Process evaluation results

Parts of this chapter have been reproduced with permission from earlier papers on the process evaluation.41–44 These are articles published under a Creative Commons Attribution-Non-Commercial-NoDerivatives (CC BY-NC-ND 4.0), and any extracts have been reproduced exactly. See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

The CICA process evaluation explored the context, implementation and response to the CICA intervention at distinct phases, recognising that complex health interventions roll out in identifiable phases or stages.107,108 As such, the results are organised according to phases: the pre-implementation phase (2–3 months prior to roll-out); the initial implementation phase (within 3–6 months of training); the intervention phase (12-month period of AHC activity from the first month following the initial Train-the-Trainer event) and the follow-up phase (post intervention, at 12 months and beyond).

The initial conception, design and project management of the CICA intervention had commenced in GM prior to the commissioning brief in 2016 and NIHR evaluation award in 2017; therefore it was outside of the scope of the process evaluation. However, time and costs spent on conception, design and project management prior to the pre-implementation phase of CICA were captured within the scope of the economic evaluation (see Chapter 6).

This process evaluation chapter starts with findings from the pre-implementation phase of CICA, during which time all 10 local authorities participated in preparatory roll-out meetings, and document analysis provided insight into each area’s local licensing policy context and infrastructure a priori. While only 9 of the 10 areas progressed to the initial implementation phase, a total of 23 stakeholders participated in baseline interviews, representing all 10 original areas. One hundred and twenty-three people subsequently attended CICA training, and of these ninety-five were volunteers, recruited as intended, living or working in the targeted communities. Training evaluation questionnaire data were collected from 98% of the lay volunteer sample population, representing all nine areas. Cascade training observations took place in five areas. Follow-up interviews were completed with 12 volunteers in 4 areas. After 12 months, seven out of nine areas remained active, with two local authorities withdrawing after 6 and 9 months. Follow-up interviews with 11 stakeholders were carried out in 8 of these areas. To conclude the process evaluation, 26 members of the public from 2 areas attended focus groups.

Pre-implementation phase

Licensing policy context

This document analysis aimed to provide a policy context to each area’s alcohol risk environment, the local authority’s vision for alcohol licensing decisions, and the framework within which volunteers would be working. Statements of Licensing Policy published by each of the 10 local authority areas were examined a priori using 10 items: 7 predetermined categories based on existing research from Scotland86 (marked with *) and three additional items to reflect alcohol licensing practice in England and Wales (item 8) and licensing activity expected of AHCs (items 9–10).

1. presentation and readability*
2. use of evidence*
3. process of consultation*
4. licensed hours for alcohol sales*
5. density/cumulative impact (referred to as ‘overprovision’ in Scotland)*
6. operating conditions, including children’s access*
7. temporary event notices (referred to as ‘occasional licences’ in Scotland)*
8. regard for health (in the absence of 5th licensing objective in England and Wales)
9. community recognition
10. information on how the public can get involved in licensing processes.

Background

None of the Statements of Licensing Policy included in the document review were due for renewal during the CICA intervention period; therefore, the policy context of licensing practice was already established and remained stable throughout each area’s CICA intervention period. Statements of Licensing Policy (referred to as ‘licensing policy’ from here onwards) in England and Wales must be renewed by local licensing authorities every 5 years;83 the anticipated renewal dates in each area ranged from January 2020 to May 2021. All licensing policies were published on the local authority website in either a PDF or Word document that could be downloaded.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Preparatory roll-out meetings

All 10 local authorities participated in preparatory roll-out meetings. Analysis of roll-out meeting documentation revealed 12 categories of external contextual factors discussed by stakeholders a priori. These ranged from factors related to identifying a suitable individual or organisation to lead the intervention to the existence of wider political support (see Table 11).

The number of external contextual factors documented a priori in each intervention area was counted to create an ‘infrastructure score’. From the 12 categories of external contextual factors identified, the maximum possible total baseline ‘CICA infrastructure’ score was 12. Actual scores ranged from 0 (in the area that did not roll out the intervention) to 10 (in three areas), showing the variability in infrastructure in place prior to roll-out (see Table 12).

Initial implementation phase

This comprises analysis of AHC pre- and post-training questionnaires and interviews with AHCs and stakeholders.

In total, 123 participants trained to become AHCs in the nine areas that rolled out CICA: 77% (n = 95) identified as lay people living or working within the community, and 23% attended in their capacity as paid professionals (n = 28). A professional was defined as a person in paid employment with existing specialised knowledge of alcohol, substance misuse and/or public health practice who attended the training as part of their responsibilities for the CICA intervention area. The training clearly reached lay volunteers from within the community, as intended. The number of professionals trained was an indication of the need to build training capacity beyond just one local co-ordinator per area. Of the nine areas, seven completed the full 12-month intervention period, delivering at least one cascade training event.

Training registers

The data collection period for registers was 12 months per area, but due to the staggered roll-out of CICA, register dates spanned a total of 20 months (September 2017 and April 2019). Training register data is differentiated between Train-the-Trainer event attendance (first-generation AHCs) and cascade training attendance (second-generation AHCs). Five Train-the-Trainer events took place, delivered centrally by the RSPH, during which AHCs from each of nine participating areas were trained. Communities in Charge of Alcohol co-ordinators recruited 48 first-generation lay AHCs. A total of 28 professionals were trained to become AHCs at the same time, including local CICA co-ordinators themselves.

At cascade training, 11 events were delivered by the CICA co-ordinators in seven areas. The mean number of months between the initial Train-the-Trainer event and the first cascade training event was 6.9 months, with the shortest gap of only 2 months and the longest 12 months, highlighting wide variation in the number of months it took each area to deliver their first cascade training event and issues experienced gaining momentum. The timeline of cascade training events following the initial Train-the-Trainer event, along with total AHCs trained, is shown in Table 13.

While seven out of the nine areas held one cascade training event in the first 12 months, only two areas cascaded more than once (a total of 11 cascade events). A further 47 community members were recruited to become second-generation AHCs at cascade events, with a small number of (three) professional participants in attendance. In a sample of five of the seven areas, we carried out a structured observation of the cascade training (n = 5 fidelity forms completed).

Alcohol health champion questionnaire data

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. (Figure not reproduced here; see the original article.)

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).

Interviews with stakeholders

Eight themes (see Table 16) report the barriers and facilitators experienced by policy and practitioner stakeholders within the initial implementation phase of CICA. These reflect factors that impacted on the setting up of the AHC role (Themes 1–4) and external factors impacting on the wider implementation of the intervention (Themes 5–8).

Factors impacting on setting up the alcohol health champion role

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.

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.

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.

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 …

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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’.

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.

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.

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).

Wider external factors impacting on implementation (stakeholder analysis)

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.

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.

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?

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.

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.

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].

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.

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.

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.

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.

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.

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.

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’.

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.

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.

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.

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.

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.

