Supporting Statement A

This request is for an approval of a sub-collection under a generic approval (Formative Research and Tool Development, OMB #0920-0840, expiration 2/28/2019), for a data collection entitled, “Examination of Jail and Prison Policies Related to STD Prevention”. Data will be collected from no more than 24 jail or prison staff members or healthcare providers contracted to provide healthcare services to jails or prisons across eight U.S. counties (i.e. LA County, CA; Cook County, IL; Miami-Dade County, FL; Kings County, NY; Fulton County, GA; Dallas County, TX; Philadelphia County, PA; and Harris County, TX) acting in their official capacities.

Surveillance reports and scientific studies have documented a high prevalence of sexually transmitted diseases among persons entering correctional facilities (e.g. jails, prisons)^1,2 Researchers have found that this high prevalence may be attributed to engaging in high risk sexual behaviors as well as suffering from a lack of access to routine screening and treatment while not incarcerated .^1,3 Researchers have also found that social and behavioral factors such as race, socio-economic status, and drug use associated with involvement in the criminal justice system are in fact the same factors associated with high STD rates in the general U.S. population.² One of the broader goals of the NCHHSTP program is to better understand the possible link between involvement in the criminal justice system, especially those who are incarcerated for nonviolent offences (e.g. illicit drug crimes), and STD rates in the communities to which they return. Communities with a disproportionate number of individuals involved in the criminal justice system often experience neighborhood destabilization, gender ratio imbalances, and disrupted sexual networks.⁵ STD rates in these communities are also often exacerbated by those involved in the criminal justice system engaging in high risk sexual behaviors which may include prostitution and illicit drug use.¹ Thus, in its first use of performance measures for the Division of STD Prevention’s (DSTDP) cooperative agreements with state and local health departments, DSTDP included a measure focusing on syphilis screening in jails.

Given the breadth of evidence demonstrating high STD risk, some U.S. jails and prisons have adopted health screening policies to help reduce STDs among those entering correctional facilities. ^1,6 Some states even have laws mandating STD/HIV testing among those in correctional facilities such as inmates convicted of prostitution or engaged in violent activities that can spread disease (e.g. biting, spitting, throwing feces).⁷ A 2003 state level analysis showed that STD testing, treatment, and counseling practices vary by state and federal prison.⁶ The same study found barriers to testing, treatment, and counseling often included confidentiality concerns, limited staff, and budget constraints.⁶ Although there has been research examining internal STD testing and treatment policies and re-entry services at the state and federal levels, there is limited research analyzing internal STD related policies, Medicaid coverage, and re-entry services and county level STD rates in both male and female correctional facilities. Additionally, data from DSTDP’s performance measures suggested that, even when health departments were implementing and funding STD testing, barriers at the correctional facilities remained. Our study hopes to provide insights into this gap by interviewing key informants involved in the provision of STD related health care services in incarcerated populations. DSTDP will use data from this information collection and from a related project to analyze state-level policies related to incarceration for minor offenses to guide future interventions and research in this area.

Within this information collection, the investigation team aims to better understand current internal jail and prison policies related to STD testing, treatment, and counseling, Medicaid coverage, and re-entry services by means of key informant interviews. Specifically, key informants will be asked questions about STD testing and treatment during incarceration and continuity of STD-related care upon inmates’ release from custody; suspension or termination of Medicaid benefits during incarceration and reenrollment upon release; and services or linkages made for individuals as they reenter their communities. By selecting a narrow geospatial focus at the county level, investigators within this collection hope to gain a detailed understanding of these internal jail and prison policies in eight U.S. counties that were among counties with the highest a high number of STD infections across several STDs (gonorrhea, primary and secondary syphilis, chlamydia, and HIV) in 2012, focusing on high volume county prisons. The qualitative information collected in this exploratory study will begin to inform investigators of how these internal policies may positively or negatively impact STD prevention among individuals involved in the criminal justice system and the communities to which they return. Additionally, the information collected in this request will inform future research or interventions focusing on the impact of criminal justice involvement on STD rates.

