SECTION I
ALCOHOL AND THE ELDERLY. THE EUROPEAN PROJECT VINTAGE: GOOD HEALTH INTO OLDER AGE

Alcohol and older people. The European project VINTAGE: good Health Into Older Age. Design, methods and major results

Alcol e anziani. Il progetto europeo VINTAGE: buona salute nell'età anziana. Disegno, metodi e principali risultati

Lucia Galluzzo^I; Emanuele Scafato^I; Sonia Martire^I; Peter Anderson^II; Joan Colom^III; Lidia Segura^III; Andrew McNeill^IV; Hana Sovinova^V; Sandra Radoš Krnel^VI; Salme Ahlström^VII; for the VINTAGE project Working Group^*

^IWHO Collaborating Centre for Research & Health Promotion on Alcohol and Alcohol-Related Health Problems, Osservatorio Nazionale alcol, Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy
^IIFaculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
^IIIDepartment of Health, Program on Substance Abuse, Government of Catalonia, Barcelona, Spain
^IVInstitute of alcohol Studies, Huntingdon, United Kingdom
^VCoordination, Monitoring and Research Unit, National Institute of Public Health, Praha, Czech Republic
^VIResearch Centre, Institute of Public Health, Ljubljana, Slovenia
^VIINational Institute for Health and Welfare, Helsinki, Finland

Address for correspondence

ABSTRACT

OBJECTIVES: The European project VINTAGE - Good Health Into Older Age aims at filling the knowledge gap and building capacity on alcohol and the elderly, encouraging evidence- and experience-based interventions.
METHODS: Systematic review of scientific literature on the impact of alcohol on older people; ad hoc survey and review of grey literature to collect EU examples of good practices for prevention; dissemination of findings to stakeholders involved in the field of alcohol, aging or public health in general.
RESULTS: Design and procedures of the VINTAGE project are described, providing also an outline of major results, with particular attention to those related to the dissemination activity.
CONCLUSIONS: Much more information and research is needed. This issue should be part of both alcohol and healthy ageing policies.

Key words: aged, alcohol drinking, Europe, research design, methods.

RIASSUNTO

OBIETTIVI: Il progetto Europeo VINTAGE - Buona salute nell'età anziana ha l'obiettivo di colmare le lacune su alcol e anziani, creando competenze e incoraggiando l'adozione di interventi basati su evidenza ed esperienza.
METODI: Revisione sistematica della letteratura scientifica sull'impatto dell'alcol negli anziani; indagine ad hoc e revisione della letteratura grigia per raccogliere esempi europei di buone pratiche di prevenzione; disseminazione dei risultati a professionisti coinvolti nel campo dell'alcol, dell'invecchiamento o della salute pubblica in generale.
RISULTATI: Vengono descritti il disegno e le procedure del progetto VINTAGE, fornendo anche una sintesi dei principali risultati, in particolare quelli relativi all'attività di disseminazione.
CONCLUSIONI: Sono necessarie più informazioni e ulteriori ricerche sull'argomento, che dovrebbe entrare a far parte sia delle politiche sull'alcol che di quelle sull'invecchiamento.

Parole chiave: anziani, assunzione di alcolici, Europa, progetto di ricerca, metodi.

INTRODUCTION

Previous scientific findings suggest that elderly subjects are particularly susceptible to the ill effects of alcohol consumption, because of biological changes associated with ageing (such as the reduction in: body water, efficiency of liver enzymes and hepatic blood flow, responsiveness of the brain, etc.), strengthened by interaction with medications.

Common alcohol-related conditions amongst older people include dementia and cognitive decline [1], cancers (of the mouth, digestive system, liver and female breast), cerebrovascular diseases, diabetes mellitus [2, 3], in addition to accidents and injuries [4]. Although light-to-moderate drinking is considered a protective factor against coronary heart diseases, the evidence shows that the degree of protection is much less in older people than in middle-aged people [5]. Furthermore, a parallel neuroprotective effect has been excluded, demonstrating that moderate alcohol consumption is not protective against normal age-related decline in total brain volume, with higher levels of consumption consistently associated with smaller volume [6].