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. (Figure not reproduced here; see the original article.)

Theme 1: perceptions of alcohol health champion training

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.

… 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.

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.

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.

Theme 2: applying knowledge and skills in the alcohol health champion role

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.

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.

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.

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.

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 …

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.

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.

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.

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

Theme 3: facilitators and barriers to undertaking the alcohol health champion role

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.

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.

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.

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.

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.

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 …

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

Theme 4: sustaining the alcohol health champion role

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.

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.

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.

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’.

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

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.

Intervention phase

Monitoring of activity

Self-reported data on the provision of brief advice were collected through local co-ordinators and reflective diaries kept by AHCs. Five out of nine CICA co-ordinators kept a tally of AHC activity during the 12-month intervention period as follows:

• 1148 conversations counted
• 251 AUDIT-Cs completed
• 65 community events attended.

The largest tally of conversations was counted and recorded by the co-ordinator in Area 1 (n = 499, 14 lay volunteers), followed by Area 9 (n = 306, 13 lay volunteers), Area 6 (n = 168, 8 lay volunteers) and Area 8 (n = 167, 17 lay volunteers). Community events attended by AHCs mirrored a similar pattern, with Area 1 most active (n = 30), followed by Area 9 (n = 23). The CICA co-ordinator in Area 1 additionally kept a time/cost diary of recorded AHC activity which indicated that AHCs spent on average 11 minutes having an informal, brief advice conversation. Further data from reflective diaries (see Table 18) showed a variety of activities and actions that had taken place (elaborated in textual comments in Appendix 4).

Four case studies highlight different ways in which AHCs were empowered to take forward other types of licensing action. The first case study demonstrated new community connections made between AHCs and the neighbourhood policing team, whereby they jointly hosted an information stall in the local library to promote reporting of licensing issues directly to the police. The second case study involved brief advice being offered to the owner of a local off-licence who disclosed concerns about their alcohol use. This led to AUDIT-C scratchcards being made available to customers to take away to raise awareness of alcohol units at point-of-sale. In terms of informal licensing action, the third case study involved an AHC noticing antisocial, noisy behaviour outside a local pub. Their knowledge of the Licensing Act 2003 and the licensing objectives gave them confidence to have an informal conversation with the manager, giving the manager the opportunity to improve the operating practices. The final case study demonstrated formal licensing action being taken against an off-licence that had their premises licence suspended. The AHC and local co-ordinator contacted their local licensing officer to report illegal sales, enabling enforcement action to take place. The premises was located outside of the boundary of their CICA area and demonstrated the potential for licensing action as interested parties to reduce harm in the wider neighbourhood.

To monitor the fidelity of cascade training to the Train-the-Trainer model provided by the RSPH and any local tailoring of the training, five observations were recorded by the research team. The five areas observed were: Area 2, Area 6, Area 8, Area 9 and Area 10. Local CICA co-ordinators facilitated the training and were all registered RSPH trainers.

During the cascade training, we observed some tailoring of the original protocol and materials. Firstly, the number of presentation slides was reduced. This was in response to initial feedback highlighting the Train-the-Trainer content had felt too intense. The pacing of the training also differed at cascade events. For example, RSPH workbooks were completed on day one in four areas as per the Train-the-Trainer model, but one area staggered the training delivery and completion of the workbook over 2 days. Overall, the standardised requirements of the RSPH Level 2 ‘Understanding Alcohol Misuse’ qualification workbook directed the cascade training, and this promoted fidelity in delivery.

All observations explained behaviour change using the Transtheoretical Model,116 defining stages of change and Prochaska and DiClemente’s principles of stage-matched interventions. No tailoring was made to introduce more recent behaviour change models such as the COM-B (Capability, Opportunity, Motivation) system.117 However, some variation was noted in the extent to which cascade training provided more attention to skill development. For example, Area 10 providing a bespoke section on ‘How to start a conversation’ as they had felt such a skill was fundamental to the AHC brief advice role, and Area 8 allocated more time to practise role-playing brief advice conversations in comparison to the Train-the-Trainer event.

The other main area of variation noted was in the delivery of the licensing action training on day 2. The coverage of what counts as evidence and exploring ‘good’ and ‘bad’ examples of representations, as per the original model, was omitted in all five cascade events observed. In the original model, the local licensing officer was invited to cofacilitate the licensing action training section; this occurred in only three out of five areas. In the other two areas, the local co-ordinator delivered the licensing section of the training alone. Since the licensing training was not within the scope of RSPH Level 2 qualification, there was no workbook assessment to prioritise or standardise delivery.

Follow-up phase

Associations between external contextual factors and total alcohol health champions trained

At follow-up, we assessed whether the baseline infrastructure score calculated in the pre-implementation phase was related to the number of alcohol champions trained over the 12-month intervention (see Table 19). At follow-up interview, CICA co-ordinators from 7 out of 10 areas reviewed these initial findings. Six interviews took place during the 12-month follow-up period and one after 9 months when the area withdrew from the project earlier than planned. In six areas, no amendments were made, and in one area, one item was amended following further clarification.

The number of lay people trained varied from 0 in Area 5 to 17 in Areas 2 and 8. Although Area 5 had participated in the preparation meetings in the pre-implementation phase, they did not roll out due to the lack of infrastructure in place. A positive correlation (using non-parametric Spearman’s rank correlation coefficient) was found between an area’s total infrastructure score and the total number of lay AHCs trained in the first year (see Table 19, r_s = 0.77, p = 0.01).

The numbers of lay AHCs trained in areas with a specific contextual factor were compared to areas without the factor using Mann–Whitney U-tests (see Table 20). From this, four external contextual factors were found to have higher numbers of lay people trained. Those having a healthcare provider in place at the outset to co-ordinate the intervention (p = 0.02); a contract in place with a commissioned service (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); and formal volunteer arrangements (p = 0.03) trained more AHCs.

Follow-up interviews with stakeholders

Key stakeholders considered factors that influenced the operationalisation and sustainability of CICA, and five themes were initially identified: (1) limited alignment with strategic, political and policy context; (2) navigating intervention assumptions; (3) ability to leverage partnerships; (4) developing new community assets; and (5) practices to facilitate the sustainability of CICA. The strategic context and leveraging partnerships focus on localised issues and will not be explored here. Rather, in these findings, three themes will be explored which are of most interest to a wider audience. Table 21 presents an overview of the themes/subthemes to be discussed.

Theme 1: navigating intervention assumptions

This theme focuses on the extent to which assumptions underpinning the interventions facilitated the operationalisation of CICA and co-ordinators’ responses to barriers experienced.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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?

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.

Theme 2: developing new community assets

This theme focuses on characteristics associated with individuals’ core to the success of CICA, including motivation, skills, confidence, capacity and capability.

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.

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.

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.

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.

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’.

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.

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.

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.

‘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.

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.

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.

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.

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.

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.

