A step-by-step guide to interventions

The following are ten recommended steps for development organizations with the intention to integrate alcohol and drug prevention in their projects and programmes. The first five steps are for defining and understanding the challenge, while the latter five are for planning of interventions.

Step 1: Discovering the problem

Make a brief description of the problem, as it has been experienced by your staff, your local partner organization or individuals from the target population:

  • How do the alcohol/drug problems manifest themselves in your project area or target group?
  • Which substance(s) create the problem?
  • Which groups (social, gender, age etc.) are involved? As users? Are there other groups than the users who are affected by the problem?

If you decide to involve in alcohol or drug prevention as part of a programme, a more systematic assessment of the alcohol and drug situation is needed. See Step 4: Describing the problem more in detail.

Step 2: Deciding to do something

Involving in alcohol and drug prevention will necessarily result in additional work, even if the new activities are integrated into your already existing programs. This should be realized already from the outset.

Topic for discussion in a responsible body:

How much time and money are we prepared to put into a preliminary assessment of the problem and – later – on possible interventions?

Step 3: Understanding the issue

There is a huge amount of available knowledge and competence on alcohol and drug problems, in all their aspects. Your organization must not adopt the full knowledge base to do a good job with prevention programs. Working together with more specialized agencies and organizations is a better strategy, at least in a preliminary phase. However, some of your staff members need a basic understanding of the issue, beyond what is common sense, myths and beliefs.

In the last chapter of this booklet, Recommended reading, you will find relevant literature and web resources for a basic introduction to the issue of substance abuse as a development concern. FORUT has published a series of booklets with the same format as this publication. This series covers various aspect of the alcohol and drug issue, relevant for a development context (poverty, unrecorded consumption, HIV/AIDS etc.).

Step 4: Describing the problem more in detail

As you start reading the basic literature on alcohol and drug problems, you will acquire the competence to make a broader and more precise description of the problems you have discovered, better than the initial picture you made under Step 1.

Before designing interventions it is useful to make a new and more precise description of the problem. This shall serve several purposes:

  1. To define if the problem is of a character and magnitude that can/should be handled by your organization.
  2. To see if it is necessary to select a more specific aspect of the problem a) to make it more manageable and b) to make it more relevant for your organization.
  3. To decide if your organization is prepared to involve in this problem.
  4. To select the most effective strategies and interventions (see Step 8).

In the first place the ambition need not be to produce a big and highly scientific report. In most cases organizations will not have the resources to conduct new research programs before taking action. The solution then is to produce a compilation of data that already exist without too much work;

  • to find existing research and documentation (reports, official statistics etc)
  • to collect experiences from your target groups, your partners, field workers, local governments etc.
  • to integrate mapping of the alcohol/drug situation in the baseline for your programme

A problem definition could start by elaborating the issues under Step 1:

1. Which are the social, health, cultural and economic consequences of alcohol/drug use in this particular case?

2. Which are the substances of abuse? How and where are they distributed and sold to users?

3. Who are the users? Age? Gender? Social groups? Geographical areas?

4. Who else, besides the users themselves, are suffering from the alcohol/drug use?

5. In which settings does the substance abuse occur? Times? Places? Social situations?

6. Which are the factors that promote the substance abuse? Social? Cultural? Economical? Personal? (For more, see Step 7)

If you want to make a broader and more systematic problem description, we recommend you to use the methodology described in the previous chapter of this booklet; “Assessment of alcohol and drug problems”:

Step 5: Identification of stakeholders

Based on the description in Step 4 and your organization’s experience; who are the stakeholders in this particular case and issue? Which groups, institutions and individuals are involved in or affected by the substance use problems?

Some alternatives:

  • Users of alcohol/drugs
  • Their families and relatives
  • Third parties affected by someone’s drinking or drug taking
  • The village or the local community
  • Vested interests in production, distribution and sale of alcohol/drugs
  • Government institutions
  • Political parties
  • The health and welfare system
  • Community Based Organisations, Faith Based Organisations, Non-Governmental Organisations
  • Local police
  • Other professions
  • Media
  • Other groups?

Step 6: Identification of possible partners

Bearing your knowledge of the community in mind, make a list of organizations, institutions, groups and individuals who could be mobilized as your partners in prevention.

Some alternatives:

  • Social groups: Women, students, youth…
  • NGOs, churches, community based organizations (CBOs)…
  • Resource persons in local governments, the scientific community…
  • Local or national governments…
  • Professional groups: Doctors, social workers, teachers, nurses, police…
  • Other development NGOs…
  • Media persons…
  • Community leaders, traditional chiefs, celebrities…

Step 7: Defining the determinants

In order to design the most effective interventions, it is essential to understand the reasons and mechanisms – also called determinants – that draw or push persons towards drinking or taking drugs and, in turn, lead to regular consumption, risky consumption and dependence.

