A new approach to prevent and reduce alcohol-related harm
A review of international experience of community-based prevention programmes to address alcohol-related harms at local level.
A key part of the Alcohol Harm Reduction Strategy for England (2004) is a focus on local responsibility for alcohol misuse and an expectation that stakeholders – local authorities, professional groups, the alcohol trade and ‘communities’ – will work together to reduce the cost to individuals and communities.
The report describes a ‘multi-component’ model to prevent and reduce harm, with evidence from programmes in the USA, Australia and Scandinavia. The approach typically requires:
- a programme of multiple, co-ordinated initiatives rather than ‘stand-alone’ projects; and
- an emphasis on encouraging change in local policies, structures, systems and drinking cultures.
The authors conclude that involvement of local communities is vital, and suggest that the use of a more explicit multi-component model would be helpful to map alcohol-related problems and design local strategies.
Local responsibility for policy implementation is a core element of national strategy to reduce alcohol-related harms. This research, by a team at Middlesex University, reviews international experience of using a ‘multi-component’ approach to develop and implement community-based prevention programmes. The method typically requires a programme of co-ordinated initiatives, and emphasises changing local policies, structures, systems and drinking cultures. The study also examined the relevance of this approach locally in the UK. It found that:
- International research supports prevention and harm reduction strategies which target groups of people and aim to change systems, social structures and factors which encourage harmful patterns of drinking.
- Evidence for the effectiveness of multi-component programmes is mixed. However, there is a growing consensus that a multi-component approach has a greater chance of success than stand-alone projects. This is partly due to the whole being greater than the sum of the parts, enabling positive changes.
- Evidence suggests that effective multi-component programmes are based on a sound theoretical framework to guide the conceptualisation of the problem, the design and implementation of the intervention programme and its evaluation.
- In all cases, the engagement and involvement of the community is vital.
- Research shows that it is important to recognise that everyone may not share the same values, expectations and goals, communities change over time and programmes may disrupt existing networks or partnerships producing unexpected and unwanted consequences.
- Ensuring the sustainability of successful initiatives requires that changes in behaviours and social structures become embedded in local policies, cultures and practices.
- Evaluation at key stages of the programme is important in assessing its success, generating understanding of change within communities and systems, learning reasons for success and failure of initiatives and planning future action to sustain positive changes. Few UK programmes have been evaluated.
- Respondents in the UK scoping exercise reported well-established partnership and multi-agency approaches to dealing with alcohol-related harms, but few of these were explicitly ‘multi-component’. Respondents differed about the value of single issue (alcohol-focused) programmes compared to embedding a response to alcohol within other initiatives.
The national Alcohol Harm Reduction Strategy for England (2004) emphasised local responsibility for policy implementation and an expectation that stakeholders – local authorities, professional groups, the alcohol trade and ‘communities’ – would work in partnership to develop responses to alcohol-related harm appropriate to the local area. Drug and Alcohol Action Teams, Primary Care Trusts and Crime and Disorder Reduction Partnerships are some of the existing organisations and networks that are relevant to the provision of an organisational base for implementing local strategies. More specifically, the national strategy stresses the need to ensure that interventions to reduce harm are:
- coherent, as isolated interventions are unlikely to succeed;
- sustained, to have long-term impact;
- strategic, as a co-ordinated strategy will aid progress; and
- measured, to chart progress and to measure the success of the strategy. The adoption of a ‘multi-component’ approach would appear to provide a suitable framework for meeting national objectives.
This project aimed to:
- review the international, English language literature on multi-component programmes as an approach to preventing and reducing alcohol-related harms;
- extract main themes and issues relevant to considering the development of such programmes in the UK context;
- investigate whether multi-component programmes were already in operation or being developed in local areas in England; and
- consider the opportunities and barriers to mounting multi-component programmes in a variety of local contexts.
