Institutionalization of community action projects to reduce alcohol-use related problems: systematic facilitators

Community-Based Healthcare Programs Sustainability Impact on the Sustainability of Host Organizations: A Structural Equation Modeling Analysis

The sustainability of community-based programs represents a major focus of the literature on community-based interventions in the last few decades. However, without sustainable host organizations to effectively implement them, many are prone to failure. This paper analyzes the influence of the sustainability factors of healthcare community-based programs on the host organization’s sustainability. Based on a sample of 11 community-based healthcare programs and 401 respondents and using structural equation modeling, the study investigated if program specific, organization specific, and community specific factors are indeed measures of community-based programs’ sustainability, if social and economic dimensions are measures of host organization sustainability, and if the sustainability of the community-based program influences thee host organization’s sustainability. The results confirmed all three research hypothesis. The main contribution of the paper is to demonstrate a direct relationship between the sustainability of community-based programs and the overall sustainability of the organizations implementing them.

A Commentary on the Limits of Alcoholic Beverage Policies

Providing one set of policy measures for all countries as if they were a single, homogeneous entity does not appear to be evidence-based, according to recent research on the effectiveness of alcoholic beverage control policies. Contextual and cultural determinants-social, economic, demographic, cultural and political-appear to be major factors of influencing change in drinking trends, drinking patterns and drinking-related harms. The variable interplay between contextual determinants and alcohol control policy measures implies diverse impacts on consumption and harm according to time, and to the different countries and groups of countries. In addition, epidemiology research manifests some limitations when applied to alcohol drinking and results are transferred from one culture to another. The conditions of individual cultures and countries should be considered when planning and evaluating alcohol control policies.

Narratives of community engagement: a systematic review-derived conceptual framework for public health interventions

Background

Government policy increasingly supports engaging communities to promote health. It is critical to consider whether such strategies are effective, for whom, and under what circumstances. However, ‘community engagement’ is defined in diverse ways and employed for different reasons. Considering the theory and context we developed a conceptual framework which informs understanding about what makes an effective (or ineffective) community engagement intervention.

Methods

We conducted a systematic review of community engagement in public health interventions using: stakeholder involvement; searching, screening, appraisal and coding of research literature; and iterative thematic syntheses and meta-analysis. A conceptual framework of community engagement was refined, following interactions between the framework and each review stage.

Results

From 335 included reports, three products emerged: (1) two strong theoretical ‘meta-narratives’: one, concerning the theory and practice of empowerment/engagement as an independent objective; and a more utilitarian perspective optimally configuring health services to achieve defined outcomes. These informed (2) models that were operationalized in subsequent meta-analysis. Both refined (3) the final conceptual framework. This identified multiple dimensions by which community engagement interventions may differ. Diverse combinations of intervention purpose, theory and implementation were noted, including: ways of defining communities and health needs; initial motivations for community engagement; types of participation; conditions and actions necessary for engagement; and potential issues influencing impact. Some dimensions consistently co-occurred, leading to three overarching models of effective engagement which either: utilised peer-led delivery; employed varying degrees of collaboration between communities and health services; or built on empowerment philosophies.

Conclusions

Our conceptual framework and models are useful tools for considering appropriate and effective approaches to community engagement. These should be tested and adapted to facilitate intervention design and evaluation. Using this framework may disentangle the relative effectiveness of different models of community engagement, promoting effective, sustainable and appropriate initiatives.

Implementation of a multicomponent Responsible Beverage Service programme in Sweden-a qualitative study of promoting and hindering factors

Aims

The objective of this study was to identify factors that either promote or hinder implementation of a multicomponent Responsible Beverage Service programme in Swedish municipalities.

Design

Forty semi-structured interviews were conducted in six municipalities and directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), was performed.

Results

The CFIR framework was useful as an underlying theoretical model in this study. Importance of the following factors, described in the five domains of CFIR, was empirically supported in this study: local needs, evidence strength and advantages of the intervention, costs and available resources, clear goals, evaluation and feedback, access to knowledge and information, clear role definitions and cooperation, and enthusiastic key persons with high confidence in the effectiveness of the intervention. Hindering factors listed by the informants were lack of enthusiasm and opportunities to specialise, low degree of self-efficacy, unengaged decision-makers, complexities of the programme, and a top-down approach.

