Comparative study of three alcohol-related harm reduction programs: an ideal-type analysis

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To offer a transversal and more relevant analysis for action, we carried out an analysis by ideal types based on typical profiles of users and professionals. Twenty-one professionals using one of the three interventions took part in this study, and twenty-one users were included. Three typical profiles for users have therefore been identified: the socially included drug user, using alcohol only not targeting abstinence, the multiple substance user in very precarious situation with an ambivalent attitude to their substance use, and the middle-class drug user who want to achieve abstinence and feels guilty. Four typical profiles for professionals have also been identified: the isolated leader, the leader of a group, the willing professional eager to improve their practices, and the professional overwhelmed by a failing system. Depending on the user's profile, certain levers and professional profiles appear to be particularly suitable for ensuring the effectiveness of the intervention and the user's adherence to the program. All our findings point to the need to adapt interventions to users' needs, rather than expecting users to adapt to the objectives of the interventions. Mobilization of the notion of proportionate universalism, as defined in 2010, could be a relevant perspective for AHR interventions. Addiction Alcohol and Alcoholism Risk Qualitative Figures Figure 1 Figure 2 Introduction Regular alcohol use has a significant impact on health: alcohol is the second leading cause of “preventable” cancers, (Marant-Micallef, 2018 ) with 28,000 alcohol-related cancers out of 352,000 new cancer cases affecting adults over the age of 30 each year. (World Cancer Research Fund/American Institute for Cancer Research, 2018 ). People with an addiction are individuals who have lost control over their use and find it difficult to abstain despite observing negative consequences. (Association, 2013 ). Persistent use means that people suffering from addiction are at greater risk of social harm (Mouquet & Villet, 2002) present a higher mortality and a life expectancy 9 to 20 years shorter than that of the population as a whole. (Rehm & Shield, 2014 ; Wedegaertner et al., 2013 ) In France, it is estimated that at least 2 to 3 million people meet the criteria for alcohol use disorder, but that only 10% of these users are receiving treatment (Cohen et al., 2007 ; Wray et al., 2011 ) The low rate of access to treatment for alcohol addiction, and the high drop-out rate after a relapse, could be explained by obstacles such as the stigma associated with addiction and treatment, the desire to try to cope alone, a lack of knowledge and awareness of the disorder, ignorance of existing services, or organizational obstacles (constraints in terms of times, costs, etc.) (Priester et al., 2016 ). In addition, many patients do not have access to treatment or drop out of their treatment due to a prerequisite of completing an inpatient abstinence period. In reality, the current care offer may not fully meet the expectations of people with addiction, particularly depending on their level of severity and/or their current willingness to commit to abstinence or reduced use. Finally, delayed access to care is associated with an increase in the severity of the addiction and its consequences, liable to make future treatment less effective (Tiet et al., 2007 ). Other approaches are needed that do not focus solely on a detox process and the usual addiction therapy. This is the case for the pragmatic and humanist harm reduction (HR) approach (Maestracci, 2009 ) that emerged following demonstration of the link between intravenous drug use and the risks of HIV infection. Harm reduction is based on respect for individuals and their needs, and assumes that abstinence is not the only answer for people who use psychoactive substances. The objective of HR is to manage and reduce the risks and health impacts associated with drug use (legal or illegal). HR leverages a broad range of strategies (dissemination of information on products, risks and ways of reducing them, substitution treatments, safe drug consumption rooms, distribution of using equipment, etc.). Alcohol harm reduction (AHR) strategies involve adapting this approach to alcohol. The definition and scope of AHR are still under construction, but they are based on the general principles of HR. The present article, resulting from the ECIAE study, a comparative assessment of three alcohol-related harm reduction programs implemented in the Nouvelle Aquitaine region of France, aims to identify appropriate interventional levers based on different types of publics and professionals. This ideal-type analysis (Weber, 1992 ) will lay down the foundations for developing and implementing interventions tailored to the different publics and the contexts in which they evolve. The use of ideal-types makes it possible to simplify reality by producing abstract categories in order to define typologies (Paugam, 2014 ). The objective of this tool, very widely used in the fields of health sociology (Gerhardt et al., 1987 ; Stapley et al., 2022 ) and public health (Fredriksson & Tritter, 2017 ; Glasdam & Stjernswärd, 2024 ), is to describe the contours of a category in order to understand and theorize certain complex phenomena. An ideal type is formed based on the salient characteristics of a given phenomenon; it is a construct of ideas used to intellectually order social reality. (15) Although this tool is theoretical and the typical profiles are not found as such in the observed phenomena, they can be used to create typologies that reduce the complexity of reality and simplify comparison. (Vigour, 2016 ) Methods The Eciae study The ECIAE study has been detailed elsewhere (Stevens et al., 2022 ) and will be presented briefly here. The ECIAE study is a theory-based evaluation used to explore effects, intervention mechanisms and the influence of context on outcomes. This study uses two methods of data collection and analysis: one qualitative and the other quantitative. The qualitative part includes a study of the documentary corpus, working seminars, observations and semi-structured interviews. Here, we will present only the qualitative results analyzed using the ideal-types method. The mixed results will be covered in another article. Description of interventions The three interventions studied here are IACA! , ETP Conso Repères and Alcochoix . They were implemented in the Nouvelle Aquitaine region and are described in the box below. Collection of qualitative data The data collection phase ran from May 2021 to July 2023. A literature review was conducted in order to learn more about AHR interventions and their specificities in the French context (currently being submitted). In order to gather information on the various interventions in terms of their implementation, levers and barriers, as well as their perceived effects, semi-structured interviews were conducted with several categories of stakeholders: experts who had participated in the development of the interventions or were coordinators or trainers for the interventions, professionals from structures having implemented the interventions, and users of these interventions. Several interview grids were created for each category of stakeholder in order to collect different types of information (see table summarizing the themes in the appendices). Observations were also carried out in the structures participating in the project, implementing one of the three interventions studied. This made it possible to identify the concrete ways in which support is provided and to pinpoint the contextual and environmental components of the interventions. A seminar to further explore the data previously collected brought together 14 experts and professionals from the structures involved in implementing the interventions, as well as members of the research teams carrying out this study, and focused on the following themes: 1) intervention modalities (objectives, definition of AHR within the intervention, concrete implementation methods (for whom, how)), 2) key ingredients (the components making the intervention effective) and 3) what elements might indicate the success or failure of this program and what the reasons or components were. Data analysis 1) Ideal-type analysis The analysis used in this article refers to ideal types, a concept first employed by Max Weber at the start of the 20th century. (Weber, 1949 ) Weber used this concept to indicate “a description derived from observations of an empirical reality or a social phenomenon” that could serve as a preliminary step in the analysis of a little-studied subject, for example. This method can therefore be used to illustrate and compare different types of behavior, thinking or feelings. The ideal type is a working hypothesis concerning a specific phenomenon. It enables us to compare different manifestations of this phenomenon according to the context in which they appear or certain characteristics (individual or societal, for example) in order to facilitate the interpretation and understanding of this phenomenon. (Gerhardt, 1994 ) These are therefore analytical constructs, used as yardsticks to consider similarities and differences between manifestations of empirical phenomena. This type of analysis requires and reflects an understanding of the diversity of the phenomenon being studied. All these ideal types thus form a typology. This theoretical framework is rarely used since the methodology was not clarified by Mr. Weber. Applications of this type of analysis can be found in psychology (Stuhr & Wachholz, 2001 ; Werbart et al., 2016 ), but since this analytical framework is flexible, it can be used with different types of qualitative data and in different fields. More recently, some authors have provided a methodological structure for this concept. (Gerhardt, 1994 ; Kvist, 2007 ; Psathas, 2005 ; Stapley et al., 2022 ; Swedberg, 2018 ) One of these structures proposes seven steps in ideal-type analysis: becoming familiarized with the dataset, writing the case reconstructions, constructing the ideal types, identifying the optimal cases, forming the ideal-type descriptions, checking credibility, and making comparisons. (Stapley et al., 2022 ) 2) Applied to our case In the context of this study, bibliographical elements, interviews (recorded and then transcribed), observation notes and seminar data formed the corpus of the data analyzed. Following the different steps outlined above (Stapley et al., 2022 ), a thematic analysis was performed using a coding grid comprising several themes corresponding to our objectives of identifying the characteristics of users and professionals as well as the barriers and levers present in these interventions. Coding was performed using NVIVO© software. Analysis of the various themes enabled us to carry out an initial descriptive analysis describing the intervention modalities (not presented here). An increase in abstraction level was carried out in order to produce a cross-sectional analysis of the interventions. In this way, we were able to identify the levers concerning professionals and users that enable adherence to the method or a perceived effect of the method. This abstraction enabled us to construct typical profiles for users and professionals. Each typical profile, based on the salient characteristics of the users and professionals we met, is made up of various components that it would appear to be essential to integrate into this abstraction in order to highlight the specificity of this category. Thinking in terms of typical profiles made it possible to go beyond the specificities of the programs, and to guarantee the anonymity of the professionals, users and structures involved in the study (Coenen-Huther, 2006 ). In order to protect this anonymity and in view of the small sample size, the positions and structures of the professionals or the names of the programs followed by the users whose words are quoted will not be mentioned. In our study, these typical profiles were then examined in relation to the interventional levers identified. This comparison of the levers identified and the typical profiles created enabled us to identify the effective combinations of typical profiles and levers that are desired or desirable, in the light of the qualitative data collected. Taken together, these analyses enabled us to draw up our recommendations. The analysis presented in this article is broken down into three separate parts: i) A brief presentation of interventional levers concerning professionals and users, ii) identification of typical profiles for professionals and users, and iii) an analysis comparing typical user and professional profiles with the levers previously identified. Results a. Sample description Twenty-one professionals using one of the three interventions took part in this study (six Alcochoix , 11 IACA! and four ETP Conso-Repères) . Of these interviews, four were with center managers, 17 with professionals (two nurses, three general practitioners, five specialized educators, two social work assistants, three social workers, two psychologists/psychotherapists). Twenty-one users were included in the study. They had an average age of 43 years and the majority were men; half of the sample had a level of education equivalent to high school leaving certificate or more. All of the participants had an alcohol use disorder diagnosed by healthcare professionals. Within this sample, 16 users took part in a qualitative interview. Table 1 Themes covered during interviews with experts, professionals and users Themes Experts Professionals Users Profile and background x x x Origin and context of program creation x Entry into program x Adoption of program x Program creation methods x Course of program x x Interventional, populational and contextual components of the program x Program evolutions and readjustments x Assessment of the program (perceived utility, accessibility, feasibility, salient points, difficulties) x Assessment of the support and of the program and its effects x Program adaptation(s) x Program perspectives x x Suggestions for improvements x Six observations were performed for two of the interventions: IACA (n = 5), ETP Conso Repère (n = 1). Observations could not be performed for ALCOCHOIX because no follow-up session was held or indicated to the research team as being possibly observable. Intervention levers Based on a study of program-related documents, interviews and observations, we identified a number of cross-sectional levers promoting the implementation and effectiveness of interventions. We opted for a cross-sectional analysis in order not to identify each intervention studied, and to highlight levers that can be mobilized in other AHR programs. A distinction can be made between levers concerning professionals and those concerning users. 