Transfer and adaptation of a drug recovery model from San Patrignano, Italy to River Garden, Scotland: a qualitative study

Abstract

Innovation in addiction recovery in Scotland includes the transfer of effective models from other countries, such as San Patrignano, Italy and Basta, Sweden. Independence from Drugs and Alcohol Scotland (IFDAS) was founded to develop a new model for Scotland, based on social enterprise. Drawing on the San Patrignano programme theory, this prospective study investigates IFDAS stakeholders’ perspectives on which mechanisms should be transferred, and which require adaptation of the delivery mode, for the Scottish context. Data collection included interviews with ten stakeholders with expertise including: drugs policy, social enterprise, alcohol and drug partnership practice and therapeutic community methods. Drawing on realist principles, data were analysed using inductive and deductive approaches and synthesised using frameworks. San Patrignano mechanisms identified for transfer include: the need for motivation, recovery peer mentors, visionary leadership and social enterprise. Adaptations from Basta include: extending abstinence to alcohol and creating a smaller, semi-permeable, residential community. Further adaptations to mechanism delivery include a ‘step-wise’ model of housing and work. Scottish contextual factors shaping adaptations include: the culture of alcohol misuse, social care standards, housing regulations and socio-cultural acceptability. This study contributes to the evidence on international transfer and adaptation of complex interventions and documents stakeholders’ theory-informed decision making in the development of a new Scottish recovery model.

Keywords:

• Transferability
• programme theory
• complex intervention
• mechanism
• context
• AOD addiction
• residential recovery community
• adaptation
• social enterprise
• Scotland

Introduction

Drug addiction is a major social and public health challenge in Scotland, with 1,339 drug related deaths registered in 2020 (National Records of Scotland (NRS), 2021). The drug related death rate is 3.6 times higher in Scotland than the UK as a whole, and is the highest in Europe (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2021; NRS, 2021). Furthermore, the extent of polysubstance use has increased (NRS, 2020a; van Amsterdam et al., 2021) with 93% of deaths in 2020 involving more than one drug (NRS, 2021). Scotland’s alcohol-specific death rate remains high (NRS, 2020b). In 2019 it was 18.6 deaths per 100,000 people, compared to England and Wales’ rates of 10.9 and 11.8 deaths per 100,000 people, respectively (Office for National Statistics (ONS), 2021). Scotland had the highest alcohol-specific death rate for males in 2019, compared to the rest of the UK (ONS, 2021), where death rates are high by international standards (World Health Organization (WHO), 2018).

An evidence-based, harm reduction approach to drugs (ACMD, 2016; Karki et al., 2016) has been implemented in Scotland for decades, and plays a crucial role (Dickie et al., 2017; Kimber et al., 2010). Building on this, the Scottish Drugs Death Taskforce led the development of ‘Medication Assisted Treatment’ (MAT) guidelines as part of the ongoing national response (Scottish Government, 2021). The concept of addiction recovery, its definition and ownership has been widely debated (Laudet, 2007; White, 2007) and is part of the discourse that shapes alcohol and other drug (AOD) treatment policy and practice in Scotland (‘Rights, Respect and Recovery’, Scottish Government, 2018). Although the original ‘Road to Recovery’ policy placed emphasis on recovery defined as: ‘a process through which an individual is enabled to move on from their problem drug use, towards a drug-free life….’ (The Road to Recovery, Scottish Government, 2008, 3, p. 23), there was limited evidence of subsequent, real broadening of provision (Best et al., 2010; Campbell et al., 2011; Rome et al., 2017). This was related to a backdrop of funding cuts and competing service demands amidst a decade of wider austerity measures (McPhee & Sheridan, 2020; Roy & Buchanan, 2016) and polarisation between treatment approaches (Kalk et al., 2018; McKeganey, 2014). Despite its foundational role, methadone is implicated in contributing to drug related mortality (Gao et al., 2016, 2021; McCowan et al., 2009; van Amsterdam et al., 2021) and has been critiqued as insufficient for those seeking longer term recovery (Eastwood et al., 2018; Kimber et al., 2010). Service users have reported mixed views on methadone maintenance (Grønnestad & Sagvaag, 2016; Mayock & Butler, 2021; Radley et al., 2017) and aspirations for a drug free lifestyle, including employment (Crutchfield Jr. & Güss, 2019; McIntosh et al., 2008; McKeganey et al., 2004). Rather than viewing harm reduction and recovery as opposing paradigms, consensus is growing on the need to recognise the importance of both approaches (EMCDDA, 2017a) within a broader economy of more flexible, nuanced provision to better meet the diverse needs of those with alcohol and other drug (AOD) addiction, which includes innovation in recovery centred models (EMCDDA, 2017a, 2017b; Kalk et al., 2018; Molina et al., 2020).

