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Tuberculosis and Injection Drug Users

An increased risk for tuberculosis (TB) is associated with injection drug users (IDUs) as well as those who use crack cocaine. When dealing with people in these categories, problems arise along the lines of adherence

to any intervention or treatment programs. Therefore, monetary incentives and educational intervention are offered as an approach to increase adherence or compliance. The purpose of the randomized controlled study by Malotte et al., (1998) was to evaluate the effects of different levels of monetary incentives as well as the use of educational intervention among active drug users to comply with TB skin test readings.

The participants were selected in Long Beach, CA either directly through street outreach or after they completed an HIV outreach project (lasting six months) for active drug users that were out of treatment at the time. The researchers targeted IDUs and also those who use crack cocaine. After completing the baseline study interview and placement of TB skin tests, the participants were given $5.00. To avoid unreliable outcomes, they needed to be sure that the participants were in fact active drug users and not simply saying so to receive the monetary incentive that was offered. The participants were inspected for needle track marks and subjected to urine tests at the time of enrollment. Excluded from the study were those who tested positive on the skin tests. The total number of participants was 1,004. In this sample were men and women of different age groups, ethnicities, educational backgrounds, and they differed along the lines of their drug and alcohol preferences. The majority of the participants were unemployed and all lived in different housing conditions and most of them claimed to have had no prior exposure to TB.

The participants were then randomly assigned to 1 of 6 experimental control groups. Those in Group 1 (n=203) received a 5-10 minute educational session (on the theory of reasoned action) and were offered $10.00 upon their return for the reading of their skin test. The participants in Group 2 (n=198) were subject to the same conditions, but were only offered $5.00 as an incentive to return as scheduled for their skin test reading. Those in Group 3 (n=99) received the educational session but received no monetary incentives while Group 4 (n=100) were only told how important the skin test reading was (no education or money was offered). Those selected for Group 5 (n=204) were offered $5.00 for their scheduled return and were told of the importance of the skin test reading, but received no educational session. The conditions for Group 6 were identical, but they were offered $10.00 rather than $5.00 as a monetary incentive.

The educational sessions that were offered to Groups 1-3 were based on the theory of reasoned action. Individual counseling was used and the focus of this study was on the behavioral beliefs and subjective norms that are most related to the behavioral intentions among drug users. Personal beliefs and outcome expectancies were explained and the personal reasons for not returning were noted. Each interview, educational session, and skin test readings were done by 1 of the only 2 nurses who were involved in the study. The attitude and behavior of the participants was measured. Self-reported information was collected and drug tests were used for the reliability of that information. The likelihood of the participants returning for skin test readings was also determined. Demographic and drug use characteristics were tested using chi-square analyses while the effects of the intervention were tested using logistic regression analyses (only on intention-to-treat basis). The participants were informed of the process and purpose of this trial through informed consent so they were aware of the monetary incentives that were being offered to select participants.

The study by Malotte et al., (1998) reported that out of 1,004 participants, 782 returned on time for their scheduled skin test reading. More than 90% of the participants receiving the $10.00 incentive and about 85% of the ones who received the $5.00 incentive actually returned for their skin test reading on time. The groups with no monetary incentive only had a return rate of 33%. Those who were 30 years old or younger and those who are employed were less likely to return. More likely to return are those who consume alcohol or the people who originally said that they would likely return for the results. The skin test results of 835 people were analyzed and 153 tested positive for TB. Those with prior exposure to TB and those who were living in unstable conditions were not more likely to test positive for TB. The participants who consumed alcohol, crack cocaine, or injection drugs were at a higher risk for positive skin test readings.

The Malotte et al., (1998) randomized clinical trial found that incentives can have a significant impact on compliance to return for skin test readings for TB. The educational interventions did not have such an effect on the rates of compliance or return. The amount of positive results of the skin test (18.3 per 100 people) confirms that those who use drugs are at a higher risk of infection. This study concluded that monetary incentives do, in fact provide a higher rate of compliance to return for skin test readings for those who are at a greater risk of contracting TB. The Malotte et al., (1998) trial was successful in accomplishing the objectives that it was set up for. The purpose was clearly defined in the beginning and the results were found to be conclusive.