1) Levers concerning the engagement of professionals Reassurance of professionals Several programs offer training designed to equip professionals with the skills they need in the area of AHR. By providing an opportunity to acquire practical knowledge and skills to help users deal with alcohol-related issues, this training is seen by professionals as providing them with the tools, reassurance and sense of legitimacy they need when tackling alcohol issues with the people they work with: “The setting allows them to talk to people more calmly about their drinking, and when people arrive drunk, […] That really helps open the discussion. That’s something the whole team does. It’s crystal clear.” - structure manager In addition, the practice analysis sessions are identified by the professionals as being essential and clearly contribute to their sense of reassurance: the professionals therefore feel they have a collective space to talk and reflect on their professional practices, their experiences, their questions and the situations that they may have found challenging. However, it should be noted that there is a need for consistency between training (both in terms of the implementation of the intervention and the attitude of professionals) and this analysis of practices, since certain inconsistencies have been observed. Steps, progression One of the elements identified as being fundamental in the interventions studied lies in their step-by-step implementation and progression. For example, the IACA ! program is organized as four sequences: a first connection phase combining welcoming and alliance, a second phase of achieving safer drinking, a third phase of stabilizing the reconstruction plan and objectives, and a fourth phase of improvement enabling launch of the coordination of the care pathway and the search for suitable partners. The three phases of the ETP Conso Repère program described in the introductory box are also worthy of mention. These progression levels, or this pathway, allow the professional to follow a certain method or guide. However, this can sometimes also be seen as a restrictive framework or appear illogical, leading to more confusion. “The very fragmented part. [...] This aspect still needs to be corrected to move on from one session to the next. […] I don’t know how it all works now. I mean, there's something that isn’t really logical in the sequence, which they've corrected. It’s true that I regularly have difficulty keeping track of what stage we’re at.” - Social worker Innovation and recognition An essential point for the implementation of AHR interventions is that the “ recognition” of professionals enables them to “innovate” in terms of their practices, drawing on methodologies and training. The aim is to instill confidence in professionals, reassure them of their skills and promote their autonomy (which is also linked to the training they receive, and to their reassurance). This recognition also sometimes enables them to find solutions for a user or a situation in which they had been feeling powerless. “It also gave me lots of ideas for solutions... in complex situations, where you can sometimes get a bit discouraged and give up and say that ‘there's nothing anyone can do for him after all!’ But, in fact, yes there is something we can do. The (program) puts solutions back into perspective, in fact.” - Social worker Involvement of the structure/team in a network of players One of the levers that seems to be particularly important in the implementation of AHR interventions is the engagement of the structure and the team around this dynamic. An acceptance, or at least tolerance, of the AHR philosophy among the center's various professionals is essential if they are to be able to provide this support. This enables users to be directed towards the program (if it is appropriate for their particular care plan) and avoids confronting them with inconsistent advice (in terms of objectives or care plan, for example) within the structure. These inconsistencies in terms of advice can arise, for example, with regard to recovery objectives (abstinence or managed use), reception and support methods, and professional attitudes and values. In the same way, the creation of a network of professionals in agreement with the AHR philosophy enables users to be immersed in a dynamic and coherent care pathway. 2) Levers concerning the engagement of users More supportive, even holistic assistance One of the fundamental levers of the intervention lies in support that adapts to the user's needs, ranging from support involving telephone calls and availability, to more comprehensive support, including help in different areas of the user's life (marital, professional, family, administrative, financial or health situations, etc.). A 35-year-old user reports that she often calls the professional looking after her “to sound the alarm and (...) call for help”. The professional’s availability is presented as major plus point: “(Professional’s name), (…) I felt that his follow-up was pretty good… more effective (…), precisely because he is much more available than the psychiatrists, (…) Whereas (professional’s name) is a very, very available person. He always makes himself available.” − 3 5-year-old user Another 44-year-old multiple substance user explains how the holistic care he received helped him: “Well, already... with (professional’s name), I could talk about my paperwork problems. So there's the Social Security that doesn't pay you because my boss never had the right papers at the right time, or so we thought. And we checked that it was my boss, well the secretary who never sent the papers at the right time. So there were times when I was paid on… the 25th, the 30th, to start with both. And then sometimes I wasn’t paid at all for three months, and so on. So, all that makes you feel bad, when you’re already an alcoholic, and you get no sickness benefit... well, it gets you down. So this program was really good, in that they really helped me with my paperwork. And that was a great help because I’m getting married. (… ). So it helped a lot with the administrative formalities.” − 4 4-year-old user Our analyses show that this kind of support necessarily demands a high level of commitment, and requires a strong, constant presence and investment on the part of the professionals involved. Engagement, empowerment and freedom One of the levers frequently mentioned by professionals is the level of commitment shown by users (i.e., their engagement and investment in the program) and their capacity to become empowered (i.e., the fact that users become more aware and take action as regards their drinking). The professionals and experts we met saw empowerment as a fundamental lever for the success of interventions Users appreciate this autonomy, this empowerment, which many associate with a sense of freedom as well as responsibility. The lexicon of freedom comes up a lot: one user reports that “we're free to say what we want”, another that they are “free to drink” , and one participant says she has “more freedom” in this program than in her previous treatment experiences. One female user explains that the professionals’ objectives are not to “control” users and stop them drinking: “We come here because we want to” . Bonding, alliance and peer involvement It appears to be particularly important to create a bond between users or between users and professionals. Indeed, the fact that the user can bond with other users, through group sessions, or can feel supported by and count on a closer relationship with the professional seems to play a fundamental role in the programs studied. Hence, group sessions, the implementation of special means of communication (e.g., telephone) and the use of support materials, such as notebooks or guides, are mobilized. Notebooks can be used as a tracking tool in a program: users use them to record their emotions, progress and difficulties in relation to alcohol use. Guides may include theoretical information about alcohol, its effects and harm reduction strategies, as well as messages encouraging people and motivating them to manage their drinking. Some users say they appreciate having “a single contact person”, "a single point of contact, instead of multiple specialists”, which may help them to form deeper bonds. Another user says he appreciates the group sessions because they get him out of the house and allow him to “see other people”, which takes his mind off “smoking, (...) drinking; we're there to talk”. Co-construction Another fundamental lever resides in people’s participation in the construction or implementation of support services. This can involve peer health mediators or peer helpers, through a community health approach. Co-construction can also be found in the joint setting of objectives (between professionals and users) during follow-up, or during group sessions. This participation ensures that methods are adapted to the needs and living conditions of users: they do not see them as being disconnected from their reality or their own particular concerns. Awareness One of the levers mentioned by both professionals and users is the awareness generated by involvement in these three programs. This awareness can relate to the quantities consumed, situations involving danger to oneself or others, vulnerabilities or even the moments that trigger drinking. This awareness provides real leverage, enabling professionals and users to target specific behaviors to be reduced or possible actions to be taken. One user explains that by writing things down she has become more aware of her alcohol use: “It has helped me, because I started noting down my drinking to track it, and when you look at what you’ve written down in your notebook, you say ‘yes, that’s not good’”. Another user also highlights this increased awareness: I have to note down what I have drunk myself (...). There’s a written trace. So when I come back to write in it again, I realize that I've gone a week without touching anything, or that I only drank on Friday, and then I see that, in fact, instead of drinking three or four liters of beer in one evening, I only had two glasses of wine. So you see the reduction straight away. (…) (…) I can see that sometimes there are peaks. (…) I saw the difference straight away... After two or three months, it changed everything. Although this growing awareness can be accompanied by a change in drinking habits, it is not always the case, which is something that some users lament ( “I still drink as much, nothing has changed” ). Theoretical or practical learning The learning provided by the programs’ support methods may relate to alcohol consumption, norms in terms of the amounts of alcohol consumed, or the consequences of alcohol use. It can also involve learning skills, tactics, strategies and practices to limit or delay drinking, and reduce the negative consequences of alcohol use. The learning can also focus on self-awareness and emotional awareness. This lever aims to reposition the user as a player in their own health and equip them to make informed choices. For example, one user mentions learning “strategic approaches to find solutions ”, “really relevant information (…) that helps us get through the various stages” . Another user says she found it very useful to learn that she should drink “at least one or two glasses of water” between each glass of alcohol. Other users also appreciated the practical advice they received from the professionals who looked after them, with “tips” such as not buying alcohol, keeping busy in their free time when boredom can lead them to drink, etc. Identification of ideal types 1) Ideal types of users benefiting from the interventions It is possible to identify three user ideal types across the three programs studied. The socially included user, using alcohol only not targeting abstinence This first typical profile is predominantly female, has a fixed address and often a stable income. Users in this category do not see themselves as dependent drug users and seek to dissociate themselves from this profile. For example, one female user explains that before starting the treatment program, she “was still drinking a bottle a day” , but that “alcohol isn’t a problem” and that, what’s more, she does not drink “all alcohols” : “I only drink champagne. That’s all. I can’t drink anything else. (…) If I don’t have any champagne, (…) I won’t drink a glass of Ricard or a whisky ”. Another user from the same program explains that she does not believe that a detox program is appropriate for her because she “doesn’t need to go that far” , unlike other users. People belonging to this profile say they have no major health problems linked to their alcohol use, but report that they may have had periods of depression. The users that fit into this profile are at ease expressing themselves verbally and in writing, and place great importance on confidentiality and anonymity during their care. The objective for this typical profile is to manage their alcohol use, without any medicinal treatments and without aiming for complete abstinence. One interviewee explained that she had stopped her previous treatment “based on medicines” because it “seemed too restrictive” . One 47-year-old user working in the construction sector explains that he opted for this type of treatment because it does not target abstinence: The thing with total abstinence is that once you crack, it all starts again. That's why I said to myself that the good thing about this program was that, um, if I could manage my drinking, it would be (...) over the long term, because (...) the fact that I could drink in moderation could make it manageable. (…) Total abstinence is impossible. (…) I don’t want to stop drinking completely, (…) that’s not my goal. Multiple substance users in very precarious situations with an ambivalent attitude to their substance use This second typical profile is predominantly male, unemployed, unqualified, and often in a precarious situation in terms of housing. This profile has a long history of psychoactive substance use. For example, in addition to alcohol, one user took hallucinogenic mushrooms, cocaine, LSD, ecstasy and speed, and had been admitted to a psychiatric hospital after having had a car accident after swallowing a large number of medicinal drugs. This typical profile has a long history of addiction treatment. One user, describing himself as a “drug addict” had already taken part in “eight or nine detox programs” , the first when he was 21 years old. These previous treatments have not always gone well: several of those interviewed reported difficulties experienced during detox programs. One user explains that he had “done several programs” and that “each time, it didn’t work” . Another user “has had treatment four times” , “two or three weeks without alcohol, locked up in (name of a detox center” and states that “it’s pointless” : “As soon as I get out again, straight away, just to piss everyone off (…) the first bar I see, and I’m off again” . Characterized by their ambivalence, people meeting this profile have difficulty expressing clear objectives regarding their substance use. One user says he went to Alcoholics Anonymous, and was not happy with the goal of total abstinence; then, the next moment, the same user states that abstinence is the only valid solution, before asserting: “I don’t believe in total abstinence” . Users with this profile report mental and physical health problems. The middle-class user who wants to achieve abstinence and feels guilty This third typical profile has undergone vocational training and works in a manual trade. They may have experimented with various psychoactive substances during their life, but consider alcohol to be their main problem. Their substance use has led to difficulties with their family and friends, and the user feels very guilty. One user explains that he “blames (himself) a lot” and “doesn't blame others” . Another user interviewed believes he is the only person who can do anything about his substance use: “It’s up to me to give myself a kick up the backside. (…) I would like to cut back, for sure (…) and have a clear head on my shoulders, (…) but it’s down to me, (…) nobody else can do it for me” . This profile says they have health problems linked to their substance use (lung and liver problems, etc.), and have often tried a number of treatment methods, usually targeting abstinence. Users with this profile have alternated between giving up and relapsing, and consider all the previous support received to have been useful, once again believing that they alone are responsible for their failures. One user compares his previous treatments to “a prison” (in the last eight years he has had “three or four” that lasted “several weeks” ), while asserting that these treatments “did him good” : “The proof: I was able to go back to work” . However, he does not want to go back into treatment because he is fed up of giving up and then relapsing again: “I don't plan to just do that all my life (...), go away as soon as things start going badly, come back, go away again, come back. (…) Rehab centers, (…) when I got out it lasted however long it lasted… (…) And then (…) when I relapsed, I went backwards again”. 