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.

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.

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.

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. […].

Theme 3: identifying practices to facilitate the sustainability of Communities in Charge of Alcohol

This theme explores practices that facilitated, or were anticipated that they would facilitate, the sustainment of CICA.

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 …

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.

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.

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.

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.

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.

‘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.

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.

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.

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?’

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.

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.

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.

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.

Licensing officer engagement

Licensing officers, delegated as lead officers for the CICA programme for their local area (henceforth referred to as ‘licensing leads’), had been expected to attend and cofacilitate the licensing half-day at both Train-the-Trainer training and cascade training. Table 22 provides an overview of the licensing context by local authority, number of AHCs trained and licensing officer engagement.

Our logic model (see Appendix 1) anticipated that following alcohol licensing training, community involvement in licensing activities would be measurable using indicators including the number of licences challenged, licence reviews requested, representations made, investigations initiated and issues reported to local licensing authorities. These would act as a proxy for community engagement. Semistructured one-to-one interviews were carried out. Routinely collected data relating to alcohol harm and descriptive statistics of licensing applications were reviewed to understand context.

Five LA licensing units provided data relating to the electoral ward where the target CICA LSOAs were located in 2020 (see Table 23). Wards were chosen as the geography because LSOA-level licensing data were not easily available; typically, there are three or four LSOAs in a ward. Four authorities cited lack of staff capacity for non-provision of data.

Data on the number of premises licence applications, reviews and representations processed within 12 months prior and 12 months during the CICA intervention were incomplete. Four areas provided data which, to our knowledge, was complete. One further area provided a full set of data but did not clarify which year one licensing application pertained to. Four authorities did not provide data due to COVID-19-related capacity issues. Data were at a larger geography (ward level) but nevertheless showed that activity had been limited, even in the areas with more licensed premises (see Table 22). Alcohol-related hospital admissions varied from 572 to 1359/100,000,121 and rates of major offences ranged from 1545 to 14,477/100,000. Data at such a geographic granularity can be used to support scene setting when making representations at licensing hearings or for more strategic considerations, such as cumulative impact policies.52

Despite a persistent context of alcohol-related harm, Table 23 suggests that while all areas reported receiving new premises licence applications during the intervention period, only one area (Area 8) recorded receiving any representations to raise concerns. Representations against new applications did increase in Area 8 during the 12-month intervention period, though the licensing lead reported that these were made by LA councillors (elected representatives) rather than community members or public health teams acting as a RA. Four areas recorded applications received for ‘full variations’ to an existing premises licence during the intervention period. A full variation is an application to significantly change a premises licence that could impact on the licensing objectives (e.g. to extend opening hours). However, only two areas (Areas 6 and 8) recorded any representations. Information provided by the Area 6 licensing lead indicated three representations were received objecting to one full variation, with one of these representations made by a resident. It is not known whether this resident was influenced by CICA/AHCs’ work. In Area 10, the number of applications for a full variation increased from 1 to 13 during the intervention period, with no concerns or objections raised.

Licensing policy context at follow-up

Due to the burden on licensing authorities that arose from March 2020 as a result of the COVID-19 pandemic,122 all nine licensing authorities had to delay the full review and renewal of their licensing policy statements. As of September 2022, five were fully reviewed and renewed; two had an interim review while awaiting a full review and consultation; and two were awaiting review (no interim or full review to date). The earliest review and renewal (full review or interim review) were published in December 2020 and the most recent in May 2022.

Before determining the licensing policy, it is a statutory requirement83 of licensing authorities to consult all RAs, including the Director for Public Health. However, it is not a statutory requirement to consult interested parties, such as residents/local community members. In our logic model, training AHCs to engage in the licensing process may have led to involvement in the consultation process if given the opportunity.

Subject to the statutory requirements, it is for each licensing authority to determine the extent of the consultation it should undertake, and whether any particular person or body is representative of the groups described in the 2003 Act. While it is clearly good practice to consult widely, this may not always be necessary or appropriate.

Section 5 of the Licensing Act 2003

It was unknown the extent of the consultations undertaken with ‘interested parties’ in the five areas that had fully reviewed and renewed their licensing policies; details of consultees other than RAs were not provided as identified in the document review at baseline. However, a keyword search for ‘champion’, ‘communities in charge of alcohol’ or CICA yielded one positive result. In their renewed 5-year policy statement, Area 8 recognised the ambition of CICA and the role of AHCs under the section ‘Partnership Working and Enforcement’, stating: ‘Champions learn about alcohol misuse and how to talk to friends and family about alcohol and how to seek support if needed, as well as learning about the licensing process and how they can help if local on and off licensed premises are causing any community concerns’.

Interviews with licensing officers

Three overarching themes were identified regarding barriers and facilitators to operationalising and sustaining CICA specific to community-based activity around licensing activity. Themes, definitions of themes and subthemes are provided in Table 24. Participants have been anonymised. As such, participant numbers do not relate to area numbers identified in Table 22.

Theme 1: extent of alignment with statutory requirements and political context

Fit with statutory requirements

The interviews highlighted challenges for communities and RAs in addressing alcohol harm through the existing legal framework if local alcohol harm issues did not directly align with one of the four licensing objectives. Licensing leads highlighted how their practice is guided by statutory requirements which do not include taking a (public) health perspective in England and Wales:

we have a statutory obligation to grant licences to premises or licence holders that have met all the criteria that is set out by the legislation. There are mechanisms that if a premises is not doing what they are supposed to do and promoting the licensing objectives, then those people can be called to task. So, the pathway side of it and the health side of it really for me isn’t our avenue.

Indeed, the impact of alcohol harm at a local level was reported by one licensing lead as something they were largely uninformed about:

I am not involved with the, for instance, the public health people, I don’t see the data on alcohol abuse in certain areas, or anything like that, I wouldn’t be able to comment on the impact locally, but I am sure there is an impact.

While LA public health teams operate as RAs and have the opportunity to comment on licensing applications, Participant 8 indicated that comments were ‘very few and far between’:

Although licensing legislation in Scotland does have public health licensing objective, in England and Wales, it doesn’t. Albeit the public health is what we call a responsible authority and can make comments on licence applications, they are very few and far between.

One licensing lead described how support had been sought by the public health team to understand how they could make effective licensing representations using health data. Advice was provided about relating the objection to the ‘public safety’ licensing objective:

So the sort of thing I discuss with the colleagues from public health is, where you have an area where you’ve got a, sort of, there is public health evidence of high deprivation or wholesale alcohol abuse or something of that nature, if they have that data and those statistics, a relevant representation may be that they will say well, look, … the admissions data for this particular area of [name of LA]- the hospital – these are the number who were treated for alcohol issues or here is this piece of data or that piece of data. And essentially their argument – the last thing that this area needs now is another place selling alcohol or an existing off-licence that is deciding it’s going to open until two o clock in the morning, for example. And their argument would be, well, on the basis of public health and public safety, this shouldn’t be allowed.

