Abstract
This article documents the methods used to assess the implementation costs of the APPRAISE (A two-arm parallel group individually randomized Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement) alcohol brief intervention (ABI) delivered to male remand prisoners across two study sites in Scotland and North East England.
We first developed a comprehensive taxonomy of the activities constituting the APPRAISE ABI. Next, data about the study staff and the subject time spent were collected for each activity, in addition to the other resources used and unit costs.
From the pilot data collection, it was possible to construct a narrative, for both study sites, how the intervention was delivered and the time required for each activity. The ABI was delivered by Change Grow Live and Humankind intervention staff. Staff salaries were obtained from both organizations to calculate the staff delivery costs for each site. Other costs, such as the printing of materials, were estimated based on APPRAISE study records. Because of the ongoing COVID-19 restrictions and limited access to prison resources and staff, there were significant deviations from the initial study protocols. As a result, we document the costs of implementing the ABI as delivered rather than as planned.
This article provides the first estimates of the implementation costs of an ABI delivered in a criminal justice setting in the United Kingdom. Although these costs are from a pilot implementation that was heavily impacted by the COVID-19 pandemic, this article nonetheless provides useful, policy-relevant information on the potential costs of providing ABI to remand prisoners. It also serves as a methodological template, guidance, and proof of concept for future micro-costing studies of ABIs in criminal justice settings.
The prevalence of risky drinking, defined as drinking alcohol at levels harmful to a person's health, is far higher among individuals within the criminal justice system (CJS; 73%; Brown et al., 2010; Coulton et al., 2012; Newbury-Birch et al., 2009, 2014, 2016) than the general population (35%) (Funk et al., 2005). In the United Kingdom, between 51% and 83% of incarcerated people are risky drinkers (Heather et al., 2008). However, for those on remand in prison (i.e., incarcerated while awaiting trial), the prevalence of risky drinking is between 62% and 68% (Newbury-Birch et al., 2016). Systematic reviews and meta-analyses indicate that alcohol brief interventions (ABIs) are effective in reducing alcohol consumption among risky drinkers in healthcare settings (Kaner et al., 2007; O'Donnell et al., 2014). However, few studies explore the effectiveness of ABIs in reducing risky drinking among individuals involved in the CJS or who are incarcerated or in a remand setting (Heather, 2016; Newbury-Birch et al., 2018). PRISM-A (Alcohol Brief Interventions [ABIs] for male remand prisoners: protocol for development of a complex intervention and feasibility study) was a U.K.-wide study by Holloway et al. (2017), which explored the feasibility and acceptability of an ABI for adult male remand prisoners in order to develop the ABI for future work that was then piloted in this APPRAISE trial. Evidence from the PRISM-A feasibility and acceptability study suggests that both staff and prisoners exhibited high levels of willingness to engage with a prison-based ABI, and prisoners even voiced their support for a longer intervention that helped men on remand develop skills and strategies useful on their liberation (Holloway et al., 2019). Therefore, the APPRAISE (A two-arm parallel-group individually randomized Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement) pilot study viewed the remand setting as providing an actionable moment for intervention, which is not as easily achieved following release from prison.
The APPRAISE pilot study was a two-arm, parallel-group, individually randomized, pilot study of an ABI that was developed for use with men on remand and conducted across two prison sites, one in North East England and one in Scotland (Holloway et al., 2021). An important component of the pilot was to demonstrate the resources needed to implement the APPRAISE ABI and to test data collection methods. Hence, as part of the pilot study, we developed a micro-costing protocol for the APPRAISE ABI and conducted an initial assessment of the implementation costs associated with delivering the APPRAISE ABI. This embedded piece of work provided an opportunity to determine the cost data that would be needed to support a more in-depth health economic analysis within a future randomized controlled trial, to pilot test the APPRAISE micro-costing methodology, and to provide one of the first estimates of the implementation cost of ABI in a CJS setting.
Although guidance on economic evaluation exists for the UK health sector (National Institute for Health and Care Excellence, 2013), the APPRAISE ABI encompasses a wider stakeholder group, including the prison, other CJS stakeholders, and the prisoners themselves. Convincing these groups of value from their own perspective may help alleviate implementation barriers should the intervention warrant wider dissemination. To that end, the broader APPRAISE economic evaluation considers multiple perspectives. In this article, we use a micro-costing methodology that reflects the opportunity costs of relevant stakeholders involved in implementing the APPRAISE ABI, with a primary focus on prison and third-sector service delivery staff. The base year for all costs was set to the 2020–2021 financial year. Discounting and inflation adjustments were not necessary because the time horizon for the analysis was less than 1 year, and all price estimates related directly to the base year.