Although a substantial absence of comprehensive and harmonized data for individuals aged 65+ prevents an evaluation of the real impact of drinking on the elderly [7], harmful alcohol use appears as a common feature of older people. Estimates from the 2007 Eurobarometer survey show that as many as 27% of European people aged 55+ years had episodes of binge drinking (5+ drinks of 50 g alcohol on a single occasion) at least once a week during the previous twelve months [8]. Older people drink for many reasons, including being sociable, to relax, and to block out loneliness [9]. They often continue the same drinking patterns they had before retirement [10], on the contrary, because of the so-called sick-quitter effect, elderly subjects who develop adverse medical conditions or physical symptoms tend to reduce their frequency of drinking or abstain from alcohol [11].

Harmful alcohol use of older people leads to reduced healthy life years, and preventable increased health and welfare costs. Nevertheless, alcohol misuse in the elderly is often underestimated, misdiagnosed and undertreated, since screening instruments, diagnostic criteria and public health initiatives are mainly focused on younger age groups. In addition, the average age of the world's population is increasing at an unprecedented rate. In just over 30 years, the proportion of older people will double from 7% to 14% of the total world population and Europe will confirm the oldest world region [12]. With the ageing of populations worldwide alcohol use disorders will increase in absolute numbers, and a real danger exists that a "silent epidemic" may be evolving [13].

A growing interest at European level is witnessed by a series of actions undertaken in recent years. The communication adopted by the European commission in 2006 set out a strategy to support the Member States in reducing the problems related to harmful and hazardous alcohol consumption [14]. This strategy included the prevention of alcohol-related harm among adults as one of five priority themes. It emphasized the importance of relevant good practices and of providing information to consumers in order to influence informed choices and reduce also the negative impact of alcohol on the workplace. The European council conclusion issued in 2009 supported the previous priority themes and more specifically recognized the need to include the age group of 60 and above in existing European information systems on alcohol consumption and harm, and to address the well-being of the ageing population [15].

In the same period, during the Swedish Presidency of the council of the European Union (EU) a report concerning alcohol consumption trends and related harms among elderly EU citizens aged over 60 [16] was commissioned by the EU Ministry of Health and Social Affairs. The main findings about alcohol consumption trends and related harms in the ten EU Member States that contributed to the report (czech Republic, Finland, Germany, Italy, Latvia, Poland, Slovenia, Spain, Sweden, and the United Kingdom) show that alcohol use in old age is an under-researched area, although most elderly Europeans drink alcohol (about 70-80% of men and 50% of women consuming alcohol during the previous year). Alcohol related deaths among elderly Europeans had increased over the past ten years in at least seven of the ten EU Member States surveyed, from 25% in Poland to more than 100% in the UK. Training programs to assist healthcare staff with the detection and management of alcohol problems among the elderly did not exist in most Member States.

The European project VINTAGE - Good health into older age, started in March 2009, was part of the ongoing process that recognized the importance of the social and health impact associated with harmful alcohol consumption among the elderly and the necessity to fill the knowledge gap in this issue. The purpose of the project was to build capacity at the European, country and local levels by providing the evidence base and collecting best practices to prevent the harmful use of alcohol amongst older people. There were three specific objectives of the VINTAGE project:

Since the risk of life-time death increases with both the volume of life time alcohol use and the frequency of heavy drinking occasions [3], scientific data, policies and programmes regarding later middle age, the work place and the time of retirement were featured in the literature reviews and the examples of best practice collected.

The aim of the present paper is that of describing the general design of the VINTAGE project, illustrating methods and procedures adopted, providing also an outline of the major results obtained, with particular attention to those related to the dissemination activity.

MATERIALS AND METHODS

The VINTAGE project was funded by the European commission under the 2^nd Programme of community Action in the Field of Health (2008-2013). The duration of the project was 21 months, from March 2009 to November 2010. It was coordinated by the Istituto Superiore di Sanità (ISS, Italy) as project leader and carried out by a network of 7 national health institutes and research centres from as many European countries (czech Republic, Finland, Italy, Netherlands, Slovenia, Spain, United Kingdom), together with 12 collaborating partners (Table 1).

