An 'alcohol health champions' intervention to reduce alcohol harm in local communities: a mixed-methods evaluation of a natural experiment

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?

Design

The stepped-wedge design describes the sequential roll-out of an intervention over time, or in other words, how the intervention is implemented in each of the intervention areas at some time point in the time series. Each intervention LSOA therefore changes from ‘control’ to ‘intervention’ and thus serves as its own control. 69

Analysis

The stepped-wedge design was analysed using hierarchical growth models (similar to previous work16,17) and analysed by multilevel mixed-effects models to account for the repeated measurements in the same areas (i.e. random intercepts), thereby accounting for different levels of the outcome in each area (e.g. alcohol-related hospital admissions in one LSOA will be ‘more similar’ than those in another LSOA, perhaps one with a much lower rate). Theoretically, it is also plausible that the temporal trend in each area differs from that in any other, which can be modelled using random slopes as well. However, exploratory analyses indicated there is insufficient statistical power to incorporate this. The outcome variables were LSOA-level counts and were analysed using mixed-effects negative binomial models (to account for overdispersion70). LSOA resident population sizes were used as offsets in the models. All models were further adjusted for quarter, area-level IMD score, average age in the area and time to account for the secular time trend across the time series. Exploratory analyses indicated that for none of the outcomes, this was a linear increase/decrease, and therefore the time trend was modelled using a basic cubic spline to account for non-linearity. Out of different potential model structures, the final models were determined based on assessment of assumptions regarding distributions of errors and model fit calculated by the Akaike information criterion. All analyses were done in R statistical software using the lme4 package for hierarchical growth modelling.

Design

Each intervention area was matched to three other, comparable, control LSOAs. Comparable LSOAs were from the same district (lower tier local authority) but not neighbouring the case area, the latter to avoid bias in the effect estimates because of spillover effects as a result of the intervention. Matching of intervention to control areas was done using propensity score matching based on an a priori selected set of confounding variables (LSOA population density, deprivation, average age and baseline alcohol-related hospital admissions and crime rates) for the year prior to the start of CICA programme (2016). Note that although these are outcome measures, in contrast to propensity score matching, here the propensity scores are only used to identify the most similar control. Matching was done using the ‘nearest neighbours’ algorithm.

Analysis

The final data set contains the time series for 76 LSOAs (19 interventions and 57 matched controls). These have been analysed as controlled Interrupted Time series (cITS)71 using the same hierarchical growth modelling analytic method as used for the stepped-wedge cluster trial, with the difference being that in these analyses, results are not just internally compared but also against trends in the control LSOAs. Unmatched mixed-effects negative binomial models were conducted. All analyses were conducted in R, using the MatchIt package for propensity score matching and lme4 package for statistical analyses.

Design

The national control analyses are similar to the local control analyses, but each intervention LSOA was matched to a comparable control from the national data set. This was done so that local idiosyncrasies would not bias results and would also completely avoid any issues of spillover. 72 Matching was similarly done using propensity scores based on the 2016 values, although because of the large amount of data (there are 32,844 LSOAs in England56), a prior selection of areas was made based on similarities in the pre-2017 time series of the primary outcome only using ‘dynamic time warping’, which is a statistical methodology that can be used for matching time series. 73 Because of (lack of) data availability, the national control analyses were done only for hospital admissions and A&E admissions.

Analyses

Statistical analyses for the national controls are similar to those of the local controls, as described above. All analyses were conducted in R, using the dtw package for dynamic time-warping and lme4 package for statistical analyses.

Design

Alternative to the local control analyses described above, we also approached the evaluation of this design using a synthetic control approach74,75 to estimate counterfactuals of ‘what would have happened had there been no CICA intervention’ for each intervention LSOA separately (henceforth named “counterfactuals”). The difference between the counterfactual and the measured outcomes can then be interpreted as the impact of the intervention. This methodology was previously successfully used in other studies of the impact of local alcohol policies on health and crime. 16,76–78

Analyses

We used Bayesian structural time series to model the pre-intervention time series of the outcome in the intervention area from a weighted combination of the time series in the matched local controls. This model was then used together with the post-intervention time series in the controls to estimate the counterfactual in the intervention areas. The methodology has been described in detail79,80 and in summary. 81 Analyses were done for each intervention LSOA separately, and the LATE was estimated by combining the effects across all areas using meta-analysis. As flagged above, as Area 5 did not end up receiving the intervention, it is excluded from these analyses. All analyses were done in R using the bsts and CausalImpact packages. Meta-analysis was done using the metagen package in R.

Licensing policy context

The document review included a review of the licensing policy context (Statements of Licensing Policy) in each local authority to discover how licensing policy was enacted prior to intervention and the ongoing monitoring of the policy/practice context. A document review was carried out by EJB and SH [patient and public involvement (PPI) representative] on publicly available Statements of Licensing Policy from each of the 10 local authorities (n = 10). These local alcohol licensing policies are legally required to be published by each local Licensing Authority at least once every 5 years, detailing how they will carry out their administrative licensing functions in accordance with the 2003 Act to promote the four licensing objectives: prevention of crime and disorder; public safety; prevention of public nuisance; and the protection of children from harm. 28,83

Document analysis involved skimming (superficial examination), reading (thorough examination) and interpretation using content analysis as an iterative process to organise information into themes, categories and case examples. 84 A directed content analysis approach was taken using predetermined categories85 based on existing research assessing the context of alcohol licensing policy statements in Scotland. 86 These predetermined categories structured the standardised data extraction form used by both members of the research team.

Alcohol availability

Alcohol availability data for CICA intervention areas were obtained from Licensing Authority registers. Each local authority Licensing Unit is responsible for maintaining the register as per Section 8 of the 2003 Act. 28 Information was sought on the number of premises licences granted for both on- and off-licensed sales of alcohol, hours of alcohol sales and size/capacity of premises (where available). Our original protocol stated that we would calculate composite alcohol availability scores from these variables. However, there was no standardised database system shared by Licensing Authorities to maintain Licensing Registers. Therefore, details of hours of alcohol sales and size/capacity limit of premises were not consistently recorded, preventing composite alcohol availability scores from being calculated. Only one consistent data set available was used as the measure of alcohol availability: the number of premises licensed to sell or supply alcohol in each intervention area. Records were exported at a ward level in Microsoft Excel^® form. Since ward-level records did not provide the granularity needed for CICA intervention areas, premises licence data were then transferred into Microsoft Access, creating a database file to enable multivalued ‘look up’ fields to obtain alcohol availability data at a LSOA level. Each local licensing authority’s web page was used to identify whether their Licensing Register28,83 was made available to the public to access online.

Preparatory roll-out meetings

Notes from preparatory roll-out meetings were used to explore infrastructure in place in all 10 areas a priori. These audio teleconferencing meetings were held between July 2017 and April 2018, each being held for 2–3 months leading up to each Train-the-Trainer event with key stakeholders from each area, convened by an overall programme manager supporting the co-ordinated implementation of CICA. Meetings were structured around a roll-out checklist created by stakeholders to guide preparation. Meeting notes were shared with the research team as secondary data and evaluated using content analysis by two researchers (EJB and SCH). Units of meaning were defined from items within the meeting checklists as ‘external contextual factors’, that were labelled, grouped into a category (categorisation matrix) and described as a theme. 85 This analysis from a priori qualitative data (2–3 months prior to roll-out) was then revisited as part of a longitudinal design of the process evaluation. At the follow-up phase, relationships were tested between external contextual factors and a key output indicator at the end of the intervention period: total numbers of lay people trained to be AHCs.

Survey and semistructured interviews with alcohol health champions

The follow-up period within the process evaluation commenced after 12 months. Champions were invited to take part in a survey and interviews and were contacted by both their local co-ordinator as well as the research team. One year post-training, a follow-up questionnaire was sent to AHCs. Questionnaires (n = 11) were completed online (using the Bristol Online Survey Tool). Reasons for loss of champions at the follow-up phase were documented where known, along with factors affecting inactivity. Semistructured interviews were held with AHCs (n = 7) to capture experiences of the CICA intervention activities they took part in. We had originally intended to recruit a purposive sample of those who had or had not remained engaged with the programme. However, because of our earlier experience at 3 months, showing that recruitment for the interview could be problematic, all AHCs were invited to take part. Interviews ranging between 24.37 and 28 minutes (average 40.5 minutes) were audio-recorded and transcribed.

Semistructured interviews with stakeholders

Semistructured one-to-one interviews with local co-ordinators/stakeholders 12 months post implementation of CICA were carried out. Sampling was purposive. Eleven local co-ordinators, representing eight of the nine CICA areas responsible for operationalising CICA, were invited to participate in a telephone or face-to-face interview 12 months post implementation. In terms of role, four were public health practitioners; four were public health commissioners; and three were substance misuse practitioners. Local co-ordinators from all areas except Area 3 and Area 5 participated (the local co-ordinator from Area 3 was no longer in post, and the intervention did not take place in Area 5). Eleven interviews were conducted following written consent: nine face to face and two by telephone. Interviews ranging between 31 and 131 minutes (average 75.90 minutes) were audio-recorded and transcribed. Written consent was gained at the outset of interviews following a period of consideration of a participant information sheet.

Licensing leads

Sampling was purposeful. Licensing leads involved in AHC training from nine LAs were invited by e-mail to participate in a telephone or face-to-face interview 12 months after the first training session for AHCs. Licensing leads from Areas 1, 2, 6, 7, 9 and 10 participated (n = 6). Licensing leads from Areas 3, 4 and 8 did not respond to interview requests. Five telephone interviews were conducted by SCH and one face-to-face interview by EJB. Audio-recorded interviews ranged between 14.6 and 38.3 minutes (average 22.18 minutes).

Licensing records

Licensing records were extracted with local authority Licensing Units where available to validate activity around licensing. This included numbers of new applications for a premises licence (including minor variations), written representations, review applications and any changes to the local authority’s Statement of Licensing Policy.

Focus groups with the community

Community members within two intervention areas were invited to attend a focus group. Local CICA co-ordinators helped advertise the focus groups using adverts/posters in local public spaces and through wider promotion within existing community networks. Focus groups explored: perceptions of alcohol harm within the community, views and opinions about the AHC role and perceptions of community cohesion within the intervention area.

A convenience sample was drawn from two CICA intervention areas (Area 1 and Area 6). Members of the public were reached through adverts in public places (e.g. local library) and via e-mail to existing community networks. Local co-ordinators, familiar with the area, led on recruitment using an electronic PDF advert as well as printed copies of A3 posters and A5 flyers provided by the research team. Participants were unknown to the research team but knew in advance that the focus group was organised by the University of Salford and aimed to give people a chance to ‘have their say about alcohol’ in return for £20 as a token of appreciation.

Three single focus groups90 were facilitated in private rooms within local libraries. A total of 26 participants attended, and written consent was obtained before the start. Two focus groups were held on the same day in June 2019 (Area 1) and one more in February 2020 (Area 6). EJB was supported by CU (administrative support inside the focus group) and SCH (administrative support outside the focus group). EJB explained how the focus group would work, its purpose and ground rules and announced when the audio-recorder would be switched on. A short description was provided of the CICA programme and the role of an AHC. Discussions lasted 38.11–60 minutes (average 48.54 minutes). Audio-recordings were transcribed (field notes not taken). Transcripts were not returned to participants for comment or correction as contact details were not obtained.