Full details of the wider trial methodology can be found in our published study protocol (Holloway et al., 2021) and final report (Holloway et al., in press). The APPRAISE study was a mixed-methods pilot study. It sought to recruit 180 adult men on remand across two different prison sites: one in the Scottish Prison Service (SPS), in Edinburgh, Scotland (n = 90); and the other in His Majesty's Prison and Probation Service (HMPPS), in Durham, England (n = 90). All cost estimates are separated by site for comparison purposes.
Prisoners meeting inclusion criteria were men age 18 years or older who had been in prison for 3 months or less on remand, were detained in either the SPS or the HMPPS study site, were able to provide informed consent for participation, and scored eight or higher on the Alcohol Use Disorders Identification Test (Saunders et al., 1993), which was included as part of the baseline questionnaire. Exclusion criteria included having been previously recruited to the APPRAISE study; unwilling or unable to give informed consent; judged by research staff as unable to make an informed decision regarding consent; identified by prison staff as a risk to themself or others; judged to be under the influence of an illicit substance by either the prison or research staff; currently taking Antabuse (or the equivalent); on a prison segregative rule; or unable to understand written study documents, which were only in English, or unwilling to agree to the research assistant working with them to understand the study documents.
Eligible prisoners were randomized, in a 1:1 ratio, to either the APPRAISE ABI condition or a control condition. In the control condition, study participants received alcohol use treatment as normally provided. In-prison usual care for alcohol use disorders comprises an alcohol assessment and referral to further alcohol treatment options if requested. In-prison treatment options were provided by commissioned service providers and typically consisted of in-depth counseling. Postrelease care coordination for alcohol treatment was provided by the same commissioned service provider as inprison services and included referral to a range of community-based treatment options, including detox, self-help, and counseling options. At the time of the APPRAISE pilot, the commissioned services contract was held by Change Grow Live (CGL) in Scotland and Humankind in England.
The APPRAISE ABI was delivered to study participants by specialist intervention staff via CGL in Scotland and Humankind in England. Although trained separately, CGL and Humankind staff delivering the APPRAISE intervention received the same training. A detailed process evaluation was conducted to ensure intervention fidelity across the two study sites and assess the potential for contamination. As reported by Holloway et al. (in press), the process evaluation concluded that, although sessions ran longer than intended, the content of the in-prison intervention sessions was delivered with fidelity and there was little evidence of contamination. The process evaluation also examined contextual differences across the two study sites. As documented in the process evaluation and as we discuss below, there were differences between the prisons that affected the cost of the intervention, but these differences largely impacted the logistics of locating study subjects.
The intended APPRAISE intervention consisted of an initial face-to-face session with the participant, while on remand, followed by three follow-up phone sessions on, or as close to, Day 3, 7, and 21 after liberation. The exact days of delivery of the postliberation session were recorded to inform the study's process evaluation. Further details about the content and theoretical basis of the different intervention components can be found in the APPRAISE study protocol (Holloway et al., 2021). Because the APPRAISE study was conducted during the initial lockdowns associated with the COVID-19 pandemic, the actual delivery of the intervention deviated considerably from the intended delivery. A full, qualitative analysis of these changes can be found in Holloway et al. (in press).
Our micro-costing study follows accepted methodology (Drummond et al., 2015) and is adapted from similar costing studies conducted by members of the study team (Bray et al., 2014). Our micro-costing study consisted of four principal steps.
Step 1: Create a taxonomy of intervention activities. A 1-day consultation exercise was held with the research and intervention staff involved in the APPRAISE pilot study to identify all resources required to implement the ABI as intended. Where possible, resources required for research purposes only were excluded because these would not be expected to occur in practice. A detailed narrative was constructed for each study site that documented the key components of the intervention delivery and the process. The intervention activities and associated resources were listed in the sequence performed, in relation to each participant.
