Interdisciplinary Research into political interest, civil society support and available data to strengthen Alcohol Policy Systems in Brazil and Peru

Alcohol consumption ('drinking') is a major cause of disease globally, and is the leading cause of preventable deaths in people aged 15-49 years old. It impacts negatively on the economy as well as drinkers and those around them, through lost days of work, violence, relationship breakdown and road traffic accidents, as well as placing a major burden on health services. Drinking is increasing in low and middle income countries (LMICs) causing harms there to rise. Drinking is not simply a matter of individual choice, as people's choices are shaped by how available, affordable and attractive alcohol is in each community and country. Alcohol companies can increase drinking by making alcohol widely available to buy, opposing government taxation to keep prices low, and designing and promoting brands that are attractive to current and future drinkers.

Research has shown that enforcing controls on where, when and by whom alcohol can be bought, increasing alcohol taxes and controlling alcohol advertising are measures likely to work to reduce harms. These measures are supported by the World Health Organization (WHO) although studies are lacking in LMICs, and they need government action and political support to be implemented. They are typically opposed by large alcohol companies. In Brazil and Peru, there are few controls on alcohol, those that do exist are not well-enforced, and there are high levels of alcohol-related harms. Charities, health organizations and others sometimes successfully work together in 'advocacy coalitions' to strengthen controls on alcohol, but have not yet done so in Brazil and Peru. In both countries, new policymakers have recently said that they are concerned about alcohol related harms and interested in introducing greater controls. This creates an opportunity to strengthen alcohol policies to reduce harms and our study will build on this opportunity.

Our aim is (1) to understand how policymakers and charities/health organizations in Peru and Brazil view alcohol consumption, harms and possible regulations, what concerns them, what action they would support, and how interested they are in working with others to improve alcohol control policies. We will do this through analysing 60 interviews, split between countries and different 'stakeholder' types i.e. policymakers and charities/health representatives. We also wish find out (2) what alcohol statistics and other data are available in each country to help policymaker decisions, how those data could be improved, and whether they could be used to find out the impact of any policy changes. We will do this by checking national statistics providers, speaking with stakeholders in both countries and international researchers.

Our team consists of six experienced researchers who have an excellent range of knowledge relevant to this bid from different academic areas (policy studies, public health, psychology, epidemiology, sociology, health economics), two of whom are based in Peru/Brazil and will lead the research there. We will be supported by a study advisory panel made up of academics, a senior WHO advisor, other health organizations and policymakers from Latin America, and researchers from the USA and South Africa, with expertise in alcohol policy as well as the study of policy changes and health systems more generally. We will recruit fulltime researchers for the study in both Peru and Brazil and offer them multiple opportunities to learn about alcohol policy research, how to use research to influence policy, and working with the media.

We will work closely with stakeholders from the start of the study and throughout to give them an opportunity to be involved in shaping (1) our interview questions and (2) our data assessment, so that they are helpful to local policy and advocacy; (3) to share our findings and find out what they think of them, and (4) to plan next steps for policy development, advocacy, and research in each country and regionally.

Alcohol consumption is a major contributor to disease and death globally and harms are rising in LMICs. Harms can be reduced by taxation of alcohol and controls on advertising and availability, measures which need political support. Civil society actors (NGOs, health) can successfully advocate for policy change but are routinely opposed by commercial actors. Research on alcohol policy systems is a notable gap in health policy analysis with no theoretically informed studies in Latin America. Alcohol policy appraisal and evaluation is a gap in LMICs more generally, data is little used, and few countries have adopted comprehensive alcohol control policies. Brazil and Peru (combined population 242M) have largely unregulated alcohol markets, despite high levels of harm particularly in disadvantaged areas.
This co-developed study will utilize the Advocacy Coalition Framework to analyze the alcohol policy system in these two countries, to accelerate research, policy development and advocacy in Peru, Brazil and the region. The study includes: 60 in-depth qualitative interviews with policymaker/civil society stakeholders (30 in each country) to explore values, beliefs and interests regarding alcohol problems and policy solutions; and scoping work to assess the availability and quality of alcohol data to underpin future policy appraisal or evaluation studies or inform advocacy or policy development. Interview data will be analyzed using the Framework method; and data assessments recorded in a database.
The study team includes local lead co-investigators (CIs) and new fulltime researchers in Brazil and Peru, and integrates CIs from multiple disciplines. Local researchers will benefit from access to a rich capacity-building programme. Impact plans include sustained engagement with national and regional policy stakeholders via four workshops, bilateral meetings, a study advisory panel, policy briefings, conference presentations, and co-authored peer-reviewed outputs.