Conclusions

This study indicates that previously identified factors shown to promote and hinder implementation processes are also valid in the context of multicomponent community action programmes like RBS. Suggestions on how to elude some of the hindering factors are proposed, e.g. to develop long-time financial plans, to provide better information about the RBS program in full, and to stress the importance of collaboration between representatives from the municipalities, police authorities and owners of on-licenced premises.

Preventive Interventions for On-Premise Drinking: A Promising but Underresearched Area of Prevention

Evidence is reviewed regarding the effectiveness of eight different approaches to the prevention of drinking driving, aggression, and other problems associated with drinking in licensed premises. Some evidence of positive effects was found for Responsible Beverage Service training (including mandatory training), laws holding servers liable for negative consequences due to intoxicated patrons, increased enforcement, ride services, and, to a lesser extent, designated-driver programs and community interventions broadly focused on on-premise drinking. House policies, risk assessments, and proactive policing showed promise but remain unproved in terms of direct effects on the prevention of problems. Codes of practice and patron education appear unlikely to be effective unless combined with enforcement or other interventions. Overall there has been an abundance of local and more extensive interventions to reduce problems in bars, but few have been rigorously evaluated. There is a need in future evaluations for strategically targeting and combining interventions according to a systematic analysis of the nature of the problem and hypothesized contributing factors.

Socioeconomic differences in alcohol-attributable mortality compared with all-cause mortality: a systematic review and meta-analysis

BACKGROUND

Factors underlying socioeconomic inequalities in mortality are not well understood. This study contributes to our understanding of potential pathways to result in socioeconomic inequalities, by examining alcohol consumption as one potential explanation via comparing socioeconomic inequalities in alcohol-attributable mortality and all-cause mortality.

METHODS

Web of Science, MEDLINE, PsycINFO and ETOH were searched systematically from their inception to second week of February 2013 for articles reporting alcohol-attributable mortality by socioeconomic status, operationalized by using information on education, occupation, employment status or income. The sex-specific ratios of relative risks (RRRs) of alcohol-attributable mortality to all-cause mortality were pooled for different operationalizations of socioeconomic status using inverse-variance weighted random effects models. These RRRs were then combined to a single estimate.

RESULTS

We identified 15 unique papers suitable for a meta-analysis; capturing about 133 million people, 3 741 334 deaths from all causes and 167 652 alcohol-attributable deaths. The overall RRRs amounted to RRR = 1.78 (95% confidence interval (CI) 1.43 to 2.22) and RRR = 1.66 (95% CI 1.20 to 2.31), for women and men, respectively. In other words: lower socioeconomic status leads to 1.5-2-fold higher mortality for alcohol-attributable causes compared with all causes.

CONCLUSIONS

Alcohol was identified as a factor underlying higher mortality risks in more disadvantaged populations. All alcohol-attributable mortality is in principle avoidable, and future alcohol policies must take into consideration any differential effect on socioeconomic groups.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Factors contributing to the sustainability of alcohol and other drug interventions in Australian community health settings

This study identifies factors that support the sustainability of interventions implemented to enhance responses to alcohol and other drug misuse in Australian community health settings. Eight completed projects that had received time-limited funding were sampled to reflect a mix of project types, contexts and success in meeting funding objectives. Projects were investigated using a case study approach involving thematic analysis. Project records were analysed and interviews were conducted with stakeholders to identify intervention elements that continued after funding ceased, and factors that supported this sustainability. Key factors identified were: embedding changes in the operations of the agency; filling a critical gap in the sector; building support from key individuals and agencies; and planning realistically for future ownership. We argue that complexity theory provides a framework to understand both the context-bound nature of intervention sustainability and differences within the literature as to how sustainability is typologised. Each factor associated with intervention sustainability identified in this study reflects an astute understanding of project context and a capacity to adapt. These factors could assist people designing interventions with time-limited funding to maximise ongoing impact of interventions. They should optimally be implemented within an overall approach of flexibility and sensitivity to context.

