Assmessment of prevalent of STI among

Prisoner in Maichew Town .

By:- 3
rd
year graduates of Bsc nurse
students
1. Berhane Kiros
2. Sesen Mehari
Advisor :- Ato Gebrie Yitaye

Thesis proposal submitted to department of
nurse for the partial fulfillment of the
requirement for the degree of bachelors of
science in Bsc nurse .
August 30/2014
MAYCHEW, TIGRAY






LIST OF ACRONYMS ................................................................ 3
1 INTRODUCTION ................................................................... 4
2 LITERATURE REVIEW ........................................................... 5
3 OBJECTIVES ......................................................................... 8
GENERAL OBJECTIVE .................................................................................. 8
SPECIFIC OBJECTIVE ................................................................................... 8
4 METHODOLOGY .................................................................. 9
4.1 STUDY DESIGN ........................................................................................ 9
4.2 STUDY AREA .......................................................................................... 9
4.3 SOURCE POPULATION ................................................................................ 9
4.4 SAMPLE SIZE DETERMINATION .................................................................... 10
4.5 SAMPLING PROCEDURE ............................................................................ 11
4.6 DATA COLLECTION PROCEDURES .................................................................. 11
5.0 ETHICAL CONSIDERATION AND DISSEMINATION OF
FINDINGS ............................................................................. 12
5.1 RESULT ........................................................................................... 12
6. WORK PLAN ..................................................................... 13
7. BUDGET ........................................................................... 14
ANNEX I ............................................................................... 16
REFERENCES ......................................................................... 18
ANNEX III ............................................................................. 19


List of Acronyms

EPS Ethiopia Prisons Service
HIV: Human
MARPS: Most at Risk Populations ()
STI: Sexual Transmission Infection
MARPS: Most at Risk Populations
MSM : Men Sex with Men ,
TB: Tuberculosis
MDRTB : Multi-Drug Resistant Tuberculosis
UNAIDS: United Nations Programme on HIV/ Acquired Immune Deficiency Syndrome
AIDS: Aacquired Immune Deficiency Syndrome
HCT Hematocrit
OST: Opioid Substitution Therapy
OIs: Opportunistic Infections
PPS: Probability Proportional to Size
FGD: Focus Group Discussions





1 Introduction
Background
STIs can cause serious health and reproductive complications, such as cancer,
central nervous system and cardiovascular system damage, blood infections,
internal organ damage, arthritis, pelvic inflammatory disease, epididymitis,
infertility, ectopic pregnancy, and maternal-infant transmission of the STI. Because
STIs are commonly asymptomatic, they frequently go undetected and untreated.
Consequently, transmission can unknowingly continue through unprotected sexual
activity. Moreover, the risk of acquiring and transmitting human
immunodeficiency virus (HIV) through sexual contact is increased in the presence
of other STIs Although HIV is an STI,

Both male and female prisoners are at a higher risk for STI infection. We define a
prisoner as any person involuntarily confined or detained in a penal institution,
including persons detained pending arraignment, trial, or sentencing. We will use
the term prison broadly for any place of detention, The assessment will
determined the prevalence of HIV, TB and other STI among prisoners, will assess
the knowledge, attitudes, behavior and practices of prisoners in relation to STIs.






2 Literature Review
STI is still a problem in Ethiopia not withstanding an impressive reduction in the
prevalence from 18.5% in the early 1990s to 6.5%. The national adult population
prevalence was estimated at 6.4% in 20051.The population of Ethiopia Prisons
Service (EPS) being a microcosm of the Ethiopian society, continues to experience
the severe social, economic and developmental consequences of the STI epidemic.
While the STI epidemic is generalized in Ethiopia, the population of Ethiopia
prisons is more vulnerable and at a higher than average risk of STI infection than
the general population.

It is therefore categorized as one of the Most at Risk Populations (MARPS) in
Ethiopia. Globally, the prevalence of STI among prisoners is reported to be
higher than in the general population. Different factors have been associated with
the high STI prevalence in prisons. While in many parts of the world it is attributed
to sharing injections inside and outside the prison and men who have sex with men
(MSM), in Sub-
Saharan Africa it is due to unsafe heterosexual sex similar to the general
population, MSM and unsafe medical practices rather than the injection of drugs.
The other related factors include overcrowding, use of unsafe skin piercing
instruments, violence, lack of education and information3, 4. Studies carried out to
determine the prevalence of STI and the associated factors among prisoners have
demonstrated varying figures from as low as 2% in USA, 28% in Vietnam to as
high as 44% in South Africa .
Sexual contact between men is common in prisons around the world. Studies from
many countries in different regions of the world have documented varying ranges
of the practice from as high as 73% in Brazil to as low as 5.2% and 4% in Nigeria
and Zambia respectively5. However, it is usually difficult to determine the exact
levels of sexual
activity in prisons because MSM is a major taboo for both prisoners and prison
officers and authorities, generally illegal and studies rely on self reporting which is
embarrassing and characterized by fears of reprisal or additional punishment.
Sexual activity in prisons is influenced by several factors that include: duration of
sentence, type of accommodation, level of supervision and the presence of young
offenders.

