To:   Judy Lux, Program DirectorCanadian Foundation for Dental Hygiene Research and Education96 Centrepointe DriveOttawa, OntarioK2G 6B1foundation@cdha.ca

The Delivery of Oral Care to Incarcerated

PopulationsThe Impact on Women Offenders

By:Priscilla Kaljanac

Natasha LeeNoemi Majer

March 26, 2012Dr Donnelly DHyg 412 Project Proposal

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Grant Application Form 2012

Date of application: March 26, 2012

Project Title: The Delivery of Oral Care to Incarcerated Populations: The Impact on Women Offenders

Lead Principal Applicant:Name: Dr Leeann DonnellyTitle: Dip DH, BDSc (DH), MSc, PhD, RDH, Professor at UBC Faculty of DentistryHost Institution/Organization: University of British ColumbiaAddress: 2199 Wesbrook Mall, Vancouver, BC, V6T 1Z3E-mail address: ldonnelly@dentistry.ubc.ca

Co-applicant:Name: Noemi MajerTitle: BSc (DH) studentOrganization: Faculty of Dentistry, University of British ColumbiaAddress: 2199 Wesbrook Mall, Vancouver, BC, V6T 1Z3E-mail address: noemi876@hotmail.com

Co-applicant:Name: Natasha LeeTitle: BSc (DH) studentOrganization: Faculty of Dentistry, University of British ColumbiaAddress: 2199 Wesbrook Mall, Vancouver, BC, V6T 1Z3E-mail address: natlee@interchange.ubc.ca

Co-applicant:Name: Priscilla KaljanacTitle: BSc (DH) studentOrganization: Faculty of Dentistry, University of British ColumbiaAddress: 2199 Wesbrook Mall, Vancouver, BC, V6T 1Z3E-mail address: pkaljanac@interchange.ubc.ca

Designated Authority:Name: Kelly SullivanTitle: Special Projects CoordinatorInstitution: University of British ColumbiaAddress: 3333 University Way Kelowna V1V 1V7 E-mail address: kelli.sullivan@ubc.ca

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1. Abstract

BackgroundThe limited research on inmates suggests that they are more likely to experience periodontal disease, dental decay and missing teeth when compared to a non institutionalized population.(1-8) Several factors and social determinants account for the poor oral health among inmates.(9-11) Furthermore women in prison have poor concepts of self and experience lowered self-esteem.(12,13) Oral health delivery in the prison setting suggests that care is focused on treatment rather than on oral disease prevention.

Objectives1. To improve the oral health of female inmates by improving plaque effectiveness

(PE) by 25% and decreasing bleeding on probing (BOP) by 25%.2. To improve the self esteem of female inmates through improving oral health and

therefore their perceived self-image through collaboration with a women’s program.

3. To collect data on the oral health of female inmates.

Material and ObjectivesAll female inmates at the Fraser Valley Institution will be asked to take part in this study regardless of length of conviction or incarceration. The program implemented will involve dental hygiene services, including client education, clinical therapy, research data collection and focus group seminars.  Baseline measurements will be taken on oral health status, and self esteem related to oral health and body image, during the participants first appointment. BOP, PE and self esteem will be measured at 6 weeks, 3 months, 6 months, 12 months and 18 months.

Expected OutcomeIt is expected that there be an improvement in plaque effectiveness by 25% and a decrease in bleeding on probing by 25%. An additional expected outcome is an increase in self esteem and satisfaction in oral health among the female inmates participants. Furthermore this project will enable female inmates to have access to preventative oral health care and information.

2. Organizational Information

2.1 Mission, goals and objectives of the organization/educational institutionThe mission of both UBC and UBC’s Faculty of Dentistry involves supporting

outstanding research to serve the people of not only British Columbia but also Canada and the world.(14,15) UBC strives to create an exceptional learning environment that fosters global citizenship and advances a civil and sustainable society.(14) The values of UBC include academic freedom, advancing and sharing knowledge, excellence, integrity, mutual respect and equity and public interest.(14) UBC Dentistry’s mission

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also includes advancing oral health through outstanding education, research, and community service. (15)Furthermore it fosters innovative research that has a positive impact on oral health science, education, and patient care. (15)