2) The typical profiles of the professionals implementing the interventions We were also able to identify four typical profiles for professionals. The isolated leader In several structures, the arrival of the program and its implementation were linked to the intervention of a single person. This person may hold a managerial position (head of department, structure manager) or be a health or social care professional within the structure. “So, in fact, we knew (program name) with Doctor X at the same time […] Everybody relied a bit on Doctors X and Y… And now, well, it's true that one of them has gone, so I think that's been felt in the continuity of this project. And in any case, that’s what we noticed, as a team” - Structure manager This person is often central to the arrival and continuity of the project, because they represent the program symbolically, and/or have obtained the resources (in terms of time and materials) to invest in the program. One of the consequences of this leadership by one person is the reliance on that person's investment and the durability of their presence in the structure. Due to the lack of general resources in the structures, if this isolated leader leaves the structure, the program has difficulty surviving. That is what happened in this structure: “the doctor who... guided us on the method (name of the intervention) (...) left and (...) in fact, was part of this harm reduction dynamic, you know!” (healthcare professional) The group leader This typical profile has mobilized a management style focusing on getting several team members involved in the implementation of the program (and HR in general) and raising awareness of it, both within and outside the organization. The program has been thought through collectively: beyond the implementation of the program, there is a real HR development project within the structure, and the aim is to implement it collectively. The program implemented is then seen as an opportunity to innovate on an organizational level, to give impetus to HR by encouraging the sharing of knowledge acquired through training in the program. The involvement and management of the department head are central to this type of leadership: one social worker reports that the management of his organization "wants us to be a little proactive in the new methods, so that this will encourage other associations and other services to perhaps not necessarily follow our example, but to see that it's possible, to say that it's possible to train in this and to apply these methods in a residential program”. This group leader will promote the dissemination and consistency of the alcohol-related harm reduction project at the center. The willing professional eager to improve their practices Despite institutional constraints, this typical profile demonstrates a high level of openness to programs. Keen to acquire new knowledge and new tools to deal with situations that can sometimes be problematic and for which they previously had no solutions, they demonstrate a real desire to progress professionally. This professional, often a social worker, is particularly open to questioning their practices, and recognizes the limits of their knowledge and approaches when dealing with the public. The question of deconstructing one's own perceptions of alcohol users and drinking practices was raised on several occasions: one social worker said that “we didn't necessarily have the tools to avoid being clumsy in our approach”. Unlike the group leader model, professionals with this typical profile develop individual strategies in their practices and in the AHR approach. While this profile is relatively positive in terms of program appropriation, its high level of engagement and questioning can lead to unacceptable working conditions in systems where resources are increasingly scarce. The professional overwhelmed by a failing system Professionals belonging to this fourth typical profile, although supportive of the programs implemented in their structure, shows certain signs of fatigue or weariness, especially if they are the only one carrying the program, like this healthcare professional: “For a long time I’ve been the only one trained (...) I'm working on several projects in the center here and... sometimes... I... don’t have the energy, but (Laughs) I'd like it if somebody else could do it”. This weariness can lead this typical profile to make harsh, or even derogatory comments about users. For example, one healthcare professional said, when speaking about program beneficiaries “for some of them, it’s not even worth offering them (the program), because they are not very compos mentis. Many of them have been much too damaged by their drinking. Some of them have absolutely no capacity for introspection.” The comments reveal much less intense engagement and a sense of weariness, which may lead to modification of the program. One healthcare professional reports that he “presents the thing rapidly, without spending three hours on it”. It’s quickly wrapped up”. A kind of resignation influences practices and the appropriation of programs and/or a more holistic AHR approach. One physician reports that “in any case, with respect to the protocol of (program name), it’s impossible to do. In six weeks, it’s impossible to fit it in, given our schedules, as well as the schedules of the people themselves”. Comparative analyses based on typical user profiles A configurational analysis of typical profiles of users enables us to identify different specific levers and typical profiles of professionals adapted to the specific needs of each profile. 1) Based on the typical profile of the socially included user of alcohol only For this typical profile, awareness and autonomy are the most appropriate levers for AHR support. In fact, the greater distance and objectivity made possible by an increased awareness of their drinking, and the greater sense of responsibility associated with engagement and empowerment, correspond to the expectations and capacities of these users. The co-construction of tools and/or strategies, or the involvement of peers in the method, could be envisaged in a very minimal (in terms of time and form) or highly adapted version. Since this typical user profile does not require a high level of professional involvement, this type of support could be provided by the four ideal types of professionals mentioned above, i.e., the isolated leader, the group leader, the willing professional eager to improve their practices, and the professional overwhelmed by a failing system. 2) Based on the typical profile of the multiple substance user in a precarious situation This profile will require more sustained and holistic support, with a particular focus on bonding and alliance. A caring and empathetic attitude on the part of the professional is essential to empower this profile. “Empowerment” refers to the process of linking an individual dynamic of self-esteem and skills development, with collective commitment and transformative social action (21, p. 27). A 35-year-old user appreciates that her support worker “highlights (her) character traits and the moral qualities (that she may have)” during the support. Co-construction and the involvement of peers seem to be essential if the method is to be appropriate and not disconnected from the reality of these users. Other levers, if appropriate to the specificities of this profile, seem to be important to consider in AHR support: support for voluntary awareness and empowerment, and if they are mobilized with care in order to limit guilt-tripping or any potential perceived violence. Theoretical and/or practical training can also be envisaged insofar as users' capacities (in terms of cognitive ability or prioritizing of needs, or in terms of theoretical and practical knowledge of alcohol use and harm reduction strategies) allow this. These users seem to better match and be closer to the attitude of the willing professional eager to improve, or the isolated leader. 3) Based on the typical profile of the middle-class user who wants to achieve abstinence and feels guilty This user has a specific goal (i.e., abstinence), even if it is difficult to achieve. In this respect, the contribution of theoretical and empirical knowledge seems to be a relevant interventional lever to support them in their progress. Bonding and alliance with the professional will also be crucial for these users, who need to be supported in order to overcome their guilt and their feeling of being entirely responsible for their state of health. As long as users' objectives are taken into account, co-construction and peer involvement could be envisaged if this is not too time-consuming. As far as professional profiles are concerned, the isolated leader could match the requirements of these users as long as the support does not require close collaboration or excessive availability. Discussion The results presented here constitute the original results of a cross-sectional analysis of three alcohol harm reduction interventions. The typical user profiles illustrate the diversity, complexity and, sometimes, ambiguity of the people who seek the support of structures offering AHR programs. This diversity of typical profiles also shows how uses, attitudes towards them and assessments of interventions can have an impact on the acceptance, adherence to and effect of these different programs. Summary of results Three typical profiles for users have therefore been identified: an alcohol user who does not use other psychoactive substances, is socially included and does not identify with other users who need treatment for their substance use; a multiple substance user in a precarious situation, with a combination of health and social vulnerabilities and a long history of treatments; and a middle class user, who have tried to stop drinking several times, unsuccessfully; they take responsibility for their addiction and feel guilty about it. Four typical profiles were identified for professionals: the isolated leader, the group leader, the willing professional eager to improve their practices, and the professional who is overwhelmed by a failing system and weary. Depending on the user's profile, certain levers and professional profiles appear to be particularly suitable for ensuring the effectiveness of the intervention and the user's adherence to the program. For the first typical profile - the socially included user who only uses alcohol - awareness and empowerment are suitable levers, as well as, possibly, work on bonding, alliance and peer involvement. This user profile could correspond to all professional profiles. The second typical profile, precarious and with multiple vulnerabilities, requires sustained and holistic support, with a strong emphasis on bonding and alliance with the professional, as well as peer involvement. This typical profile seems to match and be close to the attitude of the willing professional eager to improve, or the isolated leader. Finally, for the third typical profile, who wishes to be abstinent and feels guilty about their addiction, bonding and alliance with the professional are crucial, as is co-construction of the objectives and modalities of the intervention. The isolated leader could correspond to this third typical profile. The study's strengths and limits This study has several limits. The health situation had an impact on the deployment or implementation of interventions in certain centers, as well as on certain study modalities (replacement of a seminar by individual interviews, videoconference interviews). In addition, the users we met had an alcohol use disorder, in the majority of cases severe, whereas the programs can target individuals with a less severe use disorder. Another important factor to take into account is the confusion of users, and sometimes professionals, between support proposals and the study conducted. Far from being anecdotal, this confusion may have had a number of consequences, ranging from misinterpretation by users of what the program consists of (in terms of content but also in terms of objectives), to a lack of understanding of the support offered (confusion between callbacks for measurement and support). Particular attention was paid to this point during the analyses in order to limit this bias as far as possible. However, these limits are counterbalanced by the strengths of this study. First of all, the qualitative approach we adopted enabled us to understand the subjectivity of the players (whether professionals, users or experts) and the meaning they give to their practices and the interventions deployed. The mobilization of various methodological tools (interviews, observations, seminars) also made it possible to enhance data collection and triangulate the information gathered. The fact that we worked as part of a team also enabled us to consolidate our analyses by comparing our perspectives, since coding was performed collectively. In addition, the multi-situation aspect of this study, which cross-analyzed three different interventions implemented in different cities and structures, enabled us to put the diversity of AHR objectives and methods into perspective, facilitating an increase in generality and abstraction through comparison. Discussion of user and professional ideal-types Some of our results need to be discussed. With regard to the first user profile, it is important to note that as a woman and a socially included person with an alcohol use disorder, this typical profile runs the risk of being doubly stigmatized. (Perrin, 2022 ) In reality, addiction in women is particularly stigmatized, and women users run a number of risks: being seen as bad mothers and women of bad character, not to mention the risk of abuse and violence. (15–19) As a result of this stigmatization, women seek treatment less than men. (Perrin et al., 2021 ) Socially included people are also generally afraid to reveal their addictions, as they run the risk of losing credibility and responsibility in their work environment, or even of being made redundant, and of coming into conflict with their family and friends. (Crespin et al., 2015 ) Socially included substance-dependent people therefore often lead a “double life”. (Fontaine, 2006 ) Consequently, the lack of identification of this first profile with other alcohol-dependent users can be analyzed as a stigma-avoidance strategy. (Goffman, 1975 ; Gruel, 1985 ) The second typical profile highlights the reciprocal relationship between poverty and addiction, and the obstacles to treatment that this relationship generates. According to several studies, poverty is correlated with an increased risk of drug dependence. (Kensy et al., 2012 ) People who are homeless or have no fixed abode are at greater risk of developing a substance use disorder. Half of all homeless people have an addictive disorder in their lifetime, and people with a substance dependence are more likely to lose their jobs and homes, and to be socially isolated. (Apostolidis et al., 2003 ) People living in very precarious conditions face a number of obstacles to care and treatment, and are highly stigmatized. (Grimard, 2006 ) The use of alcohol helps people cope with living conditions on the streets, while at the same time sometimes preventing the individual from accessing housing (emergency shelters do not always accept alcohol use on their premises) or employment. The third typical profile has characteristics that may be related to two things: firstly, perhaps, the internalization of a reductionist discourse, dominant in our society (Taylor, 2008 ), asserting that the only solution to addiction is to stop using altogether. On the other hand, it can also be a question of how difficult it is for people in addiction situations to manage their substance use. People with a severe level of addiction have often tried many times before to control their drinking, but are