Background: Mental disorders are overrepresented in prisoners, placing them at an increased risk of suicide. Advancing our understanding of how different mental disorders relate to distinct stages of the suicidal process—the transition from ideation to action—would provide valuable information for clinical risk assessment in this high-risk population. Methods: Data were drawn from a representative sample of 1212 adults (1093 men) incarcerated across 13 New Zealand prisons, accounting for 14% of the national prison population. Guided by an ideation-to-action framework, three mutually exclusive groups of participants were compared on the presence of mental disorders assessed by validated DSM-IV diagnostic criteria: prisoners without any suicidal history (controls; n = 778), prisoners who thought about suicide but never made a suicide attempt (ideators; n = 187), and prisoners who experienced suicidal ideation and acted on such thoughts (attempters; n = 247). Results: One-third (34.6%) of participants reported a lifetime history of suicidal ideation, of whom 55.6% attempted suicide (19.2% of all prisoners). Suicidal outcomes in the absence of mental disorders were rare. Whilst each disorder increased the odds of suicidal ideation (OR range 1.73–4.13) and suicide attempt (OR range 1.82–4.05) in the total sample (n = 1212), only a select subset of disorders was associated with suicide attempt among those with suicidal ideation (n = 434). Drug dependence (OR = 1.65, 95% CI 1.10-2.48), alcohol dependence (OR = 1.89, 95% CI 1.26-2.85), and posttraumatic stress disorder (OR = 2.09, 95% CI 1.37-3.17) distinguished attempters from ideators. Conclusion: Consistent with many epidemiological studies in the general population, our data suggest that most mental disorders are best conceptualized as risk factors for suicidal ideation rather than for suicide attempt. Once prisoners consider suicide, other biopsychosocial factors beyond the mere presence of mental disorders may account for the progression from thoughts to acts of suicide.

Critics of government intervention for the prevention of lifestyle-related chronic disease often conceptualise such efforts as 'nanny state', reflecting a neoliberal perspective and derailing wider debate. However, it is unknown how the community perceives such interventions. Given the importance of public opinion to government willingness to implement population-level system change, we aimed to better understand Australian community attitudes towards government-led prevention, in particular whether nanny state conceptualisations reflect community attitudes. We used an iterative mixed methods approach to data collection and analysis based on focus groups (n = 49) and a national survey (n = 2052). Despite strong endorsement (91%) of personal responsibility for health, 46% of survey respondents thought government plays a large role in prevention. The nanny state conceptualisation was not dominant in either the survey or focus group data. Qualitative data analysis highlighted alternative conceptualisations, namely government as a: canny investor; leader on positive health behaviour; partner or facilitator for health. Respondents' level of support for specific interventions overlaid these general conceptualisations with considerations of the target population and risk factor, intervention mechanism and government motives. Community perceptions regarding prevention therefore reflect more thoughtful and complex interpretations of preventive actions and policies than suggested by nanny state conceptualisations. We argue that advocates and legislators should not allow debate around preventive measures to be restricted to the nanny state-libertarian continuum, but engage the community in more collectivist considerations of future health costs, beneficiaries, equity and likely outcomes of both action and inaction in order to garner community support and identify information gaps.

Background: Workplace health programs (WHPs) may improve adult health but very little evidence exists on multi-level WHPs implemented at-scale and so the relationship between program implementation factors and outcomes of WHPs are poorly understood. This study evaluated Get Healthy at Work (GHaW), a state-wide government-funded WHP in Australia. Methods: A mixed-method design included a longitudinal quasi-experimental survey of businesses registered with GHaW and a comparison group of businesses surveyed over a 12-month period. Semi-structured interviews and focus groups with key contacts and employees of selected intervention group businesses and the service providers of the program were conducted to assess program adoption and adaptation. Results: Positive business-level changes in workplace culture were observed over time among GHaW businesses compared with the control group. Multilevel regression modelling revealed perceptions that employees were generally healthy (p = 0.045 timeXgroup effect) and that the workplace promoted healthy behaviours (p = 0.004 timeXgroup effect) improved significantly while the control group reported no change in work culture perceptions. Changes in perceptions about work productivity were not observed; however only one third of businesses registered for the program had adopted GHaW during the evaluation period. Qualitative results revealed a number of factors contributing to program adoption: which depended on program delivery (e.g., logistics, technology and communication channels), design features of the program, and organisational factors (primarily business size and previous experience of WHPs). Conclusions: Evaluation of program factors is important to improve program delivery and uptake and to ensure greater scalability. GHaW has the potential to improve workplace health culture, which may lead to better health promoting work environments. These results imply that government can play a central role in enabling prioritisation and incentivising health promotion in the workplace.

