An Alcohol Brief Intervention (ABI) for male remand prisoners: an MRC complex intervention framework development and feasibility study

There are just over 90,000 prisoners in UK prisons with 20% accounting for those on remand. Those who have or are at risk of offending frequently suffer from multiple and complex health issues, including mental and physical health problems, learning difficulties, substance misuse and increased risk of premature mortality. The impact of harmful alcohol use impacts significantly not only in relation to individual health, but also to the wider community and society as a whole. The cost of alcohol to the NHS is estimated at £3.5 billion per year. Alcohol-related crime costs £11 billion per year and as many as 70% of prisoners have admitted to having been under the influence of alcohol when committing the crime for which led to their imprisonment. We know that a large number of prisoners have a high rate of alcohol problems when compared with the general population, with an even higher rate amongst remand prisoners. Remand prisoners are those who are both unconvicted and convicted and unsentenced. They spend on average of 9 weeks held in custody awaiting trial and/or sentencing. This makes it difficult for them to access regular prison based alcohol services and receive interventions or treatment. We also know that brief alcohol advice in the form of an Alcohol Brief Intervention can be effective in achieving a reduction in alcohol consumption when delivered by nurses in certain health care settings. Prison therefore offers an opportunity for nurses to identify, respond and/or refer to treatment those remand prisoners who are consuming alcohol above recommended levels. There is however, limited evidence for the effectiveness, optimum timing of delivery, recommended length, content, implementation and economic benefit of Alcohol Brief Interventions in the prison setting for remand prisoners.

The proposed research wishes to develop an Alcohol Brief Intervention that is acceptable for delivery by prison nurses to male remand prisoners who have been identified as drinking alcohol at a level that is or has caused them harm. The study will also measure how feasible it is to deliver this intervention in the prison setting to male remand prisoners.

We will undertake the development of the Alcohol Brief Intervention through in-depth interviews and surveys with male remand prisoners and prison nurses in one large prison in England and one large prison in Scotland. From the data collected we will refine and develop an acceptable Alcohol Brief Intervention that is feasible to deliver and is based on sound behavioural change concepts.

The work is of importance to fill existing gaps in this area. We currently don't know what 'type' of Alcohol Brief Intervention is needed or is acceptable to the remand prisoner population. We are also unsure as to the issues surrounding the feasibility of delivering such an intervention by prison nurses. This study will address these issues. The development of an acceptable Alcohol Brief Intervention will then enable us to undertake a future pilot study, followed by a definitive Randomised Controlled Trial (RCT) evaluating its effectiveness and cost-effectiveness and ultimately an implementation study.

Background: In the UK it is known that a significant number of male remand prisoners have a high rate of alcohol problems when compared with non-remand prisoners and the general population. There is an association between alcohol and violent crimes with a rising number of offenders citing alcohol as a contributory factor of their offending. Alcohol Brief Interventions (ABIs) based on enhancing self-efficacy (a main causal determinant of behaviour) are an effective component of a population-level approach to harmful and hazardous drinking, assisting in reducing the aggregate level of alcohol consumed and therefore lowering the whole population's risk of alcohol-related harm. However, there is no evidence as to the effectiveness of a self-efficacy enhancing ABI in male remand prisoners. The development of such an intervention is of public health importance and is therefore warranted.
Aim: The aim of this early phase study is to adapt and define a self-efficacy enhancing ABI intervention to enhance Drinking Refusal Self-efficacy (DRSE) that will be acceptable to male remand prisoners. Methods: The methods draw on the MRC framework for early phase work, focusing on development and feasibility using mixed methods. We will undertake in-depth interviews with male remand prisoners (n~24) and 2 focus groups with prison nurses (n~6-8 in each group) in 2 large prisons accommodating male remand prisoners (1 Scotland; 1 England). A random cross-sectional survey of male remand prisoners (n~400) will then be undertaken to assess acceptability and feasibility of delivery. Data gathered will then be used to inform the refinement of an acceptable intervention that is feasible to deliver through formal Intervention Mapping. Future research: This intervention will be utilised in a subsequent pilot study. Ultimately a definitive Randomised Controlled Trial (RCT) will be conducted evaluating intervention effectiveness and cost-effectiveness, followed by an implementation study.