The associations between social determinants of health, mental health, substance-use and recidivism: a ten-year retrospective cohort analysis of women who completed the connections programme in Australia.

BACKGROUND: Women with substance-use issues are overrepresented in prison. Research on women's recidivism often focuses on offending behaviour rather than the health and social circumstances women are experiencing when reimprisonment occurs. This study examines the relationship between social determinants of health (SDOH), mental health, substance-use and recidivism among women exiting prison with histories of substance-use. METHODS: A retrospective cohort study of women exiting prison who completed the transitional support programme "Connections" between 2008 and 2018. Recidivism was measured up to two years post-release. Women's support needs were measured at baseline (4 weeks pre-release) and follow-up (four weeks post-release). Ongoing needs in relation to well-established SDOH were calculated if: (1) at baseline women were identified as having a re-entry need with housing, employment, finances, education, domestic violence, child-custody and social support and (2) at follow-up women reported still needing help in that area. Women's self-reported substance-use and mental health since release were captured at follow-up. Descriptive statistics were calculated for all measures. Associations between SDOH, mental health, substance-use and recidivism were estimated by multiple logistic regression, adjusting for potential confounders. We also evaluated the mediating effects of mental health on the relationship between SDOH and substance-use. RESULTS: Substance-use was associated with increased odds of recidivism (adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI) 1.1-2.9; p = 0.02). Poor mental health (AOR 2.9, 95% CI 1.9-4.6; p = < 0.01), ongoing social support (AOR 3.0, 95% CI 1.9-5.0; p = < 0.01), child-custody (AOR 1.9, 95% CI 1.0-3.3 p = 0.04), financial (AOR 2.0, 95% CI 1.3-3.2; p = < 0.01) and housing (AOR 1.8, 95% CI 1.1-2.9; p = 0.02) needs were individually associated with increased odds of substance-use. Mediation analysis found mental health fully mediated the effects of ongoing housing (beta efficiency (b) = - 033, standard error (SE) 0.01; p = 0.05), financial (b = 0.15, SE 0.07; p = 0.05), child-custody (b = 0.18, SE 0.01; p = 0.05) and social support (b = 0.36, SE 0.1; p = 0.05) needs onto substance-use, and partially mediated the effects of domestic violence (b = 0.57, SE 0.23; p = 0.05) onto substance-use. CONCLUSION: This study underscores the critical importance of addressing the interplay between SDOH, mental health, substance-use and recidivism. An approach that targets SDOH holds the potential for reducing mental distress and substance-use, and related recidivism.

Health literacy strengths and challenges of people in New South Wales prisons: a cross-sectional survey using the Health Literacy Questionnaire (HLQ).

BACKGROUND: Health literacy is an important factor for enabling people to manage their health and live long fulfilling lives. People in prison are frequently from marginalised communities, often out of reach of conventional community based health organisations, and have poorer health outcomes. It is essential to understanding the health literacy profiles of people in prison, and its contribution to the well-established health inequities and outcomes of this population. This study aimed to use a multi-dimensional health literacy measurement tool to describe the strengths and challenges of adults incarcerated in NSW prisons. METHODS: A cross-sectional survey was conducted for people in prison across 14 publicly operated metropolitan prisons. Data were collected from 471 participants using the Health Literacy Questionnaire (HLQ). Participant characteristics and health conditions were also collected. Data were analysed using descriptive statistics. Effect sizes (ES) for standardised differences in means were used to describe the magnitude of difference between participant characteristic groups. RESULTS: Participants' median age was 38.0 (range 19 - 91) years. Males comprised 81% of the sample, 21% identified as Aboriginal and/or Torres Strait Islander, and 53% reported a health problem. People in prison had lower scores for all nine HLQ scales when compared to the general Australian population. Small to medium ES were seen for mean differences between most demographic groups. Compared to males, females had lower scores for several of the HLQ scales including 'having sufficient information to manage health' (ES 0.30 [95% Confidence Interval (CI) 0.07, 0.53]), 'ability to actively engage with health care professionals' (ES 0.30 [95% CI 0.06, 0.53]), 'navigating the healthcare system' (ES 0.30 [95% CI 0.06, 0.53]), and, 'ability to find good health information' (ES 0.33 [95% CI 0.10, 0.57]). Differing health literacy scale scores with small to medium ES were found when comparing participants by legal status. Mainly small ES were seen when comparing other participant characteristic groups. CONCLUSIONS: This study provides insights into the health literacy strengths and challenges for people in NSW prisons. These findings highlight the important role health literacy could have in addressing health disparities in this vulnerable population and can inform prison health services.

