Sections of this chapter have been reproduced from Holloway et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
This chapter reports on the origins of the APPRAISE intervention and its theoretical underpinnings, and provides a detailed description of the study intervention itself and the nature of the training for those delivering it. For completeness of the APPRAISE intervention reporting and replicability, the TIDieR checklist is used to support the structure of the chapter (see Appendix 3).45
Origins and development of the APPRAISE intervention
The APPRAISE intervention is an extended self-efficacy-enhancing alcohol intervention developed for men on remand with self-reported drinking that is harmful or hazardous. The APPRAISE intervention is based on previous ABI research focusing on self-efficacy as an appropriate basis for a single-session ABI intervention to enhance drinking refusal self-efficacy in a general hospital population.38,39
From this original work, additional intervention modification was undertaken as part of the PRISM-A study on the basis of our learning from interviews with men on remand (n = 24).40 The aim of these interviews was to explore the acceptability of a self-efficacy-enhancing ABI,40 including listening to feedback regarding the nine elements of the intervention: (1) preliminary discussion, (2) acquiring and providing information, (3) self-monitoring, (4) increasing awareness, (5) situation appraisal and appropriate coping strategies, (6) goal-setting, (7) relapse, (8) self-evaluation/self-reinforcement and (9) culmination.39,40
The nine intervention elements of the single-session delivery were found to be acceptable to men on remand who were interviewed as part of the PRISM-A study. Feedback regarding frequency and intensity of contact identified a preference for more than one session, with a desire for additional sessions being delivered in the community following liberation. The participants reported that this would provide the opportunity to put the skills gained as a result of the single-session intervention into practice, once liberated, in real-world situations in which alcohol is widely available to them.
This evidence subsequently informed the development and refinement of the single-session ABI to an extended four-session ABI, incorporating a single session to be delivered in the prison setting with the remaining three additional booster sessions to be delivered following liberation.
APPRAISE intervention: theory, elements and logic model
The APPRAISE intervention is based on Social Cognitive Theory and designed to increase self-efficacy and other self-regulatory skills to reduce alcohol consumption. Figure 1 illustrates this process in the APPRAISE logic model. According to the theory, self-efficacy is a central determinant of health behaviour change.47 Primary sources of self-efficacy that can be targeted through interventions are mastery experience, verbal persuasion, vicarious experience and physiological state.39,40,47 All these sources of self-efficacy were addressed in the intervention (see Table 1 for all elements of the APPRAISE intervention). Mastery experiences should become more likely due to intervention elements addressing feedback, goal-setting, planning for release, including plans for coping responses, and self-monitoring of the intervention. Verbal persuasion was delivered by the interventionist, as were ways to achieve a calmer physiological state during high-risk situations. The intervention was designed to also increase outcome expectations by delivering arguments and elaborations and seeking social support. The intervention aimed to develop better self-regulation skills, thus enabling individuals to address their alcohol consumption behaviour. Liberation then offered participants the opportunity to implement and act on the targeted behaviours learned in the intervention in their ‘real life’ social context. The aim was for participants to have the ability to develop and build upon these skills and self-belief through success and mastery, with their efforts leading to the adoption and maintenance of reduced alcohol consumption. Reducing alcohol consumption can provide a sense of achievement and success, which should further increase self-efficacy.39
FIGURE 1 APPRAISE logic model. (Figure not reproduced here; see the original article.)
| Opening strategies | |
|---|---|
| Element 1: preliminary discussion | Introduction to APPRAISE study |
| Introduction to APPRAISE | |
| Consent, confidentiality, engagement rules, trust | |
| Element 2: acquiring and providing information | Feedback on AUDIT score |
| Establish perception of impact of alcohol on health and life | |
| Standard units of alcohol | |
| Recommended drinking levels | |
| Alcohol-related health problems | |
| Legal drink/drive limit | |
| Tips on reducing consumption | |
| Where to obtain information/support (prison and liberation) | |
| Element 3: self-monitoring | Diary card – when, where, who, type of drink, why |
| Element 4: increasing awareness | Balance sheet – pros and cons of drinking |
| Physiological sensations identified | |
| Alternative appraisal of somatic sensations identified | |
| Strategies to reduce | |
| Element 5: situation appraisal and appropriate coping strategies | High-risk situations and antecedents of over-drinking identified |
| Alternative coping strategies identified | |
| Coping strategies verbalised by participant | |
| Praise provided | |
| Strategies developed further through co-production | |
| Strategies modelled by interventionist | |
| Participant verbalises strategies and visualises them | |
| Plan for exposure to low-risk situations and avoidance of high-risk situations | |
| General control strategies: reduction in rate of drinking, sipping, drinking low-alcohol drinks and alternating between soft or low-alcohol drinks and higher-alcohol drinks | |
| Element 6: goal-setting | Setting realistic sub-goals (short-term) |
| Facilitating success and increasing motivation | |
| Element 7: relapse | What happens if you relapse |
| What caused the relapse? | |
| How do I understand relapse? | |
| Element 8: self-evaluation and self-reinforcement | Using my alcohol diary as a means of self-evaluation and self-reinforcement |
| Self-congratulations and rewarding my success | |
| What do I attribute my success to? | |
| Element 9: culmination | Reflections and conclusions. Plans and goals reiterated and confirmed |
The six proposed mechanisms of change in the logic model are: self-efficacy, outcome expectations, goals, plans, social support and high-risk situations.
