PROJECT IMPLEMENTATION IN THE ALCOHOL AND OTHER DRUG FIELD: ENABLERS, BARRIERS AND SUSTAINABILITY

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1 PROJECT IMPLEMENTATION IN THE ALCOHOL AND OTHER DRUG FIELD: ENABLERS, BARRIERS AND SUSTAINABILITY i

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3 PROJECT IMPLEMENTATION IN THE ALCOHOL AND OTHER DRUG FIELD: ENABLERS, BARRIERS AND SUSTAINABILITY May 2010 Sarah MacLean, Lynda Berends, Barbara Hunter, Janette Mugavin and Bridget Roberts iii

4 ACKNOWLEDGEMENTS This project was commissioned by the Alcohol, Education and Rehabilitation (AER) Foundation. We are grateful to the AER Board for setting the study s broad parameters. The project Steering Group had extensive input into the research as it unfolded. We would particularly like to acknowledge the contributions of Tracey Purdam, Peter d Abbs and Robin Room. Turning Point staff spent many weeks at the AER office in Canberra, where all AER staff made us feel welcome. Thank you to Joanne Weir, Gai Atherden, Sarah Pedrana and Nick O Shea for locating files for review. We are grateful to Pat Ebeling for coordinating our visits and arranging travel. At Turning Point, Paul McElwee constructed the database utilised for the project and transferred data between software programs. This project draws on a wealth of documentary data recording the activities and outcomes of projects funded by the AER from It synthesises findings recorded by drug and alcohol workers, service managers and evaluators who reported to AER on funded projects. A range of participants were also involved in interviews concerning projects with which they had been involved. Among these were Adam Winstock, Cassandra Dunn, Dan Lubman, Kirsten Firman, Lois Gray, Lan Nguyen, Lucy Marshall, Steve Ella, Suzie Lowe and Tracey Purdam. We hope the report reflects some of the accumulated project wisdom of these contributors. Copyright 2010 Alcohol, Education and Rehabilitation (AER) Foundation. Reproduced with Permission of the Alcohol, Education and Rehabilitation Foundation. Unauthorised reproduction and other uses comprised in the copyright are prohibited without permission. Copyright enquiries can be made to the Communications and Publications Unit, Turning Point Alcohol and Drug Centre, Gertrude St, Fitzroy, Victoria 3065, Australia. Published by Inc. This project is funded by Alcohol, Education and Rehabilitation Foundation. The responsibility for all statements made in this document lie with the authors. The views of the authors do not necessarily reflect the views and position of the AER Foundation. The correct citation for this report is: MacLean, S., Berends, L., Hunter, B., Mugavin, J., & Roberts, B. (2010). Project implementation in the alcohol and other drug field: enablers, barriers and sustainability. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre. iv

5 TABLE OF CONTENTS Acknowledgements List of tables List of figures Abbreviated terms Executive summary iv viii ix x xi 1 Introduction Aim of the study Structure of this report The Alcohol, Education and Rehabilitation Foundation 2 2 Method Project steering group Project methodology Using realist synthesis Ethical issues Study limitations 16 3 Literature review Overarching themes Project types Providing services within specific contexts Conclusions from the literature 26 4 Defining project types Enhancing organisational systems and processes AOD training and workforce development Community education and prevention Engagement and treatment 32 5 Defining project contexts 35 v

6 5.1 Targeting young people Targeting Indigenous people Targeting inhalant users Based in capital cities Based outside capital cities 39 6 Defining enabling and barrier mechanisms Project planning and design Research and data collection Funding and resourcing Worker skills and expertise Organisational issues Staff team communication and relationships Partnerships, integration and coordination of services Responding to cultural diversity Engaging service users Systemic issues 48 7 Defining sustainability Staff capacity, skill and morale Organisational capacity and planning Benefits for clients Sector capacity Knowledge transfer 51 8 Enabling mechanisms by project type Enabling mechanisms across all projects Enabling mechanisms for enhancing organisational systems and processes projects Enabling mechanisms for workforce training and development projects Enabling mechanisms for community education and prevention projects Enabling mechanisms for engagement and treatment projects 61 9 Barrier mechanisms by project type 63 vi

7 9.1 Barrier mechanisms for all projects Barrier mechanisms for enhancing systems and processes projects Barrier mechanisms for workforce training and development projects Barrier mechanisms for community education and prevention projects Barrier mechanisms for treatment and aftercare projects Comparing barriers and enablers across contexts Enabling mechanisms for targeted populations Barrier mechanisms for targeted populations Enabling mechanisms for capital and non-capital city locations Barrier mechanisms for capital and non-capital city locations Sustainability Elements of sustainability for all projects Sustainability by project type Determinants of sustainability from the case study analysis Key findings and implications for service funding and development Mechanisms that enabled and impeded project implementation Mechanisms that enabled and impeded implementation by project type Mechanisms that enabled and impeded project implementation by context Factors associated with project sustainability Using the research to develop project implementation indicators Conclusion 100 Appendix 1: Enabling mechanisms and factors 101 Appendix 2: Barrier mechanisms and factors 104 Appendix 3: Evidence of sustainability 107 References 109 vii

8 LIST OF TABLES Table 1: Key steps in realist review... 6 Table 2: Project study sample exclusion criteria... 7 Table 3: Case study projects Table 4: Project types: inclusion criteria, number and percentage of sample Table 5: Project contexts: inclusion criteria, number and percentage of sample and relevant case studies Table 6: Comparison of themes from literature review with enabling and barrier mechanisms identified through project document analysis Table 7: Indicators of project sustainability after funding concludes Table 8: Enabling mechanisms by project type Table 9: Barrier mechanisms by project type Table 10: Enabling mechanisms for targeted populations Table 11: Barrier mechanisms for targeted populations Table 12: Enabling mechanisms for capital and non-capital city locations Table 13: Barrier mechanisms for capital and non-capital cities Table 14: Sustainability categories by project type viii

9 LIST OF FIGURES Figure 1: Model of driving and resisting forces in organisational development Figure 2: Enabling mechanisms for all projects Figure 3: Enabling mechanisms for enhancing systems and processes projects Figure 4: Enabling mechanisms for workforce and training and development projects Figure 5: Enabling mechanisms for community education and prevention projects Figure 6: Enabling mechanisms for engagement and treatment projects Figure 7: Barrier mechanisms for all projects Figure 8: Barrier mechanisms for enhancing systems and processes projects Figure 9: Barrier mechanisms for AOD training and workforce development projects Figure 10: Barrier mechanisms for community education and prevention projects Figure 11: Barrier mechanisms for engagement and treatment projects Figure 12: Enabling mechanisms for targeted populations Figure 13: Barrier mechanisms for targeted populations Figure 14: Enabling mechanisms for projects according to location Figure 15: Barrier mechanisms for projects according to location Figure 16: Category of sustainability by project type ix

10 ABBREVIATED TERMS ABS Australian Bureau of Statistics AOD Alcohol and other drug AER Foundation Alcohol, Education and Rehabilitation Foundation CIWA-Ar Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised DEN Drug Education Network Inc, Launceston, Tasmania DAP Drug Action Plan IT Information technology NACATSIHW Nationally accredited course for Aboriginal and Torres Strait Islander health workforce NGO Non-government organisation OHS Occupational health and safety TNF Ted Noffs Foundation VCAAP The Vietnamese Community Alcohol Awareness Project, Vietnamese Community in Australia, South Australia Chapter x

11 EXECUTIVE SUMMARY Since its inception in 2001 the Alcohol Education and Rehabilitation (AER) Foundation has funded more than 1,000 projects intended to reduce the burden of harm arising from alcohol and/or inhalant misuse in Australia. was commissioned by the AER Foundation to synthesise and analyse evidence stored in AER electronic and paper databases to build an evidence-base from these projects. Purpose of the study Projects have limited scope to achieve their intended impact on alcohol and other drug (AOD) use and misuse if they are poorly planned or implemented. While there is currently a strong emphasis on developing the evidencebase concerning the outcomes of various AOD interventions, little research systematically explores factors which enable or impede project implementation in the AOD arena. The study entailed detailed examination of completed projects funded by the AER to address three questions: 1. What conclusions can we draw from projects about enabling factors critical to successful project implementation? While there is currently a strong emphasis on developing the evidencebase concerning the outcomes of various AOD interventions, little research systematically explores factors which enable or impede project implementation in the AOD arena. 2. What conclusions can we draw about critical barriers to project implementation, and strategies adopted to deal with barriers? 3. What conclusions can we draw about determinants of sustainability in projects? This study is intended to be useful for people who are involved in the design, funding and implementation of projects, for instance, by alerting staff to difficulties which are likely to be encountered in relation to undertaking specific activities or identifying critical enablers to consider as part of program design. The study comprises three main methodological components: a brief literature review, analysis of data concerning 127 completed projects (overall project analysis), and in-depth consideration of eight project case studies (case study analysis). The report identifies mechanisms most frequently cited in project reports and evaluations as important to successful project implementation, or which were seen to constitute barriers to successful implementation (see table below). Additionally, each project was analysed by the research team to assess the extent to which project objectives had been achieved, with successful implementation defined as meeting 100% of project objectives. We then compared barriers and enabling mechanisms encountered: across four project types; for projects targeting three population groups; and, for projects located in capital cities or located outside capital cities. xi