The development, content validity and inter-rater reliability of the SMART-Goal Evaluation Method: A standardised method for evaluating clinical goals.

INTRODUCTION: Goal setting is a complex skill. The use of formal goal writing procedures (including the use of the SMART goal model) has been advocated. However, a standardised method of writing and evaluating SMART goals is currently lacking. This study comprised of two phases. The aims of phase one was to (i) develop the SMART Goal Evaluation Method (SMART-GEM) based on a SMART goal model; and (ii) investigate the content validity of the SMART-GEM. The aim of phase two of the study was to test the inter-rater reliability of the SMART-GEM. METHODS: Development of the SMART- GEM involved defining and constructing evaluation criteria suitable for auditing goal statements. A content validity assessment was conducted using an expert panel of Occupational Therapists (n = 10). Inter-rater reliability of the SMART-GEM was examined using a purposive sample of multiple raters (n = 24). RESULTS: The SMART- GEM was rated as having good content validity (individual items CVI ranged from 0.90 to 1.00; total SMART- GEM CVI = 0.99, ρ = 0.05). Agreement between raters on individual items ranged from poor (κ = 0.254) to excellent (κ = 0.965) and agreement of overall grades was fair to good (κ = 0.582). Inter-rater agreement on total scores was found to be very good (ICC = 0.895, 95% CI = 0.743 to 0.986, ρ = 0.001) with excellent internal consistency (α = 0.995). CONCLUSION: The SMART-GEM demonstrated good construct validity and very good inter-rater reliability on total score and shows promise as a standardised method to writing and evaluating clinical goals.

Effect of an office worksite-based yoga program on heart rate variability: outcomes of a randomized controlled trial.

BACKGROUND: Chronic work-related stress is an independent risk factor for cardiometabolic diseases and associated mortality, particularly when compounded by a sedentary work environment. The purpose of this study was to determine if an office worksite-based hatha yoga program could improve physiological stress, evaluated via heart rate variability (HRV), and associated health-related outcomes in a cohort of office workers. METHODS: Thirty-seven adults employed in university-based office positions were randomized upon the completion of baseline testing to an experimental or control group. The experimental group completed a 10-week yoga program prescribed three sessions per week during lunch hour (50 min per session). An experienced instructor led the sessions, which emphasized asanas (postures) and vinyasa (exercises). The primary outcome was the high frequency (HF) power component of HRV. Secondary outcomes included additional HRV parameters, musculoskeletal fitness (i.e. push-up, side-bridge, and sit & reach tests) and psychological indices (i.e. state and trait anxiety, quality of life and job satisfaction). RESULTS: All measures of HRV failed to change in the experimental group versus the control group, except that the experimental group significantly increased LF:HF (p = 0.04) and reduced pNN50 (p = 0.04) versus control, contrary to our hypotheses. Flexibility, evaluated via sit & reach test increased in the experimental group versus the control group (p < 0.001). No other adaptations were noted. Post hoc analysis comparing participants who completed ≥70% of yoga sessions (n = 11) to control (n = 19) yielded the same findings, except that the high adherers also reduced state anxiety (p = 0.02) and RMSSD (p = 0.05), and tended to improve the push-up test (p = 0.07) versus control. CONCLUSIONS: A 10-week hatha yoga intervention delivered at the office worksite during lunch hour did not improve HF power or other HRV parameters. However, improvements in flexibility, state anxiety and musculoskeletal fitness were noted with high adherence. Future investigations should incorporate strategies to promote adherence, involve more frequent and longer durations of yoga training, and enrol cohorts who suffer from higher levels of work-related stress. TRIAL REGISTRATION: ACTRN12611000536965.