The project was organized in 5 Work Packages (WPs), each one linked to definite objectives and activities, with the lead partner (ISS) responsible for coordination and management (WP1), dissemination (WP2) and evaluation (WP3). As associated partners, the University of Maastricht (UNIMAAS, Netherlands) was responsible for the development of the scientific evidence base (WP4) and the Generalitat de cataluña (GENcAT, Spain) was responsible for the development of the experience and best practice base (WP5).

WP1 - Coordination and management of the project

The VINTAGE project was originally established as an 18-month project (March 2009-August 2010), which was extended by a further 3 months. From the very beginning of the project, high priority was given to the respect of a tight timetable. As a consequence of the extension of the study period to 21 months, approved in September 2010, the work plan was revised and the deadlines of all activities not yet accomplished, or scheduled for the following period, were deferred in order to take full advantage of the study prolongation.

One of the first steps was aimed at building up a network capable of fulfilling the objectives of the project, strengthening the liaison between partners. This task was facilitated by the small number of involved partners and synergy was assured by the different experiences of investigators, all with extensive familiarity in alcohol or aging issues and in managing research projects and data. Team work and commitment were helped by a good network structure, building on previous close working relationships. During the study period, the lead partner (ISS) kept in frequent contacts with all partners and acted also as connection between participants and external organizations, both for administrative and scientific issues.

To facilitate management of the project, a management team was established during the VINTAGE kick-off meeting, composed of the project leader and coordinator, with other WPs leaders and ISS support staff. The management team was responsible for ensuring the timely completion of planned actions and deliverables, and the respect for budgetary provisions, while the single WPs leaders remained responsible for operational decisions.

The management team physically met three times, in occasion of the coordination meetings that were organized during the study period and attended by all associated partners. The aim of the first meeting (Rome 27/5/2009) was to provide full information on the structure and sequence of the work plan and to discuss methodologies in the project. The main purpose of the second meeting (Barcelona 15/12/2009) was to provide a general overview of the progress of the project, including preliminary results obtained during the first phase of data collection. The third and final meeting (Rome 18/6/2010) discussed the latest draft reports, the planned actions for dissemination and possible plans for continuation and sustainability of the work.

One of the major tasks related to the scientific coordination and management of the project consisted in defining and reaching an agreement on the general study protocol, describing aims, instruments and procedures for the accomplishment of the three specific objectives of the project.

The modus operandi used to achieve consensus in all of the work packages was that documents were circulated among partners, then commented and revised and finally adopted when there was agreement among all partners.

WP2 - Dissemination of results

A widespread dissemination of VINTAGE results was considered as crucial for the success of the project, as it could provide active sharing of evidence-based information and examples of good practices on alcohol-related harm in the elderly, influencing the harmonization of policies and programmes at European, national and local level.

The purpose of the VINTAGE dissemination was to raise awareness of the project and to share its findings. All relevant networks and governmental and non-governmental organizations of professionals involved in the health and well-being of older people at EU, country, regional and municipal level were the immediate target groups for VINTAGE dissemination, being responsible for the implementation of effective policies and programmes to reduce alcohol related harm. The public, intended as older people who were at risk of the long term consequences of heavy drinking, was the end target group of the VINTAGE dissemination, since information on alcohol-related harm and the implementation of best practices was likely to prevent alcohol harmful consumption among them.

As first step, to characterize the project and allow for better visibility and recognition of all dissemination tasks, a common graphical identity and a VINTAGE logo were designed and used in all documents and materials to facilitate identification and "branding" of the project. An overall dissemination strategy was developed and illustrated in a Dissemination Plan, which was periodically updated on the basis of the project evolution and of new dissemination opportunities.

As arranged in the dissemination plan, the VINTAGE website (www.epicentro.iss.it/vintage) was designed in the first period of the study and launched in November 2009. The website, hosted and managed by ISS, included both a public and a private restricted area, serving as the front face of the project and ensuring ongoing communication and contacts within the VINTAGE community and with the external world.