ISSUE ADDRESSED:Working in partnership is advocated as a necessary process to achieve shared goals in complex policy areas, yet little effort is dedicated to evaluating how well partnerships are functioning. This study describes the development and psychometric properties of a partnership assessment tool and illustrates its use in an obesity prevention partnership.METHODS:A literature scoping review was conducted on existing partnership assessment tools and used to develop a new tool, which was tested using the ACT whole-of-government Healthy Weight Initiative at two timepoints. The psychometric properties of the tool were evaluated using principal component analysis and Cronbach's alpha for internal consistency of domain subscales.RESULTS:The review identified 11 partnership assessment tools, from which we identified five domains of partnership to develop the new tool. Factor analysis showed each domain yielded a single subscale. Cronbach's alpha for each of the domain subscales ranged between 0.88 and 0.94 at Timepoint 1 and 0.90 and 0.95 at Timepoint 2 demonstrating very high internal consistency. All subscales demonstrated high correlation with an overall partnership rating, good internal consistency and concordance with issues raised in open-ended questions.CONCLUSION:This paper describes the development and implementation of a tool to evaluate partnership functioning, which was found to have high internal consistency and reliability. SO WHAT?: With increasing emphasis on working in partnership, using partnership assessment tools can provide useful evidence to assess whether partnerships are a successful strategy in complex programs evaluation.

Abstract Background and aim Evaluations of alcohol policy changes demonstrate that restriction of trading hours of both ‘on’‐ and ‘off’‐licence venues can be an effective means of reducing rates of alcohol‐related harm. Despite this, the effects of different trading hour policy options over time, accounting for different contexts and demographic characteristics, and the common co‐occurrence of other harm reduction strategies in trading hour policy initiatives, are difficult to estimate. The aim of this study was to use dynamic simulation modelling to compare estimated impacts over time of a range of trading hour policy options on various indicators of acute alcohol‐related harm. Methods An agent‐based model of alcohol consumption in New South Wales, Australia was developed using existing research evidence, analysis of available data and a structured approach to incorporating expert opinion. Five policy scenarios were simulated, including restrictions to trading hours of on‐licence venues and extensions to trading hours of bottle shops. The impact of the scenarios on four measures of alcohol‐related harm were considered: total acute harms, alcohol‐related violence, emergency department (ED) presentations and hospitalizations. Results Simulation of a 3 a.m. (rather than 5 a.m.) closing time resulted in an estimated 12.3 ± 2.4% reduction in total acute alcohol‐related harms, a 7.9 ± 0.8% reduction in violence, an 11.9 ± 2.1% reduction in ED presentations and a 9.5 ± 1.8% reduction in hospitalizations. Further reductions were achieved simulating a 1 a.m. closing time, including a 17.5 ± 1.1% reduction in alcohol‐related violence. Simulated extensions to bottle shop trading hours resulted in increases in rates of all four measures of harm, although most of the effects came from increasing operating hours from 10 p.m. to 11 p.m. Conclusions An agent‐based simulation model suggests that restricting trading hours of licensed venues reduces rates of alcohol‐related harm and extending trading hours of bottle shops increases rates of alcohol‐related harm. The model can estimate the effects of a range of policy options.

Alcohol misuse is a complex systemic problem. The aim of this study was to explore the feasibility of using a transparent and participatory agent-based modelling approach to develop a robust decision support tool to test alcohol policy scenarios before they are implemented in the real world.