Alcohol and other drug use before custody among Aboriginal and non-Aboriginal people in New South Wales, Australia.

OBJECTIVE: Alcohol and other drug (AoD) use is a significant factor in the poor health status of people in prison. Our aim is to explore associations of alcohol consumption with tobacco and illicit drug use among Aboriginal and non-Aboriginal people in prison to inform health services, clinical care and support. METHODS: We analysed the alcohol, tobacco and illicit drug use data of the 2015 Network Patient Health Survey of adults in custody in New South Wales (n=1,132). A comparative analysis of Aboriginal to non-Aboriginal participants including bi-variant and multivariant analysis was undertaken. RESULTS: Significantly more Aboriginal than non-Aboriginal participants reported alcohol consumption before prison that was consistent with possible dependence. More Aboriginal than non-Aboriginal participants used cannabis on a daily or almost on daily basis before prison. There was significant association between alcohol and cannabis use among Aboriginal participants. CONCLUSIONS: There are differences in Aboriginal and non-Aboriginal AoD use patterns, which should be considered when providing treatment and support programs within and post-release from prison. IMPLICATIONS FOR PUBLIC HEALTH: Specific programs are needed to assist Aboriginal people in this population who co-use alcohol and cannabis.

Feasibility of an Intervention Targeting Health through Exergaming as an Alternative to Routine Treatment (FIT HEART): protocol for a non-randomised two-armed pilot study.

BACKGROUND: Despite elevated risk of cardiometabolic disease among those with serious mental illness, and widespread recognition that physical activity interventions are required, there are multiple barriers to implementing typically recommended physical activity programmes in secure inpatient settings. Due to low mood, negative symptoms and poor socio-occupational functioning, psychiatric inpatients often lack motivation to engage in physical activity programmes. Moreover, regular access to outdoor spaces and exercise equipment is limited. As such, there is a need for novel physical activity interventions that are suitable for secure settings. This study aims to investigate the feasibility, acceptability and potential effectiveness of an intervention (exergaming) to promote physical activity among patients in a secure mental health setting. METHODS: This non-randomised, two-arm pilot study will employ a pre-test/post-test parallel group design, comparing the exergaming intervention with a "routine treatment" control. Two high-secure, sub-acute wards in the Long Bay Hospital Mental Health Unit will be non-randomly allocated to either the exergaming intervention or the "routine treatment" control group. The intervention group will receive a 12-week programme comprising three 30-min exergaming sessions per week using various Xbox KinectTM activity-based games designed to simulate moderate intensity exercise. The "routine treatment" group will continue to receive the standard model of care delivered by the Justice Health and Forensic Mental Health Network. Accelerometers will be distributed to all participants to collect daily energy expenditure, number of steps taken, intensity of physical activity and heart rate data throughout the study. The primary outcomes are (1) intervention feasibility and acceptability, and (2) baseline to post-intervention changes in physical health outcomes (levels of physical activity; cardiovascular fitness; clinical measures of cardiometabolic risk). Secondary outcomes are baseline to post-intervention changes in mental health outcomes (depression, anxiety, stress, positive psychiatric symptoms). Outcomes will be assessed at baseline, mid-intervention, and post-intervention. DISCUSSION: This research will contribute to evidence-based practice in the care of patients with serious mental illness: a vulnerable population with complex physical and mental health needs and a markedly elevated risk of cardiovascular disease. The findings will inform cardiovascular health promotion strategies and the implementation of physical activity interventions in secure inpatient settings. TRIAL REGISTRATION: ANZCTR, ACTRN12619000202167. Registered on 12 February 2019, https://www.anzctr.org.au . ANZCTR mandatory data items comply with the minimum dataset requirements of the World Health Organisation (WHO). The ANZCTR contributes trial registration data to the WHO International Clinical Trials Registry Platform (WHO ICTRP).