The recovery paradigm recognises the wider social determinants of AOD addiction (Alexander, 2000; Buchanan, 2004, 2006) which is more prevalent in areas of socio-economic deprivation, related to structural stressors, such as homelessness and unemployment (Brown et al., 2019; Parkinson et al., 2018). Through a strengths-based approach, it aims to build the recovery capital (Cloud & Granfield, 2008; White & Cloud, 2008) necessary to progress towards health and well-being, conceptualised as a personalised non-linear, recovery journey (Best et al., 2011, 2016; Rettie et al., 2020). The Therapeutic Community (TC), a unique form of residential provision, is a holistic psychosocial intervention known to be effective for those with complex addiction problems (De Andrade et al., 2019; De Leon, 2000; De Leon & Unterrainer, 2020). In keeping with a recovery perspective, Vanderplasschen et al. (2013) reported TC effectiveness for substance misuse and improvements in other life domains, such as employment. Furthermore, Dingle et al. (2019) reported effectiveness of the TC model defined as ‘sobriety and improved wellbeing’, across a range of primary substances. In addition, a recent longitudinal study reported effective recovery and positive life outcomes at nine months post-exit from two TC sites (Staiger et al., 2020). Given refreshed policy emphasis on ‘Rights, Respect and Recovery’ (Scottish Government, 2018) and ongoing AOD related mortality, there is urgent need for innovation in recovery-centred provision in Scotland. Increasingly, policy makers, NGOs and other decision makers are looking at effective interventions in other countries as possible solutions for their own settings.

Independence from Drugs and Alcohol Scotland (IFDAS) (https://ifdas.net) is a charity founded in 2013 to build an innovative Scottish drug recovery model based on social enterprise (Bitel, 2013). IFDAS was inspired by San Patrignano, Italy (https://www.sanpatrignano.com) which is one of the largest and most successful drug recovery communities in the world based on large scale social enterprise (Castrignano, 2012; Explora Research, 2018; Imperatori & Ruta, 2015; Manfre et al., 2005). San Patrignano was founded in 1978 in a context of extreme stigma, further exacerbated by fear of HIV/AIDS in the 1980s, yet has grown over 40 years into a therapeutic community of approximately 1,400 residents (Imperatori & Ruta, 2015; Perrini et al., 2010). San Patrignano previously inspired the foundation of the Basta recovery community in Sweden (https://english.basta.se/). However, the founders of Basta adapted the model to suit the Swedish context, including its distinctive welfare system (Meeuwisse, 2008). Unlike San Patrignano, which consists of one large estate encompassing over 50 social enterprise sectors spanning 650 acres, Basta consists of user-led social co-operatives and comprises smaller, geographically distributed units. Basta was launched in 1994, in the favourable socio-political context of the Swedish social democratic welfare system (Meeuwisse, 2008). Although differing in size and scope, both are holistic models that incorporate work in social enterprise as a central mechanism (Imperatori & Ruta, 2015). Importantly, both San Patrignano and Basta are recognised models of best practice in addiction recovery (Triple, 2017).

