The system that was put into place was modular and included a stock, sales, time management, financial and reporting module. Along with the flexibilty to add further modules.
The system's financial and reporting module was used daily to calculate profits along with running costs and staffing commissions.
Our natural environment is a valuable resource that we need to preserve and protect. Public conservation land provides New Zealanders with economic, environmental, and recreational opportunities. Access to these underpins our way of life. It also sits at the heart of our largest export earner – the tourism industry.
National’s sound management of our natural landscapes and our focus on balancing our environmental responsibilities with our economic opportunities is helping to build a stronger economy and create jobs, through more tourism and increased primary production. National is making the most of our great outdoors so that New Zealanders and visitors can enjoy our natural environment.
Predator Free 2050 – a plan to eradicate rats, stoats and possums from New Zealand and protect precious native species
Overseen the three largest predator control operations in New Zealand history – Battle for our Birds 2014, 2016 and 2017 – to protect native species
Developed a Threatened Species Strategy to set out a course to a safe, secure future for our native species, focused on increasing populations
Funded an $11.2 million kiwi recovery programme to save our national bird from extinction in the wild with a plan for 100,000 wild kiwi by 2030
Invested in conservation research and technology through the Biological Heritage National Science Challenge and the Conservation and Environment Science Roadmap
Built 60 new huts and 1000km of track Launched the Landmarks pilot project to promote natural and cultural heritage sites in Northland
Good to Grow partnership with Corrections enables prisoners to contribute to conservation and learn new skills
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Think you have trouble with mice? We have black bears. Years ago my wife heard the neighbors dog barking in his yard. Max was not much of a barker, but when he did that baritone voice of his rattled windows and shook the doors
My wife looked outside and there was Max on one side of his chain link fence arguing with the bear on the other side. The fence in question is waist high, not exactly an obstacle for dog or bear. Both were posturing waiting for the other to make the first move.
My wife ran outside yelling at the bear. While black bears are not particularly nice, they will back away from people if given the chance. But can we count on that? Do we know what the bear thinks? Max was facing a fight he could not win and my wife was not about to let that happen. So there my wife went out the door, in bare feet, hands waving in the air yelling at the top of her lungs at an already agitated bear. When I heard the story I knew I would put my money on my wife and it appears so would the bear. With an arrogant huff the bear slowly meandered back into the woods.
There was also the bear who raided our bird feeders. We have a cast iron shepherds hook that holds the feeders. Rather than stand up and take the food this lazy bear bent the Shepherds hook in half. I was able to bend it back with an industrial clamp and a lot of cursing. The really annoying part came later when I ventured to the top of the driveway and saw our garbage strewn across the street. Along with the garbage of several neighbors. That was a fun time.
Then there was the time I was washing dishes and glanced out the window only to see a large bear wandering in our yard with two cubs in tow. My wife looked out but couldn’t see the bear. “No, not near the woods, right here under the window” The look on her face was priceless when she looked down and there was the bear looking up at her.
One evening last fall I stepped onto our front porch to find a little bear running up and down tree trunks. We watched him for a while then we heard something much larger rustling in the leaves just behind the garage. With the reminder that momma bear wasn’t far behind we retired back into the house letting the bears do whatever it is bears do.
A few weeks ago I was taking the dog for her final walk of the evening, we got all the way to the end of the porch when we came face to face with the largest bear I’ve yet to come across. We all took a good long look at each other before slowly backing away. The bear headed off into the woods the dog and I slipped back into the house where I told my wife that we were going to hold off on our walk for a little while to give the gigantic bear a few moments to leave the area. At that moment she got a text from our neighbor trying to warn us about the very large bear that just walked through their fence and was heading our way.
Denyce, I know I’m your mother-in-law and generally don’t tell you what to do and what not to do, but please…stop chasing bears!
Too close for comfort. We get bears in our neighborhood, mostly around the elementary school, but a couple of times they’ve invaded our yard. Rarely do I actually see one, but neighbors often report that they are moseying down the streets.
Impact of a multifaceted education program on implementing a pediatric palliative care guideline: a pilot study | BMC Medical Education | Full Text
Impact of a multifaceted education program on implementing a pediatric palliative care guideline: a pilot study
A national clinical practice guideline for pediatric palliative care was published in 2013. So far there are only few reports available on whether an educational program fosters compliance with such a guideline implementation. We aimed to test the effect of the education program on actual compliance as well as documentation of compliance to the guideline.
We performed a prospective study with pre- and post-intervention evaluation on compliance to the guideline of the nurse specialists of a pediatric palliative care team for case management at a children’s university hospital. Eleven quality indicators were selected from 192 recommendations from the pediatric palliative care guideline, based on frequency, measurability and relevance. The multifaceted education program included e-learning and an interactive educational meeting. Four e-learning modules addressed 19 patient cases on symptoms, diagnostics and treatment, and a chart-documentation exercise. During the interactive educational meeting patient cases were discussed on how to use the guideline. Documentation of compliance to the guideline in the web-based patient-charts as well as actual compliance to the guideline through weekly web-based parent reports was measured before and after completion of the e-learning.
Eleven quality indicators were selected. The educational program did not result in significant improvement in compliance for any of these indicators. The indicators “treatment of nausea”, “pain medications two steps ahead” and “pain medication for 48 h present”, measured through parent reports, scored a compliance beyond 80 % before and after e-learning. The remaining indicators measuring compliance, as well as six indicators measuring documentation by chart review, showed a compliance below 80 % before and after e-learning.
The multifaceted education program did not lead to improvement in documentation of compliance to the guideline. Parent reported outcome revealed better performance and might be the more adequate assessment tool for future studies.
Although life-shortening disease is rare during childhood, yearly about 4200 children in the Netherlands are entitled to palliative care [1]. Pediatric palliative care has recently gained interest within pediatrics and the World Health Organization (WHO) introduced a pediatric palliative care definition [2]. The Dutch Association of Pediatrics (NVK) has developed an interdisciplinary clinical practice guideline (CPG) palliative care for children in summer 2013 based on available evidence as well as expert opinions [3]. The main focus of this Dutch CPG is symptom management, decision-making and organization of care. The recommendations in the guideline aim at reducing variability of care, minimize under- and over-utilization of resources, and ultimately have the potential to improve the quality of palliative care [4]. So far, no formal implementation program was launched to promote its use. It is known that CPGs don’t implement themselves, and a well-organized implementation strategy is necessary to increase the guideline’s general performance and its effectiveness to change clinician’s behavior [5, 6]. Examples of successful strategies include multifaceted educational programs [7–9]. E-learning is reported to offer high flexibility, accessibility, satisfaction and cost-effectiveness [10–13]. Additionally, improvement of knowledge after e-learning when compared to non-intervention and other teaching interventions is reported [14, 15].
Our university children’s hospital has initiated a specialized pediatric palliative care team (PPCT) in June 2012 which consists, among other specialists, of five specialized pediatric nurse specialists that fulfill the role of case manager for children with life-shortening disease and their families. The team’s goal is to provide support from the moment the child’s disease is considered incurable until death has occurred. The nurse specialists organize, coordinate and support the care from primary, secondary and tertiary healthcare professionals and also provide aftercare [16]. The team’s clinical practice and advises in treatment should ideally be based on the Dutch CPG. Although this guideline was available on the internet directly after publication and a printed version was within the office of our PPCT, it is unknown to what extend the PPCT really used and followed the guideline.
