5 per 100,000 in 1986. In 1994, the number of TB cases among residents of correctional facilities for 59 reporting areas had reached 24,361 (4.6% of the total reporting correctional population) (Braithwaite et al.). The incidence rate was 139.3 per 100,000 by 1993 and the unadjusted case rates for prison populations in many areas are significantly higher than the rates for the general population (Braithwaite et al.). According to these authors, "The 1993 TB case rate of 139.3 per 100,000 in the New York state correctional system was more than six times the case rate of 21.7 per 100,000 for the general population of New York state. Similarly, in New Jersey the incidence of TB among state inmates in 1992 was 91.3 per 100,000, compared with 12.6 per 100,000 for the state's general population in the same year" (Braithwaite et al., p. 109). At one California state prison, the annual incidence rate of TB in 1991 was 184 cases per 100,000, a rate that is more than 10 times the statewide rate and the transmission of TB also was also identified in this California prison (Braithwaite et al.).
In several recent TB outbreaks in correctional facilities, failure to detect active TB disease in inmates resulted in transmission of TB to other inmates, correctional facility employees and people in the community. Moreover, outbreaks in New York and California have involved the transmission of multidrug-resistant strains of TB to both inmates and employees of correctional facilities. Unfortunately, if tuberculosis infection is not correctly assessed and treated among in-coming prisoners, and an infected prisoner develops active tuberculosis, the extraordinarily high-density prison environment is the perfect setting for the disease to spread (Coyle et al., 2003); however, previous studies have identified deficiencies in tracking inmate tuberculosis status that have made such assessments problematic (Dolovich, 2005). In response, states across the country have refocused attention on the problem of TB in correctional facilities, and the results of these investigations have revealed a higher incidence of TB among this population than previously thought.
For instance, in one case in Pennsylvania, a court ordered the prison system to implement an appropriate tuberculosis control program throughout the state; this control program resulted in the discovery of over 400 prisoners in just one prison who, unknown to any prison authority, were infected with tuberculosis (Coyle et al., 2003). According to these authors, "The medical records of the prison were not complete enough to determine how many of these infections had resulted from the spread of tuberculosis within the prison, but there was little doubt that at least some of the active cases of tuberculosis within the system had resulted from exposure within the prison system" (Coyle et al., p. 68).
Moreover, it has been repeatedly demonstrated that tuberculosis, including highly dangerous multi-drug resistant tuberculosis, can and does spread from prisons and jails to the community. A study in San Francisco during the period 1997-1999, for example, demonstrated that slightly fewer than 44% of all persons with active tuberculosis had been incarcerated at some point before their diagnosis (Coyle et al.). In addition, medical researchers examined the DNA strains involved and determined that tuberculosis from the jail had infected the community (Coyle et al.). According to these authors, "Indeed, sixty-three percent of persons who had never been incarcerated but had developed active tuberculosis had been infected with the strain of tuberculosis associated with the jail outbreak. An earlier Centers for Disease Control study concluded that an outbreak of multidrug resistant tuberculosis in the New York State prison system involved two hospitals where prisoners were treated" (Coyle et al., p. 68).
This outbreak of TB was responsible for the deaths of 36 prisoners and one correctional officer, as well as the infection of a number of healthcare employees with a strain of multi-drug resistant tuberculosis (Dooley, Jarvis, Martone & Snider, 1992). As Mueller points out, "Medical experts say when patients stop taking the medication at some point during the year, it can keep the patient from getting well and lead to a strain of TB which is partially resistant to such treatment" (p. 101). Likewise, Eckert suggests that noncompliance with treatment regimens represents one of the most important reasons multi-drug resistant strains of TB have evolved in recent years. According to Eckert, "Many patients, for example, abandon treatment when their symptoms disappear but before all of the illness-causing pathogens are effectively killed. The tuberculosis-causing bacterium, for instance, has become increasingly difficult to treat, as too many patients have prematurely abandoned the six-month course of antibiotics" (p. 166). In this regard, Mueller points out that, "This is why health care staff members emphasize direct observation of patients taking their medication" (p. 101). Such comprehensive oversight, though, may be beyond the capabilities of some correctional facilities, as well as their ability to adequately train their staff in appropriate universal precautions that are needed when working with such populations.
Nevertheless, the need is great and time is of the essence. According to one correctional systems analyst, "Stopping the spread of TB has become a top priority because there are more than 24,000 new cases of TB every year in the United States, and TB rates in prisons and jails typically are five times higher than in the general population. Contributing to the TB challenge are the jails and prisons themselves. Most were not designed to have ventilation systems that meet standards for preventing the spread of TB" (Mueller, 1996, p. 100). Inmates and correctional healthcare workers alike are at higher risk of contracting TB than people in the general population because correctional facilities house a higher percentage of former substance abusers; in addition, HIV infections also occur in greater percentages in prisons and can facilitate the spread of TB (Mueller).
Furthermore, this analyst notes that many inmates have either not had access to adequate healthcare services prior to their incarceration or have simply ignored their healthcare needs by virtue of their past patterns of behavior, thereby making them more susceptible to contracting TB: "For many of these people it is the first time they are being examined and treated regularly for any health problems" (Mueller, p. 100).
Rationale of the Proposed Study
As early as 1904, prison management officials have recognized the need for improved care and education of inmates to help stem the incidence of TB in their institutions and to prevent its subsequent spread to the community at large (Roe, 2007). Today, treating and preventing the spread of TB in a correctional facility and the larger community in which it is situated requires a multifaceted approach (Mueller). Moreover, recidivism rates remain extraordinarily high among newly released inmates, and effecting any substantive changes in their self-destructive behaviors has defied penologists and scientists alike. Therefore, it just makes good business sense to seek to determine what will work best by asking the inmates themselves. As Braithwaite and his colleagues advise, "Inmates represent a marginalized population -- to many, an invisible population. Once inmates are convicted and sentenced to the correctional system, their debt to society often translates into simply serving time. Effective prevention efforts must garner insights from the target population (the inmates) to determine what will work best" (emphasis added) (p. 109).
The conceptual framework to be followed in the proposed study follows the precepts of public health model wherein the goal is to effect substantive changes in health standards and practices by public health administrators. This conceptual framework is congruent with the growing body of evidence showing that major changes in health behavior can be achieved by the public health sector, and that these changes in behavior are credibly associated with public health communication, including both deliberate communication programs and normal media coverage of health issues (Hornik, 2002). For example, Leviton (1996) distinguishes public health from medical applications by examining public health's focus on the health of populations and on society as a whole and offers a dual focus on individual-level behavior and on populations as a desirable one that could impact areas such as public policy and community-based trial interventions. This conceptual framework is also consistent with Mackenback and Bakker (2002), who suggest that any meaningful public health model must seek to achieve the following:
Reduce inequalities in power, prestige, income and wealth linked to different socioeconomic positions;
Reduce the effect of health on socioeconomic position, and reducing the economic consequences of ill-health;
Reduce the effect of socioeconomic position on the risk of being exposed to specific health determinants ('intermediary' material, psychosocial and behavioral factors), or reducing the effect of these determinants in the lower socioeconomic groups;
Reduce the health effects (including the consequences of illness) of being in a lower socioeconomic position through improved healthcare interventions.
The research methodology for the proposed study will be a mixed methodology, and will proceed along the timeline shown in Table 2 below.
Draft Timeline: January 2008 - December 2008.
TIME (MONTHS) (2008-2009)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1…