In brief, the public area of the website provided:

Access to the password protected restricted area of the website was reserved to VINTAGE partners, the commission Executive Agency for Health and consumers (EAHc) and the external evaluator in charge of the VINTAGE evaluation. The contents of the private restricted area were all materials, management tools, and outputs intended for confidential diffusion, including the project protocols, the Dissemination Plan, the agendas and minutes of the three meetings, the technical, financial and evaluation reports, etc.

The website was regularly updated to provide a prompt upload of information, materials and reports as soon as they were available, and in order to allow the more complete dissemination of results. In addition, a counter of hits and download actions was also activated in order to quantify the extent of the dissemination of VINTAGE findings.

Email messages introducing the project and containing the links to the online sources for VINTAGE reports and databases were actively disseminated to a list serve of stakeholders. The list was specifically created through the joint collaboration of all VINTAGE partners on the basis of existing networks and list serves of health-care professionals, alcohol policy makers and organizations (governmental, non-governmental and private) involved in the health and well being of the elderly. All partners contributed to the creation of the list serve providing e-mail addresses of subjects or institutions that, in their opinion, might contribute to, or have benefit from, VINTAGE findings. Of course, all professionals and organizations that had been contacted for WP5 data collection were also included in the list serve, with the aim of giving them the necessary and expected feedback. The dissemination of e-mail messages to the stakeholders included in the list was completed by mid-January 2011.

VINTAGE activities and results were also publicized and disseminated by means of interaction with other appropriate websites sharing the same area of interest. In this way, a seamless structure was created on the web, linking VINTAGE website to and from other networks, and storing focuses on the project and its main results on pre-existing websites, such as those of the European Alcohol Policy Alliance (EUROcARE), the Primary Health care European Project on Alcohol (PHEPA), the International Network on Brief Intervention for Alcohol and other Drugs (INEBRIA) and the institutional websites of VINTAGE partners.

WP3 - Evaluation of the project

The evaluation of the VINTAGE project was undertaken by an External Evaluator (Ann Hope) with extensive experience in both alcohol issues and project evaluation. The external evaluator was also responsible for the preparation of the Evaluation Plan and for summarizing its results in the Evaluation Report.

The main purpose of the VINTAGE evaluation was to examine whether the objectives were achieved during the lifetime of the project and if the organization was effective. The evaluation of the VINTAGE project was based on a case study methodology, treating the case as one of intrinsic interest and taking a holistic view by assessing the process, outputs and outcomes of the project.

The process evaluation examined the implementation of the VINTAGE project in terms of working ethos, organization, communication and value of project as seen by partners and observed by evaluator. The different project documents such as email communications, minutes of meetings, presentations at meetings, web page information, protocols and technical reports were reviewed. The evaluation of project staff and members' experiences and views of the VINTAGE process was carried out through a focus group organised with project participants at the last of the project meetings in Rome and by a written questionnaire to work package leaders.

The output evaluation involved a review of the project deliverables and outputs in terms of scientific accuracy, readability, usability and ease of access, by selected scientists. Two external scientists (Mats Hallgren and Gino Farchi) as well as all project partners provided a feedback loop on draft versions of the reports. The quality of the information in the main reports (evidence and best practice) was also assessed for readability and usability through a survey conducted among a random sample of key stakeholders. Two questions in the feedback questionnaire provided information on the clarity and relevance of the reports. The question on clarity was "how easy did you find the report to understand?" with a Likert scale response option from 0 (very difficult) to 10 (very easy). The question of relevancy was "how relevant is the information for your work?" with a response scale from 0 (not at all relevant ) to very relevant (10).

The long-term outcome of the project was to increase the health and wellbeing of older people. Given the short time frame of the project, three intermediate measures were adopted for the outcome evaluation, in order to estimate the influence of VINTAGE on the improvement of the conditions of elderly subjects: the dissemination reach, based on the extent of the list of stakeholders compiled for dissemination of the project results; the hits to the websites and number of downloaded documents at the end of the project; and a survey of a random sample of stakeholders (n = 300) to assess their awareness and level of importance given to this issue in their country and their intention of modifying existing policies and practices on the basis of the VINTAGE project reports.