Step 2: Measure the resources used for each activity. The staff responsible for delivering the ABI in each study site took notes of the duration of and other resources required for each intervention activity before, during, and after each stage of intervention. Examples of resources measured included the time taken to locate participants; the preparation and printing of the intervention materials; and the actual time taken for the delivery of the intervention sessions. Prison security protocols and procedures prohibited the use of electronic equipment for recording this information. Instead, handwritten research diaries were compiled that were either transcribed verbatim or scanned and shared retrospectively with the research team. Finally, retrospective qualitative discussions were held with relevant staff to identify and quantify any missing resource use data. The only intervention resource that had no study documentation was the physical room space used. The size of rooms used for various activities varied both within and across Durham and Edinburgh but was not recorded by study staff. We therefore assume that training occurred in a 15 ft by 15 ft (225 square feet) room and interventions and debriefings occurred in a 10 ft by 10 ft (100 square feet) room.
Step 3: Collect measures of unit cost. Unit costs for each resource used for each activity were identified based on the study invoices and actual expenses, except for space costs. The midpoints of salary ranges were used to calculate hourly wages for staff positions, assuming a 1,624-hour work year (35 hours per week with the UK-required 5.6 weeks of leave per year). For space costs, we used an estimate of commercial real estate rent costs (“UK towns,” 2023).
Step 4: Calculate costs. The resources used from Step 2 were multiplied by the associated unit costs from Step 3 to estimate the costs of each activity of the APPRAISE ABI. Cost estimates were then summed over activities to estimate the total cost of the APPRAISE ABI. We compare the cost based on actual resource use as identified in Step 2 to the intended delivery as documented in the APPRAISE protocol (Holloway et al., 2021).
All results are presented in pound sterling because the trial was conducted in the United Kingdom. For U.S. readers, we also convert results to U.S. dollars when discussing monetary values in the text using the average exchange rate in 2021 (“British pound to US dollar,” 2024).
Table 1 presents the costs associated with training the intervention delivery staff. The original APPRAISE protocol included an initial training session, a refresher training to be held every 6 months, and weekly debriefing meetings to be held in the prison. In Durham, all training sessions were delivered by one trainer and attended by two coordinators and two support workers as stipulated in the protocol. In Edinburgh, however, the initial training was delivered by one trainer and delivered to three support workers, and debriefings included one trainer and two support workers. The initial training session was planned to last 2 hours but took 4.5 hours when delivered. The 6-month refresher training was planned to take 30 minutes but was never delivered because of the pandemic shutdown and subsequent disruptions in the study timeline. Weekly, in-prison debriefings were planned to last 10 minutes each, which, when conducted over 24 weeks, would take 4 hours. In practice, debriefings were held approximately 3 times per week and lasted about 5 minutes each, for a total of 6 hours of debriefing time throughout the study. Hourly wages varied between Durham and Edinburgh. In Durham, the estimated hourly wage of the trainer was £16.73 ($27.23), the estimated hourly wage of intervention coordinators was £13.38 ($18.46), and the estimated hourly wage of support workers was £11.72 ($16.17). In Edinburgh, the estimated wages were £23.26 ($32.10), £15.46 ($21.33), and £11.90 ($16.42), respectively. We estimate that training would have cost £441.72 ($609.57) in Durham and £513.53 ($708.67) in Edinburgh had it been delivered per the study protocol. As delivered, however, the training cost £713.95 ($985.25) in Durham and £558.90 ($771.28) in Edinburgh. We do not include the cost of developing the training curriculum in Table 1 because this would not be a recurring cost of the APPRAISE ABI. For interested readers, the training curriculum was developed by two staff over 24 hours for a total cost of £995.55 ($1,373.86).