12 Enabling and barrier mechanisms identified across the overall study sample The table below provides a brief description of each enabling and barrier mechanisms identified through the literature review and the overall study sample. Enabling mechanisms Project planning and design Evidence-based model, good fit to needs, flexible design, appropriate scoping, rules, holistic approach, advice on implementation Research and data collection Well documented, effective data collection, informed by ongoing research Funding and resourcing Well funded, used existing resources, gained additional funding, partner agency contributed resources Staffing and leadership Employed suitable staff or contractors, staff or management provided leadership, staff training activities undertaken Organisational governance and capacity Organisation already experienced in project work, good policies & procedures and suitable systems, effective reference group Staff team communication and relationships Staff engaged and enthusiastic about project, inclusion of consultation mechanisms External communication and relationships Strong support from partner agencies or from participating communities, utilised existing networks Sensitivity to service users and settings Model culturally appropriate, intensive support, employed culturally/gender appropriate staff Barrier mechanisms Project planning and design Poor fit, inadequate scoping, poor timing, IT problems Research, evaluation and data collection Poor data collection systems, low response to evaluation, datasets missing Funding and resourcing Submissions for ongoing funding unsuccessful, other funding problems at organisation Identifying and retaining staff Delay in staff recruitment, staff or management turnover, staff lacked required skills Governance Lack of management involvement, project staff overloaded, reference group unrepresentative or ineffective Workplace integration Staff roles unclear, staff conflict, staff didn t prioritise involvement, placed additional stress on staff Engaging communities and partners Lack of partner agency or community interest in or commitment to project, reluctance to address AOD issues Meeting cultural needs of specific demographic groups Resources or approach not culturally appropriate, failed to engage specific demographic groups Participatory approach to service delivery Target group involved in development, used role models or peer approaches, activity based approach Complexities of service users Participation poor, difficulties in service users lives interfered with attendance, challenging behaviours - Wider service system challenges Lack of other services, inter-professional problems, philosophical differences in addressing AOD Key enablers to successful project implementation across the study sample Of the enablers listed above, the study identified three key elements to successful project implementation. The first and most frequently observed of these was effective partnerships with other agencies and communities that the project is designed to work with. Partner agencies for projects in the study sample included AOD or health and welfare organisations, local government, police, and training institutions. Communities were defined by geographical proximity, We found that evidence in project records of a partner agency s enthusiasm for the project and for the organisation conducting it was significantly correlated with the project concerned achieving 100% of its objectives. xii

13 ethnicity, or Indigenous status. Project reports and evaluations consistently reiterated the importance of engaging other agencies in project activities and of maintaining harmonious relationships with these agencies. This was cited by 73% (n=93) of projects in the study sample as a key element in successful project implementation. We found that evidence of a partner agency s enthusiasm for the project and positive regard for the organisation conducting it was significantly 1 correlated with the project concerned achieving 100% of objectives. Receiving in-kind resources or services from partner agencies to contribute to the project was also found to be significantly correlated with successful project implementation, perhaps because this was an indication of partner agency commitment as well as capacity. Community enthusiasm for the organisation and project (and, in the case of projects run in Indigenous contexts, commitment of community Elders) was also significantly correlated with successful project implementation. Several case studies showed how successful partnerships between agencies hinged on commitment from partners, extensive consultation over project development, and a sense of value for the contribution of all agencies involved. Project leadership was identified as a mechanism for successful project implementation in relation to over half of projects in the study sample (61%, n=78). By leadership we refer to staff (in some instances, management) taking responsibility for the project, generating enthusiasm, and ensuring activities are implemented. Stakeholders interviewed in relation to successfully implemented projects praised staff highly for their initiative and energy. Effective project planning and design was also reported as enabling implementation in around half of all projects (61%, n=78). This entailed both development of a project design likely to have desired impacts on AOD use, and planning and scoping activities appropriately. Interestingly, evidence of involving the project s target group (e.g., young people attending treatment activities, or professional staff engaged in training activities) in development of resources and approaches was also significantly correlated with successful project implementation. Again this finding was borne out in case studies, particularly those involving Indigenous or culturally and linguistically diverse communities. Other mechanisms for successful project implementation identified through the study were (in order of frequency observed) organisational governance and capacity, sensitivity to service users, staff team communications, participatory approach to service delivery, adequate funding and resourcing, and, research and data collection. Barriers to successful project implementation The study also identified a range of barriers to successful project implementation. Difficulties related to project planning and design were recorded for just under half of all projects (49%, n=62). These problems frequently related to incorrect costing of projects and developing accurate timeframes for activities. Recruiting and retaining staff was the next most frequently identified major barrier mechanism which impeded successful project implementation within the study sample (39%, n=50). Employment of staff who lacked required skills was not identified as a significant barrier in statistical terms, however there 1 Statistical differences were tested using a Fisher s exact test. All differences resulted in a p value of 0.05 or less. xiii

14 appears to be some relationship with project failure. This barrier mechanism may have emerged as significantly associated with project failure to achieve all set objectives had the study sample been larger. 2 In one case study project implementation was seriously compromised when a staff member who had brokered the relationship with a key partner agency moved on unexpectedly. Just under half of all projects encountered barriers related to project planning and design, particularly in relation to costing projects and developing accurate timeframes for activities. Just as relationships with external agencies and communities proved critical in enhancing program implementation, they also led to difficulties for 32% of projects (n=40). Breakdown of partner agency relationships throughout the course of the project was found to be significantly associated with failure to achieve 100% of project objectives. 3 Dealing with the complexities of working with service users (reported in relation to 29%, n=37) of projects) was another barrier to service implementation. This included a range of issues such as other adverse events in service users lives impacting on treatment retention, challenging behaviours, and reluctance to address AOD issues. While research and evaluation was not one of the most frequently cited barrier mechanisms, one element emerged as important within this category. Almost a third of projects encountered difficulties relating to designing or implementing evaluations. In turn, this means a lack of evidence regarding project processes and effectiveness. Key enabling and barrier mechanisms by project type To identify different sets of factors which support and impede successful implementation across varying project types, four project types were identified. Projects in the study sample were each categorised within one project type according to their main activities. A particular range of barriers and enabling mechanisms was identified according to projects in each project type. Projects aimed at enhancing organisational systems and processes (n=39) These projects typically involved the development of key organisational documents and processes to guide AOD agency management and operations. For instance, projects in this category involved development of policies and procedures manuals, financial management systems or implementation of new software to manage case files or human resources data. Where they involved training, the focus of these projects was on enhancing management capacity or training staff to use IT systems. Strong project leadership featured prominently as an enabling mechanism for enhancing organisational systems and processes projects. This may be because many of these projects entailed employing specialist consultants or contracting an agency to undertake activities which were not within the skill set of existing staff. Staff team communication and the organisation s own capacity and 2 As one cell in this matrix was less than five this finding should be viewed as tentative. 3 While the difference was not statistically significant using the Fisher s exact test, the difference was significant using the Pearson Chisquare test. xiv