Development and process evaluation of a Web-based responsible beverage service training program

Background

Responsible beverage service (RBS) training designed to improve the appropriate service of alcohol in commercial establishments is typically delivered in workshops. Recently, Web-based RBS training programs have emerged. This report describes the formative development and subsequent design of an innovative Web-delivered RBS program, and evaluation of the impact of the program on servers’ knowledge, attitudes, and self-efficacy.

Methods

Formative procedures using focus groups and usability testing were used to develop a Web-based RBS training program. Professional alcohol servers (N = 112) who worked as servers and/or mangers in alcohol service settings were recruited to participate. A pre-post assessment design was used to assess changes associated with using the program.

Results

Participants who used the program showed significant improvements in their RBS knowledge, attitudes, and self-efficacy.

Conclusions

Although the current study did not directly observe and determine impact of the intervention on server behaviors, it demonstrated that the development process incorporating input from a multidisciplinary team in conjunction with feedback from end-users resulted in creation of a Web-based RBS program that was well-received by servers and that changed relevant knowledge, attitudes, and self-efficacy. The results also help to establish a needed evidence base in support of the use of online RBS training, which has been afforded little research attention.

Long-term effects of a community-based intervention: 5-year follow-up of 'Clubs against Drugs'

AIMS

To evaluate long-term effects of a multi-component community-based club drug prevention programme.

DESIGN

A pre- (2003) and post-intervention study (2004 and 2008) design.

SETTING

High-risk licensed premises in central Stockholm, Sweden.

PARTICIPANTS

The intervention programme, 'Clubs against Drugs', included community mobilization, drug-training for doormen and other staff, policy work, increased enforcement, environmental changes and media advocacy and public relations work.

MEASUREMENT

The indicator chosen for this study was the frequency of doormen intervention towards obviously drug-intoxicated guests at licensed premises. Professional male actors (i.e. pseudopatrons) were trained to act impaired by cocaine/amphetamines while trying to enter licensed premises with doormen. An expert panel standardized the scene of drug intoxication. Each attempt was monitored by two male observers.

FINDINGS

At the follow-up study in 2008 the doormen intervened in 65.5% of the attempts (n=55), a significant improvement compared to 27.0% (n=48) at the first follow-up in 2004 and to 7.5% (n=40) at baseline in 2003.

CONCLUSION

The 'Clubs against Drugs' community-based intervention programme, a systems approach to prevention, appears to increase the frequency and effectiveness of club doormen's interventions regarding obviously drug-intoxicated guests.

Effectiveness of multicomponent programs with community mobilization for reducing alcohol-impaired driving

A systematic review was conducted to determine the effectiveness and economic efficiency of multicomponent programs with community mobilization for reducing alcohol-impaired driving. The review was conducted for the Guide to Community Preventive Services (Community Guide). Six studies of programs qualified for the review. Programs addressed a wide range of alcohol-related concerns in addition to alcohol-impaired driving. The programs used various crash-related outcomes to measure their effectiveness. Two studies examined fatal crashes and reported declines of 9% and 42%; one study examined injury crashes and reported a decline of 10%; another study examined crashes among young drivers aged 16-20 years and reported a decline of 45%; and one study examined single-vehicle late-night and weekend crashes among young male drivers and reported no change. The sixth study examined injury crashes among underage drivers and reported small net reductions. Because the actual numbers of crashes were not reported, percentage change could not be calculated. According to Community Guide rules of evidence, the studies reviewed here provided strong evidence that carefully planned, well-executed multicomponent programs, when implemented in conjunction with community mobilization efforts, are effective in reducing alcohol-related crashes. Three studies reported economic evidence that suggests that such programs produce cost savings. The multicomponent programs generally included a combination of efforts to limit access to alcohol (particularly among youth), responsible beverage service training, sobriety checkpoints or other well-defined enforcement efforts, public education, and media advocacy designed to gain the support of both policymakers and the general public for reducing alcohol-impaired driving.

