'A priori' external contextual factors and relationships with process indicators: a mixed methods study of the pre-implementation phase of 'Communities in Charge of Alcohol'.

BACKGROUND: It is widely recognised that complex public health interventions roll out in distinct phases, within which external contextual factors influence implementation. Less is known about relationships with external contextual factors identified a priori in the pre-implementation phase. We investigated which external contextual factors, prior to the implementation of a community-centred approach to reducing alcohol harm called 'Communities in Charge of Alcohol' (CICA), were related to one of the process indicators: numbers of Alcohol Health Champions (AHCs) trained. METHODS: A mixed methods design was used in the pre-implementation phase of CICA. We studied ten geographic communities experiencing both high levels of deprivation and alcohol-related harm in the North West of England. Qualitative secondary data were extracted from pre-implementation meeting notes, recorded two to three months before roll-out. Items were coded into 12 content categories using content analysis. To create a baseline 'infrastructure score', the number of external contextual factors documented was counted per area to a maximum score of 12. Descriptive data were collected from training registers detailing training numbers in the first 12 months. The relationship between the baseline infrastructure score, external contextual factors, and the number of AHCs trained was assessed using non-parametric univariable statistics. RESULTS: There was a positive correlation between baseline infrastructure score and total numbers of AHCs trained (Rs = 0.77, p = 0.01). Four external contextual factors were associated with significantly higher numbers of lay people recruited and trained: having a health care provider to coordinate the intervention (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); a contract in place with a commissioned service (p = 0.02), and; formal volunteer arrangements (p = 0.03). CONCLUSIONS: Data suggest that there were four key components that significantly influenced establishing an Alcohol Health Champion programme in areas experiencing both high levels of deprivation and alcohol-related harm. There is added value of capturing external contextual factors a priori and then testing relationships with process indicators to inform the effective roll-out of complex interventions. Future research could explore a wider range of process indicators and outcomes, incorporating methods to rate individual factors to derive a mean score. TRIAL REGISTRATION: ISRCTN81942890, date of registration 12/09/2017.

A mixed methods analysis evaluating an alcohol health champion community intervention: How do newly trained champions perceive and understand their training and role?

Globally, alcohol harm is recognised as one of the greatest population risks and reducing alcohol harm is a key priority for the UK Government. The Communities in Charge of Alcohol (CICA) programme took an asset-based approach in training community members across nine areas to become alcohol health champions (AHCs); trained in how to have informal conversations about alcohol and get involved with alcohol licensing. This paper reports on the experiences of AHCs taking part in the training through the analysis of: questionnaires completed pre- and post-training (n = 93) and semi-structured interviews with a purposive sample of five AHCs who had started their role. Questionnaires explored: characteristics of AHCs, perceived importance of community action around alcohol and health, and confidence in undertaking their role. Following training AHCs felt more confident to talk about alcohol harms, give brief advice and get involved in licensing decisions. Interviews explored: AHCs' experiences of the training, barriers and facilitators to the adoption of their role, and how they made sense of their role. Four overarching themes were identified through thematic analysis taking a framework approach: (a) perceptions of AHC training; (b) applying knowledge and skills in the AHC role; (c) barriers and facilitators to undertaking the AHC role; and (d) sustaining the AHC role. Findings highlight the challenges in establishing AHC roles can be overcome by combining the motivation of volunteers with environmental assets in a community setting: the most important personal asset being the confidence to have conversations with people about a sensitive topic, such as alcohol.

How can communities influence alcohol licensing at a local level? Licensing officers' perspectives of the barriers and facilitators to sustaining engagement in a volunteer-led alcohol harm reduction approach.

