Sustainable Disease Risk Reduction (DRR) Strategies for CJ Systems

This 5-year project was funded by NIDA in 2008 and included 2 major research phases intended to reduce HIV and other addiction-related disease risks in criminal justice (CJ) populations. The first phase of the TEXT Box--DRR Proj Info FINALDisease Risk Reduction (DRR) Project included an intervention effectiveness study, and the second addressed its implementation in CJ field settings. A manual-guided DRR planning and decision-making strategy was developed based on cognitive tools that focused on an evidence-based, visual-spatial (including TCU Mapping-Enhanced Counseling) rather than traditional didactic communication approach. In the second phase of the project, the process of intervention implementation was examined in an expanded network of CJ systems in five different states.

Effective interventions for reducing infectious diseases in criminal justice populations can offer significant public health benefits, both to offenders themselves and the public at large. However, there are challenges to “engaging” and convincing offenders with substance abuse histories to adequately plan and apply risk reduction principles during the crucial community reentry phase after imprisonment. Correctional systems also are often fragmented, representing another challenge to efforts to provide integrated care and supervision to offenders at-risk for infectious diseases. This project was funded by NIDA in 2008 to address both of these highly significant issues.

The study developed and tested an effective Disease Risk Reduction (DRR) intervention, titled WaySafe, for HIV and other infectious diseases and evaluated its implementation process (R01DA025885, funded by the National Institute on Drug Abuse, National Institutes of Health). The specific aims of the project included: (1) developing and testing a manualized DRR planning and decision-making strategy that relies on cognitive tools and focuses on risk behaviors during reentry back to the community, and (2) examining the process of intervention implementation in an expanded network of criminal justice (CJ) systems that rely on organizational needs and functioning assessments as the focus of analyses of implementation progress.

In the first phase of the project, WaySafe, a manualized DRR planning and decision-making intervention was developed and tested. The intervention utilized a visual-spatial rather than traditional didactic communication approach (Dansereau & Simpson, 2009) that focused on risk behaviors during community reentry and addressed attitudes and behaviors related to risks for contracting HIV or other infectious diseases. Key components included problem recognition, commitment to change, and strategies for avoiding behavioral risks of infections. Motivational and planning sessions were designed to be delivered near the end of institution-based substance abuse treatment, expanding beyond the didactic HIV/AIDS education currently provided.

The WaySafe curriculum included 6 weekly sessions and self-directed workbooks that clients completed between sessions. Sessions were designed to last about one hour and were typically conducted weekly. Sessions were conducted in groups by a trained counselor and included a variety of group-based and participatory activities. The 6 sessions included in WaySafe were: (1) Introduction to Mapping and included participants working on group maps while learning mapping principles, (2) Risk and Reasons which addressed risk taking and included having subgroups each working on maps around different aspects of using or not using condoms, (3) The Game in which participants formed teams and played a quiz game around facts related to HIV, AIDS, and hepatitis B and C (HBV/HCV), (4) The Should/Want Problem had teams of participants coming up with reasons why they would want to engage in a risky activity or what they should do regarding the risky activity, (5) Risk Scenes which teaches thinking about, planning, and rehearsing intentions regarding risk activities, and (6) Planning for Risks which included activities in which participants were asked to imagine themselves in the future having avoided HIV/HBV/HCV and asking them what advice they would send to their “present” self to avoid infection. Participant workbooks, distributed at the end of each session, included activities and exercises participants were asked to complete on their own to prepare for the following week’s session.

WaySafe Results

In the first phase of the project, WaySafe was implemented in 8 correctional facilities in 2 states. The facilities differed by gender, length of stay, and substance abuse treatment vendor. A total of 1,395 inmates WaySafe Leader Manual Cover 3participating in drug treatment were randomly assigned to attend the 6 weekly WaySafe sessions (N=738) or receive treatment as usual (TAU; N=657). All participants completed a pre-test and were asked to complete a post-test approximately 8 weeks later and after the six WaySafe sessions (N=1,266 completed the post-test). A Certificate of Completion was provided after the post-test. The pre- and post-tests assessed knowledge, confidence and motivation regarding HIV Knowledge, Avoiding Risky Sex, Avoiding Risky Drug Use, HIV Testing Awareness, and Risk Reduction Skills.

The study resulted to date in 11 published articles (1 article in press and 1 article under review), and 26 conference presentations. In addition, the project included a Supplement designed to develop and evaluate models to explore the proportion of infections averted by interventions affecting HIV testing uptake and interventions affecting HIV treatment uptake. Findings from the parent project have revealed that WaySafe participants had greater improvements on each of the 5 knowledge and confidence measures than did those in the TAU arm. Improvements for WaySafe were demonstrated in each of the 8 facilities in which it was implemented (Lehman et al., 2011). Rowan-Szal et al. (2011) examined WaySafe results for female offenders in 3 different facilities that differed in program length and found that female offenders in longer term programs had higher pre-test values on WaySafe measures, but that female offenders in the short-term program showed greater improvement from pre- to post-test. Treatment engagement has been shown to be an important predictor of treatment outcomes. Offenders with higher treatment engagement prior to WaySafe had higher post-test scores, but the amount of change from pre- to post-test on WaySafe measures was equivalent for both high and low engagement offenders, indicating that WaySafe appeared to be successful at reaching low engagement offenders (Lehman et al., 2011). Bartholomew et al. (2011) found that client participation in high risk behaviors prior to incarceration was associated with greater improvement in WaySafe, and results varied by gender. Furthermore, participation in WaySafe was positively associated with getting tested for HIV after release back into the community, 74% of offenders who participated in WaySafe reported getting tested for HIV compared to 55% of offenders who received TAU. Higher scores on post-test measures that represented concepts taught in WaySafe also were positively associated with reports of getting tested (Lehman et al., 2012).