Both UBC Faculty of Dentistry and the CFDHRE strive to enable and enhance dental hygiene research and education, in order to enhance the oral health and well-being of Canadians.(15,16) CFDHRE and UBC Dentistry have similar objectives in that both aim to conduct and disseminate research on/into issues relating to dental hygiene, undertake public education and the publication of information regarding dental hygiene and to receive and maintain funds towards research.(15,16)

2.2 Describe why the host institution/organization has the capacity to conduct the project.

UBC has the necessary resources to conduct research projects due to its access to equipment, research, trained specialists and experts. For example The Collaborating Center for Prison Health and Education, part of UBC’s Department of Family Practice, is undertaking activities in an effort to promote research, education, and communications in the area of prison health.(17) UBC Dentistry has conducted projects working with marginalized populations, special needs populations and within the community. As part of its strategic goal UBC’s Faculty of Dentistry encourages greater connection between UBC and the external community, including the University, organized dentistry and dental hygiene, practicing dentists and dental hygienists, and the greater communities of Vancouver, British Columbia, Canada and Internationally.(15) Furthermore UBC Dentistry seeks to develop multi-site clinical learning environments to optimize learning opportunities and better serve disadvantaged population groups.(15) It has support for faculty and staff required for the off-site clinical venue, and has the necessary resources to spread the oral health message in underserved communities.(15)

2.3 Project participants’ names, background and roles in the project.The participants involved in this project include Natasha Lee, Priscilla Kaljanac,

Noemi Majer and Dr Leeann Donnelly. Dr Donnelly is a registered dental hygienist and has a Dip DH, BDSc(DH), MSc and a PhD, who will oversee the planning, development and management of this project. She is a professor at UBC’s Faculty of Dentistry and she will be able to provide valuable mentorship and support.

Natasha, Priscilla and Noemi are fourth year students in the Dental Hygiene Degree program at UBC and will be graduating with a Bachelors Degree in Dental Science in May 2012. Natasha, Priscilla and Noemi’s roles in this project include its development, planning, implementation and management. They will provide dental hygiene services, coordinate services and resources, collaborate with the population of interest, other professionals and employees of various organizations to name a few. Furthermore Natasha, Priscilla and Noemi will be involved in the collection of research data during implementation. All participants will analyze, interpret and disseminate the data in an effort to understand and investigate the oral health of female inmates.

2.4 Describe why the individual participants in the project are qualified to conduct the project.

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Dr Donnelly has extensive knowledge and expertise in developing implementing and managing community projects and programs. She is actively involved in research and has worked with a wide range of special needs populations within the community. Her expertise involves meeting the oral health needs of an identified population by developing programs which foster partnerships and trust, interdisciplinary relationships and an excellence in care delivery.

Natasha, Priscilla and Noemi have been involved in providing care for the elderly, immigrants and the HIV positive. This care involves assessments, diagnosis, treatment planning, debridement, oral self care instruction, client education and referrals to address needs outside the scope of practice. Referrals involve the collaboration with other health professionals such as medical doctors, specialists and dentists.

Natasha, Priscilla and Noemi have also volunteered at CHIUS. CHIUS uses an interdisciplinary, team-based approach to address the needs of the downtown east side (DTES) residents.(18) It aims to remove barriers to health care, establish strong partnerships, and enhance the community's perception of health care.(18) At CHIUS Natasha, Priscilla and Noemi were involved in performing head and neck exams as well as intra oral exams. In addition they provided the residents oral self care instructions and tools.

The individual participants are qualified to conduct this project because of their experiences with marginalized populations, special needs populations and communities. The dental hygiene process of care has allowed them to develop the necessary skills to identify and understand how social determinants impact health and oral health, to practice cross cultural sensitivity and to manage medically complex clients. Furthermore all the participants are competent in building strong relationships which foster trust, communication and collaboration.