There is great interest in the transferability between settings, of complex interventions for challenges such as AOD addiction (Craig et al., 2018; Devlin & Wight, 2018, 2020). This involves better understanding the role of context (Craig et al., 2018; Pfadenhauer et al., 2017) since studies have shown an intervention found effective in one place, may fail to demonstrate similar results elsewhere (Evans et al., 2019). When considering the transferability of an intervention between countries, Schloemer and Schröder-Bäck (2018) recommended comparing contextual features between the primary and target countries. Although there are many studies, models and commentaries related to transfer and/or adaptation of interventions (Cambon et al., 2013; Escoffery et al., 2018, Evans et al., 2019; Schloemer & Schröder-Bäck, 2018), a recent systematic review highlighted the need for guidance which should:

reflect more critically on intervention mechanisms and contextual interactions to inform decisions on the need and extent of adaptations that may be warranted

and concludes,

future guidance needs to be reflective of adaptations in the context of transferring interventions across countries (Movsisyan et al., 2019, pp. 1, 17).

A subsequent scoping review showed a lack of practical studies of transfer and adaptation of interventions and confirmed:

other gaps remain, such as […] consideration of programme theories, mechanisms and contexts (Movsisyan et al., 2021, p. 17).

Furthermore, few studies document the decision-making process by stakeholders involved in the transfer and adaptation of interventions (Evans et al., 2019, 2021).

We have drawn on the realist paradigm since it enables theorising about the dynamic interaction of mechanisms and contextual features (Pawson, 2013; Pawson & Tilley, 1997). We also incorporate an ecological lens (Bronfenbrenner, 1977) to account for mechanisms and context that operate at different levels, which is necessary when analysing how a complex intervention works, overall (Westhorp, 2012). We sought stakeholders’ perceptions of ‘mechanism’ framed as a key feature that contributes to how the intervention works, and adopted the pragmatic definition of Dalkin et al. (2015) that accounts for resources and reasoning. Accordingly, we designed a qualitative study that draws on realist principles (Pawson, 2013; Pawson & Tilley, 1997) and was conducted in two phases (Schloemer & Schröder-Bäck, 2018).

In Phase 1, we built a model of the San Patrignano programme theory (Rogers, 2008; Shearn et al., 2017) based on San Patrignano stakeholders’ perspectives, comprising mechanisms and contextual factors at individual and organisational levels, to inform decision-making on the transfer or adaptation of mechanisms for the Scottish context. See Devlin and Wight (2020) and Table 1.

Table 1. Mechanisms from San Patrignano programme theory (Devlin & Wight, 2020).

Individual mechanisms	Organisational mechanisms
Commitment and motivation	Visionary leadership
Removal from former peer networks	Commitment of staff
Positive strengths-based approach	Social enterprise
Communal living/ continual socialisation	Adaptive learning organisation
Recovery peer mentor
Structure and routine
Meaningful work in social enterprises

In Phase 2 (present study), we investigated IFDAS stakeholders’ perceptions of San Patrignano mechanisms that could be transferred directly, as well as adaptations perceived necessary for the Scottish context. Although Phase 2 primarily investigated IFDAS stakeholders’ perceptions of the San Patrignano model, it also incorporates their views on its features that were modified for Basta, Sweden.

Aims

The research objectives of this study (Phase 2) are to investigate IFDAS stakeholders’ perspectives on:

1. Key intervention mechanisms that need to be transferred from San Patrignano (largely context independent);

2. Adaptations drawn from Basta which better suit the Scottish context and;

3. Adaptations drawn from both models which are tailored for, or distinct to, the Scottish context.

This study documents the international transfer and adaptation of a complex intervention to develop a new model for AOD addiction recovery in Scotland. Through doing so, it aims to contribute to the gap in evidence recently highlighted above (Movsisyan et al., 2019, 2021). In the longer term, it will allow us to determine whether stakeholders can prospectively identify intervention mechanisms for transfer or adaptation successfully for their own context.