A systematic review of post-release programs for women exiting prison with substance-use disorders: assessing current programs and weighing the evidence.

BACKGROUND: The rising rates of women in prison is a serious public health issue. Unlike men, women in prison are characterised by significant histories of trauma, poor mental health, and high rates of substance use disorders (SUDs). Recidivism rates of women have also increased exponentially in the last decade, with substance related offences being the most imprisoned offence worldwide. There is a lack of evidence of the effectiveness of post-release programs for women. The aim of this systematic review is to synthesise and evaluate the evidence on post-release programs for women exiting prison with SUDs. METHODS: We searched eight scientific databases for empirical original research published in English with no date limitation. Studies with an objective to reduce recidivism for adult women (⩾18 years) with a SUD were included. Study quality was assessed using the revised Cochrane Risk of Bias tool for randomized trials (RoB2) and the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tools. RESULTS: Of the 1493 articles, twelve (n = 3799 women) met the inclusion criteria. Recidivism was significantly reduced in five (42%) programs and substance-use was significantly reduced in one (8.3%) program. Common attributes among programs that reduced recidivism were: transitional, gender-responsive programs; provision of individualised support; providing substance-related therapy, mental health and trauma treatment services. Methodological and reporting biases were common, which impacted our ability to synthesize results further. Recidivism was inconsistently measured across studies further impacting the ability to compare results across studies. CONCLUSIONS: Recidivism is a problematic measure of program efficacy because it is inconsistently measured and deficit-focused, unrecognising of women's gains in the post-release period despite lack of tailored programs and significant health and social disadvantages. The current evidence suggests that women benefit from continuity of care from prison to the community, which incorporated gender-responsive programming and individualised case management that targeted co-morbid mental health and SUDs. Future program design should incorporate these attributes of successful programs identified in this review to better address the unique challenges that women with SUDs face when they transition back into the community.

Crystal methamphetamine use among young people entering custody: Prevalence, correlates and comorbidity.

INTRODUCTION AND AIMS: Crystal methamphetamine (CM) is associated with a range of physical and mental health harms and may be of particular concern among young people at risk of early, problematic substance use, such as those in contact with the criminal justice system. This study aimed to investigate the prevalence and correlates of regular (i.e. at least weekly) CM use among young people preceding entry into custody. DESIGN AND METHODS: Data were collected from 207 participants aged 14-18 years as part of the 2015 Young People in Custody Health Survey, a cross-sectional survey of youth in custody in New South Wales, Australia. Participants were administered face-to-face structured interviews assessing sociodemographic, childhood and family characteristics, offending history, substance use and psychopathology. Multivariable logistic regression analyses were conducted to identify factors independently associated with regular CM use. RESULTS: Regular CM use was reported by 31% of participants and was independently associated with higher levels of antisocial traits/behaviour [adjusted odds ratio (AOR) 1.13, 95% confidence interval (CI) 1.02, 1.25], increased polydrug use (AOR 1.34, 95% CI 1.14, 1.58), injecting drug use (AOR 4.06, 95% CI 1.02, 16.16) and meeting symptom thresholds for two or more current psychological disorders (AOR 3.20, 95% CI 1.15, 8.94). DISCUSSION AND CONCLUSIONS: Regular CM users present with more complex comorbidity than other young people in custody, increasing the health-care burden in custodial and community settings. Early identification and appropriate treatment of this comorbidity is crucial to improving the health, psychosocial and behavioural outcomes of this vulnerable group.

Feasibility and acceptability of take-home naloxone for people released from prison in New South Wales, Australia.