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| Training session | Durham | Edinburgh | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Unit cost (P) | Units per activity (Q) | Cost of activity (P × Q) | Unit cost (P) | Units per activity (Q) | Cost of activity (P × Q) | |||||
| Per protocol | As delivered | Per protocol | As delivered | Per protocol | As delivered | Per protocol | As delivered | |||
| Initial training | ||||||||||
| Trainer | £16.73 | 2 | 4.5 | £33.46 | £75.29 | £23.26 | 2 | 4.5 | £46.52 | £104.66 |
| Coordinator | £13.38 | 4 | 9 | £53.50 | £120.38 | £15.46 | 4 | 0 | £61.83 | £0.00 |
| Support worker | £11.72 | 4 | 9 | £46.87 | £105.46 | £11.90 | 4 | 13.5 | £47.59 | £160.60 |
| Space | £0.01 | 450 | 1,012.5 | £3.16 | £7.11 | £0.01 | 450 | 1,012.5 | £3.16 | £7.11 |
| Refresher training | ||||||||||
| Trainer | £16.73 | 0.5 | 0 | £8.37 | £0.00 | £23.26 | 0.5 | 0 | £11.63 | £0.00 |
| Coordinator | £13.38 | 1 | 0 | £13.38 | £0.00 | £15.46 | 1 | 0 | £15.46 | £0.00 |
| Support worker | £11.72 | 1 | 0 | £11.72 | £0.00 | £11.90 | 1 | 0 | £11.90 | £0.00 |
| Space | £0.01 | 112.5 | 0 | £0.79 | £0.00 | £0.01 | 112.5 | 0 | £0.79 | £0.00 |
| Weekly debrief in prison | ||||||||||
| Trainer | £16.73 | 4 | 6 | £66.92 | £100.38 | £23.26 | 4 | 6 | £93.03 | £139.55 |
| Coordinator | £13.38 | 8 | 12 | £107.00 | £160.50 | £15.46 | 8 | 0 | £123.65 | £0.00 |
| Support worker | £11.72 | 8 | 12 | £93.74 | £140.62 | £11.90 | 8 | 12 | £95.17 | £142.76 |
| Space | £0.01 | 400 | 600 | £2.81 | £4.22 | £0.01 | 400 | 600 | £2.81 | £4.22 |
| Total cost of training | £441.72 | £713.95 | £513.53 | £558.90 | ||||||
Notes: APPRAISE = A two-arm parallel group individually randomized Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement; ABI = alcohol brief intervention. Trainer, coordinator, and support worker labor are reported in person-hours (e.g., 2 people at 2 hours each equals 4 person-hours). The initial training was scheduled for 2 hours per the protocol but lasted 4.5 hours as delivered. In Durham, 1 trainer, 2 coordinators, and 2 support workers participated in the initial training and weekly debriefs in prison. In Edinburgh, 1 trainer and 3 support workers participated in the initial training, and 1 trainer and 2 support workers participated in weekly debriefs in prison. Space is measured in square-foot-hours. For readers interested in converting to US$, the average exchange rate was $1.38 in 2021, for example, £1 = $1.38 (“British pound to U.S. dollar,” 2024).
Table 2 presents the per-participant intervention delivery costs of the APPRAISE ABI. The protocol did not stipulate which activities should be conducted by coordinators versus support workers. We therefore use the midpoint of coordinator and support worker wages for the unit cost of labor when calculating per-protocol costs. The APPRAISE ABI protocol included an in-prison session and follow-up sessions at 3, 7, and 21 days postrelease. In addition to the time in session, time was required to schedule the session and locate the participant. The APPRAISE protocol assumed that, while in prison, participants would be available and in easily known and accessible locations, and so only trivial participant locating time was anticipated. Prison lockdowns associated with the COVID-19 pandemic required additional planning to locate or deliver the intervention in prisons. In Durham, the participant locating time was an average of 30 minutes per participant. In Edinburgh, this situation was further exacerbated by the multiple units within the prison and the need to move prisoners across these units. As a result, the participant locating time in Edinburgh averaged about an hour per participant.
