Work package 4(ii): feasibility and acceptability of delivering the ADVANCE digitally supported intervention

For more information, see Gilchrist et al.10 Report Supplementary Material 2 describes the SAP, and Appendix 3 describes the health economics report for WP4(ii). Some text in this chapter has been reproduced with permission from Gilchrist et al.10 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

Aims

To explore the feasibility and acceptability of digitally supported delivery of ADVANCE-D to reduce IPV perpetration by men receiving treatment for substance misuse.

Objectives

• men’s eligibility, recruitment and uptake rates; women’s support uptake rates assessed the feasibility of delivering ADVANCE-D
• attendance and completion rates; rating scales about website sessions; longitudinal qualitative interviews; follow-up rates; adverse events; therapeutic alliance assessed the acceptability of ADVANCE-D.

Study methods

A multicentre, non-randomised feasibility study with a nested process evaluation.

Recruitment, setting and participants

Men were screened during June 2021–November 2021 for eligibility against the inclusion criteria by substance misuse treatment staff or researchers. Recruitment flyers invited men to contact researchers for information. Forty-five men, who had perpetrated IPV in the past 12 months towards a female (ex)-partner with whom they still had contact, were recruited from community substance misuse treatment services in England (London, n = 3; the West Midlands, n = 1; and the South West, n = 1), Wales (South Wales, n = 1) and Scotland (Lothian, n = 1). Men receiving a perpetrator intervention, who had an order preventing them from contacting their (ex)-partner or where there were other safety concerns, were ineligible. A trained facilitator then assessed eligible men’s suitability for ADVANCE-D using the B-SAFER.186 Low-risk men were deemed suitable to participate.

A different researcher completed the baseline assessment with the male and female in the dyad.8 Researchers texted or e-mailed (ex)-partners with brief study information and then rang them to invite them to participate. Regardless of whether (ex)-partners agreed to participate, all were contacted and offered support by an ISS worker who completed the DASH185 risk assessment.

Client-centred outcomes

Changes in outcomes for men and their (ex)-partners were evaluated pre and post intervention. The ABI, rather than the ABI-R used in WP4(i), assessed men’s IPV perpetration. Measures with low understanding, acceptability and completion ratings in WP4(i) were excluded from WP4(ii): URICA-DV, Communications Patterns Questionnaire – Short Form (CPQ-SF),152 Intimate Partner Violence Responsibility Attribution Scale (IPVRAS)15 and Balanced Inventory of Desirable Responding – Short Form (BIDR-SF).158 To account for the digitally supported delivery of ADVANCE-D, the Working Alliance Inventory applied to Virtual and Augmented Reality – Short Revised; assessed therapeutic alliance rather than the WAI-SR.188 All other client-centred outcomes remained the same as WP4(i) (see Table 5). A web-based electronic case report forms (CRFs) system (InferMed MACRO) was used to collect data.

Process evaluation

Up to four longitudinal qualitative interviews were conducted to capture: views about the intervention, changes and impact over time for men and their (ex)-partners, and staff’s experience of delivering ADVANCE-D. Online feedback after each website session was completed. The interviews corresponded with completion of 4, 8, 12 and 14 weeks of ADVANCE-D. Therefore, interviews were only completed with men who remained engaged in ADVANCE-D at these pre-defined times.

Contingency management

Tablets were provided to men with 8GB of mobile data, with additional monthly data contingent on attendance. Men who completed the intervention could keep the tablet.

Research reimbursement

Participants were reimbursed (£10 voucher) per interview (up to a total of £60 vouchers).

Statistical analyses

Summary statistics were estimated to quantify relevant feasibility and acceptability parameters. T-tests were performed for outcomes pre and post intervention (where normality could be assumed) or Wilcoxon signed-rank test (where normality could not be assumed).

Health economics

The costs of providing ADVANCE-D and TAU were estimated. Descriptive statistics of quantities of various services used were calculated.

