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BACKGROUND: Women prisoners are a growing portion of the prison population. Health and social outcomes of their children have been studied and found to be poor, but little is known about child protection outcomes. OBJECTIVES: Ascertain child protection system contact of children exposed to maternal incarceration. PARTICIPANTS AND SETTING: All children born between 1985 and 2011 exposed to the incarceration of their mothers in a Western Australian correctional facility and a matched comparison group. METHODS: A matched cohort study using linked administrative data on 2637 mothers entering prison between 1985 and 2015 and their 6680 children. We estimated hazard ratios (HRs) and incidence rate ratios (IRRs) of child protection service (CPS) contact post maternal incarceration (four concern levels), comparing rates for children exposed to maternal incarceration with a matched non-exposed group, adjusting for maternal and child factors. FINDINGS: Exposure to maternal incarceration increased risk of CPS contact. Unadjusted HRs exposed vs unexposed children were 7.06 (95%CI = 6.49-7.69) for substantiated child maltreatment and 12.89 (95%CI = 11.42-14.55) for out-of-home care (OOHC). Unadjusted IRRs were 6.04 (95%CI = 5.57-6.55) for number of substantiations and 12.47 (95%CI = 10.65-14.59) for number of removals to OOHC. HRs and IRRs were only slightly attenuated in adjusted models. CONCLUSIONS: Maternal incarceration is a warning flag for a child at high risk of serious child protection concerns. Family-friendly rehabilitative women's prisons, incorporating support for more nurturing mother-child relationships could provide a placed-based public health opportunity for disrupting distressing life trajectories and intergenerational pathways of disadvantage of these vulnerable children and their mothers. This population should be a priority for trauma-informed family support services.

The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing identifies building a strong Aboriginal and Torres Strait Islander led evidence-base to inform care as a key priority. Aboriginal and/or Torres Strait Islander adolescents in contact with the criminal justice system are a highly vulnerable group of Australians, with substantial unmet needs. There is limited evidence to inform culturally appropriate models of care that meet the social and emotional wellbeing needs of justice-involved Aboriginal and/or Torres Strait Islander adolescents. This project aims to develop, implement and evaluate an in-reach and community transitional model of social and emotional wellbeing care for Aboriginal and/or Torres Strait Islander adolescents (10-17 years old) who experience detention through close engagement with Aboriginal and/or Torres Strait Islander youth, Elders, researchers, practitioners and community members, and by drawing on culturally informed practice and knowledge systems. The project is based on a multi-level mixed methods design, with a strong focus on ongoing project evaluation (based on the Ngaa-bi-nya framework) and co-design. Co-design is facilitated through culturally safe and trauma informed participatory processes based on development of strong partnerships from project initiative, design, implementation and evaluation. Application of the landscape domain of the Ngaa-bi-nya framework for Aboriginal and Torres Strait Islander program evaluation will be explored in Phase one. Aboriginal and Torres Strait Islander adolescents with experience in detention will be engaged through one-on-one interviews with data collection through the Growth and Empowerment Measure (GEM) Youth (which will be adapted from the adult version and validated as part of this study), the Kessler Psychological Distress Scale (K-10), questions around alcohol and drug use, and narrative interviews exploring exper

Background. People released from prison have poorer health than the general public, with a particularly high prevalence of mental illness and harmful substance use. High-frequency use of hospital-based services is costly, and greater investment in transitional support and primary care services to improve the health of people leaving prison may therefore be cost-effective. Methods. A prospective cohort study of 1303 men and women released from prisons in Queensland, Australia, between 2008 and 2010, using linked data was performed. We calculated healthcare costs and the cost of re-incarceration. We compared healthcare costs to the general public, and assessed the impact of past mental illness, substance use disorder, and dual diagnosis on both healthcare and criminal justice costs. Results. Healthcare costs among the cohort were 2.1-fold higher than expected based on costs among the public. Dual diagnosis was associated with 3.5-fold higher healthcare costs (95% CI 2.6–4.6) and 2.8-fold higher re-incarceration costs (95% CI 1.6–5.0), compared with no past diagnosis of either mental illness or substance use disorder. Conclusions. People released from prison incur high healthcare costs, primarily due to high rates of engagement with emergency health services and hospital admissions. Comorbid mental illness and substance use disorders are associated with high health and criminal justice costs among people recently released from prison.

