Safewards Impact in Inpatient Mental Health Units in Victoria, Australia: Staff Perspectives

Introduction: Mental health professionals working in acute inpatient mental health wards are involved in a complex interplay between an espoused commitment by government and organizational policy to be recovery-oriented and a persistent culture of risk management and tolerance of restrictive practices. This tension is overlain on their own professional drive to deliver person-centered care and the challenging environment of inpatient wards. Safewards is designed to reduce conflict and containment through the implementation of 10 interventions that serve to improve the relationship between staff and consumers. The aim of the current study was to understand the impact of Safewards from the perspectives of the staff. Methods: One hundred and three staff from 14 inpatient mental health wards completed a survey 12 months after the implementation of Safewards. Staff represented four service settings: adolescent, adult, and aged acute and secure extended care units. Results: Quantitative results from the survey indicate that staff believed there to be a reduction in physical and verbal aggression since the introduction of Safewards. Staff were more positive about being part of the ward and felt safer and more connected with consumers. Qualitative data highlight four key themes regarding the model and interventions: structured and relevant; conflict prevention and reducing restrictive practices; ward culture change; and promotes recovery principles. Discussion: This study found that from the perspective of staff, Safewards contributes to a reduction in conflict events and is an acceptable practice change intervention. Staff perspectives concur with those of consumers regarding an equalizing of staff consumer relationships and the promotion of more recovery-oriented care in acute inpatient mental health services.

Consumer Perspectives of Safewards Impact in Acute Inpatient Mental Health Wards in Victoria, Australia

Background: Inpatient mental health wards are reported by many consumers to be custodial, unsafe, and lacking in therapeutic relationships. These consumer experiences are concerning, given international policy directives requiring recovery-oriented practice. Safewards is both a model and a suite of interventions designed to improve safety for consumers and staff. Positive results in reducing seclusion have been reported. However, the voice of consumers has been absent from the literature regarding Safewards in practice. Aim: To describe the impact of Safewards on consumer experiences of inpatient mental health services. Method: A postintervention survey was conducted with 72 consumers in 10 inpatient mental health wards 9-12 months after Safewards was implemented. Results: Quantitative data showed that participants felt more positive about their experience of an inpatient unit, safer, and more connected with nursing staff. Participants reported that the impact of verbal and physical aggression had reduced because of Safewards. Qualitatively, participants reported increased respect, hope, sense of community, and safety and reduced feelings of isolation. Some participants raised concerns about the language and intention of some interventions being condescending. Discussion: Consumers' responses to Safewards were positive, highlighting numerous improvements of importance to consumers since its implementation across a range of ward types. The findings suggest that Safewards offers a pathway to reducing restrictive interventions and enables a move toward recovery-oriented practice.

Staying Quit After Release (SQuARe) trial protocol: a randomised controlled trial of a multicomponent intervention to maintain smoking abstinence after release from smoke-free prisons in Victoria, Australia

INTRODUCTION

Smoke-free policies have been introduced in prisons internationally. However, high rates of relapse to smoking after release from prison indicate that these policies typically result in short-term smoking cessation only. These high rates of relapse, combined with a lack of investment in relapse prevention, highlight a missed opportunity to improve the health of a population who smoke tobacco at two to six times the rate of the general population. This paper describes the rationale and design of a randomised controlled trial, testing the effectiveness of a caseworker-delivered intervention promoting smoking cessation among former smokers released from smoke-free prisons in Victoria, Australia.

METHODS AND ANALYSIS

The multicomponent, brief intervention consists of behavioural counselling, provision of nicotine spray and referral to Quitline and primary care to promote use of government-subsidised smoking cessation pharmacotherapy. The intervention is embedded in routine service delivery and is administered at three time points: one prerelease and two postrelease from prison. Control group participants will receive usual care. Smoking abstinence will be assessed at 1 and 3 months postrelease, and confirmed with carbon monoxide breath testing. Linkage of participant records to survey and routinely collected administrative data will provide further information on postrelease use of health services and prescribed medication.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Corrections Victoria Research Committee, the Victorian Department of Justice Human Research Ethics Committee, the Department of Human Services External Request Evaluation Committee and the University of Melbourne Human Research Ethics Committee. Results will be submitted to major international health-focused journals. In case of success, findings will assist policymakers to implement urgently needed interventions promoting the maintenance of prison-initiated smoking abstinence after release, to reduce the health disparities experienced by this marginalised population.

