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Full Text, Thesis (PhD Doctorate), Doctor of Philosophy (PhD), School of Crim & Crim Justice, Arts, Education and Law, More than 25 years after Australia received the recommendations handed down by the Royal Commission into Aboriginal Deaths in Custody (RCIADIC) Australia’s Indigenous people are still being incarcerated at disproportionate rates compared to their non-Indigenous counterparts, regardless of the attempts made by government to reduce the over-representation of Indigenous people in Australia’s prisons. Scholars have studied prisoner reentry for many years, during which time several risk and protective factors of reincarceration have been identified. However, limited research has examined beyond the question of whether Indigenous people are more likely to return to prison compared to non-Indigenous people. While we know Indigenous people are over-represented at the back-end of the criminal justice system, as more Indigenous people return to prison, and return faster than non-Indigenous people, we have little empirical understanding as to why –Why are Australia’s Indigenous people compared to non-Indigenous people more at risk of reincarceration? The present thesis seeks to unpack this question and develop a better understanding of why Indigenous people are more at risk of reincarceration post-release than non-Indigenous people. In total, three studies using a combination of descriptive, Cox proportional hazard regressions, logistic regressions, chi-square and t-test analyses were conducted with 1238 Queensland Indigenous (n = 303) and non-Indigenous (n = 935) people. The first study (Chapter 3) expands our understanding by: (a) examining group differences in characteristics within and between reincarcerated and successfully reintegrated people post-release for both groups; (b) identifying whether Indigenous compared to non-Indigenous people are more likely to be reincarcerated post-release; and (c) identifying whether any difference in risk of reincarceration can be partially explained by Indigenous and non-Indigenous peoples’ social experiences prior-to-prison, and/or th

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.

The number of people presenting to EDs with mental health problems is increasing. To enhance and promote the delivery of safe and efficient healthcare to this group, there is a need to identify evidence-based, best-practice models of care. This scoping review aims to identify and evaluate current research on interventions commenced or delivered in the ED for people presenting with a mental health problem. A systematic search of eight databases using search terms including emergency department, mental health, psyc* and interventions, with additional reference chaining, was undertaken. For included studies, level of evidence was assessed using the NHMRC research guidelines and existing knowledge was synthesised to map key concepts and identify current research gaps. A total of 277 papers met the inclusion criteria. These were grouped thematically into seven domains based on primary intervention type: pharmacological (n = 43), psychological/behavioural (n = 25), triage/assessment/screening (n = 28), educational/informational (n = 12), case management (n = 28), referral/follow up (n = 36) and mixed interventions (n = 105). There was large heterogeneity observed as to the level of evidence within each intervention group. The interventions varied widely from pharmacological to behavioural. Interventions were focused on either staff, patient or institutional process domains. Few interventions focused on multiple domains (n = 64) and/or included the patient's family (n = 1). The effectiveness of interventions varied. There is considerable, yet disconnected, evidence around ED interventions to support people with mental health problems. A lack of integrated, multifaceted, person-centred interventions is an important barrier to providing effective care for this vulnerable population who present to the ED.

Incarcerated individuals, over 95% of whom are eventually released, experience high burdens of chronic disease and behavioral health and social risk factors. Understanding the health needs of this population is critical to ensuring that general medicine physicians in prisons and in the community are adequately prepared to meet those needs. However, people in prison are significantly underrepresented in health research. In response to historical exploitation of prisoners in medical experimentation, federal guidelines appropriately require additional oversight for, and limit the scope of, research in prisons. Yet, according to a 2006 Institute of Medicine report, these requirements have produced inconsistent local regulations that often limit opportunities for incarcerated individuals to participate in research, and can slow the development of innovative medical interventions to improve their health. In this article, we describe the historical context surrounding regulations on research involving individuals in prison, the harms that can arise from excessive limitations to research in such settings, and the benefits of greater access to ethically conducted research in prison. We conclude with recommended actions that can be taken by general medicine researchers, correctional leaders, and policymakers to achieve consistent access to health research for incarcerated populations.

Full Text, Thesis (PhD Doctorate), Doctor of Philosophy (PhD), School of Crim & Crim Justice, Arts, Education and Law, Smoke-free policies have been introduced in prisons in many jurisdictions, including in Queensland, Australia, in an attempt to reduce high levels of tobacco use and related harms. However, these policies have not resulted in smoking cessation in all cases. One unintended consequence reported in some prisons has been the substitution of cigarettes with “teabacco”—tea leaves infused with nicotine replacement therapy (NRT) patches, wrapped in Bible paper. Second, studies based in the United States (US) have found that the majority of former smokers resume smoking upon release from smoke-free prisons, indicating that correctional smoke-free policies typically result in short-term smoking cessation only. The research presented in this thesis as a series of publications seeks to add to the knowledge base regarding tobacco use, cessation, and substitution among people who experience incarceration. The findings may inform interventions designed to reduce tobacco use and harm among a population with high levels of smoking-related illness. This thesis comprises eight chapters, including eight publications. First, chapter one provides an introduction to the topic, followed by a review of relevant literature. Chapter two is a systematic review of literature describing factors influencing smoking relapse following release from smoke-free prisons. This review identified only 15 relevant publications, most of these methodologically weak, and mostly US-based. Chapter three outlines the methods of the studies included in chapters four, five, and six. Chapter four includes three publications focusing on relapse to tobacco smoking following release from smoke-free prisons in Queensland. The first, based on a quantitative survey with 114 people recently released from smoke-free prisons in Queensland, found that although 94% returned to smoking following release from prison (72% on the day of release), 62% were smoking significantly less per day compared to before prison. The second pu

Highlights • 94% of ex-smokers resumed smoking after release from smoke-free prisons. • 72% of these prior smokers resumed smoking on the day of release from prison. • Most were smoking less per day than before entering smoke-free prisons. • Tailored smoking cessation interventions are needed for those leaving prison. • Such interventions should include behavioral counselling and pharmacotherapy. Abstract Background: Smoke-free prison policies are increasingly common, but few studies have investigated relapse to smoking after release from prison. This study investigated return to tobacco smoking and correlates of smoking at reduced levels after release among adults recently released from smoke-free prisons in Queensland, Australia. Methods: A cross-sectional survey of 114 people at parole offices within two months of release from prison was used. The survey measured health, social, and criminological factors related to tobacco smoking. We used logistic regression to identify factors associated with reduced post-release smoking levels compared to pre-incarceration levels. Results: 94% of participants relapsed to smoking within two months of release; 72% relapsed on the day of release. 62% of participants smoked significantly less per day after compared with before incarceration. Living with a partner (Odds Ratio (OR) 2.77, 95%CI 1.02–7.52), expressing support for smoke-free prison policies (OR 2.44, 95%CI 1.12–5.32), intending to remain abstinent post-release (OR 4.29, 95%CI 1.88–9.82), and intending to quit in the future (OR 3.88, 95%CI 1.66–9.07) were associated with reduced smoking post-release. Use of illicit drugs post-release was negatively associated with reduced smoking post-release (OR 0.27, 95%CI 0.09–0.79). In multivariate analyses, pre-release intention to remain smoke-free was associated with reduced smoking post-release (AOR 2.69, 95%CI 1.01–7.14). Discussion: Relapse to smoking after release from smoke-free prisons is common, but many who relapse smoke

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 bee