Extent of ‘political’ support

None of the licensing leads made any reference to CICA having wider backing from public officials or locally elected council members in their LAs, suggesting alcohol harm was not a political priority at the time. Only one licensing lead highlighted being supported by their line manager regarding their involvement in delivering training to the AHCs:

My Head of Service has been supportive of doing it and allowed me to have the time to go and do the presentations and so on. (Participant 8)

One licensing lead noted that by attending the training of AHCs and gaining greater insight into the ambitions of CICA, their own support for the programme grew:

after I’d been to it my view did change about … because I knew a little bit more about what the aim of it was. So, my view did change, and I thought it was a good idea what was going on.

However, while understanding the ambitions of CICA and the value of developing a community place-based approach, Participant 10 did not view implementing CICA as something for which they had responsibility or ownership. Although not explored or reported explicitly, this may have been a barrier to proactively engaging with AHCs in their area:

I guess I came on board to offer the licensing experience and support, as opposed to … I don’t know, I guess have like ownership or sort of I’m not sure if sort of responsibility, it’s the right word but …You know, if it was my project as it were I wouldn’t have considered it that.

Theme 2: operational concerns and approaches

Funding and capacity to provide ongoing support to alcohol health champions

Despite the national recommendation to encourage greater community involvement in licensing, licensing leads identified how limited funding impacted on their ability, and the ability of wider licensing teams, to engage with the community, including through rolling out CICA:

this is a very commendable project, it’s something that I think that most, if not all of them [licensing managers], want to be involved in, want to try and support, but in practical terms, the levels of support they could give it would be limited, because of the pressures on their licensing teams across the region.

With licensing leads having to absorb their involvement in CICA into their existing workload, two participants identified issues around how ‘capacity’ would impact ongoing ‘commitment and motivation’ and the sustainability of CICA:

I guess it’s getting like a lot of things, it relies on sort of the capacity and I guess commitment and motivation and sort of … I suppose one of the challenges is keeping that up.

Despite legislative guidelines recommending community involvement, Participant 3 indicated that a renegotiation of time related to CICA would be required, suggesting an ongoing challenge of committing capacity to establish, foster and develop community-based relationships:

time is of the essence unfortunately, especially now we’re cut to the quick because I was going to say that to you. If you’re running any more [cascade training courses] I would then have to … we’ve got a new different management structure, I’d have to run it past our management to make sure it was okay that I attended and stuff like that.

Identifying and harnessing useful assets

Given the role AHCs were anticipated to play in licensing activity and the opportunities for licensing leads to cofacilitate AHC training, it was notable across all interviews that discussion about licensing leads engaging with the AHCs themselves over the 12-month intervention period was limited. Interestingly, of the six licensing leads interviewed, two (Areas 6 and 10) reported not being involved in cascade training in their area, despite second-generation training taking place, suggesting that community-based engagement in alcohol licensing activity was not a priority at this time. One licensing lead did reflect on their likelihood to engage further with AHCs. Their perception was that this was more probable if AHCs were proactively bringing issues to the attention of the licensing leads/unit/department; that the lever for engagement was a level of activity and insight at local levels which actively sought out licensing engagement rather than a licensing lead proactively engaging with AHCs around intelligence gathering:

I suppose the key to it is the proactivity and I suppose the areas that there is more engagement, there is maybe a higher degree of proactivity from the person, from the residents, is to ‘look, we have these issues, how can you help us?’ I suppose there is the tendency to think, oh if you don’t hear anything everything’s fine you know and take that approach.

Only one of the licensing leads identified the cohort of trained AHCs as an asset with whom they were working on an ongoing basis to have wider conversations in the community about alcohol harm:

getting feedback from the community in what’s called the [name of LA] ‘Let’s Talk About Alcohol’ campaign and some of the CICA volunteers are involved in coming to those sessions.

This licensing lead identified a need for the LA to harness AHCs’ interest; engage them in relevant alcohol harm reduction activities; and consider ways to retain engagement over the longer term, although it is notable that the activities discussed do not directly relate to licensing decision-making:

perhaps involving them in those projects [the ‘Reducing the Strength’ and ‘Challenge 25’ campaigns] and (…) like keeping them involved, like I said we wouldn’t want them to just attend that training session, hear that information and then be completely detached from, from it. And in terms of scoping that role, like I say it’s just when we do go and, or if public health or whoever it may be, have events on or whatever, they’re involved and brought to them really just so, so they can be part of it and keep their interest, engaged, keep them engaged […]. Because they’re engaged initially at the training session and you wanna keep that engagement ongoing rather than just for that one time, then that’s the key isn’t it?

It was mooted that to gain more impact from AHCs as formal assets, the communities within which they were situated needed to become more aware of the AHCs presence and role:

Making the wider public at large aware of it, so that they know how they could get involved in it and just promoting the fact that there are these volunteers who are in the community, who’ve been trained who have an awareness of how they can get involved and just the promotion of it really.

Involvement in CICA had made some licensing leads reflect on the wider presence of volunteer-led community assets. In one area, where CICA had been less successful at becoming established, the licensing lead reflected on environmental volunteer groups working at a community level but was less aware of sustainable volunteer-based projects focused on ‘social’ outcomes, such as alcohol harm:

we have ‘Friends of Parks’ groups for instance in [name of LA] … I think the approach for the environmental stuff, that’s quite a common thing. Social stuff, I don’t know.

Another licensing lead reflected on the challenges of accessing communities on an ongoing basis due to limited resources. They suggested professionals already working at community level, such as community police officers, could become useful AHCs. This suggests that at 12 months, some licensing leads were still reflecting on how to continue capacity building and develop assets at a local level.

Meaningful training provision

Four licensing leads suggested the licensing element of the training course could be amended to make it more meaningful and appropriate for AHCs as it was ‘a little bit too in-depth’ (Participant 4). Suggestions were made regarding the key licensing elements that needed to be delivered in the training:

Effectively somebody who’s getting involved in a licensing application needs to be aware of the licensing objectives and they need to be aware of the timescale and they need to be aware of the point of contact of where they can make the applications and those are the key elements of it really.

Another licensing lead stated that AHCs only needed to know ‘the basics’:

I think laymen only need to know basics. So, it doesn’t have to be any in depth about this is how licensing works and, you know, maybe about all the law and everything else. They need to know the basics and, you know, people put in application, they put a blue notice up, it’s in the paper. You can then do this at this point.

Licensing leads found that by changing the licensing input at the cascade stage, they felt they gained more ‘buy-in’ from AHCs:

[the training input] being at a higher level wasn’t really suitable or relevant and when it was pitched at the right level, that, that helped with their buy-in.

One licensing lead felt the licensing aspect of the CICA intervention would benefit if AHCs were involved in additional activities to help extend their involvement in licensing beyond the training session:

rather than maybe just having a training session, it’s like right, go away and you know do stuff, or you know … as a variation … you may be, you know, I guess, an ongoing programme.