- Self-efficacy will be measured using: (i) an item on the Readiness to Change Ruler: ‘How confident are you that you could reduce (or stop) drinking when you are released?’ and separately (ii) the Drinking Refusal Self-efficacy Questionnaire.
- Alcohol expectancy will be measured using the Negative Alcohol Expectancy Questionnaire.
- Goals will be measured using an item on the Readiness to Change Ruler: ‘How much do you want to reduce (or stop) drinking when you are released?’
- Plans will be measured using: (i) an item on the Readiness to Change Ruler: ‘How ready are you to reduce (or stop) drinking when you are released?’ and (ii) ‘I have made a detailed plan regarding when, where and how to reduce my drinking’.
- Social support will be measured using the following items: (i) ‘The people who are important to me support me in reducing my drinking’ and (ii) ‘I have someone I can talk to about reducing my drinking’ in the Readiness to Change Ruler.
- Barriers and high-risk situations will be measured using the following items: (i) ‘I know in which situations it will be difficult for me to reduce my drinking’ and separately (ii) the question ‘to what extent do you consider this to be a high-risk situation for you?’ in the Drinking Refusal Self-efficacy Questionnaire.
APPRAISE intervention materials
The APPRAISE intervention consisted of three documents:
- APPRAISE Intervention Tool [V3_20October] (see Appendix 4)
- Intervention Tool Postcard (Unit card) [V2_25Sept19] (see Appendix 5) and
- Follow-up Manual [V1_25 Sept19] (see Appendix 6).
These documents together supported the delivery of the behaviour-change methods, linked directly to the determinants/mechanisms of change that focused on the targeted behaviour, in order to achieve the desired outcomes.
- Document 1: the APPRAISE Intervention Tool was an eight-page, double-sided A5 booklet containing all nine Intervention Elements (Table 1: APPRAISE elements) and was the material used for the first intervention session.
- Document 2: the Intervention Tool Postcard (Unit card) was postcard-sized and provided brief information about recommended drinking levels and units that was given to individuals to take away with them during Element 2 of the first intervention session.
- Document 3: the Follow-up Manual was a six-page double-sided A5 booklet for use during all three post-liberation follow-up intervention sessions (Day 3, Day 7 and Day 21). The manual contained Element 1 as a way of re-establishing dialogue following on from the first intervention session, followed by Elements 5–9 of the APPRAISE intervention.
APPRAISE intervention procedures
The APPRAISE intervention was delivered in a safe, non-judgemental environment where engagement rules and trust were affirmed. This was with the aim of enabling and supporting the intervention activities. The APPRAISE Intervention Tool booklet contained ‘Things to remember’ – notes for the interventionist to support the delivery of the intervention elements. This reminded the interventionist of the key areas within each element to be emphasised during intervention delivery. It also provided a mechanism of supporting intervention fidelity in relation to delivery of the intervention changing process variables consistent with the underpinning theory.
While the APPRAISE intervention has specific core elements, the intervention itself was person-centred in that it became individualised during the course of the participant-interventionist conversation and subsequent intervention delivery.
The starting point for this approach was assessing participants’ readiness to change by way of completion of the Readiness to Change Ruler.48 The scoring then provided information and understanding as to where the participant was in relation to their readiness to change. Similarly high-risk drinking situations were identified during Element 1 to provide further information that would build upon all the elements moving forward. This initial discussion was key to ensuring the interventionist was able to understand, recognise and respond effectively in relation to gauging how participants perceived their drinking and their motivation to change and how they used alcohol in their lives. Discussing answers to both the Readiness to Change Ruler and high-risk situations supported the delivery of an individual realistic starting point for both participant and interventionist. Depending on the results of these elements, each element could then be individualised to participants’ particular needs.