15 governance structures were also key mechanisms which were considered to enable successful implementation for these projects. Planning and design was the primary barrier mechanism identified from our analysis of enhancing organisational systems and processes projects. Scoping these projects (identifying appropriate timeframes for activities and budgets) clearly posed challenges for agencies. Workplace integration and communication was the second most frequently recorded barrier mechanism. Worker resistance to engaging in projects to develop new systems and processes constituted a significant barrier for these projects. Problematic relationships with other agencies were far less frequently identified as barriers to implementation than in other project types. AOD workforce development projects (n=18) These projects were designed to improve AOD service delivery through providing training or education. AOD workforce development projects took two main forms. Some aimed to improve capacity within the AOD workforce; for instance, by providing training to workers employed within an AOD agency, or within a range of AOD agencies. Others entailed training a range of professional staff, for instance, skilling teachers to deliver AOD training modules to school students. External communication and relationships emerged as the most commonly reported enabling mechanism to program implementation. Leadership by management and/or staff, and planning and design were also critical enabling mechanisms. As in the previous category, planning and design emerged as an important barrier mechanism for workforce development and training projects. In these projects, however, it was not primarily the scope of the project that was the issue, but designing a training package or program that would suit the needs of those who were anticipated to be involved. Difficulties involving staffing was the second most frequently identified barrier mechanism. For instance, some projects experienced serious trouble attracting and retaining suitably qualified staff. Community education and prevention projects (n=37) Projects in this category were designed to raise AOD awareness or effect policy or operational change. Some projects in this category targeted the whole population or a large group within the population, for instance, Indigenous people. Other projects focused on local community development, service coordination and planning, for instance, the development of a coordinated response to AOD use within a local government area. External communication and relationships were critical to successful implementation for community education and prevention projects, as were, to a slightly lesser degree, project planning and design and the organisation s governance and capacity. As these projects involved a range of agencies and (in some instances) targeted educational messages, tailoring the program sensitively to the setting in which it was implemented emerged as more important in this project type than in the previous two categories. Planning and design constituted the key barrier mechanism for community education and prevention projects. Staff recruitment and retention were also particularly challenging for these projects. xv

16 Engagement and treatment (n=33) The focus of these projects was on engaging people who use AOD, or who are identified as at risk of AOD misuse, to reduce use or to mitigate associated harms. Some projects provided recreation activities to divert people from AOD misuse, while others delivered AOD treatment or aftercare services. These projects frequently funded additional staff for a set period of time within an existing treatment and engagement project. Many of these projects involved partnering with other agencies to refer service users and share delivery of programs. Not surprisingly then, partnerships and relationships with external agencies was the most frequently cited enabling mechanism for these projects. Sensitivity to service users and settings also emerged as a key enabling mechanism. Within this mechanism over half the projects cited use of a culturally appropriate project model as a key enabling factor. Adopting a participatory approach emerged as important in engaging service users, a mechanism observed in relation to over half of the projects within this category. Difficulties encountered in relation to meeting the needs of service users was the most frequent barrier mechanism identified in engagement and treatment projects. Difficulties in clients lives were viewed as constituting a barrier for a quarter of projects. For instance, homelessness appeared to impede program attendance or treatment outcomes in some projects. Responding to challenging behaviours (such as clients attending the service while intoxicated) also constituted an ongoing challenge for staff. Planning and design was the second most common barrier mechanism for engagement and treatment projects. This frequently entailed concern that the program did not suit the needs of service users and required some form of adjustment, for instance, that sessions should be run more or less frequently. Enabling and barrier mechanisms for projects targeting, young people, Indigenous peoples and inhalant users These categories of project were not mutually exclusive and strong similarities in enabling and barrier mechanisms emerged from the analysis. External communication and relationships was the most frequently cited enabling mechanism for projects targeting young people, Indigenous peoples and inhalant users. Using participatory approaches to service delivery was particularly important for projects targeting inhalant users and youth, and emerged as only slightly less important for projects targeting Indigenous people. The third most commonly recorded enabling mechanism for these projects was sensitivity to service users. Of interest was that project planning and design emerged as particularly important in projects targeting young people. This suggests that these projects may be difficult to accurately scope and cost. The most frequently cited barrier mechanism across these project types was project planning and design. Managing challenges posed by service user behaviour presented difficulties for projects targeting inhalant users or young people but was of less concern in relation to projects targeting Indigenous service users. Communication and relationships with partner agencies and with participating communities was viewed more frequently as an enabler for projects targeting young and Indigenous peoples, than it was in relation to projects targeting inhalant users. xvi

17 Enabling and barrier mechanisms for projects based in capital cities and based outside of capital cities Two mutually exclusive categories were used to distinguish projects: capital city location and noncapital city location of the agency managing the project. Communication and relationships with external agencies was more frequently viewed as an enabling factor in projects based in agencies located outside capital cities. Organisational capacity and governance was more frequently mentioned as enabling project implementation in relation to projects located in capital cities than outside capital cities. All barrier mechanisms except that pertaining to coping with challenging behaviours of clients were more frequently cited in relation to projects located outside capital cities than those located in capital cities. The greatest differences between capital city and non-capital city projects emerged in relation to attracting and retaining staff, relations with community agencies and project partners, and organisational governance. For instance, non-capital city projects reported barriers pertaining to organisational governance almost six times as frequently as those in capital cities. Communication and relationships with external partners and communities was observed almost twice as frequently as a barrier in relation to projects in noncapital city settings. No project context (geographical location of project, or targeted population) or project type emerged as significantly more or less likely to meet all objectives, suggesting that AER project objectives have been designed to take into account the difficulties posed by addressing particular target groups and location outside capital cities. Projects based outside capital cities reported barriers pertaining to organisational governance almost six times as frequently as those based in capital cities. Communication and relationships with external partners and communities was observed almost twice as frequently as a barrier in relation to projects in noncapital city settings than in relation to projects located in capital cities. Determinants of sustainability Our case study analysis entailed investigation of which project elements had actually proved sustainable after the expiration of project funding. While based on a small sample (eight case studies) this component of the research enabled us to identify four determinants of project sustainably. These were: Integrating the project into the operations of the agency Case study projects illustrated the importance of organisational commitment to sustaining new systems, continuing to use new resources, or implementing a strategic plan after AER funding finished. xvii

18 Developing an intervention or resource which fills a critical gap in the sector and thus is taken up by various agencies The second determinant of sustainability identified from case studies is somewhat more difficult to plan for than the first. One case study entailed such a useful and high profile intervention as to be adopted internationally. Building support from key individuals and agencies through the life of the project Project sustainability was enhanced by gaining support throughout the duration of the project to implement activities in an ongoing way. Support from government departments or people in positions of authority were particularly important here. Planning realistically for future community ownership of activities Some projects utilising a community development approach aimed to foster community ownership of activities. Staff of one very successful project found that activities were not ongoing after expiration of funding as this proved too difficult for voluntary community members without support from funded staff. Another project s experience was that skilling community volunteers to share information about alcohol as part of daily interactions produced an ongoing effect. Four determinants of sustainability identified from case studies were: Integrating the project into the operations of the agency Developing an intervention or resource which fills a critical gap in the sector and thus is taken up by various agencies Building support from key individuals and agencies through the life of the project Planning realistically for future community ownership of activities Conclusions This study identifies a range of factors which are implicated in AOD project implementation and project sustainability, providing a detailed evidence-base for AOD professionals and policy makers involved in designing and implementing projects in a range of different contexts. It particularly highlights the importance to AOD projects of maintaining positive relationships with partner agencies and communities, of employing staff with appropriate expertise and of careful project planning and design. These should be areas where effort and resources in the AOD sector are targeted in future. The study also demonstrates how enabling mechanisms and barriers vary between types of projects, in projects located in different geographical settings and in relation to projects targeting different populations. Study findings could be used in a range of ways to enhance project implementation in the AOD field, for instance as the basis for development of project funding criteria, project performance indicators and project development training activities. xviii

19 1 INTRODUCTION Since its inception in 2001, the Alcohol Education and Rehabilitation (AER) Foundation has funded more than 800 projects intended to reduce the burden of harm arising from alcohol and/or inhalant misuse in Australia. All projects have received time-limited funding. (Turning Point) was commissioned by the AER to synthesise and analyse evidence stored in AER electronic and paper databases on the effectiveness and efficiency of a sample of completed projects funded by the AER during Aim of the study This study, titled Building an evidence-base from Alcohol Education and Rehabilitation (AER) Foundation funded projects, aims to address three questions: 1. What conclusions can we draw from projects about enabling factors critical to successful implementation? 2. What conclusions can we draw about critical barriers to implementation, and strategies adopted to deal with barriers? 3. What conclusions can we draw about determinants of sustainability in projects? 4 Study findings are intended to be a resource for service providers, policy-makers, researchers and others involved in developing or evaluating alcohol or inhalant harm prevention interventions. This study has three main methodological components. The first of these is an exploration of AER electronic and paper databases, conducted to harvest information about a sample of relevant projects. The second component comprises the validation of findings through a brief review of relevant literature concerning alcohol and other drug (AOD) projects. The third component is a series of eight in-depth case studies of selected projects, to explore identified issues and themes in greater detail. 1.2 Structure of this report This report has 13 chapters. This chapter (Chapter 1) introduces the aims of the study, and of this report. Chapter 2 outlines the methodology utilised to collect and analyse study data. Chapter 3 provides a brief overview of literature relevant to the study. Chapters 4 and 5 introduce respectively the project types, and project contexts, used to categorise projects in the study sample. Key barrier and enabling mechanisms identified through the study are outlined in Chapter 6 and elements of sustainability are introduced in Chapter 7. Chapter 8 shows the particular range of enabling factors that operates across each project type and Chapter 9 describes barrier mechanisms recorded for each project type. Chapter 10 compares enabling and barrier mechanisms encountered by projects according to the contexts of population targeted and location. In Chapter 11 we report on project elements associated with sustainability. Chapter 12 summarises findings and outlines some 4 Paraphrased from Alcohol Education and Rehabilitation Foundation Ltd (2008) 1