While licensing leads suggested the licensing content of the course was overly complicated and could be amended to be more appropriate, two officers suggested that getting engaged in licensing issues at a community level was straightforward. One lead stressed that AHCs were ‘told of how simple it can be to get involved’ (Participant 4). A second lead expanded by outlining the approach AHCs and community members should take:

I mean what we do is, every council has to, list the applications – current applications in consultation, on the website. And I guess what we do is we have a link if somebody wants to comment and some guidance notes around submitting the comments and trying to do so effectively. And we include in our policy separate advice on that. So, there’s a section on doing that. And if people are reluctant, how they … I suppose alternative measures for having those concerns raised. So, we do have information that we publicise and have available on how people can engage and do so effectively, and then also equally raise concerns. It’s things like that you can pretty easily do through the website.

Licensing leads therefore felt that processes existed to support community engagement, and this could be achieved ‘pretty easily’. However, licensing leads’ testimonies raised a range of broader factors that may have impacted on the AHCs’ ability to engage in licensing issues within the 12-month period of the CICA intervention.

Theme 3: raising licensing issues

Significant differences existed between the LAs in the number of licensed premises situated within the CICA LSOAs (see Table 22: range: 0–59). Logically, this would suggest some communities had greater opportunity to become involved in the licensing process than others. However, despite this, there were no differences in the perceived level of involvement of AHCs in contesting licensing applications by making representations across LA areas. This was despite the fact that the AHCs had appeared very engaged with the licensing aspect of the training:

I feel like my experience of the volunteers had been that they were all very engaged, certainly with the training and with the scheme. It’s actually from a licensing perspective, getting them to get involved was probably the, the right way of saying that. It’s been … I don’t feel like they’ve been involved as much as we could, as they could have been and as I would have liked, from the start, from the start of the scheme and initiative.

Licensing leads highlighted a range of structural barriers they perceived as impacting community members’ ability to influence licensing decision-making:

Traditional low levels of community involvement

Area 9’s licensing officer stated they received only one community representation during the 12-month intervention period (from a non-CICA area), indicating community engagement in licensing operating from a low base. When discussing community engagement in licensing more generally, a different licensing lead felt public ‘apathy’ was a barrier:

I just feel that there can be a kind of apathy from the public not to get involved in the applications and that it’s just the same in one, from one area to another area. An area where you’ve got particular alcohol problems, density of premises just as much as you would have an area where you’ve not got those issues.

Licensing leads suggested multiple barriers impacted on community members’ willingness to make representations, although these perceptions did not appear to be informed by direct conversations with AHCs. Perceived barriers included the ‘potential for conflict’; lack of anonymity; potential need to attend a Licensing Committee ‘hearing’; and concerns about whether their involvement would have an ‘impact’ on the outcome:

I think they can possibly get deterred from … there’s a range of things. There’s the potential for conflict. The … I suppose they could go to a hearing. There might be some doubts as to how realistic an effect or impact they can have.

Involvement in one particular licensing issue was facilitated by a licensing lead’s personal reassurance to a community member, but there was no suggestion that this involvement was related to one of the CICA areas:

sometimes it comes down to the fear of repercussions, sometimes they feel like they don’t want to get involved because they might have a viewpoint but they don’t want to get involved but I thought it was my job really to reassure them and particularly one of the complainants who changed her mind initially said that she wanted to withhold all her details and obviously so that (pause) only so much weight can be given to that representation if it’s anonymous and everything’s taken out of it if they don’t attend the hearing.

This indicates a potential conflict for community members between wishing to retain their anonymity set against a perception that anonymised community representations limit influence with licensing committees.

Ability to identify alcohol health champion involvement in licensing activity

One of the challenges identified by a number of licensing leads was whether they would be able to know if AHCs were becoming involved in informal licensing activities, for example, informing others about the Licensing Act 2003 or wider education of local community members about licensing. They acknowledged that AHCs could be using their training to inform wider community members of which they would be unaware:

So personally, I couldn’t really say to you, Oh yeah, I know that happened because it was one of the champions. But that doesn’t mean that that hasn’t happened and it’s just word of mouth and it has been one of the champions who said, Well, try that or do this or go to licensing, ask them the question.

I have not had the ‘phone calls in terms of it’s from a CICA project, but if individual X that lives on [Name of street], whatever, has been to the champion and said, all this information is available on the website, I wouldn’t necessarily know.

It was acknowledged that AHCs could utilise other routes for licensing information or support which licensing leads would be unaware of:

it may well be that they don’t necessarily only speak to me on it. They might speak to the licensing advisors (in RAs) which obviously we are dealing with, with numerous conversations every day.

Significantly, one licensing lead indicated ‘a lot of’ licensing applications over a 12-month period were ‘quite minor’ – assumed to mean minor variations – and therefore uncontested (supported by the data in Table 23) which created a challenge regarding ‘objective assessment’ of AHC involvement in increasing community engagement:

It’s difficult to gauge, because often a range of applications we get over a 1-year period, a lot of them will be quite minor and perhaps we won’t get any objections at all, because they won’t be contested by anyone. Others may be more controversial. And it’s hard to gauge whether we would have had more objections or more engagement from the community over any of these, than we would if CICA was in place or not. It’s very difficult to make an objective assessment of that.

One of the challenges identified was that AHC activity would only be recognised if AHCs declared their role or a community member informed licensing that AHCs had played a role, when a representation was made:

I think the only way we could be sure about that, if we have representations made from persons within this groups, and when they made the representation, they actually said well, actually, we are linked with the CICA project and we’ve done a lot of work and we’ve had information from that project and we think, in regard to that, we are going to object and these are the grounds we are going to object. Other than that, they don’t say who they are when they object, it’s difficult to make an objective judgement.

Working with responsible authorities

One lead indicated that the ability of AHCs or community members to address premises licensing issues may be limited unless a co-ordinated multiagency approach was taken to address licensing applications. Notably, the focus here was on licensed premises as settings that create issues relating to crime and disorder:

So perhaps one sort of route could be, with the projects, for those groups that have engaged with the project, when they have one of these issues, perhaps don’t just go straight to the licensing authority, if it’s a concern about crime issues, go and speak to the neighbourhood police officers, and say well, look, we’ve got this application come in, we’re really unhappy about this, because of this, this and this. Would the police be prepared to support us, in terms of putting our objection in?

Furthermore, licensing leads identified that communities are ‘hampered’ if the relevant RA does not object to an application, limiting the power communities have to raise concerns:

One of the issues, when we have a new premises application, a new premises licence application, is sometimes the residents will object and they might say well, we are going to object on the grounds of crime and disorder, that this premises will increase the levels of crime and disorder in the area. And the applicant will say well, hang on a minute, the police haven’t made a relevant representation, the police are quite happy with it and it sort of undermines what the residents are saying, (…) and if police don’t object it sort of hampers the residents, it makes it harder for residents to make their argument. Similarly, if you were saying, well, this premises is very noisy and it keeps residents awake at night and Environmental Health don’t object, then it makes it more difficult to make that argument.

