Process evaluation results

I think COVID and the impact of COVID, we’ll be dealing with this for a number of years going forward. And I think the longer term effects of COVID, and some of the almost the PTSD from COVID is something that’s going to play out over the next few years

As described in Chapter 5, quantitative and qualitative methods were employed to provide the data required to answer the process evaluation questions. The results of the implementation dose and quality as well as the mechanisms of change associated with the intervention are presented first. This is then followed by the results from the qualitative interview data, which focused on the feasibility and acceptability of the APPRAISE study intervention as well as any reflections on potential contamination and the context within which the intervention was delivered.

Firstly, it is important to acknowledge that the impact of the COVID-19 pandemic was felt by all participants. The pandemic resulted in prison lockdowns, social distancing and increased social isolation; pandemic measures reduced the prison staff capacity and the space available within the prison.

All participants reported on the impact of the COVID-19 pandemic on mental health. The lockdowns were identified as heightening mental health issues, by facilitating social isolation and reducing available support to the prisoners even further. The stakeholders and the interventionists recalled struggling with the different and ever-changing demands within the prison, while dealing with the unprecedented lack of social contact and restrictions outside of the prison.

Intervention implementation results

To confirm intervention implementation, data collection was planned in two ways: intervention booklets (dose delivered) and audio recordings (dose quality).

Dose delivered results

The full results of the in-prison and post-liberation intervention doses delivered are presented in In-prison and post-liberation intervention delivery, Tables 17–19. To recap, of the 68 participants randomised to the intervention condition, 53 received the in-prison intervention session (77.9%, 95% CI 66.2% to 87.1%). This percentage is greater than the 70% threshold specified as one of the criteria necessary for progression to a future larger randomised controlled trial (Objective 4c). Reasons why the in-prison intervention was not delivered are shown in Table 18. They varied from participant declining, being sentenced, released, transferred, in crises, had COVID-19 and unknown.

Only one ‘day-3 post-prison intervention’ session was attempted and was delivered (duration 30 minutes) at the Scotland site. No ‘day-7 post-prison intervention’ sessions were attempted. Only one ‘day-21 post-prison intervention’ session was attempted and was delivered to one participant (duration 30 minutes) at the England site. The main reasons why participants did not receive the post-prison interventions were (1) they could not be contacted and (2) CGL staff were unable to contact participants due to the impact of the COVID-19 pandemic.

Data for the duration (minutes) of the intervention sessions across both study sites are presented for all but one of the 53 interventions delivered in Table 19. There was a marked difference in the median time taken to deliver the intervention between the two sites: the intervention duration was half an hour in England compared to 1 hour in Scotland. The shortest time for an intervention was only 5 minutes in England whereas in Scotland it was 30 minutes. The maximum time for delivery was more aligned across sites, being 70 minutes and 80 minutes in England and Scotland, respectively.

Dose quality (fidelity) results

Interventionist training evaluation scores

Six practitioners from CGL took part in and participated in the training. Two interventionists and two team leaders at the England site and two interventionists at the Scotland study site (see the section Intervention implementation) completed a five-item ‘agree’ to ‘disagree’ Likert scale evaluation asking the trainees to score the Intervention Training sessions (see Appendix 8). Ratings for the six questions were all 4 and 5, with the exception of three practitioners from England who rated Q5 ‘The videos used during the training were helpful’ a 3. One England practitioner also rated Q3 ‘The training was what I expected’ a 3.

England interventionists and team leaders provided some written evaluation feedback. There was no written evaluation feedback from the Scotland interventionists who completed the training.

1. ‘More understanding now’
2. ‘Much more info now – trainer knew her stuff and explained really well – video clip delivery not scripted’
3. ‘Thank you, nice relaxed training’
4. ‘The intervention video – too long and should just be an overview, not full session’.

The Audio Recordings and Behaviour Change Counselling Index scores

During the course of the pilot trial, a total of three intervention sessions were successfully recorded at the Scotland site. Three recordings were reviewed and the BECCI instrument was completed. The mean Practitioner BECCI score for each of the recorded sessions was 4, which indicates the interventionist has been practising BCC to a great extent for all three of the recorded APPRAISE intervention sessions.