INTRODUCTION AND AIMS: To assess the feasibility and acceptability of a take-home naloxone program for people with a history of opioid use released from prison in New South Wales, Australia. DESIGN AND METHODS: Cross-sectional interviews with people with a history of opioid use who were recently released from prison (n = 105), and semi-structured interviews with key clinical and operational staff of Justice Health and Forensic Mental Health Network and Corrective Services NSW (n = 9). RESULTS: Among people with a history of opioid use who had recently left prison, there was very high awareness of the elevated risk of overdose following release from prison (95%) and the potential for naloxone to reverse an opioid overdose (97%). Participants considered that their personal risk of overdose was low, despite ongoing opioid use being common. Participants were largely supportive of take-home naloxone, but the majority (83%) stated that proactively obtaining naloxone would be a low priority for them following release. Key informants were supportive of introducing naloxone training and supply and identified barriers to implementation, including adequate resourcing, identifying the population for training, and developing an appropriate model of training and implementation. DISCUSSION AND CONCLUSION: There was widespread support for naloxone training in custody and distribution at release among people recently released from prison and key stakeholders in health-care provision and prisons administration. As proactively accessing naloxone is a low priority for patients, naloxone supply at release may be more effective than programs that refer releasees to local pharmacies, but developing a sustainable supply model requires consideration of several barriers.

Prisoners' experience and perceptions of health care in Australian prisons: a qualitative study.

PURPOSE: Patient-centred care is a key approach used in Australia for the delivery of quality health care, and understanding experiences and perceptions is a key part to this. This paper aims to explore prisoners' experiences and perceptions of health-care service provision in New South Wales, Australia. DESIGN/METHODOLOGY/APPROACH: In February and March 2017, 24 focus groups, consisting of 128 participants, were undertaken using semi-structured interviews that explored experiences of health care in prison. FINDINGS: A conceptualisation of the prisoners' health-care experience around the core category of access to health care emerged from the data. Enablers or barriers to this access were driven by three categories: a prison construct - how the prisoners "see" the prison system influencing access to health care; a health-care system construct - how the prisoners "see" the prison health-care system and the pathways to navigate it; and personal factors. Communication was the category with the greatest number of relational connections. RESEARCH LIMITATIONS/IMPLICATIONS: This study takes a pragmatic approach to the analysis of data, the findings forming the basis for a future quantitative study. The findings identify communication as a key issue for access to health care. ORIGINALITY/VALUE: This study provides first-hand accounts of enablers and barriers to accessing health-care services in the prison environment. To the best of the authors' knowledge, this study is the first of its kind to identify access to health care as a core category and is of value to health workers and researchers that work with the prison population.

An examination of chronic ill-health and lifestyle factors among inmates: searching for the healthy immigrant effect in New South Wales Prisons.

PURPOSE: The purpose of this paper is to compare the rates of chronic health conditions and lifestyle factors between Australian-born and overseas-born inmates and to uncover predictive relationships between lifestyle factors and health outcomes for both groups. DESIGN/METHODOLOGY/APPROACH: Data are presented from a cross-sectional study based on a sample of inmates from correctional sites in New South Wales (NSW). The inclusion of results here was guided by the literature relating to the healthy immigrant effect. FINDINGS: Results indicate that a higher proportion of Australian-born inmates consumed alcohol at higher levels and were more likely to smoke on a daily or almost daily basis than overseas-born inmates. Australian-born inmates were also more likely than overseas-born inmates to have been diagnosed with cancer, epilepsy or hepatitis C. Physical activity predicted the number of diagnoses for Australian-born inmates while physical activity and smoking frequency predicted the number of diagnoses for overseas-born inmates. PRACTICAL IMPLICATIONS: Overseas-born inmates make up a considerable portion of the prison population in NSW. A better understanding of those health and lifestyle factors that distinguish them from Australian-born inmates provides important insight regarding health promotion and the planning of service provision for those providing health care in this space. ORIGINALITY/VALUE: Comparison of the health of immigrant and native-born prison inmates has not been undertaken before and promises to provide important information regarding those factors that distinguish a sizeable minority in the prison population.

Prevalence and correlates of low self-reported physical health status among prisoners in New South Wales, Australia.