Qualitative analysis

Interviews and focus groups (staff) were recorded and transcribed verbatim. Patterns in themes across different participants and groups of participants were explored using the framework approach.164 Data for each time point interview and category of interviewee were merged into a single framework to enable comparison, interpretation and synthesis of longitudinal data. Codes were developed and data thematically coded. The consolidated criteria for reporting qualitative research checklist were followed during analysis.189

Intervention

The ADVANCE-D components are outlined in Table 11.140 All men also received their substance misuse TAU.

Key findings

Screening, recruitment and follow-up of men and their (ex)-partners are described in Figures 15 and 16.

FIGURE 15 The CONSORT diagram for male participants in the ADVANCE-D non-randomised feasibility study. IPA, intimate partner abuse. Reproduced with permission from Gilchrist et al.10 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original text. (Figure not reproduced here; see the original article.)

FIGURE 16 The CONSORT diagram for female participants in the ADVANCE-D non-randomised feasibility study. Reproduced with permission from Gilchrist et al.10 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original text. (Figure not reproduced here; see the original article.)

Participant characteristics

Forty men were offered ADVANCE-D: 16 from London, 9 from the South West, 6 from the West Midlands, 5 from Lothian and 4 from South Wales. Their mean age was 40.6 (SD 7.9), the majority were White (31/40; 77.5%), not employed (29/40; 72.5%) and in a relationship living together or apart (28/40; 70%). Over half of their partners consented to participate in the study (21/40; 52.5%). Twenty-two men were interviewed qualitatively: 4 were interviewed once, 10 were interviewed twice, 6 were interviewed three times and 2 were interviewed four times. Of the 21 (ex)-partners recruited, 11 were interviewed qualitatively: 8 once, and 3 twice. All 12 facilitators (3 were interviewed once, 8 were interviewed twice and 1 was interviewed three times) and 7 ISS workers (4 were interviewed once, 3 were interviewed twice) were interviewed.

Client-centred outcomes

Table 12 compares participants’ baseline and follow-up outcomes. Eight of the 11 women followed up reported a reduction in experiencing IPV, with 5 out of 11 reporting a reduction in experiencing controlling behaviours. They also reported reductions in their (ex)-partners using their/her children against her. Seventeen of the 25 men followed up, self-reported a reduction in using IPV, with 10 of 25 men self-reporting a reduction in using controlling behaviours. Men also reported reductions in using their/(ex)-partner’s children against them, as did their propensity for anger. Seven of the 24 men followed up reported an increase in alcohol-free days, and 11 out of 25 men followed up reported a reduction in drug-free days, in the past month.

For the quality-of-life (QoL) measures, none of the scores was significantly different between baseline and 4-month follow-up for the 25 male or 11 female participants.

Feasibility parameters

Table 13 describes the feasibility parameters for men and their (ex)-partners.

Acceptability parameters

• Many men preferred the convenience of digitally supported delivery stating accessing it from their homes and talking to facilitators by phone was ‘easier, not as daunting’ than travelling into a service especially for those with social anxiety or who were working. Others would have preferred ‘face to face’ feeling ‘a little bit more engaged’.
• Men found the overall content ‘really good’, especially the videos, as they ‘stick[s] in your head a bit more’ and gave them ‘the tools I need to do things a bit different and stop things getting worse’.
• Although several facilitators highlighted difficulties in contacting men for coaching calls, men rated therapeutic alliance highly and thought the: ‘Coaching calls were absolutely brilliant … they reinforced a lot of the messages that we were doing in the groups, and it was real-time support with what was going on in my life, which I think is invaluable’.
• Facilitators valued the ‘thorough’ risk assessment at the beginning of ADVANCE-D and thought the intervention content was ‘fantastic’, ‘valuable’ and ‘comprehensive’; however, many found it ‘unrealistic’ to cover the content in the time allocated for groups.
• Some facilitators believed remote delivery made it more ‘accessible’ and gave men more ‘flexibility to attend’, but others reported men had not ‘got to grips with the technology’ and that ‘not having faces on screen distanced people’ could make it difficult to manage risk.
• Facilitators and ISS workers welcomed the integrity support to ‘strengthen the consistency and delivery’. They found information sharing between the facilitators and ISS ‘very useful’ as ‘information that was coming from the partners themselves that was quite different to the information we were getting from the men’ (facilitator).
• ISS workers also had difficulty getting hold of (ex)-partners for support calls.
• No adverse events from men or their (ex)-partners were associated with participating in ADVANCE-D.