WP4 - Evidence base

The aims of the VINTAGE literature review were to document what was known about alcohol consumption amongst older people and the impact of alcohol on the health and well-being of older people, identifying also any specific evaluated programme to reduce the harm done by alcohol to older people and considering the impact of existing alcohol policy measures, such as controls on the price and availability of alcohol on reducing the harm done by alcohol to older people.

Systematic reviews of scientific literature were undertaken querying PubMed, MEDLINE, the cochrane Library and Google Scholar using a specific set of search terms related to aging, alcohol and health problems. Searches were restricted to the English language and since the year 2000, but extended to the middle aged group (45-64 years) in order to capture also the transition from work to retirement and the long-term effects of alcohol consumption. Key reviews of the impact of alcohol policies in reducing the harm done by alcohol were screened for information on older people [17-19].

Three hundred and sixty nine titles and abstracts were indentified in the search, from which 78 papers were retrieved. Selected papers were those that were systematic reviews or original papers not included in systematic reviews. Papers already included in systematic reviews and clinically or practice oriented papers were excluded.

Results of the systematic review of the scientific literature undertaken to document the evidence base on the impact of alcohol on the health and well being of older people and on the prevention of harmful alcohol use by older people were collected and analysed in the report "Alcohol and older People: a public health perspective" [20].

WP5 - Experience base

The strategy chosen to collect examples of best practices and effective policies and programmes consisted of reaching as many professionals as possible from governmental offices, research bodies, non-governmental institutions and the private sector and requesting them to respond to a standardized questionnaire or to provide additional contact details of professionals to whom the questionnaires could also be sent.

The data collection was led by GENcAT but done in collaboration with other VINTAGE partners. To make it more effective and facilitate the follow-up, it was organized in five different geographic areas, as described below:

Each of WP5 partners was responsible for covering all the countries included in their own area of influence for the delivery of questionnaires, issuing the necessary follow-up reminders and collecting responses and sending them back to the WP leader. To facilitate data collection, a table to keep track of all contacts, including those with no reply, and to monitor data collection characteristics, progress and results was implemented.

An ad hoc questionnaire with specific instructions was developed in MS-Word format. It was decided to avoid an online instrument because past experiences have shown that data collection with this kind of instrument is rather difficult to monitor and follow-up. The questionnaire was structured in the following sections: information on the compiler; basic information on the project, programme, best practice (name, type, objective); description of its development (background, methods of development, main elements, target, etc.); description of its implementation (funding, level of implementation, starting date, duration, results); full description of its eventual evaluation and of relative results; extra details to find out more information (contacts, website, published papers, etc.).

A specific section aimed at gathering information in case of absence of any existing good practice to describe was placed at the beginning of the questionnaire. The 5 questions of this section (negative response to the questionnaire) inquired about the reasons and barriers related to the lack of initiatives and compilers were requested to score them on a 4point Likert scale, from 4 = more important to 1 = less important.

In the instructions for compilers it was specified that the projects, programmes and practices (PPbP) could include a wide range of activities, for example, laws, policies to reduce alcohol consumption in older people, restrictions to alcohol access, as well as information messages and campaigns, or alcohol prevention and treatment services, sensitive to the elder's need, including the transition from work to retirement. It was specified that the term Project referred to any action (research, prevention, etc.) endorsed with a clear start and end point, the term Programme to a group of integrative, continuously implemented actions, and the term Best Practice to intervention approaches that, through experience or research, had proven to reliably lead to a desired result in a specific target group of people.

