Does a local Alcohol Health Champion programme have a measurable impact on health and crime outcomes? A natural experiment evaluation of Communities in Charge of Alcohol (CICA) based on triangulation of methods.

BACKGROUND AND AIM: Drinking alcohol may cause harm to an individual's health and social relationships, while a drinking culture may harm societies as it may increase crime rates and make an area feel less safe. Local councils in Greater Manchester, UK, developed the Communities in Charge of Alcohol (CICA) intervention, in which volunteers were trained to give alcohol-related advice to the public and taught how to influence policies to restrict when, where and how alcohol is sold. As part of a larger study, the aim of the current project is to measure the impact of CICA on health and crime outcomes at the lower super output (LSOA) geographical aggregation. DESIGN: Quantitative evaluation using four time series analytic methods (stepped-wedge design, and comparisons to local controls, national controls and synthetic controls) with findings triangulated across these methods. A cost-benefit analysis was carried out alongside the effectiveness analysis. SETTING AND PARTICIPANTS: The general public in Greater Manchester, UK, between 2010 and 2020. MEASUREMENTS: The primary outcome of interest was alcohol-related hospital admissions. Secondary outcomes were accident and emergency (A&E) attendances, ambulance callouts, recorded crimes and anti-social behaviour incidents. FINDINGS: Triangulation of the results did not indicate any consistent effect on area-level alcohol-related hospital admissions, A&E attendances, ambulance callouts, reported crimes or anti-social behaviour associated with the implementation of CICA. The primary stepped-wedge analysis indicated an increase in alcohol-related hospital admissions following the implementation of CICA of 13.4% (95% confidence interval -3.3%, +30.1%), which was consistent with analyses based on other methods with point estimates ranging from +3.4% to 16.4%. CONCLUSION: There is no evidence of a measurable impact of the Communities in Charge of Alcohol (CICA) programme on area-level health and crime outcomes in Greater Manchester, UK, within 3 years of the programme start. The increase in alcohol-related hospital admissions was likely the result of other temporal trends rather than the CICA programme. Possible explanations include insufficient follow-up time, too few volunteers trained, volunteers being unwilling to get involved in licensing decisions or that the intervention has no direct impact on the selected outcomes.

Listening to voices from multiple sources: A qualitative text analysis of the emotional experiences of women living with breast cancer in China.

Background: Receiving a breast cancer diagnosis and treatment is both a physical and emotional journey. Previous studies using single-source data have revealed common and culture-specific emotional experiences of patients living with breast cancer. However, few studies have combined such data from multiple sources. Thus, using a variety of data sources, the current study sought to explore the emotional experiences of women in China newly diagnosed, post-operative, or undergoing chemotherapy. We posited that even though women living with breast cancer in China have multiple channels through which they can express these emotional experiences, little variance would be found in their emotional expressivity and the themes they want to express due to cultural inhibitions. Methods: Text data from female patients newly diagnosed, post-operative, or undergoing chemotherapy were collected between June 2021 and January 2022 via a Python web crawler, semi-structured interviews, and an expressive writing intervention. Data were transcribed and subjected to thematic analysis. Reporting followed the consolidated criteria for reporting qualitative studies (COREQ) guidelines. Results: Analyses were based on 5,675 Weibo posts and comments published by 448 posters and 1,842 commenters, transcription texts from 17 semi-structured interviews, and 150 expressive writing texts. From this total collection of 461,348 Chinese characters, three major themes emerged: (i) conflicting emotions after diagnosis; (ii) long-term suffering and treatment concerns; and (iii) benefit finding and cognitive reappraisal. Conclusions: Despite gathering information from various sources, we found that distress from body-image disturbances, gender role loss and conflict, and changes in sexuality and fertility, were consistent among this sample of female Chinese patients with breast cancer. However, when women engaged actively in benefit finding and cognitive reappraisal with strong social support, patients were able to find ways to adapt and reported post-traumatic growth. Strong social support was an important facilitator in this growth. These study findings emphasize that healthcare professionals ought to increase cultural sensitivity, provide multiple channels to encourage patients to express their emotions, and incorporate screening for patients' emotional distress at all diagnostic and treatment phases as part of routine nursing care.