Similarly, studies among prisoners around the world have consistently
demonstrated higher rates of tuberculosis (TB) than in the general population6. It
has been observed that individuals that are most vulnerable to TB in the
communities are disproportionately represented in prisons. This is because the
social and economic conditions that increase vulnerability to TB also increase
vulnerability to criminal behavior and imprisonment.

In addition, since there is a strong association between HIV and TB, the high
prevalence of STI among prisoners increases the risk of TB transmission in
prisons.

There are growing fears that the high rate of TB in prisons coupled with weak
health care systems are contributing to the emergence of Multi-Drug Resistant
Tuberculosis (MDRTB) strains. To address the problem of TB in prisons, the
following interventions are recommended: early case detection through screening
of prisoners on admission,

Effective case management using DOTS, accurate and timely recording and
reporting of cases, community mobilization through IEC/BCC among others. Like
HIV and Tuberculosis, drug use is wide spread in prisons in most countries in the
world. A large number of prisoners come to prisons with established drug abuse
habits.
Other prisoners start using drugs while in prisons as a coping mechanism in an
overcrowded and violent environment to release tension. Due to needles being
scarce and illegal, injection drug users in prisons always hide and share them
exposing prisoners to a range of blood borne infections including HIV, Hepatitis B
Virus and Hepatitis C Virus. Likewise, the use of oral or inhaled psychoactive
substances may increase the likelihood of HIV transmission by impairing judgment
and hindering the adoption of preventive measures in circumstances where
these measures would be required In order to reduce HIV infection among drug
using prisoners, UNAIDS recommends that prison services should put in place
drug treatment programs as well as initiate appropriate harm reduction
interventions.

Prisoners have a right to receive health care, including preventive easures
equivalent to that available in the general community13. General principles adopted
by National AIDS programs should apply equally to prisoners and the community.
Some of the most cost effective interventions promoted in STI prevention, care and
support include: access to information especially through peers to peers activities,
access to voluntary HCT, provision of condoms, access to drug treatment for drug
dependants including Opioid Substitution Therapy (OST) for opiate dependents,
access to clean injecting equipment for injecting drug users, universal precaution,
access to disinfectant/clean piercing or tattooing equipment, meaningful
involvement of People Living with HIV, community mobilization, PMTCT,
prophylaxis and treatment of Opportunistic Infections (OIs), provision of
integrated TB/HIV collaborative services, use of ART, and nutritional
supplementation.

3 Objectives
General Objective
The objective of this study was to investigate the prevalence and risk factors of the
aforementioned infections among incarcerated in the central prison, Maichew, to
determine appropriate prevention measures.
Specific Objective
The specific objectives of the assessment were:
1. To determine the prevalence of STI among prisoners in Maichew Prisons.
2. To assess the knowledge, attitudes, behavior and practices of prisoners in
Maichew Prisons in relation to STIs.
3. To identify factors that may be associated with the transmission of STIs
4. To identify gaps in STIs prevention and care services for prisoners in
Maichew Prisons.








4 Methodology
4.1 Study design
A semi-structured interviewer administered questionnaire and a checklist will used
to Interview 80 prisoners and 5 health workers respectively from 34 prisons
sampled Using Probability Proportional to Size (PPS) technique. Biological
samples for STI, syphilis and TB tests were collected from consenting individuals.
Four Focus Group Discussions (FGD) with prisoners and four key informant
interviews will held with the Officers in-charge of purposively selected prisons.
Observation checklists will used in all the prison units to evaluate the quality of
existing prevention and care services. Quantitative data will analyzed using
STATA V.10 while qualitative data was manually analyzed.

4.2 Study area

Our Research will cover 1 prison located at Maichew, Which is called Maichew
Prison Center. In this Center there are many people comes from different part of
the Southern zone mean from Alamata, Mehoni, Korem and Addisho. Indirectly
the study will cover some part of the zone.
4.3 Source population

The study will conduct in Maichew Prisons Service The average population of
prisoners at the time of the study will estimated at 300. The prisoners in the Prison
Center constituted the study population.



