Dr Peter Gates is a Postdoctoral Research Fellow at NDARC, UNSW Sydney, with a focus on community interventions for alcohol and other drugs (AOD) harm prevention and reduction. Here, he writes about a recently published review on comprehensive community initiatives.

What is a comprehensive community initiative?

Comprehensive community initiatives (CCI) have been a popular approach to preventing or reducing alcohol and other drug (AOD) harms since the late 80s. You may not be familiar with CCI; however, you will have likely heard other terms used that describe the same thing, such as community action, community-based activities, or universal prevention. Perhaps even place-based initiatives, community mobilisation, substance control programs, or multicomponent interventions.

In our recently published review, we assessed the terms used in the last three decades and identified common defining aspects. We found that all these terms refer to a ‘comprehensive’ set of activities. That is, a multiplicity of activities or, put simply, more than one activity. By including multiple activities on individual, population, or systems levels, it is thought to be more impactful, than completing activities on their own.  

Many definitions refer to ‘community’ which is a broad term that describes any two or more people in a shared location or who have shared experience or heritage. As such, there are an infinite number of communities, so the best way to identify what community means may be to ask the person who is describing it. In the context of CCI, ‘community’ usually refers to people living in a shared place, such as a postcode. Finally, the terms also referred to initiatives, actions, activities, programmes, strategies, interventions, and so on.

Bringing these terms together, we felt that ‘comprehensive community initiatives’ appropriately represents community level approaches to preventing or reducing AOD harms. It is our hope that others will adopt this term to promote a consistent shared language.

What activities does a CCI involve?

As it happens there is no limit to what activities may be combined in CCIs, though we did find that they could be described by four ‘types’ of activities. That is, those described by: the setting in which they are delivered (such as school-based activities); the individuals delivering them (such as community or police-led activities); the individuals receiving them (such as parenting-related activities); or the activity itself (such as a media campaign). Together, these four types of activities comprise eleven initiative subtypes as shown in the figure below.

Does Australia implement CCIs?

Yes! Absolutely. Although the funding for prevention activities is a relatively small part of the drug budget (just 7% in 2021-22), the Australian Government does fund a not-for-profit organisation to support a national place-based community coalition program. Additional state funded initiatives also exist. For example, in New South Wales, the Ministry of Health has funded a consortium of specialist AOD organisations to support and fund community members to implement CCI. Under these models, coalitions, or formal and informal organisations and individuals with a shared commitment to reducing or preventing AOD use or harm, apply for annual funding to deliver CCI to their local communities (typically defined by postcode).

Larger ‘one off’ CCIs have also been implemented in Australia. The biggest and most impactful example of an Australian CCI is the Alcohol Action in Rural Communities (AARC) project. A total of 20 rural communities (with populations of 5000–20,000, located at least 100km from an urban centre) took part between 2005 to 2009. Thirteen interventions were implemented, including health services, school activities, workplace activities, sports club activities and police-led activities. Following a very rigorous evaluation, these interventions were shown to be cost effective and reduced rates of harmful alcohol consumption.

Do CCIs work?

This is a difficult question to answer. It depends on which activities are involved, what the community refers to, and what you mean by ‘work’. Hundreds of CCI have been evaluated to see if they prevented or reduced AOD harms. Unfortunately, there is no standardised approach shown to be effective in preventing different substance-related harms across different communities.

If we take alcohol and other drugs separately and consider community to be those sharing a geographic location the size of a postcode or two, things get a little clearer. For instance, we found that, just over half the review papers included in our umbrella review supported CCIs to prevent alcohol use. The evidence is lower for tobacco and cannabis and lower still for other illicit drugs. This is still a rather mixed bag though, so we looked a little closer to see if there were any activities that showed consistent impact.

What is the best CCI?

We assessed close to three hundred evaluations of different CCIs and noted the activities involved and the impact they had. Unfortunately, no activity met our criteria for demonstrating consistent impact, though some were more consistent than others. We identified that school-based activities alongside parenting-related activities have the most consistent impact across substances. These activities often work together to target social and behavioural factors, and active participation by both parents and their children is key. In contrast, these activities have also been shown to be harmful when taking a noninteractive, fear-based or factual information-only approach.

In addition, there was support for integrating media campaigns into CCI. These campaigns should aim to raise awareness and community support for the CCI objectives such as by modelling substance refusal skills or promoting positive alternatives to drug use.

These results indicate that school-based activities should include parents and focus on life skills. Where possible including a media campaign will extend the impact of a CCI to those not involved with schooling.

Where are the biggest knowledge gaps?

Our work shows that there has been a huge number of studies on a myriad of different CCI activities. However, it can be difficult for this information to be made available to non-researchers, such as those involved in community-led AOD work. There is also a lack of guidance in global and national strategic documents such as the World Health Authority's Global Alcohol Action Plan and the Australian National Drug Strategy which promote community action but do not describe which activities to use.

What are we doing to improve research into CCI?

To our knowledge, there is no online resource available summarising research on CCI. This may lead to the selection of activities that are not likely to work. CCIs may also lack clearly defined outcomes, making evaluations difficult.

To address this, we are designing an online resource summarising research on CCIs. The resource will be user friendly and designed in partnership with those involved in CCIs, including volunteers, program workers and policy makers.

You can help us design this resource. If you are interested in getting involved, please contact Dr Peter Gates at peter.gates@unsw.edu.au