BENEFICIARIES:Most LMICs have not benefited from strong alcohol policies due to a lack of stakeholder engagement and advocacy, little or no LMIC evidence base, strong coalitions opposed to change, and poor policy implementation. This foundation study will co-produce novel context-specific evidence of current alcohol policy systems and available data in Brazil and Peru and will accelerate future research and policy locally and regionally.

OUR IMPACT GOALS ARE TO:
1)Provide evidence to accelerate the development, enactment and implementation of feasible, acceptable, effective alcohol policy in Brazil and Peru and regionally.
2)Enable future policy appraisal and evaluation studies by identifying suitable alcohol data sources and inform improvements to data collection, access and quality.
3)Build stakeholder understanding of shared priorities, areas of consensus and challenges regarding policy progress and facilitate emergence of new advocacy coalitions.

WHO WILL BE INTERESTED IN THIS RESEARCH, AND HOW MIGHT THEY BENEFIT?
NATIONAL POLITICIANS, GOVERNMENTS & OFFICIALS with responsibility for aspects of alcohol regulation (e.g. Ministries of Justice, Finance, Health; Brazil's Ministry of Citizenship; Peru's Ministry of Women & Vulnerable Populations), by supporting political decision-making. We will build understanding of: how stakeholders view alcohol consumption, problems and policies; shared priorities; areas of consensus and challenges for policy progress. Engagement and dialogue established via in-country researchers, will build cross-sectoral relationships to accelerate policy development during the timeframe of the research and beyond. Our Co-Investigators (CIs) in Brazil and Peru already have national profiles on alcohol policy research and prior relationships with relevant government organisations and officials to facilitate this impact.
We will identify options for politicians and officials who want to improve data availability, quality, access etc. to support their policy decisions, and our data mapping will also fast-track future policy studies. This will enable both policy appraisal (advanced modelling to provide powerful evidence to policymakers of the likely impact of proposed policies) and policy evaluation studies (complex systems informed studies including longitudinal time series analyses and qualitative analysis, to inform policymakers of the impact of actual policy changes).

LOCAL CIVIL SOCIETY - HEALTH & ADVOCACY ORGANISATIONS engaged in issues affected by alcohol e.g. cancer, other NCDs, road safety, violence (e.g. Peru - Alliance Against Cancer, National Violence Observatory, National Institute of Health; Brazil: National Committee for Alcohol Regulation; Brazilian Association of Public Health; ACT-Alcohol). Novel evidence of policymaker and civil society priorities for action to address alcohol-related harms, will enable concerned civil society actors to coalesce around policy changes most likely to be politically feasible. Our stakeholder engagement will build understanding of the impact of alcohol on public health and organisations and a platform for the development of future advocacy coalitions. Our data scoping will identify data sources and gaps on alcohol-related harms which will support current advocacy efforts.

REGIONAL & INTERNATIONAL ORGANISATIONS concerned about alcohol-related harms e.g. the Pan American Health Organization (PAHO) - WHO Regional Office for the Americas, Healthy Latin America Coalition (CLAS), InterAmerican Heart Foundation; NCD Alliance, Global Alcohol Policy Alliance. We will analyse evidence of opportunities for policy progress, comparing the two countries, to feed into co-ordinated regional advocacy efforts, and decisions on how/where to focus related capacity building efforts. Our team has multiple strong working relationships with local, regional and international groups e.g. PAHO has been a key partner on the development of this proposal since 2017.