Contamination results

During the qualitative interviews with the participants and interventionists and those delivering care as usual, we explored the possibility of contamination. This was with the purpose of identifying any evidence of contamination between those in the intervention and control arm and/or the intervention and non-intervention (care as usual) workers. There was mention of discussion of the study between one of the remand participants and another (see sub-section ‘Coherence: acceptability of the APPRAISE intervention’ in the section ‘Remand participants’ below) but the participant stated that he did not know if the other participant got the intervention or not. No other evidence was obtained of contamination; however, it would be prudent to explore this again in any future work in the absence of a global pandemic, lockdown and restrictions across the prison estate. We had hoped to note the wing/area in the prison where the participant was located and which other participants in the study they were likely to have most contact with. However, this was not feasible in terms of the practicalities within the running of the estates at each study site.

Mechanism of change results

Quantitative and qualitative data were obtained to explore the mechanisms of change. The results of the quantitative data are presented in Chapter 4, Outcomes, Table 28 and Supplementary Material 1, Tables S3.1 to S3.7, and Table 29 and Report Supplementary Material 1, Tables S2.1 to S2.6.

In addition, we also conducted a qualitative exploration of men on remand, and CGL team and stakeholder responses to, and interactions with, the intervention, providing the opportunity to identify mechanisms of change and influencing factors (see section ‘Interview results’ below).

Context

Interviews with the three participant groups contributed to our understanding of the context within which APPRAISE was delivered, to enable the delivery and or impact of the intervention at scale. We also explored any differences in delivery in and across study sites where local organisational and devolved country contexts may haFifteen semive had implications for future intervention design and delivery. The next section provides the interview findings.

Interview results

Fifteen semistructured interviews were conducted with three participant groups from across the two study sites (Scotland and England) and are presented by participant group in Table 31.

All remand participants were from the Scotland study site only. For the CGL team and wider stakeholder groups, participants from each of the two study sites were distinguished by their participant code, by using an E for England and an S for Scotland.

Remand participants

A total of four male remand prisoners were interviewed. Due to the COVID-19 regulations, following the completion of the recruitment of participants to the study, England project staff were unable to be granted further face-to-face access to prisoners. Therefore, as previously mentioned, all prison interview participants were from Scotland. The key themes emerging from the remand participants’ reported data aligned to each of the NPT constructs respectively were: Acceptability of the APPRAISE intervention; Utility and Value to ensure ‘buy-in’ in the APPRAISE intervention; Gaining trust and ‘opening up’; and finally Provision of ongoing support to affect change (Table 32). Within each theme there were sub-themes drawn from the data that collectively provided evidence to support our understanding of the experiences of the remand participants interviewed who had received the intervention.

Coherence: acceptability of the APPRAISE intervention

When exploring the responses around the initial screening process, using the baseline questionnaire to assess alcohol use, in the main, participants were happy to answer all of the questions in the questionnaire and, in general, the questions appeared to be acceptable to the population group, with only one participant saying they found some questions too personal.

I did feel comfortable about the questions and I understood what they meant, most of them nay bother eh I felt fine answering them

Some of them are a bit personal like, but I suppose I felt alright about them, aye

The APPRAISE intervention was reported by the remand participants as being useful and having a purpose.

Good because like, like I say, I didn’t ever talk to anybody about, so it’s good to have somebody that you can talk to, and say I’m feeling like this and tempted to like, use drugs or drink

It seemed useful, do you know what I mean, to help me out going forward, you know what I mean? Get a better understanding, and not going back to old habits basically

In addition, some participants were already able to reflect upon being able to see the benefit of engaging with such an intervention. The data for Participant B also provide evidence of some form of acknowledgement between remand participants about the intervention.

I don’t even know if he got the intervention, but he said he had spoke to yous. And they, it seemed, like he’d already stopped drinking

The data suggest that remand participants were cognisant of the APPRAISE intervention and could reflect upon being participants in the study, the purpose of it and how it could be useful.

Cognitive participation: utility and value to ensure APPRAISE intervention ‘buy-in’

When considering the implementation of the APPRAISE intervention on a wider scale, a key contributor to this, which is incorporated within the Cognitive Participation construct of the NPT, is the notion of participants recognising the value of an intervention and hence facilitate their ‘buy-in’. Participants were seen to value the idea that by receiving support to reduce their drinking, it could have a positive impact on other elements of their life, including reducing re-offending and maintaining their relationships. A specific example of this was a participant who talked about being able to see the benefit of the intervention in allowing individuals to reduce their offending rates as a positive consequence of reducing their drinking.

I think it’s important, I believe that most people who have committed offences have been on alcohol or drugs eh? So, I think it is maybe important to hear people like come in prisons and say they can do stuff. And speak about drink, because there’s big problems there, it is. If they didn’t drink, they probably wouldn’t be half the people in prison. If they never had the problems with a drink. Yeah. So, if the good guys get a bit of help, then maybe it would make them not commit their offences and they wouldn’t come back.

