Introduction

Parts of this chapter have been reproduced with permission from Cook et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The following text includes minor additions and changes to the original text.

Alcohol harm: a global concern

Reducing alcohol-related harm continues to be a global public health priority, with 5.3% of all global deaths and 5.1% of all disease and injuries being attributable to alcohol.2 Use of alcohol is widely recognised to harm an individual’s health and social relationships, and increasing evidence highlights the scale of alcohol’s harm to others through second-hand effects.3–5 It also harms society more generally, as urban areas can become less pleasant and less safe to visit,6 and crime may increase.7,8 Moreover, the consumption of alcohol contributes significantly to health inequalities. A so-called ‘alcohol harm paradox’ exists where alcohol harm is higher among those living in more deprived areas, even when the amount of alcohol consumed is the same or less as those more advantaged.9 This is due to patterns of consumption (e.g. heavy episodic binge drinking), lower access to health services, increased alcohol availability with fewer community assets and the accumulative effect of multiple risk factors (e.g. smoking, obesity).10–12 Overall, alcohol use is a key risk factor for many non-communicable diseases13 (NCD) but currently, the global NCD target to reduce harmful use of alcohol by 10% by 2025 is on a poor trajectory.14

Interventions to reduce intake and harm from alcohol

Interventions that are effective at reducing alcohol harm can be implemented at an individual level,15 community level16,17 and national level.18 At the individual level, alcohol identification and brief advice (IBA), otherwise known as alcohol screening and brief interventions (ASBIs), aims to reduce alcohol-related harm through early identification of hazardous or harmful drinking in non-treatment-seeking populations. It has been shown in systematic reviews and meta-analyses to be effective among adults in a variety of settings15,19 with most trials located in primary care settings20 and emergency departments.21,22 According to the traditional classification system of preventative interventions, ASBIs are a type of secondary prevention intervention designed to lower the prevalence of alcohol use disorders and reduce the potential for future harm by promoting early behaviour change.23,24 The World Health Organization identifies ASBIs as a recommended ‘best buy’ intervention to reduce alcohol use.25

However, evidence of implementation of ASBIs as a secondary prevention intervention in non-health community settings is limited.26 Little is known as to whether alcohol IBA must always be delivered by a professional in order to be effective. While existing research demonstrates that lay health worker roles are an established approach,23 widely used for a range of public health priorities and population groups,27 no previous programmes with a specific focus on alcohol had been published in the literature.

At the community level, accessibility of alcohol is a key determinant of harm, and restricting physical access to alcohol is an additional World Health Organization ‘best buy’ as it is deemed effective, cost-effective and feasible to implement globally.2,3,25 Internationally, systematic review evidence shows that increased alcohol outlet density and temporal availability are linked to higher levels of crime and poor health. Interventions in and around the alcohol environment that improve the serving practices and standards of licensed premises can lead to small reductions in acute alcohol-related harm.18

In England, local authorities can address accessibility, serving practices and standards of operation of premises licensed to sell or supply alcohol using the regulatory framework of the Licensing Act 2003.28 Each local licensing authority must publish a statement of its licensing policy every 5 years, promoting the four statutory objectives of the 2003 Act: the prevention of crime and disorder; public safety; the prevention of public nuisance; and the protection of children from harm. Longitudinal, area-level analysis of UK data sets has shown that, at borough level (i.e. lower-tier local authorities in England), both alcohol-related hospital admissions16 and crime17 reduced faster in areas where more restrictive licensing policies are in place. Using small area-level data [lower-layer super output areas (LSOAs) with a mean population of 1500 persons], alcohol outlet density in Wales has similarly been associated with alcohol-related hospital admissions and crime data.8 Licensing action could reduce alcohol harm at a community population level through both primary and secondary prevention mechanisms of action since restricting the physical availability of alcohol can benefit the whole population universally, and targeted enforcement action can mitigate the impact of existing harm.3,24

Powers exist for local people to influence licensing decisions, but such licensing action does not generally happen, and there is a paucity of published evidence on community engagement.29 Lay people have the ability to influence local alcohol licensing policy and licensing decisions via the local licensing process, and legislation promotes greater community involvement in licensing decisions. Existing studies have identified the need to gain a better understanding of how to support community members to engage, especially those experiencing health inequalities.29–31 Utilising ‘people power’ has represented a huge untapped resource in existing local regulatory systems; however evidence highlights asymmetries of power as one of the key barriers to community engagement32 and how licensing authorities may prioritise conflict resolution and compromise between licence applicants and members of the public rather than the promotion of existing licensing objectives.33 Furthermore, where promoting community involvement in licensing decisions is not only ‘encouraged’ but is a legal requirement, concerns exist to ensure it is not tokenistic. Where there has been evidence of successful community-led alcohol controls reducing alcohol harm, further research is needed to develop and test context-specific menus of available powers communities can use, tailored to the specific identities of communities.34

