Miller, Jamie L. MPH*†; Samoff, Erika PhD, MPH*; Bolan, Gail MD*; for the Chlamydia Screening Project (ClaSP) Group
IT HAS BEEN WELL ESTABLISHED that adolescents in juvenile detention are at particularly high risk for sexually transmitted diseases (STDs).1,2 Detainees have many risk factors that are associated with STD acquisition, including early sexual debut, multiple sex partners, inconsistent use of condoms and contraception, substance abuse, history of physical and sexual abuse, and partnerships in high-risk sexual networks.3–5 STD screening in juvenile detention centers provides an opportunity to access these hard-to-reach, high-risk youths who often have no other source of health care.6–8
However, according to the August 1994 Office of Juvenile Justice and Delinquency Prevention (OJJDP) research report, less than half of the juveniles in surveyed detention centers were tested for STDs.9 Although the National Commission on Correctional Health Care and the American Correctional Association have since developed standards for STD screening in these settings, anecdotal reports suggest that competing priorities are likely limiting effective screening within these facilities (ClaSP Workgroup Members, personal communication, July 2003).
Beginning in 2005, state and county STD programs receiving funds from the Centers for Disease Control and Prevention, Division of STD Prevention were required to report on a set of STD programmatic performance measures, including the proportion of female juveniles screened for Chlamydia trachomatis (CT) in juvenile detention facilities. Improving this outcome is challenging, because many STD programs may not have previously developed relationships with these institutions and the institutions often do not have the resources to support CT screening of all at-risk youth. This measure encourages STD programs to work proactively with the staff in juvenile justice centers to increase their awareness of CT prevalence and the need for CT screening and prevention programs in this population.
The purpose of this article is to present the experience of the California program in creating these relationships, and developing strategies, methods, and tools to implement or enhance CT screening and treatment programs across diverse county juvenile justice systems. CT screening and treatment outcomes are also presented.
Program Needs Assessment
In 1998, the California Department of Health Services (CDHS), STD Control Branch, conducted a mail survey to assess STD care in the 59 juvenile justice facilities in 51 California counties. Based on testing policy information reported by 43 of those facilities, 47% tested either diagnostically or in the absence of symptoms, 38% tested diagnostically only and 15% did not test. However the actual proportion screened was less than 20% demonstrating that high volume screening of asymptomatic women was not occurring in the majority of facilities.10 These findings echoed those of the 1994 OJJDP report, despite the existence of the California Standards for Medical Care in Juvenile Detention Facilities (Title 15), which required a health screening immediately upon entry into the facility and a more comprehensive medical examination within 96 hours of entry.
Program Establishment and Requirements
In the summer of 2002, the CDHS STD Control Branch announced a request for applications for the Chlamydia Screening Project (ClaSP), a collaborative CT screening project for incarcerated women.
To be eligible for funds, each participating county health department had to meet the following requirements: (a) a commitment to establish or enhance existing partnerships between the juvenile justice system and county health department STD control programs; (b) a 15- to 19-year-old female county population of 250,000 or more; (c) 50 or more female detainees booked per year; and (d) a CT prevalence of 5% among incarcerated women tested. Participants were permitted to use up to 20% of funds for male screening. All participating counties were required to submit program information and data electronically every quarter through the Quarterly Communication Report, which included the number of detainees booked and screened by gender, information on changes in program structure or staff, and any event or circumstance that impacted performance either positively (e.g., development of a new at-entry screening system) or negatively (e.g., facility on lockdown for 2 weeks due to an outbreak of measles). In addition, line-listed data on those screened, which included date of birth, gender, race/ethnicity, booking date, urine specimen collection date, laboratory test method used, CT test result, treatment status, and date of treatment were also submitted. All data were reviewed quarterly and CT screening coverage was calculated by dividing the number of bookees screened by the total number of bookees reported for the period.
The counties also wrote an annual report that collated the quarterly information about their performance for the year. In addition to the data in the Quarterly Communication Reports, data on the location of treatment (i.e., within the facility or outside of the facility) were also required for the annual report.