We hypothesized that an education program could increase the compliance of the nurse specialists from the PPCT to the Dutch CPG. Our first research question was: what is the baseline compliance of the nurse specialists to the guideline, measured with selected quality indicators. Our second research question was: can introduction of a multifaceted education program, which we specifically designed for this purpose, improve the team’s compliance to the CGP.
To allow measurement we aimed to use preset quality indicators, measuring compliance of the CPG. An extensive literature search did not reveal such indicators [17]. Therefore, in order to measure the adherence to the Dutch CPG, we developed healthcare quality indicators. All 192 recommendations mentioned in the CPG for the diagnosis, treatment and evaluation of symptoms in the palliative phase were considered as possible quality indicators. The four authors reviewed all 192 recommendations in a joint session and together selected all recommendations with a potential to be used as a quality indicator. The four authors then individually ranked ten of the selected 28 recommendations as possible indicators according to three criteria: measurability, incidence and its clinical relevance. The most frequent and highest ranked recommendations considering measurability and importance were selected to form quality indicators. All recommendations that were ranked within the top-ten of at least three authors were automatically selected. Recommendations ranked by two authors were selected if the mean ranking position was no higher than 5.
E-learning modules and an interactive educational meeting were developed by two authors (CJ and AS) and were offered as a multifaceted education program for the nurse specialists of the PPCT. The goal of the e-learning modules is not to learn recommendations by head specifically, but primarily to stimulate regular review of the CPG and thus get familiar with using the CPG. The e-learning has four modules describing a total of 19 cases of patients with any life-shortening disease. Each module consists of 8–10 questions, addressing theoretical background as well as recommendations on symptom management given by the CPG. All chapters describing a specific symptom-group are addressed in at least one of the modules as is presented in Fig. 1. Since pain is frequently seen in palliative care, this symptom was addressed in all four modules. Each of the quality indicators is addressed in least once in one of the four modules. However, since the goal of the e-learning is to stimulate use and review of the complete CPG, the questions are not limited to the quality indicators.
Distribution of subjects of e-learning questions. Figure 1 displays the distribution of the symptoms as addressed in the e-learning questions
During the e-learning session an open access available guideline was provided, stimulating the nurse specialists to find the answer in the CPG and thus get familiar with the use of it. Since the guideline stresses the importance of correct and complete documentation of symptoms and interventions, every module ends with a documentation assignment testing performance of complete documentation by the nurse specialist/participant. After completion of the module, direct electronic feedback is provided to the nurse specialist individually, with the correct answers as well as directions on which chapter and page the answer is displayed in the guideline and the exact text of the guideline is provided.
The different modules were offered to the nurse specialists for four consecutive weeks. All five nurse specialists participated in the e-learning. One week after the last module was offered and completed, the education program was completed with an interactive educational meeting with examples of actual recent patient cases and discussions on how and when to use the guideline.
Evaluation of effects of the education program as perceived by the nurse specialist was obtained 3 months after completion, through a short web-based questionnaire addressing experiences with the education program as well as self-evaluation of degree of current adherence to the guideline. Attendants approved that data could be used for research purposes.
Documentation of compliance as well as actual compliance to the CPG was measured during two periods; pre-intervention from August first 2013 until March 8th 2014 and post-intervention from April 8th until October 8th 2014. The web-based patient charts, used for daily documentation by the PPCT, were reviewed to measure documentation of compliance. The charts were reviewed on occurrence of a clinical situation in which one of the recommendations used for the quality indicators would apply. All relevant reports were scored on whether compliance to the CPG was documented. Information on actual compliance to the CPG was retrieved from a web-based parent report on symptom occurrence and management. Parents were asked whether a symptom was present, and if so, the quality indicators concerning the symptom were literally asked to parents (Table 1). Neither the nurse specialists, nor the parents were informed that their reports would be assessed for this study. The Medical Ethical Review Committee (METC) of our university hospital the Academic Medical Centre in Amsterdam, considered the retrospective chart approach of our study to be within the regulations of the Dutch Medical Research Involving Human Subjects Act, with no requirement to retrieve informed consent from parents.
The questions for parents were: Indicator 7: Did your child suffer from nausea? If yes please check the boxes of the medication that your child received. Indicator 8: Was your child in pain? If yes; do you know what the next two steps in pain medication will be? Indicator 9: Was your child in pain? If yes; do you have enough pain medication in house to treat your child for the next 48 h? Indicator 10: Was your child tired? If yes; were you advised to keep a diary? Indicator 11: Was your child tired? If yes; were you advised to spread activities through the day?
The ranking should be interpreted as follows: the first column describes how many of the four authors have rated this indicator in his or her top ten. The second column gives the sum of the positions of the rankings. The third column gives the mean ranking calculated as column 2 divided by column 1. The lower the score in column 2 and three, the higher was the indicator ranked
We describe compliance to the CPG as well as documentation of use of the CPG, measured by predefined indicators, before and after the education program. If compliance was found in 80 % of the measurements for each indicator, it was considered as sufficient use of the CPG. We chose to test whether a compliance of 80 % was achieved, since this is the percentage we aimed to reach for adequate performance of care. Two different hypotheses were tested with the statistical program SPSS 20. First, we hypothesized that the multifaceted education program would result in a significant increase in use of the guideline. The difference between the before and after measurement of each indicator was assessed with a chi-square test. A chi-square test with a p-values of <0.05 was defined as a significant difference. Second, we hypothesized that after completion of the multifaceted education program, the nurse specialists of the PPCT would comply to the CPG in at least 80 % of the measurements of each quality indicator, as assessed with the z-test for single proportions.
A power-calculation deciding the minimum number of measurements needed to demonstrate an improvement from the pre-intervention adherence of 10 % to a post-intervention adherence of 80 %, requiring at least 13 measurements both pre- and post- intervention.
From the 28 selected recommendations on symptom management, 11 quality indicators relating to the recommendations in the CPG for pain, dyspnea, nausea, and fatigue were selected (Table 1).
The percentage of correct answers on the four e-learning modules per nurse specialist is shown in Fig. 2. The results are similar between the nurse specialists. During the interactive educational meeting, all participants showed a great deal of enthusiasm and eagerness to keep expanding knowledge and applicability of the guideline. All nurse specialists showed increased awareness of the importance and added value of correct use of the CPG, and stated to comply to the CPG increasingly. Evaluation of the education program by the nurse specialists revealed a mean satisfaction score of 7.6 out of 10 for the usefulness of the education program. The nurse specialists also rated their perceived improvement of compliance to the guideline after completion of the education program. For compliance to the guideline regarding evaluation and treatment of symptoms, their self-assessment mean score was 7.8 out of 10. The self-assessment mean score for documentation was 6.4 (Table 2).