20 implications for developing and funding projects in the AOD arena and a conclusion is provided at Chapter The Alcohol, Education and Rehabilitation Foundation The AER was initiated in April 2001 as a result of a decision between the then Prime Minister and the then Leader of the Democrats to use funds that had been collected as excise on draught beer which were in addition to rates prescribed since 1 July 2001 (Silburn et al., no date). Objectives and an administrative structure for the AER were set out in the Alcohol Education and Rehabilitation Special Account Act The AER was established with the goal of reducing alcohol and licit drug-related harm in Australia (including petrol sniffing). It was given the task of distributing more than $115 million, with the stipulation that at least 80% of this money should be spent on treatment and rehabilitation, and on public education and prevention. Indigenous people and young people were priority population groups for expenditure, and at least 20% of funds were required to be directed towards Indigenous organisations (Purdam, d'arx, Lindsay, & Thomas, 2005; Silburn et al., no date). Since 2001 the AER has advertised a number of funding rounds with funding criteria designed to meet their requirements for expenditure (Purdam et al., 2005). The AER is governed by a Board which approves funding decisions. The AER was evaluated in three waves ( , and ) by the Australian Institute for Primary Care at La Trobe University (Silburn et al., no date). Due to the availability of only small numbers of completed projects, earlier evaluations focused on reviewing policies and data collection processes. By a greater number of projects were available for review, although evaluators observed that any overall assessment of the AER s impact was severely limited by the lack of data collected by funded organisations. The evaluation focused on identifying the breakdown of funding allocated to various activities (i.e. prevention and education, research) and to target groups (i.e. Indigenous Australians and young people). It also considered AER Foundation processes and procedures for receiving and processing applications. Project impact was evaluated through a series of nine case studies of funded projects identified as successful by AER staff. In compiling these case studies, evaluators draw on stakeholder interviews and project documentation. The evaluators concluded that AER funded a range of approaches to reducing alcohol and other licit drug related harms with diverse impacts which were difficult to measure (Silburn et al., no date). While this study does not itself measure project outcomes in terms of any project s actual impact on AOD use and misuse, it does consider - through an analysis of existing documentation the process of project implementation and the extent to which set project objectives were met. 2

21 2 METHOD This is a unique study and a significant component of the project has been the development of bespoke methodology. In this chapter we introduce the overarching methodological approach that guides this research project: a modified version of realist synthesis (Pawson, Greenhalgh, Harvey, & Walshe, 2005). The project entailed the following three main methodological components: 1. a brief literature review 2. analysis of data concerning 127 completed projects (referred to as the overall study analysis and overall study sample ) 3. in-depth consideration of eight project case studies (referred to as case study analysis and case study sample ). Data collection and analysis methods are described in some detail in this chapter to contextualise study findings presented later in the report. 2.1 Project steering group Prior to the commencement of the study a Steering Group was formed to determine the scope and to clarify the key questions of the project. The team consisted of two AER representatives: Professor Peter d Abbs (AER board member) and Tracey Purdam (Executive Officer of AER) and three representatives from Turning Point: Robin Room, Lynda Berends and Sarah MacLean. The group met throughout the duration of the study and were consulted on key methodological and procedural decisions. 2.2 Project methodology As introduced above, this research focused on identifying enabling factors, barriers and determinants of sustainability within a set of projects which received AER funding between 2002 and In doing so we analysed project contracts, reports and other documentation and (where they existed) project evaluations conducted by external agencies or consultants. Although the Steering Group excluded projects from the sample where too few similar activities were funded to make useful comparisons, a heterogeneous sample of projects with differing aims and objectives was identified for inclusion. It was impractical, therefore, to utilise a systematic review methodology, which would entail focusing on a specific research question and sourcing studies through a search of databases using tailored search parameters. Realist synthesis Realist synthesis, the methodology that guides this research, is a modified version of realist review (Pawson, 2002; Pawson, Greenhalgh, Harvey, & Walshe, 2004; Pawson et al., 2005). Realist review attempts to grapple with the complexity of factors influencing a complex social intervention s impact or outcomes by reviewing theories that are actualised within the intervention, rather than the programs per se. In order to explain the realist synthesis methodology, it is helpful to explore what Pawson, Greenhalgh, Harvey, and Walshe (2004) mean when they talk about complex social interventions. A complex social 3

22 intervention can be described as a theory of action, guided by an underlying rationale of why the action will influence or create change. There are a number of actors involved in any intervention. The motivations, intention and interactions of these actors will influence the direction or impact of an intervention. In line with this, complex social interventions are situated within complex social situations; informed and influenced by the social and structural contexts within which they are enacted. The complex social intervention is a living, active and interactive theory. It contains a number of steps or processes that are connected and may influence each other. It may have a linear flow, or may operate in an iterative, cyclical or non-linear manner. It can be modified and adapted throughout the implementation process, influenced by the actions of people involved and other contextual factors. Finally, complex social interventions evolve as stakeholders become more familiar or aware of the possibilities (impacts and outcomes) associated with the theory of action. The realist synthesis methodology examines complex social interventions by identifying the important components that describe the theory underlying the social intervention. Specifically, Pawson et al (2004) examine the context, mechanisms and outcomes associated with a complex social intervention. Pawson et al (2004) use the category of context to describe the direct environment in which the intervention is being implemented. Context may operate at different levels, including a local level, for example, skill gaps; a population level, for example, target groups (youth, rural); or a political level, for example, policy environments. The category of outcomes is used to describe the connection or result of interaction between the steps (or processes) involved in the complex social intervention. This is the change that was intended (or unintended) as a result of the initial action. The element of the realist synthesis methodology that allows us to understand how the complex social intervention achieves its outcome is the mechanism. Pawson et al (2004) use the term mechanism to describe the factor or element that connects actions, situates them within the relevant context, and links them to the outcome. Realist synthesis is built on the premise that it is not programs themselves which have effects, but rather how or why they act on individuals or groups to generate change. Pawson (2002) terms the generation of effect a program mechanism. This notion allowed us to compare projects which were based on different activities however share a broadly-defined mechanism. Realist synthesis is appropriate for use with complex interventions that have multiple components, operate across multiple sites and involve multiple actors or agents. It is generally used to assess the effects of similar program mechanisms across different contexts. For example, Pawson (2002) explored the effect of incentivisation (providing incentives to people to use services or engage in programs) across the contexts (or domains) of smoking cessation, housing and correctional services. Application of realist synthesis The contexts in which public health interventions are applied invariably affect their outcomes (Jackson & Waters, 2005). No program is ever implemented within the exact same context, and a key strength 4

23 of realist review is that it aims to understand how program mechanisms work differently in varying contexts. Realist review attempts to develop a contextual understanding of program logics by asking what works, for whom in, what circumstances, in what respects and how (Pawson et al., 2004, p v). This involves understanding the relationships between the contexts in which programs are enacted (C), their underlying mechanisms (M) and their outcomes (O). Through offering a multi-factorial analysis of any program effect, Pawson and colleagues (2004) claim that realist synthesis offers policy makers complex information about how, where and why programs are likely to be effective, proposing what program mechanisms might be transferable and in what circumstances: With its insistence that context is critical and that agents interact with and adapt to policies and interventions, realist synthesis is sensitive to diversity and change in programme delivery and development. Its fundamental purpose is to improve the thinking that goes into service building. And in doing so, it provides a principled steer away from issuing misleading pass/fail verdicts of entire families of interventions and away from failed one size-fits-all ways of responding to problems. (Pawson et al., 2004, p iii) The basic steps of conducting a Cochrane systematic review of evidence have been adapted by Pawson et al (2005) to fit the conceptual CMO model, as the following table (Table 1) outlines. 5