2.5 Other participantsOther participants involved in this project include the Fraser Valley Institution

(Correctional Services Canada), the Elizabeth Fry Society and the dental professionals on and off site. The Fraser Valley Institution is a multi-level facility for women and is responsible for the safety, security and management of women who are serving sentences that are two years or longer.(19,20) Furthermore it provides programming and treatment to address the factors that led to the criminal behavior.(20) Fraser Valley institution provides inmates access to academic or vocational education, psychologist and psychiatrists, and specialized programs to address the needs of female inmates.(20) The CCRA indicates that CSC is responsible for providing "every inmate with essential health care and reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration in the community".(21)  The delivery of care is provided by health care professionals who are registered or licensed in Canada including physicians, nurses, pharmacists, psychiatrists, psychologists, occupational therapists, social workers, dentists, and other relevant specialists.(21)

The Elizabeth Fry Society of Greater Vancouver works with women inmates through programs which aid in their reintegration into society upon release.(22) A partnership with this organization would help to promote the project and thus increase awareness about the available services. The women inmates will have access to oral

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care and education which may help increase their self esteem and thus reintegration into society. Therefore a partnership with this organization will help to provide a holistic approach to meeting the needs of female inmates re-entering the community.

The incorporation of the proposed program will allow for a greater access to oral health care for the female inmates. There will be collaboration with the other dental professionals on and off site who provide existing treatment for the inmates. Both teams will be involved in the referral of inmates in order to address their specific health and oral health care needs. The projects heads of the all other health and mental health professions, social services workers and existing programs will be informed of the proposed program in order to help with the coordination and implementation of dental hygiene services.

3. Project Proposal Information

3.1 Project objectives must align with the following:Objectives:

By the end of the program, we will improve the oral health of women inmates by decreasing plaque levels by 25% and improving periodontal health as assessed with BOP by 25%.

By the end of the program, we will increase self-esteem in former inmates as measured by quantitative and qualitative assessment in collaboration with mental health professionals from the Fraser Valley Institution and volunteers from the Elizabeth Fry Society of Greater Vancouver.  

Through a partnership with the Elizabeth Fry Society, a new oral and mental health program will be created to enhance the oral health and overall mental and physical well-being of women in prison.  The program will be promoted under the premise that a healthy smile can lead to a brighter outlook on life (higher self-esteem), and brighter future in the community.  The program will have two components.  The first is a dental hygiene program consisting of routine hygiene services, counseling, education provided at client-need based intervals to improve the inmates oral health. The second component is a voluntary monthly focus group held in collaboration with mental health professionals from the Fraser Valley Institution, and Elizabeth Fry volunteers who have prior experience working with inmates through their outreach programs.  The objective of the focus groups is to further the opportunity to discuss the effects of oral health on overall health and connect with issues such as smoking, alcohol and substance abuse.  

Our program is focused on a vulnerable population and will be conducted ethically and with cultural sensitivity.  We will use both qualitative and quantitative research methods, and partner with mental health professionals and reintegration specialists.  These objectives align with the guiding principles of the CFDHRE and CDHA Dental Hygiene research agenda.(23,24) Our program cross-cuts both clinical and health services pillars of research, and aligns with CFDHRE research themes including the use of evidence based practice, treating vulnerable populations, oral disease prevention, and improving health literacy and access to care.(23)

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3.2 Target audience/target of the researchThis research will serve to improve the oral and overall mental and physical

health of women inmates by providing dental hygiene treatment and education.  Our goal is to improve the oral health and self-esteem of at risk women inmates, while contributing to the dental hygiene knowledge base of oral disease prevention, health literacy and access to care for vulnerable populations.

The target audience of this program is female inmates at the Fraser Valley Institution in Abbotsford, BC.  The research that comes out of this program will be targeted at Correctional Services Canada, and to other women’s prisons with the intent of increasing access to care at these facilities through the success of our program. Women’s health organizations and other organizations that aid in the reintegration of inmates into the community are also targeted.

3.3 Project need or significanceThe unmet needs of women inmates are outlined in a literature review (See

Appendix G). Upon reviewing the literature, it was found that women inmates have poorer health status than the Canadian population.  (9,10).  They are also more than twice as likely to have a mental disorder, suffer from chronic and or infectious disease and suffer from substance, drug and alcohol abuse. (9,10,11)  Inmates are also likely to have poor oral health and to experience periodontal disease and or decayed missing teeth. (1-8)  

The literature further revealed a need for preventative efforts such as oral hygiene programs, in order to increase oral health knowledge and oral health status among inmates. (25-27,29)  A 2010 health survey by Correctional Service Canada (CSC), indicated a need for better access to medical treatment and more health choices, including more access to dentists.  (30)  Inmates complained that long waiting lists and insensitivity to women’s unique physical and mental health issues within correctional facilities often prevented them from receiving health care. (30)Women in prison have poor concepts of self and experience lowered self-esteem.(31,32)  Studies also suggest that those with low self-esteem report more health problems, whereas those with high self-esteem, self-concept and body image took better care of their health, and were more likely to seek preventative services.(33,34) Thus improving self-esteem should help to improve their overall health of female inmates, and allow them to better integrate into the community upon release.The proposed program will improve the quality of inmates lives improving their oral health, and providing a wholesome facial image that instills self-confidence and improved self-esteem, thus giving inmates a greater chance of success when re-entering the community.

