply and adhere to the study.  They have experienced a disconnect from society, thus affecting their esteem.  
Estrangement from family because of their drug use or incarceration,  lack of housing, or unstable housing situations, and poor health, are just some examples of the basic needs that the men particularly in this population are experiencing and need addressing.  
The lack or one or more of these items in the structure, can greatly affect the participants, ability and desire to qualify, participate, and comply with this and other project which may benefit the individual.
These are just a few of the social issues which have arisen from this project and should be addressed in future projects.

## SUGGESTIONS & RECOMMENDATIONS

- Recruitment
- Partnerships
- Intervention
- Retention

**Notes:**
The MISTERS project has been an effective project considering all of the challenges, that have been mentioned earlier in this presentation.  This project is worthy and can easily be duplicated in other cities and settings.  However, at this time suggestions and recommendations are being made in order for a more concise recreation of the project.

In terms of recruitment, having a solid list of agencies and contacts at those agencies in which to recruitment men for the study is essential.  Those places may include but are certainly not limited to county, and city jails, probation and parole offices, and out patient drug treatment programs.  Enlisting a staff that familiar with both the area of inclusion and the target population.  However a suggestion, for recruitment may include allowing men regardless of their sexual behavior eligible to enroll in the study.  As Tricia noted earlier in her presentation, one of the exclusion criteria included sexual activity 30 days prior to incarceration.  It is important to remember that in fact the men maybe sexually active or become sexually active again, and the information such as STD education and condom skills would be a great benefit for the potential participant.    

Partnerships....Building a strong relationship early in the planning process with your local health departments and law enforcement agencies is a key element that is highly recommended.  Forming these relationships will help facilitate all aspect of the study, from recruitment to treatment to providing community relationships for your organization.

When planning the intervention portion of the study, it is important to remember that you are providing a service to your participants.  Careful selection of the location, time of day and day of the week that the intervention will be held are all important factors that your organization should consider.  Accessibility and ease of participation will greatly increase the project compliance.  Considering the lifestyles of this population, it may be reasonable to provide some flexibility in the time of day in which the sessions are held.  It is also recommended that the facilitators are extensively trained not only in the intervention material in which they are providing, but trained and knowledagble in other areas, such as drug addiction, job readiness, other community resources.  Our facilitators have experienced situations where often the men in the intervention sessions admire and look to the facilitators as role models and readily seek their advice and experience.
Lastly, retention...Retention efforts are key, especially in this study where participants are followed for 6 months.  Even more so because of the high risk behavior of the target population.....substance using men. 
It is also recommended that varies methods of tracking by employed.  This project utilized not only the trackers, which made phone and sometimes street contacts, but postcard reminders were mailed to the participants to remind them of their upcoming appointments.  Updating address and phone numbers and providing participants with reminder cards are all suggestions that will add in a successful retention efforts. 

## ADDITIONAL INFORMATION

- _ADDITIONAL INFORMATION_

- Recruiting and Retaining Substance Using Men Newly Released from Jail: Challenges of the MISTERS STD Intervention (P141)
- Examining Risk Perceptions of STDs including HIV/AIDS in African American Men Newly Released from Jail (P051)

**Notes:**
Our intent today was to provide you today a brief but concise insight of an innovative STD intervention with men newly from jail.  If you desire further information we will address you questions and feedback at the end of this presentation.  Additionally, we have 2 poster related to the study here at the conference. 

## ACKNOWLEDGEMENTS

- Centers for Disease Control & Prevention
- DeKalb County Health Department
- DeKalb County Jail
- Georgia Dept. Human Resources, Division of Sexually Transmitted Diseases

**Notes:**
Lastly, we would like to acknowledge for their time and devotion to the MISTERS project