Defining ‘multi-component’ programmes
What distinguishes the multi-component approach from a single component approach is:
- the existence of a strategic framework with a theoretical basis for action; n
the identification of problems defined at local levels;
- a programme of co-ordinated projects to address the problem based on an integrative programme design, where singular interventions run in combination with each other and/or sequentially together over time;
- identification, mobilisation and co-ordination of appropriate agencies, stakeholders and local communities;
- clearly defined aims, objectives, indicators and measures of effectiveness for the programme as a whole (although individual projects or activities will also have specified aims, objectives and outcome measures); and
- evaluation as an integral part of the programme from the start.
Whole communities form the target intervention group rather than individuals within the community. Programmes typically emphasise modifying drinking cultures and effecting change in local policies, structures and systems; for instance, by improving local policies on alcohol, by strengthening collaborative networks between professional or stakeholder groups, or by involving local communities in efforts to achieve change.
Evidence for a multi-component approach
Evidence for ‘multi-component’ programmes came initially from the field of cardio-vascular disease prevention, where it was hailed as successful. Subsequent evidence has come largely from alcohol research and demonstration projects conducted in the USA, Australia, New Zealand and Scandinavia. Some programmes reported substantial success, others more mixed results:
Community Trials Project (USA)
Community-based environmental prevention programmes reduced risky drinking and alcohol-involved injuries resulting from vehicle crashes and assaults or requiring hospital treatment.
Operation Safe Crossing (USA)
Media and enforcement events were significantly associated with reduced heavy drinking and associated harm at the USA and Mexican borders.
Surfer’s Paradise (Australia)
The project was successful in reducing violence, crime and disorder. However, there may have been ‘displacement’ of problem clients and data collected two years later indicated successful short-term impact only.
Waikato Rural Drink-Drive Project (New Zealand)
The number of drivers apprehended with positive alcohol breath tests decreased significantly and prosecutions for drink-driving increased by 23 per cent. Fatal alcohol-related crashes decreased from 22 per cent to 14 per cent of all fatal crashes.
Alcohol consumption declined among men but not women. Alcohol-related problems showed a statistically significant reduction for males and a decline for binge-drinkers, but no reduction among females. The project created high awareness (67 per cent) among the population and 30 per cent identified alcohol as a main issue.
An important issue in assessing success is the longer term impact of the programme. In most cases, we know very little about what happens once a programme ends. The question of sustaining and building on change is acknowledged in the literature as a crucial but under-researched topic.
The UK context
From the 1980s, increasing responsibility was placed on local authorities and local communities to develop strategies and services to respond effectively to alcohol-related problems. Attempts were made to set up structures to facilitate action – for instance, a network of regional alcohol misuse co-ordinators and Alcohol Forums, intended to support inter-sectoral working at local level. Since the mid-1990s, policy has continued to promote ‘joined-up thinking’, ‘joint working’, and ‘multi-agency partnerships’. The establishment of multi-agency groups, such as Crime and Disorder Reduction Partnerships and Drug Action Teams have provided models for collaborative working.
Until recently, prevention and community-based interventions consisted largely of a single component or a number of ‘stand-alone’ initiatives delivered by different agencies. Local authorities are now developing alcohol strategies and action plans and the notion of ‘multi-component’ approaches appears to be gaining currency in the UK. However, the scoping exercise found that:
- The term ‘multi-component’ was not used by respondents, who preferred to discuss initiatives within the context of ‘partnerships’.
- Partnership and multi-agency approaches were common in most local areas.
- Few programmes had adopted an explicit multi-component approach as described in the research literature.
- Both ‘alcohol-focused’ and ‘alcohol-embedded’ programmes have been set up. In the former case, preventing or reducing alcohol-related harms is the primary aim; in the second case, alcohol is seen as an important aspect of another problem, such as crime reduction and ‘night-time economy’ disorder.