3.4 Literature ReviewUnmet Needs

A 2010 health survey by the CSC showed that women prisoners indicated a need for better access to medical treatment and more health program choices.(30) They were dissatisfied with the quality and accessibility of the physical and mental health facilities and wanted easier access to doctors (50%), dentists (67%) and health specialists (44%).(30) Inmates also expressed difficulties getting an appointment with health professionals, citing long waiting lists. (30)  They also reported insensitivity to women’s

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unique physical and mental health issues.(30)

Oral Health statusInmates are likely to have poor oral health and to experience periodontal disease

and or decayed and missing teeth.(1-8) A study conducted by Clare (1996) on 1,971 inmates found that more than half of subjects aged 25 and older needed comprehensive periodontal examinations and therapy due to periodontal disease.(2) When compared to the Third National Health and Nutrition Examination Survey (NHANES), adult prison new admissions had a high prevalence of moderate and deep pocket depths; this prevalence exceed the results from the NHANES.(2) In a study by Nobile et al. (2007) among a random sample of 544 Italian inmates, only 10.5% of the inmates had completely healthy periodontal tissue and where not in need of treatment.(25) Studies examining the oral health status of women inmates suggest similar poor oral health findings. Badner and Margolin (1994) examined the oral health status and dental experience among 183 female inmates.(7) Inmates were more likely to experience oral pain and dental decay, to have missing teeth and a greater needed for prosthetic and restorative needs when compared to results obtained on women in the National Institute of Dental Research.(7) Similar results were reported by Heng and Morse (2002) from a study on 500 female inmates in which 78% of inmates had one or more untreated decayed teeth, and 78% had one or more missing teeth.(7) Inmates previous history of dental care suggests that care was accessed due to emergency or treatment needs rather than for oral disease prevention.(3-6) Inmates were more likely to have had an extraction during their last visit rather than restorative or preventative therapy.( 5,6) Furthermore Heildari et al.(2007) found that 67% of inmates’ last dental visit was due to pain, swelling, infection and or trauma.(4)

Self-EsteemWomen in prison have poor concepts of self and experience lowered self-

esteem.(31,32)  Prison is a difficult experience for most women, however inmates face even more issues upon release.  These include shame from embarrassment or guilt, along with stigmatization and social shame from the community.  Together, these may contribute to lowered self-esteem and feelings of despair and depression. Studies also suggest that those with low self-esteem report more health problems, whereas  those with high self-esteem, self-concept and body image took better care of their health, and were more likely to seek preventative services.(33,34) Thus improving self-esteem should help to improve their overall health of female inmates, and allow them to better integrate into the community upon release. Studies suggest that treatment programs that address self-esteem may be effective in rehabilitating female offenders, as low levels of self-esteem prior to release have been linked to re-offenses. (35,36,37) Therefore programs to address self-esteem should be a priority for correctional administrators.(37)

3.5 Approach or methodologyWe plan to integrate a combined dental hygiene program and a community

reintegration program in partnership with volunteers from the Elizabeth Fry Society of Vancouver at the Fraser Valley Institute for women. The task of promoting the program

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within the institution will be handled by the Elizabeth Fry Society, which already runs several other successful programs in the institution.  Data collected during this program will be used in a longitudinal study following program completion.  The 18 month program and study is intended to encompass the entire 57 woman population of the institution.  Because this federal prison has a minimum two- year sentence, we anticipate that the majority of the 57 inmates who agree to participate will complete the program.