Analysis of documents

Analysis of documents used content analysis, and a summative, deductive approach was taken using the ‘surface structure’ (manifest analysis) – ‘what has been said’ rather than ‘what intended to be said’. Starting with the selection of a unit of analysis, five stages of data analysis were followed: stage one decontextualisation; stage two recontextualisation; stage three categorisation; and stage four compilation. This comprehensive review of the collected data enables information relevant to the research question to be identified. 91

Analysis of interviews and focus groups

Semistructured interviews and focus groups were digitally recorded, fully transcribed verbatim by a transcription service and anonymised. The transcripts were returned as Microsoft Word (Version 2204) documents. A thematic framework method92,93 was used for data analysis. This approach enabled themes to develop both deductively from the research questions and inductively from participants’ testimonies. 94 All data were coded and analysed according to the five stages of framework analysis. Textual data were ‘charted’ in themes relating to key research questions and scrutinised for differences and similarities within themes, keeping in mind the context in which these arise. We used a predominantly inductive approach with both semantic and latent coding.

Familiarisation of the data was done by reading through all the transcripts once while listening to the original audio recordings. Notes were taken based on key recurring ideas that related to the research question. 95,96 An initial thematic framework of possible themes and subthemes was developed based on the interview schedule and emerging concepts from the notes taken. 97 All transcripts were coded according to this framework, a process known as indexing. This was done by inputting all transcripts into NVivo (Version 12 Plus) (QSR International, Warrington, UK) as a singular data set and applying codes to them using the ‘nodes’ feature.

A matrix of the framework was then developed in Microsoft Excel (Version 2206) where each column represents a theme or subtheme, and each row represents a participant. Codes were extracted from NVivo and charted into the framework in the appropriate intersections between the columns (themes) and the rows (participants). As data were charted, the framework was revised as needed, with themes and subthemes merged, split or removed in an iterative process. Summarising notes for each column (themes) and each row (participant) were added to the chart. Charting in this way allowed us to not only synthesise an interpretation of the overall data but also observe and form trends in the data for each participant and compare across participants. Researchers MC, SCH and CU (initial implementation phase) and PAC, CU, ND and EJB (follow-up phase) held review meetings to reflect on thematic development and refine the themes and subthemes. Each theme and subtheme were given a categorical label, and a map was devised to demonstrate the relationships between them. Other steps to maintain the quality of the process included: verbatim transcription, checking transcripts against recordings, being reflexive and exploring data in a nuanced manner. 98,99

Member checking

The findings were presented back to key stakeholders as well as AHCs at a conference, led by the process evaluation team, to share and discuss early CICA project findings. The presentation gained verbal input from attendees, who were invited to comment, in order to check the trustworthiness of findings. 100 The findings resonated with attendees, and no recommendations for amending the themes were suggested. Focus group findings could not be presented back to the public as contact details were not obtained.

Presentation and readability

Length varied between 27 and 92 pages (mean 47 pages). Only two out of nine policies provided details of an author/main point of contact: one signposted the reader to the Licensing Authority office within the local council as a point of contact for ‘any licensing related matter’ (Area 1), and the other provided a named contact for the lead responsible officer (Area 5).

Statements of Licensing Policy are intended to provide clarity for everyone including: ‘..local residents, businesses and licence applicants, who will be able to refer to the statement when making representations or when preparing their application’. 109 A glossary of legalistic language was only provided in four out of nine of the licensing policies. This limited the readability and accessibility of the information. Although a plain language assessment of policy wording is not a requirement within the 2003 Act or Section 182 best practice guidance, none of the policies reviewed had Plain language accreditation or specified that the use of plain language had been considered. 110 The predominant legalistic language used within the policy statements conveyed that they were applicant-focused.

Use of evidence

Guidance to support licensing authorities to fulfil their functions under the 2003 Act emphasises that actions and decisions taken to promote the four licensing objectives should be appropriate, proportionate and evidence-based. 83 Interested parties and Responsible Authorities (RAs) are reciprocally required to provide evidence when making representations. In all policy statements, evidence underpinning policy positions or model conditions was limited, if provided at all. In this excerpt, it is unclear why this recommendation may promote the licensing objectives, what processes and practices are required within the system in order to be effective and how the licensing authority is defining ‘high density’:

It is recommended that radio links or telephone communication systems should be considered for licensed premises in city and town centre leisure areas with a high density of premises selling alcohol.

Area 3

In Area 2, a recommendation was made that applicants and licensed businesses should consider obtaining alcohol IBA training so that members of staff could: ‘recognise when people may have a drinking problem, and how to give them brief advice’, but this did not have an explanatory evidence base.

Three areas highlighted the ‘authority profile’ detailing the number of licensed premises already in operation and the number of Temporary Event Notices issued on average in a year (Areas 1, 4, 9) as underpinning evidence. While two areas cited alcohol-related hospital admission figures as part of a ‘regard for health’, relevant alcohol harm data available to local authorities52 were generally not included. Only one area provided alcohol-related crime, injury and public perception survey data on drunken behaviour in the night-time economy, along with an evidence-based rationale for a framework of opening and closing times for both on- and off-licensed premises:

Taking into account the problems of crime, disorder, nuisance and ASB into the early hours of the morning, we have introduced a framework of opening and closing times for premises …. Off-Licensed Premises 8am–11pm Sun to Sat; On-Licensed Premises 1am Sun to Thurs and 3am Fri and Sat (and BH); Late Night Refreshment 1.30am Sun to Thurs and 3.30am Fri and Sat (and BH) … Applicants should note that there is no guarantee that an application will be granted if the hours of trading fall within this framework. In similar terms, an application will not automatically be rejected because the proposed hours of trading fall outside of the framework. All applications will be considered on their individual merits.

Area 8

In terms of conditions that could be proposed or imposed to prevent crime and disorder and promote public safety. In the following example, the licensing policy explains the expected outcome of adopting a ‘documented glass policy’, naming glasses and bottles as potential weapons:

Operating a documented glass policy for the premises: In the UK, glasses and bottles are the most commonly used weapons in violence occurring in drinking environments. Incidents involving glass tend to result in more severe injuries.

Area 6

While the rationale is provided, suggesting it is an intervention that is evidence-based, references to the source of evidence are not provided.

Process of consultation

The consultation process provides a mechanism for interested parties, such as local residents and community groups, to influence licensing policy principles and licensing practices. The Police Reform and Social Responsibility Bill also removed the ‘vicinity test’ to increase opportunities for members of the public/lay people to get involved in licensing decisions. 111 Across the 10 policy statements, only 1 provided a full list of consultees as an Appendix (Area 4). This is significant in terms of demonstrating transparency in how the process was undertaken and opportunities for meaningful engagement. 86 No detail was given in any of the licensing policies as to what amends were made or rejected as a result of consultation responses.

Licensed hours for alcohol sales

Two areas provided guidance on hours of alcohol sales (Area 8, Area 10). One of these areas, as noted in item 2, provided an evidence-based rationale for their framework. Where no framework was provided, other areas identified particular risk environments that may require stricter conditions: residential areas and takeaways. Two policies did not provide any guidance on hours of alcohol sales and relationships with risk environments; however, in recognition of the 24-hour licensing regime, there was an expectation that the hours of alcohol sales applied for would have to mitigate against any adverse impact on the licensing objectives:

The Authority accepts that as a general principle, the act permits activity which does not undermine the licensing objectives, taking place over 24 hours and 7 days a week. The hours requested… will normally be approved where the applicant can show that the proposal would not, with regard to the licensing objectives, adversely affect the environmental quality, residential amenity and character of any particular area.

Area 1

Density/cumulative impact

Four areas provided some criteria that would be used to assess ‘saturation’ or ‘density’, though not all set out how interested parties, such as local residents or community groups, could make a representation to initiate a cumulative impact assessment and consultation process. At the time of CICA, three areas had at least one special stress policy/cumulative impact policy in effect.

Operating conditions including children’s access

There are three types of conditions that can be attached to a premises licence: proposed (actions and steps the operator voluntarily offers to take to promote the licensing objectives); imposed (actions and steps insisted on within a licensing hearing following relevant representations); and mandatory (a set of conditions that apply to all premises licences, including the Mandatory Conditions Order 2010112 for irresponsible drinks promotions, potable water, age verification and small measures). All licensing policies provided some guidance on example conditions that could be proposed or imposed. However, as identified in item 2, it was not consistently clear if they were evidence-based ‘model conditions’, that is, with a rating of the quality of evidence/strength of recommendations.

Model conditions were themed around the four licensing objectives, with some policies setting out additional conditions to consider for vulnerable groups at higher risk of harm and/or higher-risk alcohol environments: underage drinking; children at risk of sexual exploitation; intoxicated/drunk customers; recreational drug users including the use of new psychoactive drugs; high-volume vertical drinking; alcohol delivery services; hypnotism; and large-scale events. Six out of ten areas explicitly addressed actions and steps that could be proposed or imposed to prevent the illegal sale of alcohol to a person who is drunk (Section 141 of the Licensing Act 2003). No policies detailed how Section 141 would be monitored in terms of compliance and enforcement. 113

Specific conditions recommended to protect children from harm varied, aside from those set out in the Mandatory Conditions Order 2010 in relation to age verification policies. 112 Recognising that the Act promotes free access to children into licensed premises was consistently stated as a principle: ‘It is rarely likely to be necessary that a complete ban on children entering a premises is imposed’ (Area 9). Despite a number of risks identified that may justify increased restrictions or tighter controls (i.e. operating conditions) to protect children from harm, none of the 10 policies recognised the risk of accompanying adults who become drunk or exposure to drunk customers. There were, however, types of alcohol-related selling practices highlighted in three policies to be potential threats to protecting children from harm requiring ‘a more acute need for age restrictions than normal’, namely ‘Happy Hours’ and drinks promotion nights.

Temporary event notices

The ‘light touch’ process to permitting a temporary event for the sale or supply of alcohol does not currently allow interested parties to make representations; only the police and environmental health can object and intervene. 83 Despite this, empowering communities to be aware of the processes available, the number of temporary event notices being permitted and their location, still has significance to the promotion of the licensing objectives, for example, primary schools serving alcohol as part of a temporary event to attract parents. 86 Four of the ten licensing policies explained the process involved to apply for a temporary event notice, with only one providing data on the average number issued each year.

Regard for health

With Directors of Public Health (DPA) appointed as a RA since 2013,114 all licensing policies recognised to some extent the role they can have contributing to licensing decisions. Some emphasised the powers and influence DPA could have promoting the existing four licensing objectives, irrespective of a 5th licensing objective to promote public health:

Local Health Bodies potentially have access to much data that can inform licensing decisions and policy. When such data is presented it will be considered and where links are made to any of the four licensing objectives.

Area 1

Without a 5th Public Health objective within the Licensing Act in England and Wales, two licensing policies stipulated an expectation that operating schedules would set out how they would actively promote health but without evidence-based examples:

[Name of] Council expects applicants for premises licences (and other permissions which allow the sale or supply of alcohol) to include statements in. their operating schedules as to how they will actively promote the protection and improvement of public health. Current holders of premises licences and other permissions which allow the sale or supply of alcohol are also expected to promote the protection and improvement of public health.

Area 9

One policy made more spurious suggestions that conditions could be imposed:

Although the Government did not go as far as introducing a 5th licensing objective of ‘promoting public health’, the introduction of public health as a responsible authority went some way towards starting to reduce alcohol-related health harms through use of licensing legislation. Conditions may be added by way of review of licence if there is a specific public health issue at a premise.