Displays the results of the nurse specialists on each of the four e-learning modules, shown as percentage of correct answers
After completing the education program I think I follow the guideline sufficiently regarding evaluation of symptoms
After completing the education program I think I follow the guideline sufficiently regarding treatment of symptoms
After completing the education program I think I follow the guideline sufficiently regarding documentation of symptoms
Provides the scores of some of the questions of the web based evaluation form of satisfaction as well as perceived self-assessment by the nurse specialists. The questions were addressed as “to what extend do you feel…….”, and could be answered with a VAS of 1–10 for the degree of agreement, with 1 being the lowest score and 10 the highest
We measured compliance to CPG and correct documentation of use of the CPG before and after the intervention. During the first evaluation period, 62 patients received support from the PPCT, of whom 22 patients had a malignant disease (MD) and 40 patients had a non-malignant disease (NMD). During the second evaluation period, 56 children received support from the PPCT of whom 19 patients had a MD and 37 patients had a NMD. Forty-five patients, who were supported by the PPCT during the first study period, were still supported by the PPCT at the start of the second study period. Eleven patients were newly introduced to the PPCT in between the two periods or during the second study period and thus included in the second test-period only.
Table 3 shows the number of patients with a clinical situation in which one of the recommendations used for the quality indicators could apply (identified by chart review or parent questionnaire), the number of measurements for each indicator, and the compliance for each indicator. There was no significant improvement in compliance to the CPG for any of the indicators after the education program. Before and after the education program, compliance to the CPG of at least 80 % of the measurements was seen in three quality indicators, “treatment of nausea”, “pain medications two steps ahead” and “pain medication for 48 h present”. More specifically these three indicators were all measured through parent reports (numbered 7–9). Although compliance and/or documentation of compliance was seen in some measurements of the other quality indicators, none of the other quality indicators showed a compliance in 80 % of the measurements. In one of the indicators, “evaluation of nausea”, no measurements could be performed after the education program due to absence of the symptom addressed.
Describes the compliance to the CPG for all eleven indicators before and after the multifaceted education program. The second and fifth column describe the number of available measurements for each indicator as well as the number of patients that were available for measurement. The third and sixth column describes the number of measurements which showed correct use of the CPG as well as the percentage of the total number of measurements. The fourth and seventh column describes whether a compliance of at least 80 % is seen for each indicator, assessed with a single test for proportions. The bold figures highlight the indicators where the 80% compliance was met. The last column shows whether a significant improvement in compliance is seen between the two measurements
We report a pilot study to investigate methods for improvement in compliance to the CPG for palliative care for children, by introducing a multifaceted education program. In contradiction to our hypothesis that the multifaceted education program would lead to a significant increase in compliance to the CPG, no significant difference is seen for any of the selected quality indicators before and after the education program.
Although Grol and Grimshaw found that structured implementation can improve adherence to CPGs [7], many reports argue that there is no magic bullet to change clinicians behavior to comply to a CPG [6, 18–20]. Weaver identified in an integrative review several barriers that can limit the success of implementation of palliative care processes. Barriers that could also be relevant in our setting are lack of qualified support services, lack of knowledge, lack of communication with medical setting, perceived lack of time, discomfort of physician, provider misconceptions, and finally a lack of comprehensive care culture [21]. Accordingly, recent studies on compliance to different pediatric guidelines, report compliance scores varying from 21 %, 43 % and 88 %, implying low compliance scores are regularly observed [22–24].
A multifaceted intervention including a combination of small group interactive postgraduate training, with personalized feedback, and additional instruction material, such as a website, was found to be more successful for implementation of a guideline than a single-faceted intervention [7–9]. One of the fastest growing education methods is e-learning which has been described as a dynamic, innovative and a rich way to provide learning opportunities [25]. Reported pros of e-learning are flexibility, accessibility, satisfaction and cost-effectiveness [10–12]. Cook and colleagues have shown that e-learning can increase students’ own control over the content, place and time of learning, and help students to gain knowledge and skills faster than traditional instructor-led methods [13, 15]. In addition, they compared e-learning interventions to other types of computer based educational interventions, and showed that interactivity, practice exercises, repetition, and feedback improved knowledge outcomes while using e-learning interventions [14]. So far, there are no reports that can replicate the positive effect of e-learning methods specifically on guideline implementation [26–30]. In our cohort, even after introduction of a multifaceted education program we could not show a significant difference between the pre-and post- intervention measurements.
We showed correct use of the CPG, defined as compliance in at least 80 % of the measurements, in three out of eleven indicators (numbered 7–9) before and after the intervention. These indicators evaluate the right choice of medicament to treat nausea, the upfront defining of pain treatment, and the upfront prescription of pain medication.
Two indicators (10–11), measuring the recommendations of the CPG to give certain advices to patients with fatigue showed low scores before and after the intervention. The low compliance scores on indicator 10 and 11 might be biased by the relatively short test periods of the study. Assessment of given advises to patients with fatigue, can be performed during the whole period of fatigue of the child. The PPCT might have provided specific advises according to the CPG at some point earlier outside our measurements periods. Since it is not prescribed and unwanted to repeat these advises on a weekly base no manifest application of the CGP could have been observed in our measurement episodes.
The scores in the indicators measuring documentation in the medical charts of compliance to the CPG (1–6) were low before and after the intervention. Although the low compliance scores may be in line with other publications reporting limited compliance [22, 24], several reasons may be suggested to explain the low estimated compliance in our study. During the interactive educational meeting as well as in the web-based evaluation of the education program, the nurse specialists expressed increased awareness as well as perceived improvement of compliance to the CPG. However, self-assessment of documentation of use of the CPG also revealed low scores. This might imply that the PPCT does comply to the CPG correctly but does not document the use as such and thus assessment of results through chart study might be an inadequate reflection of clinical practice. Due to the trans mural nature of our PPCT, the coordinating tasks, as well as the highly experienced nurses in the team, we did presume awareness of the importance of secure and complete documentation. However, reports describe that poor documentation of the performed tasks by nurses might lead to under-reportage [31, 32]. Paans et al., have screened patient records of 341 patients of 10 hospitals in the Netherlands to quantify the accuracy of different aspects of record documentation. The results show moderate accuracy described as 38 % for record structure, 20 % for admission data, 76 % of nursing diagnosis, 95 % for nursing interventions, 37 % for progress and outcome evaluations and 3 % for legibility of nursing reports [33]. Moreover, Abbaszadeh et al. performed a comparative study on the effect of e-learning compared to conventional training methods on nurses documentation [34]. Similar effects of an individual e-learning course and a conventional training method on nursing documentation imply that e-learning is not a superior education method to improve nurse’s documentation.
A strength of our study is that we were able to collect many measurements, by assessing web-based charts as well as parent reports of all patients receiving support of the PPCT. The easy and complete access will have limited the risk of information and selection bias. Moreover, we have developed a multifaceted education program addressing a national CPG, with high satisfaction and perceived effectiveness scores from participants that can easily be distributed to all professionals providing support in the palliative phase of children. Evaluating compliance to the CPG shortly after introduction, allows rapid implementation efforts to be developed, hopefully leading to effective implementation of the CPG and thus improving quality of care. A limitation of the study could be that not for all the indicators enough measurements were available. However, according to our power-calculation, for most of the indicators on documentation enough measurements were available for reliable analysis.
Assessment of charts has the limitation that only documentation of compliance is measured. This, together with the short test periods of the study, might have led to lower scores. Another interpretation could be that our education program was nog good enough. Perhaps lessons from the literature should have been taken more into account [21]. Finally although all members of the palliative care team were included in this study another limitation is the small number of nurses participating in the study.
Based on our study results we would argue that further research is needed to identify whether the low compliance scores are underestimated due to short study periods or suboptimal assessment, or the intervention was not optimal. Future research should focus on parent- or observer- based reports for adequate assessment of compliance and effectiveness of the multifaceted education program.
