Realist Evaluation of a Contingency Management Intervention for Relapse Prevention in Alcohol Dependence
Contingency management (CM) is a behavioural therapy using financial incentives to reinforce targeted behaviours. Despite evidence supporting CM effectiveness in promoting positive behaviours across several substance-using populations, its application for alcohol treatment is rare. Recent studies explore technology-based strategies for remote monitoring of alcohol use and reinforcement delivery, aiming to address challenges in low-resource settings. However, more research is needed on key components influencing CM interventions for treating alcohol use disorders (AUD) to further inform policymakers and stakeholders about contextual challenges.
This study aims to conduct a realist evaluation of the CM intervention within the treatment programme as part of the Alcohol Dependence and Adherence to Medicine (ADAM) trial, in order to understand how, when, for whom, and under what circumstances key components work –or do not work– in promoting treatment attendance within specialist alcohol services.
The realist evaluation conducted employed mixed methods across five phases: 1) A rapid review informed contextual factors and key mechanisms influencing CM interventions in improving attendance for AUD. 2) A protocol and internal document revision identified theories underpinning the ADAM trial’s treatment programme. 3) Stakeholder consultations aided in formulating an initial programme theory based on context-mechanisms-outcomes (CMO) hypotheses. 4) The CMO hypotheses underwent testing through the analysis of data collected from semi-structured interviews with trial participants receiving the CM intervention. 5) Finally, semi-interviews with staff members refined the programme theory.
A total of 31 semi-structured individual interviews were conducted for this study, involving participants from the ADAM trial randomly assigned to receive the CM intervention. The participants interviewed comprised 12 females and 19 males, with ages ranging from 26 to 71 years. These individuals were recruited from 16 specialist alcohol treatment services located in London, Birmingham, and Yorkshire and Humber.
Findings showed CM’s dual impact on promoting treatment attendance and reducing alcohol use through mechanisms of acknowledgement and goal-setting. Most participants viewed the reward as ‘something to look forward to’, encouraging them to persist in treatment and strengthen their commitment to treatment goals. Receiving thank-you messages and details of amount accrued, played a pivotal role in making participants feel recognised for their contribution to the trial and motivated to successfully complete treatment. Unexpectedly, lower-income participants expressed less interest in financial incentives. The main dropout reasons mentioned were relapse and experiencing side effects from acamprosate.
This research contributes valuable insights into the nuanced dynamics of CM interventions, which are vital for designing effective programmes in specialist alcohol services.