24 Table 1: Key steps in realist review Step 1. Clarify the scope of the review Step 2. Search for evidence Step 3. Appraise primary studies and extract data Step 4. Synthesise evidence and draw conclusions Step 5. Disseminate, implement and evaluate Identify the review question What is the nature and content of the intervention? What are the circumstances or context for its use? What are the policy intentions or objectives? Refine the purpose(s) of the review Theory integrity does the intervention work as predicted? Theory adjudication which theories about the intervention seem to fit best? Comparison how does the intervention work in different settings, for different groups? Reality testing how does the policy intent of the intervention translate into practice? Articulare key theories to be explored Draw up long list of programme theories by exploratory searching (see Step 2) Group, categorise or synthesise theories Design a theoretically based evaluative framework to be populated with evidence Exploratory background search to get a feel for the literature Progressive focusing to identify key programme theories, refining inclusion criteria in the light of emerging data Purposive sampling to test a defined subset of these theories, with additional snowball sampling to explore new hypotheses as they emerge Final search for additional studies when review near completion Use judgement to supplement formal critical appraisal checklists, and consider fitness for purpose Test the relevance does the research address the theory under test? Test rigour does the research support the conclusions drawn from it by the researchers or reviewers? Develop bespoke set of data extraction forms and notation devices Extract data to populate the evaluative framework with evidence Synthesise data to achieve refinement of programme theory that is, to determine what works for whom, how and under what circumstances Allow purposes of review (see Step 1b) to drive the synthesis process Use contradictory evidence to generate insights about the influence of context Present conclusions as a series of contextualised decision points of the general format If A, then B or In the case of C, D is unlikely to work Draft and test out recommendations and conclusions with key stakeholders, focusing especially on levers that can be pulled in here-and-now policy contexts Work with practitioners and policy-makers to apply recommendations in particular contexts Evaluate in terms of extent to which programmes are adjusted to take account of contextual influences revealed by the review: the same programme might be expanded in one setting, modified in another and abandoned in another From Pawson, Greenhalgh, Harvey, and Walshe (2005, p. 24) This approach, whilst outlined sequentially above, needs to be an iterative and fluid process. Each step should be revisited as more information is uncovered, or as different understandings are developed. It is a complex and multi-layered approach that ultimately yields a breadth of information about what works, for whom and in what circumstances (Pawson et al 2004, p. 3). 6

25 2.3 Using realist synthesis In this section we describe how the steps involved in conducting realist synthesis were adapted for utilisation in this study across the three study components; brief literature review, overall study analysis and case study analysis. Step 1. Clarifying the scope of the review The AER s database of completed projects was the source of all projects considered within the study. The AER has funded more than 1,000 projects over the last 8 years; however a group of 127 completed projects was identified for the study sample through assessing each project against agreed exclusion criteria, which we refer to as the overall study sample. The eight case studies were selected from within this overall study sample. Each project within the AER database was assessed by two criteria: relevance and rigour (Pawson et al., 2005) for inclusion in the project study sample. Programs were considered relevant where their underlying mechanism was similar enough to other projects so that something could be learned about how they worked in comparison with others. We interpreted rigour as having sufficient documentation from which to assess whether project objectives were met, defined as the presence of either a final project report or external evaluation in the files. Projects funded for $20,000 or less were also excluded on the basis that they were subject to different reporting requirements. The Steering Committee agreed on the following exclusion criteria, as outlined in Table 2 below. Table 2: Project study sample exclusion criteria Project type Capital works and equipment purchase, software purchase as the sole activity Conference, convening and attendance, meetings, and associated travel Workshops which include a significant training component will be included Festivals and alcohol free events Research External evaluation research Scholarships, workplace exchange and funding toward postgraduate studies Employment Merging services Projects focused on improving financial management capacity Projects without any external evaluation or final report Small grant less than $20,000 Examples Build accommodation; refurbishment Funding for conferences; funding for meetings or travel to meetings Large alcohol- free event Research to identify interventions to reduce burden of harm associated with alcohol misuse Evaluation of whole NSW government project Stipends for specified individuals Employment of two training officers where no other objective is stated Merging of local AOD services Corporate financial management training 7

26 Project documentation is stored electronically and on paper files at the AER. Each project file includes initial applications, records of relevant AER funding decisions, service agreements, project interim and final reports and other documentation of activities provided by the funded agency. External evaluations were commissioned for some projects and these were also stored in project files. All data for projects included in the study sample were included in the file review. Step 2. Search for evidence Literature review A brief literature scan was conducted to examine the key mechanisms operating within each social intervention, given the breadth of interventions examined in this project. This scan informed the development of the database tool. We also reviewed literature concerning methods followed in relevant research projects i.e. (Collins, Johnson, & Becker, 2007; Cummings, 1999; Giesbrecht & Haydon, 2006; Holder, 2004; Wood, Shakeshaft, Gilmour, & Sanson-Fisher, 2006). These references were identified through a search of key terms including community alcohol and other drug intervention, realist synthesis and meta-analyses. Studies of complex health and welfare interventions were also reviewed, after the database was developed and initial analysis commenced, to develop an understanding of various ways of identifying underlying mechanisms and project types for later analysis (i.e. Cummings, 1999; Gray, Saggers, Sputore, & Bourbon, 2000; Loxley et al., 2004). Once a set of four project types and five contexts had been identified through analysis of the database, specific searches were conducted to develop a brief literature review concerning relevant enabling factors and barriers to successful implementation across project types and contexts. Terms for identified project types and target group contexts were used to inform searches for reviews and other key texts in major health and social research databases: Ovid Medline, PsychInfo, Scopus, the Campbell and Cochrane libraries, ProQuest Social Science Journals and Health & Society. The researchers also drew on their own professional libraries in accessing relevant articles and texts. Step 3. Appraise primary studies and extract data Database development Data from files included in the project study sample were recorded in an Access database. This database was developed for the study after a preliminary review of a sample of files. The database was designed to gather information and administrative details relevant to projects in the study sample and to include fields pertaining to: the context of (C) of each project (including, funding amount, time frame, urban, rural or remote location, populations targeted) project mechanism (M) (identified through analysis of enabling factors and barriers) outcomes (O) (whether projects met, partially met, did not meet or failed to provide evidence of meeting agreed objectives) and evidence of sustainability after the conclusion of funding 8

27 Given the nature of the study, a predominantly qualitative approach was required to examine the common and differentiating features influencing project success. Some fields or questions were particularly complex and required free text for later coding. For instance, it was not feasible to develop an understanding of project mechanisms prior to analysis of the data. For this reason an open coding system was used to record enabling factors and barriers as data collection proceeded. Broad program mechanisms could not be identified until all projects had been considered and an initial data analysis stage had been completed to identify barrier and enabling factors. Data entry Data were recorded in Access for each project. Some data were recorded manually while other data were imported directly from AER electronic records. Data recorded for each project were reviewed by a second researcher and refined as project categorisation developed. Step 4. Synthesise evidence and draw conclusions Synthesise evidence The analysis of data stored in the Access database developed for the project required an extensive process of synthesis; whereby common and contrasting concepts were clarified. This involved categorising projects, contexts and mechanisms to support meaningful data comparison. Categorising project types We reviewed various strategies for classifying interventions. For instance, the Institute of Medicine (Roberts, 2004) system distinguishes between four categories: 1. universal prevention interventions targeting a broad population, i.e. primary school children 2. selected prevention interventions targeting at risk groups and aiming to develop positive coping and life skills 3. indicated prevention interventions targeting those already engaged in problematic practices such as harmful AOD use, but who are not yet considered dependent, aiming to reduce progression and risk 4. treatment treatment interventions targeting substance-dependence individuals We required a small number of project types to ensure that each category would include sufficient numbers of projects to enable data analysis. The best fit for categorising projects in the study sample emerged as an adapted version of the typology put forward by the Institute of Medicine. We list these here and through the report in an order which enables us to group projects which do not involve service users (project types 1&2), which do involve service users (project types 3&4) and projects where education is a significant component (project types 2&3). We report on the following project types: 1. enhancing organisational systems and processes projects which work to improve organisational responses to AOD through enhanced systems and processes 9