The program was coordinated by a CDHS STD Control Branch manager in collaboration with county health department and juvenile justice coordinators in participating health jurisdictions. Most of the coordinators are county health department staff. Others are probation medical staff or jointly employed by the departments of health and probation.
Start-up site visits were conducted by the local coordinators as well as the state manager to identify barriers, provide technical assistance for program implementation and to ensure consistency in data collection. County coordinators and juvenile justice partners attended annual meetings at which both overall and site-specific best practices were shared. They also participated in interim workgroups as a means of sharing information and enhancing programs. The focus of these workgroups (e.g., laboratory, screening, and treatment issues) varied each year, depending on topics brought forward during the annual meeting or generated by data reviews or site visits. CDHS provided technical assistance on an ongoing basis and conducted site visits every 2 years, or more frequently, as needed.
In January 2003, 15 county health departments were funded (range $20,000 to $50,000) to work with 18 juvenile justice facilities; by the end of 2006, this had increased to 18 county health departments and 22 facilities. In 2006, the median proportion of detainees who were female within these facilities was 23% (range, 17%–39%), and the median number of booked women was 629 (range, 139–1460). The hours of medical services in facilities ranged from 8 hours 5 days a week to 24 hours 7 days a week. Medical services were provided by county health department staff in 6 facilities, ambulatory or hospital staff in 5, external medical contract staff in 6, or county probation or juvenile health staff in 5.
County health departments, in partnership with their juvenile justice and/or probation department staff, provided urine-based nucleic acid amplification test CT screening as close to booking as possible. Rapid notification of test results and appropriate treatment for those individuals who tested positive and were still in the facilities were provided by medical staff, and those who were released before treatment were contacted either by juvenile justice nursing staff or by county disease control investigators.
Screening and Treatment Outcomes
In 1998, CT screening among incarcerated youth in county juvenile facilities was limited. Ten of the 18 counties that later received ClaSP funding participated in the 1998 California survey. At that time, only 2 of these facilities in the counties were screening a high proportion of female bookees for CT. The remaining 8 were either testing if symptoms indicated infection or screening a subset of bookees. In the first year of ClaSP program implementation, 13 institutions created screening programs. For those counties reporting data in the 1998 survey, the proportion of bookees screened increased from 35% (range 1% to 98%) in 1998 to 66% (range, 39%–86%) in 2006. Evaluating the period of program implementation only for all ClaSP participating counties, the proportion screened increased in 11 of 17 counties (median increase 37%; range, 7%–226%) and decreased in 6 of 17 counties (median decrease 16%; range, 6%–48%) from 2003 to 2006.
The average proportion screened for counties (11 counties) with large institutions (500 and above bookings) was 56% (range, 24%–86%), whereas the proportion screened for counties (7 counties) with medium/small institutions (499 bookings or less) was 71% (range, 37%–98%). Only 2 counties offer medical services 24 hours per day, 7 days per week; in these counties, the proportion screened for 2006 was low (28% and 39%). These screening rates were lower than those reported by some institutions with facilities providing medical services less than 24 hours a day.
Eighty-nine percent of CT specimens were processed by the county public health laboratories in 2006. The proportion of total tests that were positive was consistently high across all 4 years (13.6%, 13.8%, 12.9%, and 11.7%) as the overall proportion screened went from 54% in 2003 to 59% in 2006. The number of new cases identified rose from 821 in 2003 to 877 in 2006. The number of new cases identified is associated with the increase in the number of booking and proportions screened.
Treatment was provided to 86% (n = 705) of test positive bookees in 2003 and 89% (n = 779) in 2006, demonstrating a sustainable high proportion treated despite the increase in number of cases identified. Eighty-three percent (15/18) of the counties provided specific data regarding where treatment was provided (within the institutions vs. outside the institution) in their most recent annual reports. Overall, among those 15 counties reporting 93% (594/642) of the treated CT test-positive women received medication while still housed within the juvenile justice institution. With changes in courier service, laboratory processing, and result notification procedures, there were a small number of test positive cases that were treated outside of the institutions. In those instances, those positive cases are followed up by the county health department. Through rapid notification to those health departments, a high proportion of released youth are found and treated. Whether or not the youth are found and treated by health department staff, the results of these investigations are then shared with the facility to document treatment status for those test positive youth. This has the added benefit that if the youth was not treated, and is rearrested and rebooked, the medical staff knows that particular youth was not found for treatment and can provide it within 24 hours.