BACKGROUND: There are significant challenges associated with studies of people released from custodial settings, including loss to follow-up in the community. Interpretation of findings with consideration of differences between those followed up and those not followed up is critical in the development of evidence-informed policies and practices. We describe attrition bias in the Prison and Transition Health (PATH) prospective cohort study, and strategies employed to minimise attrition. METHODS: PATH involves 400 men with a history of injecting drug use recruited from three prisons in Victoria, Australia. Four interviews were conducted: one pre-release ('baseline') and three interviews at approximately 3, 12, and 24 months post-release ('follow-up'). We assessed differences in baseline characteristics between those retained and not retained in the study, reporting mean differences and 95% confidence intervals (95% CIs). RESULTS: Most participants (85%) completed at least one follow-up interview and 162 (42%) completed all three follow-up interviews. Retained participants were younger than those lost to follow-up (mean diff - 3.1 years, 95% CI -5.3, - 0.9). There were no other statistically significant differences observed in baseline characteristics. CONCLUSION: The high proportion of participants retained in the PATH cohort study via comprehensive follow-up procedures, coupled with extensive record linkage to a range of administrative datasets, is a considerable strength of the study. Our findings highlight how strategic and comprehensive follow-up procedures, frequent contact with participants and secondary contacts, and established working relationships with the relevant government departments can improve study retention and potentially minimise attrition bias.

The COVID-19 pandemic has intensified national attention to homelessness over the course of 2020 because of concern about the spread of the novel coronavirus amongst homeless persons. It has also produced compelling reasons to look more closely at the long-neglected area of homelessness policy, and created opportunities to reverse years of inattention. Homelessness disproportionately affects adolescents and young adults, with rates rising before the pandemic. Recent homelessness funding increases and housing policy responses have also addressed health and social needs, and are continuing for the time being, however the risk of the virus is likely to remain for some time. Although Victoria has now successfully suppressed a second wave of infection in the community, the risk of a third wave is ever-present. As temporary homelessness funding and housing policy responses are scaled back, we may see a delayed ‘wave’ of adolescent and young adult homelessness, compounded by the multiple economic and social impacts of the pandemic, and associated state-wide lockdown. Preventing this ‘wave’ requires immediate evidence-based multi-sectoral action.

People who inject drugs (PWID) are disproportionately represented among individuals who experience imprisonment and often have more complex physical and mental health needs than people in prison without injecting histories. The trajectories of PWID after prison release are poorly understood, hampering the development of effective strategies to address their distinct health needs. The Prison and Transition Health (PATH) Cohort Study is characterising the post-release trajectories of incarcerated male PWID in Victoria, Australia. We outline study methodology and baseline characteristics of participants prior to their release. Four hundred participants were recruited from three prisons and completed researcher-administered baseline interviews covering socio-demographics, social supports, physical health, mental health, alcohol and other drug use, and pre-release and transitional service utilisation. The median age among participants was 36 years (IQR 30–42), and they reported a median of five (IQR 3–9) previous adult incarcerations. Almost half (49%) were reliant on government payments prior to incarceration. One quarter (25%) of participants reported removal from their parents’ care as children and 64% reported being a parent or primary caregiver to children. Most participants (81%) reported a previous mental health diagnosis and 44% reported three or more diagnoses. The most common drugs injected prior to incarceration were crystal methamphetamine (80%) and heroin (62%), and most (85%) reported being under the influence of drugs at the time of committing offences for which they were currently incarcerated. Injecting drug use during their current sentence was reported by 40% of participants, and 48% reported engaging with some form of drug treatment during their current sentence. Study participants are characterised by significant mental health and substance use morbidities, social disadvantage and criminogenic histories that present challenges for the provision of po