The notion of possible utility and value of engaging in such an intervention appeared to link to the acceptability to engage and the motivation and willingness to change their current drinking behaviour. Remand participants recognised that they needed help with reducing their alcohol consumption outside of prison, from completing the initial baseline question and intervention session, and hence appeared to welcome receiving support and having a new way of approaching it.

I wanted that support, I wanted that definitely, and into, I wanted that into it as well, you know, how you can change and how you can do better with your life, you know what I mean? It’s just that wee bit knowledge, that what I never had and that goes a long way when you’ve got it and then you’re off doing it, you know what I mean?

Within the data, remand participants were seen to talk about not knowing where to go to access or receive the support or help they needed when early in the process of thinking about reducing their alcohol consumption.

If you’ve got that from inside going out, then you’ve got more of a chance I would say of you actually doing it.

Therefore, as the first intervention session was delivered within the prison setting, it was seen as beneficial to participants to allow them to consider new habits once liberated.

Collective action: gaining trust and ‘opening up’

The idea of gaining trust and building a rapport during the first intervention session was reported recurrently, and is one which is highly indicative of the Collective Action construct of the NPT. Building and maintaining trust and having staff members who possess the relevant characteristics and qualities to be able to do so was seen to significantly increase the acceptability of the APPRAISE intervention.

some people just cannae, I don’t know they just cannae talk to people, do you know what I mean, for whatever reason, so I, that might be like your only barrier would be like getting through to people and saying, listen were just here to talk about this, if you want to talk but just many people understand why they don’t want to talk to people about things but, but whatever went on in their life basically they’re not willing to share.

The issue of being unable or not wanting to talk about or vocalise problems to staff was discussed by the participants. However, one participant talked about feeling more comfortable to talk to a peer and it feeling more acceptable and relatable to engage with someone who had lived experience or who could empathise with an individual’s situation and offer a positive pathway for change.

I mean, not to say you’re intimidating or anything like that. You’re not, but it’s like, men don’t like to talk generally, especially on issues. They kind of close down. But yeah, you need to get some people inside, I guess. You know, so if you get someone here that goes out and reaches out to people in the hall there, that would help I think. It’s easier than them coming to you. If there’s somebody like me going to them, and going like, listen, man, I think that’d be good for you, I’ve done it and I can tell you this, this is what’s helped me, this is what it’s like, you don’t have to be fearful, if you don’t want to, you know what it is, you don’t have to do it. You don’t have to say this. You don’t have to say that. You know but give it a chance.

It was clear that being able to open up and to speak to the individual delivering the intervention was important to the prison participants. The same participant talked about the importance of building a rapport with the support worker and gaining a relationship of trust to facilitate the delivery of the intervention.

I’ve got a lot of trust, I’ve got a lot of trust in this lassie. And that’s only because she was helping me, she was helping me with things I didn’t know nothing about, do you know what I mean?

The sharing of information with the intervention delivery staff emerged as key. A challenge around the acceptability of the APPRAISE intervention was observed when the prison participants talked about being unable to ‘open up’ and talk to a new interventionist or support worker about their personal experiences or alcohol consumption.

Reflexive monitoring: provision of ongoing support to affect change

When asked about what would improve the intervention session or add to its usefulness or making it worthwhile, participants considered the offer of a continuous and ongoing package of support to be most useful.

Continuous, continuous support, you know what I mean. And letting people know, you’re definitely having the possibility of contacting people, you know, you’re just not being left to your own devices, to your own thoughts.

All four participants welcomed the idea of having continuous and ongoing support, that they could access easily and build on the content of the intervention, in times of need for additional support.

The discussion on the post-release intervention sessions identified them as being less acceptable and feasible to remand participants. The remand participants talked about the importance of the post-release intervention support being obtained quickly, before an individual was able to return to their old habits.

I think if that, work, that help was still there right at the gate, waiting for the guy to go out to you’d have many a chance of like benefiting.

However, many of the participants reflected upon the challenges of a participant being released from prison and establishing any reduction in their alcohol consumption, regardless of receiving an ABI in prison. They talked about an individual being released from prison and then finding themselves in situations where alcohol was freely accessible again or being in the company of other individuals that they used to drink with or who were drinking around them and falling back into previous risky drinking habits.