Environmental Strategies for Prevention of Drug Use and Risks in Clubs

Environmental prevention strategies in club settings where music and dance events are featured could provide an important new arena for the prevention of drug use and other risky behaviors (e.g., sexual risk taking, intoxication and drug use, aggression, and driving under the influence). Electronic music dance events (EMDEs) occur in clubs that attract young, emerging adults (18-25 years of age) and attract individuals who engage in various types of drug use. Borrowing from the environmental prevention studies that focus on reducing alcohol use and related problems, a model for drug prevention in the club setting is proposed. Initially, an overview of the relationships between EMDEs and drug use and other risky behaviors are presented. Next, rationales for environmental strategies are provided. Finally, an environmental approach to prevention of drug use and risky behaviors in clubs is described. This comprehensive set of environmental strategies, is designed to be mutually supportive and interactive. Environmental strategies are believed to provide potential for developing an efficacious prevention strategy. The environmental prevention approach presented here is composed of three intervention domains: (1) Mobilization, (2) Strategies for the Exterior Environment, and (3) Strategies for the Interior Environment.

The sustainability of systems of care for children's mental health: lessons learned

The federal Comprehensive Community Mental Health Services for Children and Their Families Program was initiated in 1992 to provide grants to states, communities, territories, and Indian tribes to develop systems of care to serve children and adolescents with or at risk for emotional disorders and their families. As part of the national evaluation of this program, a study was undertaken to assess the ability of funded sites to sustain their systems of care beyond the federal grant period. The study involved a web survey and telephone interviews with local and state respondents to examine the extent to which key components of systems of care were maintained during the period in which federal funds were phasing out and during the post grant period. Study results demonstrate positive and negative changes that occurred in the communities which are included in the sample, with respect to maintaining the availability of each service included in the broad service array, the implementation of system of care principles, the system of care infrastructure, and the achievement of system of care goals. In addition, results identify factors that contribute to or impede the ability to sustain systems of care, and the effectiveness of various strategies for sustainability. Study findings offer guidance not only to federally funded system of care communities but also to non-funded communities engaged in system of care development to enhance their ability to sustain systems of care for this population over time. Findings will also assist federal, state, and local policymakers, technical assistance providers, family members, advocates, and other key stakeholders to more effectively support the development of viable, sustainable systems of care.

Dissemination of prevention: community action targeting alcohol use-related problems at licensed premises

In 2003, a community action program targeting alcohol use-related problems at licensed premises was disseminated to municipalities in Stockholm County. The intervention program includes local mobilization, training in responsible beverage service, and stricter enforcement of extant alcohol laws. This research studies the dissemination process, which was based on Diffusion of Innovations Theory. The communities followed a systematic model for dissemination: engaging a local coordinator, conducting interviews with owners of licensed premises, creating an action group, presenting results from studies to the local media, and initiating training in responsible beverage service. Evaluation of uptake is based on meeting minutes from local action groups and activity reports. Preliminary results indicate that the dissemination strategy has been fairly successful. Half of the communities (7 of 14) contacted are implementing the model program. Further research is needed to more fully explore the potential of the use of the Diffusion of Innovations Theory, taking into consideration different stages of community readiness.

A system for evaluating local alcohol and drug use prevention initiatives

Local alcohol and drug use prevention in Sweden has witnessed a substantial surge in recent years, with government funding for local coordinators in every municipality. Whether this has contributed to the recent decline in alcohol use among young people is unknown. The ESAPP project evaluates local alcohol and drug prevention in the 18 municipalities that comprise Stockholm. In order to obtain knowledge of prevention activities and their role in outcomes and to stimulate sharing of experiences, a Web-based reporting system was developed in collaboration with the local coordinators. There has been considerable variation in the use of this reporting system and its potential has not been realized.

Fostering organizational change through a community-based initiative

Program funders and managers are increasingly interested in fostering changes in the policies, practices, and procedures of organizations participating in community-based initiatives. But little is known about what factors contribute to the institutionalization of change. In this study, the authors assess whether the organizational members of the Bronx Health REACH Coalition have begun to change their functioning and role with regard to their clients and their staff and in the broader community, apart from their implementation of the funded programs for which they are responsible. The study identifies factors that seemed to contribute to or hinder such institutional change and suggests several strategies for coalitions and funders that are seeking to promote and sustain organizational change.