At the conclusion of the workshops, attendees were asked to complete a workshop evaluation survey (WEVAL) which asked about reactions to the training and anticipated usage of mapping and WaySafe. About six months after the workshops, Workshop Assessment Follow-up (WAFU) surveys were sent to counseling staff at participating programs to assess implementation, use of the materials, training of other staff, and barriers to implementation.

Implementation Phase

A second phase of the project examined the process of intervention implementation among correctional and community programs (serving criminal justice clients) in 5 different states. Two-day “train-the-trainer” workshops were conducted with 1-2 key counseling staff from each participating program. The workshops covered cognitive mapping principles, the WaySafe curriculum, and ended with a discussion of implementation issues. About one to two months prior to the workshop, counseling staff at each participating program were asked to complete Organizational Readiness for Change (ORC) surveys. At the conclusion of the workshops, attendees were asked to complete a workshop evaluation survey (WEVAL) which asked about reactions to the training and anticipated usage of mapping and WaySafe. About six months after the workshops, Workshop Assessment Follow-up (WAFU) surveys were sent to counseling staff at participating programs to assess implementation, use of the materials, training of other staff, and barriers to implementation.

Selected Publications

Lehman, W. E. K., Rowan, G. A., Greener, J. M., Joe, G. W., Yang, Y., & Knight, K. (in press). Evaluation of WaySafe: A disease-risk reduction curriculum for substance-abusing offenders. Journal of Substance Abuse Treatment.

Lehman, W. E. K., Gould, M., & Flynn, P. M. (2013). HIV/AIDS and substance use. In P. M. Miller (Ed.), Interventions for addiction: Comprehensive addictive behaviors and disorders (Chapter 25, pp. 235-243). San Diego: Elsevier Inc., Academic Press.

Yang, Y., Knight, K., Joe, G. W., Rowan-Szal, G. A., & Lehman, W. E. K. (2013). The Influence of client risks and treatment engagement on recidivism. Journal of Offender Rehabilitation, 52, 544-564.

Lehman, W. E. K., Greener, J. M., & Flynn, P. M. (2012). Organizational Readiness for Change in correctional and community substance abuse programs. Journal of Offender Rehabilitation, 51(1-2), 96-114. PMCID: PMC3325111

Rowan-Szal, G. A., Joe, G. W., Bartholomew, N. G., Pankow, J., & Simpson, D. D. (2012). Brief trauma and mental health assessments for female offenders in addiction treatment. Journal of Offender Rehabilitation, 51(1-2), 57-77. PMCID: PMC3474366

Simpson, D. D., Joe, G. W., Knight, K., Rowan-Szal, G. A., & Gray, J. S. (2012). Texas Christian University (TCU) Short Forms for assessing client needs and functioning in addiction treatment. Journal of Offender Rehabilitation, 51(1-2), 34-56. PMCID: PMC3325103

Lehman, W. E. K., Simpson, D. D., Knight, D. K., & Flynn, P. M. (2011). Integration of treatment innovation planning and implementation: Strategic process models and organizational challenges. Psychology of Addictive Behaviors, 25(2), 252-261.

Selected Presentations

Lehman, W. E. K., Rowan-Szal, G. A., Joe, G. W., Bartholomew, N. G., & Knight, K. (2012, June). Relationship between HIV testing following incarceration and participation in WaySafe: A disease-risk reduction intervention for offenders. Presented at the annual meeting of the College on Problems of Drug Dependence, Palm Springs, CA.

Bartholomew, N. G., Joe, G. W., Rowan-Szal, G. A., Lehman, W. E. K., & Yang, Y. (2011, October). Pre-custody HIV risk behavior as a factor in the effectiveness of WaySafe. Presented at the Addiction Health Services Research (AHSR) Annual Meeting, Fairfax, VA.

Lehman, W. E. K., Rowan-Szal, G. A., Joe, G. W., Bartholomew, N. G., Yang, Y., & Knight, K. (2011, October). Treatment engagement and success in WaySafeA disease risk reduction intervention for offenders. Presented at the Addiction Health Services Research (AHSR) Annual Meeting, Fairfax, VA.

Rowan-Szal, G. A., Joe, G. W., Bartholomew, N. G., Yang, Y., & Lehman, W. E. K. (2011, October). Implementation for a disease risk reduction intervention for women offenders in residential substance abuse treatment. Presented at the Addiction Health Services Research (AHSR) Annual Meeting, Fairfax, VA.

Lehman, W. E. K., Rowan-Szal, G. A., Greener, J. M., Bartholomew, N. G., & Knight, K. (2011, June). A disease-risk reduction curriculum for substance abusing offenders. Presented at the annual meeting of the College on Problems of Drug Dependence, Hollywood, CA.