Methods

Data collection

Data collection included in-depth, semi-structured interviews (conducted by AD) with 10 IFDAS stakeholders. They were sampled purposively (Palinkas et al., 2015) for their experience in the early development of the model and considered ‘information rich’ (Malterud et al., 2016). All (ten) stakeholders were individuals who volunteered their time, expertise and worked on the development of the new Scottish model (Table 2). Stakeholders were IFDAS Board members with roles therein and/or special Advisors to the Board. All ten (out of 10) stakeholders approached agreed to participate. The founder of IFDAS was the gatekeeper who enabled access for the researcher (AD) to conduct interviews. It is important to highlight the multi-disciplinary nature of the stakeholders, each of whom held expertise across different domains including: AOD policy and practice, therapeutic community methods, Alcohol and Drug Partnership (ADP) practice, education and training, and social enterprise. Mini-biographies of participants interviewed are presented in Table 2. Nine of the 10 stakeholders had visited or were ex-residents/managers of San Patrignano and/or Basta and four stakeholders had visited both communities. One stakeholder gained insight and knowledge of both communities from web-hosted films, reports, and documents publicly available, and from IFDAS meetings. Therefore, all stakeholders interviewed were familiar with the main components of San Patrignano and/or Basta, including how they differed.

Table 2. IFDAS stakeholders’ mini-biographies.

Stakeholder role in IFDAS	Background	Expertise	Experience of San Patrignano and/or Basta
1. Founder & director of development.	Ex-national ADP support co-ordinator. Chair, Recovery Consortium & consultant in social programme impact.	Entrepreneurship, philanthropy. Evaluation of social programmes, including AOD policy & practice.	Visited San Patrignano (2012, 2013, then annually) & Basta (2014).
2. Director of fund-raising and marketing & member.	Manager of youth homelessness & employment project. Ex-CEO, Access to Industry.	Developing models of training, education & employment for ex-offenders with AOD addiction.	Visited San Patrignano (2013).
3. Specialist advisor. Founding peer mentor.	UK national who completed San Patrignano programme. Lived experience of AOD addiction recovery.	Knowledge and practice of therapeutic community methods. Peer group mentor in San Patrignano.	Ex-resident & peer mentor, San Patrignano (2014–2017).
4. Specialist advisor & member.	Senior academic, international drugs policy. Extensive background in drugs research to inform policy.	Research expertise in drugs policy field. International drugs policy advisor.	Visited San Patrignano (2013).
5. Secretary & trustee.	Co-ordinator of regional ADP. Founder of grassroots recovery charity.	ADP models of practice and Recovery Oriented Systems of Care (ROSC). Assets based community development & grassroots recovery initiatives.	Visited San Patrignano (2013) & Basta (2014).
6. Treasurer & trustee.	Board member of homelessness charity & ex-manager of medium enterprise. Volunteer at residential community.	Experience of and advocate for, lay volunteering in community-based solutions for social issues.	Visited San Patrignano (2012, 2013) & Basta (2014).
7. Specialist advisor & member.	Successful, international social entrepreneur.	Social enterprise development. Founding member of enterprise community for adults with learning disabilities.	Visited Basta (2014).
8. Chair of business planning sub-group & member.	Senior academic; research and evaluation. Interest in social farming and rural economy.	Horticulture, commercial orchards. Sustainable land management and food production.	Viewed San Patrignano & Basta web materials at IFDAS inception (2013).
9. Chair of risk management sub-group & member.	Swedish national, lived experience of addiction recovery through Basta. Progressed to management in Basta.	Knowledge of Basta. Leadership in recovery social enterprise. Management of work training for recovery. Expertise in recovery methods.	Ex-resident & manager, Basta (2009–2014); visited San Patrignano (2011).
10. Founding chair then Honorary President.	Ex-UK Cabinet Office & Scottish Office. Fellow, RSE. Chair, Carnegie UK Trust & David Hume Institute.	Government expertise. Interest in social enterprise and international transfer of best practice in social policy.	Visited San Patrignano (2013).