BACKGROUND:To achieve population-wide health improvement, public health interventions found effective in selected samples need to be 'scaled up' and implemented more widely. The pathways through which interventions are scaled up are not well characterised. The aim of this paper is to identify examples of public health interventions which have been scaled up and to develop a conceptual framework which quantifies and describes this process.METHODS:A multi-stage international literature search was undertaken to identify examples of public health interventions in high income countries that have been scaled up or implemented at scale. Initial abstract review identified articles which met all the criteria of being a: 1) public health intervention; 2) chronic disease prevention focus; 3) program delivered at a wide geographical scale (state, national or international). Interventions were reviewed and coded into a conceptual framework pathway to document their scaling up process. For each program, an in-depth review of the identified articles was undertaken along with a broad internet based search to determine the outcomes of the dissemination process. A conceptual framework of scaling up pathways was developed that involved four stages (development, efficacy testing, real world trial and dissemination) to which the 40 programs were mapped.RESULTS:The search identified 40 public health interventions that showed evidence of being scaled up. Four pathways were identified to capture the different scaling up trajectories taken which included: 'Type I - Comprehensive' (55%) which passed through all four stages, 'Type II - Efficacy omitters' (5%) which did not conduct efficacy testing, 'Type III - Trial omitters' (25%) which did not conduct a real world trial, and 'Type IV - At scale dissemination' (15%) which skipped both efficacy testing and a real world trial.CONCLUSIONS:This is the first study to classify and quantify the potential pathways through which public health interventions in high income countries are scaled up to reach the broader population. Mapping these pathways not only demonstrates the different trajectories that occur in scaling up public health interventions, but also allows the variation across scaling up pathways to be classified. The policy and practice determinants leading to each pathway remain for future study, especially to identify the conditions under which efficacy and replication stages are missing.

Development of effective policy responses to address complex public health problems can be challenged by a lack of clarity about the interaction of risk factors driving the problem, differing views of stakeholders on the most appropriate and effective intervention approaches, a lack of evidence to support commonly implemented and acceptable intervention approaches, and a lack of acceptance of effective interventions. Consequently, political considerations, community advocacy and industry lobbying can contribute to a hotly contested debate about the most appropriate course of action; this can hinder consensus and give rise to policy resistance. The problem of alcohol misuse and its associated harms in New South Wales (NSW), Australia, provides a relevant example of such challenges. Dynamic simulation modelling is increasingly being valued by the health sector as a robust tool to support decision making to address complex problems. It allows policy makers to ask ‘what-if’ questions and test the potential impacts of different policy scenarios over time, before solutions are implemented in the real world. Participatory approaches to modelling enable researchers, policy makers, program planners, practitioners and consumer representatives to collaborate with expert modellers to ensure that models are transparent, incorporate diverse evidence and perspectives, are better aligned to the decision-support needs of policy makers, and can facilitate consensus building for action. This paper outlines a procedure for embedding stakeholder engagement and consensus building in the development of dynamic simulation models that can guide the development of effective, coordinated and acceptable policy responses to complex public health problems, such as alcohol-related harms in NSW.

The objective of this review was to synthesise evidence on the health and social support needs of Aboriginal and Torres Strait Islander people leaving prison and on programs which aid successful community re-entry. A systematic literature review was undertaken of peer-reviewed and grey literature published between 2001 and 2013, focusing on the post-release needs of Aboriginal and Torres Strait Islander adults and pre- and post-release programs. Aboriginal and Torres Strait Islander people have high health and social support needs on leaving prison. There is little literature evidence that re-entry programs commonly consider health needs, support linkages with primary care or Aboriginal Medical Services, or are designed in consideration of the particular needs of Aboriginal and Torres Strait Islander people. In the absence of evaluative evidence on re-entry programs in this group, we have synthesised the best practice recommendations. Re-entry programs must be culturally competent in design and delivery, holistic, take a long-term view, involve families and communities, demonstrate interagency coordination and promote linkages between prison and community-based services. There is an urgent need for accessible pre- and post-release programs which meet the particular needs of Aboriginal and Torres Strait Islander people, including their health needs. Programs must be flexible, comprehensive and accessible to those on remand or with short sentences. Stronger linkage with primary care and Aboriginal and Torres Strait Islander community controlled health organisations is recommended.

