Place-based initiatives emerged originally in the field of health, guided by new ideas relating to the social determinants of health, the role of the socioecological context, implementation science, and the importance of community empowerment. Although there are considerable variations, it is possible to identify an underlying model which focuses on providing universal, structural interventions that seek to improve health and well-being by modifying the social context in which health-related behaviour occurs.

On behalf of the Department of Health, the Health Research Board commissioned this report to systematically review and synthesise the international evidence on place-based and other geographically defined responses to drug-related threats in communities.  The key findings of the review are set out below under the four research questions.

Key findings
Research question 1: How is the association between the characteristics of places and drug-related threats understood in the literature?

The relationship between neighbourhood characteristics and drug-related threats is typically theorised in the literature using the risk and protective factor framework. Drawing on local data and direct knowledge of the local context, community coalitions are expected to identify elevated risk and depressed protective factors. This information can then be used to guide the choice of intervention and to set targets for community actions. For example, community coalitions in Communities That Care (CTC) are expected to select “effective preventive interventions to change locally identified elevated risk and suppressed protective factors” (Oesterle et al. 2015). The authors argue that this approach has limitations in that the conceptualization of risk and protective factors in terms of individual-level characteristics can reduce the visibility of factors such as stigmatisation, systemic racism, social isolation, community disorganisation, local problems and economic hardship and organised crime.

Research question 2: What criteria are used by policymakers and funders to select locations for place-based initiatives?

The criteria used to select locations vary according to the intervention being implemented. In the case of PROmoting School-university-community Partnerships to Enhance Resilience (PROSPER), eligibility requirements included having 1,300–5,200 students enrolled at local schools and having stakeholder agreement to random assignment, as well as a willingness and capacity to support implementation if assigned to the intervention condition. In the case of CTC, communities chosen were small- to moderate-sized incorporated towns with their own governmental, educational, and law enforcement structures, ranging from 1,500 to 50,000 residents (Oesterle et al. 2015). To be included in the CTC trial in Germany, communities had to have at least one secondary school and a willingness to sign a cooperative agreement for study participation with the principal investigator. The Dutch quasi-experimental study tested the effectiveness of CTC in 10  cities with an average population of about 65,500. Target communities for HCS include counties, towns, and city districts located in states burdened with above-average rates of opioid overdose morbidity and mortality.

The three largest trials that have been implemented so far to evaluate place-based initiatives have used weak forms of spatial targeting, while the Icelandic Population Model (IPM) is not associated with spatial targeting. Although not discussed in detail in the literature, it would seem that the designers of trials selected locations where a positive programme effect could be identified.

Research question 3: What place-based initiatives to tackle drug-related threats to communities show signs of promise?

PROSPER and CTC are the only place-based initiatives that have been shown to have a significant impact on drug-related harms, following well-designed controlled trials. Both programmes targeted young adolescents and focused primarily on smoking and drinking alcohol, but they nevertheless had an impact on drug use that persisted over time and was detectable for most of the high school years. There is robust empirical evidence that both programmes were effective in reducing drug use among adolescents in small rural towns. Furthermore, an evaluation of the roll-out of CTC in Pennsylvania reported significant effects in relation to past 30-day and lifetime marijuana use as well as lifetime use of any drug. The effects were stronger for CTC districts which implemented evidence-based programmes. One of the strengths of PROSPER and CTC is that they have continued to collect data on participants even as they complete high school, attend college, and enter the labour market.

The evidence that has been published regarding the effectiveness of the IPM is largely observational but has convinced many policymakers and practitioners of its value. This is partly because data from Iceland on substance use among young people compare favourably with data from other countries, although it is not clear what role the IPM played in this and what influence factors such as national policies and other specificities (low population density, relative affluence) may have had.

(HEALing Communities Study) HCS is a good example of a programme which is expected to produce significant improvements in drug-related harms in the target communities but has not yet demonstrated effectiveness. As this programme is situated at the frontier of research and practice-related innovations in place-based initiatives, it is arguably the most promising study of all. The resources allocated to studying HCS will ensure that dozens of publications will appear over the next few years analysing all aspects of this programme. HCS thus offers an excellent opportunity to assess the potential of place-based initiatives to reduce drug-related harms. The least promising initiatives are Pulling Levers and Second Chance or Else (SCORE), and their failure to produce positive effects is arguably related to their inability to engage with local communities. There is evidence now from several projects that repressive place-based initiatives headed by law enforcement agencies are unlikely to yield positive impacts.