Asset-based community development

The Communities in Charge of Alcohol (CICA) intervention was designed using an asset-based community development (ABCD) approach, where a health asset is any factor which enhances the ability to create or sustain health and well-being.35 This is in line with the National Institute for Health and Care Excellence (NICE) guidance on behaviour change, which advocates building on existing community resources and skills.36 The principles of the approach are to: allow time for communities to realise and acknowledge their individual and collective assets and to rebuild their confidence and networks, enable local people to take the lead and build trust with communities by demonstrating that involvement leads to change. The approach seeks to build community networks, which are health promoting. At the time of the National Institute for Health and Care Research (NIHR) commissioning brief in 2016, ABCD approaches were being promoted widely23 and were attractive in terms of current fiscal challenges and cuts to services, but there was relatively little evidence for their effectiveness.37

Context to the Communities in Charge of Alcohol evaluation

In 2014, the Greater Manchester Combined Authority (GMCA) agreed a Greater Manchester (GM) Alcohol Strategy 2014–17, which included taking forward a programme of activity to reduce alcohol-related harm while retaining a focus on growth and reform, promoting effective practice within GM and challenging the status quo on key national issues. Within the strategy, there was a particular focus on the role of the community in reducing alcohol harm and the expanded use of licensing and regulatory powers to address alcohol availability. In pursuing these objectives, the GMCA entered into a partnership with the Royal Society for Public Health (RSPH) to develop training for and introduce alcohol health champions (AHCs) in all 10 GM local authority areas in 2017. The principle of community lay health champions has been well established;38–40 the focus on alcohol and the community’s role in licensing is the novel contribution of this study.

This was the first time that GM had attempted to co-ordinate an approach to building health champion capacity across all 10 local authorities. It was underpinned by the GM Health and Social Care Strategic Partnership’s commitment to a ‘Radical Upscale in Prevention’ as one of the four key programmes within the ‘GM Taking Charge’ Strategy. Thus, an important opportunity presented itself, coinciding with the commissioning brief from the NIHR Public Health Research (PHR) Board in 2016 identifying the need for research on the effectiveness of locally delivered interventions to reduce intake and harm caused by alcohol.

Research objectives

The main aim of the research was to evaluate the effectiveness and cost consequences of the community AHC programme, known as CICA.

Primary objective

To determine the effect of the CICA intervention on area-level key health and crime performance indicators.

Outcome evaluation objectives

1. Determine the effect on area-level key health performance indicators: alcohol-related hospital admissions, accident and emergency (A&E) attendances and ambulance call-outs.
2. Determine the effect on key crime indicators (street-level crime data).
3. Determine the effect on key antisocial behaviour (ASB) indicators.

Research questions

• Does the intervention result in (statistically significant as well as relevant in absolute terms) improvement in health and crime indicators?

Economic evaluation objectives

1. Identify set-up and running costs using a standardised costing exercise (examination of commissioning documents and contracts).
2. Resolve costs by sector (health, ambulance and police) before, during and after CICA setup.
3. Quantify benefits due to reduced hospital admissions, ambulance call-outs, emergency department use, crime and ASB.

Research questions

• What are the set-up/ongoing costs in terms of in-kind contributions (time of residents, public sector officers, councillors and voluntary organisations)?
• How much did the set-up phase cost (venue hire, refreshments, training)?
• How much per year will the process cost to run (advertising, venue hire, external facilitation)?
• What are the savings in terms of reduced crime, hospital admissions and ambulance call-outs? What are the cost benefits and cost consequences of CICA?

Secondary objectives

To understand the context and factors that enable or hinder the implementation of the intervention, including establishing, operationalising and sustaining the CICA intervention.

Process evaluation objectives

1. Explore policy context and variation in licensing practice, including any impact of devolution in GM.
2. Explore barriers/facilitators at key stages of the intervention (recruitment of AHCs to initial training and cascade training; delivery of initial training and cascade training; using skills beyond the training in AHC activity; retention of AHCs).
3. Explore responses to AHC training, modelling of health behaviours, perceptions of community cohesion and development.
4. Determine the numbers of trainees, brief interventions applied and community awareness events organised/participated in.
5. Examine and quantify the amount and success of community involvement in licensing issues.
6. Determine whether there is a change in composite measures of alcohol availability.

Research questions

• How was licensing policy operationalised in the local area prior to CICA? Does the context (devolution) impact on licensing?
• What are the main barriers/critical success factors?
• How many people were trained, did they engage with the training and did they put it to use?
• How many brief interventions were applied?
• Has licensing (and therefore alcohol availability) been influenced by community involvement?
• Does citizen participation increase as a result of the intervention?