While participants may attend recare visits as advised by the dental hygienist, data collection has its own schedule. At the start of their participation, the women will be invited to a focus group study (See Appendix A). Initial concepts about oral health and self-esteem will be gathered qualitatively through semi-structured interviews. In addition, self-esteem data will be quantified through a survey, which will be given at the beginning and at the exit of the study (See Appendix B). In regards to oral health, clinical data will be collected at baseline, as well as recalls at 6 weeks, 3 months, 6 months, 12 months and 18 months from the participant’s first treatment.

Our program partners at the Elizabeth Fry society will help with recruitment.  Co-applicants will conduct focus groups once a month as newcomers arrive. Various organizational partners, experts, and health professionals such as psychologists will collaborate in the focus groups to give expert assessment of their mental health.   Initial focus groups will present an opportunity to build rapport with inmates, and assess their program expectations, their perception of oral health care, as well as self-image and self-esteem levels. Open-ended questions will be asked about their perceptions of oral health and its relations to self-esteem. All responses will be recorded by hand and by tape. This is also an opportunity to allow the program staff to lay out the details of the program, including what kind of results to expect and the commitment required of the participants.  At this point, we would stress that the goal is not cosmetic restoration of their teeth, but a healthier smile through proper hygiene care.  For example, bleaching will not be provided.

Mental health data from questionnaires and focus groups will be compared to control data from identical questionnaires and focus groups at the Alouette Correctional Centre. The control population at Alouette will receive the usual care from the existing health programs, while the program group at the Fraser Valley Institution will receive dental hygiene, mental health services and reintegration programming from our combined program. These questions will again focus on perceptions of self, self-image, and attempt to identify improvements in self-esteem.

At the initial clinic session, an oral assessment will be conducted including extraoral, intraoral, and dental exams (See Appendices C,D). Inmates with urgent dental needs and those who have not seen a dentist in the last year will be referred to a dentist. The program group will be assessed at baseline for plaque levels using disclosing tablets and recorded according to the O’Leary Index. Full mouth probing will also be performed in order to assess BOP according to the Gingival Bleeding Index. Examiner calibration will ensure inter-examiner reliability. Using assessment data, the oral hygiene needs of the inmates will be diagnosed and an individualized dental hygiene plan treatment plan will be developed for each woman. Individualized oral hygiene instruction will be provided based on diagnosis.  Inmates will be provided with oral hygiene aids based on individual needs, and will be instructed in their use

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accordingly.   Oral health education such as the link between oral health and overall health, and the effects to alcohol and tobacco will also be addressed at each care appointment.  Referrals to other health programs will be made accordingly.  At each data collection recall, a re-evaluation of their plaque and BOP will be documented.  

At the conclusion of the program, final quantitative data will be analyzed against baseline using standard statistical tests to determine whether the program has met its dental hygiene objectives.   Qualitative questionnaire data and quantitative survey data from the final focus group will be compared to baseline and with data from the Alouette Correctional Centre.  Statistical tests include the Friedman test to assess quantitative clinical data between recall appointments and baseline. Wilcoxon signed rank test will be used to determine whether the program group showed any statistically significant improvements in self-esteem compared to the control group.  Qualitative data will be assessed using grounded theory.

Outcomes will be analyzed and discussed with program costs to also determine the cost effectiveness of the program.  The long term effects of the program is beyond the scope of this program, but a follow-up study may be done in the future to assess the impact of the program on the successful reintegration of these women into the community.

A decision on the success of the program will be made based on analysis of the data.   The ultimate goal of the project will be to implement similar programs in other correctional facilities in partnership with women’s organizations that have connections within the facility.

3.6 Products or outputsFemale inmates who enrolled and consented to the participation of the proposed

project will partake in a focus group, and have comprehensive dental hygiene care that has a recare scheduling system in place.

Assessment records for each individual on clinical and self perception data at baseline and recall visits will be kept; aside from documenting emergency dental treatment, detailed records of periodontal health measurements will be taken. Please refer to Item 3.10. Services will include oral cancer screening, debridement, and fluoride treatment. At the same time, individuals will be educated and counseled on oral self care and its importance, as well as the impact of certain risk behaviours on oral health and its appearance. Oral care aides such as toothbrushes, toothpaste, and interdental aides such as floss and interdental picks will be provided depending on client needs. A system for referrals to other health programs will be implemented as needed, such as self-esteem counseling and addiction programs. For inmates who did not wish to participate, dental services will be provided to them the same way as it had been at the facility.