TRIAL REGISTRATION NUMBER

ACTRN12618000072213; Pre-results.

Barriers and facilitators of maintained smoking abstinence following release from smoke-free prisons: A qualitative enquiry

BACKGROUND

The prevalence of smoking among people entering prisons is high. Despite increasing adoption of prison smoke-free policies, relapse to smoking after release from prison is nearly universal, and policy to effectively mitigate this is largely absent. Informed by a risk environment framework, we aimed to identify key barriers and facilitators to maintaining smoking abstinence among former smokers released from smoke-free prisons.

METHOD

Twenty-one people released from smoke-free prisons in Queensland, Australia, were followed up from a larger survey of 114 former prisoners. Semi-structured interviews were used to explore the perceived barriers and facilitators of maintained smoking abstinence.

FINDINGS

Identified barriers to continued abstinence included pre-release intention to resume smoking; normalisation of smoking in home or social environments, resumption of smoking as a symbolic act of freedom and resistance from and to a restrictive environment; a perception that smoking provides stress relief to their difficult lives, and the use of tobacco/smoking to cope with cravings experienced on release for illicit substances. A number of interviewees were unable to provide clear reflective reasons for relapse. For those who did manage to remain abstinent for a period of time, identified facilitators included an awareness of the health and financial benefits of smoking abstinence, the use of intrinsic motivation, distraction from nicotine cravings using alternative activities, and social support from family and peers.

DISCUSSION

Interventions promoting continued smoking abstinence among people exiting smoke-free prisons should focus on targeting the perceived individual- and environmental-level barriers to maintained smoking abstinence while simultaneously promoting perceived facilitators, so as to reduce smoking-related health and economic disparities in this marginalised population.

Emergency health service contact and reincarceration after release from prison: A prospective cohort study

BACKGROUND

Adults released from prison often have complex health needs. They are at high risk of poor health outcomes and reincarceration, with health service use unlikely to be planned.

AIMS/HYPOTHESES

To determine the incidence of emergency health service (EHS) use, ambulance attendance and/or emergency department presentation, among 1,181 adults released from Australian prisons. We hypothesised that EHS contact would be associated with increased reincarceration risk.

METHODS

Baseline surveys were conducted within 6 weeks before release. Postrelease EHS contacts and reincarceration were identified through prospective data linkage. For each participant, EHS contacts within a 24-hour period were combined to make an episode. We used Cox proportional hazards regression to examine the relationship between EHS episodes and reincarceration, controlling for covariates.

RESULTS

More than half (53.3%) of participants had at least one EHS contact over a median of 25.6-month follow-up. In adjusted analyses, compared to those with no EHS contacts, the hazard of reincarceration was greater for participants who had one to three EHS episodes (hazard ratio [HR] = 1.84; 95% confidence interval [CI] [1.48, 2.29]) or four or more (HR = 2.35; 95% CI [1.67, 3.29]).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Emergency department attendance by people with a history of imprisonment may be indicative of wider decompensation. Improved management of such patients may improve health outcomes and have collateral benefits for reducing reincarceration.

Age-specific incidence of injury-related hospital contact after release from prison: a prospective data-linkage study

Background

In population studies, the risk of injury declines after early adulthood. It is unclear if a similar age difference in the risk of injury exists among people released from prison.

Methods

Prerelease survey data collected between 1 August 2008 and 31 July 2010, from a representative cohort of sentenced adults (≥18 years) in Queensland, Australia, were linked prospectively and retrospectively to person-level emergency department, inpatient hospital and correctional records. To ascertain predictors of injury-related hospital contact, we fit a multivariate Andersen-Gill model and tested the interactions between age group (<25 years, ≥25 years) and each variable.

Results

In 1307 adults released from prison, there were 3804 person-years of follow-up. The crude injury rate was 385 (95% CI 364 to 407) per 1000 person-years and did not differ according to age group. Factors associated with increased injury-related hospital contact included a history of mental illness, preincarceration injury, a history of incarceration, release from a short prison sentence (<90 days), being reincarcerated during follow-up and identifying as Indigenous. The effect of mental illness, risky alcohol use, prior incarceration and intellectual disability differed across age group and predicted increased risk of injury among people aged ≥25 years compared with their counterparts without these characteristics.