This information collection is authorized by Section 301 of the Public Health Service Act (42 U.S.C. 241) (Attachment 1).

Overview of the Information Collection System

Data will be collected through key informant interviews conducted by telephone or in-person if resources allow. (see Attachment 3—Instrument: Key Informant Interview Guide). The key informant interview instrument will be used to gather information from key informants regarding prison policies, protocols, and/or practices related to STD testing, treatment, and counseling protocols, procedures during incarceration and upon release, the degree to which pre-existing STD are treated and followed upon incarceration, and linkage to services and resources upon release, including health care and assistance obtaining health insurance/Medicaid. This method was chosen to obtain detailed information regarding jail and prison facility policies in which probes can be used to gather further information from key informants. The information collection instrument was pilot tested by 1 public health professional in the Public Health Management Corporation. Feedback from this group will be used to refine questions as needed, and establish the estimated time required to complete the information collection instrument.

Items of Information to be Collected

A semi-structured Key Informant Interview Guide has been developed by the research team in consultation with CDC (see Attachment 3—Instrument: Key Informant Interview Guide). Qualitative measures include open-ended questions to gather information about prison policies, protocols and/or practices related to:

STD screening, testing, treatment protocols and procedures during incarceration and upon release
The degree to which pre-existing STDs are treated and followed upon incarceration
Linkage to services and resources upon release, including health care and assistance obtaining health insurance/Medicaid

The data collection instrument consists of 26 open ended main questions to gather both qualitative measures described above and quantitative estimates related to demographic and other characteristics of the inmate population. The quantitative information will provide information to complement and aid in our understanding of the qualitative information. The instrument will collect information on the following:

Key Informant role description and length of time in role and field
Inmate population description
Medicaid/health insurance coverage and assistance in reenrollment upon release
Internal facility policies for STD screening, testing, and treatment
Barriers to testing and treatment
The degree to which pre-existing STDs are treated and following upon incarceration
Linkages to services and resources post-release

Due to limited resources, it is anticipated that the interviews will be conducted over the telephone. If feasible, interviews with Philadelphia prison staff may be conducted in-person at the facility. No audio- or video-recording of interviews will be conducted. Instead, PHMC staff will take detailed notes during the interview. Immediately following the interview, PHMC staff will use the notes taken during the interview to develop a detailed summary of the interview. All names and identifiers will be removed from the notes. MaxQDA, a qualitative analysis software package, will be used to code and analyze the data. During the analysis process, data will be tagged with codes to identify key concepts and themes. Themes and coding categories will be organized into a codebook that will contain code definitions, instructions on the appropriate use of a code, and examples of when a particular code should be applied. A bulleted report will be written to summarize key emergent themes related to prison STD screening, treatment and prevention policies, with quotes from key informants to illustrate these themes.

Purpose and Use of the Information Collection

The purpose of this information collection is to explore internal jail and prison policies related to STD testing, treatment, and counseling during incarceration and the continuity of STD-related care upon inmate release. Key information on services and linkages are made for individuals as they reenter their communities will also be provided through the information collection.

The information be collected in eight counties across the United States with the highest rates of gonorrhea, chlamydia, and syphilis. By targeting counties with high STD rates, investigators will have the best opportunities for better understanding how internal policies in jails and prisons in these counties related to STD testing, treatment, and counseling, Medicaid coverage, and re-entry services may positively or negatively impact STD prevention among individuals involved in the criminal justice system and the communities to which they return. Additionally, the information will aid DSTDP in our future research or interventions focusing on criminal justice involvement and STDs.

The information collection will be used to create a dataset that contains internal prison polices, protocols, and practices regarding STD testing, treatment, and counseling, and linkage to health care services and resources upon inmate release. Information on linkages to healthcare services post-release will be used to complement a statewide assessment of laws that may impact STD rates, such as sentencing guidelines and collateral consequences of conviction, i.e., consequences that limit your rights due to a prior conviction.