28 2. AOD training and workforce development projects which aim to improve AOD service delivery or awareness through provision of training to the AOD workforce or to other service providers, for instance teachers or pharmacists 3. community education and prevention projects that attempt to raise AOD awareness, prevent misuse or effect policy change by influencing the population or a large group within the population i.e. Indigenous people, or through local community development and planning 4. engagement and treatment projects designed primarily to engage and influence individuals and groups who misuse AOD or who are at risk of doing so, or to provide treatment and aftercare. 5 A small number of projects entailed objectives that might be classed within two categories. To avoid double counting we identified the most suitable category for each of these projects by examining the project summary or other documentation to identify key activities. These project types and associated criteria for inclusion are described in Chapter 4. Identifying contexts A range of data on project context was also collected in the Access database. These included whether an external evaluation was conducted in relation to the project partner agency involvement project cost (coded as less than $100,000, $100,000 to $199,999, $200,000 to $299,999, $300,000 to $399,999 and over $400,000) project location according to postcode project duration in days project target group (workers, Indigenous people, culturally and linguistically diverse communities, youth, inhalant users, communities experiencing socio-economic disadvantage, forensic service users, older people and alcohol users) 5 Our third category community education and prevention - equates to universal prevention in the Institute of Medicine typology for categorising intervention types. Our fourth category engagement and treatment - amalgamates three Institute of Medicine classifications: selected prevention, indicated prevention and treatment (Roberts, 2004). 10

29 Data were subsequently analysed in relation to five project contexts. These contexts were selected because they were considered likely to be of interest to AOD professionals, policy makers and others designing and delivering interventions. The first three were identified by the target populations they were designed to influence. These are projects that targeted: 1. young people 2. Indigenous peoples 3. inhalant users The second two contexts were defined by geographic location, and include projects that were: 1. based in agencies in capital cities 2. based in agencies outside capital cities. 6 Criteria for inclusion of projects in these context categories are described in detail in Chapter 5. Identifying mechanisms Project mechanisms were developed through a complex process involving two levels of analysis. This occurred through the data collection phase as an iterative process involving reading literature that categorised factors and through drawing on categories in the data. Barriers and enabling factors to successful implementation and indications of sustainability were recorded as text fields in the Access database. First cycle coding entailed the development of provisional and descriptive codes to categorise descriptions of enablers and barriers to successful project implementation recorded in project files (Saldana, 2009). Enabling factors and barriers recorded for only one project were excluded prior to further analysis. These categories are referred to in the report as enabling factors and barrier factors. Fifty one enabling factors and 54 barrier factors were identified. Second cycle coding entailed pattern coding to identify broad mechanisms that operated across a number of projects. Pattern codes are used to...identify an emerging theme, configuration or explanation. They pull together a lot of material into a more meaningful and parsimonious unit of analysis (Miles and Huberman, 1994, cited in Saldana, 2009, p. 152). Enabling factors were grouped as nine key pattern codes and barrier factors were grouped as ten key pattern codes. For consistency with realist synthesis terminology these pattern codes have been termed mechanisms. The mechanisms are listed in conceptual order, with mechanisms that pertain specifically to the project and its funding listed first, moving to staffing and organisational issues, to relationships with external agencies, and with mechanisms concerning service users and the service system concluding the list. 6 This distinction was determined using the Australian Standard Geographical Classification (2006) from the Australian Bureau of Statistics. Projects were classified according to agency postcode. 11

30 The number of mechanisms identified across projects created a challenge for the project, as there were far more mechanisms in this project than in a typical realist synthesis (Pawson et al, 2005). This was because studies included in our sample were not selected on the basis of sharing an underlying theory or mechanism, but rather mechanisms were identified within a set sample of projects. Enabling and barrier mechanisms identified from the project analysis are outlined in Chapter Six. Appendices 1 and 2 show the enablers and barriers identified at both the levels of factor and of mechanism. Identifying outcomes Successful implementation was defined by the project Steering Committee as meeting all project objectives. Project objectives were recorded in the service agreement for each project. As service agreements are signed by both funding agencies and grantees they are the most reliable indication of both parties agreement as to what should be achieved. Objectives listed in service agreements were used as the basis of assessments of successful implementation wherever possible. However, for some projects the objectives listed in the service agreement were generic to all projects within a funding category or funding round, and they did not reflect the specific range of activities implemented to meet needs in a local context. This put the project at risk of being judged on objectives that may not have been relevant to it and, as such, as not having achieved anticipated outcomes. For instance, many earlier organisational capacity projects had three generic objectives which sometimes did not match neatly to the activities and outputs of projects and thus made them less likely to be assessed by the researchers as having met 100% of objectives. Objectives (often drawn from project applications) are mapped onto AER electronic records as outputs. Project intentions and achievements are also recorded as outcomes and in some instances also as impacts (the latter two fields are completed by AER staff as interim and final reports arrive). For projects with generic objectives in service agreements, we looked at the project outputs and outcomes as listed on the AER database and entered these into our database. This was done under the assumption that these outcomes and outputs represent both the AER s and the grantee s expectations about what the project should achieve. Objectives stipulating the agency concerned should secure ongoing funding for the project were excluded on the basis that obtaining ongoing funding is determined in part by availability of funding sources and thus is largely outside the control of the agency concerned. Success on this measure was not considered relevant to project implementation. Rating project implementation To determine a global score for each project reflecting successful project implementation, a set of objectives for each project was identified based on the method identified above. Each objective was rated as either met, partially met, not met or unknown. Project objectives were rated using the following formula: objective met = 1 partially met = 0.5 not met/unknown = 0 12

31 Projects were given an overall score based on an average of their achievement of objectives. This score was translated into a percentage. The following formula was utilised to categorise projects as either successfully or less successfully implemented: 100% of objectives met were considered successfully implemented (n= 77) Less than 100% of objectives met (n=50) Draw conclusions Barriers, enabling factors and elements of sustainability identified for each project were coded using Excel software. All Excel data were subsequently exported to SPSS for analysis. The major point of variation in this study from Pawson et al s (2005, p. 24) model for realist synthesis is that the conclusions are not expressed as a series of contextualised decision points of the general format; if A, then B or in the case of C, D is unlikely to work. This is because the number of mechanisms identified through considering a diverse set of projects made it difficult to reach this level of detail with confidence. Instead statistical analyses were run in SPSS searching for associations between project success (defined as meeting 100% of objectives) and other variables including contextual factors, project types, project mechanisms and enabling factors and barriers. This enabled us to identify key factors associated with success, for instance factor A supports project success. Fisher s Exact Test was used to assess significance, with a p value of 0.05 or less assess as denoting significance. The small sample size of projects in the study made it difficult to achieve statistically significant results. Nonetheless we report on a small number of significant correlations between the range of variables included in the study and this measure of project implementation. One substantial (but non-significant) correlation is also described. Identifying elements of sustainability In reading through project reports and evaluations we documented evidence of project sustainability. These categories for evidence of sustainability were developed using a similar process to that utilised to identify barrier and enabling mechanisms. We firstly identified lower-level elements of sustainability, and then grouped these elements conceptually as categories. Appendix 3 lists sustainability categories and associated elements. Step 5. Disseminate, implement and evaluate Case study review The final component of this research is a series of case studies of AER funded projects. The purpose of this study component is to define and describe successful implementation in context and to identify factors associated with sustainability. Each case study consists of a unique case analysis, for individual cases, followed by cross-case analysis examining themes, similarities and differences across cases. Although Pawson does not describe the use of case studies as part of realist synthesis, other researchers have incorporated case studies as part of realist synthesis reviews. For instance, Koenig (2009) and Leone (2008) use case studies to identify and explore theoretical models of what works for 13

32 whom in what circumstances. Koenig suggests that evaluators might use case studies to test hypotheses and to refine or generate theory on how and in which contexts programs based on particular theoretical constructs may be seen to produce specific effects. Case study sampling Stake advises that case studies should be selected not to be representative but because they may provide insight into an issue or refinement of theory developed for the project (1998, p. 88). Cases - whether critical, extreme, typical, successful, unsuccessful - are then selected according to the research purpose (Patton, 1990). The Success Case Method, for example, samples and examines extreme cases to identify generic success factors (Brinkerhoff, 2003). Following this method, two case studies were selected (in consultation with AER representatives) from each project type as identified above; one exemplifying successful implementation and the other providing an example of a project which encountered some barriers to implementation. In some instances projects identified as experiencing barriers to implementation went on to produce excellent outputs. Projects were preferred where they had been completed subsequent to 2007, and where an external evaluation had been conducted, however it was not always possible to select a case study project within each category and according to these criteria. We also tried to obtain a mix of capital city and non-capital city projects, projects targeting Indigenous people, inhalant users and young people and to represent a mix of states and territories within the case study sample. Representatives from each agency which had operated case study projects agreed to the inclusion of their agency s project in the study. Each of the case studies is introduced in Chapter 4. Table 3, below, shows the projects were included as case studies and the organisations which managed funding for these projects. 14