There has been a shift towards provision of mental health care in community-based settings in Australia. However, hospitals continue to care for people in acute mental health wards. An increasing proportion of the people in wards are admitted involuntarily, subject to restrictions of movement to minimize risk of harm to self and others. In response to concerns about the safety of people absconding from care, Queensland Health introduced a policy requiring all acute mental health wards in the State to be locked. In response, the Queensland Mental Health Commission funded a project to understand the impact of this policy and develop evidence-based recommendations regarding provision of least restrictive, recovery-oriented practices in acute wards. Facilitated forums were conducted with 35 purposively selected participants who identified as consumers, carers, or staff of acute mental health hospital wards, to test the acceptability, feasibility, and face validity of a set of evidence-informed recommendations for providing least restrictive, recovery-oriented practices. Participant responses were recorded, and data were analysed through an inductive, thematic approach. A recovery-oriented approach was supported by all stakeholders. Reducing boredom and increasing availability of peer support workers were considered key to achieving this. Focusing less on risk aversion was reported as central to enabling true Recovery Orientation. This project enabled recognition of the perspectives of consumers, carers, and staff in the consideration of evidence-informed recommendations that could be implemented to provide least restrictive care in the context of locked doors.

People brought in by police (BIBP) to the ED are a potentially vulnerable group. This narrative scoping review aimed to identify, evaluate and summarise current literature regarding the frequency of presentation, demographic and clinical profile of patients (including reason for presentation), care delivery, and outcomes for people BIBP to the ED, and identify current gaps in knowledge. The review involved searching EMBASE, CINAHL and PubMed using a combination of terms: emergency/ED coupled with police custody/watch house or police presentation, for papers published in English language from January 2006 to November 2017. A total of 20 studies met the inclusion criteria. These included 17 observational (non-randomised controlled trials) quantitative studies and three descriptive case reports. The proportion of presentations to ED that were BIBP varied depending on the study design and sampling frame. People BIBP often presented with mental health problems, substance use problems, aggressive behaviour and injury caused by self or others. Of studies focused specifically on patients arriving to the ED in mental health crisis (i.e. suicidal ideation or self-harm), 18-27% were BIBP. ED presentations BIBP were mostly male and typically younger than people arriving by other means. The nature of care provided in the ED and outcomes of the acute episode of care were typically not well described. Limited research regarding people BIBP to the ED limits the ability to comprehensively understand their demographic and clinical profile and outcomes of emergency care. Further research is required to inform if and where in the patient's journey further improvements may be targeted.

Contains fulltext : 196928.pdf (publisher's version ) (Open Access), BACKGROUND: In patients with differentiated thyroid cancer (DTC), serial (124)I PET/CT imaging is, for instance, used to assess the absorbed (radiation) dose to lesions. Frequently, the lesions are located in the neck and they are close to or surrounded by different tissue types. In contrast to PET/CT, MR-based attenuation correction in PET/MR may be therefore challenging in the neck region. The aim of this retrospective study was to assess the quantitative performance of (124)I PET/MRI of neck lesions by comparing the MR-based and CT-based (124)I activity concentrations (ACs). Sixteen DTC patients underwent PET/CT scans at 24 and 120 h after administration of about 25 MBq (124)I. Approximately 1 h before or after PET/CT examination, each patient additionally received a 24-h PET/MR scan and sometimes a 120-h PET/MR scan. PET images were reconstructed using the respective attenuation correction approach. Appropriate reconstruction parameters and corrections were used to harmonize the reconstructed PET images to provide, for instance, similar spatial resolution. For each lesion, two types of ACs were ascertained: the maximum AC (max-AC) and an average AC (avg-AC). The avg-AC is the average activity concentration obtained within a spherical volume of interest with a diameter of 7 mm, equaling the PET scanner resolution. For each type of AC, the percentage AC difference between MR-based and CT-based ACs was determined and Lin's concordance correlation analysis was applied. Quantitative performance was considered acceptable if the standard deviation was +/- 25% (precision), and the mean value was within +/- 10% (accuracy). RESULTS: The avg-ACs (max-ACs within parentheses) of 74 lesions ranged from 0.20 (0.33) to 657 (733) kBq/mL. Excluding two lesions with ACs of approximately 1 kBq/mL, the mean (median) +/- standard deviation (range) was - 4% (- 5%) +/- 14% (- 28 to 29%) for the avg-AC and - 9% (- 11%) +/- 14% (- 33 to 33%) for the max-AC. Lin's concordance correlation

