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.
For individuals in contact with the criminal justice system, the prevalence of at-risk drinking is far higher than in the general population. There is very little evidence of efficacy or effectiveness of alcohol interventions in reducing risky drinking amongst those in the criminal justice system and in particular men on remand in prison. This is compounded by the limited evidence for the optimum timing of delivery, recommended length, content, implementation and economic benefit of an extended alcohol intervention in the prison setting.APPRAISE (A two-arm parallel group individually randomised Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement) will therefore provide vital evidence to inform a future definitive randomised controlled trial (RCT) of an extended alcohol intervention for men on remand in prison. The remainder of this chapter provides the background research and rationale for APPRAISE, presents the study aims and objectives, and concludes by describing the structure of the remaining chapters of this report.
Prevalence of at-risk drinking in the United Kingdom criminal justice system
Hazardous drinking is defined as a repeated pattern of drinking that increases the risk of psychological or physical problems,2 whereas harmful drinking is defined by the presence of these problems.3 Drinking at hazardous or harmful levels is categorised as risky or at-risk drinking.
The prevalence of at-risk drinking, which includes drinking at levels that harm a person’s health, is far higher amongst those in contact with the criminal justice system (73%).4–9 In the UK, between 51% and 83% of incarcerated people are classified as risky drinkers.10 For those on remand in prison, the prevalence is between 62% and 68%.8 This compares to 35% in the general population.11 Furthermore, rates of alcohol dependence among those who are incarcerated (43%) are 10 times higher than for the general population.8
Interventions
Parts of this section have been reproduced from Newbury-Birch et al.,8 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.
Alcohol brief interventions (ABIs) are a secondary prevention activity, which is aimed at people who are drinking in a pattern that is likely to be harmful to health and/or well-being. They have been frequently shown to be effective in primary health care,12,13 but they are typically delivered by practitioners who are not addiction specialists, to non-treatment, opportunistic populations.14
ABIs largely consist of two different approaches: simple structured advice, which after screening raises awareness through provision of personalised feedback and advice on steps to reduce drinking behaviour and its adverse consequences; and an extended brief intervention, which generally involves behaviour-change counselling. Extended brief intervention introduces and evokes change by giving the participant the opportunity to explore their alcohol use, as well as their motivations and strategies for change. Both forms share the common aim of helping people to change drinking behaviour to promote health.14
There is a wide variation in the duration and frequency of ABIs. However, typically they consist of between one and four sessions and are very short in nature (between 5 and 60 minutes).15 They generally include personalised feedback on alcohol intake in relation to what the recommended limits are and discussion of both health and social risks, and may include setting personal targets which can include psychological and motivational interviewing.15 One example of this is using the FRAMES (Feedback, Responsibility, Advice, Menus, Empathy, Self-efficacy) approach.14
Due to the established links between risky drinking and crime and the costs to society, in both health and social care, it is important to find interventions that are effective. It has been shown that interventions that capitalise on the ‘teachable moment’ are conducive to behaviour change, for example where individuals consider their alcohol use within the context of their offending behaviour and its punitive consequences.16,17
There is robust evidence from systematic reviews and meta-analyses to indicate that short alcohol interventions are effective in reducing alcohol consumption amongst risky drinkers in healthcare settings.18,19 There is very little evidence of efficacy or effectiveness of alcohol interventions in reducing risky drinking amongst those in the criminal justice system, including the prison system, 20,21 and in particular remand prisoners. However, there has recently been evidence in the UK that alcohol (and drug) interventions can have an effect in reducing recidivism.22 Furthermore, short alcohol interventions have been shown to reduce recidivism in the probation setting.7 Nevertheless, there is limited evidence for the optimum timing of delivery, recommended length, content, implementation and economic benefit of an extended alcohol intervention in the prison setting. Likewise, there are weaknesses within the current evidence base with regard to the theoretical underpinnings of such interventions. This risks an intervention with a weak theoretical base and poorly specified ‘active’ ingredients, and which is less likely to deliver the desired outcomes.
Current evidence of alcohol interventions for those in the criminal justice system
A recent systematic review of the efficacy of psychosocial alcohol interventions for incarcerated people found that interventions in the prison setting have the potential to positively impact their relationship with and use of alcohol;21 however, because of small numbers and the use of different outcome measures it was not possible to conduct a meta-analysis or generalise findings. Notably, none of the studies focused on men on remand, as compared with other subgroups within prisons. Remand refers to those who are either unconvicted or convicted and unsentenced, held in custody awaiting trial and/or sentencing.