In conclusion, in this study we showed that a multifaceted education program, including e-learning did not increase (documentation of) compliance to the CPG. Documentation of compliance, as measured by 6 indicators through web-based chart review, remained low after the multifaceted education program. Sufficient compliance to the CPG was seen in three indicators measured through parent reported performance before and after the intervention. Additional research is required to define different methods for assessment of guideline compliance in clinical practice as well as to investigate optimal education for guideline performance.
We would like to thank Ellen vd Pas, for her cooperation in the development of the e-learning modules. We would like to thank medical student Annika vd Meer for her extensive contribution by reviewing the web-based charts. We also would like to thank prof. Dr. Martha Grootenhuis for her extensive review of the manuscript. This research was supported by funding from Agis.
CJ participated in the design of the study, participated in the selection of quality indicators as well as in the development of the multifaceted education program, participated in the collection of data and analyzed all data, and drafted the manuscript. AS participated in the design of the study, participated in the selection of quality indicators as well as in the development of the multifaceted education program, and helped to draft the manuscript. LK participated in the design of the study, participated in the selection of quality indicators, and extensively reviewed the manuscript. AV participated in the design of the study, participated in the selection of quality indicators, and extensively reviewed the manuscript. All authors have read and approved the final manuscript.
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Promoting prudent use of antibiotics: the experience from a multifaceted regional campaign in Greece | BMC Public Health | Full Text
Promoting prudent use of antibiotics: the experience from a multifaceted regional campaign in Greece
Antibiotic resistance, a major public health problem, has been linked to antibiotic consumption. In Greece both consumption and resistance rates are among the highest in Europe. A multifaceted campaign targeting both physicians and parents of school children was implemented for the first time in order to educate the public and update doctors, aiming to promote judicious use of antibiotics and hopefully decrease its consumption.
The programme consisted of a public education campaign and academic detailing of primary care physicians in the district of Corinth in Peloponnese. The experience and perceptions of parents were recorded in the meetings in the form of course evaluation and assessment, anonymous questionnaires. The use of Rapid Antigen Detection Test (RADT) for streptococcal pharyngitis by primary care physicians was also assessed by use of anonymous questionnaires. Antibiotic consumption was compared before and after the programme between the district of Corinth and the other districts of Peloponnese, as well as at a national level.
Antibiotic consumption remained unaltered at 26 Defined daily doses per 1000 Inhabitants per Day (DID) in accordance with the trend in other regions and at a national level. However, the utilization of Amoxycillin and Penicillin was increased by 34.3%, while the use of other antimicrobial classes including macrolides, cephalosporins and fluoroquinolones decreased by 6.4-21.9%. The use of RADT did not lead to a significantly decreased antimicrobial consumption.
A multifaceted educational programme targeting both the general public and primary care physicians was associated with rationalization in the choice of antimicrobial. A reduction in the total antimicrobial consumption was not achieved.
Antibiotic resistance is an increasing problem of public health. There is an association between antibiotic resistance and antibiotic consumption [1]. In Europe there are significant differences between northern and southern countries in antibiotic consumption with parallel differences in resistance. Greece is among the countries with the highest consumption and resistance rates among European Countries [2, 3].
Antibiotic consumption is highest in the community compared to hospitals and is especially associated with upper respiratory tract infections during the winter months [4]. The great majority of these prescriptions are not necessary, due to the viral cause in the majority of these infections. Therefore antibiotic overuse in the community can be targeted without any health hazards.
A number of interventions has been implemented with variable success [5]. These interventions have taken various forms and are targeted either to the public, including education and media campaigns, or to physicians in the form of academic detailing among others alone or in combination. The outcome of these interventions has been difficult to assess due to the multiple confounding factors that affect antibiotic use, including seasonal and annual variability in the incidence of infections. However, a majority of the studies indicated a reduction in the antibiotic prescription rates following the intervention [3].
Based on the above data a multifaceted regional campaign was performed targeting both the public and primary care physicians in the region of Corinth in Greece in 2009–10.
The educational material and the programme were organized by the Medical School of the University of Athens in cooperation with the Prefecture of Corinth and the Medical Association of Corinth in Peloponnese. It consisted of a public education campaign and academic detailing of the primary care physicians in the district of Corinth (Jan-Feb 2009) and an assessment of the use of Rapid Antigen Detection Test (RADT) for Streptococcus pyogenes group A by the primary care providers (Feb-Apr 2010).
Seventeen two-hourly educational meetings were organized in all major municipalities of the district with parents of children in nursing care and primary school. The title of the meetings was “What Do Greek Parents Need to Know on the Proper Use of Antibiotics”. Before the meeting parents were asked to fill an anonymous questionnaire for their experience and perceptions on the use of antibiotics in common clinical scenarios (Additional file 1). In every meeting there was a short introductory lecture by a physician specialized in infectious diseases. Following this, parents were given an educational pamphlet on the use of antibiotics for common infections in the community, published by the Institute of Pharmaceutical Research and Technology (IFET) and available for download at http://www.ifet.gr/antibiotics_site/FrameSet6.htm. An open discussion in the form of question-and-answer followed between parents and experts. The only mass media intervention in the present campaign was a press-conference organized by the prefecture for the local media at the start of the intervention. Filling the questionnaire by parents was on a voluntary basis and anonymous, in the scope of providing a background for the discussion to follow and the issues raised by the parents.
This was carried out in the form of meetings with the physicians who provide primary care for patients with respiratory tract infections including general practitioners, pediatricians, otorhinolaryngologists and chest physicians. The meetings included a lecture entitled “Bugs and antibiotics: the role of the Greek physician in the fight against microbial resistance” followed by four short interactive sessions based on the management of specific cases. Such cases included patients with acute pharyngitis, otitis media and urinary tract infections. The meetings were organized under the auspices of the local Medical Association. The use of bedside RADT for Streptococcus pyogenes was discussed with the participating physicians. Participating physicians also received a booklet on the management of community acquired infections edited by the National Organization for Medicines (EOF) and another with the guidelines of the Greek Center for Disease Control and Prevention (KEELPNO) on the treatment of infections (also available to download at http://www.keelpno.gr, http://www.eof.gr and http://www.ifet.gr).
In addition, five meetings were arranged with primary care physicians at the five public primary health care centers. These meetings were based on the same programme with the first meeting. Another meeting was arranged with district dentists under the auspices of the local Dental Association. This meeting was targeted on the use of antibiotics by dentists including endocarditis prophylaxis.
In January 2010 primary care physicians in the region including both pediatricians and general practitioners were invited via the local medical association to share their experience with use of RADT test and the management of patients with pharyngo-tonsillitis. Physicians volunteering to participate would fill-in an anonymous form with details on Centor criteria [6], the use of RADT, the results and the antimicrobials prescribed, if any (anonymity referred to both doctor and case details). The form had been previously implemented in another study [7]. The end of the recording was in April 2010 paralleling the winter season with the highest rate of upper respiratory infections in Greece.
All questionnaires used in the campaign were anonymous. The questionnaires filled for the RADT use survey were also anonymous and had been subjected to approval by the Ethics Committee of the University General Hospital ATTIKON [7]. The survey for the use of RADT was performed under the approval of the regional Medical Association of Corinth. The public campaign was approved and took place under the auspices of the Prefecture of Corinth and was designed and executed in compliance with the Helsinki Declaration.