Attendance

The majority of men offered ADVANCE-D attended at least one session (39/40; 97.5%). On average, they attended 11.4 (SD 9.1) sessions (Figure 17), but attendance varied by site. For men, 48% of all sessions (core, website and coaching calls) offered were attended. Fifty-nine per cent of men attended 75–100% of the core sessions.

FIGURE 17 Summary of ADVANCE-D attendance by the type of session offered. a, core sessions = goal-setting session, ‘welcome’ video group session and 6 video group sessions. (Figure not reproduced here; see the original article.)

Website ratings

Men rated each website session men from 1 (‘strongly disagree’) to 7 (‘strongly agree’). Overall, men found the website easy to use (mean 5.8; SD 1.7), understood each session’s purpose (mean 6.2; SD 1.1), increased their knowledge and skills about topics covered (mean 5.9; SD 1.3) and were able to concentrate (mean 5.8; SD 1.4). Men were positive about the website: ‘It was great. It was easy to use. I was impressed. It was better than I expected’ (P040010), ‘Very valid and great content’ (P040015). Website sessions reinforced what they had learnt in group sessions and vice versa (P030020; P0400122): ‘When you do the session by yourself online after the group, I find that helpful in a different way. you talk about stuff in the group and then you go and do the online session and then that’s what I sit down with the notebook make notes. They work very well together’ (P040011).

The look and feel of the website was updated based on users’ feedback. In addition, the ability to select from three different avatars was added (Figure 18).

FIGURE 18 Updated ADVANCE-D avatar options. (Figure not reproduced here; see the original article.)

Health and social care service use

Costs of ADVANCE-D

The cost per man for facilitators to deliver ADVANCE-D was £131 (± £98), plus £106 (± £137) to support his (ex)-partner. Training costs were £1728 per staff member (with 3 facilitators and 1 ISS worker trained at each site). The costs of sustaining the ADVANCE-D platform were £4536.

Discussion

Despite ‘considerable concern about the use of “online”, “virtual”, or “digital” programmes delivered remotely’,184 we found it was feasible to adapt face-to-face content from our ADVANCE group intervention for digitally supported remote delivery using a blend of video groups, self-completed website sessions and coaching calls. Similar to an exploratory study of a US online court-mandated perpetrator programme conducted pre COVID,184 we found higher attendance by men in substance use treatment to ADVANCE-D than our in-person ADVANCE group intervention.184 We also found higher retention and attendance in ADVANCE-D compared to ADVANCE. To our knowledge, this is the first evaluation of a digitally supported perpetrator intervention (for men who misuse substances) delivered during COVID-19.183,190 By providing hardware, mobile data and headphones, we attempted to address digital poverty when delivering ADVANCE-D.

Limitations

The target sample size of 60 men was not reached. Findings are limited due to the small sample size and the non-randomised nature of this evaluation.

Cross-cutting work package: influencing policy and practice

Dissemination and debate

At inception of this programme grant, a blog and website were established to share findings, and post-relevant articles, reports and news on IPV and substance misuse. There are 68 subscribers to the ADVANCE blog, and 133 posts were published.

Findings were presented at 9 national and 35 international conferences. Eleven open access manuscripts were published. Two dissemination events were held at the research programme’s conclusion: including 35 in person and 179 online national and international attendees. The hybrid event was opened by the Domestic Abuse Commissioner for England and Wales. A dissemination video was also produced: https://vimeo.com/725588324/4c3ce80940.

Summary reports were made available to participants, and presentations of findings were given to participating sites.

