Identifying promising approaches and initiatives to reducing alcohol related harm

Alcohol Insight Number 91

Research and Development Grant

Background

This study aimed to identify promising approaches that could be included in multi-component programmes (MCPs) to reduce alcohol related harm at local level in the UK. MCPs involve the identification of alcohol related problems at the local level and implementation of a programme of co-ordinated projects to tackle a problem. They are based on an integrative design where singular interventions run in combination with each other and/or are sequenced together over time; the identification, coordination and mobilisation of local agencies, stakeholders and community are key elements (Thom and Bayley, 2007). This study was underpinned by the recognition that the voices of practitioners are often marginalised in the debates about ‘what works’ and it set out to include their views. So whilst acknowledging the importance of the international research literature, care was taken not to privilege it over other ‘softer’ sources e.g. knowledge and experience of practitioners.

Objectives

  1. Using three key sources (published international research literature; grey literature from the UK ; the knowledge of stakeholders involved in developing and delivering local alcohol policy and interventions) we aimed to develop criteria to judge the ‘promise’ of initiatives;
  2. With these criteria in mind, we aimed to identify and provide descriptions of ‘promising’ initiatives which have been implemented in the UK.

Methods

  • A comprehensive narrative review of the international research literature which focussed on identifying multi-component programmes and published since 2000 was conducted
  • A review of the UK grey literature and unpublished interventions was undertaken. The primary source was ‘Local Initiatives’ (formerly Hub of Alcohol Projects and Policies HubCAPP), a web based resource of local alcohol initiatives in England and Wales.
  • A scoping exercise was carried out:
    • Information was collected via an email questionnaire to key informants working in the alcohol field (e.g. alcohol leads, alcohol co-ordinators, substance misuse co-ordinators), across the UK. Respondents were asked to identify examples of up to three projects or initiatives that they considered to be ‘promising’ or innovative that were being/had been used to tackle alcohol related harms in their area. We received information about 72 projects.
    • Follow up telephone interviews were conducted to gather further information about selected initiatives that fulfilled at least one of the following criteria in terms of their innovative approach:
      • to demonstrate a new approach at reducing alcohol related harm, either in its development and/or delivery to an at-risk group whose needs had to-date remained unaddressed;
      • to adapt an existing approach to a novel setting;
      • to identify a novel approach or process to enhance the development or delivery of an intervention

To avoid duplication, projects posted on ‘Local Initiatives’ (database on Alcohol Learning website) which had already been examined as part of the grey literature review were excluded. In addition, initiatives identified as innovative in a particular locality but known by researchers to have been implemented elsewhere, or more widely, were rejected. With these criteria in mind, information was collected on a sample of 26 initiatives.

  • A workshop was held in November 2012 which brought together an invited group of practitioners working in the alcohol field, with the aim of drawing on the expertise and knowledge of key stakeholders to think about what ‘works’, how to identify ‘promise’ and develop initiatives to tackle alcohol related harms.

Key Findings

As the study progressed it became apparent that the MCP approach was only one of several ‘models’ that could provide a framework for those working to reduce alcohol related harm at a local level. Other models which appear to have also influenced the developments of recently emerging ‘promising’ initiatives are the ‘partnership’ approach and the ‘innovation’ approach.

  • These ‘models’ are not mutually exclusive, indeed there is overlap, particularly between the MCP and partnership approaches. Both the MCP and partnership approach suggest that not only should there be a clear rationale for developing and implementing an intervention overall, but the commitment of all the relevant agencies needs to be secured. Again sharing commonality with features of the MCP approach each ‘partner’ agency needs to have a clear overall aim with appropriate outcome measures.
  • There is clear evidence to indicate that local areas are taking active steps to reduce alcohol related harm in their localities, with a broad range of partners working together to achieve this common goal. Whilst local areas draw on elements of the multi-component approach – in particular partnership working- we found just one example of a multi-component programme in the UK (Community Action Blackburn, Scotland). Partnership working has evolved to be the accepted and established way of working to reduce alcohol related harm (Thom et al, 2011). The Community Alcohol Partnership (CAP) project (which started in St Neots, Cambridgeshire) provides a well documented example of a local initiative that has gone on to be adopted and adapted by a diverse range of local areas.
  • Another important influence is the innovation model, which is underpinned by the concept of change that improves performance and which has been recently used in the South East Alcohol Innovation Programme (SEAIP). Key to the programme was that it asked practitioners to come up with new innovative ideas to reduce alcohol related hospital admissions and the award of small grants by enabled them to test them ‘risk free’. Projects that emerged from the SEAIP included the Portsmouth ‘Frequent Flyer’ project, which involved intensive work with those individuals who had the highest level of repeat alcohol related hospital admissions and the Hampshire Pharmacy Intervention and Brief Advice (IBA) project in which IBA was delivered in community pharmacies).
  • ‘Tacit’ knowledge as well as evaluation – both formal and more informal –appears to play a part in whether an initiative is perceived as successful by practitioners or not. Rather than adopting one ‘model’, on the whole, local areas seem to take a pragmatic approach incorporating elements of various models depending on local needs and context.
  • Local responses to alcohol-related harm are shaped by national policy and guidance. In particular, the influence of National Indicator 39 (NI 391)1 and the Department of Health’s Alcohol Improvement Programme (2008-2011) was clear to see within this study, with many of the promising initiatives identified being High Impact Changes (e.g. Alcohol Health Workers; delivery of IBA) and which specifically aimed at reducing alcohol related hospital admissions.
  • Respondents recognised that they could learn from the experiences of other areas and valued opportunities to share success and the learning gleaned from implementing new initiatives (i.e. things that went less well/could be done differently). Online resources including the Alcohol Learning Centre (ALC), ‘Local Initiatives’ (formerly HubCAPP) on the ALC , and the Home Office good practice database were key mechanisms for sharing ‘promising’ approaches and learning from the field.
  • We found examples of successful transfer of initiatives (often with adaption) from one area to another. The SE Alcohol Innovation Programme involved transferring innovations from one area to another as part of the process of testing whether a ‘promising’ innovation could be rolled out more widely. In similar vein, we found examples of initiatives used in other spheres (e.g. with drug users) then being successfully applied to the alcohol field.
  • Funding, policy priorities and targets influence what initiatives are implemented on the ground, providing both opportunities (e.g. funding to pilot an idea) and constraints (e.g. on the type of project funded). In other words, local areas are not entirely ‘free’ to do what they feel is appropriate for their locality but must ‘fit’ into the boundaries set by national policy and available funding. Moreover, local areas have to respond to changes in national policy and in central government.
  • Evaluation is regarded as an important tool in demonstrating both the value of an initiative and the learning emerging from the process of developing and delivering that initiative. This learning is often best captured by using a qualitative approach involving discussions with practitioners and professionals, community and service users in the field, rather than over-relying on ‘hard’ outcome measures.