Background: People who have been in custody are more likely to experience multiple, long standing health issues. They are at high risk of illness and injury post release and experience poor access to health services both of which contribute to high rates of recidivism. The study was conducted to examine Aboriginal and non-Aboriginal former prisoners' risk of hospitalisation and rehospitalisation in the five years post release from custody and identified the common reasons for hospitalisations.Methods: Common reasons for hospital admission were identified by conducting descriptive analysis of linked data, related to former prisoners, from NSW Ministry of Health and Corrective Services NSW. This relied upon admitted patient data for 1899 patients. Of this cohort, 1075 people had been admitted to hospital at least once and remained out of custody over a five year period. The independent variables we studied included age, sex, and whether or not the person was Aboriginal. We conducted univariate and multivariate analysis on the following dependent variables: number of admissions over five years after release; more than one admission; days between custody and first hospitalisation; and days between first and second hospitalisation.Results: Mental and behavioural disorders, injuries and poisoning, and infectious or parasitic diseases were the three most common reasons for admission. Aboriginal and non-Aboriginal former prisoners had a broadly similar pattern of reasons for admission. Yet Aboriginal former prisoners were more likely than non-Aboriginal former prisoners to have a shorter mean interval between hospital admission and readmission (187 days compared to 259 days, t = 2.90, p-0.004).Conclusions: Despite poorer health among Aboriginal people, there were broadly similar patterns of reasons for admission to hospital among Aboriginal and non-Aboriginal former prisoners. There may be a number of explanations for this. The cohort was not a representative sample of the NSW prison population. There was an overrepresentation of individuals with cognitive disability (intellectual disability, acquired brain injury, dementia, fetal alcohol spectrum disorder) in the study population, which may have impacted on this group accessing hospital health care. Alternatively perhaps there were fewer presentations to hospital by Aboriginal former prisoners despite a greater need. The shorter interval between hospital admission and readmission for Aboriginal former prisoners may suggest the need for better follow up care in the community after discharge from hospital. This presents an opportunity for primary health care services to work more closely with hospitals to identify and manage Aboriginal former prisoners discharged from hospital so as to prevent readmission.

Development of effective policy responses to address complex public health problems can be challenged by a lack of clarity about the interaction of risk factors driving the problem, differing views of stakeholders on the most appropriate and effective intervention approaches, a lack of evidence to support commonly implemented and acceptable intervention approaches, and a lack of acceptance of effective interventions. Consequently, political considerations, community advocacy and industry lobbying can contribute to a hotly contested debate about the most appropriate course of action; this can hinder consensus and give rise to policy resistance. The problem of alcohol misuse and its associated harms in New South Wales ( NSW), Australia, provides a relevant example of such challenges. Dynamic simulation modelling is increasingly being valued by the health sector as a robust tool to support decision making to address complex problems. It allows policy makers to ask 'what-if' questions and test the potential impacts of different policy scenarios over time, before solutions are implemented in the real world. Participatory approaches to modelling enable researchers, policy makers, program planners, practitioners and consumer representatives to collaborate with expert modellers to ensure that models are transparent, incorporate diverse evidence and perspectives, are better aligned to the decision-support needs of policy makers, and can facilitate consensus building for action. This paper outlines a procedure for embedding stakeholder engagement and consensus building in the development of dynamic simulation models that can guide the development of effective, coordinated and acceptable policy responses to complex public health problems, such as alcohol-related harms in NSW.

Issue addressed The Australian National Partnership Agreement on Preventive Health (NPAPH) charged states and territories with the development and implementation of the Healthy Workers Initiative (HWI) to improve workplace health promotion. Most evaluation efforts focus on the setting (micro) level. In the present study the HWI at the meso-level (state program development) was examined to understand how jurisdictions navigated theoretical, practical, and political priorities to develop their programs, and the programmatic choices that support or hinder perceived success. Methods Interviews with HWI program coordinators and managers across seven Australian jurisdictions explored decision-making processes related to developing and implementing the HWI and the impact of defunding. Interviews were audio-recorded, transcribed and analysed using thematic analysis. Results Despite taking a variety of approaches to the HWI, jurisdictions had common goals, namely achieving sustainability and capacity for meaningful change. These goals transcended the performance indicators set out by the NPAPH, which were considered unachievable in the given timeframe. Four ways jurisdictions sought to achieve their goals were identified, these were: 1) taking an embedded approach to workplace health promotion; 2) ensuring relevance of the HWI to businesses; 3) engaging in collaborative partnerships with agencies responsible for implementation; and 4) cultivating evolution of the HWI. Conclusions This meso-level evaluation has provided valuable insights into how health promotion program coordinators translate broad, national-level initiatives into state-specific programs and how they define program success. The study findings also highlight how broader, contextual factors, such as jurisdiction size, political imperatives and funding decisions impact on the implementation and success of a national health promotion initiative. So what? When evaluating the translation of complex initiatives, a meso-level analysis can reveal valuable principles for informing program effectiveness and sustainability. It can also identify alignment between macro- and meso-level goals and where macro-level specifications may hinder or assist those goals.