We anticipate including the following correctional facilities:

Philadelphia Prison System in Philadelphia, PA which houses approximately 8,800 inmates in 6 facilities
Harris County Sherriff’s Office Correctional facilities, in Houston, TX, with an inmate population of more than 11,000 across three facilities as of 2009
Los Angeles County Jail, operated by the Los Angeles County Sheriff’s Office, which houses 20,000 inmates across its facilities—the largest of the facilities is the Men’s Central Jail
Cook County Jail, in Chicago, IL, which houses approximately 9,000 inmates
Miami-Dade County Corrections and Rehabilitation Department in Miami, FL, which holds 5,642 inmates in five correctional facilities
New York City Department of Corrections, which serves Bronx, Kings, New York, Queens, and Richmond counties and houses 10,240 inmates across 15 facilities, most of which are on Rikers Island
Fulton County Jail, in Atlanta, GA, which houses approximately 5,500 inmates
Dallas County Jail, which houses 6,500 inmates

The facilities selected for inclusion in the research include the facilities in each county serving the local jail population. In some counties, it is anticipated that key informants will represent one (typically the largest) of several facilities within the county jail system; in others key informants may elect to address the STD related policies that govern the entire jail system. The limitations of this research includes the non-generalizable, non-random, and potentially subjective characterization of qualitative research, primarily due to the low sample size in only eight counties across the United States. However, the intent of this research is to focus on the depth of information that can be gained by conducting exploratory data collection within a narrow geospatial (county level) scope compared to the breadth of knowledge that can be gained from quantitative studies with large sample sizes. In addition, since the interviews will not be recorded and transcribed verbatim, it is possible that some information provided during interviews may be missed. However, the research team will rely on extensive and detailed note-taking as well as written policies, to the extent provided by the facilities. Finally, the research is limited by the way in which the counties of focus were selected. Since they were selected based on STD rates, it is likely that the data will not be generalizable to all urban, suburban, rural, or tribal areas across the U.S. However, given the narrow scope of the research, focusing on the jurisdictions with the highest rates of STDs will best inform STD prevention research.

Use of Improved Information Technology and Burden Reduction

Data will be collected via key informant interviews conducted via telephone or in person in which the interviewer will take written notes that will be typed within 24 hours to ensure full recall. The interviews will not be video or audio recorded. This method was chosen to reduce the overall burden on respondents. The information collection instrument was designed to collect the minimum information necessary for the purposes of this project.

Efforts to Identify Duplication and Use of Similar Information

There are some scholarly articles that analyzed HIV and/or STD prevention practices in prison populations at the state and federal level. However, a search of the literature has found no recent analyses or studies conducted by BJS or others that specifically analyze jail and prison STD testing, treatment, and counseling and Medicaid coverage policies in both male and female inmates and county level STD rates. Most of the studies that we found either focused on other diseases or did not provide information about facility level policies. For example, one study focused on sexual violence reported by juvenile correctional authorities.⁹The other study focused on chronic conditions among inmates with disabilities that included TB, hepatitis B and C, and sexually transmitted infections.¹⁰Thus, we have not found any evidence that BJS collects data on internal jail/prison policies related to STD testing, treatment, and counseling, as well as inmate linkages to STD services upon release. Therefore, we do not believe that these data will result in a duplication of effort, and they will be very valuable for STD prevention efforts.

CDC partners with professional STLT organizations, such as the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the National Association of Local Boards of Health (NALBOH) along with the National Center for Health Statistics (NCHS) to ensure that the collection requests under individual ICs are not in conflict with collections they have or will have in the field within the same timeframe.

Impact on Small Businesses or Other Small Entities

No small businesses will be involved in this information collection.