Respondents suggested a number of advantages of embedded programmes. By ‘framing’ alcohol as a key element of other problems:
- the issue is kept high on local agendas;
- alcohol issues become relevant across different policy areas;
- it may help to secure resources; and
- it may help prevent ‘issue fatigue’ – boredom or the feeling that the problem has been dealt with already. The disadvantages of embedded programmes were also recognised:
- It may reduce ‘issue status’ in relation to other local concerns and priorities, with possible implications for sustaining action on alcohol as changes occur in community agendas.
- It may also miss dealing with some important elements of harm. For instance, it could concentrate on more visible public health aspects of problem alcohol use to the neglect of chronic alcohol problems and hidden problems such as alcohol-related domestic violence.
The focus of most programmes reported by respondents was on alcohol-related problems in town or city centres. This could be a result of a bias in the sample towards urban areas, or it may reflect current national priorities and perceived concerns regarding the ‘night-time economy’ and related anti-social behaviour. Over half of the projects had aims which were part of broader violent crime and anti-social behaviour objectives.
Implementing multi-component programmes
The review and scoping highlighted a number of difficulties faced in attempting to mount multi-component programmes.
National-local policy tensions: Tensions may arise between national policy requirements and the perceived needs and aims of local policy. In the scoping sample, some respondents criticised a perceived focus on criminal justice responses at the expense of health aspects; some felt that national priorities were not always relevant to local concerns and that there was confusion in policy aims.
Sustainability: Many programmes are developed using limited, short-term resources; they sometimes rely on ‘charismatic’ leadership in the local community or on input from research teams. This means that positive change may not be sustained.
Institutionalisation: Ensuring the sustainability of successful initiatives requires that changes in norms, behaviours and social structures become ‘institutionalised’ or embedded in local policies, cultures and practices. Such changes may require shifts in the balance of professional power or policy networks or may be seen as a challenge to the status quo in communities.
Transferring programmes: Scoping sample respondents reported a tendency for projects and programmes which appear to work in one local setting to be applied elsewhere without any specific evidence that the model would transfer successfully.
Evaluation: Evaluation of a programme as a whole is rarely undertaken. It is, therefore, difficult to assess the success of the programme, to understand possible shortcomings and failures and to judge whether a similar programme could be transferred usefully to a different local context.
Community involvement: Gaining and keeping community support and involvement was recognised as a key factor in programme implementation. However, considerable barriers to achieving this were described. These included:
- tensions between the expectations and understandings of different groups regarding, for instance, the main aims of the programme;
- the role of ‘the community’ in relation to professionals, power sharing and decision making;
- conflicting priorities in allocating resources;
- possible unwanted effects of interventions on social cohesion, and existing structures and networks;
- the possibility that action may increase the exclusion of some groups (such as the young and most disadvantaged); and
- assessing the limits of community willingness and ability to participate.
International research provides considerable support for encouraging the development of multi-component programmes for the prevention and reduction of alcohol-related harm. There is also a good case to be made for shifting the emphasis from individually oriented interventions to policy-based interventions which target communities as a whole. Despite the implementation difficulties described in the literature, there is evidence that multi-component approaches offer a promising way forward through the creation of strong infrastructures to promote change. This includes a focus on the development of local policy, the strengthening of local partnerships and networks and the appropriate mobilisation of local communities to support the programmes. The review suggests:
- Better use of explicit conceptual frameworks is required to inform the design, implementation and evaluation of programmes.
- Evaluation of programmes as a whole as well as of individual projects is important in understanding what works and why.
- In mounting programmes, greater consideration of sustainability and ‘institutionalisation’ of change is needed.
- Research is needed to explore how communities can be ‘shifted’ towards adopting community prevention approaches rather than targeting individual behaviour.
About the project
The report is based on a narrative review of English language publications, and consultation with eleven international experts. There were also brief interviews with 25 respondents in the UK, representing different types of organisations (Drug and Alcohol Action Teams, Alcohol Action Teams, Crime and Disorder Reduction Partnerships, Primary Care Trusts) in different geographical locations. The project was carried out by Betsy Thom and Mariana Bayley from the Drug and Alcohol Research Group at Middlesex University.