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 partic

Restrictive practices are used in response to conflict and aggression in psychiatric inpatient settings. Reducing such practices is the focus internationally of policy and legislative change, many initiatives, and a growing body of research. Safewards is a model and a set of 10 interventions designed to reduce conflict and containment in inpatient services. In the current study, we aimed to assess the impact of implementing Safewards on seclusion in Victorian inpatient mental health services in Australia. The study used a before-and-after design, with a comparison group matched for service type. Thirteen wards opted into a 12-week trial to implement Safewards and 1-year follow up. The comparison group was all other wards (n = 31) with seclusion facilities in the jurisdiction, matched to service type. Mandatorily-reported seclusion event data for all 44 wards over a 15-month period were analysed using negative binomial regression. Adherence to Safewards was measured via fidelity checklists at four time points: twice during the trial, post-trial, and at 1-year follow up. Seclusion rates were reduced by 36% in Safewards trial wards by the 12-month follow-up period (incidence rate ratios (IRR) = 0.64,) but in the comparison wards seclusion rates did not differ from baseline to post-trial (IRR = 1.17) or to follow-up period (IRR = 1.35). Fidelity analysis revealed a trajectory of increased use of Safewards interventions after the trial phase to follow up. The findings suggest that Safewards is appropriate for practice change in Victorian inpatient mental health services more broadly than adult acute wards, and is effective in reducing the use of seclusion.

© The Royal Australian and New Zealand College of Psychiatrists. Objective: Prisoners are at increased risk of both self-harm and suicide compared with the general population, and the risk of suicide after release from prison is three times greater than for those still incarcerated. However, surprisingly little is known about the incidence of self-harm following release from prison. We aimed to determine the incidence of, identify risk factors for and characterise emergency department presentations resulting from self-harm in adults after release from prison. Method: Cohort study of 1325 adults interviewed prior to release from prison, linked prospectively with State correctional and emergency department records. Data from all emergency department presentations resulting from self-harm were secondarily coded to characterise these presentations. We used negative binomial regression to identify independent predictors of such presentations. Results: During 3192 person-years of follow-up (median 2.6 years per participant), there were 3755 emergency department presentations. In all, 83 (6.4%) participants presented due to self-harm, accounting for 165 (4.4%) presentations. The crude incidence rates of self-harm for males and females were 49.2 (95% confidence interval: [41.2, 58.7]) and 60.5 (95% confidence interval: [44.9, 81.6]) per 1000 person-years, respectively. Presenting due to self-harm was associated with being Indigenous (incidence rate ratio: 2.01; 95% confidence interval: [1.11, 3.62]), having a lifetime history of a mental disorder (incidence rate ratio: 2.13; 95% confidence interval: [1.19, 3.82]), having previously been hospitalised for psychiatric treatment (incidence rate ratio: 2.68; 95% confidence interval: [1.40, 5.14]) and having previously presented due to self-harm (incidence rate ratio: 3.91; 95% confidence interval: [1.85, 8.30]). Conclusion: Following release from prison, one in 15 ex-prisoners presented to an emergency department due to self-har

© 2017 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd Background: Intellectual disability and patient activation may be important drivers of inequities in health service access and health outcomes for people with intellectual disability transitioning from prison to the community. We assessed the association between intellectual disability and patient activation after prison release and examined whether this association varied, depending on whether intellectual disability was identified prior to prison release. Methods: Overall, 936 prisoners were screened for intellectual disability by using the Hayes Ability Screening Index and completed the Patient Activation Measure (PAM) within 6 weeks of prison release and again at 1, 3 and 6 months post-release. We estimated the association between intellectual disability status and PAM scores by using a multilevel linear model, adjusting for sociodemographic, behavioural, health and criminogenic factors. We used propensity score matching to estimate the impact of being identified with intellectual disability prior to release from prison on the change in mean PAM score after prison release. Results: Compared with those who screened negative for intellectual disability, ex-prisoners who screened positive, both with and without prior identification of intellectual disability, had significantly decreased mean PAM scores [(B = -4.3; 95% CI: -6.3, -2.4) and (B = -4.5; 95% CI: -6.8, -2.3), respectively] over 6 months of follow-up. Among those who reported being identified with intellectual disability prior to release from prison, a significant increase in PAM score at the 6-month follow-up interview (B = 5.89; 95% CI: 2.35, 9.42; P = 0.001) was attributable to being identified with intellectual disability prior to release. Conclusions: Ex-prisoners screening positive for possible intellectual disability have decreased patient activation for at lea