Learning Alliances

Learning Alliances consist of multiple stakeholders, disciplines and cultures working together to develop local cross-sector solutions.191 We had previously established a successful Learning Alliance in London in 2014 which was continued during this programme. An additional Learning Alliance was established in the West Midlands. We aimed to hold 15 Learning Alliances, but 20 were held to guide the research by sharing experiences and informing best practice in IPV and substance misuse and transferring knowledge into practice, with many organisations participating in the piloting of ADVANCE and ADVANCE-D.

Conclusions on the research programme

Some text in this chapter has been reproduced with permission from Gilchrist et al.10 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

What was and what was not successful

The ADVANCE has been offered to 54 men and ADVANCE-D to 40 men as part of feasibility work not designed to be able to demonstrate effectiveness. The promising findings should be interpreted with caution given the small sample sizes and study designs. A full effectiveness trial with longer-term follow-up is required to explore effectiveness. Our research has shown that both the in-person group (ADVANCE) and digitally supported (ADVANCE-D) interventions can be delivered safely by trained staff in substance use treatment. However, staff require protected time for delivery. The intervention content was well received by men and facilitators. Some men preferred digital over in-person sessions as they offered increased accessibility. Acknowledging that the non-randomised feasibility study of ADVANCE-D was conducted during the pandemic, we found higher attendance and follow-up rates for men offered ADVANCE-D compared to ADVANCE.

Direct comparison of attendance at ADVANCE and ADVANCE-D with other perpetrator interventions for men who misuse substances was difficult due to the heterogeneity in the duration and format of interventions. In the USA, a 12-session integrated individual intervention for court-mandated perpetrators who misuse substances found that 70% completed eight core sessions,110 compared to 68% in ADVANCE-D. In the Netherlands, men attending Integrated treatment for Substance abuse and Partner violence, a 16-session group perpetrator intervention for men in substance misuse treatment, reported that 37% completed at least 75% of sessions (defined as treatment completion), with a mean of 9/16 sessions attended.112 In ADVANCE-D, 59% of men completed at least 75% of the eight core sessions, and 48% of all 32 sessions offered were completed. Forty-four per cent of ADVANCE-D website sessions offered were completed. This finding is similar to one study of non-court-mandated, non-substance misusing perpetrators found they completed 44% of the eight online modules (guided self-help delivered via the internet with an identified therapist who provided support and guidance of therapeutic activities).192

Research, intervention development and adaptation were informed by the Learning Alliance and PWLE.

Implications for practice and lessons learnt

Our research identified the complex interplay between substance use and IPV perpetration in the context of intoxication, withdrawal, acquiring drugs, impact on relationships and wider dynamics of power, control and psychological vulnerabilities.

The systematic review and meta-analysis found little evidence for effective interventions to reduce IPV for men who misuse substances, highlighting the need for more research to identify what works for this population.

Findings from the feasibility RCT of the ADVANCE group intervention compared to TAU supported progression to a definitive trial.

While the pandemic necessitated a move from in-person to online intervention delivery,193,194 ADVANCE-D has long-term applicability post pandemic, including in other settings. Supervised completion of ADVANCE-D website sessions and in-person (rather than remote) group and coaching sessions at substance use treatment services could enhance attendance, completion and engagement, and ensure adherence.

Integrated support for female (ex)-partners alongside regular case management meetings and clear, respectful and information sharing protocols are essential components of the ADVANCE and ADVANCE-D Programmes. Co-training and integrity support for facilitators and women’s support services are needed to build strong professional relationships across services working with men and supporting women.

Recommendations for future research

Due to the small sample sizes in the evaluations of ADVANCE and ADVANCE-D and the limited data in our review, it was not possible to examine effective dosage or the effectiveness of individual intervention components. There remains a need for definitive comparative trials of these interventions.

Future studies should ensure outcomes from (ex)-partners are collected.4

Definitive trials of ADVANCE and ADVANCE-D are needed with longer-term follow-up recommended of at least 12 months, including an RCT comparing the effectiveness of ADVANCE and ADVANCE-D. Consideration should be given to using record linkage to assess recidivism and health and social care outcomes for perpetrators, victim/survivors and their children. Applicability of ADVANCE and ADVANCE-D in other settings and populations remains to be tested.