Despite the World Health Organization's assertion that communities need to become involved in reducing alcohol harm, evidence of community engagement in alcohol licensing decision-making in England remains limited. The evaluation of the Communities in Charge of Alcohol (CICA) programme offers policymakers, Licensing authorities and public health practitioners, evidence regarding a specific volunteer-led, place-based approach, designed to enable community engagement in licensing with the aim of reducing localised alcohol harm. This study explored factors affecting the sustainable involvement of volunteers in alcohol licensing decision-making from six licensing officers' perspectives, through semi-structured interviews. Routinely collected crime, disorder, and hospital admissions data were reviewed for further context as proxy indicators for alcohol-related harm. Licensing officers perceived sustainable engagement to be impacted by: (i) the extent of alignment with statutory requirements and local political support; (ii) the ability of licensing officers to operationalise CICA and support local assets, and; (iii) the opportunity for, and ability of, volunteers to raise licensing issues. The perspectives of licensing officers indicate complexities inherent in seeking to empower residents to engage in licensing decision-making at a community level. These relate to statutory and political factors, funding, social norms regarding engagement in licensing decision-making, and the need for networks between critical actors including responsible authorities and communities. The evidence indicates that after increasing community capacity to influence alcohol availability decision-making at a local level, communities continue to struggle to influence statutory processes to affect alcohol availability where they live and work. More understanding of how to enable effective community engagement is required.

An asset-based community development approach to reducing alcohol harm: Exploring barriers and facilitators to community mobilisation at initial implementation stage.

Globally there is a need to engage communities in actions to reduce alcohol harm. This paper reports on the initial implementation phase of an asset-based community development (ABCD) approach to reducing alcohol harm in ten pre-identified areas across Greater Manchester (UK). This qualitative study highlights the experiences of stakeholders responsible for, or engaged in, implementation. Findings show that it is challenging to recruit sufficient volunteers in a specific, small area/community, which may limit the ability to build health assets. Wider policy and organisational factors that should be understood prior to implementing a place-based volunteer-led health promotion programme are also identified. TRIAL REGISTRATION: https://www.isrctn.com/ISRCTN81942890.

Communities in charge of alcohol (CICA): a protocol for a stepped-wedge randomised control trial of an alcohol health champions programme.

BACKGROUND: Communities In Charge of Alcohol (CICA) takes an Asset Based Community Development (ABCD) approach to reducing alcohol harm. Through a cascade training model, supported by a designated local co-ordinator, local volunteers are trained to become accredited 'Alcohol Health Champions' to provide brief opportunistic advice at an individual level and mobilise action on alcohol availability at a community level. The CICA programme is the first time that a devolved UK region has attempted to coordinate an approach to building health champion capacity, presenting an opportunity to investigate its implementation and impact at scale. This paper describes the protocol for a stepped wedge randomised controlled trial of an Alcohol Health Champions programme in Greater Manchester which aims to strengthen the evidence base of ABCD approaches for health improvement and reducing alcohol-related harm. METHODS: A natural experiment that will examine the effect of CICA on area level alcohol-related hospital admissions, Accident and Emergency attendances, ambulance call outs, street-level crime and anti-social behaviour data. Using a stepped wedged randomised design (whereby the intervention is rolled out sequentially in a randomly assigned order), potential changes in health and criminal justice primary outcomes are analysed using mixed-effects log-rate models, differences-in-differences models and Bayesian structured time series models. An economic evaluation identifies the set-up and running costs of CICA using HM Treasury approved standardised methods and resolves cost-consequences by sector. A process evaluation explores the context, implementation and response to the intervention. Qualitative analyses utilise the Framework method to identify underlying themes. DISCUSSION: We will investigate: whether training lay people to offer brief advice and take action on licensing decisions has an impact on alcohol-related harm in local areas; the cost-consequences for health and criminal justice sectors, and; mechanisms that influence intervention outcomes. As well as providing evidence for the effectiveness of this intervention to reduce the harm from alcohol, this evaluation will contribute to broader understanding of asset based approaches to improve public health. TRIAL REGISTRATION: ISRCTN 81942890 , date of registration 12/09/2017.