© Cambridge University Press 2015. Background Understanding individual-level changes in mental health status after prison release is crucial to providing targeted and effective mental health care to ex-prisoners. We aimed to describe trajectories of psychological distress following prison discharge and compare these trajectories with mental health service use in the community. Method The Kessler Psychological Distress Scale (K10) was administered to 1216 sentenced adult prisoners in Queensland, Australia, before prison release and approximately 1, 3 and 6 months after release. We used group-based trajectory modeling to identify K10 trajectories after release. Contact with community mental health services in the year following release was assessed via data linkage. Results We identified five trajectory groups, representing consistently low (51.1% of the cohort), consistently moderate (29.8%), high increasing (11.6%), high declining (5.5%) and consistently very high (1.9%) psychological distress. Mood disorder, anxiety disorder, history of self-harm and risky drug use were risk factors for the high increasing, very high and high declining trajectory groups. Women were over-represented in the high increasing and high declining groups, but men were at higher risk of very high psychological distress. Within the high increasing and very high groups, 25% of participants accessed community mental health services in the first year post-release, for a median of 4.4 contact hours. Conclusions For the majority of prisoners with high to very high psychological distress, distress persists after release. However, contact with mental health services in the community appears low. Further research is required to understand barriers to mental health service access among ex-prisoners.

Background The world prison population is large and growing. Poor health outcomes after release from prison are common, but few programmes to improve health outcomes for ex-prisoners have been rigorously evaluated. The aim of this study was to evaluate the impact of individualised case management on contact with health services during the first 6 months postrelease. Methods Single-blinded, randomised, controlled trial. Baseline assessment with N=1325 adult prisoners in Queensland, Australia, within 6 weeks of expected release; follow-up interviews 1, 3 and 6 months postrelease. The intervention consisted of provision of a personalised booklet ('Passport') at the time of release, plus up to four brief telephone contacts in the first 4 weeks post-release. Results Of 1179 eligible participants, 1003 (85%) completed =1 follow-up interview. In intention-to-treat analyses, 53% of the intervention group and 41% of the control group reported contacting a general practitioner (GP) at 1 month post-release (difference=12%, 95% CI 5% to 19%). Similar effects were observed for GP contact at 3 months (difference=9%, 95% CI 2% to 16%) and 6 months (difference=8%, 95% CI 1% to 15%), and for mental health (MH) service contact at 6 months post release (difference=8%, 95% CI 3% to 14%). Conclusions Individualised case management in the month after release from prison increases usage of primary care and MH services in adult ex-prisoners for at least 6 months post-release. Given the poor health profile of ex-prisoners, there remains an urgent need to develop and rigorously evaluate interventions to increase health service contact in this profoundly marginalised population. Trial registration number ACTRN12608000232336.

INTRODUCTION: Ex-prisoners with a history of injecting drug use (IDU) experience disproportionate drug-related harm. Rapid resumption of substance use following prison release is common and evidenced in high rates of overdose mortality. However, few studies have documented the rate of IDU resumption following prison release or identified risk factors for relapse. METHODS: Structured interviews were conducted with 533 adults with a history of IDU in Queensland, Australia prior to release from prison and approximately 1, 3 and 6 months post-release. Incidence of self-reported IDU resumption was calculated overall and for each follow-up interval. Risk factors associated with time to resumption of IDU were estimated using discrete-time survival analysis. RESULTS: IDU resumption was reported by 41% of participants during a median of 98days of follow-up (IQR=94-121), an overall crude incidence of 1.06 per person-year. The highest rate was observed in the first month (23%; crude incidence 2.24 per person-year). In adjusted discrete-time survival analyses, being unemployed at the previous interview (AHR=1.59; 95%CI:1.10-2.30), shorter incarceration (=90days vs. >365days; AHR=2.20; 95%CI:1.33-3.65), and IDU during the index incarceration (AHR=2.80; 95%CI:1.92-4.09) were significantly associated with time to IDU resumption; parole was protective (AHR=0.66; 95%CI:0.47-0.92). CONCLUSIONS: Evidence-based efforts to prevent IDU in prison and IDU resumption after release are important for both prisoner and public health. Enhancing opportunities for employment and capitalising on the short-term benefits of parole for ex-prisoners may delay resumption of IDU after release from prison. These strategies should complement rather than replace harm reduction efforts for this high-risk population.