4.4 Sample size determination

The study will use a two stage sampling design. The two stages will the prison
level and the individual level. The sample size for the prison units will determined
using the following formula by Bennet et al (1991)

N =
()

Where,
N = The number of prisoner
p = The probability of outcome of interest. In this case the outcomes of interest
include knowledge of STI prevention, practices and attitudes towards STI.
b = prisoner size. That is the number of prisoners we will to select from prison
Center .
D = Design effect. Computed as 1+(b-1)roh. Where roh is the rate of homogeneity
which
measures intra-prison.
S =standard deviation. It is a measure of variation in occurrence of outcome from
person
to person and it is changed depending on the precision required.

When p =0.5, b =14, D=2 and S =0.032 the number of prisoner required is 35. In
order to allow for non response or poorly answered questionnaires, we will make
the number of respondents 40. Women will over sampled to 20% from 5% to allow
comparisons with men.


4.5 Sampling procedure
The Center will be the attendants to the Maichew Prison center. From the
attendance Prisoners sampling will be taken by simple random sampling technique.
4.6 Data collection procedures
From August 20 to September 15, 2014, a private firm administered the
questionnaire in each Prisoner with a signed consent form. We will organize
inmates for the day and time the we will arrive to distribute questionnaires. Since
we did not have the sample list and inmates were specifically instructed not to put
their name or the name of anyone else on the questionnaire, it was impossible to
link the consent form with the completed questionnaire. In this manner, inmates
could be assured of their anonymity and confidentiality.

Each prisoner completed a self-administered questionnaire: behind a privacy
screen when completed in a group setting; in his/her cell if in segregation; or
through private one-on-one interviews if an prisoner requested assistance. All
participating prisoners received the answers to the questionnaire's STI knowledge
questions after data collection was complete within their prison.

Several factors will limit prisoner recruitment and research completion in the
correctional environment including the transfer of prisoners between institutions,
the departure of prisoners at warrant expiry, and prisoners on conditional leave
during the survey period.


5.0 Ethical consideration and dissemination of findings
Ethical clearance is secured from research and publication office of ethical
clearance committee, Mekelle University deans are informed about the objective
and significance of the study. To get hold of the their permission through official
latter will take from mekelle university. Prisoners will be asked to respond self-
administered questionnaires on voluntary bases, oral consent will be obtained from
each study participants after explained of the objective and importance of the
study. The Prisoners name will not be written. Also shared confidentiality will
assure to participates, data collectors and supervisor.
5.1 Result
The result of this study will expected to identify Privence of STI in Maichew
Prison Center. Thus the study finally will be relevant for service providers,
planners, and policy makers and the community at large and will give baseline
information for further studies.








6. Work plan
SN Activities Responsible
body
Months and Weeks
August September
1 2 3 4 1 2 3 4
1 Preparing proposal and
submitting
GMs
2 Communicate with
administrative body of the
health center
GMs
3 Preparation of study tools GMs
4 Transport to data
collection site
GMs
5 Select data collectors GMs
6 Data collection GMs
7 Data Entry and clearance GMs + RA
8 Data processing and
analyzing
GMs + RA
9 Submission of research
result
GMs
10 Preparing workshop for
appropriate means to
disseminate findings
GMs
NB GMs: Group Members
RA: Research Assistance

7. Budget
7.1 Stationeries and consumables
NO Item Unit Number Unit Price Total price
1 Bag Each 02 50 100
2 calculator Each 01 120 120
3 Eraser Each 01 2 02
4 Note book Each 02 25 50
5 Pen Each 10 5 50
6 pencil Each 02 2 04
7 Binder Each 02 28 56
8 Photo copy
paper
Ream 02 120 240
9 sharpner Each 02 3 06
10 Staples Pack 02 7 14
11 Deplicaing
service
Each 500 1 500
12 ruler Each 02 5 10
Subtotal 1150




7.2 personal cost
Work type qualification Salary perdiam Duration
of work
No of
employed
Total
Supervisors training - - 100 - 1 100
Supervisor(advisor) Msin emergency
medicine
- - - - -
Principal investigator - - 50 - 5 250
Printing service Stationary
owners
- - - - 200
Binding service Stationary
owners
- - - - 100
subtotal 650

7.3 Transport and communication
Transport/ travel cost to the study area to
Maychew HC
300
Communication service( telephone service) 200
internet service 250
Subtotal 750

7.4 Grand total
Number description Total cost
1 stationeries and consumables 1150
2 personal cost 650
3 transport and communication 750
4 grand total 2550