OBJECTIVE:Given the paucity of research among prisoners, this study aimed to examine the prevalence and psychiatric comorbidity associated with adult ADHD.METHOD:The study was conducted at four NSW correctional facilities (2 male; 2 female).RESULTS:Thirty-five percent of the sample screened positive for adult ADHD, and 17% of the sample met criteria for a full diagnosis. After adjustment, benzodiazepine dependence, borderline personality disorder, social phobia, antisocial personality disorder, and a number of lifetime psychological disorders remained significantly and independently associated with the diagnosis of adult ADHD. Lowering the threshold on the ADHD Self-Rating Scale to ≥3 (vs. ≥4) increased the sensitivity (80%-93%), but lowered the specificity (55%-47%).CONCLUSION:Adult ADHD among NSW prisoners is elevated, with substance use disorders and psychiatric comorbidity common. A greater acceptance of this disorder among prisoners, and appropriate treatment, is warranted.

Aims and Rationale: Cycling in and out of prison is recognised as extremely damaging and disempowering for the families of Aboriginal Australians and their communities. We examined the impact of in...

Issue addressed: Get Healthy at Work (GHaW) is a statewide program to reduce chronic disease risk among NSW workers by helping them make small changes to modifiable lifestyle chronic disease risk factors and create workplace environments that support healthy lifestyles. It has two primary components: a workplace health program (WHP) for businesses and online or face-to-face Brief Health Checks (BHCs) for workers. In this paper, we discuss our evaluation to identify areas for improvement in the implementation of WHP and to assess the uptake of BHCs by workers.Methods: Routinely collected WHP and BHC program data between July 2014 and February 2016 were analysed. A baseline online survey regarding workplace health promotion was conducted with 247 key contacts at registered GHaW worksites and a control group of 400 key contacts from a range of businesses. Seven telephone interviews were conducted with service provider key contacts.Results: As at February 2016, 3133 worksites (from 1199 businesses) across NSW had registered for GHaW, of which 36.8% started the program. Similar proportions of GHaW (34.0%) and control (31.7%) businesses had existing WHPs. BHCs were completed by 12 740 workers, and of those whose risks were assessed, 78.9% had moderate or high risk of diabetes and 33.6% had increased or high risk of cardiovascular disease. Approximately half (50.6%) of eligible BHC participants were referred to Get Healthy Information and Coaching Service (GHS) and 37.7% to Quitline. The uptake of face-to-face BHCs compared with online was significantly higher for males, people aged over 35 years, those undertaking less physical activity and those less likely to undertake active travel to work. Service providers suggested that the program's structured five-step pathway did not offer adequate flexibility to support worksites' progress through the program.Conclusions: During the evaluation period, a substantial number of NSW worksites registered for GHaW but their progress was slow because of the limited flexibility offered by the program model.So what? Workplace-based health promotion programs have potential to reach people at risk of chronic disease, but the implementation of such programs need to be more flexible than traditional health promotion programs in terms of delivery modes and timeframes.