33 Table 3: Case study projects Project name Mt Theo Palka-Jarrija Project. Management Capacity Building in a Complex Alcohol and Drug Service Nationally accredited course for Aboriginal and Torres Strait Islander health workforce (NACATSIHW) CD ROM to support the routine use of CIWA- AR in the general hospital setting Vietnamese Community Alcohol Awareness Project (VCAAP) Launceston Drug and Alcohol Action Plan (DAP): A Community Approach to Substance Use Prevention Be Real, Be in Control An activity-based cognitive behavioural group intervention for young inhalant users Organisation Mt Theo - Yuendumu Substance Misuse Aboriginal Corporation, Northern Territory The Ted Noffs Foundation, New South Wales School of Public Health, University of Sydney, New South Wales South Western Sydney Area Health Service - Drug Health Service, New South Wales Vietnamese Community In Australia South Australian Chapter Inc., South Australia Launceston City Council, Tasmania South Burnett CTC 7 Youth Services, Queensland Orygen Research Centre, Victoria Case study data collection and analysis Interviews were arranged with up to four key stakeholders for each case study. A total of 22 interviews were conducted, involving 16 individual participants. For two case studies only two stakeholders each were interviewed; in one instance we felt we already had ample information on the project and appropriate interviewees were unavailable at the time; in the other instance we did not receive a response to requests for a third interviewee. For each project, interview participants comprised AER staff and the key contact person for each project as recorded on the AER records (excluding in one project where this person had left the agency concerned), and a third who had been closely involved in the project. For the six projects where a third or fourth stakeholder was interviewed, suitable interviewees were recommended by a previous interviewee. Informed consent was obtained from all interview participants. A semi-structured questionnaire based on the key questions for the research was used to guide interviews. Interviews were transcribed and analysed using the software package NVivo 8. Transcripts were coded thematically according to the key concerns of the research: enabling factors, barriers, strategies to address barriers, elements of 7 The official name of this service is South Burnett CTC Youth Services. CTC originally stood for Community Training Centre, however the name was changed when the service took on a more diverse role. 15

34 sustainably and how sustainability was achieved. For each case study interview data were triangulated with analysis of reports and other documentation. Some of the case study material utilised in the report is sensitive. For example, stakeholders interviewed in relation to a small number of projects disagreed on key implementation issues. Due to the small sample of interviewees involved, and because this process is not an evaluation of any specific project, we have collated findings across project type and according to project context rather than identifying specific projects by name in our analysis. This means that we report, for instance, on issues which arose for case study projects in non-capital cities, or projects involving treatment and engagement, rather than success or otherwise in relation to any one project. 2.1 Ethical issues Ethical approval to conduct the research was obtained from the University of Melbourne Human Research Ethics Committee (HREC). To protect the confidentiality of agencies and workers, projects included in the first component of this research (the overall project sample) are not named in this report. The case study component of the project involved interviews with participants who were involved in some way with the projects selected as case studies. Prior to commencement of interviews, study participants were given a statement written in plain language that outlined the aims of the study and the implications of their participation. Participants were advised that they were free to withdraw at any time from the study or could refuse to answer any question, and that they would not be named in any report or publication other than in the acknowledgement section if they chose for this to occur. 2.2 Study limitations While care has been taken to ensure systematic assessment of implementation for each project, variations in data available to the researchers mean that findings should be viewed as indicative of broad trends rather than as precise findings. For instance, some projects provide evaluations or final reports that report neatly against each objective as stated in the service agreement. Others use different formats, for instance reporting on lists of activities, so it was sometimes difficult to identify precisely which objectives were achieved or what the project s priority objectives were. Barriers and enabling factors were clearly identified for some projects; in others the researchers were required to make interpretive decisions about what constituted barriers and enabling factors from available documentation. 16

35 3 LITERATURE REVIEW The purpose of this literature review is to summarise significant background information to the study. While many studies identify elements associated with successful project outcomes such as client treatment completion or reductions in AOD use, few specifically identify enabling factors or barriers to successful project implementation. If programs are appropriately designed there is likely to be some overlap between factors which promote or impede successful implementation and those which are associated with effective program delivery. As such, factors concerning both implementation and outcomes are reviewed here. The review will briefly outline overarching themes concerning the critical factors enabling or impeding AOD projects, and other relevant health and welfare activities, reported in the literature. Second, we consider the projects according to their main activity (matching the project types introduced above) and third, according to the contexts in which they are implemented. 3.1 Overarching themes Ten overarching themes associated with successful project implementation and barriers to implementation were identified from a review of the literature. These themes informed the development of mechanisms identified for analysis in this project. Themes identified from the literature were: 1. program design 2. research and data collection 3. funding and resourcing 4. organisational governance and capacity 5. staff team coordination and relations 6. worker skills, expertise and capacity to provide leadership 7. partnerships, integration and coordination of services 8. responding to cultural diversity 9. encouraging service user participation 10. systemic issues Program design In some ways a key question of this study is What makes a good project? Numerous well-evidenced and well-honed models and frameworks clarify and guide how to plan, implement and evaluate a project: many are universally applicable, while some are styled specifically for particular program types and settings. Program theory, logic modelling and similar approaches help to map activities, outcomes and indicators, and aid both implementation and evaluation. Examples that can be found in the AOD and health promotion fields are: a resource kit for workforce development (N. Skinner, Roche, 17

36 O'Connor, Pollard, & Todd, 2005) and a Victorian web-based compendium of tools (Victorian Health Service Management Innovation Council, 2008). When researchers at the Australian National Drug Research Institute (Strempel, Saggers, Gray, & Stearne, 2004) compiled five examples of best practice in Indigenous drug and alcohol projects they discovered that, while every project had a unique history and context, above all else, the elements common to each of the five projects are: clearly defined and effective management structures and procedures; trained staff and ongoing staff development programs; good multi-strategy and collaborative approaches; strong leadership; and adequate and continuing funding, and clearly defined realistic objectives aimed at the provision of appropriate services that address community needs (Strempel et al., 2004, p. 74). Key success factors in community-based lifestyle interventions have been identified as: extensive reach, adoption and engagement; sufficient time for social and societal changes to take place; substantial commitment from all stakeholders; and, sufficient funding (Verheijden & Kok, 2005). Projects and interventions are profoundly impacted by the contexts in which they operate, including the policy process, the priority placed on research, and the funding environment. Designing the program to fit its intended context is critical to success. Where exemplary programs are known of, planners tend to try and reproduce them without adequately considering their own unique context (including people, place, time, cultural requirements of participants and other resources available): this may undermine success (McLaren, Ghali, Lorenzetti, & Rock, 2007). Research and evaluation Health policy and practice are expected to be evidence-based. There is also a need to demonstrate program accountability through measuring performance against identified indicators of effectiveness. These imperatives necessitate an ongoing commitment to research, monitoring, and evaluation, including the provision of adequate funding for these activities (Lichtveld & Cioffi, 2003; Wise & Signal, 2000). Locally conducted research and evaluation can also assist in identifying service priorities based on actual need, rather than service provider perceptions or preferences (Robinson & Pennebaker, 2002). Future initiatives need to have appropriate evaluations as a standardised part of prevention initiatives, and include the development of national databases of what is going on locally (Giesbrecht & Haydon, 2006). Current national health policy strongly highlights evidence, research and continuous learning and improvement as a lever for reform (National Health and Hospitals Reform Commission, 2009). Funding and resourcing Spooner and Dadich (2009) found (from the research literature and extensive national consultations) that despite increased funding, non-government organisations (NGOs) are experiencing financial deficits which impede both workforce development and service delivery. They cite as examples the failure of funders to pay the full cost of services/projects, including infrastructure, increasingly complex clients, increased organisational costs, for example the Goods and Services Tax, infrastructure, compliance (exacerbated by the different reporting requirements of different funding bodies), increased competition for funds, and the tendency for funding to be short term and project-specific (Spooner & Dadich, 2009, p. 38). 18