unable to control themselves once they start. They come to believe that they are in an “all or nothing” situation, and that the only realistic option for them is total abstinence. With regard to the profiles of the professionals identified, they point to the absolute necessity of taking into consideration their professional situation and attitudes with respect to abstinence and AHR. A number of articles in the scientific literature stress the fact that, if an intervention is to be properly implemented, it is essential for the various players and structures involved to harmonize their values. Several studies report that professionals are in conflict over various issues (e.g., consumption norms to be provided to users). (Minian et al., 2021 ) It is essential for professionals to consult one another and to agree on clear rules. (Parkes et al., 2022 ; Pauly et al., 2021 ) This aspect is linked to the need, outlined below, to involve staff in the implementation of a program. More generally, the scientific literature insists that, to be effective and gain the support of users and professionals alike, interventions must be based on scientific evidence, (Ingram et al., 2021 ; Tofighi et al., 2016 ) since that increases their credibility and promotes consistency of practices and discourses. The aim is to draw on the results of scientific research concerning the effectiveness of an intervention, and to mobilize this scientific data with professionals and users alike, to attest to the legitimacy and relevance of the support offered. It is also important for this intervention to be co-constructed by users and professionals so that it makes sense for both. (de Wit et al., 2019 ) Moreover, this harmonization of values cannot be achieved without taking into consideration the cultural contexts in which the interventions will be implemented. (Klimas et al., 2014 ; Schwebel et al., 2022 ) In reality, depending on the context (even within the same society), cultural perceptions of alcohol and harm reduction vary, and can limit the effectiveness of the intervention. (Klingemann & Klingemann, 2017 ; Majer et al., 2014 ; Minian et al., 2021 ) Finally, interventions involving several therapeutic strategies are presented as being particularly effective. (Kelly et al., 2020 ; Lévesque et al., 2017 ; Pettigrew et al., 2021 ; Ray et al., 2020 ; Swendeman et al., 2021 ) Recommendations and perspectives All our findings point to the need to adapt interventions to users' needs, rather than expecting users to adapt to the objectives of the interventions. (Barrio & Gual, 2016 ) According to the harm reduction philosophy (Morel et al., 2012 ), alcohol harm reduction interventions must be adapted to the user's needs, depending on the severity of their addiction and the level of their craving, (Klingemann & Klingemann, 2017 ) as well as to the expectations expressed and the user's profile. Mobilization of the notion of proportionate universalism, as defined in 2010, (29) could be a relevant perspective for AHR interventions This principle states that “actions should be universal, but with an intensity and a scale that is proportional to the level of disadvantage”. An AHR intervention guided by the theoretical framework of proportionate universalism would therefore present a core of universal actions or levers proposed to all users and then, depending on the specific needs identified by this analysis of typical profiles, a range of targeted actions, tailored to the needs and objectives of the different publics concerned by alcohol use disorders. These targeted actions could then be considered not only in terms of the user's socioeconomic situation, but also using identified criteria, such as stigmatization, empowerment, the need for an alliance or co-constructed objectives, or the leadership of the professional involved. However, the user's objective needs to be reviewed and reassessed regularly. With this in mind, the method used for each intervention must be flexible and adaptable. (Swendeman et al., 2021 ) This ties in with the idea of setting objectives and co-constructing interventions with users, already mentioned in the literature. (Collins et al., 2012 ; Ingram et al., 2021 ). This article highlights the benefits of an ideal type analysis for the evaluation of such complex interventions, aimed at people in situations of vulnerability with multiple facets and manifestations. It also raises questions about the relationship between professionals and users, and the ability of our healthcare system to integrate these different user profiles. Abbreviations AHR Alcohol Harm Reduction DPO Data Protection Officer ECIAE cross-evaluation of the Iaca, Alcochoix and ETP Conso-repère programs ETP Patient Therapeutic Education GDPR General Data Protection Regulation HAS French National Authority for Health HR harm reduction PIA Privacy Impact Analysis Declarations Consent for publication All authors read and approved the final manuscript. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethical approval The project has been carried out in full accord with current relevant legislation (e.g., the Charter of Fundamental Rights of the EU) and international conventions (e.g., Declaration of Helsinki). The project respects the obligations related to the EU General Data Protection Regulation (GDPR). The study protocol was submitted to our university Data Protection Officer for analysis and did not qualify as falling under the rules applying to “Research Involving the Human Person”. This protocol did not therefore require the solicitation of an ethics committee but only registration in the DPO register and the implementation of a Privacy Impact Analysis (PIA). All sensitive data collected in the framework of the study are routine data, the collection of which is part of National Authority for Health (HAS) recommendations. Our university has ensured that all the regulatory procedures related to the ECIAE study have been carried out. The methods’ development, data collection, and analysis took the following issues into account: • Anonymity of study respondents will be preserved and ensured at all times. Unnecessary collection of personal data has been avoided, and respondents had the right to review outputs and withdraw consent. All personal data have been coded, removed from the data for analysis and stored separately. Only designated research staff have access to the keys linking data with personal information. • Information regarding the study and the right to refuse to participate have been distributed to all study participants., In the case of refusal, alternative means of data collection have been explored (e.g., alternative respondents). Competing interests The authors declare having no competing interest Author Contribution Statements 1 rst , 2 nd and last authors drafted this article and all authors the 5 authors revised the manuscript. The project design was developed by 4 th and 5 th authors. 1rst, 3 rd and last authors were involved in implementing the project and in developing the evaluation design, under the supervision of 4 th author. All authors read and approved the final manuscript. Funding Statement This study has received funding from regional health agency of New Aquitaine (ARS Nouvelle Aquitaine). Award/grant number : N/A Acknowledgement The authors are very grateful to all those who took part in the project. References Apostolidis T, Rouan G, Eisenlhor S. Construction du rapport aux drogues dans un contexte de précarité. Psychotropes. 2003;9(2):65–81. https://doi.org/10.3917/psyt.092.0065 . Association AP. (2013). Diagnostic and statistical manual of mental disorders (Fifth Edn.). American Psychiatric Association. Washington, DC . Bacqué M-H, Biewener C. L’empowerment, un nouveau vocabulaire pourparler de participation ? 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4546141","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317589162,"identity":"2b439946-1f2c-47d7-9787-27e76d621e7d","order_by":0,"name":"Sarah Perrin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYJACZgjF2MDwgceGgUECxLEhUgvjDJk0qJY0orQAGTw2hwlrkW8/+/BzAcMdOfPZh9se8OScT+yf3XzwAUPCPZxaDM6kG0vPYHhmLHMusd1A4sztxBl3jiUbMCQU49YCdII0D8PhxBk8jG0Shj23Extu5JhJMP5IwO2w/mfMv4Fa6sFaEv+dS5wP0sKQgFsLw400NpAtCRIgLQd4DiRuIKTF4MYzNmseg2eGIFskG3iSjTfeSEs2SMCjRb4/jfk2T8UdeQke9mfSf3jsZOfdSD744AM+h0HsOgBnOjaASEIagAChxZ6w4lEwCkbBKBhpAAC0iFHvVuFvAQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Bordeaux, INSERM","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Perrin","suffix":""},{"id":317589163,"identity":"33781db7-4ce0-4333-9572-5fc5b1bd1beb","order_by":1,"name":"Amandine Fillol","email":"","orcid":"","institution":"University of Bordeaux, INSERM","correspondingAuthor":false,"prefix":"","firstName":"Amandine","middleName":"","lastName":"Fillol","suffix":""},{"id":317589164,"identity":"33b0a1a2-535e-42e2-b7f3-55dfe533d7bc","order_by":2,"name":"Nolwenn Stevens","email":"","orcid":"","institution":"University of Bordeaux, INSERM","correspondingAuthor":false,"prefix":"","firstName":"Nolwenn","middleName":"","lastName":"Stevens","suffix":""},{"id":317589165,"identity":"9ab0e08b-e827-45f3-88c6-b327fd416a93","order_by":3,"name":"Linda Cambon","email":"","orcid":"","institution":"University of Bordeaux, INSERM","correspondingAuthor":false,"prefix":"","firstName":"Linda","middleName":"","lastName":"Cambon","suffix":""},{"id":317589167,"identity":"58eb3ca2-fdba-4b59-b320-1f503f76420f","order_by":4,"name":"Judith Martin-Fernandez","email":"","orcid":"","institution":"University hospital of Bordeaux","correspondingAuthor":false,"prefix":"","firstName":"Judith","middleName":"","lastName":"Martin-Fernandez","suffix":""}],"badges":[],"createdAt":"2024-06-07 12:36:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4546141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4546141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59380056,"identity":"315ede13-6fb5-4d52-8eb9-3de9f6b5de33","added_by":"auto","created_at":"2024-07-01 05:23:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":452199,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003edescription of the interventions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4546141/v1/e361558dadce687d4fa4c258.png"},{"id":59380055,"identity":"825d28eb-6d52-43be-840e-b2a9210baece","added_by":"auto","created_at":"2024-07-01 05:23:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130337,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eComparative analyses of levers and typical profiles of professionals adapted to typical profiles of users\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4546141/v1/a34fe88af633348b83fed6b6.png"},{"id":62275343,"identity":"32fb9c79-1f19-42c2-aee4-9a9b91e102d1","added_by":"auto","created_at":"2024-08-12 11:10:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1147514,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4546141/v1/04309fa0-9641-4de3-84d0-59a274c4aea0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative study of three alcohol-related harm reduction programs: an ideal-type analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRegular alcohol use has a significant impact on health: alcohol is the second leading cause of \u0026ldquo;preventable\u0026rdquo; cancers, (Marant-Micallef, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) with 28,000 alcohol-related cancers out of 352,000 new cancer cases affecting adults over the age of 30 each year. (World Cancer Research Fund/American Institute for Cancer Research, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). People with an addiction are individuals who have lost control over their use and find it difficult to abstain despite observing negative consequences. (Association, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Persistent use means that people suffering from addiction are at greater risk of social harm (Mouquet \u0026amp; Villet, 2002) present a higher mortality and a life expectancy 9 to 20 years shorter than that of the population as a whole. (Rehm \u0026amp; Shield, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Wedegaertner et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) In France, it is estimated that at least 2 to 3\u0026nbsp;million people meet the criteria for alcohol use disorder, but that only 10% of these users are receiving treatment (Cohen et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Wray et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) The low rate of access to treatment for alcohol addiction, and the high drop-out rate after a relapse, could be explained by obstacles such as the stigma associated with addiction and treatment, the desire to try to cope alone, a lack of knowledge and awareness of the disorder, ignorance of existing services, or organizational obstacles (constraints in terms of times, costs, etc.) (Priester et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In addition, many patients do not have access to treatment or drop out of their treatment due to a prerequisite of completing an inpatient abstinence period. In reality, the current care offer may not fully meet the expectations of people with addiction, particularly depending on their level of severity and/or their current willingness to commit to abstinence or reduced use. Finally, delayed access to care is associated with an increase in the severity of the addiction and its consequences, liable to make future treatment less effective (Tiet et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOther approaches are needed that do not focus solely on a detox process and the usual addiction therapy. This is the case for the pragmatic and humanist harm reduction (HR) approach (Maestracci, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) that emerged following demonstration of the link between intravenous drug use and the risks of HIV infection. Harm reduction is based on respect for individuals and their needs, and assumes that abstinence is not the only answer for people who use psychoactive substances. The objective of HR is to manage and reduce the risks and health impacts associated with drug use (legal or illegal). HR leverages a broad range of strategies (dissemination of information on products, risks and ways of reducing them, substitution treatments, safe drug consumption rooms, distribution of using equipment, etc.). Alcohol harm reduction (AHR) strategies involve adapting this approach to alcohol. The definition and scope of AHR are still under construction, but they are based on the general principles of HR.\u003c/p\u003e \u003cp\u003eThe present article, resulting from the ECIAE study, a comparative assessment of three alcohol-related harm reduction programs implemented in the Nouvelle Aquitaine region of France, aims to identify appropriate interventional levers based on different types of publics and professionals. This ideal-type analysis (Weber, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e1992\u003c/span\u003e) will lay down the foundations for developing and implementing interventions tailored to the different publics and the contexts in which they evolve. The use of ideal-types makes it possible to simplify reality by producing abstract categories in order to define typologies (Paugam, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The objective of this tool, very widely used in the fields of health sociology (Gerhardt et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1987\u003c/span\u003e; Stapley et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and public health (Fredriksson \u0026amp; Tritter, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Glasdam \u0026amp; Stjernsw\u0026auml;rd, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), is to describe the contours of a category in order to understand and theorize certain complex phenomena. An ideal type is formed based on the salient characteristics of a given phenomenon; it is a construct of ideas used to intellectually order social reality. (15) Although this tool is theoretical and the typical profiles are not found as such in the observed phenomena, they can be used to create typologies that reduce the complexity of reality and simplify comparison. (Vigour, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e "},{"header":"Methods","content":"\u003ch2\u003eThe Eciae study\u003c/h2\u003e\n\u003cp\u003eThe ECIAE study has been detailed elsewhere (Stevens et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e) and will be presented briefly here. The ECIAE study is a theory-based evaluation used to explore effects, intervention mechanisms and the influence of context on outcomes. This study uses two methods of data collection and analysis: one qualitative and the other quantitative.