I dunno like, some people might work like, aye you might work with people in the jail, and like outside the jail, but it would be a lot harder outside the jail, because obviously other people could come in here with all good intentions of going to interventions, or whatever it may be, but when it gets out there it’s all going to be different, eh?

On a more practical point, participants spoke about the difficulties that they would face in contacting an interventionist once they were released and vice versa. One participant talked about lacking a phone, and hence being unable to receive calls to arrange a follow-up session with a support worker or to contact them quickly if he needed any additional support.

You see now, outside everybody expects people to have phones. I was like, I’ve not got a phone, you know what I mean, so, they’d look at me and go, well some of my workers would go, ‘what you’ve not got a phone?’ How, now, wait a minute and they might now think different and go, ‘we need to write you a letter’. You know, and that, a letter can take days to try and get to you, whereas a quick phone call is like there and then isn’t it.

Therefore, different methods of keeping in contact with men post-release appeared to be a key area warranting further consideration in future work, to facilitate successful implementation and success of the intervention over time.

Change Grow Live team participants

A total of six members of the CGL team participated in the semistructured interviews. The team members were all responsible for delivering alcohol and substance use interventions, within the prison setting, prior to the study and were all employed by the respective commissioned service provider at the time of the study taking place. This included those who delivered the APPRAISE intervention at both study sites and had received the intervention training. From the CGL team participant data, four key themes emerged: making sense of new ways of intervention practice; engaging in the APPRAISE intervention content; investing in alcohol prevention interventions; and scaling up the APPRAISE intervention (Table 33). Subthemes for each were identified, providing an insight into the context and system within which the intervention was delivered and providing key areas for recommendations if the APPRAISE intervention were to be scaled up and implemented. The CGL team participants reflected upon several factors related to the prison setting and alcohol services that they reported were relevant to the acceptability, feasibility and implementation of the APPRAISE intervention.

Coherence: making sense of new ways of intervention practice

In order to deliver the APPRAISE intervention, the CGL team who were to be involved in delivering the intervention and supporting the study were required to undertake APPRAISE training. Even though they were likely to have been delivering/managing/supporting a form of alcohol brief intervention within the prison setting previously, they were asked to complete training. Interview participants were asked about the training they received to determine whether it was fit for purpose and whether it was acceptable and feasible to them. Training is a key part of the NPT’s Coherence construct as it relates to the participants’ understanding of what was expected of them and being able to see the value of a new intervention or practice.

Generally, the training was well received by the interventionists. It was seen to be pitched at an appropriate level for them to understand the components of the APPRAISE ABI and to feel confident with the delivery following the session.

When we came to doing the APPRAISE books we knew exactly, yeah. It went well.

Even participants who were not feeling enthusiastic about undertaking the training felt that it was a valuable experience and allowed them to gain the skills and knowledge they needed to deliver the intervention.

I was quite keen not to go through it. But I’m glad we did. Because otherwise I wouldn’t have known that tool so well.

The less acceptable elements of the training appeared to be the role-play components, the amount of paperwork and the overall length of the session. One participant said they did not usually enjoy role-playing in training sessions, but they agreed that it added value to the training, in developing their understanding around the best ways to deliver an intervention to a prisoner.

I’m always apprehensive about role playing. It’s not anybody’s favourite thing to do. But actually, it was, it was quite good.

The feedback about the length of the training was that the session was too long, and that the content could be covered effectively in a shorter time frame.

I’m thinking maybe even just the one half-day probably would have been enough. Erm, cos yeah, I sort of felt like I had it after the first one, kind of thing.

In addition, the same participant felt that the amount of materials provided was overwhelming, and that they didn’t have time to look at them post training.

I remember getting a lot of paperwork though, supposed to read through and didn’t. I had every good intention of reading the paperwork. Yes. Just never found the time.

When talking about the intervention itself and the content, the interventionists were largely positive and indicated that it was well received by both the prisoners and the delivery staff.

everyone we talked to thought it went very well.

They seemed like the, you know, it was interesting for them, it was a little bit different. Yeah, no, it was, it was good. Yeah, there was a little bit of resistance with some, but not with many, I would say.

The fact that the ABI was different from the usual treatment and was ‘more structured’ and ‘repetitive’ in content appeared to be a facilitator for wider implementation.

I think there was actually a bit of intrigue around it, just because it was something new and something different. And you tend to find that does sort of pique people’s interest? That actually the idea of this something new, something different. That might be what works for them? Was something worth sort of buying into?

Being able to see the difference from current ways of working or usual care is part of the Coherence construct of NPT. Being able to identify how the APPRAISE intervention is different and valuing those differences can be a key facilitator of early implementation.