The questionnaire was delivered to 309 experts and professionals from more than 40 European countries. At the end of the survey a total of 53 negative and 36 positive responses were received. All collected examples (positive response to the questionnaire) were systematically entered into the Database on Best Practices (http://vintage.saveva.com/) and evaluated through a two-step assessment process. In the first stage, examples were analyzed according to the following criteria: focus of interest (only alcohol, versus alcohol and other drugs); target population (exclusively designed for older people or adapted to their needs, versus general population); evaluation strategies (not evaluated at all, versus evaluated or still under evaluation); objective and scope (covering phases from design and implementation to analysis and presentation of results). In the second stage, the quality of the collected examples was evaluated according to the fulfilment of the following set of criteria: needs assessment, accessibility, setting approach, collaborative capacity building and partnership, evaluation, sustainability, transferability, availability of results, transparency of funding and support. The assessment process was carried out anonymously. In order to classify collected PPbP according to the accuracy of data, objectives and scopes of the initiative two independent assessments were carried out by two researchers of WP5 leading contractor.

The second strategy applied to find European examples of best practices was the review of grey literature to retrieve published material about practices, projects, programs aimed at preventing the harmful use of alcohol in the elderly. Search terms were organized in four groups, including alcohol, elderly, prevention, aging, etc. connected by means of appropriate Boolean operators. These terms were systematically entered into well-known sources of grey literature and Internet-based databases and meta-searchers, such as: cRD, PsycINFO, Ixquick, Metacrawler, cordis, ProQuest, etc. Several databases - such as Hpsource.net and WHO-Global Information System on Alcohol and Health - were searched to collect existing laws and infrastructures, but no relevant information was obtained.

Results were classified as best practices if fulfilled all the following criteria, or relevant if fulfilled at least one of them: specifically designed for the elderly; objectives and strategies based on scientific evidence; implemented in a population, sample or group of older people; assessed by means of quality criteria. Documents found through the grey literature review were then classified into the following categories: raising awareness or social reinsertion/harm reduction; prevention/early intervention; treatment; personnel training; needs assessment; elderly care/social and community support.

A total of 21 websites were used as sources of information. Although about 2900 references were identified, none of the documents, papers, reports or publications fulfilled the best practice criteria described above, whereas 96 of them could be classified as relevant and entered into the Grey Literature Database (www.saveva.com/vintage_articles/default.aspx). The database shows a brief description of each document and the complete reference and link (if available) to access it, facilitating the search by key words, topic or title.

The procedure and results of the survey addressed to professionals and researchers throughout Europe and of the grey literature review concerning effective policies and programmes on the prevention of alcohol use among older people were described in detail in the report "Best practices on preventing the harmful use of alcohol amongst older people, including transition from work to retirement" [21].

After the formal conclusion of the project, an online instrument, based on the questionnaire in MS-Word format used for the survey, was also implemented and placed on the project website (www.epicentro.iss.it/vintage/assessment.asp) to facilitate the sustainability of the project and continue the collection of initiatives for preventing harmful alcohol use among the elderly.

RESULTS

The main findings of the VINTAGE project were made available online from the project official website (www.epicentro.iss.it/vintage/outputs.asp) and then actively submitted to the attention of professionals, policy makers, researchers and experts involved in the field of alcohol, aging or public health in general.

Results from WP4 - Evidence Base and those related to WP5 - Experience Base have also been described in detail in other papers of this monographic issue. For this reason, the present paper is mainly focused on results of the dissemination activity and on its ability to improve knowledge and to build capacity, encouraging evidence- and experience-based decisions, for the prevention of harmful use of alcohol among elderly subjects all over European countries. Reported results are partially based on those originated by the independent and external evaluation of the project.

Dissemination of findings

The influence of VINTAGE findings on the improvement of the health condition and wellbeing of the elderly was estimated through the extent of the dissemination to the appropriate target groups, the number of hits to website and of downloaded documents, and by a survey conducted on a random sample of stakeholders who had received the e-mail messages with VINTAGE results, to obtain their feedback about the quality, relevance and usefulness of the project findings.

Dissemination reach

The final version of the stakeholders list developed to disseminate the VINTAGE outputs and outcomes via the website included about 700 health-care professionals, alcohol policy makers and organizations (governmental, non-governmental and private) involved in alcohol policy or aging, both at health and social level. In addition to experts involved at European or regional level, 49 countries were represented.

To measure diffusion of the project outcomes the hits to the websites and downloads of reports were examined in two different periods (Figure 1). The first was used for the external evaluation of the project and took into consideration the 15 months from the website launch until the end of the study (November 2009-January 2011). The second period was based on the 12 months following the project conclusion (February 2011-January 2012).