The documentation of subjective and objective information at each visit, not only serves as a tracking of health data for the female inmates, but also acts as a tool for evaluating the program’s potential significance in improving clinical and self-reported oral health. Intraoral and extraoral exams are performed as part of due diligence, and attention to lesions may alleviate the individual’s concern of the mouth. Dental hygiene treatments and referrals will directly impact dental and periodontal health through the increased access to care. Counseling acts to increase health literacy and promote

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awareness. Oral care products combined with education will enable the individual to achieve better self care themselves.

3.7 Intended results/outcome/impact of the projectThe project objective of data collection on the oral health status of female

inmates will be attainable in the short-term. Data is gathered at the initial appointment as well as subsequent re-evaluation visits, thus forms a growing base of knowledge towards understanding the oral health of this population. Since oral cancer screening will also be done at each appointment, the unintended outcome is an early detection of potential cancerous lesions amongst this high risk population.

The other project objective is to improve the periodontal health of female inmates, which is focused on both short and long-term outcomes.  The short-term outcome for this is a reduction of plaque levels and bleeding on probing by 25%. This will be achieved by increased oral care delivery efficiency of services indicated in Item 3.7. The long-term outcomes would be a reduction in chronic periodontal disease progression. The unintended outcome anticipated is a reduction of caries risk.

The project objective of increasing self-esteem will be met by the long term-outcomes. In conjunction to regular dental hygiene treatment, a change in perception of the importance of oral self care and in client compliance over the years will result in enhancing the females’ self-perception of health and aesthetics.

3.8 Work plan

Date Action

October 8, 2012

Deadline to apply for funds

October 15, 2012

Obtain ethics approval from UBC

November 1, 2012

Begin selecting research team members

November 15, 2012

Work with collaborators, ie administration at Fraser Valley Institute, to explain project scope and limitations, and to finalize operation plans and contract.

December 1, 2012

Debrief and train team on each person’s role

January 1, 2013

Promote project with Elizabeth Fry society, who will help with recruitment at both Fraser Valley Institute and Alouette. Send invitations and consent forms to incarcerated female offenders.

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April 1, 2013 Begin project and data collection (ie. Assessments and focus groups)

April 1, 2013 – October 1, 2014

Themes about associated self-esteem from focus groups are constantly updated. Conduct re-evaluations at 6-week, 3-month, 6-month, 1-year, 1.5 -year recalls. Perform recare as appropriate for the participant

April 1, 2013 – October 1, 2014

Follow up with site management and stakeholders to update needs and gain feedback

October 1, 2013

Request of continuing funding for further research past one year time-frame

April 1, 2014 Prepare an interim report at midpoint of project. Revise if necessary.

October 31, 2014

Complete project

November 2014 – January 2015

Conduct data analysis and form conclusions about the project

February 2015 Hand out site and client satisfaction forms and assure confidentiality

February – March 2015

Have report reviewed, make revisions

March, 2015 Submit final report

March, 2015 Look to publish results and findings

April, 2015 Present information to stakeholders and public at large through various media (See Knowledge translation plan)

3.9 Knowledge translation planA final report will be written at the end of the study, and will be sent for

publication in various relevant journals. This report will share detailed methodology, results, and discussions, which includes the strength and weaknesses of the study, limitations, and future recommendations for research. The main audience of this

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professional publication is for researchers, dental professionals and professionals working with the inmate population. Researchers may be interested in this population’s oral health or in further research. A publication in accessible journals can increase awareness and inform dental professionals, of the disparities within this population. The co-applicants will travel to the 2015 CDHA and NCCHC conference, where they will be able to disseminate research findings.

Stakeholders will be updated regularly through correspondences, of the progress of the research, as well as addressing questions from them. At the end of the study, findings will be shared with Fraser Valley Institute site management, similar incarceration facilities, government officials, and other stakeholders. Knowledge on the results and its impact will be disseminated through a language-appropriate poster presentation.

For interested participants, this information will be made accessible to the public at large on the Elizabeth Fry Society website, so the participants may know the results of the study they participated in, and through which the message of the importance of oral health can be emphasized (given that those were the study results).

