The Intersectoral Prevention Laboratory (TIPL) is a Danish national initiative with the goal of strengthening collaboration across sectors. This brief report addresses our experiences of involving local stakeholders to achieve community focus on a pressing problem and stimulate action; thus, our primary focus will not be on the findings and outcomes of the study but instead on the tools used in the process and the impacts on the outcome. We will present the methods used to engage and mobilize participants and reflect upon the implications of this for change and capacity building in the local community.
Background
Rural municipalities in Denmark face several public health challenges unique to those areas and not necessarily found in more urban municipalities. More people in the outskirts of Denmark are obese and consume higher levels of alcohol compared to urban municipalities, resulting in a higher incidence of alcohol-related liver diseases—more than five times as many in some places (Kraglund et al., 2021). Thus, recruiting citizens to participate in available alcohol treatment is an crucial step in curbing alcohol-related consequences in families and the local community. Family members’ involvement in alcohol treatment is also important, as the whole family is negatively affected by a family member’s alcohol misuse. Further, family involvement has been shown to enhance treatment completion and is linked with better treatment results for the individual seeking help (Kourgiantakis & Ashcroft, 2018).
TIPL was contacted by two municipalities in 2019 looking for inspiration and help in finding a way out of a deadlock: a well-established program for family-focused alcohol treatment existed, but it was difficult to recruit families and, further, to identify the causes for low recruitment. The program was named “Better well-being through early intervention and family-focused alcohol treatment for families with alcohol problems.” The basic components of the program were the identification of families with underaged children (where one or more adults displayed problematic alcohol consumption), and a referral to family-focused treatment through practitioners from various municipal institutions. In family-focused treatment, all family members are offered conversations with a therapist either individually, as a couple, or with the whole family. The program is based on systemic, narrative, and cognitive theory and motivational interviewing (Broen til Bedre Sundhed, 2020).
Methods
Background for the Case Study
In 2019, TIPL partnered with two Danish rural municipalities to explore recruitment challenges in family-focused alcohol treatment and seek possible solutions (Sakal et al., 2020). To achieve this, we involved local stakeholders with knowledge on the target group and alcohol treatment to discuss their experiences and perspectives on low recruitment to alcohol treatment with the purpose of better understanding the target group and involving relevant stakeholders in finding solutions. Dr. Anders Blædel Gottlieb Hansen, Dr. Anne Sidenius, and Ida Foxvig from TIPL together with two project managers from the program, planned and facilitated four consecutive workshops and developed a system map. Our empirical data consist of the system map, observations, and notes from workshops and follow-up conversations with the two project managers about their experiences implementing solutions developed at the workshops.
System Map
The system map was created with inspiration from systems thinking, which refers “…to the notion that we should understand the broader system if we want to successfully address complex problems” (Waterlander et al., 2020, p. 2). System mapping is a qualitative modeling approach inspired by system dynamics. System mapping uses informal maps and builds on the premise that researchers and participants make implicit causal assumptions explicit through the mapping process (Hovmand, 2014). This approach was deemed relevant, as we wanted to illustrate and understand the factors that influenced the problem. The system map was thus used to understand the extent of the problem’s complexity, to identify factors that influence problematic alcohol consumption, and to identify relevant stakeholders who were then invited to the workshops. In this way, the system map informed the planning of the four workshops and gave an overview of the problem. For pragmatic reasons, we chose to undertake this process of system mapping in a small group consisting of the three aforementioned authors from TIPL and the two municipal project managers. This preliminary map was later presented and discussed among the larger group of participants at Workshop 1 (see Appendix). We followed a procedure in which the map is drawn by a group of “experts” (in this case, TIPL and the project managers) and afterwards reviewed by a broader panel representing civil society and relevant sectors (Workshop 1) (Rutter et al., 2019).
Future Workshops
At the workshops, local stakeholders (NGOs and various aid organizations, public schools and day cares, youth education, social housing organizations, health visitors, the local hospital, and municipal units such as job centers) were invited to discuss their professional perspectives on problematic alcohol consumption in families and identify reasons for low engagement with family-focused alcohol treatment. Participants were primarily frontline workers, but leaders from several NGOs were also represented. In addition, affected families were invited, and three participants (one NGO representative and two citizens) were sober alcoholics who had successfully completed treatment. The workshops were based on a method originating from action research called “Future Workshop,” which focuses on moving participants from identifying key challenges and barriers to a phase of visions and dreams, and finally to a process of concretizing the aforementioned visions for the problem in question (Nielsen, 2007). The “Future Workshop” format was chosen because of its ability to engage and involve local stakeholders in dialogue about common criticisms, goals, and ideas around new practices and approaches in the interaction between different perspectives and positions. Throughout the process, we sought and encouraged local ownership and a sense of commitment to the developed solutions. We recruited participants through a pragmatic snowballing strategy; 65 persons were invited, and on average 39 local stakeholders from 22 organizations participated in the four workshops (conducted in Fall 2019). The goal was for local stakeholders to work together to create a greater understanding of the problem with recruitment, possibly offer suggestions for alternative strategies, and activate partnerships among the participating stakeholders and institutions. The overarching theme for the four workshops was, “Early identification and recruitment of families with problematic alcohol consumption: What are the challenges and how do we create solutions together?” The first two workshops focused on key challenges in identifying and recruiting the target group and possible explanations, while the final two focused on visions for the future and potential solutions (see Appendix, Table 1).