37 Similarly, research on mental health promotion service capacity noted short-term funding cycles and programs funded via research grants without a maintenance phase are seen as counter-productive to building capacity (Robinson & Pennebaker, 2002). This is a challenge also for AER-funded projects, which all receive time-limited funding. Organisational characteristics Again, the literature on the factors within organisations that best facilitate successful program delivery is vast. Overall it appears that organisational culture is crucial to effective program delivery. Organisations that are flexible enough to respond to the needs of employees may increase their capacity to attract and retain valuable staff (Page & Willey, 2007). For example, such flexibility may include the provision of family-friendly working conditions, or the redesign of work roles to allow a mix of duties (e.g. part managerial, part direct service provision). Organisations are supported through effective management and efficient policies and procedures. For example, staff supervision and performance appraisal mechanisms that are based upon an agreed position description and key performance indicators also contribute to workforce competency through constructive feedback, identifying areas requiring additional training or supervision, and providing encouragement. In studying the sustainability of AOD non-government organisations, Spooner and Dadich (2009) identified key problems with workforce capacity, including a lack of investment in management and organisational capacity, difficulties recruiting and retaining managers and staff, and a lack of evidencebased practice. Staff team coordination and relations The existence of positive relationships between members of staffing teams is strongly implicated in organisational efficiency. Allocating staff roles clearly and equitably is essential to reducing workplace conflict. Commenting specifically on community-controlled Indigenous organisations in Queensland, but resonant throughout the literature, Gray and colleagues observe that: the single largest barrier to better coordination of services is the current workloads of staff within organisations (Gray, Green, Saggers, & Wilkes, 2009, p. 106). Worker skills and capacity to provide leadership Recruitment and retention rates partly depend upon the attractiveness of the sector to potential and existing employees relative to other opportunities. The appeal of a sector can be influenced by factors such as remuneration and work conditions, clear career development opportunities, and the working environment (N. Skinner et al., 2005). The value of retaining skilled and qualified staff reaches beyond the individual level as it enhances the collective workforce through encouraging cohesive team work and provides increased opportunities for mentoring and supervision (Skinner & Roche, 2005). Managers of specialist AOD agencies in Australia reported that the main difficulties associated with recruitment were remuneration, stress and burnout, poor organisational support, and the stigma associated with alcohol and other drug use (Alcohol and other Drugs Council of Australia (ADCA), 2003). 19

38 It is important that organisational structures support the retention of staff who participate in training programs. Resnick and colleagues (2007) caution that without the opportunity for advancement both financially and professionally, staff trained by an organisation are likely to eventually leave for another organisation or even another sector, with the organisation forfeiting the advantages of their increased knowledge and skill. A credible leader can contribute to program success through effectively instigating and managing change in order to advance the organisation or sector (Aarons, 2006; Corrigan & Garman, 1999). The leadership qualities possessed by an individual are determined by their experience, training and personality (Robinson & Pennebaker, 2002). Attributes commonly associated with effective leadership include passion and tenacity, high level interpersonal skills, vision and goal setting capabilities, sound experience, political skills, integrity, curiosity, flexibility, patience, and the ability to take risks and learn from the consequences (TASC, 2004). Partnerships, integration and coordination of services Partnerships among organisations in the community emerge in the literature as significant to project success. A rigorous evaluation of partnership strategies in Victorian primary care found that partnerships were most successful when there was: a common purpose, effective communication and clarity about roles and relationships; positive attitudes by stakeholders about the common purpose and by member agencies towards the partnership and each other; supportive policy, planning and resources; and relevant effective skills and leadership (Saxon, 2008). Collaborations and alliances have been described on a continuum of increasing intensity, from networking, through coordination and cooperation, to collaboration. The demands on time, trust and turf increase along the continuum: hence the importance of clarity of partner role and of positive attitudes (Himmelman, 2002; Walker, 2000). Interventions are also most effective where they integrate with other elements of the service system. A social-ecological framework demonstrates that prevention initiatives increase their effectiveness when interconnected at all levels of influence, from the individual to community, across different population groups, across clinical and community service sectors, and across local, state and national governments. The strategies and systems to ensure integration, however, require additional research and development (Ockene et al., 2007). Responding to cultural diversity A review of factors that contribute to long-term maintenance, sustainability, or institutionalisation of community AOD harm prevention projects found that honouring community values and cultural relevance, cultivating key leader support, and utilizing Indigenous staff were key characteristics of successful projects. Other factors included developing local resources, maintaining flexibility, and leveraging prior success (Holder & Moore, 2000). Encouraging service user participation There are many challenges involved in encouraging service user participation and retention particularly in the AOD field where some service users lifestyles may impede their capacity to engage with providers or to regularly attend appointments (Lynda Berends, Devaney et al., 2004). This 20

39 frequently necessitates a highly flexible approach to AOD service delivery. Some studies have shown how providing service users with opportunities to have input into program planning and design encourage ongoing involvement. Systemic issues AOD services rarely lead to change in any individual s behaviour in isolation from other factors. A range of elements of the service system are often required to address any AOD issue, and broader systemic issues such as availability of adequate housing strongly impact on any individual s decisions around AOD consumption (Crabb, 2000). Anderson and others argue that educational alcohol interventions, including the kind funded by AER, are only effective as part of a broad alcohol harm minimisation strategy. A review of the evidence for effectiveness and cost-effectiveness of policies and programs to reduce the harm caused by alcohol asserts that educational programmes should not be implemented in isolation as an alcohol policy measure, or with the sole purpose of reducing the harm caused by alcohol, but rather as a measure to reinforce awareness of the problems created by alcohol and to prepare the ground for specific interventions and policy changes (Anderson, Chisholm, & Fuhr, 2009, p 2242). Robinson and Pennebaker (2002) remark upon a tension between top-down and bottom-up processes. In their study of service delivery capacity of mental health promotion and illness prevention in Western Australia, key stakeholders commented on the desirability of a clear state-level policy framework to guide local practice. Policies developed without adequate community consultation, however, were seen to be deficient in addressing unique local needs. 3.2 Project types We now turn to consider literature pertaining broadly to the project types identified for analysis in this study. Organisational systems and processes projects Researchers have identified a need for development of effective AOD treatment service management, particularly in the areas of service linkages, partnership approaches to service delivery and customercentred service delivery (Treloar, 2004). An organisation...is defined by its purpose, goals, objectives, resources, and constraints (Kennedy & Moore, 2001, p. 18). Targets for organisational development can include organisational design (i.e. internal relationship structures such as subgroups, hierarchies, lines of accountability), leadership and management, and organisational norms and values (i.e. culture). Organisational development is most usefully regarded as a long-term process, involving ongoing iterations (Annandale & Richard, 2007). Heward, Hutchins and Keleher (2007) use case studies to argue that an understanding of organisational change is critical to capacity building in health promotion. Figure 1 provides an illustration of a model of competing forces. This model is useful in highlighting the barriers to success for organisational capacity projects, including poor leadership, lack of time, internal politics and communication difficulties and fear of change. 21

40 Figure 1: Model of driving and resisting forces in organisational development Organizational change force field model (adapted from Lewin by Heward, Hutchins, & Keleher, 2007, p. 173) Workforce development and training The concept of workforce development is broad and can be defined in multiple ways. One inclusive view is that workforce development includes any activity that enables personnel to work more effectively (Saunders & Robinson, 2002, p. 231). Such capability building activity can be targeted at the individual, organisational, or system level (Kennedy & Moore, 2001) and overlaps with some organisational capacity building activities. Workforce development goes beyond education and training to encompass recruitment and retention, workforce planning, professional and career development, and worker wellbeing. Successful workforce development operates at individual, organisational, structural and systemic levels (N. Skinner et al., 2005). The implementation of training and development programs has been evaluated, providing evidence on factors contributing to their success. Regarding public health workforce development in the US, Litchveld and Cioffi (2003) argue that it is necessary to identify the core competencies required to fulfil various roles within a workforce, and that the provision of ongoing training opportunities to achieve these competencies is essential to the preparation of a sustainable and competent workforce. While there may be more than one pathway to achieving and demonstrating competence, it is recommended that competency development be closely related to actual practice. Uptake of relevant opportunities to improve competence may be encouraged by organisational and individual incentives such as credentialing, professional recognition and remuneration (Lichtveld & Cioffi, 2003). Facilitators of and barriers to ongoing learning were identified in a study involving training implementers and training recipients (including general practitioners, practice managers and nurses). These were considered in relation to the pre-existing learning culture of the participating primary care settings (Boudioni, McLaren, Woods, & Lemma, 2007). The main elements that facilitated successful learning included: relationship-building between implementers and recipients to increase levels of mutual trust and understanding; clear policy support for staff development; encouragement from 22

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