The participants AUDIT score, obtained following screening, was shared with them during Element 2 to feedback and provide information on recommended drinking levels, units and the impact alcohol may have been having on themselves, others and their life on the whole. Giving the Intervention Tool Postcard (Unit card) to the participant provided an easy-to-carry postcard-size information resource which could be studied following intervention sessions and post liberation.
In addition, the booklet had a perforated page that was removed at the end of Element 8 and was given to and kept by the individual receiving the intervention. The page was a takeaway ‘personal planner’ with reinforcement triggers of the key behaviour-change methods and mechanisms.
APPRAISE intervention training
Intervention training was provided at both study sites to members of the Change Grow Live (CGL) team who were supporting the delivery and which included those practitioners who would be delivering the APPRAISE intervention itself.
The aims of the training for interventionists were to:
- have an awareness and understanding of the APPRAISE intervention
- understand AUDIT Scores and what they mean
- have an awareness of the Readiness to Change Ruler and Risky Situation Assessments and why we use them
- be confident working with the APPRAISE booklet; and
- be able to deliver the APPRAISE intervention.
The training material ‘(APPRAISE training plan1_VG) (see Appendix 7) for the APPRAISE intervention provides interventionists with:
- a written brief on the theoretical underpinnings of the intervention
- paper copies of the three APPRAISE intervention documents
- paper copy of the APPRAISE elements
- online narrated review of the three APPRAISE intervention documents
- intervention delivery video
- paper copy of the AUDIT instrument; and
- opportunity to engage in intervention delivery role-play exercises.
On completion of the training, a six-question Likert scale survey (see Appendix 8) as a form of evaluation of the training undertaken was self-completed by interventionists and CGL team members from both study sites (see Intervention implementation).
APPRAISE intervention delivery mode and location
Following completion of baseline assessments and randomisation, those allocated to the intervention arm were invited to attend their first of three intervention sessions. This was delivered face to face by the identified interventionist at each study site. It was delivered in a quiet room either on the residential wing, a landing or in one of the CGL designated rooms and was delivered at both sites by CGL interventionists. Four members of the CGL team from the England study site and two members from the Scotland study site attended the intervention delivery training.
At the beginning of data collection, both study sites had allocated two interventionists. Due to resource capacity and sick leave during the data-collection period, Scotland had one interventionist and England had two interventionists able to deliver the interventions.
We asked the three interventionists for details of their education and previous training experience. This request was made during COVID-19 when we were only able to communicate via e-mail. While there was a willingness to provide the information, due to the incapacity of interventionists to find the time we were unable to obtain that information.
The APPRAISE intervention comprises nine elements (Table 2) to be delivered in four steps: Step 1 comprises a 1 × 40-minute face-to-face session in which the nine elements are covered and delivered by a trained practitioner from CGL in the prison setting. Steps 2, 3 and 4 are 20-minute sessions conducted by phone, on or close to day 3, 7 and 21 post liberation. The post-liberation sessions include elements 1 (preliminary discussion), 5 (situation appraisal), 6 (goal-setting), 7 (relapse), 8 (self-evaluation/self-reinforcement) and 9 (culmination). Table 3 provides details of the intervention sessions, duration, intensity and dose.
