Inmate ed program spurs more clinic follow-up visits
Inmate ed program spurs more clinic follow-up visits
A San Francisco case study
Inmates who are released from jail before they complete treatment for latent TB infection have such abysmal rates of follow-up and completion at local TB clinics that many programs don’t even attempt to start them on the therapy. That’s been the case in San Francisco jails, where the follow-up rate for prisoners mid-treatment hovers at about 3%.
One recent study, however, found some intriguing news. Compared with a onetime monetary incentive, a series of short educational sessions worked equally well at getting released inmates to show up for their first clinic appointment, the study found. But when it came to getting the inmates to finish treatment, education worked twice as well.
Of 558 inmates enrolled in the trial, 325 were released before completing therapy. Those in the education group received a 15-minute, one-on-one educational session every two weeks when they were in jail. Those in the incentives group got the promise of a $25 food coupon if they would show up at clinic for follow-up within a month of release. Those in a control arm got a single educational session the first time they were given isoniazid.
Those in either intervention group were likely to make their first clinic visit than controls (education group, 37%; incentive group, 37%; and controls, 24%). Plus, those in the education group were more likely to finish therapy than either the incentive group or the controls (education, 24/37, or 65%; incentives, 14/42, or 33%; and controls, 12/25, or 48%).
"Some would say that’s a glass half-empty," laughs Mary White, MD, professor at the University of California at San Francisco School of Nursing, and principal investigator in the study. "We prefer to say it’s half-full. We were especially pleased to see the long-term effect of the educational sessions."
The sessions were a blend of some education — what latent TB infection means, and why it should be treated — and part counseling and "cheerleading," says White. She adds that it came as no great surprise that inmates who were educated about their latent infection did better at finishing treatment than those who were only promised an incentive for showing up the first time. "It’s not rocket science. If you’re giving someone a food coupon to make that first visit, they do it — and then they’re out of there."
White’s team made other discoveries along the way. For example, the process of tracking down each released inmate to all three groups to ask why they’d missed their follow-up clinic appointment had a surprisingly positive effect. "Often, the reaction was something like, Oh, yeah — I forgot my clinic appointment!’" says White. Prompted by that reminder, many in all three groups did indeed go straight to the clinic. Delighted, White and her colleagues promptly christened that as "the follow-up booster effect."
"To me, that suggests that making even one contact with inmates after release will really enhance follow-up," she adds.
Of course, finding inmates to provide that reminder is no easy task. Some studies seeking to discover why inmates comply poorly with follow-up have failed to find any inmates at all. White’s secret weapon, it turns out, was an exquisitely detailed form asking names and locations of every conceivable contact and venue — including "where they cashed their checks, their family, their friends, and their hangouts." The last line of the form read, "If I’ve done all these things and I still can’t find you, how would you find yourself?"
Culturally competent’ assistants do the trick
To top it off, White hired "culturally competent" assistants who knew the streets and neighborhoods to do the hunting. "We found an absolutely huge number of subjects," she adds.
White figures that one reason even the control arm of her study looks good (compared to the jail’s 3% baseline) is because the participating jails told White’s group they’d have to provide those educational sessions themselves and not depend on jail staff to provide them. That meant the sessions consisted of carefully scripted, 15-minute encounters between inmates and research assistants, not the 15-second perfunctory mumble.
Another reason, she adds, probably has to do with the fact that the participating jails told researchers that they’d need to do their own educational sessions, not depend on the jail staff to provide them. That necessity, in turn, meant that even the single educational "control" session the researchers performed was a thorough, 15-minute encounter, not the jail’s usual, 15-second perfunctory mumble.
In real life, it’s not likely that many jails will assent to doing a 15-minute educational session every two weeks, White concedes. But in an effort to try to see whether some of her results can be translated to everyday practice, White is in the midst of a second study, this one designed to see if a single educational session — performed by jail discharge planners and done at a different time from that initial, perfunctory clinic visit — will still have a positive effect.
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