Cognitive participation: engaging in the APPRAISE intervention content

Similarly, to the remand participants, the CGL team participants stressed the importance of staff motivation and encouragement. Building a rapport between the prisoner and the interventionist delivering the intervention meant the prisoner was more likely to share their alcohol consumption habits and engage with the intervention content.

You know, just conversation, building some kind of rapport and relationship.

That’s the most important thing. Motivation and encouragement that’s the most important thing.

CGL team participants reported their belief that if the staff were motivated and encouraging when delivering the ABI, the prisoners were more likely to engage and take more from it. This is indicative of the Cognitive Participation construct of the NPT, which considers how key individuals can drive the intervention forward and support the implementation of an intervention. If the APPRAISE interventionists are motivated and can see the value of such an intervention, this could facilitate the implementation further.

The need for staff buy-in is also reflective of the Cognitive Participation construct of NPT, where implementation is supported by the relevant individuals buying into an intervention. The issue of staff capacity and space is encompassed within the Collective Action construct, which relates to the need for those involved in delivery of the intervention to have the motivation, capacity and ability to deliver it.

Collective action: investing in alcohol prevention interventions

From the interviews it was clear that the services and treatment options that were currently available to the men on remand were limited. The interventionists valued an ABI that was targeted at men on remand, as they generally had fewer services available to them, and it provided a window of opportunity to offer support post release.

There are a lot of services in here that are only available for people who have been convicted.

The lack of service and treatment options available to the remand population at the time the interviews were undertaken was accompanied by reports that alcohol consumption was being viewed as less important or the ‘lesser of evils’ within the remand prison setting. One participant labelled alcohol as ‘being continuously left behind’, as the primary focus tended to be on substances that were more likely to cause significant damage in the short term, by overdosing or causing immediate harm.

I think alcohol is left behind a bit. A lot of concentration is on heroin, and methadone. Because the powers that be are so worried about people overdosing, which, obviously we all are.

CGL team participants reported how it had been eye-opening for the remand prisoners involved in the study to better understand the risks associated with alcohol consumption as opposed to drug use.

On a more practical level and building upon the prison setting as a suitable or feasible location for intervention delivery, a commonly reported issue was the lack of space. All of the participants reported room availability being very limited and often interventionists had struggled to find acceptable rooms to deliver the APPRAISE intervention.

Issues with rooms is kind of permanently a thing. And there, there’s never enough space.

As the interventionists were delivering the APPRAISE intervention over and above their usual service provision and need for rooms, room availability was even more stretched than usual and available space was very limited.

I couldn’t, because there weren’t enough rooms to facilitate the APPRAISE project, whether it was you in with interviewing somebody or [name removed] over to do the intervention with somebody. And it was just like for goodness sake, but you know. But, again, that’s life. And that’s how it goes. And that is just one of the ties with having such little room in this place.

more dedicated time, more dedicated space. And at the end of the day, you need, you need that buy in.

This is reflective of the Collective Action construct of NPT as it highlights the importance of how the host organisation, that is, the prison estate, is able to adequately support the implementation of the new practice; the pressures on suitable room availability could hinder the feasibility of an intervention future roll-out.

Reflexive monitoring: scaling up the APPRAISE intervention

A specific element of the intervention content that the interventionists from the Scotland study site reported they had found was a challenge for men on remand during intervention delivery was in navigating the variable numbering system of different scales. Two CGL team participants talked about the need to standardise the numbering so as to not exclude or frustrate the interventionists during delivery.

But the one thing that confused me and confused a few of the guys that I did the brief intervention with, was the change in the numberings. So, I think one of the, some of them were between one and five, and some of them were between one and 10. And that did throw people off, myself included.

One participant talked about the difficulties of maintaining implementation fidelity in an ever-changing, dynamic environment, such as the remand prison setting.

different workers have different approaches and different service users have different appointments.

Similarly, to the remand participants, the CGL team participants found the post-release follow-up sessions to be less acceptable and feasible to conduct in practice. Follow-ups were made challenging by inability to make contact with prisoners post release and this was further hampered by the COVID-19 pandemic, which made it impossible to meet face-to-face. The interventionists reflected upon the different methods of establishing contact with the prisoners. Letters were often seen as helpful, as a tool for prisoners to refer back to, and also sending text messages, prior to making a phone call, to introduce who was calling them.

sending a letter can be quite helpful, because sometimes it’s just that kind of post release panic of trying to get everything sorted out. And then the dust settles, and then they go, ‘Oh, yeah, I was offered that support’.