Research question 4: What indicators have been developed to measure the impact of these interventions?

In CTC and PROSPER, impacts were measured in different ways: (1) by assessing the nature of the interventions they promoted (e.g. number of evidence-based programmes adopted), (2) fidelity of implementation, and (3) by quantifying substance use over the past month or year (or over the respondents’ lifetime). The primary aim of HCS is to reduce opioid overdose deaths, while the secondary outcomes of interest include reducing overdose events, opioid misuse, and injection drug use, MOUD and behavioural treatment, treatment retention, people receiving recovery support, access to naloxone, and targeting other health conditions, including hepatitis C, HIV, and endocarditis.

Brown et al. (2015) use longitudinal cross-lagged panel models to explore the relationship between community coalitions and programme outcomes. They highlight the following qualities as relevant to the success of place-based initiatives: collaborative processes (how coalition members interact as a team), coalition capacities (including the attitudes, knowledge, and skills of the coalition members and paid coordinator), and coalition activities (how coalitions direct their energy). All these features of coalitions predicted their capacity to implement preventive programmes. Bašić (2015) concluded, based on findings from interviews with community leaders in Croatia, that building community readiness is an essential step before implementing place-based initiatives, and this concept can be measured using a local version of a survey questionnaire originally used in the USA.

Research question 5: Could these place-based initiatives and indicators be used in Ireland?

It is important to be aware of differences in national context, social structure, and neighbourhood characteristics considering transferring initiatives from one country to another. There may be specific features of the national or regional context which are essential to the success of an initiative in its original form. An evidence-based programme or a place-based initiative that has been found effective in one country may not be equally effective in another. However, there may not be the time and resources to develop a completely new framework and to test it, along with locally specific interventions. It might make sense, in this case, to use an existing model, even if this decision brings with it certain risks, while being sure to set aside a budget to evaluate the initiative in its new context.

The starting point for a debate about the usefulness and applicability of place-based initiatives in Ireland should arguably be the Irish context itself: what kinds of drug-related harms are observed at local level and how could new approaches contribute to improving conditions? What resources and knowledge are already present and how can these be mobilised to tackle risk factors and to strengthen protective factors? Most place-based programmes share common frameworks which can help with choosing, designing, and implementing an intervention.  But it is difficult to answer the question whether an intervention will work in a local context.

In order to be effective, interventions must be well-suited to the local context and capable of producing the desired impacts. There is thus a role for researchers to work with community coalitions in order to evaluate existing interventions, identify obstacles, and explore alternative approaches. Because innovation is central to place based initiatives, community coalitions may come up with new ideas about how to intervene to tackle drug-related harms and innovations should be expected and welcomed at the intervention level. From this perspective, it is the community coalition which must decide whether an existing intervention or survey questionnaire meets its needs, or whether a new tool or programme should be developed. If a robust monitoring framework is in place, the coalition can assume responsibility for this choice, in the knowledge that all impacts will be assessed in an impartial way.

Local and Regional Drug and Alcohol Task Forces in Ireland have a few similarities with place-based initiatives. The Task Forces are expected to bring together organisations and individuals from the statutory, community, and voluntary sectors to develop an integrated locally based response to problem drug use.  They address these challenges by identifying local needs and promoting the development of projects which can satisfy these. They work cross-sectorally and inter-institutionally with the aim of ensuring that local responses are coherent, integrated, and effective.

It should be possible to as assess the capacity of the Task Forces from this perspective, beyond a formal description to ascertain whether there is effective local ownership of the Task Forces and the level of community engagement that place-based initiatives need for innovation. It is also necessary to measure the impact that the Task Forces have at local level. This represents a significant challenge, as their introduction was not accompanied by a framework for data collection and statistical assessment. This underlines the importance of measuring, monitoring, and evaluating place-based initiatives to ensure accountability.