Place-based factors regarding licensing engagement

Licensing leads identified that factors to do with the intervention areas themselves may have impacted on the ability of AHCs to get directly involved in influencing licensing issues within the timescale of the intervention period. For instance, Area 9 has 22 licensed premises. During the interview with the licensing lead, the licensing register was checked regarding applications made during the intervention period. Low levels of activity across the LA overall were reported and confirmed by a later data check (see Table 23). Limited engagement in licensing by AHCs was suggested as a result of limited opportunities to become involved:

I can’t say that I’ve seen any benefit of it [CICA] but I think that is probably because there haven’t been any issues or the type of applications we’ve been having in. I’ve just been having a quick flick (through the register). We have had a couple of applications in [area name] but nothing that would really cause any problems.

A lack of licensing issues that needed pursuing during the time frame of the intervention was also reported by Participant 8:

I am not aware off the top of my head of any real problems within [area name] and any potential reviews that the responsible authorities, be it the police, licensing authority, trading standards, that are calling for review of licences because we’ve got such problems.

This lack of opportunity may in part be due to changes in the overall licensing environment. One licensing lead suggested applications were shifting towards ‘online sales’ and ‘tried-and-tested’ suppliers, such as supermarkets, and that the overall level of engagement in relation to alcohol licensing activity was low:

I’ve not had anything off anybody. We’ve not been inundated with applications, I must admit. And we seem to be changing the face of [area name]. We get applications now more for … like they want to open a business that’s online. So, they want to do the sales online. We get a few of them. We’ve got quite a lot of new developments, haven’t we? So, we’ve got places like, the little shops are now like, the [Names of three large supermarket chains], so they’re more tried-and-tested people.

Similarly, during the interview, the licensing lead in Area 6 (20 licensed premises) did not ‘recall any particular licensing applications’ during the 12-month intervention period.

Opportunities to get involved due to ‘problems with specific premises’ were also perceived by licensing leads as ‘unpredictable’. The likelihood therefore of ‘problem premises’ suddenly appearing in the specific intervention area was perhaps unlikely during the period of the intervention:

equally, if you’re then looking at problems with specific premises, again that’s the only other situation whereby you might need to get involved, and again that’s unpredictable as to whether you know there will be problem premises.

One licensing lead reiterated the focus on intelligence gathering through web-based online forms and digital spaces as a significant ‘place’ for community licensing engagement:

as soon as anybody phones it’s, ‘What’s your email address? I’ll send you the link to this or send you the link to that.

Building community capability

Licensing leads continued to report positive support for the ABCD approach underpinning CICA and the principle of identifying and mobilising individual and community assets:

I thought it was a really good idea (…). And one of the challenges, I guess for members of the public, in licensing is sort of getting to grips, I guess, with the processes and you know I think it can often be a bit daunting. So, the idea of having training and sort of growing experience for them, you know, was a good one.

It was notable, however, that across all interviews, discussion about the AHCs themselves was limited. Only two discussed issues relating to accessing communities to address alcohol harm in the community and a further licensing lead spoke about the sense of social value gained by AHCs. Given the key role AHCs were anticipated to play in delivering the intervention and the role licensing leads were anticipated to have in cofacilitating first- and second-generation AHC training, it is interesting to note the limited conversation related to the volunteers as assets. Only one licensing lead described continuing relationships with their AHCs by the ‘Council’ (LA):

and I see some of the volunteers, now I’ve seen them since at [Provider organisation name] when I’ve gone to meetings and stuff, they’re aware of, of who I am and I’m involved and that yeah, just a friendly face really that can chat about things and how they’re involved because I know that the Council have made use of the CICA volunteers.

Two licensing leads identified a need to understand how CICA could impact on licensing activity at scale. Notably, licensing leads in the nine authorities across GM received no ‘central’ briefing regarding why specific intervention areas had been selected or specific information regarding the intervention theory underpinning the implementation process. A view was shared that a wider network of AHCs operating across a wider footprint may demonstrate an ‘effect’ from the training:

And it’s just I think perhaps it’s because the... like the cohort were from one particular area. Maybe it may take several cohorts from different areas to spread that message around the borough for them to get involved more and that may be how we can see the effect that that training can have.

A different licensing lead questioned whether the way the intervention was set up enabled it to have sufficient ‘reach’ to make a ‘difference’:

The thing I probably wondered about was how does this scale up to an area like [name of LA]. There’s 300,000 residents in [name of LA] and there’s lots of localities probably where we have issues related to deprivation and alcohol with these groups, or there should be. So, I don’t know enough about the programmes to comment on that, but I suppose the question is: does it reach out enough to make a real big difference?

In two different areas, despite neither licensing leads being involved in cascade training, both perceived building community asset capability as positive and empowering the lives of residents:

I think it can only help, in the areas where you have it. Because it’s only going to be a positive thing, because it’s going to help the lives of the residents, living in those areas, and it’s going to empower those people to engage with the licensing authority when the time comes.

It was acknowledged, however, that building community capability ‘needs time’, ‘momentum’ and commitment:

It has potential but it needs time and it needs people who are committed. If you’ve got both those things, then you’ve got the chance of success. But I’d say, particularly sometimes in these communities it’s a struggle, you’ve got to keep at it because people soon lose momentum. You’ve got to not badger people but keep them onboard at regular intervals while something’s in its infancy until it beds in and possibly that’s what didn’t happen here.

One licensing lead acknowledged the opportunity for a consultative role for AHCs in future policy development:

it would be great if there was, I suppose, a real network of these kind of representatives and individuals who I suppose you could engage with, not only in respect of an area, but I suppose in respect of wider licensing issues, and licensing consultations and … I mean, we’ve not done any licensing consultations, but for example you know I would include the CICA rep in any sort of revisions to the policy and things like that.

Interviews with alcohol health champions

After the first 12 months of the intervention, we reviewed the number of lay champions who remained in contact with the local co-ordinator and recorded whether they were active or inactive as an AHC (see Table 25).

Just over half of the AHCs (54%) who had taken part in training were no longer in contact with the local co-ordinator. Some local co-ordinators were aware of the reasons why these champions had dropped out, such as competing pressures with full-time work or personal life; not feeling able to embed in day-to-day job; feeling isolated when a network of champions did not grow; getting banned from the local community centre; attending training for personal awareness only (did not want to be ‘active’); not understanding why the training was recommended as part of their recovery treatment plan; moving out of the CICA area.

While it was unknown to what extent individuals who lost contact with their local co-ordinator may have continued to use their training in their personal or working lives, we defined ‘active’ as someone who continued to be actively engaged in AHC activities in the AHC community network.