Rationale for APPRAISE
In 2021, 16% of the prison population in England and Wales, and 19% in Scotland, were remand prisoners.23,24 This equated to around 12,750 in England and Wales and 1700 in Scotland. Approximately 25% of individuals will not receive a custodial sentence.25 People spend on average 10 weeks in custody while on remand.26 During this time, many do not have the opportunity to access mainstream prison health or public health services.27
It has been shown that there is a complex interplay between individual and contextual factors and risky drinking behaviours and alcohol-related crime.28 Addressing alcohol harm in prisons, at what can be considered a ‘teachable moment’, where there is an opportunity for people to reflect on their risky drinking and their current position, could potentially reduce the risk of re-offending and costs to society, and help to address health inequalities.29 While there is an inevitable uncertainty in estimating the costs of alcohol-related crime and disorder, most estimates suggest they represent a considerable economic burden.
A recent Cabinet Office estimate reported that alcohol-related crime in England cost society £21.5 billion.30 However, this estimate is outdated and there are concerns regarding the assumptions and methodological judgements used in deriving this estimate.31 Better-quality estimates from four high-income countries placed the total costs of alcohol at 2.6% of gross domestic product (GDP) in 2007, of which 3.5% was made up of law-enforcement costs.32,33 It has been shown that intervening to reduce alcohol use is cost-effective, generating both long- and short-term savings. Public Health England (PHE) estimated that every £1 invested in effective alcohol treatment brings a social return of £5. Evidence estimates that health savings of £4.3 m and crime savings of £100 m per year can be made as a result of appropriate alcohol interventions.34 It has also been suggested that providing effective treatment is likely to significantly reduce the costs relating to alcohol as well as increase individual social welfare.35
In 2017, the Scottish Parliament Health and Sports Committee held an inquiry into prisoner health care to consider how health and social care and medicines in prison are accessed and the effectiveness of health and social care in prison. The Inquiry report set out recommendations for the Scottish government to prepare a strategic plan to address prison social and health care.36 Furthermore, National Institute for Health and Care Excellence (NICE) Guidelines [NG57]37 for people in prison acknowledge that adequate healthcare provision for prisoners would reduce pressure on community services later.
Theoretical background
The intervention in this study (the APPRAISE study) builds on previous research which has explored the theoretical validity of a self-efficacy-enhancing alcohol intervention,38,39 and was originally tested as part of a pilot cluster RCT in a general hospital setting with evidence of a potential effect.38 In our recently completed Medical Research Council Public Health Intervention Development (MRC-PHIND) funded PRISM-A (Alcohol Brief Interventions for Male Remand Prisoners) study, we undertook development and refinement of this self-efficacy-enhancing alcohol intervention within the prison setting, working with men on remand to include a synthesis of their views, with reviews of the evidence base and theoretical underpinnings.40
This current study worked solely with men on remand. We acknowledge that there are also women prisoners who have alcohol-use disorders. There is evidence that women face different issues when imprisoned, and different barriers to services, which are important to note.41,42
The PRISM-A study with men on remand, carried out in two prisons in the UK, showed a high prevalence of risky drinking [82% scored more than 8 on the Alcohol Use Disorders Test (AUDIT)]. These numbers are comparable to other findings in the prison system in the UK,4–8 but more than three times as high as in primary care settings.11 In the PRISM-A study, we were able to access, recruit, consent and identify those who were risky drinkers. We also found high levels of willingness of staff and participants to engage with the self-efficacy-enhancing intervention we tested for acceptability, and a willingness to participate in a trial that would involve follow-up at 6 and 12 months. Analysis of 24 in-depth interviews with male remand participants demonstrated strong substantiation that the intervention could help men on remand to develop skills and strategies that would be particularly useful on liberation. We also identified through the interviews a stronger preference amongst the participants for interventions of longer duration and that such interventions should incorporate a post-liberation component.
This is an under-researched area with large gaps in knowledge. A systematic review of alcohol interventions for offenders in the criminal justice setting identified a lack of evidence-based intervention strategies and highlighted the paucity of knowledge in this area, and in particular the lack of UK-based studies and the absence of rigorous studies focusing on men on remand.8,21
Given the limited evidence on the effectiveness of psychosocial alcohol interventions for men on remand, we aimed to address this gap by carrying out a two-armed individually randomised pilot study to assess the feasibility and acceptability of a self-efficacy-enhancing intervention that had been developed during the PRISM-A study.40 The results from this study will enable us to undertake a future definitive RCT evaluating its effectiveness and cost-effectiveness.
The study aligns to the MRC framework,43 using mixed methods with two linked phases conducted in two sites in the UK: Scotland and England.
Phase I involves a two-arm, parallel-group, individually randomised pilot study. The pilot evaluation provides data on feasibility and an assessment of the likely impact of the APPRAISE intervention to inform the feasibility of a future definitive multicentre RCT.
Phase II comprises a process evaluation. We have drawn on the MRC framework for process evaluation to guide the planning, design and proposed conduct of the process evaluation.44 The aim of the process evaluation is threefold: first, to assess how the intervention was implemented, second, to undertake some preliminary exploration of change mechanisms underpinning the intervention and third, to assess the context within which the intervention is delivered.