3.10 Evaluation planSelf-esteem will be measured by focus group interview questions and a survey:

A set of predetermined questions will be asked in each focus group. This forms the qualitative portion of the study to gain a better understanding of the female’s perceptions and experience about oral health or the lack thereof. A secondary purpose is to see if any design modifications are warranted throughout the study. The saturation technique will be used with ground theory to analyze the data.  Identifying common themes serves to find information about potential association of oral health with mental and physical health of these women.

The survey refers to a written form asking female offenders to rate how they feel about certain self-concepts. The Likert scale allows quantitative comparisons to be made. The Wilcoxon signed rank test will be used to compare the self-esteem survey since it is ordinal data. The scores at baseline and at the exit of the study will be compared for female offenders in Fraser Valley. Their scores at the exit of the study will also be compared to the scores of female offenders at the Alouette Prison, who did not receive the regular oral care and may serve as the ‘control’ group. A lack of significant difference in self-esteem scores would mean insignificant associations to oral health.

Clinical findings:

Bleeding on probing is measured by Gingival Bleeding Index, and plaque level by Plaque Control Record (O’Leary Index). Since the project aims to collect data on the participant’s periodontal health, these measurements are suitable because higher percentage for each points to worse periodontal disease. These indices are selected because the comprehensive periodontal charting would already provide full-mouth information about the presence of plaque and bleeding on each of the six tooth surfaces. Data is collected at baseline, six-week, three-month, six-month, twelve-month, and eighteen-month recall visits when possible. The Friedman test will be used to

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compare these multiple measurements for each individual, since the sample size is small and nonparametrical.  A 25% reduction in bleeding and plaque levels would indicate successful short-term results.

Participation dropouts are anticipated as some inmates are released before the study is over. All available data will be kept and analyzed. The intention to treat protocol will be in place. Collaborations with the statistician and colleagues in the analysis of the study not only ensure accuracy but also triangulation.Aside from data collection, the dental hygiene investigators will also evaluate the program in its study design, and its execution through satisfaction forms from the stakeholders and its clients. The program merit, worth, and significance will be determined by the quality and value of the program, as well as the difference the program makes.4. BudgetExpenditures

I)Non- Salary Costs

a) Travel and Meeting Costs

Travel for Research Program:Gas $ 1.40 per litre; 110 km per trip.90 trips in total; 5 trips per month for a total of 18 months.

1400.00

Travel for Conferences ( Discuss Research Findings)-          2015 Annual CDHA Conference in Halifax Canada

for 3 nights. Return airfare at $1000 per person. Registration $300 per person. Hotel $150 per night. Food $100 per day.

-          2015 Updates in Correctional Health Care in San Antonio, Texas for 3 nights. Return airfare at $700 per person. Registration $400 per person. Hotel $150 per night. Food $100 per day.

6450.00

5850.00

Subtotal 13,700.00

b)Supplies and Services

Office Supplies; paper, binders, pens, pencils, staples etc

700.00

Sundries; Bibs, Caviwipes, gauze, safety gloves, masks, safety glasses, fluoride, disclosing tablets and barriers

1600.00

Oral self care tools; toothbrushes, toothpaste, floss, denture brushes, soft picks

820.00

Educational material including oral health pamphlets, 600.00

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work sheets, handouts and brochures

4 Instrument kits; 8 instruments each kit including replacement costs over a 18 month period

2100.00

Computer program for research data collection and management- SPSS

700.00

Subtotal 6520.00

c) Overhead Access to research databases via UBC (i.e. Pub Med) Provided for by UBC

Subtotal 0.00

d) Other Expenses

Publication costs 1000.00

Subtotal 1000.00

II)Salary and Personnel

Statistician at $50.00 per hour for a total of approximately 35 hrs

1750.00

Subtotal 1750.00

Total 22970.00

Total Costs: $22,970Other Sources of Funding: None at presentTotal Requested from the CFDHRE: $22,970

Budget NarrativeI) Non- Salary Costs

a) Travel Costs For research program

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o The participants request funds in order to travel to the facility 5 times per month from New Westminster to Abbotsford. The participants will be car pooling in order to decrease fuel costs from New Westminster to Abbotsford BC for a total of 110 km round trip. Gas price is $1.40 per litre; 10 km per litre. Participants will be travelling to the facility 5 times a month for a total of 18 months. $1.40× 110(km)÷10(km per litre)×90(# of trips)=$1400