Programmatic Outcomes: Barriers
During the implementation phase of this program, many barriers to screening and ensuring expedient treatment were identified by county coordinators, juvenile justice medical staff, or the state coordinator (Tables 1 and 2). These included issues of prioritization, procedural barriers, and resource limitations, as well as inherent differences between the cultures of providers of security and medical services (detailed in Table 1). The most common result of this difference in cultures was that medical staff were not routinely notified that a detainee was being released, which impacted their ability to provide treatment and continuing medical care outside the facility. In addition, there were occasional conflicts regarding the management of detainees with mental health issues. Many of the facilities were meeting only the California Title 15 Guidelines, which state that every detainee must receive a medical assessment within 96 hours of booking. Because many youth are released within 48 hours of booking, an assessment at 96 hours results in a high proportion of bookees not receiving screening.
Programmatic Outcomes: Facilitators
As the program evolved, the systems evolved, despite the ongoing changes in staffing, medical services, and competing priorities. Counties began implementing “best practices” to improve their overall performance in proportion screened and proportion treated. Practices that resulted in improved chlamydia screening and treatment included education of staff and changes in procedures which are listed in Tables 1 and 2.
The most significant facilitator to implementation was the existence of Title 15 regulations that dictate standards for medical assessments of detainees in the juvenile, jail and prison systems in California. Title 15 indicates that the medical assessment should include a general physical as well as specific assessment for existence or risk of communicable disease as well as other health issues. Screening close in time to booking results in a higher screening rate because, as reported by coordinators, a high proportion of youth booked are released within 24 to 48 hours of booking. If the booked women are not screened at booking or close to booking, the opportunity to diagnose and treat a new case of CT is missed. County program coordinators, in conjunction with county medical/probation staff, used a rigid interpretation of the intake screening guidelines of Title 15 to improve the timing of screening from 2 to 4 days from booking to zero to 2 days from booking. Another facilitator of high screening rates was the implementation of routine screening of all female bookees (in comparison to previous testing of only symptomatic bookees) in many institutions. Many counties changed their institutional medical protocols to include CT screening of all booked female detainees as the standard. Often, those that revised their medical protocols also used blanket medical consent, signed by the parent, guardian, or court, as consent to chlamydia screening and treatment. Counties using contracted medical care provided routine screening by revising the medical care contracts to specifically include routine screening of all detainees, and/or augmented public health laboratory testing dollars to cover the costs of screening detainees at the juvenile hall in their county. In facilities that had fewer hours of medical coverage, many innovative approaches, such as the use of custody staff for specimen collection, prioritizing women for examinations, and tracking those booked to ensure timely collection of specimens, were used.
Participation of the group in setting standards for the program also facilitated program improvement. At each of the last 2 annual meetings, consensus benchmarks were determined by county booking size. Having county coordinators and their respective juvenile justice partners determine an attainable benchmark for screening coverage resulted in group ownership of this benchmark.
Performance-based contracting began with contracts in 2005 and included a baseline benchmark (screen 55% of female juveniles booked). Site visits and technical assistance as well as the peer to peer sharing of best practices are provided as focused assistance to those counties not reaching their baseline. Performance data for each county and for the entire program are reviewed annually. Seventy-six percent of the counties have met this benchmark, and 33% continue to improve well beyond the benchmark (e.g., screening 98% of bookees).
Many barriers were identified and remedies implemented during the first few years of the ClaSP program. The majority of the barriers were remedied by the coordinators working closely with the medical providers within the hall and the laboratory staff.