Antibiotic consumption data was kindly provided by IMS, Greece for the district of Corinth, the other districts of Peloponnese and on a national level. Only antibiotics prescribed for respiratory tract infections were included in the study. These were phenoxymethylpenicillin, amoxicillin and the combination of amoxicillin and clavulanate, 1st and 2nd generation cephalosporins, macrolides and the fluoroquinolones levofloxacin and moxifloxacin. Defined daily doses (DDD) per 1000 inhabitants per day (DID) were calculated based on the ATC/DDD index of the WHO collaborating Centre for Drug Statistics Methodology. The rest of districts in Peloponnese and the national rate served as controls and data were compared before and after the campaign between January 2009 and February 2009 with Fisher’s exact test. In the RADT-related questionnaire, the prescription rate of antibiotics was compared with Fisher’s exact test between those reporting using the RADT vs. those that did not.
In total 772 parents participated in the meetings (approximately 7% of the estimated number in total, if a 1:1 child: parent ratio is considered - a total of approx. 11000 children attended primary school and kindergartens in the prefecture of Corinth in 2009). In the academic detailing 111 out of 486 physicians in the prefecture (approximately 20%) and 30 out of 151 dentists (approximately 23%) were present (data derived from http://www.statistics.gr for the year 2009).
In total 293 parent/care giver responses were collected (38% of attendees). Demographic data and responses are described in Table 1.
*Adverse events reported: 31 (35.6%) rash, 26 (29.9%) allergic reaction, 16 (18.4%) diarrhea and 14 (16%) combination of these.
Antibiotic utilization in the region of Corinth was unchanged in January and February 2009 at 26 DID and increased to 32 DID in March 2009. This trend reflected the overall trend at a national level as well as at a regional level in the neighboring districts where no intervention was implemented (Figure 1). However, when the utilization of antibiotic groups was compared it appeared that in the district of Corinth there was a 34,3% increase in the use of Amoxycillin and Penicillin, while the utilization of macrolides, 2nd generation cephalosporins, fluoroquinolones and amoxicillin clavulanate decreased 21.9%, 6.4%, 21.9% and 9.4% respectively (p = 0.02) (Figure 2 and Table 2). On the other hand, no significant change in the antibiotic distribution was observed in the same time period at the national utilization rates. In addition, in the neighboring districts of Arkadia and Lakonia the use of macrolides, fluoroquinolones and amoxicillin/clavulanate increased by 22.7%, 12.6% and 10.3% respectively and the use of amoxicillin/penicillin and of 2nd generation cephalosporins decreased by 20.9% and 7.4% respectively (Figure 2). In March 2009, however, antibiotic use in the district of Corinth reverted to previous levels and antibiotic group percentages approached again the national rates.
Trend of antibiotic utilization during the winter months of 2008 and 2009 on a national and regional level in the districts of Peloponnese.
Relative utilization of various antibiotic groups before and after the intervention in the district of Corinth compared to the National rate and the neighbouring districts of Lakonia and Arkadia.
Utilization of various antibiotic groups (DDD) before and after the intervention in the district of Corinth compared to the neighbouring districts of Lakonia and Arkadia
Thirteen physicians provided questionnaires for the use of RADT study, with a total number of 270 patient cases. Eleven physicians - 8 pediatricians, 2 otorhinolaryngologists and 1 general practitioner- reported consistent use of RADT group. They contributed 216 (80%) cases questionnaires. Two physicians – one general practitioner and one pediatrician - reported an empirical approach without RADT treatment group and contributed 54 (20%) cases questionnaires. In the RADT group 177 (85.1%) patients and in the empirical treatment group 34 (64.2%) patients were children (p < 0.001). The utilization of antibiotics in the two groups is presented in Table 3. Reasons for administration of antibiotics despite a negative RADT are described in Table 4. Administration of antibiotics according to Centor scale in both groups is depicted in Table 5. Throat swab culture was performed in only 16 (5.9%) cases, among which 4 were positive.
*Only in 14 of these patients the Centor score was >1. In four patients there was a rash reminiscent of scarlet fever.
Number (%) of patients prescribed an antibiotic according to Centor score in the empirical and RADT-based groups
Antibiotic resistance is an emerging public health issue of major concern worldwide which has been associated with antibiotic consumption [1, 8]. The majority of antibiotics are prescribed in outpatients for upper respiratory tract infections, which are usually of viral origin [4, 9]. Therefore, a great proportion of prescribed antibiotics is unnecessary and provide only selection pressure for the emergence of resistant bacteria. Antibiotic consumption is a complex issue influenced by multiple factors, including attitudes, knowledge and behavior of prescribers and patients, as well as the pharmaceutical industry. Interventions targeting a single aspect affecting antibiotic use have in the majority of cases failed to achieve significant changes in antibiotic consumption. Multifaceted interventions are usually more successful but also more costly and organizationally challenging [10].
The present campaign was designed to address antibiotic consumption in upper respiratory tract infections in a primary care setting during the winter months of 2009 and 2010, when the majority of unnecessary antibiotics are usually prescribed. It included initiatives targeting the public and specifically parents of young children, as well as academic detailing of health care providers in the primary care sector. Academic detailing (or “educational outreach”) is effective at inducing change in prescribing behavior in various settings [11].
Antibiotic utilization behavior in the target population was assessed by the use of a questionnaire addressing the main public behaviors associated with antibiotic overuse. In accordance with previous studies in both in Greece [12] and in other countries [13, 14] the majority of antibiotics are prescribed for upper respiratory tract infections while a significant minority of the public use antibiotics without prescription and may stock antibiotics at home. These data confirm that there is a significant gap between academic knowledge and everyday prescription practice and patient behavior regarding antibiotics. It must be stressed that antibiotics are prescription-only drugs in Greece. However this is not strictly enforced, potentially leading to over the counter antimicrobial sales by pharmacies.
According to the results of the study no major change in the total number of antibiotics prescribed was detected. However the observed data indicate that in the targeted district antibiotic utilization was more rational, as reflected by significantly increased use of amoxicillin or penicillin according to the national guidelines and a decrease in the use more broad-spectrum antimicrobials like macrolides, 2nd generation cephalosporins, fluoroquinolones and amoxicillin/clavulanate. However, after the end of the campaign, antibiotic use tended to revert to previous levels, indicating the need for continuous educational initiatives (or at least of longer duration or repetitive).
One of the limitations of the analysis of the data is the before-after design with comparisons on the months before and after the intervention. Such analyses do not account for seasonal or other temporal confounding factors. A time-series analysis might be more informative. However, data were available only for limited time points, preventing time-series analysis. A further limitation that may have affected the effectiveness of the intervention is the rate of participation of both healthcare professionals and parents. A bias towards increased participation of physicians and parents already familiar with appropriate antibiotic use cannot be excluded either.