Consequences of Collecting the Information Less Frequently

This request is for a one time information collection. There are no legal obstacles to reduce the burden. If no data are collected, CDC will be unable to:

Fully understand the complex relationship between involvement in the criminal justice system and STD acquisition at the county level
Collect the necessary information from credible sources who are directly involved with policies regarding inmate STD testing, treatment, and counseling
Fully understand the gaps in STD testing, treatment, linkage to care, and prevention within the jail and prison systems at the county level

Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

There are no special circumstances with this information collection package. This request fully complies with the regulation 5 CFR 1320.5 and will be voluntary.

Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

For sub-collection requests under a generic approval, Federal Register Notices are not required. A Federal Register Notice for the generic clearance 0920-0840, exp. 02/29/2016 was published on 08/2/2012, Vol. 77, No. 149, pages 46094-46095. No comments were received.

Archana Bodas LaPollo, Senior Project Director, Public Health Management Corporation, archana@phmc.org

Phone: (215) 731-2155

Jami Leichliter, Supervisory Health Scientist, CDC, Email: gzl3@cdc.gov

Phone: (404) 639-1821

Harrell Chesson, Health Economist CDC_, Email: hbc7@cdc.gov

Phone: (404) 639-8182

Ryan Cramer, Public Health Advisor - CDC, Email: uxj0@cdc.gov

Phone: (404) 639-0019

Kendra Cuffe, Health Scientist - CDC,

Email: kkn2@cdc.gov

Phone: (404) 639-1847

Explanation of Any Payment or Gift to Respondents

CDC will not provide payments or gifts to respondents.

Protection of the Privacy and Confidentiality of Information Provided by Respondents

The CDC NCHHSTP Coordinator has determined that the Privacy Act does not apply to this information collection. STLT governmental staff and / or delegates will be speaking from their official roles and will not be asked, nor will they provide individually identifiable information.

Institutional Review Board (IRB) and Justification for Sensitive Questions

No information will be collected that are of personal or sensitive nature. This information collection is not research involving human subjects.

Estimates of Annualized Burden Hours and Costs

The estimate for burden hours is based on a pilot test of the information collection instrument by [1] of public health professional. The average estimated time to complete the instrument including time for reviewing instructions, gathering needed information and completing the instrument is approximately [70] minutes (1 hour and 10 minutes). Based on the pilot, the estimated time range for actual respondents to complete the instrument is [70] minutes. For the purposes of estimating burden hours, the upper limit of this range (i.e., [70] minutes) is used for a total of 28 burden hours.

Exhibit A-12A: Estimated Annualized Burden Hours

Form Name

Type of Respondent

No. of Respondents

No. of Responses per Respondent

Average Burden per Response (in hours)

Total Burden Hours

Key Informant Interview Guide

Prison Staff(i.e. Guards

Healthcare providers

Administrators)

1.17

TOTALS

Estimates for the average hourly wage for respondents are based on the Department of Labor (DOL) National Compensation Survey estimate for [prison guard, healthcare provider (i.e nurse, physician, etc.), and administrator] (http://www.bls.gov/ncs/ocs/sp/nctb1349.pdf). Based on DOL data, an average hourly wage of $[32.04] is estimated for all [24] respondents. Table A-12.B shows estimated burden and cost information.

Exhibit A.12.B. Annualized Cost to Respondents

Type of Respondent

Total Burden Hours

Hourly Wage Rate

Total Respondent Costs

Prison Staff(i.e. Guards

Healthcare providers

Administrators)

$32.04

$897.12

TOTALS

$897.12

Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers

There will be no direct costs to the respondents other than their time to participate in each information collection.

Annualized Cost to the Government

There are no equipment or overhead costs. Contractors, however, are being used to support development of the assessment tool, data collection, and data analysis. The only cost to the federal government would be the salary of CDC staff and contractors. The total estimated cost to the federal government is $[25,864]. Table A-14 describes how this cost estimate was calculated.