PURPOSE: The purpose of this paper is to examine the prevalence and predictors of low self-reported physical health status among NSW prison inmates. DESIGN/METHODOLOGY/APPROACH: Cross-sectional random sample of 1,098 adult male and female prisoners, interviewed as part of the 2015 Justice Health and Forensic Mental Health Network Patient Health Survey. FINDINGS: Almost a quarter of participants had "low self-reported physical health status". Independent predictors of "low health status" were having been in out of home care before the age of 16 years, being illiterate, smoking 20 or more cigarettes a day, not eating more than one serve of fruit a day, not being physically active in the 12 months before incarceration, higher body mass index score and low self-reported mental health status. Many of these predictors are modifiable risk factors for chronic disease, which could be targeted during incarceration. ORIGINALITY/VALUE: This paper demonstrates the utility of a using a single item measure of self-reported physical health status among Australian prisoners, and helps to characterise those prisoners in greatest need of intervention for issues relating to their health.

Long-term effects of forearm support: computer users working at conventional desks.

UNLABELLED: Recent research has demonstrated that forearm support might be preferable to working in the traditional "floating" posture for computer users. A previous field study in a call centre reported a significant decrease in discomfort following 12 weeks of using a conventional desk for forearm support. The aim of this follow up study was to determine the long-term effect (21 months post intervention) of forearm support on reported musculoskeletal discomfort in the previous sample of intensive computer users. METHODS: The follow-up sample consisted of 33 females and 2 males (59% of original group). Data were collected via self-report questionnaires and workstation assessments. RESULTS: Despite a significant reduction in discomfort for most body regions following the initial intervention, the only significant decrease in discomfort over 21 months was for the neck. Reported discomfort for all other body regions had decreased, apart from the shoulder in which there was a reported increase in discomfort. The results of this follow up study indicate that forearm support has a positive effect on the reduction of neck discomfort. The increase in shoulder discomfort indicates that a concave desk may be preferable to the conventional desk if the forearm support posture is to be adopted.

Clinical outcomes research from the occupational therapist's perspective.

With increasing costs and scarcity of resources, occupational therapists need to embrace outcomes research to demonstrate the effectiveness of its clinical interventions. To explore clinicians' perspectives on clinical outcomes research a qualitative study was undertaken involving three in-depth group interviews with 15 occupational therapists from the South Western Sydney Area Health Service. Five broad themes permeated participants' perception: (a) defining the process, (b) factors that impact on participation in clinical outcomes research, (c) organizational influences, (d) the value of clinical outcomes research, and (e) potential partnerships with academics. Three conceptual categories are identified: knowledge and understanding about clinical outcomes research, clinicians' experience conducting or participating in clinical outcomes research and the relevance of clinical outcomes research to occupational therapy clinical practice. Similarity to findings in the international literature on occupational therapists' engagement in clinical research suggests that the findings from this small sample of Australian therapists are robust. The implications of the findings for continuing professional education programmes and clinical supervision are presented.

Psychological therapies for the management of co-morbid depression following a spinal cord injury: a systematic review.

The evidence about psychological therapies used to manage co-morbid depression after a spinal cord injury is presented here. A comprehensive search of five electronic databases identified nine studies (participants, n = 591) meeting inclusion criteria. Pooled statistical analyses were conducted in combination with narrative synthesis. Overall, multimodal cognitive behavioural therapy was found to be moderately effective (standardised mean difference = -0.52; 95% confidence interval = -0.85, -0.19). Activity scheduling, psychoeducation, problem solving and cognitive therapy may be particularly beneficial therapies within cognitive behavioural therapy. Further high-quality randomised controlled trials are needed to better substantiate these findings.

An interactive education session and follow-up support as a strategy to improve clinicians' goal-writing skills: a randomized controlled trial.