Objective: Systematic reviews (SRs) should include policy-relevant information in order to more readily inform policy and practice. We investigated whether SRs of overweight and obesity prevention interventions are framed in such a way that maximises their usefulness for policymakers. Method: We conducted a systematic review of SRs of overweight and obesity prevention interventions published in 4 databases any time up to December 2014. We analysed the SRs for their usefulness to policymakers, using a coding frame developed based on literature around what policymakers want and need from systematic reviews. Systematic reviews were assessed for a) policy links and framing; b) quality assessment and conflict of interest statements: and c) discussion of policy implications. Results: Of the 153 SRs that met the inclusion criteria, very few(7%) had authors from policy-based organisations, 48% had funding from such organisations, and almost a third (31%) framed their introduction or aims around policy. Most (69%) discussed issues affecting generalisability of the SR findings but only a quarter (24%) discussed cost or cost-effectiveness of the intervention under investigation. Less than a third (29%) of SRs discussed the policy implications of their findings. SRs that were policy-framed were significantly more likely to discuss costs (PR = 1.8, 95% CI 1.0-3.0) and policy implications (PR = 2.5, 95% CI 1.5-4.0). Conclusion: SRs should discuss the policy and practice implications of their findings to maximise the influence of SRs on policy making. It is recommended that SR guidelines are updated to include generalisability and discussion of policy and practice implications as a requirement. (C) 2015 Elsevier Inc. All rights reserved.

Background: Aboriginal Australians are more likely than other Australians to cycle in and out of prison on remand or by serving multiple short sentences-a form of serial incarceration and institutionalisation. This cycle contributes to the over-representation of Aboriginal Australians in prison and higher rates of recidivism. Our research examined how primary health care can better meet the health care and social support needs of Aboriginal Australians transitioning from prison to the community.Methods: Purposive sampling was used to identify 30 interviewees. Twelve interviews were with Aboriginal people who had been in prison; ten were with family members and eight with community service providers who worked with former inmates. Thematic analysis was conducted on the interviewees' description of their experience of services provided to prisoners both during incarceration and on transition to the community.Results: Interviewees believed that effective access to primary health care on release and during transition was positively influenced by providing appropriate healthcare to inmates in custody and by properly planning for their release. Further, interviewees felt that poor communication between health care providers in custody and in the community prior to an inmate's release, contributed to a lack of comprehensive management of chronic conditions. System level barriers to timely communication between in-custody and community providers included inmates being placed on remand which contributed to uncertainty regarding release dates and therefore difficulties planning for release, cycling in and out of prison on short sentences and being released to freedom without access to support services.Conclusions: For Aboriginal former inmates and family members, release from prison was a period of significant emotional stress and commonly involved managing complex needs. To support their transition into the community, Aboriginal former inmates would benefit from immediate access to culturally-responsive community - primary health care services. At present, however, pre-release planning is not always available, especially for Aboriginal inmates who are more likely to be on remand or in custody for less than six months.

Little is known about the environmental and organisational determinants of workplace violence in correctional health settings. This paper describes the views of health professionals working in these settings on the factors influencing workplace violence risk. All employees of a large correctional health service in New South Wales, Australia, were invited to complete an online survey. The survey included an open-ended question seeking the views of participants about the factors influencing workplace violence in correctional health settings. Responses to this question were analysed using qualitative thematic analysis. Participants identified several factors that they felt reduced the risk of violence in their workplace, including: appropriate workplace health and safety policies and procedures; professionalism among health staff; the presence of prison guards and the quality of security provided; and physical barriers within clinics. Conversely, participants perceived workplace violence risk to be increased by: low health staff-to-patient and correctional officer-to-patient ratios; high workloads; insufficient or underperforming security staff; and poor management of violence, especially horizontal violence. The views of these participants should inform efforts to prevent workplace violence among correctional health professionals.

Co-occurring substance use disorder and posttraumatic stress disorder is prevalent among prisoners, however there are few evidence-based treatment options available for this population. This pilot study investigated the acceptability, feasibility and preliminary efficacy of implementing partial-dose (eight-session) Seeking Safety among 30 Australian male prisoners. Findings demonstrate that Seeking Safety is desirable, acceptable, and feasible among male prisoners with a history of substance use and trauma. In addition, the study indicated promising results for substance use and mental health outcomes, which is particularly notable given the overall severity of the sample. The study also had significant Aboriginal and/or Torres Strait Islander representation. A full scale trial of this intervention is required to further evaluate efficacy and inform practice to improve the mental health of this vulnerable population.