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| Training session | Durham | Edinburgh | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Unit cost (P) | Units per activity (Q) | Cost of activity (P × Q) | Unit cost (P) | Units per activity (Q) | Cost of activity (P × Q) | |||||
| Per protocol | As delivered | Per protocol | As delivered | Per protocol | As delivered | Per protocol | As delivered | |||
| In-prison session | ||||||||||
| Participant locating | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.50 | £0.00 | £6.69 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.00 | £0.00 | £0.00 | £11.90 | 0.00 | 1.00 | £0.00 | £11.90 |
| Unspecified | £12.55 | 0.00 | 0.00 | £0.00 | £0.00 | £13.68 | 0.00 | 0.00 | £0.00 | £0.00 |
| Space | £0.01 | 0.00 | 50.00 | £0.00 | £0.35 | £0.01 | 0.00 | 100.00 | £0.00 | £0.70 |
| Intervention | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.53 | £0.00 | £7.09 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.00 | £0.00 | £0.00 | £11.90 | 0.00 | 0.90 | £0.00 | £10.71 |
| Unspecified | £12.55 | 0.75 | 0.00 | £9.41 | £0.00 | £13.68 | 0.75 | 0.00 | £10.26 | £0.00 |
| Space | £0.01 | 75.00 | 53.00 | £0.43 | £0.30 | £0.01 | 75.00 | 90.00 | £0.43 | £0.51 |
| Information booklet | £0.42 | 1 | 1 | £0.42 | £0.42 | £0.42 | 1 | 1 | £0.42 | £0.42 |
| AUDIT and readiness ruler | £0.24 | 1 | 1 | £0.24 | £0.24 | £0.24 | 1 | 1 | £0.24 | £0.24 |
| Alcohol unit postcard | £0.19 | 1 | 1 | £0.19 | £0.19 | £0.19 | 1 | 1 | £0.19 | £0.19 |
| Total | £10.69 | £15.28 | £11.54 | £24.67 | ||||||
| First (3 days) post prison | ||||||||||
| Participant locating | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.00 | £0.00 | £0.00 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.25 | £0.00 | £2.93 | £11.90 | 0.00 | 0.25 | £0.00 | £2.97 |
| Unspecified | £12.55 | 0.08 | 0.00 | £1.00 | £0.00 | £13.68 | 0.08 | 0.00 | £1.09 | £0.00 |
| Space | £0.01 | 8.00 | 25.00 | £0.06 | £0.18 | £0.01 | 8.00 | 25.00 | £0.06 | £0.18 |
| Telephone calls | £0.25 | 5 | 15 | £1.25 | £3.75 | £0.25 | 5 | 15 | £1.25 | £3.75 |
| Intervention | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.00 | £0.00 | £0.00 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.00 | £0.00 | £0.00 | £11.90 | 0.00 | 0.50 | £0.00 | £5.95 |
| Unspecified | £12.55 | 0.33 | 0.00 | £4.14 | £0.00 | £13.68 | 0.33 | 0.00 | £4.51 | £0.00 |
| Space | £0.01 | 33.00 | 0.00 | £0.23 | £0.00 | £0.01 | 33.00 | 50.00 | £0.23 | £0.35 |
| Total | £6.68 | £6.86 | £7.15 | £13.20 | ||||||
| Second (7 days) post prison | ||||||||||
| Participant locating | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.00 | £0.00 | £0.00 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.25 | £0.00 | £2.93 | £11.90 | 0.00 | 0.25 | £0.00 | £2.97 |
| Unspecified | £12.55 | 0.08 | 0.00 | £1.00 | £0.00 | £13.68 | 0.08 | 0.00 | £1.09 | £0.00 |
| Space | £0.01 | 8.00 | 25.00 | £0.06 | £0.18 | £0.01 | 8.00 | 25.00 | £0.06 | £0.18 |
| Telephone calls | £0.25 | 5 | 15 | £1.25 | £3.75 | £0.25 | 5 | 15 | £1.25 | £3.75 |
| Intervention | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.00 | £0.00 | £0.00 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.00 | £0.00 | £0.00 | £11.90 | 0.00 | 0.00 | £0.00 | £0.00 |
| Unspecified | £12.55 | 0.33 | 0.00 | £4.14 | £0.00 | £13.68 | 0.33 | 0.00 | £4.51 | £0.00 |
| Space | £0.01 | 33.00 | 0.00 | £0.23 | £0.00 | £0.01 | 33.00 | 0.00 | £0.23 | £0.00 |
| Total | £6.68 | £6.86 | £7.15 | £6.90 | ||||||
| Third (21 days) post prison | ||||||||||
| Participant locating | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.00 | £0.00 | £0.00 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.25 | £0.00 | £2.93 | £11.90 | 0.00 | 0.25 | £0.00 | £2.97 |
| Unspecified | £12.55 | 0.08 | 0.00 | £1.00 | £0.00 | £13.68 | 0.08 | 0.00 | £1.09 | £0.00 |
| Space | £0.01 | 8.00 | 25.00 | £0.06 | £0.18 | £0.01 | 8.00 | 25.00 | £0.06 | £0.18 |
| Telephone calls | £0.25 | 5 | 15 | £1.25 | £3.75 | £0.25 | 5 | 15 | £1.25 | £3.75 |
| Intervention | ||||||||||
| Labor | ||||||||||
| Coordinator | £13.38 | 0.00 | 0.00 | £0.00 | £0.00 | £15.46 | 0.00 | 0.00 | £0.00 | £0.00 |
| Support worker | £11.72 | 0.00 | 0.50 | £0.00 | £5.86 | £11.90 | 0.00 | 0.00 | £0.00 | £0.00 |
| Unspecified | £12.55 | 0.33 | 0.00 | £4.14 | £0.00 | £13.68 | 0.33 | 0.00 | £4.51 | £0.00 |
| Space | £0.01 | 33.00 | 50.00 | £0.23 | £0.35 | £0.01 | 33.00 | 0.00 | £0.23 | £0.00 |