A mixed funding approach can help meet the urgent requirement for a level of health care in prison commensurate with need and equivalent to community standards.

OBJECTIVE: Australia's prison population is growing at a rate well in excess of population growth. Indigenous Australians are over-represented by a factor of 13. Prisoners are a profoundly marginalised group characterised by complex health and social needs. Despite improvements in health during incarceration, poor health outcomes after release are common, and the net effect of incarceration is usually health depleting. Given the need for effective care coordination, primary care plays a pivotal role in meeting the health needs of this population. In this paper we review what is known about patterns of primary care utilisation in ex-prisoners, identify evidence-based strategies for increasing access to primary care in ex-prisoners, and consider how such contact may shape subsequent health service outcomes. CONCLUSIONS: Primary care is a necessary but not sufficient condition for effective post-release support. Positive outcomes may depend more on the quality than the quantity of care received. Given massive over-representation of Indigenous people in Australia's prisons, and compelling evidence of preventable morbidity and mortality after release from prison, effective models of care for this population are an important component of closing the gap in Indigenous life expectancy.

© 2015 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd. Background: Reliable ascertainment of intellectual disability (ID) is important to identify those with special needs, in order for those needs to be met in the criminal justice system. Although the Hayes Ability Screening Index (HASI) is valid and widely used for the identification of possible ID, the risk of inter-rater bias between researchers when scoring the HASI has not yet been established. The current paper estimates the inter-rater reliability of the HASI in a sample of Indigenous and non-Indigenous prisoners in Western Australia. Methods: We estimated intra-class correlation coefficients (ICC) for the consistency of agreement among three blinded raters using a two-way random-effects model assessing the inter-rater agreement of the HASI. Kappa was also estimated for the dichotomous HASI screening threshold outcome between the raters. Results: The HASI exhibited very good within-subject consistency of agreement for Section B (ICC=0.95; 95%CI:0.94-0.96), Section C (ICC=0.97; 95%CI: 0.96-0.98) and Section D (ICC=0.90; 95%CI: 0.87-0.92) subscales and for the total scaled score (ICC=0.97; 95%CI: 0.96-0.98). The inter-rater reliability of the dichotomous adult ID screening threshold (<85) was also very good (Kappa=0.95). Conclusions: The current study provides new evidence that the HASI has a low risk of bias from between-rater scoring and can be reliably scored by both non-clinicians and clinicians with little training, when administered in prison settings. Pre-scoring training should focus on the more subjective 'clock-drawing' section, in order to maximise inter-rater reliability.

Objective: To describe the association between ex-prisoner primary care physician contact within 1 month of prison release and health service utilisation in the 6 months following release. Design: A cohort from the Passports study with a mean follow-up of 219 (±44) days postrelease. Associations were assessed using a multivariate Andersen-Gill model, controlling for a range of other factors. Setting: Face-to-face, baseline interviews were conducted in a sample of prisoners within 6 weeks of expected release from seven prisons in Queensland, Australia, from 2008 to 2010, with telephone follow-up interviews 1, 3 and 6 months postrelease. Participants: From an original population-based sample of 1325 sentenced adult (≥18 years) prisoners, 478 participants were excluded due to not being released from prison during follow-up (n=7, 0.5%), loss to follow-up (n=257, 19.4%), or lacking exposure data (n=214, 16.2%). A total of 847 (63.9%) participants were included in the analyses. Exposure: Primary care physician contact within 1 month of follow-up as a dichotomous measure. Main outcome measures: Adjusted time-to-event hazard rates for hospital, mental health, alcohol and other drug and subsequent primary care physician service utilisations assessed as multiple failure time-interval data. Results: Primary care physician contact prevalence within 1 month of follow-up was 46.5%. One-month primary care physician contact was positively associated with hospital (adjusted HR (AHR)=2.07; 95% CI 1.39 to 3.09), mental health (AHR=1.65; 95% CI 1.24 to 2.19), alcohol and other drug (AHR=1.48; 95% CI 1.15 to 1.90) and subsequent primary care physician service utilisation (AHR=1.47; 95% CI 1.26 to 1.72) over 6 months of follow-up. Conclusions: Engagement with primary care physician services soon after prison release increases health service utilisation during the critical community transition period for ex-prisoners.