Discussion
Several important learnings arose from the project. What follows is a post hoc reflection approximately a year after the project was finalized, revolving around the tools and methods used in the process, how these were linked to our desired impact, and how this knowledge can be used by other scholars. Action research, in combination with systems thinking, was our starting point in determining a format for the process that would lead to solving recruitment problems (Haynes et al., 2020; Nielsen, 2007). However, we did not systematically apply systems thinking. Instead, it was used as inspiration for preparing the system map. The system map did not focus on linkages, feedback loops, and interactions among different factors (traditionally addressed in system dynamics), but rather helped us in seeing the larger picture (Rutter et al., 2019). We also used the system map as a starting point for group discussions in Workshop 1, and we asked participants how the map could be improved. In some groups, the map led to discussions involving various perspectives (and thus revisions) of the map, but in other groups we failed to effectively involve participants in discussions regarding the content of the system map. This could be due to the abstract nature of the map and lack of participants’ involvement in drawing the map. There is a strong rationale for involving the community in the design of a system map, as it can lead to a higher degree of ownership and commitment to finding solutions to the problem. An example of this is a participatory technique known as group model building (GMB) (Allender et al., 2016; Frerichs et al., 2016; Hovmand, 2014). The logic behind GMB is that creating a system map helps stakeholders reflect on their own perspectives and experiences, which allows them to develop collaborations by gaining system insights through the development and analysis of a common map (Hovmand, 2014). Involving local stakeholders when developing the map could also have enhanced the understanding of how problems with alcohol in the community are embedded in and are part of a larger system.
Action research has a long record of involving participants in identifying key challenges and generating solutions to problems (Brydon-Miller et al., 2003), and we therefore chose the “Future Workshop” as the participatory process. This approach provided a framework for structured discussions and engaged the diverse range of participants in understanding the problem and finding solutions. However, in the last phase (implementation) we became aware that we had failed to mobilize the local community to take responsibility for implementing the proposed ideas for solving recruitment challenges. The workshops also aimed to activate partnerships across participants—but only the municipal project managers moved forward with ideas from the final workshop. Here we faced the constraints of a real-world lack of commitment and resources. While the methodology applied was helpful in identifying key challenges and generating solutions, the lack of community action raised the issue of the importance of capacity building. Capacity building is a term that covers the ability of “…communities to define, assess, and act on issues they consider to be of importance…” (Liberato et al., 2011, p. 1). According to Liberato et al. (2011), capacity building consists, among other aspects, of both “resource mobilization” and “partnership/linkages/networking” (p. 5). Resource mobilization and collaboration are closely related to an ecological perspective, in which changing the local ecology by increasing community resources to deal with current problems and future issues is at the forefront (Trickett, 2019). During workshops, we encouraged an increased focus in the community on families with problematic alcohol consumption and created an awareness that recruiting more families goes hand-in-hand with a joint effort between the municipality and local stakeholders. This also led to a shared understanding of the problem and the social system of which family-focused alcohol treatment is a part. The engagement and persistent attendance of the local stakeholders throughout the four workshops indicated an interest and urgency in improving the lives of families with alcohol problems. While we partly succeeded in creating capacity building in the community, future work should place an even greater focus on implementation, capacity building, and involvement of the local stakeholders is warranted.
Thus, it is critical from the beginning to assess how the involvement of community participants is linked to the desired impact (Trickett & Beehler, 2017). One way we could have assessed this was by using the Community Readiness Model, a questionnaire developed to better understand the process of community change, with “readiness” being the degree to which a community is prepared and able to take action on an issue (Plested et al., 2006). Another reflection on the lack of implementation of the proposed ideas points to the importance of engaging community leaders, i.e., leaders from local government, education, and health agencies (Gerritsen et al., 2020). Although we ensured representation of a broad range of local stakeholders, only a few local community leaders participated in the workshops. In the literature, it is stressed that involving leaders “who have the authority, capacity, and networks to lead systems change across the community” (Allender et al., 2016, p. 4) is important.
Conclusion
In this project, the “Future Workshop” and system mapping was conducted as two time-separated tracks, which were then connected in the first workshop. We started out with a system map to better understand the problem. The “Future Workshop” was the template and approach on which we based the four workshops. The “Future Workshop” worked well as a participatory method, albeit we should have enhanced our focus on implementation and capacity building in the community. However, system mapping, with the expert-driven process we chose, did not work as well and failed to result in local commitment and ownership. Instead of two parallel processes, GMB could have served as a method that combined a participatory and systems approach and thus involved a broader segment of the stakeholders in the local community. It’s possible that this approach would have fostered the local commitment and ownership we sought.
In the project, local participation from a broad range of stakeholders and a shared understanding of the local context gave rise to an increased focus on and awareness of alcohol challenges in the community. This resulted in a more comprehensive understanding around the problem of recruiting people for family-focused alcohol treatment and gave valuable input to the two municipalities. However, an important learning is that implementation and capacity building should have been better integrated from the beginning. This was evident in the final workshop, where the suggested solutions were left to the municipalities, as none of the stakeholders took them up.
We conclude with these learning points, which are pertinent for others who face the challenge of involving community stakeholders to achieve changes in a community:
- Reflect upon how to assess whether the community is ready for (or desires) change before designing a process to engage local stakeholders.
- Reflect upon how to integrate capacity building and implementation from the beginning regardless of the approach used to involve local stakeholders.
- When using methodologies inspired from systems thinking, such as system mapping, engaging a wide range of relevant stakeholders in creating a system map by using a participatory technique, such as group model building, is recommended.
- Recruit the right stakeholders to workshops. Implementation requires the engagement of community leaders who have the authority, capacity, and networks to lead systems changes across the community.