Interviews were conducted at the early stage of intervention development [July–November, 2017] and captured the views of stakeholders, all of whom had been involved since the inception of the IFDAS charity (29th May, 2013). At this stage in 2017, and following a three-year search, a site for the Scottish recovery community had been identified and purchased that was named ‘River Garden’. Planning permission had been granted but there were no residents on site and it was prior to the official opening of the community (23rd March, 2018). The in-depth, semi-structured interviews explored stakeholders’ perceptions of key features that contribute to how San Patrignano works and how it differs from Basta. Interviews explored stakeholders’ perceptions of San Patrignano key mechanisms for transfer directly, as well as aspects of the Scottish context that require the intervention to be adapted (Pawson & Tilley, 1997) including adaptations from Basta. Wider contextual features in Scotland were captured through exploring stakeholders’ perceptions of facilitators and barriers.

The interview data was complemented by other IFDAS documents including: the founder’s report on the San Patrignano scoping visit; the IFDAS five-year business plan; and researchers’ notes from key meetings (e.g. Annual General Meetings (AGMs)), site visits and other events (e.g. Scottish Parliament reception for IFDAS River Garden and the official opening ceremony on 6th and 23rd March, 2018, respectively).

Ethical approval was granted by the University of Glasgow, College of Social Sciences Research Ethics Committee (number: 400160123) and fully informed, signed consent was obtained prior to interview. All (ten) stakeholders previewed and provided written consent for information presented in mini-biographies in Table 2.

Data analysis and synthesis

All interviews were digitally recorded, transcribed verbatim, proof-read for accuracy, and uploaded into QSR NVivo Version 12 software for data management and analysis. Data analysis involved a combination of inductive and deductive approaches (Fereday & Muir-Cochrane, 2006; Miles & Huberman, 1994). Through iterative interrogation of the interview transcripts, we devised a coding schedule based on inductive findings, grounded in the data (Lincoln & Guba, 1985) to form categories that were then structured to prior, higher order concepts of ‘mechanism’ and ‘context’ (Pawson & Tilley, 1997). Both AD and DW independently coded a sub-sample (3/10) of interview transcripts to ensure consistency of coding. Deductive analysis involved assessing which San Patrignano mechanisms stakeholders thought should be transferred directly and which intervention adaptations were necessary to suit features of the Scottish context. Other qualitative data were coded manually with the same schedule. Regular meetings were held between authors to build a consensus understanding of findings.

Data synthesis was guided by Framework Analysis (Ritchie & Spencer, 2002) and findings structured at the individual and organisational levels, in keeping with an ecological (systems) perspective (Bronfenbrenner, 1977; Westhorp, 2012). The findings are based primarily on key stakeholder interviews and representative quotes are presented within the results sections using descriptors in the following format: KS_(1–10): interview with Key Stakeholder (1–10). Other analytical extracts from stakeholder interviews embedded within the results narrative are similarly described as: KS_(1–10). These findings are triangulated with results from other data sources (e.g. IFDAS business plan) wherever possible, to enhance rigour (Patton, 2002). We also conducted participant validation through presentation and critical reflection with a sub-group of (four) interviewees at River Garden (17th April, 2019), who agreed with the core emergent findings.

Findings related to IFDAS stakeholders’ understanding of the San Patrignano programme are reported first. Thereafter, findings are synthesised and structured under three main sections in keeping with the aims of the study. We provide a schematic overview diagram in which we summarise the findings in Figure 1. The study is part of a Medical Research Council (MRC) funded research programme on the transferability of complex interventions between different contexts and was conducted by researchers independent of San Patrignano, Basta or IFDAS River Garden. This qualitative research study followed reporting standards for qualitative research (O’Brien et al., 2014).

Figure 1. Overview of stakeholders' perceptions of transferable San Patrignano mechanisms and Scottish contextual features, and related adaptations for River Garden [• individual level ▪ organisational level].

Results

Stakeholders’ understanding of the San Patrignano programme

All stakeholders had knowledge of the San Patrignano model and most (8/10) had previously spent time there on a study visit (Table 2). Due to their background and expertise, they understood the mechanisms on which it was based, how it differed from current provision and the context of need in Scotland. Indeed, the founder has visited San Patrignano annually since establishing IFDAS in 2013.