Institutionalization of a community action program targeting licensed premises in Stockholm, Sweden

The objective of this article is to evaluate the level of institutionalization of a community action program targeting licensed premises in Stockholm. Five key factors were identified for institutionalization: adoption, sustainability, key leader support, structural changes, and compliance. A scale was developed to assess the strength of each factor. The results indicate a high degree of institutionalization (score 13 on a scale from 5 to 15). The authors conclude that the program activities have been sustained at a high level. A written agreement ensures that the participating organizations take responsibility for the continuing work.

Community action and the regulation of alcohol availability: Modelling the connections

In Australia, as in other countries, recent initiatives aimed at reducing alcohol-related harm have focused on the local community as the site of interventions, and in many cases have included local controls on alcohol availability as a key component. In this process, liquor licensing authorities – as the statutory agency primarily responsible for regulating alcohol availability – have been called upon to act as instruments of public health. Historically, however, their primary function has not been to promote public health, but rather to maintain orderly markets. Moreover, their power to intervene in market processes has in many instances been curtailed under deregulatory policies accompanying globalisation. Taken together, these trends generate a need for a theoretically-informed understanding of the role of liquor licensing bodies and other regulatory agencies in a context of locally-based initiatives aimed at reducing alcohol-related problems.

This paper proposes a conceptual framework for meeting this need. Liquor regulatory systems are seen as agencies of social control mandated by the state. Three key components of these systems are identified: 1) laws and regulations governing the activities of liquor licensing authorities; 2) the structure and resourcing of agencies established to uphold the laws and regulations, and 3) practices through which decisions are reached by the licensing authorities. Each of these has influence independently of, but also in interaction with, each other.

The initiation of local action focusing on alcohol problems generates a complex social field within which economic and political agencies, some operating at a purely local level, others at a national or even global level, compete to promote and defend their interests, and in which culturally ascribed beliefs and practices associated with drinking alcohol at the micro-social level are endorsed, challenged and/or defended. Within this field, liquor licensing authorities become agencies upon which competing claims are made. The processes involved can be analysed in terms of four phases: 1) agenda setting and problem definition; 2) specification of alternatives; 3) decision-making; 4) implementation.

The components and processes outlined in the paper are illustrated with reference to instances of local action in northern Australia. The model proposed will serve, it is argued here, as a framework for more systematic comparative analysis of such local actions.

Extending the reach of nutrition education for older adults: feasibility of a Train-the-Trainer approach in congregate nutrition sites

Low-income older adults are difficult to reach with nutrition education. This study examines the feasibility of a Train-the-Trainer approach using congregate nutrition site (CNS) managers to deliver nutrition education. The study suggests that CNS managers were receptive to the role of trainer, CNS participants were satisfied with this method, and the acceptability of managers as trainers did not vary with participants' levels of risk of malnutrition. Although the sample size (53 participants and 4 managers) and convenience sampling method limit generalizability, the promising results suggest the potential benefits of this method and the need for further study.

Community prevention of alcohol problems

Local communities have begun using policy to affect the drinking environment itself as an approach to reducing alcohol involved trauma. That is, policy is used to produce structural changes in the drinking environment. In turn, changes in the environment effect changes in drinking behavior. This paper describes an effort in three communities in two states to reduce alcohol problems at the community level, "Preventing Alcohol Trauma: A Community Trial." This trial was a 5-year research project with a goal to reduce local alcohol-involved injuries and deaths in three experimental communities with populations of approximately 100,000 each (one in northern California, one in southern California, and one in South Carolina). The communities contained racial and ethnic diversity as well as a mix of urban, suburban, and rural settings. Each of these three communities had a control community that did not receive the prevention interventions. The project used an environmental policy approach to prevention and five mutually reinforcing components were implemented: (1) community mobilization to develop community organization and support, (2) responsible beverage service to establish standards for servers and owners/managers of on-premise alcohol outlets to reduce their risk of having intoxicated and/or underage customers in bars and restaurants. (3) a drinking and driving component to increase local drunk-driving enforcement efficiency and to increase the actual and perceived risk that drinking drivers would be detected, (4) an underage drinking component to reduce retail availability of alcohol to minors, and (5) an alcohol access component to use local zoning powers and other municipal controls of outlet numbers and density to reduce availability of alcohol. Results show that the project reduced alcohol-involved crashes, lowered sales to minors, increased the responsible alcohol serving practices of bars and restaurants, and increased community support and awareness of alcohol problems.