Just under a third of AHCs (29%) remained ‘in contact and active’. Due to the cascade training approach, this number included second-generation champions who may have only recently trained. Of those who were still in contact but ‘inactive’ (n = 16), reasons known to local co-ordinators at 12 months included: securing paid employment; changing volunteer roles (becoming recovery volunteers, domestic abuse campaigning volunteer); returning to study/education; poor health; relapse of harmful/dependent drinking. All active and inactive champions in contact with the local co-ordinator were invited to interview. Due to the reduced target population available, instead of a purposive sampling approach (as per protocol), all those who responded were interviewed.

Seven follow-up interviews were conducted in total, representing four areas: five out of seven AHCs were first-generation AHCs (remained in contact for at least 12 months). Only one participant had also been interviewed within the initial implementation phase. Two overarching themes were identified when examining the champions' experiences after CICA had been running for 12 months. Themes and sub-themes are shown in Table 26. Participants are anonymised.

Theme 1: connecting inside and out

Growing, progressing, moving forward

Looking back on how they had personally developed over the year, champions spoke of how it had boosted their self-esteem and built their confidence to have brief conversations with people about alcohol:

Everyone goes ‘I don’t drink’. ‘Well, if you let me explain …’ and it’s actually given me the confidence to go out and do that, whereas when I first started I was like, ‘Okay it’s fine, it’s fine’ and I was quite shy about it.

Additionally, they built confidence being in a large group, recognising how they had changed over the course of the year:

I can sit with twenty people now and do a group, you know, whereas last year I wouldn’t.

Some champions spoke about the reason why they joined the training in the first place, to gain more qualifications for their CV and how the experience exceeded their expectations:

when I first come into it, it was kind of yeah, I’ll do this training it’ll be another certificate to add on to my CV and my qualifications to help me grow, progress, moving forward in my own personal development. And I had no pre-conceived expectations, but from doing it, I found it really beneficial, really rewarding.

Some champions spoke about the benefits to their job prospects, not just from the training and experience of AHC activity but also by having a referee in the local co-ordinator, a person they could put down on job applications:

What I’ll say to you, through doing that (CICA), it’s certainly made people that viewed my CV think, well (name of AHC) has been involved in something … that may have helped people think ‘Well he’s worth giving an opportunity to’. The main thing behind that, the (name of local co-ordinator), he’s sort of like helped me with references.

To AUDIT-C or not AUDIT-C

The AUDIT-C scratchcard (see Figure 1) was offered to all areas as a resource to support having informal conversations to identify alcohol risk and offer brief advice. Champions interviewed at follow-up spoke extensively about the pros and cons of using the AUDIT-C tool and how it influenced their ability to make connections with people.

We use the AUDIT-C quite a lot to be fair. Most of the time I’ll start off a conversation and then we’ll ask them to fill in the AUDIT-C, and nine times out of ten that works. So I wouldn’t go straight … personally I wouldn’t go straight in with the AUDIT-C, but others find the AUDIT-C as a way to start a conversation, so it’s just personal preference I think.

There was a concern that bringing out the AUDIT-C scratchcard could affect the authenticity of the conversation, with concerns that what began as an informal chat could suddenly appear contrived and ‘not what CICA was about’, causing an unintentional disconnect between the AHC and the person:

I found that I didn’t use the AUDIT-C all the time because for me that could be a barrier, because that could for somebody who’s aware that they’re drinking too much, that could be the red flag that ‘oh she’s led me into this’. Do you know what I mean? ‘She’s producing something now, she knew that she was going to produce this’ and if it’s just a conversation you wouldn’t necessarily be that prepared … CICA’s very natural, it’s supposed to be just a conversation, and then all of a sudden, you’re producing this tick list or you know, let’s do this questionnaire kind of thing, and it’s like ooo, maybe that wasn’t as genuine a conversation as I thought it was.

Due to the popular use of scratchcards to win a prize, one AHC found that it was an eye-catching and effective conversation starter to help connect with people, but some people were suspicious they were being sold something:

They were fantastic and it’s a … I mean it’s a great icebreaker to start with because you know it’s a scratchcard – oh what’s that? Or they’d say I’m not paying any money. No it’s not that.. just come over. It’s a really nice icebreaker but some people really take notice of them.

Not knowing whether using AUDIT-C was making a difference to individuals or the wider community brought up questions for AHCs about how to measure the effects of their activities:

..I could do 30 Audit Cs but that might not even be one of the people that are being antisocial or that have a problem or that present at A&E. So, it’s how do we measure it, is it measurable? At the moment, we don’t think so, and I’m not the only one who says that.

Not using AUDIT-C but instead sharing knowledge gained from the CICA training in other ways was found to make a significant difference to a work colleague in an informal, opportunistic conversation:

… one night we had a conversation and just a chat about the training and he was asking me about the training and I said ‘oh it’s great’ you know, and we were just talking, and he kind of, gave a little bit of information about himself, and we were looking at ways that maybe he could reduce that and he said ‘yeah I really need to have a think about it’, and I said ‘well, what do you think you could do first, just to start that?’ and he actually did a month free cos, we worked his units out and he was on something like 70, 80 units a week he was on … so he was quite shocked at that and then he did a month completely alcohol free, and even to this day, you know much later on he’s still aware of it and he does the free month, every time we have the Sobertober … previously he wasn’t and it was kind of accepted and a bit of a joke and a bit of a laugh.

‘We’re actually a proper outfit’

Having a clear identity as an AHC was highlighted by a number of participants as being important for role legitimacy, their sense of having the ‘right’ to undertake alcohol health activity, as well as the responsibility:

… people need to know that you’re a proper body. They don’t want to be talking to any Jack Jones out there. It’s not really appropriate, that. You’re dealing with people’s lives here, aren’t you? They’re not just numbers.

The support provided to AHCs by the local co-ordinators was extremely valued, but the lack of budget and the quality of engagement/takeaway resources available to them were limited. This reflected negatively on the value of their own role:

Their support is brilliant, I can’t fault them. What I can fault is … they’re wanting us to do something with no budget. We’ve got garbage leaflets that we hand out, that look like they’ve been done on a cigarette box. It’s rubbish, we’ve had no support that way. When we do events, people want something to take away, be it a keyring or whatever, we don’t have any funding whatsoever to do anything like that. That’s my main bug bear, is the funding … I’ve said it from the beginning, I think we need a budget, we need to be able to do something. And we haven’t.. I think we do need to have a face … and then we can show people that we’re actually a proper outfit.

Theme 2: being in charge of alcohol

Power to say no

Alcohol health champions interviewed experienced a number of misperceptions about their role and, at times, confrontation. This led to a number of occasions where they said ‘no’:

I had a shop telling me to move when I was talking to someone outside it, and I just said ‘you do not own the street love. And I will stand here and talk to this person’ … I said ‘you do not own this street, that’s your shop and I will not move I am talking’.