'A priori' external contextual factors and relationships with process indicators: a mixed methods study of the pre-implementation phase of 'Communities in Charge of Alcohol'.

BACKGROUND: It is widely recognised that complex public health interventions roll out in distinct phases, within which external contextual factors influence implementation. Less is known about relationships with external contextual factors identified a priori in the pre-implementation phase. We investigated which external contextual factors, prior to the implementation of a community-centred approach to reducing alcohol harm called 'Communities in Charge of Alcohol' (CICA), were related to one of the process indicators: numbers of Alcohol Health Champions (AHCs) trained. METHODS: A mixed methods design was used in the pre-implementation phase of CICA. We studied ten geographic communities experiencing both high levels of deprivation and alcohol-related harm in the North West of England. Qualitative secondary data were extracted from pre-implementation meeting notes, recorded two to three months before roll-out. Items were coded into 12 content categories using content analysis. To create a baseline 'infrastructure score', the number of external contextual factors documented was counted per area to a maximum score of 12. Descriptive data were collected from training registers detailing training numbers in the first 12 months. The relationship between the baseline infrastructure score, external contextual factors, and the number of AHCs trained was assessed using non-parametric univariable statistics. RESULTS: There was a positive correlation between baseline infrastructure score and total numbers of AHCs trained (Rs = 0.77, p = 0.01). Four external contextual factors were associated with significantly higher numbers of lay people recruited and trained: having a health care provider to coordinate the intervention (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); a contract in place with a commissioned service (p = 0.02), and; formal volunteer arrangements (p = 0.03). CONCLUSIONS: Data suggest that there were four key components that significantly influenced establishing an Alcohol Health Champion programme in areas experiencing both high levels of deprivation and alcohol-related harm. There is added value of capturing external contextual factors a priori and then testing relationships with process indicators to inform the effective roll-out of complex interventions. Future research could explore a wider range of process indicators and outcomes, incorporating methods to rate individual factors to derive a mean score. TRIAL REGISTRATION: ISRCTN81942890, date of registration 12/09/2017.

A mixed methods analysis evaluating an alcohol health champion community intervention: How do newly trained champions perceive and understand their training and role?

Globally, alcohol harm is recognised as one of the greatest population risks and reducing alcohol harm is a key priority for the UK Government. The Communities in Charge of Alcohol (CICA) programme took an asset-based approach in training community members across nine areas to become alcohol health champions (AHCs); trained in how to have informal conversations about alcohol and get involved with alcohol licensing. This paper reports on the experiences of AHCs taking part in the training through the analysis of: questionnaires completed pre- and post-training (n = 93) and semi-structured interviews with a purposive sample of five AHCs who had started their role. Questionnaires explored: characteristics of AHCs, perceived importance of community action around alcohol and health, and confidence in undertaking their role. Following training AHCs felt more confident to talk about alcohol harms, give brief advice and get involved in licensing decisions. Interviews explored: AHCs' experiences of the training, barriers and facilitators to the adoption of their role, and how they made sense of their role. Four overarching themes were identified through thematic analysis taking a framework approach: (a) perceptions of AHC training; (b) applying knowledge and skills in the AHC role; (c) barriers and facilitators to undertaking the AHC role; and (d) sustaining the AHC role. Findings highlight the challenges in establishing AHC roles can be overcome by combining the motivation of volunteers with environmental assets in a community setting: the most important personal asset being the confidence to have conversations with people about a sensitive topic, such as alcohol.

How can communities influence alcohol licensing at a local level? Licensing officers' perspectives of the barriers and facilitators to sustaining engagement in a volunteer-led alcohol harm reduction approach.