For conferenceso Both the annual CDHA and NCCHC conferences will allow for the

opportunity to disseminate research findings. All three co-applicants will be travelling to these meetings. The trip to Halifax will include return airfare at $1000.00 per person for a total of $3000.00; registration fees are $300 per person for a total of $900.00. Hotel at $150.00 per night for a total of $450.00 and $100 per day in food costs for a total of $400.00 over four days. The trip to San Antonio will include return airfare at $700.00 per person for a total of $2100.00; registration fees include $400 per person for a total of $1200. Hotel costs are estimated to be $150 per night for 3 nights totaling $450. Food costs are estimated to be $100 per day for a total of $400 over the course of 4 days.

b) In order to plan, implement, manage and conduct research at the facility the participants are requesting funds for supplies and services as outlined

Office supplies are estimated to cost $700.00 Sundries are estimated to cost $ 1600.00 Oral self care products; 57 inmates in total. $1.50 per toothpaste, $1.25 per floss,

$1.75 per toothbrush,$2.00 per denture brush and $.75 per package of soft picks Each self care tool, for a total of 3, will be given to inmates after each hygiene appointment depending on recare interval. 57×3 (estimated times inmate will be seen) ×4.5 (price for necessary tools such as toothbrush, toothpaste and floss) = $770.00. Cost of denture brushes and soft picks $50.00.

o Soft picks and denture brush will be given on a needs bases Educational material including the cost of paper and photocopying estimated to

be 600.00 Four cassettes containing 8 instruments each will include an explorer, double

sided mirror, Marquis probe, an anterior and posterior universal scaler and 3 gracey curettes. Instruments will need to be replaced once during implementation of program. Cost of cassettes; 4×$80.00 = 320. Cost of instruments; 32(instruments in total)× $40(cost of one instrument) + $500 (estimated cost of replacement) = $2100.

Computer software for the recording and management of research data estimated to cost around $700 including annual fees.

         c) UBC to provide free access to the UBC research database and search engines such as Pub Med and Google Scholar.

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d) Publication costs are funds needed to publish research findings. This cost also includes the use of an editor. Estimated cost is $1000.

II) Salary and Personnel

A statistician will be hired to analysis the research data collected. Estimated cost per hour to hire a statistician is $ 50.00 for a total of 35 hrs; total $1750.00.

5. Required AttachmentsAppendix A: Focus Group Questions

Appendix B: Self-esteem Survey

Appendix C: Extraoral/ Intraoral Exam

Appendix D: Odontogram

Appendix E: Client Satisfaction Form

Appendix F: Site Satisfaction Form

Appendix G: Literature Review

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References

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26. Osborn M, Butler T, Barnard PD. Oral health status of prison inmates- New South Wales, Australia. Aust Dent J. 2003; 48(1): 34- 8.

27. Badner V, Margolin R. Oral health status among women inmates at Rikers Island correctional facility. J Correct Health Care. 1994;1: 55- 72.

28. Heng CK, Morse DE. Dental caries experience of female inmates. J Public Health Dent. 2002; 62(1): 57- 61.

29. Mixson JM, Eplee HC, Fell PH, Jones JJ, Rico M. Oral health status of a federal prison population. J Public Health Dent. 1990; 50: 257-261

30. Barrett MR, Allenby K, Taylor K. Twenty years later: Revisiting the task force on federally sentenced Women. Correctional Service Canada. 2010; No R-222. Available from: http://www.csc-scc.gc.ca/text/rsrch/reports/r222/r222-eng.shtml#_Toc276046046

31. Dodge M and Pogrebin MR. Collateral Costs of Imprisonment for women: Complications of reintegration. Prison Journal, 2001; 81:42.

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33. Glasner JB, Greifinger, RB.  Correctional health care: A public health opportunity. Annals of Internal Medicine. 1993; 118(2): 139-145.

34. Brewer MK, Baldwin D. The relationship between self-esteem, health habits, and knowledge of BSE practice in female inmates. Public Health Nursing. 2000; 17(1): 16-24.

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37. Byrne MK, Howells K. The psychological needs of women prisoners: Implications for rehabilitation and management, 2002; 9(1). Available from: http://www.tandfonline.com/doi/abs/10.1375/pplt.2002.9.1.34