An additional element was added to the study, as part of the study extension, during and in response to the COVID-19 pandemic. Following approval from National Institute for Health and Care Research (NIHR), we carried out a survey of prisons in Scotland, England and Wales to ascertain what alcohol services are available in male remand prisons and how coronavirus disease discovered in 2019 (COVID-19) has affected these services.
Study aims and objectives
APPRAISE comprised a two-arm, parallel-group, individually randomised, pilot study of a self-efficacy-enhancing psychosocial alcohol intervention for men on remand in prison. It aimed to provide the evidence to support the design of a future definitive multicentre RCT for which new funding would be sought. APPRAISE had the following objectives and questions.
Objective 1: to pilot the study measures and evaluation methods to assess the feasibility of conducting a future definitive multicentre, pragmatic, parallel-group RCT.
- Is it feasible to conduct a future multicentre RCT of a self-efficacy-enhancing psychosocial alcohol intervention for men on remand?
- Can we obtain reasonable estimates of the parameters necessary to inform the design and sample size calculation for a future definitive multicentre RCT? This includes standard deviations of potential continuous primary outcomes and estimates of recruitment, retention and follow-up rates.
- How well do participants complete the questionnaires necessary for a future definitive RCT?
- Can we collect economic data needed for a future definitive RCT?
- Can we access recidivism data from the Police National Computer (PNC) databases for trial participants?
- Can we access health data from routine NHS data sources for trial participants?
Objective 2: to assess intervention fidelity.
- What proportion of the interventions are delivered as per protocol?
- Is there any evidence of contamination between the two conditions and/or between those workers delivering the intervention.
- To what extent was the intervention changing process variables consistent with the underpinning theory?
Objective 3: to qualitatively explore the feasibility and acceptability of a self-efficacy-enhancing psychosocial alcohol intervention and study measures to staff and for men on remand and on liberation.
- How acceptable are the trial and intervention procedures (including context and any barriers and facilitators) to the following key stakeholders: men on remand in prison and on liberation; prison staff (including healthcare staff); commissioners; policy-makers and third-sector partners?
Objective 4: to assess whether operational progression criteria for conducting a future definitive RCT are met across trial arms and study sites and, if so, develop a protocol for a future definitive trial. Operational progression criteria are based on previous research results.7
- Do the two prisons invited to the study agree to take part?
- Based on knowledge from previous data, do at least 90 eligible participants consent to take part and be randomised across the trial arms?
- Do at least 70% of participants who consent to the trial receive the intervention?
- Are at least 60% of those who received the intervention followed up at 12 months across trial arms and study sites?
Objective 5: to carry out a survey to ascertain what alcohol services are available in male remand prisons and how COVID-19 has affected services.
Structure of the report
The report comprises nine chapters, providing details of the background to the study, the rationale for the study, and an account of the research design, methods and findings. Reporting of public patient involvement (PPI) involvement and on equality diversity and inclusion is included. The report concludes by answering whether the study met its aims and objectives, learning from the study, strengths and limitations, while reflecting on the impact of COVID-19 and details of the recommendations for a future definitive trial.
This first chapter has provided the background research and rationale for the study and presented the study aims and objectives. Chapter 2 details the development of the intervention, presents the various elements of the intervention and theoretical underpinnings, and aligns itself to the Template for Intervention Description and Replication (TIDieR) framework.45 delivery mechanisms as well as the logic model. Intervention training is also described. Chapter 3 reports the pilot trial methods including the management of the study, governance as well as ethics and research clearance. Chapter 4 presents the pilot trial findings, addressing Objectives 1 and 4. Chapter 5 reports the qualitative process evaluation methods. Chapter 6 presents the qualitative process evaluation findings, addressing Objectives 2 and 3. Chapter 7 details the results of the collection and access of economic data and recidivism data for trial participants, addressing Objective 1. Chapter 8 presents the APPRAISE COVID-19 survey methods and results. This was an additional piece of work we agreed with NIHR to carry out during COVID-19 and as part of the study extension period. Chapter 9 presents the discussion, PPI overview, strengths and limitations, recommendations for future RCT and conclusion. The aim of PPI was to provide meaningful engagement with stakeholders who had direct experience of the prison system, ranging from those who have experience of incarceration to those who run third-sector organisations supporting people on release from prison. Our PPI co-applicant was present to contribute in all PMG meetings. The Guidance for Reporting Instrument of Patients and the Public – short form (GRIPP2) form46 identifies the PPI study engagement (see Appendix 1). Finally, recommendations for a future definitive trial are presented. Due to COVID-19, we faced unavoidable modifications to the APPRAISE study. These are reported across chapters at the relevant points. To support completeness of reporting these unavoidable and important modifications to the trial due to COVID-19 (extenuating circumstances), we also completed the CONSERVE checklist9 (see Appendix 2).