I would send that text explaining who I am because I know these guys and they won’t answer numbers they don’t know.

After being a part of the APPRAISE pilot study, the interventionists appeared to be positive about it being scaled up and extended as a larger study to determine the effectiveness of the intervention and could see the potential of the APPRAISE intervention in the setting.

yeah, I think it’s, a bigger study would be good. Very definitely.

I quite liked the project. Would be nice to see it done like on a larger scale because I do think it has, it has potential.

When asked to reflect upon the factors that would enable the delivery and facilitate future scale-up, a key facilitator of the pilot study in the setting was the researcher being able to understand the context and the management of the prison and hence being flexible and accommodating to any unexpected situations that arose.

I would say that the research team was flexible, which was good, and because they appreciated the difficulties and the pressures that we are often under as a team, due to various factors such as staffing, for example.

Being flexible aided the acceptability of conducting a research study within a prison and the researchers, within the APPRAISE study, were able to build a rapport with staff and support them with any issues as required, which would also be important within a future trial or considering future roll-out.

A commonly talked about barrier to research within the prison was capacity, in addition to the issue of space. Thinking specifically about staff capacity, interventionists talked about already having a high case load of prisoners, prior to working on the APPRAISE study, and therefore they often felt apprehensive about the thought of a research study adding to their burden.

I think concern for anything that we end up doing that’s an addition to somebody’s core duties that they do, there’s always just like, concerns about how that’s fitting in. But then, I think they had a bit more reassurance once it’s like, ‘okay, we’re only going to ask you for this amount of commitment’.

Therefore, exploring ways to ameliorate these issues would contribute to future feasibility of roll-out. On a positive note, the interventionists were in agreement that the APPRAISE study did not add significantly to their workload in practice. However, it has to be remembered that the majority of the post-liberation intervention delivery did not take place due to COVID-19. And participants did talk about how they thought a larger-scale trial in the future may be more difficult in terms of capacity.

would just be capacity for workers so I guess if it was a larger study, it’s just how?

Stakeholder participants

The final group of interview participants consisted of stakeholders who were involved with the delivery or the management of the APPRAISE pilot study. This group consisted of five participants ranging from the researcher who was managing one of the study sites and going into the prison to recruit the participants, to prison staff who were involved with the undertaking of the study and recruitment. The four main themes were: understanding the diversity of the prison population for APPRAISE intervention delivery; acceptability and utility of APPRAISE intervention champion; the value of networking; and awareness of the individuality of the prison environment and vulnerability of the remand population. Subthemes emerging from the stakeholder interviews are presented (Table 34).

The themes and subthemes emerging from the stakeholder interview data were very similar to those of the interventionist data. Similar findings were reported around the prison’s logistical constraints affecting the APPRAISE intervention feasibility, such as space and staff capacity, the importance of engagement with prisoners and the lack of currently available support for prisoners on remand. Overlapping findings are not discussed further in this section to avoid repetition. The novel themes and subthemes that came out of the stakeholder data were around the intricacies of the prison environment and how it affected the study and intervention delivery, the individual differences across the setting and across the participants, and further barriers and facilitators to delivery of the APPRAISE intervention.

Coherence: understanding the diversity of the prison population for APPRAISE intervention delivery

The need for joined-up care and signposting to different services links to another key finding from the stakeholder data, around understanding the remand prison population. A key facilitator in ensuring that the APPRAISE intervention was acceptable and feasible in practice was the delivery staff being able to understand the population. As the stakeholder group included mainly prison staff, it included people who understood this population well.

we need to understand the cohorts we’re dealing with as well as the remand group, particularly younger drinkers and particularly the kind of thinking around it.

This included being able to understand that younger drinkers were likely to have different drinking patterns, in comparison to an older population group. Therefore, having an understanding of the diverse population group and how to work with them would be advantageous when considering the future delivery and wider implementation.

A barrier which was reflected upon briefly in the prisoner findings, and directly linked to understanding the population involved, was considering the language used in both the intervention and questionnaire. Several stakeholders who had significant experience working with remand prisoners talked about the need to simplify the language for it to be acceptable for the population. The findings highlighted that the population group often had literacy or comprehension difficulties.

I get that I think some of it is come from, you’re already, you know, evidence based and use trials. You know questionnaires, but you’re working with a different clientele?

Another stakeholder participant talked about the fact that the language that was acceptable to academics isn’t always acceptable for this population group. This led to the discussion around the need to ‘demystify’ overly complex language.