Annex I
1. How many people have you had sex with during your lifetime? If you answer 0 (zero), go to question
#10.
0 1- 5 6 -10 11 -15 16 20 +20
2. How many people have you had sex with in the last 3 months?
3. My sex partners are (check all that apply): Men Women
Both
4. Do you participate
Anal sex? Yes No
Vaginal sex? Yes No
5. When you have sex, do you use a condom or other barrier?
Always most of the time not often never
6. Have you ever paid for sex or traded sex for drugs, food,
Yes No
7. Have you ever had sex while high on drugs or alcohol?
Yes No
8. Have you ever had sex with someone infected with (check all)
Hepatitis B Hepatits HIV/AIDS
STD Not more
9. Have you ever had sex with someone who injected drugs?
Yes No Not Sure
9b. If YES, was it (check all that apply)
current sex partner past sex partner
10. Check any disease or condition you have had (check all that apply):
syphilis (bad blood) Genital/ Sex warts Gonorrhea (clap)
Herpes HIB Chlaymydia
Hepatitis A Hepatitis B Hepatitis A
11. Have you ever used non-injecting drugs like marijuana?
Yes No Not Sure
12. Have you ever injected drugs?
Yes No Not Sure
12b. If YES, did you ever share needles, syringes, or works?
Yes No Not Sure
13. Have you ever snorted drugs (i.e., cocaine, speed, heroin, ecstasy,
Yes No Not Sure
13b. If YES, have you ever shared straws while snorting?
Yes No Not Sure
14. Did you ever have a blood transfusion before 2014?
Yes No Not Sure
15. Have you ever had a tattoo?
Yes No
16. Have you ever had body piercing (other than your ears)?
Yes No Not Sure
17. Have you ever been tested for HIV?
18. Yes No Not Sure










References
Centers for Disease Control (CDC) (2005). Syphilis-CDC Fact Sheet. Retrieved June 15,
2008, from http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm.
Centers for Disease Control (CDC) (2006a). Chlamydia-CDC Fact Sheet. Retrieved June
15, 2008, from http://www.cdc.gov/std/chlamydia/STDFact-Chlamydia.htm.
Centers for Disease Control (CDC) (2006b). Ghonorrhea-CDC Fact Sheet. Retrieved
June 15, 2008, from http://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm.
Cochran, W.G. (1977). Sampling Techniques, 3rd edition. New York: John Wiley &
Sons, Inc.
Correctional Service of Canada (2001). Commissioner's directive 770: visiting. Ottawa,
Ontario: Correctional Service of Canada.
Correctional Service of Canada (2004). Commissioner's directive 821: management of
infectious diseases. Ottawa, Ontario: Correctional Service of Canada.
Correctional Service of Canada (2008a). Commissioner's Directive 800: Health Services.
Ottawa, Ontario: Correctional Service of Canada.
Correctional Service of Canada (2008b). Infectious disease surveillance in Canadian
federal penitentiaries, 2002-2004. Ottawa, Ontario: Correctional Service of Canada.
Ford, P.M., Pearson, M., Sankar-Mistry, P., Stevenson, T., Bell, D., & Austin, J. (2000).
HIV, hepatitis C and risk behaviour in a Canadian medium-security federal penitentiary.
Queen's University HIV Prison Study Group. QJM: An International Journal of
Medicine, 93(2), 113-9.
Garland, J., Morgan, R., & Beer, A. (2005). Impact of time in prison and security level on
inmates' sexual attitude, behavior, and identity. Psychological Services, 2(2), 151-162.
Hensley, C., Tewksbury, R., & Wright, J. (2001). Exploring the dynamics of
masturbation and consensual same-sex activity within a male maximum security prison.
The Journal of Men's Studies, 10, 59-71.
Hosmer, D., & Lemeshow, S. (2000). Applied logistic regression, 2nd edition. New
York: John Wiley & Sons Inc.
Last, J. (1995). A dictionary of epidemiology (3rd edition). New York: Oxford University
Press.
Nagelkerke, N.J.D. (1991). A note on a general definition of the coefficient of
determination. Biometrika, 78(3), 691-2.
Price Waterhouse (1996). 1995 National inmate survey: final report (No. SR-02). Ottawa,
Ontario: Correctional Service Canada.
Public Health Agency of Canada (2007a). HIV/AIDS Epi Updates. Surveillance and Risk
Assessment Division, Centre for Infectious Disease Prevention and Control, Public
Health Agency of Canada.




Annex III
Consents
We are 3
rd
year mekelle university graduated class Health department we are invite
all child bearing mothers in maichew Town to join the study KAP assessment
among mothers attending maichew Health Center with their children.
The questioners includes questions about your age, educational status, reproductive
history, your opinion towards immunization and other questions.
It is very important that you understand that everything you say will be completely
confidential and your name will not be documented also you may stop the
questioner at any time if you do not wish to continue. And you may discontinue
you participation in the study all together if you do not wish to continue.
Your participation in this study will help many women in this community receive
better services in the future when they come to health center with their children for
immunization.
Do you have any question?
Will you participate in this study ( yes ) (No) if yes continues the questioner