\u003c/p\u003e\n\u003cp\u003eThe qualitative part includes a study of the documentary corpus, working seminars, observations and semi-structured interviews. Here, we will present only the qualitative results analyzed using the ideal-types method. The mixed results will be covered in another article.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eDescription of interventions\u003c/h2\u003e\n\u003cp\u003eThe three interventions studied here are \u003cem\u003eIACA!\u003c/em\u003e, \u003cem\u003eETP Conso Rep\u0026egrave;res\u003c/em\u003e and \u003cem\u003eAlcochoix\u003c/em\u003e. They were implemented in the Nouvelle Aquitaine region and are described in the box below.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eCollection of qualitative data\u003c/h2\u003e\n\u003cp\u003eThe data collection phase ran from May 2021 to July 2023. A literature review was conducted in order to learn more about AHR interventions and their specificities in the French context (currently being submitted).\u003c/p\u003e\n\u003cp\u003eIn order to gather information on the various interventions in terms of their implementation, levers and barriers, as well as their perceived effects, semi-structured interviews were conducted with several categories of stakeholders: experts who had participated in the development of the interventions or were coordinators or trainers for the interventions, professionals from structures having implemented the interventions, and users of these interventions.\u003c/p\u003e\n\u003cp\u003eSeveral interview grids were created for each category of stakeholder in order to collect different types of information (see table summarizing the themes in the appendices). Observations were also carried out in the structures participating in the project, implementing one of the three interventions studied. This made it possible to identify the concrete ways in which support is provided and to pinpoint the contextual and environmental components of the interventions.\u003c/p\u003e\n\u003cp\u003eA seminar to further explore the data previously collected brought together 14 experts and professionals from the structures involved in implementing the interventions, as well as members of the research teams carrying out this study, and focused on the following themes: 1) intervention modalities (objectives, definition of AHR within the intervention, concrete implementation methods (for whom, how)), 2) key ingredients (the components making the intervention effective) and 3) what elements might indicate the success or failure of this program and what the reasons or components were.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) Ideal-type analysis\u003c/p\u003e\n\u003cp\u003eThe analysis used in this article refers to ideal types, a concept first employed by Max Weber at the start of the 20th century. (Weber, \u003cspan class=\"CitationRef\"\u003e1949\u003c/span\u003e) Weber used this concept to indicate \u0026ldquo;a description derived from observations of an empirical reality or a social phenomenon\u0026rdquo; that could serve as a preliminary step in the analysis of a little-studied subject, for example. This method can therefore be used to illustrate and compare different types of behavior, thinking or feelings.\u003c/p\u003e\n\u003cp\u003eThe ideal type is a working hypothesis concerning a specific phenomenon. It enables us to compare different manifestations of this phenomenon according to the context in which they appear or certain characteristics (individual or societal, for example) in order to facilitate the interpretation and understanding of this phenomenon. (Gerhardt, \u003cspan class=\"CitationRef\"\u003e1994\u003c/span\u003e) These are therefore analytical constructs, used as yardsticks to consider similarities and differences between manifestations of empirical phenomena. This type of analysis requires and reflects an understanding of the diversity of the phenomenon being studied. All these ideal types thus form a typology.\u003c/p\u003e\n\u003cp\u003eThis theoretical framework is rarely used since the methodology was not clarified by Mr. Weber. Applications of this type of analysis can be found in psychology (Stuhr \u0026amp; Wachholz, \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e; Werbart et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e), but since this analytical framework is flexible, it can be used with different types of qualitative data and in different fields. More recently, some authors have provided a methodological structure for this concept. (Gerhardt, \u003cspan class=\"CitationRef\"\u003e1994\u003c/span\u003e; Kvist, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Psathas, \u003cspan class=\"CitationRef\"\u003e2005\u003c/span\u003e; Stapley et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Swedberg, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eOne of these structures proposes seven steps in ideal-type analysis: becoming familiarized with the dataset, writing the case reconstructions, constructing the ideal types, identifying the optimal cases, forming the ideal-type descriptions, checking credibility, and making comparisons. (Stapley et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e2) Applied to our case\u003c/p\u003e\n\u003cp\u003eIn the context of this study, bibliographical elements, interviews (recorded and then transcribed), observation notes and seminar data formed the corpus of the data analyzed. Following the different steps outlined above (Stapley et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), a thematic analysis was performed using a coding grid comprising several themes corresponding to our objectives of identifying the characteristics of users and professionals as well as the barriers and levers present in these interventions. Coding was performed using NVIVO\u0026copy; software.\u003c/p\u003e\n\u003cp\u003eAnalysis of the various themes enabled us to carry out an initial descriptive analysis describing the intervention modalities (not presented here). An increase in abstraction level was carried out in order to produce a cross-sectional analysis of the interventions. In this way, we were able to identify the levers concerning professionals and users that enable adherence to the method or a perceived effect of the method.\u003c/p\u003e\n\u003cp\u003eThis abstraction enabled us to construct typical profiles for users and professionals. Each typical profile, based on the salient characteristics of the users and professionals we met, is made up of various components that it would appear to be essential to integrate into this abstraction in order to highlight the specificity of this category. Thinking in terms of typical profiles made it possible to go beyond the specificities of the programs, and to guarantee the anonymity of the professionals, users and structures involved in the study (Coenen-Huther, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). In order to protect this anonymity and in view of the small sample size, the positions and structures of the professionals or the names of the programs followed by the users whose words are quoted will not be mentioned.\u003c/p\u003e\n\u003cp\u003eIn our study, these typical profiles were then examined in relation to the interventional levers identified. This comparison of the levers identified and the typical profiles created enabled us to identify the effective combinations of typical profiles and levers that are desired or desirable, in the light of the qualitative data collected. Taken together, these analyses enabled us to draw up our recommendations.\u003c/p\u003e\n\u003cp\u003eThe analysis presented in this article is broken down into three separate parts: i) A brief presentation of interventional levers concerning professionals and users,\u003ca id=\"#FNLinkFn1\" class=\"FNLink\" href=\"#Fn1\"\u003e\u003c/a\u003e ii) identification of typical profiles for professionals and users, and iii) an analysis comparing typical user and professional profiles with the levers previously identified.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ea. Sample description\u003c/h2\u003e \u003cp\u003eTwenty-one professionals using one of the three interventions took part in this study (six \u003cem\u003eAlcochoix\u003c/em\u003e, 11 \u003cem\u003eIACA!\u003c/em\u003e and four \u003cem\u003eETP Conso-Rep\u0026egrave;res)\u003c/em\u003e. Of these interviews, four were with center managers, 17 with professionals (two nurses, three general practitioners, five specialized educators, two social work assistants, three social workers, two psychologists/psychotherapists). Twenty-one users were included in the study. They had an average age of 43 years and the majority were men; half of the sample had a level of education equivalent to high school leaving certificate or more. All of the participants had an alcohol use disorder diagnosed by healthcare professionals. Within this sample, 16 users took part in a qualitative interview.\u003c/p\u003e \u003c/div\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes covered during interviews with experts, professionals and users\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfessionals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUsers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfile and background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrigin and context of program creation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEntry into program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdoption of program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram creation methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCourse of program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventional, populational and contextual components of the program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram evolutions and readjustments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssessment of the program (perceived utility, accessibility, feasibility, salient points, difficulties)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssessment of the support and of the program and its effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram adaptation(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram perspectives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuggestions for improvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSix observations were performed for two of the interventions: \u003cem\u003eIACA\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;5), \u003cem\u003eETP Conso Rep\u0026egrave;re\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;1). Observations could not be performed for \u003cem\u003eALCOCHOIX\u003c/em\u003e because no follow-up session was held or indicated to the research team as being possibly observable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIntervention levers\u003c/h2\u003e \u003cp\u003eBased on a study of program-related documents, interviews and observations, we identified a number of cross-sectional levers promoting the implementation and effectiveness of interventions. We opted for a cross-sectional analysis in order not to identify each intervention studied, and to highlight levers that can be mobilized in other AHR programs. A distinction can be made between levers concerning professionals and those concerning users.\u003c/p\u003e \u003cp\u003e1) Levers concerning the engagement of professionals\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eReassurance of professionals\u003c/h2\u003e \u003cp\u003eSeveral programs offer training designed to equip professionals with the skills they need in the area of AHR. By providing an opportunity to acquire practical knowledge and skills to help users deal with alcohol-related issues, this training is seen by professionals as providing them with the tools, reassurance and sense of legitimacy they need when tackling alcohol issues with the people they work with:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The setting allows them to talk to people more calmly about their drinking, and when people arrive drunk, [\u0026hellip;] That really helps open the discussion. That\u0026rsquo;s something the whole team does. It\u0026rsquo;s crystal clear.\u0026rdquo; -\u003c/em\u003e structure manager\u003c/p\u003e \u003cp\u003eIn addition, the practice analysis sessions are identified by the professionals as being essential and clearly contribute to their sense of reassurance: the professionals therefore feel they have a collective space to talk and reflect on their professional practices, their experiences, their questions and the situations that they may have found challenging. However, it should be noted that there is a need for consistency between training (both in terms of the implementation of the intervention and the attitude of professionals) and this analysis of practices, since certain inconsistencies have been observed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSteps, progression\u003c/h2\u003e \u003cp\u003eOne of the elements identified as being fundamental in the interventions studied lies in their step-by-step implementation and progression. For example, the \u003cem\u003eIACA !\u003c/em\u003e program is organized as four sequences: a first connection phase combining welcoming and alliance, a second phase of achieving safer drinking, a third phase of stabilizing the reconstruction plan and objectives, and a fourth phase of improvement enabling launch of the coordination of the care pathway and the search for suitable partners. The three phases of the \u003cem\u003eETP Conso Rep\u0026egrave;re\u003c/em\u003e program described in the introductory box are also worthy of mention. These progression levels, or this pathway, allow the professional to follow a certain method or guide. However, this can sometimes also be seen as a restrictive framework or appear illogical, leading to more confusion.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The very fragmented part. [...] This aspect still needs to be corrected to move on from one session to the next. [\u0026hellip;] I don\u0026rsquo;t know how it all works now. I mean, there's something that isn\u0026rsquo;t really logical in the sequence, which they've corrected. It\u0026rsquo;s true that I regularly have difficulty keeping track of what stage we\u0026rsquo;re at.\u0026rdquo; -\u003c/em\u003eSocial worker\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInnovation and recognition\u003c/h2\u003e \u003cp\u003eAn essential point for the implementation of AHR interventions is that the \u0026ldquo;\u003cem\u003erecognition\u0026rdquo;\u003c/em\u003e of professionals enables them to \u003cem\u003e\u0026ldquo;innovate\u0026rdquo;\u003c/em\u003e in terms of their practices, drawing on methodologies and training. The aim is to instill confidence in professionals, reassure them of their skills and promote their autonomy (which is also linked to the training they receive, and to their reassurance). This recognition also sometimes enables them to find solutions for a user or a situation in which they had been feeling powerless.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It also gave me lots of ideas for solutions... in complex situations, where you can sometimes get a bit discouraged and give up and say that \u0026lsquo;there's nothing anyone can do for him after all!