Area 3

Community recognition

Perhaps most pertinent to CICA’s logic model was the extent to which communities were recognised with the local licensing policy statement. This varied, with language used that at times presented as applicant focused rather than balanced with neutrality.

Our officers will always seek to assist applicants in completing applications and considering relevant conditions – particularly with a view to accommodating likely representations from residents and responsible bodies.

Area 7

A potential unintended consequence of language used could deter interested parties from having a voice if they identified as being in the minority:

The Authority acknowledges the advice of DCMS [Department for Digital, Culture, Media and Sport] that the views of local minorities should not be allowed to predominate over the general interests of the community.

Area 1

Promoting liaison and compromise between applicants and local residents was encouraged in 5 of the 10 policies. However, there was no detail or guidance on support available to community members within discussions or mediation meetings.

Information on how the public can get involved in licensing processes

Lastly, since the AHC training would provide lay volunteers with awareness of the processes and procedures available to the public to get involved in licensing decision-making, the document review examined whether the licensing policy itself contained community-centred guidance on how to do it (see Table 10).

In contrast to the excerpt highlighted in item 9, which offered support to applicants, none of the policies sought to assist community members in completing representations and considering relevant conditions. Where assistance was signposted, this was to local councillors (Area 1, Area 6, Area 8), and in this context, a local councillor could help if a member of the public has concerns about reprisal.

Response to alcohol health champion training

In total, 93 out of 95 lay AHCs completed pre- and post-training questionnaires representing nine areas (98% response rate). Nearly three-quarters of lay AHCs (74.2%) were aged between 31 and 60 years old (Table 14). More women were recruited to CICA compared to men (61.3% female), and the majority (69.9%) self-identified as being of white ethnicity. Educational attainment varied, with 9.7% reporting having no qualifications and nearly half (49.5%) having either General Certificate of Secondary Education (GCSE)/National Vocational Qualification (NVQ) Level 2 or A Level/NVQ Level 3 qualifications. In terms of modelling healthy behaviours, almost two-thirds (65.6%) did not drink alcohol at all or were classed as lower-risk drinkers according to AUDIT-C questionnaires. 51 Corroborating this, in pre-training questionnaires, 89.2% of the participants agreed/strongly agreed with the statement that they ‘try to live a healthy lifestyle by not drinking too much’.

In a free-text section of the pre-training questionnaire, space was provided for participants to describe their motivations for attending the CICA training. Content analysis was used to categorise units of text into a categorisation matrix and themes (see Figure 11). Three main themes of motivation were identified: lived experience (own harmful drinking or identifying as in recovery); help others (customers, care for my community, for my children); and for own development (personal or professional development, knowledge, skills).

FIGURE 11.

Motivations to attend CICA training.

On the final day, at the end of training, post-training questionnaires were completed. These were analysed using the related samples sign test to ascertain any changes in attitude towards AHC role activity post training (Table 15). Nearly all AHCs agreed/strongly agreed that they felt more confident that they could talk about the harms associated with alcohol and give alcohol-related brief advice than they did pre training (91.4% compared with 79.6%) (p < 0.001). The number of AHCs who reported community engagement in local licensing decisions as important increased from 91.4% to 92.5% (p = 0.001). Furthermore, AHCs felt more confident post training that they could raise issues about venues selling alcohol (90.3%, compared with 74.2% pre training) (p < 0.001).

Theme 1: effective recruitment of alcohol health champions

The requirement for volunteers to live or work within the specific geographical areas identified for the intervention (defined by LSOA boundaries) created challenges for recruitment. Many local co-ordinators described recruiting AHCs as ‘being really hard’ or ‘really difficult’. Many appear to have misunderstood the intervention principle1 that the aim of CICA was to build capacity in a specific community as part of a place-based approach. Instead, they referred to the constraints of taking part in the research study:

I think, one, because of the constraints of the areas for the pilot was a bit difficult.

Area H

A second barrier reported related to low levels of existing engagement pre intervention by the provider organisations in the CICA areas. One local co-ordinator described working with a local multiagency team ‘just to go onto the estate every week’ (Area F), while another described having to work through networks of individuals and organisations to access these communities:

speaking to people as much as possible to connect us with people who can connect with people in the communities.

Area G

In some areas, recruitment was facilitated by local co-ordinators investing time and energy by taking potential volunteers ‘for a brew’ (northern English slang for a cup of tea) or by becoming a known face in the community where recruitment would take place. Additionally, social attitudes towards alcohol programmes were reported as a barrier to recruitment:

no-one wants to talk about alcohol, nobody ever wants to talk about alcohol because everybody thinks oh just leave them alone, they’re only having fun, or blah blah blah.

Area D

Implementation was facilitated by enabling local co-ordinators to approach different types of people to become volunteers, including people who had experienced alcohol and substance misuse themselves and who understood the challenges:

some of our participants are recovering alcoholics, they’ve also been kind of, they’ve three or four years some of them had not touched a drop erm, so they know the challenges themselves …

Area A

While accessing potential volunteers through drug and alcohol services or through recovery housing services facilitated recruitment, two local co-ordinators described the challenges they faced working with volunteers drawn from these services. For some, this created additional pressure, anxiety and a sense of being out of their depth in the initial implementation of CICA:

some of them are still battling with their own addiction. They’re also still struggling with loneliness and getting a job and, the many things that happen, you know as a result of them going through a drug and alcohol service. It’s really, I’m finding it really hard. That’s not my, that’s not my job, it’s not my expertise either.

Area F

Two areas developed links with people who wanted to get back into employment:

we worked with the Department of Work and Pensions (DWP) for looking at people who wanted to get employment and who were interested in accessing courses and things like that.

Area G

Some areas recruited members of local public health teams or individuals who had prior experience of working in schools or for organisations such as the police, housing organisations or providers.

Social media, particularly Facebook, appeared to offer potential in facilitating recruitment. However, converting initial interest into actual engagement in training was experienced as far more challenging:

But then social media being social media, when you started chasing people up and going, yeah, that’d be great, if you give me an email address and I’ll get you some information,… it turned out that people seemed to be kind of going, yeah, I’m interested in that but when it actually came to the reality of it they were a little bit less keen.

Area E

Only one local co-ordinator raised early concerns about how to retain AHCs over the long term and embed AHC activity into local plans:

I don’t know, how do you keep them … I don’t know how the other teams are doing it, you know, the other areas are doing it, because if you’re just asking people to just to speak to you once a month, twice a month, it’s not gonna be, it’s gonna die off quite quickly I would say.

Area C

Retention of AHCs was reported as a potential barrier to successful implementation. When volunteers decided ‘it wasn’t for them’, this often resulted in local co-ordinators having to ‘start again’.

Theme 2: the effective delivery of appropriate training

In some areas, the provider was not RSPH accredited, or they did not have access to an accredited RSPH training centre. This was a prerequisite for the training to go ahead, in order for AHCs to receive a formal qualification. Four local co-ordinators reported being unexpectedly required to commit resources to enable accreditation. Where the RSPH accreditation centre was ‘all set up’, commissioners still needed to become familiar with the accreditation processes prior to training roll-out:

so, it’s been, it’s one of those processes, it’s like a getting, getting yourself familiar with it really.

Area E

The training itself was described as ‘intense’, ‘tiring’, ‘a bit of an overload’ and ‘a lot to do in a short space of time’ by stakeholders, but overall, they felt their AHCs responded well and benefitted from being ‘challenged and pushed’. Education and literacy levels were highlighted as potential barriers in three areas:

… there was some people … who, who hadn’t been in education for such a long time and for some of those to feel confident in taking on board the training, I think the training was, there was a lot.

Area A

The concept of cascade training was considered ‘quite daunting’, while some local co-ordinators were concerned that AHCs felt ‘comfortable’ prior to carrying out cascade training and needed ‘plenty of time to get them up to speed’. Another expected the AHCs to cascade the training, including the licensing component, on their own with light touch support:

I’m hoping the first lot of champions that were trained, initially, are going to be able to deliver that training, so I don’t necessarily have to be involved and I can dip in and out if they need me to. But it is about empowering the community, so, once you’ve empowered them, you don’t really want to carry on holding their hand if they don’t need it to be held. But, I’m happy to be there if they need me.

Area E

Other areas felt CICA would be facilitated more effectively if professionals, such as outreach and engagement workers, participated in the initial training to enable them to lead cascade training and support AHCs:

I thought, you know it’s gonna be really relevant to [name] to be on the training. She’s delivered training before so I thought [name] and maybe either [name] or [name] can support each other to deliver it.

Area J

The licensing input was considered a significant factor in developing AHC’s interest in CICA:

the part of it [that] was taking champions and volunteers seriously.

Area D

Those licensing leads interviewed were energised and enthusiastic about the opportunities for AHCs to make a difference from a licensing perspective. They described the AHCs as ‘really positive’, ‘enthusiastic’, ‘keen’ and ‘passionate’, showing significant interest in licensing. This was reflected by one licensing lead feeling:

like a rabbit caught in the headlights because there was a lot of questions.

Area A

Several licensing leads reported how focused the AHCs were in considering how to engage their communities in licensing issues, and one commented on the good, understanding participants showed regarding licensing and the Licensing Act:

Yes, the discussions, they weren’t just sat in silence, they were asking questions of me in my role, they were sharing experiences and how they might engage with their community members, as to rolling the project forward.

Area F

However, one licensing lead identified the training content as too dense, suggesting that more opportunities should be provided to increase relevance to AHCs by focusing discussion on the areas in which they live and making it easier for AHCs to deliver:

but to make it more relevant to the actual champions. Just to maybe relate it to something that they’re aware of. You know, a particular premises, or an experience that they’ve had.

Area E

Consequently, some local co-ordinators were keen to adapt and change the training content for training the future AHCs. This included considering removing some of the licensing elements of the training:

So, I wonder if we could, I don’t know, prune it a bit or change it a bit or just give them what they basically need.

Area E

Theme 3: getting to grips with the AHC role

One local co-ordinator (Area F) identified issues of ‘fit’ for the role and acknowledged that their ‘service user AHCs’ (i.e. those accessing alcohol treatment services) had little previous experience of volunteering. However, this view was not articulated by other local co-ordinators, with one describing their first cohort of AHCs as strong, confident people:

the first cohort of champions were really strong people. There were people from [organisation] and there were a couple of strong individuals from within the community as well, who felt confident.

Area E

Not knowing how or where to start with this new role was highlighted as a challenge for the local co-ordinator:

… the challenge we faced was just understanding to start with where it all fitted in, I think.

Area A

Local co-ordinators described some AHCs as being unclear about their role. Concern was also expressed that role boundaries were not always observed by volunteers from alcohol recovery services when engaging with the local community:

Try and work on things like boundaries, social skills, there’s a hell of a lot to cover because these people think that we are there to help them and sometimes they go back into talking about their experiences and that’s not what the community, you know the alcohol health champion’s role is.

Area F

Despite these challenges, local co-ordinators valued their AHCs and were committed to protecting, developing and encouraging them in their roles:

I want to get ‘em trained up, inducted, get them ID badges. They’ve now got t-shirts, got a full set of kit so I want them getting out there and getting ready for a bit of fun kind of thing.

Area C

Local co-ordinators identified CICA as a stepping stone for AHCs through gaining experience, an accreditation, access to the council’s job pages and confidence:

getting somebody that’s maybe doing nothing at the moment, to get them doing a little bit of voluntary work. They build up their confidence, they apply for a job, maybe working within a school, maybe doing something, you never know and before long, they’ve got a role and you know that, for us, that, that’s the win-win.