Key ingredients for developing a promising approach

Drawing on the different data it was possible to identify the ‘key ingredients’ needed for developing a promising approach to tackle alcohol related harms. These key ingredients are set out in the figure below.

Key ingredients for developing a promising approach to reducing alcohol related harm

Great emphasis is placed on demonstrating the financial value of initiatives (e.g. cost savings) and care needs to be taken to ensure that other outcomes (e.g. clinical) are given due attention. Finally, given that:

  1. It is highly likely that many well evidenced/accepted interventions began as an idea or ‘hunch’
  2. Problems, policy and society change so responses need to be flexible and may need to be adapted or even reconsidered over time

It is essential to have mechanisms that:

  • Value the tacit knowledge of a broad range of practitioners within the field about what ‘works’, also what ‘might’ work (e.g. new ways of working) and what does not work (or works well enough i.e. what needs improving)
  • Encourage the generation of ideas for new ways to address problems or improve current practice (from practitioners, service users)
  • Provide ‘risk free’ opportunities to pilot and evaluate new initiatives and have a pathway for ‘promising’ approaches to be tested further
  • Enable learning to be shared across areas in easily accessible ways e.g. online resources, forums, events (local, regional and national).

Sources of further information about ‘promising approaches’ to reduce alcohol related harm

The following list is not exhaustive rather it gives pointers to those interested in finding out more:

Alcohol Learning Centre (ALC)

A treasure trove of information and resources on alcohol matters. The ‘Local Initiatives ’database can be searched in a variety of ways e.g. by project type, project setting, PCT, region http://www.alcohollearningcentre.org.uk/LocalInitiatives/projects/. The ALC also hosts debate and discussion forums, for example, the Hospital Alcohol Liaison Forum

Community Action-Blackburn (Changing Attitudes to Alcohol)

Community Action- Blackburn (West Lothian, Scotland) is a community led project aimed at making positive changes to the alcohol culture using a whole community approach. The report of the evaluation of the CAB pilot project can be accessed at the website. CAB is part of the Community Action on Alcohol project run by Alcohol Focus and funded by the Robertson Trust and two further community projects have been established – Neilston in East Renfrewshire and Lochgilphead/Ardrishaig in Argyll, see http://www.alcohol-focus-scotland.org.uk/national-communities-project

Community Alcohol Partnerships (CAP)

CAPs have been established across the country, the website includes case studies, details of current CAPs and a CAP Toolkit. Report on the evaluation of the Kent CAP.

The South East Alcohol Innovation Programme

The website contains information about innovation projects supported by SEAIP including the Portsmouth Frequent Flyer project and the Hampshire Pharmacy IBA project. The SEAIP evaluation report contains detailed information about the High Impact Innovation projects which were funded.

Please note the links were accessed 28th February 2012 but may not stay ‘live’ indefinitely.

Research Team

Rachel Herring, Mariana Bayley, Anthony Thickett, Katie Stone and Seta Waller from Middlesex University, Drug and Alcohol Research Centre.

Acknowledgements

We are grateful to Alcohol Research UK and the Joseph Rowntree Foundation who funded this study and all those who took part. We would also like to extend our thanks to Joanne McCallum (formerly of Alcohol Concern) for her assistance.

References

HM Government (2008) National Indicators for local authorities and local authority partnerships: handbook of definitions. Annex 1: Stronger and Safer Communities. London: Department for Communities and Local Government.

Thom, B. and Bayley, M. (2007) Multi-component Programmes: An Approach to Prevent and Reduce Alcohol Related Harm. York: Joseph Rowntree Foundation.

Thom, B., Herring, R., Bayley, M., Waller, S. and Berridge, V. (2011) Partnerships: a mechanism for local alcohol policy implementation

Footnote

1 Public Service Agreement (PSA 25) for the period 2008/9-2010/11 aimed at reducing the harm caused by drugs and alcohol. NI 39 measured the rate of alcohol related admissions per 1000,000 population using Hospital Episode Statistics. NI 39 was used to measure progress on PSA 25 and the aim was to “reduce the trend in the increase of alcohol related hospital admissions” (HM Government, 2008, p.67).

Follow Up Workshop

Following on from this study, the group held a workshop in March 2012, to explore the experiences of working with ‘Frequent Flyers’, who form a set of clients repeatedly admitted to hospital or attending A&E for treatment for alcohol-related conditions.  Here’s a summary report of the workshop.

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