\u0026rsquo; But, in fact, yes there is something we can do. The (program) puts solutions back into perspective, in fact.\u0026rdquo; -\u003c/em\u003e Social worker\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInvolvement of the structure/team in a network of players\u003c/h2\u003e \u003cp\u003eOne of the levers that seems to be particularly important in the implementation of AHR interventions is the engagement of the structure and the team around this dynamic. An acceptance, or at least tolerance, of the AHR philosophy among the center's various professionals is essential if they are to be able to provide this support. This enables users to be directed towards the program (if it is appropriate for their particular care plan) and avoids confronting them with inconsistent advice (in terms of objectives or care plan, for example) within the structure. These inconsistencies in terms of advice can arise, for example, with regard to recovery objectives (abstinence or managed use), reception and support methods, and professional attitudes and values. In the same way, the creation of a network of professionals in agreement with the AHR philosophy enables users to be immersed in a dynamic and coherent care pathway.\u003c/p\u003e \u003cp\u003e2) Levers concerning the engagement of users\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMore supportive, even holistic assistance\u003c/h2\u003e \u003cp\u003eOne of the fundamental levers of the intervention lies in support that adapts to the user's needs, ranging from support involving telephone calls and availability, to more comprehensive support, including help in different areas of the user's life (marital, professional, family, administrative, financial or health situations, etc.). A 35-year-old user reports that she often calls the professional looking after her \u0026ldquo;to sound the alarm and (...) call for help\u0026rdquo;. The professional\u0026rsquo;s availability is presented as major plus point:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;(Professional\u0026rsquo;s name), (\u0026hellip;) I felt that his follow-up was pretty good\u0026hellip; more effective (\u0026hellip;), precisely because he is much more available than the psychiatrists, (\u0026hellip;) Whereas (professional\u0026rsquo;s name) is a very, very available person. He always makes himself available.\u0026rdquo; \u0026minus;\u0026thinsp;3\u003c/em\u003e5-year-old user\u003c/p\u003e \u003cp\u003eAnother 44-year-old multiple substance user explains how the holistic care he received helped him:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Well, already... with (professional\u0026rsquo;s name), I could talk about my paperwork problems. So there's the Social Security that doesn't pay you because my boss never had the right papers at the right time, or so we thought. And we checked that it was my boss, well the secretary who never sent the papers at the right time. So there were times when I was paid on\u0026hellip; the 25th, the 30th, to start with both. And then sometimes I wasn\u0026rsquo;t paid at all for three months, and so on. So, all that makes you feel bad, when you\u0026rsquo;re already an alcoholic, and you get no sickness benefit... well, it gets you down. So this program was really good, in that they really helped me with my paperwork. And that was a great help because I\u0026rsquo;m getting married. (\u0026hellip; ). So it helped a lot with the administrative formalities.\u0026rdquo; \u0026minus;\u0026thinsp;4\u003c/em\u003e4-year-old user\u003c/p\u003e \u003cp\u003eOur analyses show that this kind of support necessarily demands a high level of commitment, and requires a strong, constant presence and investment on the part of the professionals involved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEngagement, empowerment and freedom\u003c/h2\u003e \u003cp\u003eOne of the levers frequently mentioned by professionals is the level of commitment shown by users (i.e., their engagement and investment in the program) and their capacity to become empowered (i.e., the fact that users become more aware and take action as regards their drinking). The professionals and experts we met saw empowerment as a fundamental lever for the success of interventions Users appreciate this autonomy, this empowerment, which many associate with a sense of freedom as well as responsibility. The lexicon of freedom comes up a lot: one user reports that \u0026ldquo;we're free to say what we want\u0026rdquo;, another that they are \u003cem\u003e\u0026ldquo;free to drink\u0026rdquo;\u003c/em\u003e, and one participant says she has \u0026ldquo;more freedom\u0026rdquo; in this program than in her previous treatment experiences. One female user explains that the professionals\u0026rsquo; objectives are not to \u003cem\u003e\u0026ldquo;control\u0026rdquo;\u003c/em\u003e users and stop them drinking: \u003cem\u003e\u0026ldquo;We come here because we want to\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBonding, alliance and peer involvement\u003c/h2\u003e \u003cp\u003eIt appears to be particularly important to create a bond between users or between users and professionals. Indeed, the fact that the user can bond with other users, through group sessions, or can feel supported by and count on a closer relationship with the professional seems to play a fundamental role in the programs studied. Hence, group sessions, the implementation of special means of communication (e.g., telephone) and the use of support materials, such as notebooks or guides, are mobilized. Notebooks can be used as a tracking tool in a program: users use them to record their emotions, progress and difficulties in relation to alcohol use. Guides may include theoretical information about alcohol, its effects and harm reduction strategies, as well as messages encouraging people and motivating them to manage their drinking. Some users say they appreciate having \u0026ldquo;a single contact person\u0026rdquo;, \"a single point of contact, instead of multiple specialists\u0026rdquo;, which may help them to form deeper bonds. Another user says he appreciates the group sessions because they get him out of the house and allow him to \u0026ldquo;see other people\u0026rdquo;, which takes his mind off \u0026ldquo;smoking, (...) drinking; we're there to talk\u0026rdquo;.\u003c/p\u003e \u003cp\u003eCo-construction\u003c/p\u003e \u003cp\u003eAnother fundamental lever resides in people\u0026rsquo;s participation in the construction or implementation of support services. This can involve peer health mediators or peer helpers, through a community health approach. Co-construction can also be found in the joint setting of objectives (between professionals and users) during follow-up, or during group sessions. This participation ensures that methods are adapted to the needs and living conditions of users: they do not see them as being disconnected from their reality or their own particular concerns.\u003c/p\u003e \u003cp\u003eAwareness\u003c/p\u003e \u003cp\u003eOne of the levers mentioned by both professionals and users is the awareness generated by involvement in these three programs. This awareness can relate to the quantities consumed, situations involving danger to oneself or others, vulnerabilities or even the moments that trigger drinking. This awareness provides real leverage, enabling professionals and users to target specific behaviors to be reduced or possible actions to be taken. One user explains that by writing things down she has become more aware of her alcohol use: \u003cem\u003e\u0026ldquo;It has helped me, because I started noting down my drinking to track it, and when you look at what you\u0026rsquo;ve written down in your notebook, you say \u0026lsquo;yes, that\u0026rsquo;s not good\u0026rsquo;\u0026rdquo;.\u003c/em\u003e Another user also highlights this increased awareness:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI have to note down what I have drunk myself (...). There\u0026rsquo;s a written trace. So when I come back to write in it again, I realize that I've gone a week without touching anything, or that I only drank on Friday, and then I see that, in fact, instead of drinking three or four liters of beer in one evening, I only had two glasses of wine. So you see the reduction straight away. (\u0026hellip;) (\u0026hellip;) I can see that sometimes there are peaks. (\u0026hellip;) I saw the difference straight away... After two or three months, it changed everything.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough this growing awareness can be accompanied by a change in drinking habits, it is not always the case, which is something that some users lament (\u003cem\u003e\u0026ldquo;I still drink as much, nothing has changed\u0026rdquo;\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eTheoretical or practical learning\u003c/p\u003e \u003cp\u003eThe learning provided by the programs\u0026rsquo; support methods may relate to alcohol consumption, norms in terms of the amounts of alcohol consumed, or the consequences of alcohol use. It can also involve learning skills, tactics, strategies and practices to limit or delay drinking, and reduce the negative consequences of alcohol use. The learning can also focus on self-awareness and emotional awareness. This lever aims to reposition the user as a player in their own health and equip them to make informed choices. For example, one user mentions learning \u003cem\u003e\u0026ldquo;strategic approaches to find solutions\u003c/em\u003e\u0026rdquo;, \u003cem\u003e\u0026ldquo;really relevant information (\u0026hellip;) that helps us get through the various stages\u0026rdquo;\u003c/em\u003e. Another user says she found it very useful to learn that she should drink \u003cem\u003e\u0026ldquo;at least one or two glasses of water\u0026rdquo;\u003c/em\u003e between each glass of alcohol. Other users also appreciated the practical advice they received from the professionals who looked after them, with \u0026ldquo;tips\u0026rdquo; such as not buying alcohol, keeping busy in their free time when boredom can lead them to drink, etc.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIdentification of ideal types\u003c/b\u003e \u003c/p\u003e \u003cp\u003e1) Ideal types of users benefiting from the interventions\u003c/p\u003e \u003cp\u003eIt is possible to identify three user ideal types across the three programs studied.\u003c/p\u003e \u003cp\u003eThe socially included user, using alcohol only not targeting abstinence\u003c/p\u003e \u003cp\u003eThis first typical profile is predominantly female, has a fixed address and often a stable income. Users in this category do not see themselves as dependent drug users and seek to dissociate themselves from this profile. For example, one female user explains that before starting the treatment program, she \u003cem\u003e\u0026ldquo;was still drinking a bottle a day\u0026rdquo;\u003c/em\u003e, but that \u003cem\u003e\u0026ldquo;alcohol isn\u0026rsquo;t a problem\u0026rdquo;\u003c/em\u003e and that, what\u0026rsquo;s more, she does not drink \u003cem\u003e\u0026ldquo;all alcohols\u0026rdquo;\u003c/em\u003e: \u003cem\u003e\u0026ldquo;I only drink champagne. That\u0026rsquo;s all. I can\u0026rsquo;t drink anything else. (\u0026hellip;) If I don\u0026rsquo;t have any champagne, (\u0026hellip;) I won\u0026rsquo;t drink a glass of Ricard or a whisky\u003c/em\u003e\u0026rdquo;. Another user from the same program explains that she does not believe that a detox program is appropriate for her because she \u003cem\u003e\u0026ldquo;doesn\u0026rsquo;t need to go that far\u0026rdquo;\u003c/em\u003e, unlike other users. People belonging to this profile say they have no major health problems linked to their alcohol use, but report that they may have had periods of depression.\u003c/p\u003e \u003cp\u003eThe users that fit into this profile are at ease expressing themselves verbally and in writing, and place great importance on confidentiality and anonymity during their care. The objective for this typical profile is to manage their alcohol use, without any medicinal treatments and without aiming for complete abstinence. One interviewee explained that she had stopped her previous treatment \u003cem\u003e\u0026ldquo;based on medicines\u0026rdquo;\u003c/em\u003e because it \u003cem\u003e\u0026ldquo;seemed too restrictive\u0026rdquo;\u003c/em\u003e. One 47-year-old user working in the construction sector explains that he opted for this type of treatment because it does not target abstinence:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe thing with total abstinence is that once you crack, it all starts again. That's why I said to myself that the good thing about this program was that, um, if I could manage my drinking, it would be (...) over the long term, because (...) the fact that I could drink in moderation could make it manageable. (\u0026hellip;) Total abstinence is impossible. (\u0026hellip;) I don\u0026rsquo;t want to stop drinking completely, (\u0026hellip;) that\u0026rsquo;s not my goal.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMultiple substance users in very precarious situations with an ambivalent attitude to their substance use\u003c/h2\u003e \u003cp\u003eThis second typical profile is predominantly male, unemployed, unqualified, and often in a precarious situation in terms of housing. This profile has a long history of psychoactive substance use. For example, in addition to alcohol, one user took hallucinogenic mushrooms, cocaine, LSD, ecstasy and speed, and had been admitted to a psychiatric hospital after having had a car accident after swallowing a large number of medicinal drugs.\u003c/p\u003e \u003cp\u003eThis typical profile has a long history of addiction treatment. One user, describing himself as a \u003cem\u003e\u0026ldquo;drug addict\u0026rdquo;\u003c/em\u003e had already taken part in \u003cem\u003e\u0026ldquo;eight or nine detox programs\u0026rdquo;\u003c/em\u003e, the first when he was 21 years old. These previous treatments have not always gone well: several of those interviewed reported difficulties experienced during detox programs. One user explains that he had \u003cem\u003e\u0026ldquo;done several programs\u0026rdquo;\u003c/em\u003e and that \u003cem\u003e\u0026ldquo;each time, it didn\u0026rsquo;t work\u0026rdquo;\u003c/em\u003e. Another user \u003cem\u003e\u0026ldquo;has had treatment four times\u0026rdquo;\u003c/em\u003e, \u003cem\u003e\u0026ldquo;two or three weeks without alcohol, locked up in (name of a detox center\u0026rdquo;\u003c/em\u003e and states that \u003cem\u003e\u0026ldquo;it\u0026rsquo;s pointless\u0026rdquo;\u003c/em\u003e: \u003cem\u003e\u0026ldquo;As soon as I get out again, straight away, just to piss everyone off (\u0026hellip;) the first bar I see, and I\u0026rsquo;m off again\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eCharacterized by their ambivalence, people meeting this profile have difficulty expressing clear objectives regarding their substance use. One user says he went to Alcoholics Anonymous, and was not happy with the goal of total abstinence; then, the next moment, the same user states that abstinence is the only valid solution, before asserting: \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t believe in total abstinence\u0026rdquo;\u003c/em\u003e. Users with this profile report mental and physical health problems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThe middle-class user who wants to achieve abstinence and feels guilty\u003c/h2\u003e \u003cp\u003eThis third typical profile has undergone vocational training and works in a manual trade. They may have experimented with various psychoactive substances during their life, but consider alcohol to be their main problem. Their substance use has led to difficulties with their family and friends, and the user feels very guilty. One user explains that he \u003cem\u003e\u0026ldquo;blames (himself) a lot\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;doesn't blame others\u0026rdquo;\u003c/em\u003e. Another user interviewed believes he is the only person who can do anything about his substance use: \u003cem\u003e\u0026ldquo;It\u0026rsquo;s up to me to give myself a kick up the backside. (\u0026hellip;) I would like to cut back, for sure (\u0026hellip;) and have a clear head on my shoulders, (\u0026hellip;) but it\u0026rsquo;s down to me, (\u0026hellip;) nobody else can do it for me\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThis profile says they have health problems linked to their substance use (lung and liver problems, etc.), and have often tried a number of treatment methods, usually targeting abstinence. Users with this profile have alternated between giving up and relapsing, and consider all the previous support received to have been useful, once again believing that they alone are responsible for their failures. One user compares his previous treatments to \u003cem\u003e\u0026ldquo;a prison\u0026rdquo;\u003c/em\u003e (in the last eight years he has had \u003cem\u003e\u0026ldquo;three or four\u0026rdquo;\u003c/em\u003e that lasted \u003cem\u003e\u0026ldquo;several weeks\u0026rdquo;\u003c/em\u003e), while asserting that these treatments \u003cem\u003e\u0026ldquo;did him good\u0026rdquo;\u003c/em\u003e: \u003cem\u003e\u0026ldquo;The proof: I was able to go back to work\u0026rdquo;\u003c/em\u003e. However, he does not want to go back into treatment because he is fed up of giving up and then relapsing again: \u003cem\u003e\u0026ldquo;I don't plan to just do that all my life (...), go away as soon as things start going badly, come back, go away again, come back. (\u0026hellip;) Rehab centers, (\u0026hellip;) when I got out it lasted however long it lasted\u0026hellip; (\u0026hellip;) And then (\u0026hellip;) when I relapsed, I went backwards again\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e2) The typical profiles of the professionals implementing the interventions\u003c/p\u003e \u003cp\u003eWe were also able to identify four typical profiles for professionals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eThe isolated leader\u003c/h2\u003e \u003cp\u003eIn several structures, the arrival of the program and its implementation were linked to the intervention of a single person. This person may hold a managerial position (head of department, structure manager) or be a health or social care professional within the structure.