| Element | Description |
|---|---|
| Element 1: preliminary discussion | Participants re-introduced to study and APPRAISE, made aware of the purpose of the engagement, emphasising confidentiality, consent and trust. Mirrored aspects of ‘Opening strategies’.48 Readiness to Change Ruler completed and list of high-risk drinking situations identified on a scale of 0–5. |
| Element 2: acquiring and providing information | Focus on participants reported level of alcohol consumption as per screening AUDIT score and their perception of the impact of alcohol on their health and life. Six key pieces of information provided: Standard units of alcohol; Recommended drinking levels; Alcohol-related health problems; Legal drink/drive limit; Tips on reducing consumption; Where to obtain information/support. Intervention Tool Postcard (Unit Card) given to keep. |
| Element 3: self-monitoring | Participant introduced to the idea of keeping a diary post liberation: they are guided through how they would complete the diary with the support of the interventionist. They are informed that the diary will encourage them to reflect and record when, where and with whom, if anyone, they have consumed alcohol, why and what type of drink to enable self-monitoring on liberation, acting as a source of self-evaluation and record of progress.49 |
| Element 4: increasing awareness | Pros and cons of drinking recorded on a balance sheet of drinking. Physiological drinking sensations experienced discussed with strategies to identify and reduce with alternative appraisal of somatic sensations identified, for example alternative stress-relieving strategies, such as relaxation techniques rather than alcoholic drink. |
| Element 5: situation appraisal and appropriate coping strategies | High-risk situations and antecedents of over-drinking identified and alternative coping strategies considered. Situations are identified in order that appropriate coping and response strategies are practised prior to the situation next occurring. Coping strategies verbalised by participant, praise provided and strategies developed further and modelled by interventionist. Participants talk through the strategy and visualise themselves carrying it out (covert modelling). The better ingrained and more automated the response is, the higher one’s self-efficacy and the lower the probability of relapse.50 Avoidance of high-risk situations may be necessary in the first instance (although can be unrealistic) until mastery with low-risk situations is achieved (progressive mastery). Core set of general control strategies also discussed: reduction in rate of drinking, sipping drinks, low-alcohol-content drinks and alternating between soft or low-alcohol and higher-alcohol drinks. |
| Element 6: goal-setting | Realistic sub-goals set, short-term so that unachievable goals initially avoided. Setting proximate goals in relation to self-efficacy development can facilitate success promptly with increase in motivation towards accession to distal goals. This approach likened to a stepladder approach of focusing on the few rungs in front of you. For example, goal may be to reduce quantity of alcohol consumption on certain days of the week. |
| Element 7: relapse | Likelihood of relapse discussed and importance of identifying the events that resulted in the relapse, not attributing relapse to stable causes, such as ability or uncontrollable causes as this can result in lowering of self-efficacy and expectation of future success. Attribution to relapse discussed and focus on appraisal due to unstable causes and not to a personal failure/ability. Majority of relapses occur as a result of emotional distress, social pressure and interpersonal conflicts, therefore appropriate relapse strategies are discussed and practised. |
| Element 8: self-evaluation and self-reinforcement | Reward for success through affective self-reaction, for example, self-congratulations. The alcohol diary is a means of self-evaluation and self-reinforcement, success is attributed to their ability and skill, resulting in feelings of pride. |
| Element 9: culmination | Reflection of preceding discussion, conclusions drawn, praise given on progress and decisions made. Plans and goals reiterated and confirmed. Agreement regarding mobile phone follow-up on liberation. |
| Element | Elements of intervention39 | Enhancing self-efficacy | Delivery mode and location | Number of sessions and location |
|---|---|---|---|---|
| 1 | Preliminary discussion | Verbal persuasion | Face-to-face (P)Mobile phone (L) | 1 (P)3 (L) |
| 2 | Acquiring and providing information | Verbal persuasion | Face-to-face (P) | 1 (P) |
| 3 | Self-monitoring | Verbal persuasion | Face-to-face (P) | 1 (P) |
| 4 | Increasing awareness | Physiological state | Face-to-face (P) | 1 (P) |
| 5 | Situation appraisal and appropriate coping strategiesa | Vicarious experience | Face-to-face (P)Mobile phone (L) | 1 (P)3 (L) |
| 6 | Goal-settinga | Verbal persuasion | Face-to-face (P)Mobile phone (L) | 1 (P)3 (L) |
| 7 | Relapsea | Performance attainment | Face-to-face (P)Mobile phone (L) | 1 (P)3 (L) |
| 8 | Self-evaluation/self-reinforcementa | Performance attainment | Face-to-face (P)Mobile phone (L) | 1 (P)3 (L) |
| 9 | Culmination | Performance attainment | Face-to-face (P)Mobile phone (L) | 1 (P)3 (L) |
APPRAISE post-liberation intervention modifications due to coronavirus disease discovered in 2019
The outbreak of the COVID-19 pandemic had a significant impact on the project. Due to COVID-19 restrictions, access to both study sites for the RAs and research team was halted. It became clear quite quickly that the impact of the pandemic resulted in there being limited or no capacity for the interventionists to follow up on liberation data of those in the intervention group or deliver post-liberation intervention. Prison staff were also unable to provide us with liberation data, as their focus was rightly on the COVID-19 response in prisons. Similarly, RAs were unable to go into the prisons and access liberation data.
Modifications on timing of the post-liberation intervention delivery were made in an attempt to provide flexibility, if there was an opportunity to deliver the post-release interventions. This meant that post-release intervention sessions could still be attempted where possible with the originally intended interval between them maintained to the extent possible (4 days between sessions 2 and 3, and 14 days between sessions 3 and 4).