Area A

Theme 4: addressing communication challenges

Most local co-ordinators reported finding the right message to ‘sell’ CICA ‘quickly and succinctly’ as a significant barrier:

it was about just having an understanding so we could then sell the product to people, that was the biggest challenge really.

Area A

Local co-ordinators reported time spent discussing CICA with existing LA volunteers or potential volunteers who had indicated interest only to find that they had no connection to the LSOA and therefore did not meet the recruitment ‘criteria’. Local co-ordinators also perceived communication challenges in how volunteers should provide brief advice:

I think if we get too involved with having a conversation, sooner or later there’s either nervous laughter or there’s a sort of ‘oh no, just stop lecturing me, I have a hard job every week, I just want to enjoy myself at the weekend, just leave me alone’.

Area I

However, one local co-ordinator suggested that working with a provider service which offered free personalised support to help improve health and well-being, including conversations around smoking, mental well-being and healthy eating, facilitated brief advice conversations as they took place in the wider context of a person’s well-being:

… with the lifestyle-type service it’s well, we’re not talking about your alcohol today, we’re seeing how you feel about your family you know, or trying to get that motivation, finding the motivation.

Area D

It became evident that different areas had different perceptions regarding what CICA ‘success’ would look like. One local co-ordinator believed the number of licensing reviews initiated in the intervention area would be the main indicator of whether the intervention worked:

specifically from a licensing service point of view if we’re not getting any erm, reviews in from members of the public having been engaged with by an alcohol champion, then from that perspective I think then perhaps from … it’s not been really beneficial on that part, but if we do then erm, obviously it shows that it’s working.

Area A

In contrast, a licensing lead for a different LA felt that initiating reviews was not a key outcome. Rather, the training should lead to more emphasis on community-led mediation, thereby preventing increases in the workload of the local Licensing Committee (Area E).

Theme 5: identifying useful assets

Local co-ordinators described contextual variables, including the availability (or otherwise) of local assets and services (i.e. existing hubs, cafés, networks), as having the potential to affect grassroots mobilisation of volunteers. Free local physical assets were reported as essential, including a central area where people could meet at no cost (community centre, health centre or community café):

[Location] that’s got a community building, and it’s actually originally a pavilion for the bowling greens, but we have access to that at, and no cost to use it for us.

Area B

In areas where multiagency teams (housing, ASB teams, the police, community link workers, employment and welfare services and voluntary sector organisations) worked together, AHCs benefitted by being given practical advice on providing brief advice to community members by these professionals:

The multi-agency team, while they’re litter-picking with the champions say, ‘this is how you do it, this is how you have conversations’ because they don’t have those skills, the champions at the moment to be able to link litter-picking, picking up cans of lager with having a conversation around health or alcohol.

Area F

The presence of established drop-in centres in the locality was seen to facilitate multiagency and place-based working, enabling new networks and relationships. One local co-ordinator described it as a ‘kind of fertile ground’ within which the ABCD model sat well.

However, the range of activities multiagency teams were asked to engage with was reported as making their roles extensive, with concern being highlighted by one local co-ordinator that they were being asked to do too much, and this limited their ability to provide further support to AHCs:

I think money is so tight that multi-agency teams are getting pushed by everybody to add on a bit of this and a bit more, do you know what I mean?

Area F

Some local co-ordinators reported poor formal assets, including a ‘seedy back room’ or no central hub or coherent networks, creating barriers to initial implementation.

Besides the physical (more formal) assets, ‘informal assets’ such as the volunteers themselves, and community activists were considered key facilitators:

it’s [local area] got a number of assets, the [name] centre, which is a former sort of housing office, and obviously [person’s name] is a brilliant community asset so she gets things going in that area.

Area E

Furthermore, if local co-ordinators were known – ‘it’s my patch’ – in the chosen CICA intervention area, this was seen to be facilitative:

I can make use of my contacts and because of my autonomous role out in the community I’m making many more.

Area D

Theme 6: operational challenges

At implementation, some commissioners were unable to commission an appropriate provider organisation to deliver the intervention due to lack of available candidate services. Either relevant ‘service level agreements’ (the contract between the local authority and the service provider) had terminated and new service providers were being commissioned – impacting on roll-out – or there had been no scope to ‘add’ CICA to existing contracts:

we’ve only got the drug and alcohol team who will be helping me to run this and they have recently been decommissioned and a new commissioner, a new provider is starting in April [3 months after initial training].

Area F

Concerns about having the capacity to deliver the essential elements of CICA were frequently emphasised. Area 5 identified a lack of capacity to manage AHC volunteers as curtailing their involvement in CICA:

so even if we could recruit volunteers initially, we certainly couldn’t manage the volunteers, because there’s no post within our organisation as part of the new tender arrangements. So actually, even if you got 10 volunteers, we still couldn’t manage them, we’d have to get someone else to manage them.

Area I

One licensing lead was apprehensive that increasing the knowledge of community members might result in generating more administrative work, leading to Licensing Committee hearings, for which the department would not receive additional funding to manage.

Two stakeholders raised issues about funding for training, specifically in relation to implementing the cascade training, for which no prior funding had been made available:

from promotion, to making leaflets, to delivery and so and forth.

Area G

Similarly, a licensing lead indicated funding constraints would affect implementation despite the view that empowering the community to support preventative approaches was more appropriate than relying on enforcement or requiring the support of drug and alcohol services:

… a further option is to get more areas rolled out, across Greater Manchester. I think that would be absolutely fantastic. But, as I say, we’ll have to see. [LA name] has its own difficulties with funding and I’m pretty sure it wouldn’t automatically happen here, in the scale it possibly needs.

Area F

Despite meetings taking place prior to training roll-out, some local co-ordinators remained confused about CICA until participating in the training (i.e. post recruitment of potential AHCs):

Some of us would come away and actually still email each other and say ‘I don’t really know what we’re doing yet’ and I think for me yeah, I think for me it was only when we did the training I actually started getting a feel of everything.

Area A

Similarly, licensing leads described being unclear about their personal roles and responsibilities, feeling that they ‘came to it cold’ (Area B).

Theme 7: attitudes to community engagement in licensing

Licensing leads acknowledged that at a neighbourhood level there existed a low base of involvement in licensing decision-making, despite expectations from licensing authorities that community members take a proactive investigatory stance to licensing issues. One licensing lead cited the non-reporting of issues which flouted licensing laws, including underage drinking on licensed premises, as evidence:

I am sure that people within the community would have known that that was probably going on but erm, nothing was reported to me in that regard, so we’re starting from zero information from the community.

Area D

A reduction in funding to local authorities was acknowledged as contributing to reduced opportunities for community engagement around licensing:

Things had happened in the past but it kind of all got stopped and lost when there was a lot of, when all the austerity measures were stepping in around 2015.

Area H

For one local co-ordinator, low levels of community engagement were attributed to a ‘fear of reprisals’, as any official representation to the licensing authorities becomes ‘public’:

… and sometimes I have had conversations with members of the public ‘but I don’t want my name going in the public domain’.

Area A

Encouragingly, licensing leads welcomed CICA as an approach that could improve the rate and type of intelligence received by the licensing team:

… best information you can get is from community because they do know what’s going on, on the ground.

Area D

They reflected that building and enhancing new or existing relationships which could support licensing objectives was a positive aim for CICA:

the idea of having local people with knowledge around the licensing system which typically they don’t have as lay people. And then knowing how to effectively engage in the process, yeah, I think there are definitely benefits for that.

Area H

Local co-ordinators and licensing leads commented on the gains that had been made in developing new relationships through the training and the potential for public health improvements through more partnership-based working in the future.

Theme 8: alignment with strategic, political and policy context

Finally, stakeholders reported that implementation as being affected by the extent to which CICA aligned with local alcohol harm strategies and the political and policy contexts of their local areas. Some stakeholders reported variable levels of support from their democratically elected local representative (local councillor), which impacted on perceptions of wider support for a place-based, community-led approach:

I was kind of hoping I’d have a bit more support from the councillor.

Area C

In contrast, some highlighted the significant role of LA DPHs in supporting CICA:

… We’ve got [name of DPH]’s full sort of weight behind not only the alcohol health champions but also the health champion network in general.

Area E

Some local co-ordinators reported issues with commissioning arrangements and others with key role vacancies at the time of implementation (e.g. no full-time commissioning lead), which created barriers in gaining ‘buy-in’:

The problems you’ve got when you’re not commissioned … is, I have to try and get buy-in from that multi-agency team and it’s difficult, one thing I don’t have any influence … it’s different to, to areas where a commissioner is directly commissioning a provider service; and, which a community health promotion like this is embedded into what they do.

Area F

Interviews with lay alcohol health champions

Interviews were carried out with newly trained lay AHCs within the first few months post training. Table 17 details characteristics of interview participants, including the type of service provider leading the co-ordination of CICA in their area. Motivations to take part in CICA ranged from own personal harmful alcohol use (self-identified as ‘in recovery’), family experience of alcohol harm, to a wish to learn more (personal development) and help others in the community.

Figure 12 shows in a thematic map the overarching themes identified from interviews: (1) perceptions of AHC training; (2) applying knowledge and skills in the AHC role; (3) barriers and facilitators to undertaking the AHC role; and (4) sustaining the AHC role, including thoughts on cascading the training to others.

FIGURE 12.

Thematic map: making sense of the AHC role.

Reflections on the training and refining training delivery

Participants expressed pleasure from the training and gaining new knowledge, reporting that they ‘enjoyed it’ and ‘learned quite a lot’ and that it was a positive experience knowing that they ‘can help people’. However, the training content was considered by some AHCs as a lot to fit into a short space of time. Changes in both the language and structure of the training were suggested as something that would be beneficial:

That was difficult for me that day … and [the trainer] was rushed … I would stagger it and I would change some of the language away from what was delivered … I mean it’s not like a job where you’ve got the time to do the induction and ask a colleague and get to know the language.

Peter, Area 6

… I thought it was a bit too much in a short period of time. If we could sort of spread it, then maybe … we had a lot of handouts.

Grace, Area 9

The intensity of the course may not have left enough time for AHCs to explore and evaluate information or to check that all participants had properly understood. There were occasions where misperceptions arose. This included Kathryn, when recounting her experience of an off-licence shop selling alcohol to her intoxicated relative:

… That rule I think should be put on shops as much as pubs so that a law should be made that if they come in in an absolute state [drunk] you should not be allowed to sell them that alcohol … but they can’t if the law isn’t there.

Kathryn, Area 9

However, the Licensing Act 2003 prevents the sale of alcohol to a person who is drunk in both on- and off-licensed premises, which had been explained within the training.

Delivering brief advice

Each of the participants spoke about their experiences of giving brief advice about alcohol and signposting to other appropriate services if more specialist support was needed. Alcohol health champions delivered information in various ways, for example, in everyday conversation or as part of wider health and well-being advice. All had used brief advice tools, including an AUDIT-C scratchcard or an ‘alcohol wheel’ (to demonstrate the number of alcohol units and calories in each drink). Some AHCs reflected on the importance of offering non-judgemental advice and approaching the subject gently, giving the conversation a ‘natural flow’ because they did not want to make people ‘feel uncomfortable’. Brief advice on swapping and reducing alcoholic drinks was friendly rather than authoritarian:

… I don’t kind of preach it to them … I would alternate an alcohol drink with a soft drink to try and reduce the amount of units that they’re taking in.