Conclusions

Unlike in the general population where the risk of injury declines with age, older adults released from prison are at similar risk compared with their younger peers. Adults released from prison with mental illness, a history of injury-related hospital contact and who identify as Indigenous are particularly indicated groups for injury prevention.

Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990-2016

BACKGROUND

Rapid demographic, epidemiological, and nutritional transitons have brought a pressing need to track progress in adolescent health. Here, we present country-level estimates of 12 headline indicators from the Lancet Commission on adolescent health and wellbeing, from 1990 to 2016.

METHODS

Indicators included those of health outcomes (disability-adjusted life-years [DALYs] due to communicable, maternal, and nutritional diseases; injuries; and non-communicable diseases); health risks (tobacco smoking, binge drinking, overweight, and anaemia); and social determinants of health (adolescent fertility; completion of secondary education; not in education, employment, or training [NEET]; child marriage; and demand for contraception satisfied with modern methods). We drew data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, International Labour Organisation, household surveys, and the Barro-Lee education dataset.

FINDINGS

From 1990 to 2016, remarkable shifts in adolescent health occurred. A decrease in disease burden in many countries has been offset by population growth in countries with the poorest adolescent health profiles. Compared with 1990, an additional 250 million adolescents were living in multi-burden countries in 2016, where they face a heavy and complex burden of disease. The rapidity of nutritional transition is evident from the 324·1 million (18%) of 1·8 billion adolescents globally who were overweight or obese in 2016, an increase of 176·9 million compared with 1990, and the 430·7 million (24%) who had anaemia in 2016, an increase of 74·2 million compared with 1990. Child marriage remains common, with an estimated 66 million women aged 20-24 years married before age 18 years. Although gender-parity in secondary school completion exists globally, prevalence of NEET remains high for young women in multi-burden countries, suggesting few opportunities to enter the workforce in these settings.

INTERPRETATION

Although disease burden has fallen in many settings, demographic shifts have heightened global inequalities. Global disease burden has changed little since 1990 and the prevalence of many adolescent health risks have increased. Health, education, and legal systems have not kept pace with shifting adolescent needs and demographic changes. Gender inequity remains a powerful driver of poor adolescent health in many countries.

FUNDING

Australian National Health and Medical Research Council, and the Bill & Melinda Gates Foundation.

Corrections for Academic Medicine: The Importance of Using Person-First Language for Individuals Who Have Experienced Incarceration

This Invited Commentary addresses the use of labels and their impact on people involved in the criminal justice system. There are 2.2 million adults incarcerated in the United States and close to 6.6 million under correctional supervision on any day. Many of these people experience health inequalities and inadequate health care both in and out of correctional facilities. These numbers are reason enough to raise alarm among health care providers and criminal justice researchers about the need to conceptualize better ways to administer health care for these individuals. Using terms like "convict," "prisoner," "parolee," and "offender" to describe these individuals increases the stigma that they already face. The authors propose that employing person-first language for justice-involved individuals would help to reduce the stigma they face during incarceration and after they are released. Coordinated, dignified, and multidisciplinary care is essential for this population given the high rates of morbidity and mortality they experience both in and out of custody and the many barriers that impede their successful integration with families and communities. Academic medicine can begin to address the mistrust that formerly incarcerated individuals often have toward the health care system by using the humanizing labels recommended in this Invited Commentary.