BACKGROUND: Recent research indicates that allied health clinicians have difficulty articulating client needs and priorities into specific and measurable goals. As a result, a number of strategies to facilitate improvement in allied health clinicians' goal-setting skills have been recommended in the literature. In order to assist clinicians develop the skills required to set SMART goals, it is necessary that the strategies are rigorously tested. AIM: To determine if a 50-minute education session and 3-month email and telephone support programme improves clinicians' SMART goal-writing skill and accurately predicts improved goal-writing behaviour. METHODS: Concealed random allocation of participants (n = 120) into two parallel groups: (1) intervention group received education on writing goals using the SMART Goal Evaluation Method as part of a workshop on outcome measurement and received 3 months of follow-up support (n = 60); and (2) control group attended a workshop on evidence-based practice (n = 60). RESULTS: Education and follow-up support improved clinicians' SMART goal-writing skills at both the 3- and 6-month review (Yates chi(2) = 4.324, d.f. = 1, P = 0.0375). Structural equation modelling revealed education and follow-up support is an accurate predictor of SMART goal-setting behaviour change at both 3 months (standardized regression weights = 0.21; P = 0.014) and 6 months (standardized regression weights = 0.19; P = 0.02) post intervention. Changes were modest and developed over a 6-month period. CONCLUSION: This study provides empirical evidence that a programme of educating clinicians in a standardized method of goal setting and providing follow-up support improves allied health clinicians' SMART goal-writing skills.

Development and psychometric testing of the Clinician Readiness for Measuring Outcomes Scale.

BACKGROUND: If allied health professionals are to begin measuring outcomes routinely, a change in attitudes and behaviour is necessary. However, individuals need to be ready to change and often move through several stages before practice change is observed. AIM: To develop and test the psychometric properties of a questionnaire that determines clinicians' readiness to measure outcomes. METHODS: A study of instrument development, validation and reliability. Ten expert allied health professionals were involved in content validity testing. A further 396 allied health professionals completed the questionnaire to establish content and construct validity, internal consistency and temporal reliability (or stability). Of these 396 allied health professionals, 70 participated in the temporal reliability assessment. Content validity was established using the Content Validity Index (CVI). Construct validity was determined using confirmatory factor analysis (CFA) and internal consistency was ascertained using Cronbach's alpha. Temporal reliability was confirmed using intraclass correlation coefficients (ICC 3,1). RESULTS: A 30-item questionnaire was developed, reflecting the five stages of change from the Transtheoretical Model of Change, and commonly cited barriers to outcome measurement. Content validity was excellent (CVI = 0.96). Using CFA, a two-factor model provided best fit. Based on CFA results, four items were dropped resulting in a 26-item questionnaire (range 26-156). Internal consistency reliability was excellent (alpha = 0.94). Temporal (stability) reliability ICC (3,1) was very good (r = 0.86, P = 0.0001). CONCLUSIONS: The final 26-item questionnaire takes 10 minutes to complete and 5 minutes to score. The Clinician Readiness for Measuring Outcomes Scale provides educators with useful information about clinician readiness and helps identify strategies for affecting behaviour change.

Atmospheric chemistry of nonanal.

During the Southern Oxidants Study 1999 field campaign at Dickson, TN, we conducted measurements of the n-aldehydes propanal, pentanal, hexanal, heptanal, octanal, and nonanal. Propanal and nonanal tended to have the largest concentrations, with afternoon maxima of approximately 0.3 ppb. These aldehydes typically represented a significant fraction of the VOC reactivity defined as k(OH)[VOC]. However, this information is misleading with regard to the impact of these aldehydes on ozone formation, as their oxidation can represent a significant NOx sink. Motivated by the relatively large nonanal concentrations, we conducted a laboratory study of the products of the nonanal + OH reaction. The OH + nonanal reaction rate constant was determined via the relative rate technique and found to be 3.6 (+/- 0.7) x 10(-11) cm3 molecule(-1) s(-1). Under conditions of high [NO2]/[NO], we determined that 50 +/- 6% of OH-nonanal reaction occurs via abstraction of the aldehydic H-atom through measurement of the peroxynonanyl nitrate yield. We also studied the production of organic nitrates from OH reaction with nonanal in the presence of NO. As expected, a major product (20% at large [NO]/[NO2]) of this reaction was 1-nitrooxy octane. We calculate that the branching ratio for 1-nitrooxy octane formation from peroxyoctyl radicals is 0.40 +/- 0.05. On the basis of these measurements, we find that for more than 50% of the time OH reacts with nonanal (for midday summer conditions) an organic nitrate or PAN compound is formed, making this important atmospheric aldehyde an effective NOx sink.