I think the other things is finally around brief interventions is to demystify an awful lot of language that people use in treatment eh I think academics are the worst for it.

Cognitive participation: acceptability and utility of the APPRAISE champion

Thinking about some of the findings which might increase the acceptability and utility of the APPRAISE intervention in practice, it was reported by one stakeholder that the use of ‘intervention champions’ could be advantageous. The stakeholder talked about the importance of having an individual, within the prison setting, who clearly saw the purpose of the intervention and who was motivated to engage others to deliver and implement it. The stakeholder participant was able to see the effectiveness of having an intervention champion in other settings, therefore they believed it would be useful to employ this strategy within the remand prison setting.

they become your champions, they do it everywhere else why not do it around this particular intervention, because when they are gone, they trained the next leader.

This finding is concurrent with the Cognitive Participation construct of the NPT, as it includes the concept that key individuals are responsible for driving an intervention forward. Similarly to the prisoner participants, the stakeholder participants could also see the benefit and relevance of employing people with lived experience of alcohol use or the prison setting, in the intervention delivery process, as it appeared more acceptable to the prisoners.

that’s where lived experiences are really important, peer support, peer mentors, mutual aid groups, recovery networks, visible recovery.

The discussion around prisoners and their individual needs is linked to another finding that prison staff were often apprehensive about allowing research to be undertaken in the remand setting. One participant talked about how they felt protective of prisoners taking part in research studies and that they had to be able to see the benefit to the prisoner in taking part in the research, before allowing a study to take place.

Some staff are very protective of their prisoners as well and they don’t like to see tours coming in or high school kids coming in, or university guys just coming in, because we don’t want people in our care to be treated like, you know, it’s like a fishbowl.

This is again reflective of the NPT Cognitive Participation construct, as the stakeholders needed to be able to see the value of the new ABI to the prisoners, before agreeing to take part in the research study.

Collective action: the value of networking

Another perceived facilitator to the APPRAISE intervention delivery was being able to work with other services to create a network and to offer signposting, and stakeholder participants frequently talked about the importance of adopting a ‘joined-up’ approach. One participant talked about promoting a ‘social network’, to support the different treatment services.

If your cat is sick and your car breaks down who do you ring? You don’t ring the same person, so from that perspective that’s why networks are really important, your social networks, so what you need to understand is what social networks and what other services do they buy into, where do they go.

Working with other services and the sub-theme of trust came across in the findings. This is reflective of the Collective Action construct of NPT, as it includes the concept of participants being able to maintain their trust in each other’s work and expertise throughout the work of an intervention, such as the APPRAISE ABI.

Reflexive monitoring: awareness of the individuality of the prison environment and vulnerability of the remand population

As expected, the remand prison setting was found to be dynamic and largely unpredictable. This meant that there was a constant pressure felt by the prison staff to be able to adapt to the changing environment and situations.

my main interest is in this place is keeping the place safe, keeping it decent, but keeping people alive when they come in, because I manage an awful lot of chaos in a very confined custodial setting.

They’ve also usually got quite a lot of chaotic things happen in the background.

Specific challenges that were discussed across the two study sites, and at times which affected the study and recruitment, included prisoners’ illicit drug and alcohol use, physical violence and the prison going into lockdown. Poor mental health was also a commonly reflected-upon issue that added to the unpredictable nature of the population. The reported stigma of being on remand was felt to contribute to this, with one participant reflecting upon the challenges associated with a prisoner adapting to their environment.

Just a week on remand can mean family breakdown, loss of job, loss of status, stigma, self-esteem, down the toilet, you know, so that’s you, you know, you’ve got it branded, is right in the middle of your forehead.

The trauma experienced by the remand prisoners as reported by one stakeholder participant identified that this also extended to their release, and the APPRAISE study findings indicated that this was a contributing factor to why the follow-ups were difficult in practice (aside from COVID-19), as the prisoners struggled to ‘re-establish their lives’ post release.

And you know that that traumatic, that trauma they’ve just went through, probably might not be the one trauma they have. They’re now leaving custody to try and re-establish their life under a great deal of stress and pressure, and probably are here at least in part due to alcoholism.

The individual nature of both the prisoners and the prison setting was highlighted. Stakeholder participants commonly reflected that what worked in one prison may not necessarily work in another, due to the individuality of the settings. However, there was a consensus that although there were differences experienced across prisons, there would also be a certain degree of consistency.

obviously quite different in general quite different prisons, but you would expect some consistency.