Constituents of "teabacco": A forensic analysis of cigarettes made from diverted nicotine replacement therapy lozenges in smoke-free prisons

Following the implementation of prison smoke-free policies, there have been reports of prisoners creating substitute cigarettes made from nicotine replacement therapy patches or lozenges infused with tea leaves ("teabacco"). No studies have analyzed the chemical constituents of teabacco made from nicotine lozenges, so as to document any potential related health hazards. Teabacco samples were made by a participant who reported creating teabacco while incarcerated in a smoke-free prison in Queensland, Australia, and the process was video-recorded for replication in a laboratory. A simple linear smoking system captured the teabacco smoke for analysis. Inductively coupled plasma optical emission spectroscopy (ICP-OES) was used to analyze elemental composition and gas chromatography coupled with a mass spectrometer (GC-MS) analyzed the captured smoke using the National Institute of Standards and Technology mass spectral library. Analyses determined that quantities of copper, aluminum, and lead concentrations, and levels of inhaled total particulate matter, were above recommended guidelines for safe ingestion. Analysis of teabacco smoke using GC-MS identified potentially toxic compounds catechol and nicotine. However, our findings show that smoking this form of teabacco is less harmful than smoking teabacco made from nicotine patches, or smoking traditional tobacco cigarettes. Considering the limited potential health harm of smoking teabacco made from lozenges, and that nicotine lozenges represent the only form of smoking cessation support for individuals entering smoke-free prisons, we caution against the removal of nicotine lozenges from Queensland's prisons, at least until further research directly establishes health harms associated with this form of teabacco.

Injecting drug use is an independent risk factor for reincarceration after release from prison: A prospective cohort study

INTRODUCTION AND AIMS

Once involved in the criminal justice system, people who inject drugs (PWID) have a high probability of multiple system encounters. Imprisonment typically fails to rehabilitate PWID, who upon return to the community are at considerable risk of returning to injecting drug use (IDU) and poor health and social outcomes. We examined the effect of IDU resumption, and a suite of other sociodemographic, criminogenic, health and behavioural indicators, on the timing of reincarceration among adults with a history of IDU following release from prison.

DESIGN AND METHODS

Structured interviews were conducted with 561 PWID in Queensland, Australia prior to release from prison and approximately 1, 3 and 6 months post-release. Data were linked prospectively with correctional records and the National Death Index. Data collected at multiple time-points were treated as time-varying covariates. Kaplan-Meier survival estimates and Cox proportional hazards models were used to estimate the rate and hazards of reincarceration.

RESULTS

Sixty-eight percent of participants (n = 350) were reincarcerated over a combined observation time of 1043.5 years, representing a rate of 33.5 per 100 person-years (95% confidence interval [CI] 30.2-37.2). Time-invariant predictors of reincarceration in PWID were: male gender (adjusted hazard ratio [AHR] = 1.62, 95% CI 1.19-2.21), older age at release (AHR = 0.97, 95% CI 0.95-1.00), previous adult (AHR = 2.00, 95% CI 1.41-2.84) or juvenile (AHR = 1.78, 95% CI 1.27-2.49) imprisonment, shorter imprisonment (≤90 days vs. >365 days, AHR = 2.09, 95% CI 1.30-3.34), release on parole (AHR = 2.29, 95% CI 1.82-2.88) and drug-related sentence (AHR = 1.84, 95% CI 1.34-2.53). Time-varying predictors included resumption of IDU (AHR = 2.04, 95% CI 1.60-2.61), unemployment (AHR = 1.53, 95% CI 1.07-2.19) and low perceived social support (AHR = 1.41, 95% CI 1.05-1.90). Very-high psychological distress at the most recent interview was protective against reincarceration (AHR = 0.65, 95% CI 0.44-0.95).

DISCUSSION AND CONCLUSIONS

Efforts to prevent resumption of IDU and address disadvantage, social inclusion and health service access in ex-prisoners through the scale-up and integration of prison-based and post-release interventions are likely to reap both public health and criminal justice benefits.

Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis

The world prison population is growing at a rate that exceeds the rate of population growth. This issue of Epidemiologic Reviews comprises articles in which researchers summarize what is known about some of the key health issues facing people in prison, particularly in relation to human immunodeficiency virus and other blood-borne viral infections. A key recurring theme is that addressing the health needs of people in prison is important to reducing health inequalities at the population level—that prisoner health is public health. The reviews also highlight some critical evidence gaps, notably the lack of evidence from low- and middle-income countries, and the limited number of longitudinal studies in which health behaviors, health outcomes, or health service experiences after release from prison are documented. Despite growing evidence of the poor health of detained adolescents, none of the included reviews considered this population. Further research on the health of young people who cycle through juvenile detention should be a priority. Despite a rapidly growing literature on the health of people who experience incarceration, some critical health issues remain poorly understood, and there has been insufficient attention devoted to co-occurring health conditions and the consequent need for coordinated care. Key populations in custodial settings remain understudied, limiting capacity to develop targeted, evidence-based responses to their health needs. The quality of many studies is suboptimal, and although rigorous, independent research in correctional settings can be challenging, it is not impossible and is critical to laying the groundwork for evidence-based reform.