It has been shown in various settings that the use of RADT for the detection of streptococcal antigens on pharyngeal swabs improves the diagnostic accuracy of streptococcal pharyngitis compared to the clinical criteria alone, and is comparable to and more practical than the use of pharyngeal swab culture [7, 15, 16]. In addition access to RADT to pediatricians has been associated with a 50% decrease in the use of antibiotics compared to management based on clinical criteria, from 72 to 33%. RADT has been recommended by the guidelines for the management of pharyngitis by the Infectious Disease Society of America [17]. In the present study, physicians providing primary care in both children and adults in everyday clinical practice for the winter season of 2010 had also participated in the educational campaign in the previous year. No difference in the use of antibiotics was observed between those with and those without use of RADT. A variety of reasons may account for this difference from previous studies. It appears that physicians in the present study not using RADT prescribed less antibiotics (38.9%) compared to similar groups in previous studies, indicating perhaps better adherence to clinical indications. The effect of the previous educational campaign cannot be adequately assessed. Another interesting finding is that the most usually cited reason for prescribing antibiotics despite a negative RADT was a clinical picture “consistent with” streptococcal pharyngitis. Culture of a pharyngeal swab was performed in a minority of patients reflecting probably the impracticality of this procedure, because of the time required for the result and the necessity for a second appointment. Pharyngeal swab cultures which are recommended by the IDSA guidelines for certain groups were available in most other studies and may have contributed to the observed higher reduction in the use of antibiotics.
Even though no reduction was observed in the antibiotic prescription rate, there were significant differences in the type of antibiotics prescribed in the two groups. In the RADT group penicillin and amoxicillin, which are the recommended antibiotics according to the guidelines, were prescribed more frequently compared to all other categories. This was accompanied by a significant decrease in the use of both macrolides and cephalosporins, indicating that the use of RADT encourages treatment with more narrow-spectrum antibiotics. The latter finding is especially important in Greece where consumption of macrolides is especially high with accompanying high rates of resistance.
In conclusion, a multifaceted campaign was performed for the first time in Greece, addressing the multiple factors that influence the utilization of antibiotics (providers and public). In general, it revealed the gap that needs to be filled in the proper education of the public in terms of antibiotic use and it provided a starting point for improvement in certain aspects of providers’ practices in terms of antibiotic prescribing. Similar campaigns implemented for longer period of time and at a larger scale may promote the prudent use of antibiotics, with a final aim to reduce antimicrobial resistance in the community.
We thank the Prefect of Corinth, Nikolaos Tagaras for the support to the project, the Chairman of the Medical Association of Corinth, Panagiotis Papapanagiotou for the help with the organization of the physicians meetings and the RADT cases questionnaires and Katerina Papanikolaou from the Prefecture of Corinth for the help with the logistics and implementation of the project.
All authors have participated actively in the design and have made substantial contributions to the execution of the campaign, including the on-site meetings with parents/cares and/or primary care physicians. In addition, DP drafted the manuscript and performed the statistical analysis; AA, AP and GP contributed to the conception and design of the campaign; EG prepared the educational material for the parents’ meetings; MS, ST, LG, DK, PP, VS, GK, SS contributed to the acquisition of data; IK contributed in the drafting of the manuscript; KK and HG contributed to the original concept and design for the campaign and to the interpretation of data. All authors have read and approved the manuscript, and have given final approval for submission.
Consumption of antimicrobials in ATC group J01 (antibacterials for systemic use) in the community (primary care sector) in Europe, reporting year 2010. [http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/esac-net-database/Pages/Antimicrobial-consumption-rates-by-country.aspx]
Incarceration history is associated with lower rates of condom use and increased HIV risk. Less is known about duration of incarceration and multiple incarcerations’ impact on condom use post-release.
In the current study, we surveyed 1,416 adults in Mississippi about their incarceration history and sexual risk behaviors. Generalized estimating equations (GEE) were used to test associations between duration of incarceration, multiple incarcerations, socio-demographic factors, substance use, sexual behavior, and event level condom use at last sex.
After adjusting for covariates, having been incarcerated for at least 6 months two or more times remained significantly associated with condomless sex.
This study found a strong, independent relationship between condom use and multiple, long-term incarceration events among patients in an urban STI clinic in the Deep South. The results suggest that duration of incarceration and multiple incarcerations have significant effects on sexual risk behaviors, underscoring the deleterious impact of long prison or jail sentences on population health. Our findings also suggest that correctional health care professionals and post-release providers might consider offering comprehensive sexual and reproductive health services and those providing community care should consider screening for previous incarceration as a marker of risk.
Nearly seven million people pass through the criminal justice system in the United States (US) annually, including almost two million in jails or prisons and more than four and a half million on probation or parole [1]. Although the rates of incarceration have gradually declined in recent years, the US continues to have the world’s highest incarceration rates [1].
Incarcerated populations experience higher rates of chronic and infectious diseases than the general populace [2]. Most incarcerated individuals have a history of substance abuse and half qualify as dependent [3–5]. Hepatitis C, HIV, and other sexually transmitted infections (STIs) are highly prevalent in incarcerated populations [6], with rates of HIV for incarcerated individuals three times that of their non-incarcerated counterparts [7]. An estimated 14 % of all HIV positive people in the US pass through a jail at some point in any given year [8].
In Mississippi the rate of HIV is also high. Jackson, Mississippi, has the 4th highest HIV infection rate in the nation at 36.7 per 100,000 in 2011 [9]. The HIV rate among incarcerated populations in Mississippi is 2.2 % for male prisoners and 2.6 % for female prisoners compared to national HIV rates among incarcerated men and women of 1.4 %, 1.9 %, respectively [7].
While a large body of research has focused on the shared risk factors for both incarceration and HIV [10, 11], some previous investigations have specifically evaluated the association between history of incarceration and risky sexual behavior, including condom use [12, 13]. A study in Vancouver, Canada found that among people who inject drugs, those who experienced incarceration in the past 6 months were significantly more likely to report inconsistent condom use with casual partners [14]. Another study that included 106 recently incarcerated men found that 40 % reported multiple sex partners and many reported engaging in condomless sex with committed and casual partners (71 and 26 %, respectively) post-release [15]. Similarly, a recent investigation of 293 African Americans also demonstrated that incarceration was associated with number of sex partners and frequency of condomless sex [16]. Also, Grinstead and colleagues (2008) found that partners of incarcerated men cited inconsistent condom use post-release as a concern [13]. Motivation to engage in condomless sex may increase post-release due to the desire to reconnect with partners, to demonstrate trustworthiness, or for family planning reasons (e.g. intentional pregnancy) [17]. Recent research has also suggested that sexual risk behavior might also increase post-release because of disruption of primary partnerships following incarceration [18]. Finally, criminal justice involvement can create instability in which there is a disconnection from social networks and a lack of housing and employment opportunities all of which have been demonstrated to increase risk-taking behavior [11].
Less is understood, though, about the duration of incarceration and repeated incarceration, and sexual risk behavior. Khan and colleagues (2011) found that HIV infection was associated with both incarceration for 1 year or less and incarceration for 1 year or longer [19]. Building on these findings, the current study aims to understand if repeated incarceration or specific lengths of incarceration (e.g. serving shorter vs. longer sentences) affects sexual risk behavior to varying degrees. This is important to discern because understanding the specific effect of duration of sentence and repeated incarceration could provide essential information about critical points of intervention to lower the risk of condomless sex post-release. This study examines associations between participants’ incarceration experiences, specifically frequency and length of incarceration on condom use at last sex (hereafter “condomless sex”) among STI clinic attendees in Jackson, Mississippi.