Despite the World Health Organization's assertion that communities need to become involved in reducing alcohol harm, evidence of community engagement in alcohol licensing decision-making in England remains limited. The evaluation of the Communities in Charge of Alcohol (CICA) programme offers policymakers, Licensing authorities and public health practitioners, evidence regarding a specific volunteer-led, place-based approach, designed to enable community engagement in licensing with the aim of reducing localised alcohol harm. This study explored factors affecting the sustainable involvement of volunteers in alcohol licensing decision-making from six licensing officers' perspectives, through semi-structured interviews. Routinely collected crime, disorder, and hospital admissions data were reviewed for further context as proxy indicators for alcohol-related harm. Licensing officers perceived sustainable engagement to be impacted by: (i) the extent of alignment with statutory requirements and local political support; (ii) the ability of licensing officers to operationalise CICA and support local assets, and; (iii) the opportunity for, and ability of, volunteers to raise licensing issues. The perspectives of licensing officers indicate complexities inherent in seeking to empower residents to engage in licensing decision-making at a community level. These relate to statutory and political factors, funding, social norms regarding engagement in licensing decision-making, and the need for networks between critical actors including responsible authorities and communities. The evidence indicates that after increasing community capacity to influence alcohol availability decision-making at a local level, communities continue to struggle to influence statutory processes to affect alcohol availability where they live and work. More understanding of how to enable effective community engagement is required.

An asset-based community development approach to reducing alcohol harm: Exploring barriers and facilitators to community mobilisation at initial implementation stage.

Globally there is a need to engage communities in actions to reduce alcohol harm. This paper reports on the initial implementation phase of an asset-based community development (ABCD) approach to reducing alcohol harm in ten pre-identified areas across Greater Manchester (UK). This qualitative study highlights the experiences of stakeholders responsible for, or engaged in, implementation. Findings show that it is challenging to recruit sufficient volunteers in a specific, small area/community, which may limit the ability to build health assets. Wider policy and organisational factors that should be understood prior to implementing a place-based volunteer-led health promotion programme are also identified. TRIAL REGISTRATION: https://www.isrctn.com/ISRCTN81942890.

Exploring Strategies for Using Social Media to Self-Manage Health Care When Living With and Beyond Breast Cancer: In-Depth Qualitative Study.

BACKGROUND: As breast cancer survival rates improve and structural health resources are increasingly being stretched, health providers require people living with and beyond breast cancer (LwBBC) to self-manage aspects of their care. OBJECTIVE: This study aimed to explore how women use and experience social media to self-manage their psychosocial needs and support self-management across the breast cancer continuum. METHODS: The experiences of 21 women (age range 27-64 years) were explored using an in-depth qualitative approach. The women varied in the duration of their experiences of LwBBC, which facilitated insights into how they evolve and change their self-management strategies over time. Semistructured interviews were analyzed inductively using a thematic analysis, a polytextual analysis, and voice-centered relational methods. RESULTS: The use of multiple social media platforms, such as YouTube, Facebook, WhatsApp, and Twitter, enabled women to self-manage aspects of their care by satisfying needs for timely, relevant, and appropriate support, by navigating identities disrupted by diagnosis and treatment and by allowing them to (re)gain a sense of control. Women described extending their everyday use of multiple platforms to self-manage their care. However, women experienced social media as both empowering and dislocating, as their engagement was impacted by their everyday experiences of LwBBC. CONCLUSIONS: Health care professionals (HCPs) need to be more aware, and open to the possibilities, of women using multiple social media resources as self-management tools. It is important for HCPs to initiate value-free discussions and create the space necessary for women to share how social media resources support a tailored and timely self-managed approach to their unique psychosocial needs.

Communities in charge of alcohol (CICA): a protocol for a stepped-wedge randomised control trial of an alcohol health champions programme.