Prevalence of Drug Injection, Sexual Activity, Tattooing, and Piercing Among Prison Inmates

Prisoners engage in a range of risk behaviors that can lead to the transmission of viral infections, such as HIV, hepatitis B and hepatitis C. In this review, we summarize the epidemiologic literature from 2007 to 2017 on 4 key risk behaviors for human immunodeficiency virus and hepatitis C virus among prisoners globally: drug injection, sexual activity, tattooing, and piercing. Of 9,303 peer-reviewed and 4,150 gray literature publications, 140 and 14, respectively, met inclusion criteria covering 53 countries (28%). Regions with high levels of injection drug use were Asia Pacific (20.2%), Eastern Europe and Central Asia (17.3%), and Latin America and the Caribbean (11.3%), although the confidence interval for Latin America was high. Low levels of injection drug use in prison were found in African regions. The highest levels of sexual activity in prison were in Europe and North America (12.1%) and West and Central Africa (13.6%); low levels were reported from the Middle East and North African regions (1.5%). High levels of tattooing were reported from Europe and North America (14.7%), Asia Pacific (21.4%), and Latin America (45.4%). Prisons are burdened with a high prevalence of infectious diseases and risk behaviors for transmission of these diseases, and, commonly, a striking lack of evidence-based infection control measures, even when such measures are available in the surrounding community. Given that most prisoners return to these communities, failure to implement effective responses has repercussions not only prisoner health but also for public health.

Brief intervention on Smoking, Nutrition, Alcohol and Physical (SNAP) inactivity for smoking relapse prevention after release from smoke-free prisons: a study protocol for a multicentre, investigator-blinded, randomised controlled trial

INTRODUCTION

Smoking remains the leading risk factor for disease burden and mortality worldwide. Heavy Smoking is often associated with poor Nutrition, Alcohol abuse and Physical inactivity (known as 'SNAP'). Australia's first prison smoking ban was introduced in the Northern Territory in July 2013. However, relapse to smoking after release from prison is normative. Holistic and cost-effective interventions are needed to maintain post-release abstinence to realise the potential public health impact of smoke-free prison policies. Rigorous, large-scale trials of innovative and scalable interventions are crucial to inform tobacco control policies in correctional settings.

METHODS AND ANALYSIS

This multicentre, investigator-blinded, randomised parallel superiority trial will evaluate the effectiveness of a brief intervention on SNAP versus usual care in preventing smoking relapse among people released from smoke-free prisons in the Northern Territory, Australia. A maximum of 824 participants will be enrolled and randomly assigned to either SNAP intervention or usual care at a 1:1 ratio at baseline. The primary endpoint is self-reported continuous smoking abstinence three months after release from prison, verified by breath carbon monoxide test. Secondary endpoints include seven-day point prevalence abstinence, time to first cigarette, number of cigarettes smoked post release, Health Eating Index for Australian Adults, Alcohol Use Disorder Identification Test-Consumption and International Physical Activity Questionnaire scores. The primary endpoint will be analysed on an intention-to-treat basis using a simple log binomial regression model with multiple imputation for missing outcome data. A cost-effectiveness analysis of the brief intervention will be conducted subsequently.

ETHICS AND DISSEMINATION

This study was approved by the University of New South Wales Human Research Ethics Committee (HREC), Menzies HREC and Central Australia HREC. Primary results of the trial and each of the secondary endpoints will be submitted for publication in a peer-review journal.

TRIAL REGISTRATION NUMBER

ACTRN12617000217303; Pre-results.

Lifetime prevalence and correlates of self-harm and suicide attempts among male prisoners with histories of injecting drug use

BACKGROUND

Histories of self-harm and suicide attempts are common among people in prison in Australia, and substance dependence is an established risk factor for these lifetime experiences. We describe the prevalence of self-reported history of non-suicidal self-injury (NSSI) and suicide attempts in a cohort of men with recent histories of injecting drug use (IDU) imprisoned in Victoria, Australia. Baseline interviews from the Prison and Transition Health (PATH) prospective cohort study were conducted in the weeks prior to release from prison among 400 incarcerated men who reported regular IDU in the six months prior to incarceration.