A total of 1,542 participants were enrolled in the study between January and June 2011. All participants were recruited at the Crossroads Clinic, a publicly funded STI clinic in Jackson, Mississippi. Eligibility criteria included: 1) being at least 18 years of age, 2) presenting for STI/HIV screening, 3) willingness to complete a 30-min computerized survey, and 4) ability to speak and read English. All patients presenting at Crossroads Clinic during the study period were offered an opportunity to participate by clinic staff; 93 % of those who were invited to participate completed the survey. Data was collected on a desktop computer with a self-administered survey programmed using Illume ™ (Datstat, Washington). The survey included questions about demographic, behavioral, structural and social factors. Participants did not receive compensation for their participation. All participants provided informed consent, and the University of Mississippi Medical Center, the Mississippi State Department of Health, and The Miriam Hospital’s institutional review boards approved the study. Of the 1,542 participants, 126 (8.2 %) did not report partner information. Therefore, the final sample included 1,416 participants who reported on at least one sexual partner. These participants reported on condom use for a total of 2,822 sexual events.
Socio-demographic information collected included gender, age, sexual orientation, level of education completed, employment status, marital status, housing status, and monthly religious service attendance.
Participants were asked to report the discrete number of times they had ever been incarcerated (e.g. in your lifetime, have you ever been incarcerated (in jail or prison); how many times have you been incarcerated for 6 months or more?) for: 1) 30 days or less, 2) 6 months or less, and 3) more than 6 months. Responses to each question were coded as never, once, or two or more times. These were not mutually exclusive variables. For example, a participant might have been incarcerated for less than 30 days, but also incarcerated another time for more than 6 months. From these variables, a single incarceration experience variable was created with five mutually exclusive categories representing never incarcerated, incarcerated only one time for less than 6 months, incarcerated more than one time for less than 6 months, incarcerated only one time for greater than 6 months, and incarcerated more than one time for more than 6 months. Participants also indicated whether their partners had been incarcerated at any time during the past 6 months.
Information related to sexual partnership was also collected. Individuals were asked to list their three most recent sexual partners in the past year. For each of these three partners participants were also asked to: 1) indicate whether or not they considered them to be a main partner (versus a causal partner), 2) state whether or not they (or the partners) were engaging in multiple partnerships at the same time, 3) whether they depended on them (and if these partners depended on the participant) for financial or material resources, including, bills and housing, food, childcare, and transportation costs, 4) if they had used drugs at last sexual encounter, 5) whether they had ever had anal, oral or vaginal sex, and 6) whether they had engaged in condomless sex. We also asked participants to report their total number of lifetime partners.
Heavy episodic drinking (having more than five alcoholic drinks at one time) and participant or partner alcohol use at last sex for the most recent three sexual partners was measured [20]. Drug measures included frequency and history of marijuana, cocaine and/or crack, and an “other drug use” variable, which measured any use of heroin, methamphetamine, ecstasy, special-k and/or non-prescribed prescription drug use ever.
Generalized estimating equations (GEE) models were used to test associations between incarceration history, socio-demographic factors, substance use, sexual behavior and event-level condomless sex. GEE analysis was used to account for the fact that participants reported event level data on condom use at last sex with up to three recent sexual partners, leading to correlated outcomes within individuals. Specifically, GEE analysis uses the empirical variance “sandwich” estimator to obtain correctly specified standard errors when the outcomes are correlated [21]. The binary condom use outcome was modeled using a logit link function, and an unstructured within-person correlation matrix was specified. All GEE analyses were conducted using SAS PROC GENMOD (Version 9.2; SAS Institute, 2009).
As a first step, bivariable GEE models were tested for associations between each of the incarceration variables (frequency of and repeated incarceration for < 6 months, and > 6 months), other covariates of interest, and condomless sex. Covariates that were found to be significant at p < 0.10 were then retained in a final multivariable GEE logit model. In post-hoc analyses, we also tested for interactions between gender and each incarceration variable, and the main partner designation and each incarceration variable. The results showed no significant interactions between gender, main partner designation and the incarceration variables. Therefore, results are provided for the model without interactions.
The population was largely African American (N = 1,343; 94.9 %), and the majority were women (62.6 %, n = 884). Participants ranged in age from 18 to 56 years, with a mean age of 24.8 years (SD = 6.13). Nearly six percent (5.7 %) of the population self-identified as bisexual (n = 81) and 5.2 % self-identified as gay/lesbian (n = 74). More than half (58.6 %) reported having at least some college education (n = 828), 52.6 % worked at least part time (n = 745), 47.7 % had stable housing (n = 675), 35.4 % reported that they financially or materially depended on at least one partner (n = 496), and 35.7 % of participants had at least one partner who was dependent on them (n = 500). Nineteen percent (19.0 %) of participants reported a history of incarceration (n = 262), 17.8 % had been incarcerated for 6 months or less (n = 253), 6.0 % had been incarcerated for more than 6 months (n = 82), and 6.6 % reported that they had a partner who had been incarcerated in the past six months (n = 90). Overall, 11.1 % of participants reported being incarcerated more than once (n = 153). Of the 2,822 sexual events, condoms were reportedly used in 45.0 % (n = 1,271) of the events. See Table 1 for descriptive statistics.
Sociodemographic and behavioral characteristics reported by participants attending a publicly funded STI clinic in Jackson, Mississippi (N = 1,416)
Bivariable GEE models (see Table 2) indicated that those significantly more likely to report condom use at last sex were: single [OR: 1.63 CI 95 %: (1.23, 2.15)], younger [OR: 1.26 CI 95 %: (1.05, 1.50)], had a college degree [OR: 1.60 CI 95 %: (1.19, 2.14)], and attended religious services at least once a month [OR: 1.27 CI 95 %: (1.06, 1.51)]. Conversely, condom use was less likely with main partners [OR: 0.37 CI, 95 %: (0.32, 0.44)], persons who reported being financially or materially dependent on a partner [OR: 0.39 CI 95 %: (0.31, 0.47)], having a partner that was dependent on the participant [OR: 0.34, CI 95 %: (0.28, 0.43)], being female [OR: 0.76 CI 95 %: (0.63, 0.90], heavy episodic drinking less than monthly [OR: 0.77, CI 95 %: (0.60, 0.97)], and a history of cocaine or crack use [OR: 0.52 CI 95 %: (0.33, 0.85)]. With regard to incarceration experience, only having been incarcerated two or more times for more than 6 months was associated with a significant decrease in the likelihood of condom use at last sex [OR = 0.47, 95 % CI = 0.27, 0.82].
Univariate correlates of event level condom use at last sex reported by participants attending a publicly funded STI clinic in Jackson, Mississippi
The results of the final multivariable GEE logit model are shown in Table 3. Being female [adjusted OR (AOR): 0.71 CI 95 %: (0.58, 0.87)], engaging in heavy episodic drinking less than monthly [AOR: 0.71 CI 95 %: (0.55, 0.92)], having more than 10 lifetime partners [AOR: 0.73 CI 95 %: (0.58, 0.93)], considering their current partner as their main partner [AOR: 0.42 CI 95 %: (0.35, 0.50)], and having a partner who financially or materially depended on them [AOR: 0.50 CI 95 %: (0.40, 0.63)] were all independently associated with a lower likelihood of condom use at last sex. Having some college education and having a college degree were both associated with an increased likelihood of using condoms at last sex [AOR: 1.35 CI 95 %: (1.11, 1.65) and AOR: 1.45 CI 95 %: (1.08, 1.94) for some college education and college degree or higher, respectively]. After adjusting for covariates and other incarceration variables, having been incarcerated two or more times for more than 6 months remained significantly associated with decreased condom use. The odds of using a condom at last sex were 2.3 times lower [AOR: 0.44 CI 95 %: (0.24, 0.81)] for participants who reported having been incarcerated multiple times for more than 6 months.