The idea of individuality also extended to the prisoners and acknowledging their differences and individual needs. Stakeholders talked about the importance of the services, offered to remand prisoners, not just acting as a tick-box exercise, but being able to adapt and encompass prisoners’ individual differences.

I think, trying to just keep away from a map that’s got tick boxes on it, is better. We need to talk to that individual about their individual needs and how it’s affecting their individual well-being.

One participant talked about how prisoners were often seen to be excluded and labelled as ‘hard to reach’, due to them not engaging in a particular activity or service. However, this was often more complex than that because prisoners were seen to be likely to be struggling with various issues, or it was found that the service did not meet their needs or was not acceptable to them etc.

services generically are quite often designed where people don’t feel they’re included.

Therefore, it appeared to be important to consistently appraise the ABI to ensure it is not a ‘one size fits all’ approach and that it meets a range of different prisoners’ needs. This is reflective of the Reflexive Monitoring construct of NPT, which highlights the importance of modifying relational work in the appraisal of a new practice or intervention. Clearly clarifying which components of the ABI can be subject to modifications and which need to exist as ‘core components’ will aid implementation in a future trial.

Summary of findings

Analysis of the 16 interviews highlighted key findings from the qualitative work, in regard to the acceptability and the feasibility of the APPRAISE intervention. The in-prison APPRAISE intervention session appeared to be acceptable and feasible to receive and deliver according to all of the participants we asked. The intervention sessions delivered post liberation appeared to be more challenging in practice and less feasible to complete because of a plethora of different factors, such as being unable to re-establish contact with males upon their release and individuals relapsing to their previous risky alcohol consumption when alcohol was more freely available. Therefore, it would be imperative to explore different ways to make contact with the men post release and to provide more emphasis to strategies of avoiding relapse in future work, if pursuing an intervention which included post-release sessions. Picking up on the value of networking, it may be prudent to explore how the Probation Service could play a role in facilitating making contact with the men post liberation.

The prisoner participants appeared to welcome receiving support for making changes to their alcohol consumption and talked about the utility and value of the intervention in order to ensure buy-in from them. Importantly, they also mentioned the need for the provision of ongoing support and the practicalities of that. Fundamental to the men was the importance of fostering an environment that promoted an individual to feel comfortable and trusting of the interventionist, in order for the men to open up and share their personal experiences and discuss their consumption patterns and potentially other areas of their lives that were relevant to drinking.

The interventionist findings also included the importance of building a rapport with prisoners when undertaking the intervention sessions. In addition, they talked about how the prison setting and culture affected the acceptability and the feasibility of implementing an intervention due to the lack of currently available options to the remand population, the lack of available space in the prison and limited staff capacity. Investing in alcohol prevention interventions were identified as important as other behaviours that impact on health and well-being. The intervention training and content appeared to be largely acceptable and were key to identifying the purpose of the intervention, while understanding the impact of the intervention would facilitate scaling up in the longer term, although it was thought that the time taken and the materials used could be reduced to ensure the feasibility in future roll-out. The delivery significantly benefited from staff buying into the intervention and being motivated and engaged with the content.

The final stakeholder group expressed the need for implementation to fully understand and respond to the diversity across the prison population and the different drinking patterns that may exist. They also believed that the language used could be modified and simplified to be more acceptable for the remand population. In addition, the need to create safe spaces, fostering inclusivity and adaptation to meet the individual needs of the remand population, was identified. An awareness of the vulnerability within the prison environment for those on remand and being cognisant of this in working to implement new interventions within the estate was identified as being required. The relevance of the lived experience and that those with it can have a role to play alongside the wider network of services could shape the implementation of the APPRAISE intervention.

Finally, all participants interviewed appeared to be enthusiastic about facilitating future work in the area and building upon the delivery of the ABI in the APPRAISE study. Researchers were able to introduce the study effectively, develop rapport with the prison staff and maintain flexibility to ensure minimal disruption to the setting, even during the unprecedented COVID-19 pandemic. The fact that participants relayed that the services and treatment options currently available to remand prisoners were extremely limited further highlights the need to broaden the existing services in this area and work towards a future trial of the APPRAISE intervention to determine the APPRAISE intervention effectiveness.

This, therefore, further confirmed the importance of the remand prison setting as a suitable location for delivering the APPRAISE intervention and the importance of the wider network that could support implementation.

Although this did not appear to have a negative impact on delivery, in a future roll-out it may be prudent to condense training sessions and the accompanying materials to ensure that it remains acceptable and feasible to a larger cohort of interventionists.