RESULTS

Participants completed a researcher-administered structured questionnaire that collected information on sociodemographics, substance use patterns, and physical and mental health indicators. More than one third (37%) reported a history of NSSI and almost half of participants (47%) reported a history of suicide attempts. In multivariable Poisson regression models, a history of NSSI was associated with: being aged 30-39 years; moving accommodation three or more times in the year prior to current sentence; self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting three or more previous drug overdoses. History of suicide attempts was significantly associated with: self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting a history of 1-2 and > 3 drug overdoses.

CONCLUSION

We observed a disconcertingly high lifetime prevalence of non-suicidal self-injury and suicide attempts among incarcerated males with a history of recent regular injecting drug use. Significant associations with indicators of mental illness and drug related harms support the need to prioritise in-prison screening and early intervention to reduce the risk of future harms for this population.

In Sickness and in Prison: The Case for Removing the Medicare Exclusion for Australian Prisoners

Many current and former prisoners experience significantly higher rates of physical and mental health problems than others in the community, and are among the most marginalised and disadvantaged people in society. This article argues that granting prison health services an exemption under s 19(2) of the Health Insurance Act 1973 Cth would make the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme-funded services available to prisoners who meet the eligibility criteria. Australian prisoners would then receive a level of care at least equivalent to that offered by community health services. Reducing health inequities that prisoners experience, particularly Indigenous prisoners, is essential for them continuing to receive health care following release and successfully reintegrating into the community. Further, granting the exemption would assist the Australian Government to meet its international human rights obligations to provide equitable health care for all Australians.

Acceptability of prison-based take-home naloxone programmes among a cohort of incarcerated men with a history of regular injecting drug use

Background

Take-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia.

Methods

The sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison.

Results

Most participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03–4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32–4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14–5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73–11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18–0.77) was associated with decreased odds of willingness to participate in a prison THN training.

Conclusion

Our findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to participate in THN training prior to release. Factors associated with willingness to participate in prison THN programmes offer insights to help support the implementation and uptake of THN programmes to reduce opioid-overdose deaths in the post-release period.

Self-harm and suicidal behaviour among incarcerated adults in the Australian Capital Territory

BACKGROUND

Suicide is the leading cause of death in prisons worldwide. Improved understanding of the factors associated with suicide is necessary to inform targeted suicide prevention and interventions. Here we aim to (a) document the prevalence of suicide attempts, suicidal ideation, self-harm, and mental disorder; and (b) identify demographic, mental health, and criminal justice correlates of suicidal ideation, in a sample of incarcerated adults in Australia.

METHODS

Data were obtained from the 2016 Detainee Health and Wellbeing Survey conducted in the Alexander Maconochie Centre, the Australian Capital Territory's only adult prison. Interviews with 98 incarcerated adults were conducted in October 2016. Descriptive statistics were calculated for all measures. Crude differences between participants who reported experiencing suicidal ideation in their lifetime and those who did not were compared using Fisher's exact test.

RESULTS

Nearly half of the participants (48%, n = 47) reported lifetime suicidal ideation and 31% (n = 30) reported attempting suicide at some point in their lives. Eighteen participants (18%) reported a lifetime history of having engaged in self-harm. Factors significantly associated with suicidal ideation included lifetime history of mental disorder, self-harm, experiencing a drug overdose, and being hospitalized in the past 12 months.

CONCLUSION

The burden of suicidal ideation and prior suicide attempts among people in prison is substantial. Incarceration is a pivotal opportunity to identify people with a history of mental health problems and target interventions aimed at reducing adverse outcomes including suicide mortality.

Cost-utility analysis of low-intensity case management to increase contact with health services among ex-prisoners in Australia

OBJECTIVES

The economic burden of incarceration is substantial in Australia. People released from prison are at high risk of poor health and this is an important predictor of recidivism. The 'Passports Study' was a randomised controlled trial of an intervention designed to increase health service utilisation after release from prison. The aim of this study is to conduct a cost-utility analysis of this transitional programme.