BACKGROUND: Communities In Charge of Alcohol (CICA) takes an Asset Based Community Development (ABCD) approach to reducing alcohol harm. Through a cascade training model, supported by a designated local co-ordinator, local volunteers are trained to become accredited 'Alcohol Health Champions' to provide brief opportunistic advice at an individual level and mobilise action on alcohol availability at a community level. The CICA programme is the first time that a devolved UK region has attempted to coordinate an approach to building health champion capacity, presenting an opportunity to investigate its implementation and impact at scale. This paper describes the protocol for a stepped wedge randomised controlled trial of an Alcohol Health Champions programme in Greater Manchester which aims to strengthen the evidence base of ABCD approaches for health improvement and reducing alcohol-related harm. METHODS: A natural experiment that will examine the effect of CICA on area level alcohol-related hospital admissions, Accident and Emergency attendances, ambulance call outs, street-level crime and anti-social behaviour data. Using a stepped wedged randomised design (whereby the intervention is rolled out sequentially in a randomly assigned order), potential changes in health and criminal justice primary outcomes are analysed using mixed-effects log-rate models, differences-in-differences models and Bayesian structured time series models. An economic evaluation identifies the set-up and running costs of CICA using HM Treasury approved standardised methods and resolves cost-consequences by sector. A process evaluation explores the context, implementation and response to the intervention. Qualitative analyses utilise the Framework method to identify underlying themes. DISCUSSION: We will investigate: whether training lay people to offer brief advice and take action on licensing decisions has an impact on alcohol-related harm in local areas; the cost-consequences for health and criminal justice sectors, and; mechanisms that influence intervention outcomes. As well as providing evidence for the effectiveness of this intervention to reduce the harm from alcohol, this evaluation will contribute to broader understanding of asset based approaches to improve public health. TRIAL REGISTRATION: ISRCTN 81942890 , date of registration 12/09/2017.

"Thanks for Letting Us All Share Your Mammogram Experience Virtually": Developing a Web-Based Hub for Breast Cancer Screening.

BACKGROUND: The decision around whether to attend breast cancer screening can often involve making sense of confusing and contradictory information on its risks and benefits. The Word of Mouth Mammogram e-Network (WoMMeN) project was established to create a Web-based resource to support decision making regarding breast cancer screening. This paper presents data from our user-centered approach in engaging stakeholders (both health professionals and service users) in the design of this Web-based resource. Our novel approach involved creating a user design group within Facebook to allow them access to ongoing discussion between researchers, radiographers, and existing and potential service users. OBJECTIVE: This study had two objectives. The first was to examine the utility of an online user design group for generating insight for the creation of Web-based health resources. We sought to explore the advantages and limitations of this approach. The second objective was to analyze what women want from a Web-based resource for breast cancer screening. METHODS: We recruited a user design group on Facebook and conducted a survey within the group, asking questions about design considerations for a Web-based breast cancer screening hub. Although the membership of the Facebook group varied over time, there were 71 members in the Facebook group at the end point of analysis. We next conducted a framework analysis on 70 threads from Facebook and a thematic analysis on the 23 survey responses. We focused additionally on how the themes were discussed by the different stakeholders within the context of the design group. RESULTS: Two major themes were found across both the Facebook discussion and the survey data: (1) the power of information and (2) the hub as a place for communication and support. Information was considered as empowering but also recognized as threatening. Communication and the sharing of experiences were deemed important, but there was also recognition of potential miscommunication within online discussion. Health professionals and service users expressed the same broad concerns, but there were subtle differences in their opinions. Importantly, the themes were triangulated between the Facebook discussions and the survey data, supporting the validity of an online user design group. CONCLUSIONS: Online user design groups afford a useful method for understanding stakeholder needs. In contrast to focus groups, they afford access to users from diverse geographical locations and traverse time constraints, allowing more follow-ups to responses. The use of Facebook provides a familiar and naturalistic setting for discussion. Although we acknowledge the limitations in the sample, this approach has allowed us to understand the views of stakeholders in the user-centered design of the WoMMeN hub for breast cancer screening.