Table A-14: Estimated Annualized Cost to the Federal Government

Staff (FTE)	Average Hours per Collection	Average Hourly Rate	Average Cost
Senior Project Director, Public Health Management Corporation Assisting with development of data collection instrument and methods, pilot testing, IRB review preparation, quality control, report/manuscript preparation	485	-	$18,900
Fellow [unpaid], Public Health Management Corporation Assisting with development of data collection instrument and methods, pilot testing, IRB review preparation, quality control, report/manuscript preparation	40	-	$0
Health Scientist (GS-12) Assisting OMB package preparation	25	$35.14	$878.50
Health Scientist (GS-14) Assisting with development of data collection instrument and methods, OMB package preparation,	40	$49.38	$2,469.00
Public Health Analyst (GS-13) CDC/DSTDP lead on project, assisting with development of data collection instrument and methods, provide legal expertise	57	$41.79	$2,382.00
Health Economist (GS-14) Provide economic and modeling expertise	25	$49.38	$1234.50
Estimated Total Cost of Information Collection			$25, 864

Explanation for Program Changes or Adjustments

This is a new information collection.

Plans for Tabulation and Publication and Project Time Schedule

[Data will be tabulated and published as either a report of peer-reviewed journal article. Data tables will be made available to the Division of STD Prevention by the Public Health Management Corporation who was funded by CDC/DSTDP to conduct the investigation. Data will be analyzed to analyze jail and prison internal STD policies regarding STD testing, treatment, and counseling services, Medicare coverage, and linkage to care post release.]

Project Time Schedule

Design questionnaire (COMPLETE)

Develop protocol, instructions, and analysis plan (COMPLETE)

Pilot test questionnaire (COMPLETE)
Prepare OMB package (COMPLETE)
Submit OMB package (2-4 weeks)

OMB approval (TBD)
Conduct assessment (Assessment open 3 weeks)
Code, quality control, and analyze data (1-2 months after OMB approval)
Prepare reports (2-3 months after OMB approval)
Disseminate results/reports (3-6 months after OMB approval)

Reason(s) Display of OMB Expiration Date is Inappropriate

We are requesting no exemption.

Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification. These activities comply with the requirements in 5 CFR 1320.9.

REFERENCE LIST

Centers for Disease Control and Prevention (CDC). Evaluation of large jail STD screening programs, 2008-2009. [cited 08/01/2015] http://www.cdc.gov/std/publications/jailscreening2011.pdf.
Hogben M, Leichliter JS. “Social determinants and sexually transmitted disease disparities”. Sex Trans Dis. 2008;35:S13-18
Braithwaite RL, Arriola KRJ. Male prisoners and HIV prevention: A call for action ignored. Men’s Health Forum. 2003:93;759-763
Westergaard RP, Spaulding AC, Flanigan TP. HIV among persons incarcerated in the US: a review of evolving concepts in testing, treatment and linkage to community care. Curr Opin Infect Dis. 2013;26(1):10-16.
Clear TR. Imprisoning communities. Oxford University Press. 2007.
Grinstead O, Seal DW, Wolitski R, et al. HIV and STD testing in prisons: perspectives of in-prison service providers. AIDS Education and Prevention: 2003;15(6):547-560.
Temple University. State statues explicitly related to sexually transmitted diseases in the United States, 2013. 2014. [cited 08/01/2015] http://www.cdc.gov/std/program/final-std-statutesall-states-5june-2014.pdf
Centers for Disease Control and Prevention (CDC). "National Public Health Performance Standards Program (NPHPSP): 10 Essential Public Health Services." Available at http://www.cdc.gov/nphpsp/essentialservices.html. Accessed on 8/14/14.
Bureau of Justice Statistics. Prison Rape Elimination Act of 2003. [Bureau of Justice website]. July 2008. Available at: http://www.bjs.gov/content/pub/ascii/svrjca0506.txt/ Accessed Feb 1, 2015.
Bureau of Justice Statistics. About a third of prison and jail inmates reported a disability in 2011-12. [Bureau of Justice Statistics website]. December 14, 2015. Available at: http://www.bjs.gov/content/pub/press/dpji1112pr.cfm. Accessed Feb 1, 2015.

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File Title	O2C2-Supporting-Statement-A-Template-NICKNAME-SSA
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