The average number of visits per day was 3.7 during the first period of observation and 3.9 in the second period, showing an elevated level of interest in the project even after its formal conclusion. Of the 1664 total number of visits to the website during the project, 718 visits occurred after the launch of the reports. During the course of the project there were 740 visitors from 62 different countries who entered the VINTAGE website for the first time; the absolute unique visitors to the website during the second period of observation were 929, leading to an average number of unique visitors per month of 49.3 for the 15-month period and of 77.4 for the 12-month period.

The average number of page views for each visit was 2.6 during the study and 2.0 after its conclusion. The page with the highest number of hits, excluding homepage and project description, was the project findings page with 786 visits during the study (680 unique page views) and 455 visits in the second period of observation (395 unique page views).

Since the first notification in December 2010 to the list serve of stakeholders that the report on evidence was available on the website, 519 downloads of the report were recorded. The second report on best practice was uploaded to the website in mid January 2011 and 18 downloads of the report took place during the 10day period before the end of the first evaluation. The download actions registered during the year which followed the study conclusion were 388 for the evidence report and 315 for the best practice report.

Feedback from stakeholders

A random sample of 300 stakeholders was invited by the VINTAGE external evaluator to provide feedback on the two main reports of the project. The response to the first report circulated (evidence report) was n = 43, with a response rate of 14%. The response to the second report survey (best practice report) was just n = 17 (response rate 3%), due to a very short timeline of one week necessary to meet the deadline for completion of the evaluation report. Although the response rate was low, the responses received represented a wide range of countries, in addition to international organisations. In the responses to the first report the following countrieswere represented: Albania, Austria, Belarus, Belgium, Bosnia Herzegovina, croatia, czech Republic,Germany,Greece,Hungary,Iceland,Ireland, Italy, Latvia, Lithuania, Montenegro, Netherlands, Norway, Poland, Portugal, Romania, Scotland, Spain, Switzerland, UK. Half of the responses received were stakeholders from government agencies, 40% were from non-governmental organizations (NGOs) and 10% were from university and research institutions. Most of the respondents were active in the alcohol, public health and public policy areas.

Two questions in the stakeholder feedback questionnaire provided information on the clarity and relevance of the reports from those with responsibility for aging population policy or alcohol policy and programme development. The questions on clarity ("how easy did you find the report to understand") and relevance ("how relevant is the information for your work") were scored on a scale from 0 to 10. The higher the score the greater the reported clarity and relevance of the reports. As shown in Figure 2, participants reported the highest mean values on clarity (8.2) and relevance (7.2) for the evidence report, and somewhat lower values for the best practice report, 7.5 and 6.5 respectively.

The stakeholders were also surveyed to assess their awareness and the importance given to the issue of alcohol and older people in their country, the newness and usefulness of the information in the reports and their intention of modifying existing policies and practices, based on the VINTAGE project reports.

The results presented in Table 2 suggest that stakeholders believe alcohol and older people is not an issue addressed very much (mean 3.4) at the country level. However, on the other hand stakeholders believe a higher importance (mean 6.7) should be given to this issue as part of alcohol policy in their countries. The evidence report provided new information (mean 6.9) and most importantly was considered to be very useful (mean 7.3) for stakeholders in their work. The extent to which the information provided in the report would change the focus of their work was less evident (mean 4.8). Some stakeholders reported that they were already doing work in this issue. The figure may also reflect the fact that this issue was not well addressed in their own country and so needed to be included in the alcohol policy agenda to allow for inclusion in their work.

Stakeholders were also asked to identify the three most important issues in the report that they intended to incorporate into their work. There were three broad areas mentioned: information, policy issues and interventions. The dissemination of information and the need to gather more information and research on alcohol and older people were identified. The policy issues mentioned were to include older people in national alcohol policy and to integrate alcohol in health strategies for older people. The importance of targeting the middle aged to prevent large increases in alcohol harm in the future elderly cohort was stressed, as well as working with older people currently. Stakeholders identified early identification and brief intervention and the interaction of alcohol with medications as important prevention programmes for older people. The suggestion that existing effective alcohol policy (price and availability) could also work among older people was seen as important. It was also stated that older people's organizations would need to be active stakeholders in order to get the report recommendations on the policy agenda.