| Total | £6.68 | £13.07 | £7.15 | £6.90 | ||||||
| Total cost of APPRAISE ABI | ||||||||||
| Labor | £24.84 | £28.42 | £27.08 | £37.47 | ||||||
| Nonlabor | £5.89 | £13.63 | £5.89 | £14.19 | ||||||
| All | £30.73 | £42.06 | £32.97 | £51.67 | ||||||
Notes: APPRAISE = A two-arm parallel group individually randomized Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement; ABI = alcohol brief intervention; AUDIT = Alcohol Use Disorders Identification Test. The protocol did not stipulate which activities should be conducted by coordinators versus support workers. We therefore use the midpoint of coordinator and support worker wages for the unit cost of labor when calculating per protocol costs, which we label as “unspecified” in the table. Labor is reported in person-hours (e.g., 2 people at 2 hours each equals 4 person-hours). Space is measured in square-foot-hours (e.g., 100 square feet used for 15 minutes equals 25 square-foot-hours). The unit cost of phone calls is the per-minute rate for pay-as-you-go phones, which were used in the trial. For readers interested in converting to US$, the average exchange rate was $1.38 in 2021, for example, £1 = $1.38 (“British pound to US dollar,” 2024).
Once participants were located, the in-prison session was intended to last 45 minutes and included the administration of the Alcohol Use Disorders Identification Test and readiness ruler, an information booklet, and an alcohol unit postcard. In Durham, the in-prison sessions averaged slightly over 30 minutes, and in Edinburgh, they averaged just under an hour. Although session lengths were highly variable, the distribution appeared to be approximately symmetric with the median length being approximately the same as the mean (Holloway et al., in press). All participants in both study sites received the intended materials. In total, the in-prison session in Durham would have cost £10.69 ($14.75) per participant had it been delivered per protocol but cost £15.28 ($21.09) as delivered. In Edinburgh, the total cost of the in-prison session would have been £11.54 ($15.93) per participant if delivered per protocol but was £24.67 ($34.04) as delivered. The increased cost as delivered relative to per protocol is attributable primarily to the unexpected cost of locating participants.
For the postrelease sessions, the protocol assumed that approximately 5 minutes would be required per session to schedule and contact the participant. In reality, participants were much more difficult to locate, and interventionists spent about 15 minutes (3 attempts at about 5 minutes per attempt) trying to schedule sessions. Importantly, this effort was usually unsuccessful as only one 3-day postrelease session, no 7-day postrelease session, and only one 21-day postrelease session were delivered. All postrelease sessions were intended to last 20 minutes. The single 3-day postrelease session was delivered in Edinburgh and lasted 30 minutes. The single 21-day postrelease session was delivered in Durham and lasted 30 minutes. Given the extensive participant locating time that was spent on sessions that ultimately did not happen, all postprison sessions incurred costs despite not actually being delivered. In Durham, each postprison session would have cost £6.68 ($9.22) if delivered per protocol. As delivered in Durham, the 3-day and 7-day postprison sessions cost £6.86 ($9.47) due entirely to participant locating time and the 21-day session cost £13.07 ($18.04) for the one participant who received it. In Edinburgh, each postprison session would have cost £7.15 ($9.87) if delivered per protocol. As delivered in Edinburgh, the 3-day postprison session cost £13.20 ($18.22) for the one participant who received it, and the 7- and 21-day postprison sessions cost £6.90 ($9.52) entirely because of participant locating time.
Summing costs across all sessions, the APPRAISE ABI would cost £30.73 ($42.41) per participant in Durham and £32.97 ($45.50) in Edinburgh if delivered per protocol, with most of this cost being attributable to labor. As delivered, however, the APPRAISE ABI costs £42.06 ($58.04) per participant in Durham and £51.67 ($71.30) in Edinburgh. Although most of this cost is driven by labor, the increased nonlabor costs associated with phone calls made in attempts to contact participants are also a substantial driver of cost.
Our micro-costing study was conducted alongside the APPRAISE pilot and feasibility study. As such, it was intended to develop and fully pilot test the micro-costing protocol to be used in a definitive trial. Although minor modifications to our methods would be appropriate for a full-scale trial, our study has shown that a detailed, micro-costing study is feasible in prison-based research. Moreover, our micro-costing protocol requires a detailed tracking of all activities involved in the delivery of the intervention and so helps to document how challenges unique to prison settings may necessitate changes to the intervention protocol. Beyond achieving the intended goal of demonstrating the feasibility of study methods, our micro-costing study has resulted in several other, tangible contributions to the ABI research literature.
First, we have shown and, to an extent, quantified how the challenges of prison-based ABI research can have meaningful implications for implementation costs and, therefore, long-run adoptability and sustainability. In particular, we have shown that participant tracking and locating, both within and out of the prison, is a substantial cost. Although other prison-based brief intervention studies have noted this same issue (e.g., Lee et al., 2012), we are the first study to formally document its impact on the service delivery cost. Clearly, the COVID-19 pandemic exacerbated the issue, but meaningful resources should be allocated to finding participants and ensuring that they attend intervention sessions. Future effectiveness and efficacy studies should account for this, and future implementation studies should explore novel and innovative solutions to mitigate the cost of finding participants for in-prison and postliberation intervention sessions.
Second, although each session of the APPRAISE ABI was relatively inexpensive, the difficulty in scheduling postliberation sessions suggests that the effort spent on these sessions may not be cost beneficial. This conclusion is admittedly speculative because the pilot effectiveness study was not intended to isolate the differential effect of multiple sessions. However, most of the cost of the postliberation sessions, as implemented, was attributable to participant locating costs. As before, the COVID-19 pandemic likely contributed to the difficulty in scheduling out-of-prison sessions, but findings from the APPRAISE process evaluation (Holloway et al., in press) suggest that the pandemic did not create the underlying issues but rather exacerbated them.
Last, we have shown that, like most primary care ABI protocols, the APPRAISE ABI is an inexpensive option for addressing hazardous alcohol use. Even with the additional costs of locating and scheduling sessions with participants, the cost of the APPRAISE ABI compares favorably to the cost of ABIs delivered in primary care and other medical settings. In a review of the ABI implementation cost literature, Bray et al. (2012) report that the median cost of an ABI in a medical setting was $48 in 2009, or £49 in 2021. Importantly, the estimate from Bray et al. (2012) is for a single brief intervention session lasting less than 15 minutes, whereas the APPRAISE ABI cost is comparable but includes the cost of multiple sessions of 20 to 30 minutes, or longer, as well as additional time spent locating participants. To our knowledge, only one other study has estimated the cost of delivering a brief intervention in a prison setting. Prendergast et al. (2017) report that the cost of delivering their study intervention in a U.S. jail was approximately $567 per person in 2014, or £502 in 2021. The much higher cost reported by Prendergast et al. (2017) is likely attributable to two key differences between their study and ours. First, their intervention was for multiple drugs, not just alcohol, and included brief interventions for low-risk use, brief treatment for moderate-risk use, and referral to formal treatment for high-risk use. Second, Prendergast et al. (2017) used DATCAP (Drug Abuse Treatment Cost Analysis Program) costing methodology, which is a non-activity, or top-down, approach and does not isolate the cost of specific intervention activities. As noted by Bray et al. (2012), top-down approaches such as the DATCAP are typically associated with higher cost estimates of ABIs than activity-based approaches such as ours.
Another difference between our study and previous cost studies is that the APPRAISE protocol did not isolate a universal screening program from research data collection; therefore, we were unable to separately estimate the cost of screening for hazardous alcohol use. We note, however, that screening for hazardous alcohol use costs very little per screen—less than $4 in 2009 according to Bray et al. (2012). Furthermore, the very high rate of hazardous alcohol use in prisons reduces the rate of negative screens, making a universal screening program more cost-efficient. Nonetheless, future studies should estimate the cost of universal screening for hazardous use in prison settings to better inform budget planning. We do not include administrative or indirect costs associated with labor or space, which is commonly done in many cost studies. We decided to exclude these costs because they would conflate true differences in cost driven by differing staff qualifications or local market conditions with idiosyncratic differences in administrative cost structures across the two universities participating in the APPRAISE pilot (University of Edinburgh and Teesside University). As a result, however, our cost estimates slightly underestimate the true economic cost of the APPRAISE ABI.
Although we have included participant locating time in our cost estimates, that time proved more difficult to determine and hence more difficult to provide a precise estimate of the staff cost associated with it. As noted by Holloway et al. (in press), the time taken to schedule a follow-up intervention session or just to successfully make contact to start the intervention session remotely (by telephone) varied significantly. Some individuals could be reached quickly, or it could be ascertained quickly that the preferred, provided contact methods were no longer valid. This was in contrast to those who were unable to be reached after frequent attempts, by different methods of contact, or those who would reply once and then would stop replying. Successful completion of follow-up interventions was low, even with large amounts of time spent attempting to make contact. However, it was difficult to discern what role the COVID-19 pandemic played in this lack of successful contact. Thus, it should be explored in a future cost analysis.
We excluded the cost of conducting follow-up research data collection from our micro-costing study, but our efforts to conduct follow-up data interviews may be informative for future studies attempting to conduct postprison intervention sessions. Because participants had given their consent to be contacted in various ways to obtain research data, the research team tried many different methods of contact such as social media, email, telephone calls, and text messages. Often, the telephone numbers would belong to a family member, meaning the team would receive a new number from that person and start again. For those participants who gave their addresses, the team contacted their local probation services office to ask those staff to pass on follow-up surveys. However, some participants were released to an address that was different from that provided, which meant this strategy was not always successful. Despite these efforts, follow-up data response rates remained low. Engaging study subjects at their probation office is one solution, but this would link the study data collection or the intervention delivery to the CJS, which we were consciously trying to avoid. Research on ways to engage this population outside of the CJS is needed if we are to avoid continually isolating and stigmatizing this vulnerable population.
Finally. our micro-costing study focused on the perspective of prison staff and third-sector service delivery staff because they were the most directly involved in the delivery of the APPRAISE ABI, but other perspectives are relevant for a full economic evaluation. The health sector is an obvious additional perspective that would capture costs or cost savings generated by changes in healthcare use that result from the ABI. Exploring the data needed to include this perspective in a more complete economic evaluation was part of the larger APPRAISE pilot study (Holloway et al., in press). The prisons, third-sector delivery staff, and healthcare sector are all elements of the larger, governmental perspective that should also be considered. The broader governmental perspective is particularly important for interventions like the APPRAISE ABI because one sector of the government (CJS) may incur costs to save resources for another sector (health or social services). Representing this broader perspective in a full economic evaluation is crucial to informing global budgets that may shift resources from one sector to another.
Our study has provided the first estimate of the cost of delivering an ABI in a prison setting in the United Kingdom and the first activity-based cost estimate of delivering an ABI in a prison setting anywhere in the world. Our study has demonstrated that activity-based costing methods can be successfully used in prison settings. It is particularly important to use activity-based costing methods when estimating the intervention costs of short-duration interventions such as ABIs. Furthermore, based on data from the APPRAISE feasibility and pilot study, our results suggest that it costs no more to deliver an ABI in a prison setting than it does to deliver it in a medical setting. Our results also suggest that considerable cost efficiencies can be achieved if better participant locating and scheduling processes can be developed. If ABIs in prison settings, such as that piloted in APPRAISE, can be effective, our cost results strongly suggest that they will also be cost-effective.
Dorothy Newbury-Birch reports grants from Durham City Council, NIHR, South Tees HDRC, and Middlesbrough County Council. Andrew Stoddart reports grants from the NIHR and MRC. Aisha Holloway reports grants from the RCN Foundation and The Burdett Trust for Nursing; consulting fees from WHO; and Non-executive Director roles from the Law Society Scotland and the Florence Nightingale Foundation. There are no other disclosures to report.
Partial funding for this study was provided by the National Institute for Health and Care Research Public Health Research Programme (17/44/11); Trial Registration Number ISRCTN 27417180.
Acknowledgment
The authors thank Joanne Boyd and Jamie Smith for their comments on and corrections to the manuscript. Victoria Guthrie provided invaluable contributions throughout the APPRAISE pilot study and assisted in the development of the APPRAISE cost study protocol. The authors thank all the interventionists, prison staff, and remand prisoners who participated in APPRAISE. All remaining errors are the sole responsibility of the authors.
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