While working collaboratively with PWLE and key stakeholders effectively informed research phases and intervention development and adaptions based on experience and practice; the personal and professional impact of PPIE was not assessed. Further research to determine the impact of PPIE is needed.

Equality, diversity and inclusion

The proportion of ethnic (excluding White) minority men was 24% in both WP4(i) and WP4 (ii), representative of male substance use service users (ranging from 4% in the South West to 32% in London). A meta-analysis reported that service users strongly preferred a therapist with the same ethnicity.195 Little health and social care research regarding digital therapy/interventions exists, but one study found most users chose avatars portraying their ethnicity.196 A more recent review found online translation in medical consultations may improve patients’ healthcare satisfaction.197 WP4(ii), subsequent versions of the website avatar were developed, with PPIE input, to be more inclusive of other minority ethnic groups. Further research should determine whether additional languages and providing digital coaches portraying different ethnic minorities increases engagement and acceptability of the ADVANCE-D website sessions.

The ADVANCE and ADVANCE-D were designed intersectionally to ensure inclusivity, accessibility and suitability for male IPV perpetrators towards women from all cultures and ethnicities. Given the small sample of men from ethnic minority groups in our studies, nothing can be concluded about the acceptability and their progression through the programme. Further research with larger samples of ethnic minority men should explore ADVANCE and ADVANCE-D acceptability and effectiveness. Further research is needed to adapt ADVANCE and ADVANCE-D for women, and for gender and sexual minority groups.

A recent review of perpetrator programmes for ethnic minority men reported greater effectiveness with greater cultural engagement: through culturally trained facilitators, and addressing relevant cultural, patriarchal and gender norms.198 ADVANCE and ADVANCE-D facilitators were trained to be culturally sensitive and responsive.

Men’s average age in the ADVANCE and ADVANCE-D studies was over 40. In 2022–3, 60% of male substance use treatment users were over 40 years old and < 10% were under 30. Younger men might be reached through delivering the intervention to men in probation, armed forces, via police diversion schemes or other perpetrator services.

The intervention was designed to be inclusive and accessible for disabled (including learning disabilities) and neurodiverse men. The ADVANCE-D website includes a digital coach that speaks the words on screen to assist with literacy. Facilitators are encouraged to be flexible, adapt their input, provide between session support for those with additional needs (e.g. dyslexia or neurodiversity) and promote overlearning and automatic responding, given the short-term memory difficulties people with dyslexia can have.

A study exploring the experiences and perspectives of domestic abuse practitioners working with male perpetrators with autism and/or attention deficit hyperactivity disorder supported tailored and flexible approaches to programme delivery to address their specific needs, including preparation and support for programme engagement, addressing challenges with sensory sensitivities, programme structure and understanding of programme content.199 Practitioners also recommended including one-to-one and/or online formats for neurodiverse men. While ADVANCE and ADVANCE-D acceptability for neurodivergent men remains to be explored, this report’s recommendations were followed when designing ADVANCE-D. Both ADVANCE and ADVANCE-D interventions included one-to-one sessions, and ADVANCE-D allowed for flexibility and adapted content, and more one-to-one sessions (n = 13) and website sessions to build on group session discussions.

We developed the ADVANCE and ADVANCE-D programmes to reduce IPV in underserved men who misuse substances. Tablets (men), smartphones (women) and mobile data and technological support were provided to address digital poverty and literacy. Out with trial conditions, services or charities would need to meet these costs, but hardware could be reused with subsequent groups. Men could also attend services and use the services’ Wi-Fi to complete the website sessions.

The PPIE included UK-wide people with IPV and/or substance misuse lived experience. The research team included members with a range of experience and expertise. More junior team members were supported with drafting manuscripts, grant applications and dissemination.

ADVANCE and ADVANCE-D addressed male-perpetrated IPV towards women. Future research should adapt or develop perpetrator programmes for gender and sexual minority groups.