SETTING

Australia DESIGN: A hybrid simulation model was developed to estimate the changes to total economic costs and effectiveness expressed as quality-adjusted life-years (QALYs) from the adoption of the 'Passports' intervention compared with the control group. Model parameters were informed by linked data from Queensland Corrective Services, Medicare, Pharmaceutical Benefits Scheme, Queensland Hospital Admission Patient Data Collection, Emergency Department Information System and National Death Index. Health-related quality of life was measured using the Short-Form 8 Health Survey (SF-8). The primary outcomes were the costs and estimated QALYs associated with the intervention group and the control group. Probabilistic sensitivity analysis was conducted to test parameter uncertainties.

RESULTS

Compared with the control group where no attempt was made to encourage health service utilisation, an average participant in the intervention group incurred an extra cost of AUD 1790 and experienced slightly reduced QALYs, which indicated that the intervention was dominated in the baseline analysis. Probabilistic sensitivity analysis revealed that the transitional programme had a low probability of being cost-effective with the outcome measures selected.

CONCLUSION

The findings of this study do not provide economic evidence to support the widespread adoption of the Passports intervention. Due to the reductionist nature of the cost-utility approach, it may be that important health-related benefits have been omitted. Another research approach using a wider range of health-related measures might generate different conclusions.

'Teabacco': Smoking of nicotine-infused tea as an unintended consequence of prison smoking bans

INTRODUCTION AND AIMS

Following the introduction of smoke-free policies in prisons in several countries, there have been anecdotal reports of prisoners creating cigarettes by mixing nicotine patches or lozenges with tea leaves ('teabacco'). Among a sample of people recently released from smoke-free prisons in Queensland, Australia, the aims of this study were to explore the perceived popularity of teabacco use, motivations for its use and describe the process of creating teabacco to identify potential associated health risks.

DESIGN AND METHODS

This study used a mixed-methods design. Eighty-two people recently released from prison in Queensland, Australia completed surveys at parole offices measuring teabacco use while incarcerated. Twenty-one teabacco smokers took part in follow-up, qualitative interviews to explore survey responses in greater depth.

RESULTS

The majority of survey participants (57%) reported smoking teabacco while incarcerated, with 37% smoking teabacco frequently (> once per week). Teabacco use was primarily motivated by cigarette cravings. Participants described the perceived inevitability of prisoners finding substitutes for tobacco. Multivariate analyses found that self-rated poor physical health, having been incarcerated five or more times, experiencing cigarette cravings while incarcerated, and use of illicit drugs while incarcerated were positively associated with frequent teabacco use in prison.

DISCUSSION AND CONCLUSIONS

Our findings suggest that teabacco use has become common practice in Queensland's smoke-free prisons. Correctional smoking bans are an important public health initiative but should be complemented with demand and harm reduction measures cognisant of the risk environment.

The importance of including aliases in data linkage with vulnerable populations

BACKGROUND

Records pertaining to individuals whose identity cannot be verified with legal documentation may contain errors, or be incorrect by intention of the individual. Probabilistic data linkage, especially in vulnerable populations where the incidence of such records may be higher, must be considerate of the usage of these records.

METHODS

A data linkage was conducted between Queensland Youth Justice records and the Australian National Death Index. Links were assessed to determine how often they were made using the unverified (alias) records that would not have been made in their absence (i.e. links that were not also made using solely verified records). Anomalies in the linked records were investigated in order to make evaluations of the sensitivity and specificity of the linkage, compared to the links made using only verified records.

RESULTS

From links made using verified records only, 1309 deaths were identified (2.6% of individuals). Using alias records in addition, the number of links increased by 16%. Links made using alias records only were more common in females, and those born after 1985. Different records belonging to the same individual in the justice dataset did not link to different death records, however there were instances of the same death record linking to multiple cohort individuals.

CONCLUSIONS

The inclusion of aliases in data linkage in youths involved in the justice system increased mortality ascertainment without any discernible increase in false positive matches. We therefore conclude that alias records should be included in data linkage procedures in order to avoid biased attenuation of ascertainment in vulnerable populations, leading to the concealment of health inequality.