Darren, Area 6

Understanding, making sense of and being involved in licensing issues within the alcohol health champion role

The AHCs demonstrated some positive knowledge of the Licensing Act 2003 following their training. Most were aware of the requirements for responsible retailing regarding drink promotions and checking the age and level of intoxication of individuals purchasing alcohol in accordance with the legislation. Peter, for example, noted that a supermarket in his local community had prominent displays of alcohol at the entrance, which, although not strictly regarded as irresponsible retailing in the Act, was considered by him as drawing attention to the alcohol:

… the first thing you get as you walk through the doors is there’s literally a stand out in the front of the door and the first thing they’ve got on there was alcohol.

Peter, Area 6

However, a different supermarket was reported as showing responsibility by being strict on underage alcohol sales and not selling alcohol to those perceived as intoxicated:

… the girls asked for identification [from underage customer] … the girl who was service on the till refused to serve one gent ‘cos she actually said ‘in my opinion you’ve had enough to drink already’ … it just shows that some stores are taking a stance.

Peter, Area 6

While some AHCs reported a preference for direct action, for instance, by approaching managers of licensed premises, others preferred educating other community members on how to tackle licensing problems. The AHCs highlighted how the training had increased their awareness of the powers available to communities and the need to work collaboratively to address licensing issues:

… if it’s in a residential area, if it’s close to housing, I would say ‘have you spoke to your neighbours?’ … and if you get together as a group and then approach as a group, and I would also say to them don’t feel that you can’t actually get your local council involvedDarren, Area 6

… And it’s knowing that I can talk if somebody came to me complaining or even just an informal discussion with them about their experience with their neighbourhoods then I could encourage them or empower them to go and challenge whatever’s happening.

Grace, Area 9

Making sense of the UK Chief Medical Officers’ lower risk drinking guidelines

Alcohol health champions demonstrated a nuanced understanding of the UK low risk drinking guidance115 (up to 14 units of alcohol per week; 1 unit = 10 ml or 8 g of alcohol). AHCs felt that they are ‘just a recommendation’ and ‘a guide’ and that within those guidelines, people should still be careful. The AHCs showed understanding that people’s responses to alcohol consumption varied, which they shared when giving brief advice, as expressed by Darren:

… it’s a guide ‘cos what you will find, you can have two people of the same body mass, and one person will get drunker quicker than the other person … you just need to be aware that not everybody’s body is the same …

Darren, Area 6

Amy felt that advice needed to be individualised, and even people who were drinking less than the recommended upper limit of the guidelines might still value guidance on reducing alcohol intake:

… I’d still encourage them to cut it down … I’d just go more along the line of well do you think that’s too much? What do you want to be drinking a week? Yeah I think they’re [the guidelines] good just for people to get an idea of where it is that could affect your health massively.

Amy, Area 8

Misperceptions and misunderstandings about the role

The intended role of an AHC was to reduce alcohol-related harm by intervening early through either individual or community action. Informal conversations using the principles of alcohol IBA were aimed primarily at reaching those drinking at hazardous levels to prevent harmful, higher-risk drinking. However, some AHCs viewed CICA as largely directed at those already drinking harmfully, who may possibly be alcohol dependent:

I think [different area] would be better to hit on. In [place] … I’ve seen a lot more alcoholics up there than anything that touches a little bit of this place.

Kathryn, Area 9

The principle of CICA was to have informal conversations where appropriate, with a focus on the quality of the conversations with people who may not otherwise have accessed alcohol advice. There were no pre-set targets for numbers of conversations to be carried out by AHCs. However, some participants were concerned about not having enough conversations with community members about alcohol:

Everyone feels like they’re bring … they’re not getting enough numbers.

Peter, Area 6

This misunderstanding may have meant that AHCs did not consider a conversation as ‘counting’ unless they used tools such as AUDIT-C.

Facilitators: relationships, knowledge, physical assets and events

Facilitators to the role were identified as positive relationships between the AHCs enabling them to support one another in their roles, personal attributes and knowledge already possessed by AHCs and key community members and the availability of local physical assets such as libraries and community centres that could be utilised for having conversations. For example, Darren already had an established volunteer role in his local library (a key physical asset), co-ordinating a weekly coffee morning. This gave him the opportunity to network with key, community-based individuals (such as the library manager) and put the CICA training skills into practice, where appropriate, at the coffee mornings with local community members. This started almost immediately after attending the initial training:

… I run an informal coffee morning where there’s basically no boundaries to what we can talk about … and the new manager who’s coming in, she’s all about the library being used as a community hub.

Darren, Area 6

Other existing and established community events were facilitators of the AHC role. Summer carnivals and attendance at health and well-being events, such as wider health promotion events (e.g. incorporating blood pressure tests), enabled AHCs to deliver alcohol advice as part of a larger volunteer team. At these community events, AHCs saw advantages of having a presence alongside drug and alcohol service providers. The informal nature provided a degree of anonymity for those seeking advice without the commitment to seeking out formal alcohol services:

… at the carnival and the stalls … I think it’s so light-hearted … and they are just willing to chat … a couple went to the back of the stall and actually spoke to [local co-ordinator] about serious things that they’re facing … that’s like just off the carnival.

Amy, Area 8

Grace described how AHCs in Area 9 worked alongside other volunteers and healthcare providers as part of wider health promotion events outside the scope of CICA, using the opportunity to offer brief advice about alcohol use:

As an alcohol health champion, I have taken people’s blood pressure and advised them on how they can cut down on their drinking … signposted them to their GPs … yeah, I did that as part of a community.

Grace, Area 9

Life experiences of AHCs were reported as key to the role, and these included being an active member of a community and being a community-minded individual:

Over the years I’ve just blended in with the community and done things … it’s about connecting on a community level.

Peter, Area 6

Barriers: physical location, bureaucracy and conflicts of interest

In this early phase of the intervention, AHCs had not experienced many barriers in offering brief advice, although they were aware of potential barriers. One example was in setting up a drop-in service, which was felt to ‘restrict people’ who were concerned they might be seen attending a particular location, such as a specific café, that they would not normally attend. There were also concerns that members of the wider community might be ‘a bit aggressive’ towards AHCs, although these were hypothetical concerns at this stage of their role.

Negotiating licensing processes was viewed as a potential barrier, ‘full of bureaucracies’. However, when faced with this, Peter felt that it was ‘easier to go in’ to the licensed premises to discuss issues directly than go through the paperwork of putting in an official representation (commenting/complaining in writing to the licensing authority), thus working around the barrier showing a positive example of AHC action. Peter applied his new knowledge of alcohol licensing legislation (Licensing Act 2003) to talk to an initially defensive manager of a pub (public house; licensed to sell/supply alcohol ‘on the premises’), who felt that issues of litter, empty glasses and noise around his premises were ‘not a licensing issue’. To maintain a positive relationship with the local community, Peter reminded the manager of his responsibility to the neighbourhood, and this had the positive outcome of reducing some of the ASB around the premises:

Clear the glasses, tell them if they want a drink go inside but don’t have them sitting out at two and three in the morning chatting away because you’re making money … He said yeah but when I shut the door they’re outside they can do what they want. Well then you need to know, if they’re your clients at the pub, that there’s kids across the road that need sleeping … That’s how it went … ’cos he was being all defensive like, it’s outside the pub, it’s not a licensing thing … and we’re neighbours.

Peter, Area 6

An example of a more definite barrier was identified by Amy, who had a potential conflict of interest regarding taking licensing action due to working part time in a pub. Amy felt ambivalent about raising concerns about a pub setting:

Yeah, I’m not a complainer really. That’s just me … I probably wouldn’t do it for a pub, but I might do it for a shop. ‘Cos I think pubs have to earn a living and I don’t know. I think if you’re going into a pub, you know you want a drink. If you’re going into a shop, I don’t know …

Amy, Area 8

Perhaps more pervading was a potential sociocultural barrier to making complaints within a community: ‘We don’t grass each other up’.

Cascading the training to others

At the time of the interviews, four AHCs were looking forward to cascading the training to new AHCs, and one had already been involved in a cascade training session. They suggested ways in which the original training could be developed. There was a feeling that the training needed ‘to be slower’, perhaps held over more days, and the content needed simplifying to ‘change the language’. They felt that they required a refresh of the information and some time to ‘carry out some more research about it’ before they cascaded to others. On the whole, with some of those changes in place, AHCs were confident in and positive about planning the cascade training, not just in their own communities but also beyond the study intervention area:

Well hopefully, like I’ve said to [local co-ordinator], we can then, once we’ve done a bit of training, we can maybe see about extending it to other areas … we can widen the net out.

Darren, Area 6

However, there was a feeling that their role in cascade training in the future should be in assisting rather than leading the training sessions, which they felt less confident about:

I loved it, it was brill … when somebody is on their own … at least you can partner up with them and they don’t feel on their own, having to struggle … I would love to keep helping … but I don’t fancy doing it on my own … If I had to teach one person I could do it. If I had to teach a whole class, no.

Katherine, Area 9

The CICA training programme was accredited by the RSPH, and this was generally seen as positive when recruiting new AHCs because it cemented its importance and identified it as ‘a properly structured piece of training’ that gave the programme a level of approval. Some felt that the RSPH accreditation and qualification were ‘important’ but that there should be some other incentive offered alongside that ‘might be more meaningful’ to new trainees:

… tie it in with something that they need … you can get points and credit towards some education … a bus pass or something … a recognition.

Peter, Area 6

However, the use of accredited training also led to delays because, in some areas, the training centres first needed to be accredited by RSPH. This was frustrating to some AHCs and contributed to difficulties in keeping momentum and retaining new recruits:

We’ve got a number of people interested … in doing the course … it’s this delay of getting the accreditation to do it, it’s the longer it’s going on it might, they might just think ‘oh you mentioned this 2 months ago’ … it’s when you keep putting it off, that’s when you wonder whether or not they’ll just think ‘oh I can’t be bothered now’.

Darren, Area 6

Local support of alcohol health champions

Notwithstanding the types of activities AHCs explored in their role, there was a clear reliance on the local CICA co-ordinator. For some, having a lead professional located within a local health and well-being service appeared to offer a sense of validity:

It’s not as though we’re trying to do it as a community thing without any backing, we’re actually doing it with the backing behind us

Darren, Area 6

For others, the personal attributes of their local co-ordinator made a significant impact on their own sense of self-efficacy and that without the co-ordinator’s encouragement, they would not have stayed involved.

Knowing that the local CICA co-ordinator was available further supported the AHCs’ confidence in the role. This seemed to be particularly helpful in enabling AHCs to manage their role boundaries effectively during brief advice conversations. If the level of information disclosed needed further signposting and support, having quick access to their co-ordinator by e-mail or phone provided reassurance that the AHC was not alone.

Widespread community inertia to tackling alcohol harm

Underpinning CICA was a perception that utilising community advocacy to reduce alcohol harm and the availability of alcohol represented an ‘untapped resource’. 1 However, the extent of community inertia to take action on alcohol harm impacted operationalisation and sustainability. For instance, AHCs and the local co-ordinator in Area 7 found residents reluctant to engage in conversations about alcohol:

I think what we picked up from our regular meetings was, if it’s around healthy eating, you had more engagement and more interest from that community […] soon as you turned it around … well, ‘you know what about alcohol’ or ‘what about cutting down’ or having conversations around promoting safer drinking, it’s just really hard to engage.

Participant 1

In two local authorities, business owners identified alcohol misuse as an issue but paid lip service to supporting community-based action:

She (shop owner) was like, ‘alcohol. I am sick of it’. Going on, ‘Everywhere we go, trying to stop these licences, but there’s nothing we can do about it’, blah blah, blah. We tried […]’Is there anything that we can do? […] ‘come up’ [for the training]. […]. But they just weren’t forthcoming, they just … that was it, the buck stopped.

Participant 3

There was inertia from residents around getting involved in the licensing process, despite frustrations with loud noise from licensed venues. In one area, there was concern expressed about the overall number of licenses issued:

they said ‘there are too many people with licences. […] It’s too easy to get a licence, too many people have licences’, and they wanted … because it was noisy at night and stuff. […] we said, ‘Well, can we come and join your committee and maybe come and have a chat at your committee’, […] but they didn’t actually really want to do anything.

Participant 3

Area 9 utilised the Licensing Public Register during AHC training sessions but described an inertia or lack of interest shown by the AHCs to getting further involved in licensing decision-making:

They were interested at the training but beyond that … and then, if they saw a [blue] sticker (indication of a new licensing or variation to an existing application), that was it! There wasn’t much more of wanting to share that knowledge or do anything about it. And I don’t know whether that’s because of me not pushing it or … I don’t know, I don’t know what the answer is. They’re not really interested, I don’t know.

Participant 11

Active role of first-generation alcohol health champions

The intervention design anticipated that first-generation AHCs would lead on the recruitment for second-generation AHCs; however only two of the areas (Areas 1 and 8) were able to successfully recruit through existing volunteers. In some areas, recruiting through alcohol and drug services for first- or second-generation AHCs impacted on capacity building (see Theme 2) and was limited in terms of leading recruitment activity:

the champions that we chose were … are … have been through the treatment service so you’re dealing with very vulnerable adults complex […] so if I had to do this again […] I think we would really try and get volunteers, which were wider than their Drug and Alcohol service … I think for sustainability.

Participant 1

the second group were mainly still users, as such, they were alcohol-dependent, and that’s why we’ve … probably the wrong group that we recruited on the second phase, really. They weren’t quite ready.

Participant 9

All co-ordinators found people interested in the idea of becoming an AHC, suggesting the underlying premise of CICA was seen to offer value. However, in some areas, neither local co-ordinators nor their AHCs had the capacity to recruit effectively:

I didn’t have the time to do it (publicity to recruit) and I attempted to get the alcohol health champions to do that and get it up and running […] It was probably a bit much for them, and it was certainly too much for me.

Participant 3

As a consequence of first-generation AHCs not recruiting, the need for recurring recruitment driven by the co-ordinator, in hard-to-reach areas was described as ‘hardcore’ (Area 8).

in terms of … the amount of work and effort that goes … to get in volunteers and champions to attend training, it’s quite high.

Participant 1

A further premise underpinning CICA was that first-generation AHCs would roll out cascade training. Co-ordinators from many areas found the AHCs did not have the confidence and skills to be able to deliver cascade training, as originally envisaged:

just to get people to volunteer then we were asking to train them up and ask them to deliver to others … we found … you normally find in these communities that they don’t have the confidence or the skillset to do that.

Participant 1

An assumption that AHCs would be able to deliver the training on their own, having received Train-the-Trainer training, as part of their Level 2 training, was potentially therefore misplaced.

Even in an area which was successful at sustaining CICA beyond 12 months, second-generation champions were experienced very differently to the first cohort, pointing towards challenges underpinning volunteer-based approaches:

I thought they were going to be perfect, to be honest. But you never know, and I just think, again, that’s what the nature, or the risk you’ve got with volunteers, because you can give them as much support as possible, if they’re not ready to engage, then they’re not ready to engage.

Participant 11

Despite these challenges, in one area, a strong group ethos developed between the AHCs, supported by the local experienced volunteer co-ordinator:

And like I say, there’s about four or five of them that, from the first cohort, that have stayed with us. Yeah. Some have gone into paid employment, but they’ve stayed with us, and they’re the ones that basically have kept the momentum going.

Participant 7

Retention not attrition

However, an unexpected consequence of CICA was caused by AHCs moving into paid employment, training or education in all areas, impacting the sustainability of the programme:

when you are training such a small number of people initially, when you have two who are immediately taken out of the picture for other reasons, you’re very much left without enough peer support and, kind of, your momentum really is almost gone almost straightaway.

Participant 8

Interestingly, generally local co-ordinators had no expectation that AHCs would continue to give brief advice or have alcohol-related conversations if they were no longer directly involved with the service they had been working with ‘because they’ve got a life’. This suggests that volunteers’ interest was seen as transitory rather than perceiving community members as engaged ‘assets’ whether or not they remained in contact with their local co-ordinator or service:

And then people started getting jobs, which is absolutely brilliant, but then they lose … obviously they’re not going to carry on having (brief) conversations because they’ve got a life. So, sometimes the success of helping somebody can hinder you. If that makes sense?

Participant 11

In an area that has sustained CICA, the social value that AHCs gain is celebrated as a real success for the programme, despite leading to attrition:

I mean, it is a powerful tool, and that’s why I said that with the CICA Programme, it potentially … for certain individuals it will lead to so many things, given the right support and opportunities. And that’s what we … well, that’s what we’ve been doing, and that’s what we will continue to do.

Participant 9

Capacity, capability and confidence of alcohol health champions and local co-ordinators

In all areas, CICA was led by local co-ordinators as an additional scope of work, with no additional funding to support implementation in eight of the nine areas. In those areas that were successful in recruiting more than one cohort of AHCs, local co-ordinators detailed the scope of the ‘CICA’ role as ‘difficult’ and included the ongoing recruitment of AHCs, mentoring existing and new AHCs, managing a volunteer team, assessment for the qualification and keeping volunteers engaged:

So yeah, it’s difficult with just a few hours a week, it really is.

Area 9

At 12 months, limited capacity due to lack of funding was identified as a barrier and frustrating:

I don’t think it can be done on the fly. Speaking as somebody who’s been doing it on the fly, you know what I mean? […] it’s been another part of a busy job. […] I’ve been up for it, and it’s been a good experience […] but I think to not have the time and resources to dedicate to it makes it a very frustrating experience.

Participant 5

Continual challenges in recruiting and retaining engagement of AHCs were experienced as demotivating:

I probably at that point was a bit disheartened because I think that was the point where we’d booked for seven people and six cancelled, and I thought, I don’t know what else to do.

Participant 3

Sustainability was also impacted by the capacity, and capability, of local co-ordinators to lead on delivering the cascade training to further cohorts of AHCs. Some local co-ordinators found they struggled to deliver the training and that role would be difficult for ‘a layperson’:

When I delivered the first one, I thought, ‘Wow, it’s going to be very difficult for a layperson who has no experience in brief advice conversations to stand up here for 2 days’. I was struggling.

Participant 11

Despite the challenge for AHCs in delivering cascade training, Area 8 reported proactive engagement from the first-generation AHCs and a successful outcome:

the best part of the training was seeing the first-generation health champions start to deliver the training, and being really nervous and being really unconfident and being really scared and all that kind of stuff, and then just getting up there and going *Boom* and really, really smashing it and I’m thinking ‘wow, you’ve done spectacularly well there’.

Participant 5

While all local co-ordinators found AHCs were unable to lead cascade training events due to limited skills and lack of confidence in some areas, AHCs also lacked confidence to begin brief advice conversations due to the topic:

Other people just felt, well I do drink, people here know that I drink, again, what permission do I have to tell somebody else that they drink too much? And so, I think the topic itself provides a challenge, […]and it can feel hard to have those conversations about how much is too much.

Participant 8

As it became clearer that AHCs lacked the confidence to open brief advice conversations, local co-ordinators used different strategies to strengthen AHCs’ self-efficacy. These included plans to deliver motivational interviewing training (Area 2); buddying the AHC with an experienced support volunteer (Area 9); and developing AHC's broader public health knowledge and understanding and providing additional skills sessions (Area 8).

We […] didn’t feel comfortable that those volunteers, who had passed (the qualification) would be ready to go out and face the community. So myself and [Name of local lead], kind of, went back and had a number of workshops with the first cohort […]. And going through areas again and picking off areas that would be more relevant in terms of having conversations with communities and building up some of that.

Participant 9

Consequently, the AHCs became independent and ‘self-sufficient’ with the capability and confidence to engage with the community:

And now I’ve got good people who go out, even if I’m not here […] they’ll come and pick the green bag up. They’ve got a green bag with everything in; their banner, all the leaflets, the Audit-Cs. And they just pick it up and off they go. So, they might set up in the library here, they might go to the health centre around the corner […] So, they’re very self-sufficient, as long as I keep the bag stocked up, they’ve got a good routine going.

Participant 7

‘Hand holding’ alcohol health champions

Volunteers required far more support on an ongoing basis than was originally envisaged by leads or articulated in terms of the expectations for CICA and became a significant barrier:

It [ongoing support] needed to be far greater than we could reasonably provide.

Participant 8

As local co-ordinators were largely supporting CICA within their existing workloads, the unexpected need to ‘hand hold’ became a barrier which impacted on capacity building and embedding CICA:

, but then when it came to actually going down and doing it [the AHCs going to run a drop in session at a local café], they struggled a bit with that, really. And I don’t feel I had enough time to dedicate to supporting them with that as well.

Participant 5

Some areas set up support sessions ‘every couple of weeks’ (Area 8) for AHCs, where they ‘reiterated what we were trying to do’. In Area 9, the local co-ordinator

sent out a text every Monday morning, ‘This is what we’ve got planned’, […] So, we do ‘What have we done last month?’ A plan for this month and study that, do it and then act upon it.

Participant 11

In one area that has continued to sustain CICA, the effort and demand on the time of the local lead were deemed worthwhile in terms of the results gained:

I think [Name of local co-ordinator] has been there 100 per cent of the time for them, you know, to a point where it was sometimes a bit hand holding and that, kind of, was expensive in terms of his time, because he wasn’t allowed then to do some of his work, because he felt as though he needed to support them. And if you look at the long term of it, it was worth it, because they’re now actually doing things that they don’t need hand holding for.

Participant 9

Here, a managed ‘hand-holding’ approach was used to build AHCs confidence to have brief advice conversations, starting in ‘safer’ spaces such as a health-centre hub:

it was really hand holding to start with, because it had to be … because they were very, very nervous, but now I think they would take on anybody, to be honest.

Participant 9

A different local lead (Area 4) identified that investing the time in ‘hand holding’ to support the development of AHC confidence was integral to building AHC capability and therefore would take ‘time’.

Experiences of giving brief advice

Four out of the eight areas shared examples of AHCs providing brief advice demonstrating successful capacity building. Sustaining interest in delivering brief advice focused on AHCs providing advice to ‘strangers’ rather than family and friends. Evidence was provided of brief advice conversations held in taxis (Area 9), with people met on a canal towpath (Area 6) and with people at carnivals (Areas 1 and 8) for instance:

[Name of AHC] did his very first conversation in the taxi on the way home (from the training day) with the taxi driver. His very first Audit C. And he was buzzing, he was absolutely buzzing about it, which is great.

Participant 11

In Area 9, AHCs learnt how to structure conversations. Evidence was provided of engaging with individuals over a longer timescale – to support a reduction in overall alcohol use – facilitated by goal-setting with the recipient of the brief advice:

and then, we’d have a conversation and we could get somebody to set a goal to reduce their alcohol, […] we’re saying to them, ‘How about you reduce from 14 units to 12 units?’ something like that, […]. If we were setting them a goal […] then we’d call them back in a month and say, ‘How did you get on with that?’ That was one good thing.

Participant 11

Local leads in Areas 1, 4 and 9 warmly recognised the commitment of their AHCs, describing them as being ‘proud’ for ‘everything they’ve done’. Interestingly, local co-ordinators celebrated this success through quantifying brief advice activity and reporting on it:

obviously, we’re delighted that we’ve smashed the 200 hours (CICA volunteer time) in 12 months. To get 200 hours of people’s time, to be out there talking to the community, and be confident and be … and wishing to do that, I think it’s massive. I think it’s massive.

Participant 7

he did the training and he was just at a very high level of his volunteering […] and that was when we went out and did lots of community engagement and we did 300 brief intervention in 15 days.

Participant 4

However, in some areas, volunteers were less comfortable in having brief advice conversations, and the area struggled to effectively operationalise CICA:

The topic made it uncomfortable for some people, and let’s face it, we know health professionals who struggle to have a conversation with people about how much they drink. […].

Participant 8

Identifying the right ‘place’ and timeline to successfully build community capability

Most local co-ordinators debated issues around operationalising CICA in the LSOAs chosen. Two local co-ordinators felt that targeting less deprived areas, and with more established patterns of volunteering, may have worked more effectively and enabled the programme to embed:

it has potential I think definitely. The programme lends itself really well to places that are … like very established and run really well […]. Our volunteer groups that have been established a long time that may be … are used to working in this way … I think the model really fits really well with that …

Participant 1

Five local co-ordinators felt the sustainability of CICA was affected by the LSOA-level approach taken to the intervention. Four argued that using a wider geographical footprint within a town or city centre would have supported operationalisation by providing access to different levels of capability within the community to deliver CICA:

I could have imagined taking that community-based model to other places within the borough, and finding we had local residents with the capability, already, to pick up the model and take it somewhere. Yes. I think that the area we focused on – as having a high level of need – it’s much harder to find people who were able to do that.

Participant 8

In relation to taking CICA into other areas within the local authority, one local co-ordinator said:

there’s so much more we can do there, absolutely loads.

Participant 11

One local co-ordinator hypothesised that operationalising CICA in more affluent areas might have more success in creating engagement with the licensing process, due to different ‘tolerance’ levels:

our more affluent areas often make far more complaints and objections around licensed premises than some of our more deprived areas. […]. So, if it’s an area without a huge number of licensed premises and with reasonably high tolerance levels, potentially for some street drinking, or kids having alcohol, or things like that, it [alcohol availability] just might not be an issue for that group of people.

Participant 3

The 12-month timeline for operationalising and evaluating CICA was also seen as problematic. Some local co-ordinators identified 12 months to embed a community-based approach as unrealistic:

It can take years to get stuff established, can’t it? You know what I mean? Especially groups and community groups and stuff. You know, three years, you know? To just … to get it anywhere, into any kind of shape, really.

Participant 5

Consequently, the initial ambition of training 35 AHCs combined with a 12-month time frame skewed activity towards recruitment and training rather than building the capability of the first generation:

It’s almost been like, right we’ve got to get 30 people trained up by next January, and stuff like that. And I think, on reflection, I don’t know how realistic that was, really. And I think that’s again been a bit of a driver for banging training on, when we’ve not really been ready to bang that training on. Rather than thinking, right we’ve got a small group here, let’s grow that.

Participant 5

‘No Key Performance Indicators (KPIs) – why bother?’

Local co-ordinators shared different opinions about targets or goals that hindered or facilitated operationalising CICA. In two areas, recruitment targets were viewed as a barrier. At 12 months, these two areas had struggled to recruit and carry out cascade training, which may explain the negative focus on recruitment targets:

I just think … the way that the CICA is … sort of written around having 30 odd … to have a specific number of cascade … is it 35 or 30? I think … yeah, there was a … an estimate of trying to aim for … building that capacity. I just think … you know maybe that’s just too far … it’s just not achievable really. I think it just has to be whatever works in that area.

Participant 1

For some local co-ordinators, the absence of goals in relation to the number of brief advice conversations expected and the number of AUDIT-Cs required was a barrier, so local-level goals were put in place to encourage and motivate AHCs. In one area, the local co-ordinator found methodically measuring activity so that feedback could be given to both commissioners and the AHCs was motivational, facilitated engagement and ongoing support:

Since we’ve started, we’ve […] seen 571 individuals and spoken to them about alcohol, whether it affects them, their family, a loved one, a neighbour, a work colleague, or somebody in … or just generally by their community. We’ve done 101 mini-Audit-Cs. We’ve given out 652 leaflets at different events. And we’ve done over 200 hours of volunteers completed.

Participant 7

While some AHCs found targets motivating, others were reported as being concerned about being ‘embarrassed’ if they had not had ‘enough’ brief advice conversations which became a barrier and contributed to attrition in one area:

There was always a bit of a concern about a need to do a certain amount of work […] people (the AHCs) perceived, I need to do a certain number of things, otherwise I’m embarrassed to go back and talk to [Name of local co-ordinator], or the other colleagues involved, because I feel like I’ve not done anything.

Participant 8

Some local co-ordinators reported feeling pressured to ensure brief advice conversations were carried out, despite there being no targets. In one area, this was reported as necessary ‘to keep the project afloat’ and to ‘garner a good impression’ with commissioners: Two local co-ordinators identified the CICA work going on in other GM areas as a driver to complete more conversations in some areas:

then, I guess with the local meetings and people going ‘Oh, I’ve done X amount of Audit-Cs, and I’ve done this, and I’ve done that’, and they’re thinking ‘oh shit, right, I need to get some Audit-Cs in, don’t I?’

Participant 5

It can become an issue, perhaps, when a commissioner is telling you, ‘Just get a venue, just use volunteers. So-and-so in town X are doing fine.

Participant 4

Local co-ordinators’ responses to completing a (non-prescribed) number of brief advice interventions begin to demonstrate the complexity of monitoring and evaluating brief advice interventions. The absence of targets at local level left one local co-ordinator to question the use of a ‘blunt instrument’ to determine the success of the CICA intervention:

What do they want from it? Do they want people to drink less? Do they want people to present to A&E less? Do they want less domestic violence? I don’t know, broadly speaking … If you’re going to be using admissions to A&E as a KPI, it’s a very blunt instrument, isn’t it? I don’t necessarily think it proves anything.

Participant 4

Interestingly, none of the local co-ordinators discussed the absence of targets related to licensing activity.

Broadening skills and engagement beyond the alcohol health champion role

Some areas (Areas 1, 8 and 9) found benefit in extending the range of training provided to the AHCs to give them a wider health remit. Using wider conversations about health was seen to facilitate conversations about alcohol consumption:

So, if you’ve got somebody and you’re testing their blood pressure, the next thing you know is you’ve got a card there. So, they can do an Audit-C depending on their age, but they’ve also got the lifestyle risk assessment. […] Then they will talk to people about their smoking and definitely their alcohol, so they’re getting an Audit-C then.

Participant 11

As a result of leading on CICA, some local co-ordinators identified that new volunteers – whether AHCs specifically or broader lifestyle volunteers – would benefit from initial training and the development of underpinning knowledge in public health:

what we are going to do though, from now on, is we are going to do the Level 1 ‘Understanding Public Health’(qualification) […] around obesity, physical activity, healthy eating, all those things, smoking […]. Because public health is the big picture. It affects everybody.

Participant 9

Increasing cultural and social significance

Perceptions that excessive drinking had become normalised in the area were referred to in all three focus groups. This was in the context of alcohol use becoming ‘trendier’ and popularised as an activity:

…people think that there is no such thing as life without booze. You see it on Facebook every day, it’s wine o’clock, everyone’s living for the next drink and that’s not even alcoholics, that’s just, there doesn’t seem to be anything without alcohol.

Focus Group 1, Participant 2

It’s a bit more glorified now isn’t it? And it doesn’t matter I don’t think whatever background you come from, whether you’re from affluent or not affluent, everybody drinks …

Focus Group 2, Participant 1

Now, pubs are quite open to allowing children in, so from an early age that’s what children are seeing. So, they’re considering it normal but it’s not, like you say, a parent going out for a pint, it’s doubles and shots, and they’re watching their parents do this and this is what they’re growing up with. Therefore, they think it’s okay but then they just take it to the next level and then their children think that’s okay.

Focus Group 3, Participant 1

It was suggested that drinking shaped social activities and events, and ‘not drinking’ was seen to be abnormal: ‘They’re sort of insistent, they think you’re being funny by not letting them buy you a proper drink’ (Focus Group 2, Participant 2). In contrast, buying large quantities of alcohol from off-licensed premises was considered to be the norm:

When I’ve been in the supermarket and you see it, particularly a woman with a trolley full of drink, I’m thinking is it all for her? Or is it a party or is it … you can, if you drink a lot now you can get away with it, put two or three bottles of whatever, wine in the … nobody thinks anything of it now.

Focus Group 2, Participant 4

Cycle of community breakdown and alcohol misuse

Unemployment and lower socioeconomic factors were seen to be perpetuating increased use of alcohol, contributing to a sense of community breakdown, intersecting with coexisting health, crime and ASB:

I think we have massive issues here with unemployment, with substance misuse, both drug and alcohol and I wouldn’t say alcohol’s more than drugs … you see it more and more and then obviously there is that increase in issues with mental health and antisocial behaviour, vandalism, poor [name of high street pharmacy] must be shoplifters paradise. And you just see these things and we need help.

Focus Group 2, Participant 1

Levels of ASB, such as littering and noise, were more noticeable in Focus Group 1, along with concerns for violent crime:

These idiots have parties in their back yard that go on all night and when I say all night we’re talking until like five o’clock in the morning, drink, drugs, loud music. Totally no respect for the neighbours or anybody else. If you complain you can receive death threats. And you’re worried about your windows going through.

Focus Group 1, Participant 1

The impact of noise at a hyperlocal level was particularly highlighted, and due to the small proximity, the knock-on effect of feeling vulnerable:

The noise. It’s affected everybody in the street that I live on. In fact I live on a little estate but one party going on all night can affect the whole estate because it’s that small. So it’s really, it is rough, but it leaves you vulnerable.

Focus Group 1, Participant 4

Concerns were expressed about drink spiking, risks of child sexual exploitation and crimes that do not get reported to the police:

… people will either wilfully get them drunk, so they’ll have their drink spiked and they’re taken advantage of and they wake up not knowing what happened and gradually realisation kicks in. Half of them don’t tell anybody, doesn’t get reported to the police, and there are actually groups of people who will target young ladies of the ages of 13 upwards in that situation.

Focus Group 1, Participant 6

As alcohol misuse becomes more visible in the community, participants spoke of how communities break down further: ‘once you’ve destroyed a community it’s difficult to rebuild it’ (Focus Group 1, Participant 1). Having a lost sense of purpose was identified as a factor compounding a cyclical nature to community breakdown:

… people have lost respect for themselves and in having no respect for themselves they’re doing the drinking, they’re doing the drugs to try and find a reason for being. Because a lot of them can’t get jobs, can’t get into work, they’ve lost the sense of being.

Focus Group 1, Participant 4

Increasing accessibility

All three focus group discussions recognised the changing nature of alcohol availability:

You can get alcohol everywhere now … whereas now supermarkets, so it’s much more accessible. So even if you weren’t thinking about it, say if you had an issue with alcohol, you were to go to the supermarket, there’s the alcohol.

