Professor of Health Policy, School of Health and Social Sciences, Middlesex University*
You have studied and written a great deal about multi-component approaches to reducing alcohol-related harms. What was the genesis of this work?
After more than a decade of campaigning from health and alcohol-specific lobbies, a national Harm Reduction Strategy for England was issued in 2004. Key elements of the national strategy are an emphasis on local responsibility for policy implementation and an expectation that stakeholders will work together in partnership to reduce alcohol-related harm– from local authorities and professional groups to the alcohol industry and community members. My colleagues and I have examined this multi-component approach, and in 2006, we completed a comprehensive review of multi-component programs around the world.
How did you approach this comprehensive review?
Overall, we took into account the underpinnings of the national strategy in the U.K., which stresses the need to ensure that interventions to reduce harm are: (1) coherent, as isolated interventions are unlikely to succeed; (2) sustained, as short term initiatives will have little long-term impact; (3) strategic, because without a coordinated strategy, there is likely to be little progress; and (4) measured, because without ways to chart progress, the success of the strategy cannot be measured.
What are some of the key characteristics of the multi-component approach?
This approach typically requires a program of coordinated initiatives rather than “stand-alone” projects and emphasizes changing local policies, structures, systems, and drinking cultures. The involvement of local communities is also central to such programs.
What are some of the advantages of this approach?
The advantages of this approach have been examined in trials and demonstration projects for over two decades. Based on our review, the adoption of a multi-component approach would provide a suitable framework for meeting national objectives to address alcohol-related harm at the local level. International research also supports prevention and harm reduction action which targets specific populations and aims to change or modify the systems, social structures, and normative factors which create or sustain harmful drinking patterns.
Have you come across convincing evidence of the effectiveness of this approach?
The evidence for multi-component programs from the U.S., Australia, New Zealand, and Scandinavia is still mixed, as there are some unresolved questions and difficulties regarding how to best initiate and implement such programs. Despite these issues, the evidence from our review suggests that multi-component approaches have a greater chance of success than stand-alone projects which target groups, behaviors, and drinking contexts more or less in a vacuum. This is partly due to the positive effects of program components working together to secure positive changes. In other words, the whole is greater than the sum of its parts.
Are there particular programs you would cite as successful?
The many programs we reviewed include the Waikato Rural Drink-Drive Project in New Zealand, which has reported a significant decline in the number of drivers apprehended with positive alcohol breath tests, a 23 percent increase in drunk-driving prosecutions, and a decrease in fatal alcohol-related crashes—from 22 percent to 14 percent. In the U.S., a community-based prevention program called the Community Trials Project reported successfully reducing risky drinking and alcohol-involved injuries resulting from vehicle crashes and assaults. And in Australia, the Surfer’s Paradise project has been successful in reducing violence, crime, and disorder; however, data collected two years later indicated that the impact may have been primarily short-term.
Based on your research and review, which program components would you say are key to the effectiveness of multi-component programs?
I would say that it’s important for multi-component programs to be based on a sound theoretical framework which guides the design and implementation of the program. In addition, program evaluation is important in assessing overall success, generating an understanding of change within communities and systems, and learning the reasons for success and failure of initiatives. Also, the engagement and involvement of communities is a key element in all cases.
Can you elaborate on the community component?
It’s very important to recognize the heterogeneity within local communities. For example, everyone may not share the same values, expectations, and goals, communities change over time, and programs may disrupt existing networks and partnerships. Such dynamics can result in unexpected and unwanted consequences. The sustainability of successful initiatives to reduce alcohol-related harm requires that changes in norms, behaviors, and social structures become ”institutionalized” or embedded in local policies, cultures, and practices.