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So, in fact, we knew (program name) with Doctor X at the same time [\u0026hellip;] Everybody relied a bit on Doctors X and Y\u0026hellip; And now, well, it's true that one of them has gone, so I think that's been felt in the continuity of this project. And in any case, that\u0026rsquo;s what we noticed, as a team\u0026rdquo;\u003c/em\u003e - Structure manager\u003c/p\u003e \u003cp\u003eThis person is often central to the arrival and continuity of the project, because they represent the program symbolically, and/or have obtained the resources (in terms of time and materials) to invest in the program. One of the consequences of this leadership by one person is the reliance on that person's investment and the durability of their presence in the structure. Due to the lack of general resources in the structures, if this isolated leader leaves the structure, the program has difficulty surviving. That is what happened in this structure: \u003cem\u003e\u0026ldquo;the doctor who... guided us on the method (name of the intervention) (...) left and (...) in fact, was part of this harm reduction dynamic, you know!\u0026rdquo;\u003c/em\u003e (healthcare professional)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eThe group leader\u003c/h2\u003e \u003cp\u003eThis typical profile has mobilized a management style focusing on getting several team members involved in the implementation of the program (and HR in general) and raising awareness of it, both within and outside the organization. The program has been thought through collectively: beyond the implementation of the program, there is a real HR development project within the structure, and the aim is to implement it collectively. The program implemented is then seen as an opportunity to innovate on an organizational level, to give impetus to HR by encouraging the sharing of knowledge acquired through training in the program.\u003c/p\u003e \u003cp\u003eThe involvement and management of the department head are central to this type of leadership: one social worker reports that the management of his organization \u003cem\u003e\"wants us to be a little proactive in the new methods, so that this will encourage other associations and other services to perhaps not necessarily follow our example, but to see that it's possible, to say that it's possible to train in this and to apply these methods in a residential program\u0026rdquo;.\u003c/em\u003e This group leader will promote the dissemination and consistency of the alcohol-related harm reduction project at the center.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eThe willing professional eager to improve their practices\u003c/h2\u003e \u003cp\u003eDespite institutional constraints, this typical profile demonstrates a high level of openness to programs. Keen to acquire new knowledge and new tools to deal with situations that can sometimes be problematic and for which they previously had no solutions, they demonstrate a real desire to progress professionally. This professional, often a social worker, is particularly open to questioning their practices, and recognizes the limits of their knowledge and approaches when dealing with the public. The question of deconstructing one's own perceptions of alcohol users and drinking practices was raised on several occasions: one social worker said that \u003cem\u003e\u0026ldquo;we didn't necessarily have the tools to avoid being clumsy in our approach\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eUnlike the group leader model, professionals with this typical profile develop individual strategies in their practices and in the AHR approach. While this profile is relatively positive in terms of program appropriation, its high level of engagement and questioning can lead to unacceptable working conditions in systems where resources are increasingly scarce.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eThe professional overwhelmed by a failing system\u003c/h2\u003e \u003cp\u003eProfessionals belonging to this fourth typical profile, although supportive of the programs implemented in their structure, shows certain signs of fatigue or weariness, especially if they are the only one carrying the program, like this healthcare professional: \u003cem\u003e\u0026ldquo;For a long time I\u0026rsquo;ve been the only one trained (...) I'm working on several projects in the center here and... sometimes... I... don\u0026rsquo;t have the energy, but (Laughs) I'd like it if somebody else could do it\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis weariness can lead this typical profile to make harsh, or even derogatory comments about users. For example, one healthcare professional said, when speaking about program beneficiaries \u003cem\u003e\u0026ldquo;for some of them, it\u0026rsquo;s not even worth offering them (the program), because they are not very compos mentis. Many of them have been much too damaged by their drinking. Some of them have absolutely no capacity for introspection.\u0026rdquo;\u003c/em\u003e The comments reveal much less intense engagement and a sense of weariness, which may lead to modification of the program. One healthcare professional reports that he \u003cem\u003e\u0026ldquo;presents the thing rapidly, without spending three hours on it\u0026rdquo;. It\u0026rsquo;s quickly wrapped up\u0026rdquo;.\u003c/em\u003e A kind of resignation influences practices and the appropriation of programs and/or a more holistic AHR approach. One physician reports that \u003cem\u003e\u0026ldquo;in any case, with respect to the protocol of (program name), it\u0026rsquo;s impossible to do. In six weeks, it\u0026rsquo;s impossible to fit it in, given our schedules, as well as the schedules of the people themselves\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eComparative analyses based on typical user profiles\u003c/h2\u003e \u003cp\u003eA configurational analysis of typical profiles of users enables us to identify different specific levers and typical profiles of professionals adapted to the specific needs of each profile.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e1) Based on the typical profile of the socially included user of alcohol only\u003c/h2\u003e \u003cp\u003eFor this typical profile, awareness and autonomy are the most appropriate levers for AHR support. In fact, the greater distance and objectivity made possible by an increased awareness of their drinking, and the greater sense of responsibility associated with engagement and empowerment, correspond to the expectations and capacities of these users. The co-construction of tools and/or strategies, or the involvement of peers in the method, could be envisaged in a very minimal (in terms of time and form) or highly adapted version. Since this typical user profile does not require a high level of professional involvement, this type of support could be provided by the four ideal types of professionals mentioned above, i.e., the isolated leader, the group leader, the willing professional eager to improve their practices, and the professional overwhelmed by a failing system.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e2) Based on the typical profile of the multiple substance user in a precarious situation\u003c/h2\u003e \u003cp\u003eThis profile will require more sustained and holistic support, with a particular focus on bonding and alliance. A caring and empathetic attitude on the part of the professional is essential to empower this profile. \u0026ldquo;Empowerment\u0026rdquo; refers to the process of linking an individual dynamic of self-esteem and skills development, with collective commitment and transformative social action (21, p. 27). A 35-year-old user appreciates that her support worker \u003cem\u003e\u0026ldquo;highlights (her) character traits and the moral qualities (that she may have)\u0026rdquo;\u003c/em\u003e during the support. Co-construction and the involvement of peers seem to be essential if the method is to be appropriate and not disconnected from the reality of these users. Other levers, if appropriate to the specificities of this profile, seem to be important to consider in AHR support: support for voluntary awareness and empowerment, and if they are mobilized with care in order to limit guilt-tripping or any potential perceived violence. Theoretical and/or practical training can also be envisaged insofar as users' capacities (in terms of cognitive ability or prioritizing of needs, or in terms of theoretical and practical knowledge of alcohol use and harm reduction strategies) allow this. These users seem to better match and be closer to the attitude of the willing professional eager to improve, or the isolated leader.\u003c/p\u003e \u003cp\u003e3) Based on the typical profile of the middle-class user who wants to achieve abstinence and feels guilty\u003c/p\u003e \u003cp\u003eThis user has a specific goal (i.e., abstinence), even if it is difficult to achieve. In this respect, the contribution of theoretical and empirical knowledge seems to be a relevant interventional lever to support them in their progress. Bonding and alliance with the professional will also be crucial for these users, who need to be supported in order to overcome their guilt and their feeling of being entirely responsible for their state of health. As long as users' objectives are taken into account, co-construction and peer involvement could be envisaged if this is not too time-consuming. As far as professional profiles are concerned, the isolated leader could match the requirements of these users as long as the support does not require close collaboration or excessive availability.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results presented here constitute the original results of a cross-sectional analysis of three alcohol harm reduction interventions. The typical user profiles illustrate the diversity, complexity and, sometimes, ambiguity of the people who seek the support of structures offering AHR programs. This diversity of typical profiles also shows how uses, attitudes towards them and assessments of interventions can have an impact on the acceptance, adherence to and effect of these different programs.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eSummary of results\u003c/h2\u003e \u003cp\u003eThree typical profiles for users have therefore been identified: an alcohol user who does not use other psychoactive substances, is socially included and does not identify with other users who need treatment for their substance use; a multiple substance user in a precarious situation, with a combination of health and social vulnerabilities and a long history of treatments; and a middle class user, who have tried to stop drinking several times, unsuccessfully; they take responsibility for their addiction and feel guilty about it. Four typical profiles were identified for professionals: the isolated leader, the group leader, the willing professional eager to improve their practices, and the professional who is overwhelmed by a failing system and weary.\u003c/p\u003e \u003cp\u003eDepending on the user's profile, certain levers and professional profiles appear to be particularly suitable for ensuring the effectiveness of the intervention and the user's adherence to the program. For the first typical profile - the socially included user who only uses alcohol - awareness and empowerment are suitable levers, as well as, possibly, work on bonding, alliance and peer involvement. This user profile could correspond to all professional profiles. The second typical profile, precarious and with multiple vulnerabilities, requires sustained and holistic support, with a strong emphasis on bonding and alliance with the professional, as well as peer involvement. This typical profile seems to match and be close to the attitude of the willing professional eager to improve, or the isolated leader. Finally, for the third typical profile, who wishes to be abstinent and feels guilty about their addiction, bonding and alliance with the professional are crucial, as is co-construction of the objectives and modalities of the intervention. The isolated leader could correspond to this third typical profile.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eThe study's strengths and limits\u003c/h2\u003e \u003cp\u003eThis study has several limits. The health situation had an impact on the deployment or implementation of interventions in certain centers, as well as on certain study modalities (replacement of a seminar by individual interviews, videoconference interviews). In addition, the users we met had an alcohol use disorder, in the majority of cases severe, whereas the programs can target individuals with a less severe use disorder. Another important factor to take into account is the confusion of users, and sometimes professionals, between support proposals and the study conducted. Far from being anecdotal, this confusion may have had a number of consequences, ranging from misinterpretation by users of what the program consists of (in terms of content but also in terms of objectives), to a lack of understanding of the support offered (confusion between callbacks for measurement and support). Particular attention was paid to this point during the analyses in order to limit this bias as far as possible.