The second report on best practice (Table 3) also provided stakeholders with new (mean 6.5) and useful information (mean 6.6) similar to the first evidence report. However, the extent to which the information will change the focus of their work was lower (mean 4.8). Of the stakeholders who did respond, there was positive agreement (mean 7.3) that the issue of alcohol and older people should be continued and supported by EU project funding.

The most important issues in the best practice report that stakeholders intended to incorporate into their work included the importance of sharing the grey literature results with colleagues as well as to increase awareness of best practice. The need to design better quality evaluations of interventions and report outcomes was also identified. However, it was felt that the best practice report was a first step in a process which needed to be built on in the coming years and more work was required with older people.

CONCLUSIONS

The absence of comprehensive and harmonized data for individuals aged > = 65 years has prevented an evaluation of the real impact of drinking on the elderly until now, even though significant life changes, coupled with the aging process, make this group particularly vulnerable to alcohol harmful effects. In addition, most of the focus of alcohol awareness campaigns and government policies has tended to be on under-age drinking.

The VINTAGE project clearly fills a gap in understanding the issue of alcohol and older people. The project outputs were well received by stakeholders providing new and useful information and a commitment to incorporate elements of the reports into their work with older people. The support from experts outside the project in collecting the rather limited examples of best practice, as well as the feedback from stakeholders, demonstrate that those who work with or on behalf of older people believe that this issue needs to be part of both alcohol policy and healthy ageing policy.

VINTAGE may be considered the initial spark to make policy makers aware that much more information and research is needed throughout all European member states to meet the challenges of the significant demographic increase in the European older population in the coming years and that further investments should be sustained. In particular, VINTAGE suggests that it is possible to develop appropriate age-oriented alcohol policies and interventions, thereby triggering a process of improvement of the health status of that part of the population that is increasing at an unprecedented rate.

Acknowledgments

The VINTAGE project "Good Health into Older Age" is a project funded by the Executive Agency for Health and Consumers, under the European Commission Second Programme of Community Action in the Field of Health 2008-2013 (Grant Agreement no. 20081203). The authors of this paper would like to thank Gino Farchi and Mats Hallgren who reviewed the reports. Thanks also to all the professionals who took part in the collection strategy and participated in the survey on best practices reporting their initiatives or providing unpublished materials. We particularly wish to thank Ann Hope as independent evaluator of the whole project, whose work is at the basis of many of the dissemination results reported in the present paper. Finally, a special thank to Rosaria Russo for the technical and administrative support and collaboration given to the working team, and to Pierfrancesco Barbariol and Lorenzo Fantozzi for the time spent on the creation and management of the VINTAGE website.

Conflict of interest statement

There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.

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Address for correspondence:
Emanuele Scafato
Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità
Via Giano della Bella 34
00161 Rome, Italy
E-mail: emanuele.scafato@iss.it

Submitted on invitation.
Accepted on 30 May 2012.

* see Appendix

Appendix

The components of the VINTAGE project Working Group are: Emanuele Scafato (Project Leader), Lucia Galluzzo (Project coordinator) - centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy; Peter Anderson, Onno Van Schayck - Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands; Joan colom, Lidia Segura, Jorge Palacio-Vieira - Department of Health, Program on Substance Abuse, Government of catalonia, Barcelona, Spain; Andrew McNeill - Institute of Alcohol Studies, Huntingdon, United Kingdom; Sandra Radoš Krnel - Research centre, Institute of Public Health, Ljubljana, Slovenia; Salme Ahlström, Esa Osterberg - National Institute for Health and Welfare, Helsinki, Finland; Hana Sovinova - coordination, Monitoring and Research Unit, National Institute of Public Health, Praha, czech Republic; claudia Gandin, Silvia Ghirini, Sonia Martire, Alessandra Rossi, Lucilla Di Pasquale - centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy.