Overview
Communities in Charge of Alcohol introduced the first alcohol-focused champion role of its kind in 2017 as part of the delivery plan for the GM Alcohol Strategy 2014–17. Developing a dedicated community lay health champion role – an AHC – to reduce alcohol harm at a hyperlocal level across all 10 city region local authorities provided an opportunity to evaluate CICA as a natural experiment. It was critical that an evaluation on this scale and nature occurred, as it presented an important opportunity for evaluating a multicomponent, community-centred public health intervention.
Our research project aimed to evaluate the effectiveness, cost–benefits and cost– consequences of implementing the CICA programme and understand the context and factors that enabled or hindered the intervention. Mixed-methods process evaluation data demonstrated that, among individual AHCs trained, there was significant activity, with local co-ordinators recording hundreds of occasions of brief advice given and qualitative accounts of life-changing conversations. However, we also found that there were significant challenges to setting up and maintaining the intervention: only around a third of the hoped-for number of champions were trained in nine areas, and over two-thirds of those trained were inactive after 12 months. The ambition to empower local people to get involved in licensing decisions to change the alcohol risk environment was not realised.
Given that the ‘dose’ of the intervention was dilute, it was unsurprising that the quantitative outcome analysis, which made use of area-level data, showed no consistent significant effect on rates of health and crime indicators. Consequently, the cost evaluation did not show CICA to be cost-effective.
Discussion of the outcome analysis
The results of the quantitative evaluation of the CICA intervention do not indicate any measurable impact on alcohol-related hospital admissions, A&E admissions or ambulance call-outs to the area, nor on reported crimes or reported ASB incidents specifically as a result of the CICA intervention. Local AHCs as an intervention to engage communities in brief advice and statutory processes to affect alcohol availability in their local area have to date not been implemented elsewhere, so these results cannot be directly compared with results from other evaluations. However, there are a couple of observations that we can make.
Given the type of intervention, which is relatively low key in terms of direct impact, we had hypothesised that likely impacts on hard public health outcomes such as those included in this study (in contrast to softer, more difficult-to-measure outcomes such as impacts on the ‘experience’ of the neighbourhood, feelings of belonging to a community and feelings of safety, for example) were always going to be small at best, particularly with respect to the relatively short time period of up to 3 years from the implementation start date of the programme, in which it would have been difficult to fundamentally change the alcohol environment of a community. Theoretically, once the initial group of local alcohol champions starts engaging with the licensing regime in an area and starts engaging the wider community in this, and if training of additional champions in subsequent rounds were to commence, this could lead to measurable change in the outcomes in this evaluation within several years. However, these findings show that it may be unrealistic to expect this within the confines of the current evaluation.
The data set, both in terms of length of post-intervention period and number of areas included, might just not have been sufficiently large to pick up smaller effects. However, while increasing the sample size may have given us more power to detect smaller effects, such small effects may have been meaningless in terms of making a practical impact.
Where there were statistically significant effects, with the exception of ambulance call-outs and ASB incidence (for most models), these indicated an increase in incidence of these harmful outcomes rather than a decrease following the intervention. Possible explanations are that they are either (1) artefacts in the data where reporting went up significantly nearer the end of the time period in this study, and/or (2) these result from the non-random allocation of the CICA intervention, whereby the intervention was allocated to particular geographical areas where there were concerns over high rates of alcohol harm. If CICA had no effect on these selected outcomes, it is plausible that alcohol-related hospital admissions and crimes increased more in problem areas than in comparable other areas. We attempted it to minimise this bias by matching to comparable control areas, but this might not have been sufficient.
It might have been predicted that, of the two main activities undertaken by AHCs (involvement in licensing and brief advice conversations), the licensing activity would have had greater potential to have a bigger impact on area-level outcomes. Therefore, the finding from the process evaluation, that even after increasing community capacity to influence alcohol availability decision-making at a local level, communities did not engage with statutory processes to affect alcohol availability in their local area is congruent with the null finding in the quantitative analysis. There was initial enthusiasm and confidence expressed post training by AHCs to get involved in alcohol licensing action. However, the licensing context at baseline highlighted that the scope to strengthen restrictions for existing licensed premises at a hyperlocal level varied, with the number of premises licensed to sell or supply alcohol in the target areas ranging from 0 to 59. This variation was consistent with data (where available) on the number of new alcohol licensing applications submitted to the local authority, comparing the 12-month period pre-CICA with the 12-month intervention period during CICA. Alcohol health champions were further limited in putting their training into practice if there were few (or no) new applications to increase the density of licensed premises in the area. Other formal metrics, such as the number of licensing issues positively reported to RAs resulting in a recorded crime or incident of ASB, were unknown.
It was challenging to recruit and retain sufficient volunteers in a specific, small area/community, with the most active areas training 17 champions in the first 12 months. While adjoining LSOAs provided a geographical unit of study for the outcome analysis, this limited the ability to build a groundswell of health assets. Stakeholders, including licensing officers, felt that extending CICA training and CICA activity to a local authority level may provide greater opportunities to mobilise community members in areas where there are higher numbers of licensed premises. As previously noted, in some chosen LSOAs there was little or no opportunity to get involved in alcohol licensing, suggesting the criteria used to select the target areas were not always aligned to the programme’s objectives. However, more than two-thirds of volunteers had become inactive at 12 months, and interviews with local co-ordinators and AHCs indicated that they found licensing processes complex and were reluctant to get involved in licensing action. We also observed, in the documentation review of local alcohol policies, that policies were orientated to support the needs and interests of the applicant, rather than towards persons wishing to raise a concern. This suggests that even with more time and more volunteers, an impact on the health and crime outcomes of this evaluation might not have been conceivable.
Discussion of the process analysis
We assessed the process over four phases: pre-implementation, initial implementation, during the intervention and follow-up. Our aim at the pre-implementation/roll-out phase was to identify the infrastructure at baseline. Existing evaluations have recognised the importance of a supportive infrastructure when implementing new community health champion programmes, but more research is needed to explore what aspects positively influence process indicators such as recruitment, training numbers and retention.
Multicomponent public health interventions such as CICA have interacting individual and community components, influenced by and interacting with contextual factors; they are complex interventions.124 In terms of degrees of task difficulty, the CICA intervention (as described in ‘intervention description’ in the Methods section) required local co-ordination and project management, continuous volunteer recruitment, support and supervision. The cascade model of AHC training required the organisation of both Train-the-Trainer and delivery of cascade training events. RSPH candidate workbooks required assessment and external verification in order to award volunteers with the Level 2 qualification ‘Understanding Alcohol Misuse’. Licensing officers who may or may not have experience training lay people were expected to codeliver an ‘introduction to alcohol licensing’ at both Train-the-Trainer and cascade training events. The number of organisations involved in the implementation of CICA (RSPH, commissioning teams, service providers and wider stakeholders in the intervention area) led to inherent complexity, as were the fixed procedures required when setting up RSPH-accredited cascade training. While the co-ordination, recruitment, training format, support and supervision of AHCs could be tailored flexibly to the local context in each CICA intervention area, the formal procedures available for members of the public (and therefore AHCs) to influence licensing decisions were fixed within the statutory processes prescribed within the 2003 Act.
In the pre-implementation phase, we identified significant variation between areas in terms of the infrastructure in place to deliver the CICA intervention. For example, some areas struggled to identify a suitable professional to support and co-ordinate at the local level. Ultimately, those areas that had more of the infrastructure were able to train more volunteers. Also in pre-implementation phase, we attempted to measure a baseline composite score of alcohol availability, which was to be based on hours of sale, size of premises (on licensed premises only) and number of premises. Theoretically, this information should have been available to extract from licensing registers. However, in practice, the only variable that could be consistently obtained was the overall number of premises. The lack of structured data and inconsistency in data management systems used means that it is not possible to get an overall picture of alcohol supply in an area, and this hinders the ability to work out which areas have high (or increasing) density and hinders the ability to evaluate outcomes of licensing interventions. However, since AHCs did not tend to take action in the area of licensing, the lack of this process indicator did not affect the conclusions of this study.
Results from the initial implementation phase demonstrated that some AHCs were confident in providing alcohol advice to family members, friends and strangers in their communities. In contrast, a lack of confidence in raising alcohol as a topic is commonly reported as a barrier by health and community-based professionals,26 despite ASBIs continuing to be a WHO ‘best buy’ to reduce hazardous and harmful drinking in primary care.125 This suggests that lay people with this skill and confidence could be a significant asset for a community, though fidelity as a behaviour change intervention was unknown. In order to perform this role, AHCs required significant support, and universally, local co-ordinators described a high level of personal involvement, which they had not anticipated, to meet the needs of the programme. They noted two-thirds of the AHCs had disengaged at 12 months, and this low engagement may have been attributable to low acceptability of the CICA intervention, both while participating (concurrent acceptability) and afterwards (retrospective acceptability),126 as evidenced further by their lack of participation in any follow-up interviews. The burden of activity for newly trained AHCs included not just putting into practice opportunistic brief advice conversations and getting involved in licensing action, but also helping with wider recruitment and cascade training.
Evaluation at the initial phase of the intervention also revealed that the time taken to establish such an intervention had been underestimated: commissioners and providers seeking to develop assets-based approaches need time to establish confidence and networks within local communities in order to develop a partnership-based approach prior to intervention implementation. Recruitment was challenging, and co-ordinators struggled to ‘sell’ CICA as a product, and despite successfully securing volunteers to attend a 2-day course, individual participants may not have known exactly what they had signed up to. Local co-ordinators celebrated the social value gained by AHCs through gaining new experiences, accreditation and improved confidence. However, these personal successes added to AHC attrition as some subsequently took up employment within 3 months of training, leaving them with insufficient time for the role. Additionally, consistent with previous findings,127 the extent of strategic and political support at a local area level impacted on the success of this phase of implementation. In fact, in one area, despite an original commitment, the intervention was not established.
From a licensing perspective, links between LA licensing teams and AHCs needed to be built from a low level. There were several barriers to AHCs and the community getting involved in the licensing process, including the complexity of training content delivered within a half-day session, its dilution in cascade training as noted in training observations, ‘applicant-centred’ statements of licensing policy and processes, a limited number of licensed premises in the target areas and fear of reprisals. Importantly, licensing leads reported that despite the commitment to promote community involvement in licensing decisions in the 2003 Licensing Act, there were no resources allocated to make it happen. Taking part in CICA highlighted to licensing officers the limited capacity, they had to commit to regular training sessions for the public and to be a source of ongoing support for AHCs. Further concerns were raised around the administrative resources needed if the ambition of CICA was realised, with more reports of issues, complaints and representations to be processed.
A reoccurring theme from the different strands and time points of the process evaluation was a misperception that the CICA brief advice component of the intervention was (or should be) a tertiary intervention, focused on people who had developed a dependence on alcohol. There was a tendency to assume that alcohol harm was something that happened to ‘others’. This came from the co-ordinators in some areas (some of whom recruited from the recovery community, who in turn were motivated to help those like them), the AHCs themselves and also from the community focus groups. This was in contrast to the original theory that brief advice might be most effective in the majority of drinkers as a secondary prevention intervention, that is those who were drinking at increasing or higher risk levels and were not alcohol dependent. Although direct observations to assess intervention fidelity were not possible due to the opportunistic nature of brief conversations, interview findings suggest that this shift may not have necessarily been intervention drift but instead, an innovative adaptation to fit the presenting needs of their community to aid access to community alcohol treatment services.128
Future iterations of a programme such as CICA would need to take into account this tendency to ‘other’ the issue of alcohol. Indeed, at the outset, we created a ‘dark logic model’ (see Appendix 5),1 which mapped potential unintended consequences. One of these was ‘opportunity harm: missed opportunities to reach at risk groups’. The tendency to focus away from those drinking at just above risky levels was an opportunity harm. These opportunity harms can also lead to direct harms, including potential time delays for at-risk populations. We also identified, a priori,1 that it was feasible that CICA could cause direct harm to those AHCs who were in recovery. While we had some evidence that a few champions were still managing their own alcohol recovery journeys, which caused them personal issues, there was no evidence that these issues were caused directly by participating in CICA.
Discussion of the economic analysis
The economic evaluation followed the quantitative data analysis findings which show no economic and social benefit of CICA on health (alcohol-related hospital admissions, A&E admissions, ambulance call-outs) and non-health outcomes (crimes and ASB).
So far, no economic evaluation has determined the value for money of a complex community-based intervention such as CICA adopting the same outcomes and methodological approach. The cost analysis shows that the main cost driver of CICA was the first-generation training. This is because it includes costs associated with the design and development of the training package (£17,136; 15% of the total costs), which would not be necessary in the case of scale-up of the intervention. In terms of benefits, our results indicate that CICA reduced the likelihood of ambulance calls. However, the intervention areas still presented an increase of 2% in ambulance calls which was smaller than the control areas, where a 10% increase was detected. All other outcomes had similar results in the intervention and control areas.
The current evidence from economic evaluations shows ambiguous results. Some studies have shown a good value for money of community-based interventions in reducing specific health and non-health outcomes; others have shown no significant impact. For example, a well-implemented community action programme targeting on-licensed premises in Stockholm reported a reduction in police-recorded violent crime, and violent crime permeated wider to neighbouring areas.129 The programme was cost-effective, saving €39 for every €1 invested, and demonstrated a large-scale roll-out, suggesting the intervention is highly feasible. Like CICA, this Stockholm intervention involved community mobilisation to raise awareness of alcohol harm in the community; however Responsible Beverage Service training was delivered to bar servers rather than training to empower community members. Unlike CICA, community mobilisation was supported by strengthened enforcement of alcohol laws, and the violence outcome was analysed through a survey among victims of violence.
A multisectoral economic evaluation130 analysed the value for money of delivering different intensities of a brief intervention by comparing a client information leaflet (CIL), with brief advice, and brief lifestyle counselling. This case study focused on the probation arm of the larger Screening and Intervention Programme for Sensible Drinking (SIPS) in England. The multisectoral economic evaluation was an extension of the ‘impact inventory’ developed by the Second Panel on Cost-Effectiveness in Health and Medicine131 and evaluated the interventions from the perspectives of health and criminal justice sectors. From the criminal justice perspective within the SIPS case study, brief lifestyle counselling reduced crime and costs to the criminal justice system compared to a CIL. In addition, brief lifestyle counselling resulted in a more significant reduction in avoided reconvictions and cost savings compared with a CIL. In the healthcare system sector, brief lifestyle counselling reduced quality-adjusted life-years losses to the victims and the associated healthcare costs. This is a comprehensive economic evaluation as it analysed the cost-effectiveness for two different sectors separately. The CICA economic evaluation also involved different sectors of society (e.g. health, justice, local authority). Still, the cost–benefit analysis and CCA do not provide the results disaggregated by sector. In CICA, AHCs were trained to provide CILs and brief advice, but not brief lifestyle counselling.
In contrast, a review of evidence on the effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol found that community-based interventions, such as mass-media awareness campaigns, are not expensive [implementation cost expressed in international dollars(I$) I$0.20–0.80 per year per person].132 However, these interventions do not significantly affect consumption levels or health outcomes. The studies mentioned above have important differences from CICA in terms of their methodological approach to economic evaluation, population and interventions. So, our results are not directly comparable to other studies.
Strengths of the study
The quantitative evaluation of the CICA programme has several strengths. The data set was relatively large and should have been able to detect relatively small impacts on any of the outcomes, if these exist. The researchers had some influence on the time point of when the intervention would be implemented in each of the areas; this was randomised by the researchers and broadly followed which is likely to have minimised bias of areas considered to be most ‘at risk’ being implemented first, for example. A particular strength of this evaluation was the parallel evaluation of the same intervention using four different evaluation designs and three different analytic methods, each with its own strengths and limitations. This methodological triangulation was one of the recommendations to improve natural experiment evaluations.60 We believe this approach guarded against incorrect inferences that would have likely occurred had we relied on only one of the evaluation designs or analytic methods.
The quantitative outcome evaluation was backed up by a robust process evaluation using mixed methods, which was able to glean significant insight into the barriers and facilitators to establishing an AHC intervention. Findings will also be useful to inform other asset-based community interventions. The process evaluation data were useful to describe the ‘dose’ of the intervention, from which we are able to conclude that the null findings from the outcomes evaluation may not be as a result of the intervention not working but rather that the dose may have been too dilute.
This study adopted a robust economic evaluation approach recommended by the GM local authority. Costs were collected by using a bottom-up approach and corrected by using the optimism bias which gives more accuracy to the cost estimates.
Limitations of the study
This evaluation also had several limitations. Unfortunately, we were not able to obtain all data for all comparisons, and, as a result, comparisons to national controls could not be done for ambulance call-outs and incidence of reported crimes. Although the researchers were able to influence the time when the implementation of the intervention started in each area, they had no influence on the selection of the intervention areas itself. These areas were selected by the respected councils based on considerations of alcohol-related harms to the area, and, as a result, this allocation of the intervention could not be considered as an as-if random process.60 This is likely to have impacted on the evaluations, and the observation that several of the impact estimates indicated an increase in harms on health and on crime instead of reductions suggest that some bias is likely to have been present despite the successful matching of the local and national control areas to the interventions using propensity scores. Although data sets were large, the number of events recorded per LSOA per month was small for some outcomes. Aggregation over time or over geography could have improved this but would have resulted in analyses that were less specific to the intervention areas and less accurate over time. Although we included both sensitivity analyses and exhaustive methodological triangulation, these were done on a data set on which the information was obtained from the same source (although these differed for each outcome) using the same data generation methodology. If there is some bias resulting from this, it would have been present in all of our analyses, and it is therefore recommended to (also) conduct triangulation of results using different data sets from different sources and using different data generation methods.61 This evaluation would have benefitted from such additional data, but unfortunately, we were not able to obtain these for this study.
Limitations of the process evaluation included under-recruitment to follow-up interviews with volunteers and focus groups that only representing two areas. Due to the low numbers of alcohol champions remaining engaged in the intervention, the sample size for follow-up was small. Furthermore, we were not able to get the direct views of those champions who had disengaged from the programme. While difficult to do, this could have generated useful information. However, local co-ordinators were well represented in the interviews, and as a result of their regular contact and supervision of champions, they were able to offer good insight into what the champions were experiencing and, for those who dropped out, reasons why they had disengaged.
There were further limitations to monitoring brief advice activity through direct observations because of the risk of Hawthorne effects; therefore, we were unable to assess the competency of AHCs and the fidelity of their conversations to behaviour change techniques. Nor was it possible to talk to any recipients of brief advice in the context of a brief, opportunistic conversation. Diaries were developed in response to this and were used by AHCs across seven areas. Furthermore, the philosophy behind the CICA intervention (asset-based community development) aimed to give champions the skills, confidence and support to utilise them as they saw fit within their community. While some local co-ordinators attempted to count the number of conversations and events each quarter, commissioners did not impose or expect a specified amount of activity from each champion. Since this process activity data were not collected consistently across areas, it was not possible to correlate process activity with the primary outcome data.
Economic evaluation of complex public health interventions may require broader methodological approaches to capture health and non-health costs and benefits and direct and indirect impacts of the interventions. A multisectoral economic evaluation approach would be valuable to determine the value for money of CICA-like interventions from different stakeholders and sectors in the society.
Equality, diversity and inclusion
Participant representation
In terms of protected characteristics,133 we used pre-training questionnaires to capture demographic data. Representation from ethnic minority groups was as follows: 3.2% identified as Asian/Asian British, and 4.3% identified as black/African/Caribbean/Black British. However, no response was provided to the ethnicity monitoring question by 22.6% of participants (n = 21), despite other demographic details being completed within the same form. Maximising participation of ethnic minority communities in research needs to start at the application stage134 and include ethnic minority PPI representation.
A wide age range of participants aged between 18 and 65+ attended (48% aged between 41 and 60). Slightly more women became AHCs compared to men (61%), though representation from transgender communities was unknown. Sexual orientation was not monitored, making the proportion of heterosexual/straight, gay or lesbian, and bisexual participants unknown. We reflected on the gaps in our demographic data collection and the importance of designing research instruments that follow best practices in relation to sexual orientation and trans monitoring.135
In terms of resources used within the intervention to gain the RSPH Level 2 qualification, participants were required to complete candidate workbooks. It became apparent at the start of the first roll-out training event that participants experienced the learning material as very intense over the 2 days, and writing answers in workbooks was challenging for some who had been out of education or work for some time. The RSPH trainer (at first-generation training events) and local co-ordinators (at cascade training) addressed this by providing reasonable adjustments and support for candidates who expressed concerns about reading and writing, especially at a fast pace. Our pre-training questionnaires indicated that educational qualifications varied, with 9.7% reporting having no qualifications and nearly half (49.5%) having either GCSE/NVQ Level 2 (national qualifications typically taken at age 16) or A Level/NVQ Level 3 qualifications.
Communities in Charge of Alcohol interventions were targeted in communities whose common interest was a shared geographical area where they lived or worked. All areas had high levels of deprivation. While alcohol harm is experienced by all sections of society, research has identified an alcohol-harm paradox whereby people of low socioeconomic status experience greater harm than those of high socioeconomic status, despite drinking the same amount of alcohol or less.12 Since CICA recruited people directly from communities at a LSOA level, we believe its ABCD design helped ensure that participants, albeit lower than expected numbers, were representative of socioeconomic inclusion groups.
Public involvement in Communities in Charge of Alcohol
Aim of public involvement in the Communities in Charge of Alcohol study
Our strategy for PPI was to actively involve public representatives in all stages of our research, from design to data collection, interpretation and pathways to impact. The GRIPP2 short form has been used here to describe our PPI activities as a tool to improve the quality, transparency and consistency of the international PPI evidence base.136
The ‘public’ was defined as anyone directly or indirectly affected by alcohol use, its sale or its supply or another person’s drinking. Experts by experience (Alcohol Concern, 2017) included the public, service providers, service users, commissioners and licensing officers/RAs working within or representing the communities chosen as intervention case areas.
Methods used for public involvement
In the design and application stage of CICA, Principal Investigator (PAC) and Co-Investigator (EJB) carried out consultation meetings with public representatives from established community networks. A handout was created with a user-friendly project outline of the logic model. A lay representative, coinvestigator SH, was recruited from one of these community networks to be a co-applicant on the grant application and to represent the study team via membership in the SSC.
The CICA intervention had already been in the design stage at the time of the NIHR grant application. This was outside the influence of the research team. A steering group and ‘local leads’ meetings had been convened by Public Health England, attended by representatives from all 10 GM local authorities. Meetings were co-ordinated by staff from Public Health England who had responsibilities for health and well-being programme management in the North West of England. Face-to-face and teleconference meetings provided a forum for commissioners, service providers and practitioners to exchange ideas about the design of the research and particularly the process evaluation methods of CICA.
During the data collection phases of the study, our public representative (SH) directly participated in aspects of the process evaluation with the process evaluation (University of Salford) team. As a coinvestigator, SH attended monthly investigator meetings between 2017 and 2022 as well as SSC meetings between 2017 and 2021. SH cowrote the PPI sections of the NIHR Progress Reports.
In our pathway to impact plans, we directly recruited and involved AHCs, local co-ordinators and SH to contribute to the co-design of impact activity, the production of creative products and engagement events. A number of methods were used to invite experts with CICA experience to get involved, including storyboard consultation workshops, filming and speaking at engagement events.
Results of public involvement
The positive and negative outcomes of PPI in the study are reported around three key areas of activity: design and application feedback, data collection and pathways to impact.
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.
Discussion and conclusions
Overall, PPI involvement had a number of positive effects at different stages of the CICA study. Our public involvement approach was effective in actively engaging public representatives in all stages of our research, from design to data collection, interpretation and pathways to impact. Attrition of volunteers meant that the perspectives of AHCs who contributed to PPI activities were likely to be biased towards those who had been active and invested in CICA.
Reflections/critical perspective of public involvement
A major tenet of community-centred approaches to health and well-being is the use of participatory methods to address and reduce inequalities in power.40 Members of the public were not actively involved from the outset in the decisions about CICA, so they did not have a say in developing options and deciding together which communities might want to be ‘in charge of alcohol’ in their area. This was outside of researcher control, since the intervention had already been conceived by GM stakeholders and was well into the design process at the outset of this study. Since a CICA ‘community’ was predetermined as a small geographic unit of population, the study assumed people had a ‘shared stake’ in it as a place where they lived or worked, but this was not explored. The geographically imposed boundaries of CICA meant that it was also unknown to what extent communities of interest or identity may have wanted to get involved.
We reflected on differing levels of power sharing within community-centred approaches, opportunities for the public to define their own ‘community’ unit of population in PHR and identifying their own outcomes of interest. With true asset-based approaches, the community works together with the researcher to define the health issues and co-design the intervention. The intervention and the outcomes are not known from the outset. This makes it more difficult to specify the intervention (and therefore the evaluation methods) when applying for research funding. Such applications, which are short on detail on the intervention and the evaluation methods, are less attractive/higher risk for funders if priority is given to ‘robust’ quantitative designs with clearly specified interventions, logic models and evaluation methods.
There is a need to understand the differences between engaging members of the public to take part in a community-based research process compared to patients coming through the door of a clinical setting. Additionally, there is a need to explore the barriers and facilitators to encouraging members of the public from deprived communities to take part.