\u003c/p\u003e \u003cp\u003eHowever, these limits are counterbalanced by the strengths of this study. First of all, the qualitative approach we adopted enabled us to understand the subjectivity of the players (whether professionals, users or experts) and the meaning they give to their practices and the interventions deployed. The mobilization of various methodological tools (interviews, observations, seminars) also made it possible to enhance data collection and triangulate the information gathered. The fact that we worked as part of a team also enabled us to consolidate our analyses by comparing our perspectives, since coding was performed collectively. In addition, the multi-situation aspect of this study, which cross-analyzed three different interventions implemented in different cities and structures, enabled us to put the diversity of AHR objectives and methods into perspective, facilitating an increase in generality and abstraction through comparison.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eDiscussion of user and professional ideal-types\u003c/h2\u003e \u003cp\u003eSome of our results need to be discussed. With regard to the first user profile, it is important to note that as a woman and a socially included person with an alcohol use disorder, this typical profile runs the risk of being doubly stigmatized. (Perrin, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) In reality, addiction in women is particularly stigmatized, and women users run a number of risks: being seen as bad mothers and women of bad character, not to mention the risk of abuse and violence. (15\u0026ndash;19) As a result of this stigmatization, women seek treatment less than men. (Perrin et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) Socially included people are also generally afraid to reveal their addictions, as they run the risk of losing credibility and responsibility in their work environment, or even of being made redundant, and of coming into conflict with their family and friends. (Crespin et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) Socially included substance-dependent people therefore often lead a \u0026ldquo;double life\u0026rdquo;. (Fontaine, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) Consequently, the lack of identification of this first profile with other alcohol-dependent users can be analyzed as a stigma-avoidance strategy. (Goffman, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1975\u003c/span\u003e; Gruel, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1985\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe second typical profile highlights the reciprocal relationship between poverty and addiction, and the obstacles to treatment that this relationship generates. According to several studies, poverty is correlated with an increased risk of drug dependence. (Kensy et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) People who are homeless or have no fixed abode are at greater risk of developing a substance use disorder. Half of all homeless people have an addictive disorder in their lifetime, and people with a substance dependence are more likely to lose their jobs and homes, and to be socially isolated. (Apostolidis et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) People living in very precarious conditions face a number of obstacles to care and treatment, and are highly stigmatized. (Grimard, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) The use of alcohol helps people cope with living conditions on the streets, while at the same time sometimes preventing the individual from accessing housing (emergency shelters do not always accept alcohol use on their premises) or employment.\u003c/p\u003e \u003cp\u003eThe third typical profile has characteristics that may be related to two things: firstly, perhaps, the internalization of a reductionist discourse, dominant in our society (Taylor, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2008\u003c/span\u003e), asserting that the only solution to addiction is to stop using altogether. On the other hand, it can also be a question of how difficult it is for people in addiction situations to manage their substance use. People with a severe level of addiction have often tried many times before to control their drinking, but are unable to control themselves once they start. They come to believe that they are in an \u0026ldquo;all or nothing\u0026rdquo; situation, and that the only realistic option for them is total abstinence.\u003c/p\u003e \u003cp\u003eWith regard to the profiles of the professionals identified, they point to the absolute necessity of taking into consideration their professional situation and attitudes with respect to abstinence and AHR. A number of articles in the scientific literature stress the fact that, if an intervention is to be properly implemented, it is essential for the various players and structures involved to harmonize their values. Several studies report that professionals are in conflict over various issues (e.g., consumption norms to be provided to users). (Minian et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) It is essential for professionals to consult one another and to agree on clear rules. (Parkes et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Pauly et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) This aspect is linked to the need, outlined below, to involve staff in the implementation of a program.\u003c/p\u003e \u003cp\u003eMore generally, the scientific literature insists that, to be effective and gain the support of users and professionals alike, interventions must be based on scientific evidence, (Ingram et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Tofighi et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) since that increases their credibility and promotes consistency of practices and discourses. The aim is to draw on the results of scientific research concerning the effectiveness of an intervention, and to mobilize this scientific data with professionals and users alike, to attest to the legitimacy and relevance of the support offered. It is also important for this intervention to be co-constructed by users and professionals so that it makes sense for both. (de Wit et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) Moreover, this harmonization of values cannot be achieved without taking into consideration the cultural contexts in which the interventions will be implemented. (Klimas et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Schwebel et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) In reality, depending on the context (even within the same society), cultural perceptions of alcohol and harm reduction vary, and can limit the effectiveness of the intervention. (Klingemann \u0026amp; Klingemann, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Majer et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Minian et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) Finally, interventions involving several therapeutic strategies are presented as being particularly effective. (Kelly et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; L\u0026eacute;vesque et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Pettigrew et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ray et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Swendeman et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eRecommendations and perspectives\u003c/p\u003e \u003cp\u003eAll our findings point to the need to adapt interventions to users' needs, rather than expecting users to adapt to the objectives of the interventions. (Barrio \u0026amp; Gual, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) According to the harm reduction philosophy (Morel et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), alcohol harm reduction interventions must be adapted to the user's needs, depending on the severity of their addiction and the level of their craving, (Klingemann \u0026amp; Klingemann, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) as well as to the expectations expressed and the user's profile. Mobilization of the notion of proportionate universalism, as defined in 2010, (29) could be a relevant perspective for AHR interventions This principle states that \u0026ldquo;actions should be universal, but with an intensity and a scale that is proportional to the level of disadvantage\u0026rdquo;. An AHR intervention guided by the theoretical framework of proportionate universalism would therefore present a core of universal actions or levers proposed to all users and then, depending on the specific needs identified by this analysis of typical profiles, a range of targeted actions, tailored to the needs and objectives of the different publics concerned by alcohol use disorders. These targeted actions could then be considered not only in terms of the user's socioeconomic situation, but also using identified criteria, such as stigmatization, empowerment, the need for an alliance or co-constructed objectives, or the leadership of the professional involved. However, the user's objective needs to be reviewed and reassessed regularly. With this in mind, the method used for each intervention must be flexible and adaptable. (Swendeman et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) This ties in with the idea of setting objectives and co-constructing interventions with users, already mentioned in the literature. (Collins et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Ingram et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This article highlights the benefits of an ideal type analysis for the evaluation of such complex interventions, aimed at people in situations of vulnerability with multiple facets and manifestations. It also raises questions about the relationship between professionals and users, and the ability of our healthcare system to integrate these different user profiles.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAHR\u0026nbsp; \u0026nbsp;\u0026nbsp;Alcohol Harm Reduction\u003c/p\u003e\n\u003cp\u003eDPO\u0026nbsp; \u0026nbsp; \u0026nbsp;Data Protection Officer\u003c/p\u003e\n\u003cp\u003eECIAE\u0026nbsp;cross-evaluation of the Iaca, Alcochoix and ETP Conso-rep\u0026egrave;re programs\u003c/p\u003e\n\u003cp\u003eETP\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Patient Therapeutic Education\u003c/p\u003e\n\u003cp\u003eGDPR\u0026nbsp;\u0026nbsp;General Data Protection Regulation\u003c/p\u003e\n\u003cp\u003eHAS\u0026nbsp; \u0026nbsp; \u0026nbsp;French National Authority for Health\u003c/p\u003e\n\u003cp\u003eHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;harm reduction\u003c/p\u003e\n\u003cp\u003ePIA \u0026nbsp; \u0026nbsp; \u0026nbsp;Privacy Impact Analysis\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConsent\u0026nbsp;for\u0026nbsp;publication\u003c/h2\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eThe project has been carried out in full accord with current relevant legislation (e.g., the Charter of Fundamental Rights of the EU) and international conventions (e.g., Declaration of Helsinki). The project respects the obligations related to the EU General Data Protection Regulation (GDPR). The study protocol was submitted to our university Data Protection Officer for analysis and did not qualify as falling under the rules applying to \u0026nbsp;\u0026ldquo;Research Involving the Human Person\u0026rdquo;. This protocol did not therefore require the solicitation of an ethics committee but only registration in the DPO register and the implementation of a Privacy Impact Analysis (PIA). All sensitive data collected in the framework of the study are routine data, the collection of which is part of National Authority for Health (HAS) recommendations. Our university has ensured that all the regulatory procedures related to the ECIAE study have been carried out.\u003c/p\u003e\n\u003cp\u003eThe methods\u0026rsquo; development, data collection, and analysis \u0026nbsp;took the following issues into account:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Anonymity of study respondents will be preserved and ensured at all times. Unnecessary collection of personal data has been avoided, and respondents \u0026nbsp;had the right to review outputs and withdraw consent. All personal data have been coded, removed from the data for analysis and stored separately. Only designated research staff have access to the keys linking data with personal information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Information regarding the study and the right to refuse to participate have been distributed to all study participants., In the case of refusal, alternative means of data collection have been explored (e.g., alternative respondents).\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare having no competing interest\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution Statements\u003c/h2\u003e\n\u003cp\u003e1\u003csup\u003erst\u003c/sup\u003e, 2\u003csup\u003end\u003c/sup\u003e and last authors drafted this article and all authors the 5 authors revised the manuscript. The project design was developed by 4\u003csup\u003eth\u003c/sup\u003e and 5\u003csup\u003eth\u003c/sup\u003e authors. 1rst, 3\u003csup\u003erd\u003c/sup\u003e and last authors were involved in implementing the project and in developing the evaluation design, under the supervision of 4\u003csup\u003eth\u003c/sup\u003e author. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding Statement\u003c/h2\u003e\n\u003cp\u003eThis study has received funding from regional health agency of New Aquitaine (ARS Nouvelle Aquitaine).\u0026nbsp;Award/grant number\u0026nbsp;: N/A\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors are very grateful to all those who took part in the project.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eApostolidis T, Rouan G, Eisenlhor S. Construction du rapport aux drogues dans un contexte de pr\u0026eacute;carit\u0026eacute;. 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Article 4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Addiction, Alcohol and Alcoholism, Risk, Qualitative","lastPublishedDoi":"10.21203/rs.3.rs-4546141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4546141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe present article aims to identify appropriate interventional levers based on different types of publics and professionals, by comparing three alcohol-related harm-reduction programs implemented in France. To offer a transversal and more relevant analysis for action, we carried out an analysis by ideal types based on typical profiles of users and professionals. Twenty-one professionals using one of the three interventions took part in this study, and twenty-one users were included. Three typical profiles for users have therefore been identified: the socially included drug user, using alcohol only not targeting abstinence, the multiple substance user in very precarious situation with an ambivalent attitude to their substance use, and the middle-class drug user who want to achieve abstinence and feels guilty. Four typical profiles for professionals have also been identified: the isolated leader, the leader of a group, the willing professional eager to improve their practices, and the professional overwhelmed by a failing system. Depending on the user's profile, certain levers and professional profiles appear to be particularly suitable for ensuring the effectiveness of the intervention and the user's adherence to the program. All our findings point to the need to adapt interventions to users' needs, rather than expecting users to adapt to the objectives of the interventions. Mobilization of the notion of proportionate universalism, as defined in 2010, could be a relevant perspective for AHR interventions.\u003c/p\u003e","manuscriptTitle":"Comparative study of three alcohol-related harm reduction programs: an ideal-type analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-01 05:23:19","doi":"10.21203/rs.3.rs-4546141/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a3561027-f112-404f-948b-aa225ee185c6","owner":[],"postedDate":"July 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-12T11:02:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-01 05:23:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4546141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4546141","identity":"rs-4546141","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}