We have demonstrated that establishing and sustaining a strong CT screening program, including timely diagnosis and treatment, among detainees in large and small juvenile justice settings, can be accomplished by fostering collaborations between public health departments and correctional entities. The ClaSP program resulted in increases in the proportion of female bookees in juvenile halls screened for chlamydia (59%), the number of cases identified (877), and the proportion of cases treated (89%). Screening all sexually active young women (including those who are asymptomatic) for chlamydia is recommended by the Centers for Disease Control; screening (rather than testing only symptomatic women, the practice of many of the juvenile halls before the ClaSP program) in this setting provides appropriate health care to young women who may not access care in any other setting. Reducing the time from booking to screening and treatment resulted in confirmed treatment in 89% of cases. This screening program provided a structure for a productive collaboration between health and correctional authorities to provide chlamydia screening and treatment to this highly vulnerable population.
During the implementation of this program, we learned that developing and nurturing collaboration between county juvenile justice managers/medical staff and the public health department was critical and that all parties needed to flexible. This was facilitated by ensuring that both parties were brought to the table while developing their implementation plan for this program. This process also served as an educational platform for learning more about each other's cultures, goals, and operational perspectives. To create effective screening programs, we found that it was very important to demonstrate the need for CT screening services to correctional staff, who may not be aware of the burden of STDs within their population. In at least 10 of the counties, educational presentations were provided for the medical or custody staff to provide the rationale for screening these highly at-risk youth at booking or as close to booking as possible. Involving the facility managers and other administrative heads was also important to ensure that everyone was working toward the same goal. Lastly, continuous feedback and sharing of data and progress toward goal attainment were critically important.
The most significant changes in screening were in those counties that developed or applied innovative approaches through the use of best practices (remedies to identified barriers; Table 2). The counties with a “medium” number (500–999) of bookings per year and “small” number (fewer than 500) of bookings per year were more likely to integrate changes than were the counties with a larger number of bookings per year. Changes in the very large facilities (>1000 female bookings per year) were the most difficult due to sheer numbers.
Over time, this program evolved at every level: at the facility level, the county level, and the state level. The combination of diverse populations and approaches demonstrated the value of having multiple practice models among these facilities. The county coordinators and their juvenile justice partners were pivotal in the identification of critical areas where improvements could be made and in ensuring ongoing performance improvement. The fact that this program was funded at the state level allowed for a coordinator to conduct site visits, hold conference calls and annual meetings to coordinate program implementation, share best practices, provide technical assistance, and facilitate peer to peer problem solving to improve performance across counties.
Challenges and Recommendations
Working in juvenile hall settings provides an opportunity for corrections and public health programs to work together to have an impact on the burden of communicable diseases in large urban areas.11,12 This collaboration can be very productive and yet faces significant challenges. Continuing challenges specific to this program include high turnover in juvenile hall staff, competing medical and custody priorities, and who bears the burden of cost for testing. Another important challenge has been a trend toward privatization of medical services at the county and state levels.13 ClaSP program participants have been instrumental in ensuring that public health services, specifically chlamydia screening, were included in the scope of work for the contracting juvenile hall medical services. The largest challenge to providing screening for youth in detention remains the identification of funding to sustain these efforts. This is especially true as federal, state, and county funds for public health services are diminishing.
Developing program protocols jointly results in shared learning experiences and shared expectations; this process facilitates the success of this collaborative programs. Experience with medical services contracted to private organizations suggests that county probation and public health departments should collaborate to ensure that language regarding STD or other public health services is included in contracts awarded to private medical services providers. Communication in the form of annual meetings and ongoing workgroups leads to the development of creative solutions to shared problems.
Lastly, next steps should include implementing other prevention programs such as family planning, HIV testing and counseling and viral hepatitis services with STD screening programs serving these high-risk populations in juvenile detention facilities to maximize limited resources and enhance service integration at the client level.
High screening levels with high case yields and treatment rates in the juvenile correctional setting can be accomplished and sustained, despite many barriers, if effective collaboration between public health and correctional entities is established. At the March 2007 national invitational workshop on health care in the juvenile justice system, the Acting US Surgeon General said “Please continue to create partnerships, share experiences, and strengthen the bridge between the juvenile justice community and other Federal agencies. Our ability to collaborate and build on our strengths through partnerships will make a tremendous difference”.14 The ClaSP program demonstrates that effective programmatic collaborations between correctional and health department staff can deliver recommended health care services and support for vulnerable populations in juvenile correctional facilities.