Availability is a key to understand the prevalence of substance use, as well as how and when such use takes place, as described in a previous chapter of this booklet. In the figure below it is indicated (with red arrows) that each of the four factors independently influence consumption levels and patterns. At the same time the four aspects of availability interact and influence each other (shown with dotted/green arrows). If a substance is easily accessible, the social acceptance tend to increase, – and the other way around; if a substance is socially accepted and attractive for individuals, the demand for easier access will often be stronger and politicians will be less prepared to restrict the sale.

The availability model

This model can be used to define which determinants in a given culture and community that contribute towards increased use of alcohol and drugs:

  • How easy is it to buy the most problematic substances? Is a substance legal or not? Number of outlets or sales points? Hours and days of sale? Etc.
  • What are the costs of the various substances compared to the income level of the population? Are discounts, cheap varieties etc. used to promote increased consumption?
  • How attractive is a substance in the population? What do people believe that the effects of the drugs are? Which expectancies do people have to the effects of a substance? Are there prevailing myths and misbeliefs around the substances? Is advertising and other promotions used to influence peoples’ attitudes and habits?
  • What is the social value of using a substance, and alcohol in particular? Which image do you paint of yourself by using one or the other substance? Which expectancies do people have to the social effects of a substance? What do individuals believe that other individuals expect you to do? What are people’s notions about non-users? What do people think/fear will happen if you do not use alcohol or a drug?

The next part of this exercise is to define which determinants that – after all – can be influenced by your interventions. Some things are relatively easy to change, others are more difficult. In politics and advocacy work one often has to start by picking the lowest hanging fruits and at the same time keep your long-term objectives and strategies in mind.

Step 8: Defining strategies and interventions

“There are many things we do with good intentions. Some of these undoubtedly improve our world. But a good part of our effort goes waste for lack of a clear enough idea of how best to get the results we want.” This is the starting point of the FORUT publication “Strategies to Address Alcohol Problems”, written by Professor Diyanath Samarasinghe at the University of Colombo, Sri Lanka.

Choosing the right strategies and interventions is of course the crucial issue in these Ten Steps for prevention of alcohol and drug problems. The choice of interventions must be made with the objective to achieve a maximum result with a minimum of resources.

The good news is that there is a broad evidence base for selecting which are the more and the less effective interventions. This international evidence is summarized in the WHO-sponsored study “Alcohol – No Ordinary Commodity” (Thomas Babor et al). The overall conclusion in this study is that restricting the sale and promotion of alcohol is the most cost-effective way to reduce alcohol-related harm. Such regulations should then be combined with education and mobilisation efforts, as described by The Prevention Triangle.

The sad side of the story is that the most effective measures – restrictions on availability – also are the most controversial. The more popular interventions (information etc.) also seem to be less effective, at least if they are implemented as stand-alone or one-off activities. There are good reasons to assume that a batch of coordinated interventions is more effective than single and isolated activities.

Bearing in mind the determinants you have defined in Step 7, the next step is to select strategies and activities for prevention of alcohol and drug problems:

How can you influence the most important determinants in your particular case?

  • How can physical availability to alcohol or drugs be more restricted in the target area? Are new regulations needed? Or is poor implementation of already existing regulations the real problem? If so, how can enforcement of regulations then be improved?
  • How can you make alcohol and drug use less accepted and attractive in the local culture?
  • How can you challenge prevailing alcohol expectancies in the target population? The acceptance and pardoning of bad behaviour by drunken people. The glamorisation of alcohol or drug use.
  • How can you give people knowledge about the real effects of alcohol or a drug? How can prevailing myths be challenged?
  • How can you sensitise people about the harm caused by alcohol and drug use on innocent victims around the user?

Mobilizing local communities has proven to be an effective strategy to reduce alcohol and drug problems. This is also recommended in the WHO Global strategy to reduce the harmful use of alcohol (WHO, 2010). The strategy in particular points at the potential to produce change in collective rather than in individual behaviour. Involvement of local communities may also secure that chosen interventions are sensitive to cultural norms, beliefs and value systems.

Step 9: Integrating the issue

It will be easier to make your alcohol and drug prevention activities a success, both internally and externally, if you manage to link the planned efforts to your already established programs and activities. You will then create synergies, and you can draw more effectively on the already existing competence in your organization.

An important issue for internal clarification is therefore: How can new activities in the field of alcohol/drug prevention best be integrated into your existing strategies and programmes?

Step 10: Training of staff and partners

Some of your key staff will need extra training on the topics and activities you have chosen. Many others will need basic education and, most of all, motivation for their own involvement.

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