Multivariable model results for incarceration correlates of condom use at last sex reported by participants attending a publicly funded STI clinic in Jackson, Mississippi
This study, conducted at a public STI clinic in Jackson, Mississippi, is among the first to explore the relationships between duration of incarceration, multiple incarcerations and condom use. The findings of this study demonstrate that repeated incarceration for more than 6 months at a time was independently associated with increased odds of condomless sex. The current study is also among the first studies to explore incarceration and condom use in the Deep South, which has the highest rates of STIs and HIV in the country [22].
Our findings add to a mounting body of evidence that links incarceration to risky health behaviors and poor health outcomes [23, 24]. This study also supports other recent findings that demonstrate the relationship between incarceration and lower rates of condom use post-release [11, 25]. Reasons for this association might include longer periods of sexual deprivation and lack of access to sexual health education while incarcerated and post-release. The findings of the current study highlight that longer-term and repeated incarceration is associated with condom use while short-term incarceration was not associated with condom use. Previous research has demonstrated that incarceration can dissolve primary sexual relationships, and, thus, is related to increased sexual risk taking after release, which may be especially true for those serving long sentences [18]. In addition, incarceration disrupts existing social support networks and introduces chaos into individuals’ lives in the form of lack of access to economic opportunities and housing, all of which could lead to a de-prioritization of sexual health [24, 26, 27].
Given the association between multiple incarcerations, duration of incarceration and condom use in our study, greater efforts are needed to address the sexual health needs of individuals with criminal justice involvement, especially those with longer and more frequent incarcerations. While many criminal justice systems do provide preventative screenings during incarceration a recent study found that only 46.9 % of all prisons and 16.6 % of jails provided STI testing [28]. Testing initiatives should continue to be strengthened and buttressed with broader sexual health education programs and comprehensive discharge planning that includes linkage to relevant medical care especially for individuals who have previously been incarcerated. Recent research has demonstrated that the effect of expanded HIV testing should be augmented by condom use interventions [29].
In addition, providing incarcerated individuals with discharge planning services that include linkage to sexual health services and provision of condoms upon release could also decrease the likelihood of sexual risk taking in the community. Also Pre-exposure prophylaxis (PrEP) interventions could reduce HIV acquisition risks for HIV-uninfected individuals engaging in condomless sex post-release. PrEP is a once daily medication for at-risk persons that can dramatically reduce the risk of HIV acquisition [30–32]. A recent study found that adherence to PrEP among people who inject drugs to be generally high, but participants who had been incarcerated had lower levels of drug adherence, which dramatically enhances PrEP’s efficacy [33]. Little is currently known about how to implement PrEP after discharge, but the results of the current study suggest that offering PrEP upon release should be explored.
After release STI providers and other community based organizations that care for high-risk patients should adopt tools that screen for criminal justice involvement as a marker of risk. This could take the form of asking about criminal justice history upon intake or during routine appointments or could include cross-sector partnership between criminal justice agencies and community-based clinics. This partnership would facilitate linkage to sexual health services post-release and diminish risk by promoting the use of various STI prevention techniques. With access to history of criminal justice involvement data, providers may be able to better serve the needs of formerly incarcerated patients, tailoring treatment and intervention plans to the potentially enhanced risk introduced by incarceration.
Finally, our findings also have important policy implications. The duration and number of times incarcerated seem to have compounding effects on sexual risk behaviors after release. This finding adds to a growing body of literature that elucidates the negative effects of sentencing policies on correctional and community health. For instance, previous research has shown that incarceration, particularly repeated incarceration, increases the risk of virologic failure among HIV infected people who inject drugs [34, 35]. The rise of the use of mandatory minimum sentencing and “three strikes” laws have resulted in more people, particularly African Americans, becoming incarcerated for longer periods of time [11]. A de-escalation of mass incarceration, which has recently been touted by conservative and liberal policymakers alike, and a move away from harsh sentencing reforms, could have positive benefits for the sexual health of African Americans in the Deep South, who are disproportionately arrested, convicted and incarcerated and tend to serve longer sentences [36].
This study has several limitations. First, the explanatory and outcome variables were based on self-report, which could result in misclassification. In addition, because the study was cross-sectional it is difficult to infer causality between incarceration history and condom use behaviors. Also, the study was limited to persons accessing a publicly funded STI clinic and is also a restricted sample of individuals who have engaged in high-risk sexual behavior. Additionally, the sample is mostly women (nearly 63 %) whereas a much smaller percentage of the justice involved population is female. Because of these sample restrictions generalizability is limited. Moreover, while it is important to know that duration of sentence matters in relation to incarceration and condom use, we only analyzed incarceration of less than 6 months and greater than 6 months due to sample size constraints. Future research should build on our findings and further assess how a wider range of sentence variation affects sexual risk behavior in a larger sample of individuals with a history of incarceration. In addition, we did not ask about type of facility (prison or jail). For instance, jails typically have higher turnover rates than prisons meaning individuals, overall, serve shorter sentences, and, thus, spend less time in jail facilities. Finally, while we found a relationship between longer-term, repeated incarceration and condomless sex, there is still a need to understand the latent factors that undergird this relationship. More information is needed about the mechanisms of both incarceration (e.g. deprivation, isolation) and the post-release experience (e.g. lack of social support) and how they might affect decisions about condom use. Qualitative research would help elucidate how these incarceration-related factors mediate the relationship between incarceration and condom use.
This study found a strong, independent relationship between condom use and multiple, long-term incarceration events among patients in an urban STI clinic in the Deep South. Efforts to provide comprehensive sexual health, HIV and STI screening services, and PrEP, in combination with increased access to condoms for inmates during incarceration and upon release, could lead to less sexual risk taking post-release. Ultimately, reducing the number of incarcerated individuals could have positive effects on the sexual health of those with criminal justice experience as well as their home communities.
The research and manuscript preparation were supported by NIH grants: K23AI096923, K01AA020228, P30AI042853, R25MH083620, R25DA035692, and T32DA013911.
The data described herein come from a conducted a cross-sectional survey with men and women in Jackson, MS. We are unable to make the data available at this time because a public use dataset has not yet been created and the principal investigator is still conducting analyses relevant to the primary outcome(s) of the study.
LBR and SP led the writing of the manuscript. JR led the data analysis. ASN conceptualized the study design and oversaw all study procedures. JR, AG, LM, PC, JH, BM, CB, RR, TA, and ASN all contributed to the interpretation of results and writing of the manuscript. All authors read and approved the final manuscript.
The institutional review board (IRB) at the Miriam Hospital approved all study procedures. Informed consent for participation in the study was obtained from respondents at the time of enrollment.
Department of Sociology and Social Work, North Carolina Agriculture and Technology State University, Greensboro, NC, USA
Institute for Community Health Promotion, School of Public Health, Brown University, Providence, RI, USA
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