Affirming their role boundaries became important in some instances, where they were being asked to fill gaps in statutory service provision for those experiencing serious alcohol harm, such as ‘high impact dependent drinkers’:123

We’ve had a lady from … I can’t remember which housing trust she’s from, but she contacts us regularly to say, ‘This tenant is an alcoholic, that tenant is an alcoholic, can you go and knock on their door and help them?’ ‘No, that’s not what we do’. So, people misinterpreting what we do, but they are contacting us to say this person and that person has a problem.

Alcohol health champion activity was not without confrontation, and saying ‘no’ included refusing to cold-calling door to door:

We have had abuse from people that are drunk, and we just leave them to it. We’ve had it in the library, and we’ve had it at an event that we did at [location], but you just brush over it, just leave them to it. They’re only a minute amount of people, so it’s not every time we go somewhere or everything we do … I think if we went out canvassing on the streets or went to people’s doors, like was suggested, the area that it is, I just wouldn’t do that for my own safety, and all the other volunteers feel the same … I don’t think it would work as well.

The challenges some volunteers experienced taking part in CICA when still engaged in structured community alcohol treatment led to experiences in one area where instead of explicitly saying ‘no’ to taking part, people voted with their feet and stopped coming:

I felt that stopped people coming to, because, although we were meeting as CICA, these people were still ex-addicts and they were still kind of under a support treatment kind of, not treatment but kind of, it was a support session for them, as well as CICA, and I think, if anything, it would prevent them coming.

Is knowledge power?

There were a number of effects and reflections that arose for participants following their licensing training. For one person, the knowledge they gained from the licensing training about the need for ‘evidence’ if reporting licensing issues became a hindrance to taking action:

because I’d not got my mobile phone handy, I couldn’t get the evidence. Because I couldn’t just say ‘Oh, it is such a place’, that’s not good enough, you need the photographic evidence.

For some, knowledge of the licensing process was boring or confusing:

No it bored me. I can’t be doing with it. That bit of it just over my head. I’m not good like that.

Despite finding it hard to understand, one champion was interested in being able to have the opportunity to have a refresher:

I’ve not had anything to do with the licensing. To tell you the truth, I didn’t understand it … So, if you ever do that again, I’d like to sit in.

Understanding the processes required by licensing authorities to use online public registers, submit representations, and, in some areas, report issues online highlighted the reliance on AHCs having the digital capability to get involved in licensing decisions:

they’re not tech savvy shall we let’s say and that is another like hurdle they have to come to. It is like I can’t do that on computers and stuff and I think if there was another way, you know.

There were suggestions to share knowledge gained around licensing by raising awareness with the wider community using a leaflet that AHCs could distribute and use as a conversation tool:

I wouldn’t have even known, at all, I wouldn’t have known we could do that, just as the general public … We can do that, but you can do it as Joe Bloggs as well, and a lot of people don’t know that. Have we used it? No, we’ve never really used it, unfortunately, and I think that’s because the general public, the general Joe Bloggs, as I would have counted myself, we wouldn’t have … Maybe we could put a leaflet together to explain that that might help, so we’ve got something physical to hand out.

For some participants, they felt more passionate about the brief advice AHC role activity compared to getting involved in licensing, and it was important to them to have this flexibility to decide how little or much they wanted to use their CICA knowledge and skills:

I suppose there’s been opportunities to, if I wanted to, but I’m more interested in the face-to-face conversations with people within the community. I’m aware of the stuff, and what can be done if issues come up around the licensing and people perceive a shop or a pub kind of becoming a problem, or a nuisance within the area where kids are congregating, at the local shop and shop keepers serving them alcohol when they shouldn’t be. So, I’m aware of that stuff and how to intervene or the people who need to approach to put things in place and be made aware of that stuff, but, as I say, I’m more passionate about the face-to-face stuff with people, within the community, my local, me neighbours, people who live down the street on the estate.

For others, they found the knowledge they gained about alcohol licensing and how to report issues and complaints the most valuable aspect of the CICA training:

Yeah well it helped a lot in many ways, in personal ways. It built me up to be more confident and the teaching around the council reporting way, you know, when you can report to off licences and stuff, that was so valuable. I’m gonna say that is what I got most off the course because I still pass it to people outside … What I would say is if the training, maybe on the audience, it might be delivered a bit slower on the licensing.

One participant suggested a missed opportunity within the licensing training to get AHCs signed up to receive notices of applications for their area. They felt that this on-the-spot practical step may have been a simple bridge that local licensing officers could have used to keep in touch with people after the training, keep them informed and remind them how they could put into practice their knowledge:

I’m going to sort that out, I’m going to get the applications for my area coming to my email and I didn’t do it because life’s busy and it doesn’t get done. But had that been set up in the training or given me the opportunity to get that done, then who knows, I’d have opened a few of them and that would have got me learning more … Almost that practical step? Yeah. Just helping that yeah? And it wasn’t hard, but I didn’t do it.

Branching out

Alcohol health champions felt that communities needed to have the power to be able to branch out and not be limited to prescribed target areas:

I think it’s daft that we have target areas, to be honest, because our target area is a housing estate. We ain’t going to go up into that housing estate. I went and did a housing association meeting, I ended up doing it on my own because my colleagues, unfortunately, couldn’t do it, and I was waiting for the police to turn up. They were fighting, they were scrapping, it was this one versus that one and it’s like, ‘What on earth?’. And that’s apparently tame for what it normally is. So, I said to (name of local co-ordinator), ‘I’m not going back into one of them’.

Branching out within the wider local authority area was seen to have the potential to provide more opportunities for AHC activities, particularly attending community events, as they were considered to be one of the most successful activities they undertook in their role:

… Maybe branch out into the local area, like into [local authority area], because they do a lot of events that we could attend. So for other areas, getting as many events in as possible. Because that’s the easiest way we found of spreading the word.

And lastly, allowing time for a community AHC programme to grow and expand was important, not just when branching out within a small community but also wider, recognising the value of small incremental change and ‘planting seeds’:

I see it as yes moving forward and it growing and becoming bigger and getting that message out there to the wider community, not just my local community, to other people … listen I’ve seen this work and benefit people within my community, and other people might not see that straight away, but you see little things and little changes in the way people are thinking, they’re acting and behaviours, and as I say planting them seeds.

Focus groups with communities

Two main overarching themes from the focus group analysis were perceptions of alcohol consumption within society and the felt needs within the community. Themes and subthemes are provided in Table 27. Participants are anonymised within each single session focus group (Focus Group 1, Focus Group 2, Focus Group 3).

Theme 1: alcohol consumption ingrained in society

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.

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 …

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Theme 2: felt needs of the community

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.

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.

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?.

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 …

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?

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.

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.

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.

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?

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.

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.

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.

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.

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.

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.

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.