Focus Group 2, Participant 5

Accessibility was also defined by its affordability and cheap prices:

You can go to [name of supermarket] now and buy a case of 24 for £11–12, is it? People just stay in now, don’t they? They don’t bother going out.

Focus Group 3, Participant 2

One participant further suggested that areas of deprivation were targeted by the alcohol industry to increase outlet density at the same time as lowering prices:

That’s what the cheap alcohol is all about, and it’s on every corner. It’s difficult to see that in more affluent areas, you wouldn’t go down and see that because it’s just … it’s demographics. They see depravity (sic) appear, so they say, ‘Right, we can approach them and give them what they want at a cheaper price’, and that’s where it gets people.

Focus Group 3, Participant 2

Regulation

Some participants perceived larger supermarkets to sell alcohol legally and responsibly but felt more regulation was needed for smaller independent premises:

The supermarkets are brilliant at controlling it, but the smaller shopkeepers, they’re not just selling alcohol at stupid o’clock in the morning, they’re selling drugs over the counter.

Focus Group 1, Participant 3

On-licensed premises, such as pubs, were seen to be more responsible and less profit-driven in comparison to off-licensed premises:

The businesses will still sell to them, therefore contributing to the problem, instead of saying, in a pub, if you were kicking off, they’d go, ‘Right, no more, you’re not having it’. Shops don’t do that; they will willingly sell to anyone because they’re a business and they need to make profit.

Focus Group 3, Participant 1

A small number of participants demonstrated awareness of the licensing procedures required to notify the public when a new premises licence application is submitted:

When you apply to open a … I don’t know, [name of off-licence chain] or whatever, the Council is supposed to put it in writing, that’s why you see it on lamp posts and things … But it’s also, in certain cases, in the paper as well, isn’t it?.

Focus Group 3, Participant 2

However, the meaningfulness of the required approaches to advertising applications to the public was doubted:

Have you looked at the public notices of kind of licences and seen who’s applying for licences? It’s actually has no one ever … you’d think it’s in the Advertiser or whatever …

Focus Group 2, Participant 1

Problems paired with drug use

In Focus Group 1 and Focus Group 2 (Area 1), the felt needs of the community predominantly centred around the prevalence of both alcohol and other drug use and concerns for young people.

Youngsters on parks that are passing things round and the, obviously they’re mixing it with other things, it’s not always just about alcohol. We’ve got a number of dealers that live nearby, there’s parks where you’ve got empty cans. And some people are just throwing them out the cars as they drive by. And I just think, what do you have to do to get these people to just respect the area around them and where people live?

Focus Group 1, Participant 3

Accessibility to other drugs was also seen to be a factor:

I think there’s been a shift … I can remember talking about it when I grew up, access to drugs was far more difficult. I think now you can go anywhere. So I think there’s the kind of alcohol and drugs as a combination and it’s a lifestyle choice.

Focus Group 2, Participant 3

Combining stimulant drugs such as cocaine when going out was perceived to be the norm:

I spoke to a young guy yesterday, he’s 19 years old and he hasn’t been going out and he literally said to me every single person when he goes out is using coke. And I find that quite shocking because it’s so readily available and it’s an expensive drug.

Focus Group 2, Participant 1

Help seeking

Focus Group 3 particularly felt there was a need for an AHC role to act as a bridge, exchanging helpful information about alcohol licensing between authorities and the community:

I definitely think there should be somebody you can go to and say, ‘Look, this is going wrong, is there anything you can do about it?’ Or, ‘Can we change this?’ And somebody needs to be in that role, to go to whoever the hierarchy are and say, ‘Look, we’re getting complaints’, or, ‘You’re being complemented on what you’re doing’, blah blah. And have a say within that community.

Focus Group 3, Participant 2

One proposal was for an AHC to act as a middle person:

It’s just a way of getting the community to actually relate to the Council and vice versa, but using that spokesperson, that middleman or whatever, it would just be easier, wouldn’t it?

Focus Group 3, Participant 5

Having AHCs have a watchful eye over the community was also valued:

… they would be almost like your local community guardian, going around checking if everything is okay within the area, yeah.

Focus Group 3, Participant 6

However, concerns were expressed about potential repercussions for a community member having such an advocacy role:

If you’re stood behind a 13-year-old who’s getting beer, you’re not going to be the one that turns around and says, ‘He’s 13’, because all his mates outside are going to jump you on the way out, or you just don’t know what the consequences are going to be. So, even though it’s a community responsibility, we don’t feel like, as a community, we can be responsible. Which is hard.

Focus Group 3, Participant 1

Perceived negative consequences of an AHC getting involved in licensing were not only associated with young people’s reactions but the wider community:

That would be good in an ideal world, but they would be targeted then, I think, somebody like that. They would get targeted by youths, by people who were drinking and coming out of pubs … If I closed that down, stuff like that, I would be a wanted man.

Focus Group 3, Participant 5

In terms of alcohol brief advice and information seeking, ‘othering’ was evident in the language, stereotyping those who needed help as ‘alcoholics’ or people with addiction now in recovery. Poor responses were described from local services, particularly for people with multiple coexisting issues:

I’ve got friends in recovery who, and friends who aren’t in recovery who need recovery and they’re meeting that same problem. So they go for help with the mental health and they’re just getting shoved away because of drug and alcohol addiction.

Focus Group 1, Participant 2

Another concern was the configuration of community services and stereotyping people who would benefit from structured alcohol treatment:

So for example I’ve got another friend who’s just come into recovery who was a terrible binge drinker, she would cause havoc all the time when she’d had a drink and she did go to [name of service] several years ago and they said because she wasn’t drinking every day, she wasn’t an alcoholic. So that gave her the green light then to go out, be a nuisance, carry on drinking until the point that she’s almost nearly killed herself.

Focus Group 1, Participant 2

Participants valued the informal, brief advice aspect of the AHC role, not just to provide information, signpost, but also to act as a listening ear:

It is that gap that needs to be bridged because there’s so many people who are looking for help but they’ve no idea where to go for it. And how to access it. And so having those alcohol champions visible in places.

Focus Group 1, Participant 2

One participant knew one of the local AHCs as a friend and highlighted some of the positive changes they had seen in them:

… one of my closest friends is actually now an alcohol champion and what it’s done for her and her perspective and being able to make her see and realise was absolutely amazing in 12 months she went from walking with her head down like that and not making eye contact with anybody, to like this and being able to look you straight in the eye and talk to everybody. Because she’s now aware of things that are going on and how to cope with things that she wasn’t aware of before.

Focus Group 1, Participant 4

Design and application feedback

A total of 13 public representatives from 4 different community networks contributed to the design and application stage of the CICA research in March to April 2016.

We met with volunteer health champions (n = 2) from a Level 1 Health Champion network who debated the feasibility of being able to raise alcohol as part of an informal conversation with family, friends and colleagues. This led us to add ‘organising/attending community awareness events’ as an additional secondary outcome measure within the process evaluation.

Forever Manchester, who co-ordinate volunteers involved in ABCD, challenged us on how ABCD theory fitted with our proposal (n = 1). This was because the CICA intervention started with an issue/deficit (alcohol harm) decided by the 10 GM local authorities and not a community’s strengths. This influenced our logic model by clarifying how existing strengths, motivations and skills need to be identified, mapped and recognised, but it also informed our dark logic model, as we hypothesised potential unintended ‘equity harms’.

The LGBT Foundation, which provides advice, support and information to lesbian, gay, bisexual and trans communities, co-ordinates a team of volunteers who patrol city centre areas to support people with issues during a night out. We met the Village Angels’ co-ordinator and one of the volunteers (n = 2), who suggested that people in recovery from alcohol dependence ‘find pride in a sense of recovery and can be highly motivated to volunteer’. Anticipating CICA areas may consider recruiting volunteers to the AHC role from local recovery communities further informed the development of our dark logic model, hypothesising potential unintended ‘opportunity harms’ or ‘direct harms’ that could arise.

Fallowfield Community Guardians are local residents who act on behalf of local residents to influence licensing regulation and enforcement in their area of South Manchester. A consultation meeting was held with six local residents and two local councillors (n = 8). They felt the research was relevant and needed but had a concern that the proposed quantitative outcome measures may not capture what matters to local residents and ‘would not be visible in the data’. They proposed that key performance of indicators of ASB should be measured in addition to reported crime to help address what residents are motivated by to reduce alcohol harm (passive drinking effects), for example, transient noise, litter and deliberate damage (tipping over bins). ASB was subsequently added as an outcome measure.

SH cowrote the plain language summary for our application and created a short video for use within CICA training: sharing her experience getting involved in licensing action and advocacy (reporting issues to local licensing officers) and licensing decisions (making representations against new premises licence applications).

Data collection

Our public representative SH additionally directly participated and was paid for her contribution to aspects of the qualitative research, including training observations as well as a document review of local licensing policies. SH attended Train-the-Trainer CICA events at the beginning of the sequential roll-out in September 2017 and at the end of May 2018. Data extraction was completed with EJB on 10 statements of licensing policy (one per local authority) between April 2019 and July 2019.

Pathways to impact

Three AHCs took part in a storyboarding event in March 2018 with the process evaluation (University of Salford) team along with SH. All were reimbursed for travel expenses, and lunch was provided. The second opportunity for PPI involvement invited AHCs to be part of the filming. Nine AHCs agreed to be filmed for the video, and all were given a voucher as a token of appreciation for their time. The resulting documentary benefitted from being designed by people directly involved in CICA and share their journeys as AHCs, from training to being active in their community, the success of the programme so far and success stories of individuals.

In that same year, November 2018, GM Health and Social Care Partnership launched the ‘Big Alcohol Conversation’ which involved public engagement with 80 local voluntary, community and social enterprise (VCSE) organisations and more than 5000 people. At the engagement launch event with GM’s Mayor Andy Burnham, AHCs spoke on stage about their motivation and experiences as an AHC and the role communities can have to prevent and reduce alcohol-related harm. The AHCs found the experience speaking on stage and having their photo taken with the Mayor of GM personally rewarding and validating to feel part of a high-profile public engagement campaign.

In October 2019, we held an Early Findings CICA Stakeholder Conference, attended by a cross-section of stakeholders, including AHCs. SH also attended the event. The presence of the champions made a positive impact on our project in a number of ways, especially assisting us to sense-check our early process evaluation findings. For example, one AHC told us that they recognised the anticipated mechanisms of action of CICA enacted in his local community at a local meeting he attended. We also heard how participating in the conference had a positive impact on another champion’s self-esteem. She described having never visited/attended a higher education setting before and how the invitation and participation on the day made AHCs feel validated. Two champions also contributed to the making of a new set of short films at the stakeholder event about local area-level impact.

In 2020, as plans to host and attend conferences were disrupted by COVID-19, plans for dissemination activity were adapted. One such activity resulted in the development of a ‘speedy drawing animation’ to promote CICA impact stories. When developing the speedy drawing animation, input was sought again from a sample of AHCs. They received a storyboard containing early ideas, asking for their comments about its accuracy and representativeness. One AHC commented:

The part of engaging advice and encouraging people to take part in AUDIT-C is greatly appreciated because this really helps the advisor to enlighten the person doing the AUDIT-C about where they are at with alcohol consumption and whether they are wanting to make some small changes to make a bigger difference to health and wellbeing.

Our PPI representative shared the positive impact of being actively involved in the CICA project and its research in local licensing activity and how it gave her increased knowledge about health harms from alcohol and extra credibility when participating in licensing objections.