We’re inspired by the big picture which is the programme theory, which you have articulated accurately and the operational detail of it needs to be…what would work here? (KS_1)

Mechanisms to transfer from San Patrignano

Stakeholders identified mechanisms to transfer from San Patrignano with minimal adaptation, which were categorised as operating at the individual or organisational levels.

Individual level: commitment and motivation; removal to safe residential environment; recovery peer mentors; positive strengths-based approach

Stakeholders endorsed the need for commitment and motivation to a new recovery lifestyle which, in keeping with San Patrignano, is abstinence based and emphasised that residents should join the community through choice, not coercion.

You can never force someone to leave their addiction, it needs to come from within. (KS_9)

They spoke of the importance of removal to a safe drug-free, residential environment for an extended (∼3 year) period. The long duration contrasts with current short-term provision in Scotland and eight stakeholders agreed it is an essential feature to transfer. Equally, the immediate and ongoing support of recovery peer mentors with lived experience is a key mechanism being adopted, adding ‘authenticity’ (KS_1) to the model. All interviewees agreed on adopting the positive, strengths-based approach in which residents are treated with respect and as having potential. This was one of the foundations on which San Patrignano was built and will also underpin the new community in Scotland.

People feel valued, like they’re worth something, they have something to contribute. So instead of we’ve always focussed on how much have you been drinking, when did you last inject, it’s more positive meaning everybody has something to offer, a skill, an asset, or numerous ones. We’ve not been good in the past, in terms of building on that. (KS_5)

Organisational level: visionary leadership; social enterprise; being an adaptive learning organisation

The other (nine) IFDAS stakeholders emphasised the founder’s visionary leadership as a critical organisational mechanism, similar to San Patrignano. They regarded the founder as holding appropriate expertise, skills, knowledge and networks required to drive innovation in recovery forward, with KS_10 describing the founder as a ‘catalytic individual’. Also, KS_7 reflected on the founder's inspirational leadership.

Well KS_1’s been enormous you know, bringing that concept from Italy saying, ‘We can do this here.’ Having the confidence and laying a lot of his personal life and work on the line inspires other people… (KS_7)

The founder was passionate about addressing the gap in recovery provision in the context of the dominant, disease-based model and increasing drug related death rate in Scotland.

The medical part of treating addiction gets 85% of the resources even though it’s only the beginning of the recovery journey…So I thought we need some innovations in recovery but there’s no money… So I thought 'If we leave government to sort this out, it'll never be sorted out in my lifetime!' and drug-related deaths keep going up and up. and every death is somebody's son, somebody’s daughter, you know? These aren't just numbers, these are people! (KS_1)

Interviewees commented on the founder’s skill in assembling a multi-disciplinary stakeholder group with a relevant cross-section of expertise. The founder built a strong relationship with San Patrignano and showed ‘a spark of genius’ (KS_5) in helping some UK nationals seeking recovery to access the San Patrignano community with the possibility of them returning as the first peer mentors in IFDAS.

It was part of our staff development for want of a better expression. (KS_1)

Stakeholders understood the need for social enterprise as the underpinning economy to remain independent of government funding thereby retaining autonomy. However, unlike San Patrignano, IFDAS did not benefit from wealthy private donors.

There was a guiding thing that we weren’t going to depend on public funding. Because in Basta they do and in San Pa they don’t…We’ve gone with no public funding because that gives you more freedom and I think that was a wise decision although it’s one that comes up for re-visiting quite often… (KS_8)

Five stakeholders were concerned about developing a viable commercial business plan in these circumstances, although grant funding was being actively pursued. Stakeholders spoke of the challenge of trying to secure funding and suitable premises concurrently as a ‘chicken and egg scenario’ (KS_3) and expressed frustration at the lack of funding or funding-in-kind.

Yeah, it’s a bit chicken and egg, we won’t give you money ‘til you’ve got a property, you can’t buy a property ‘til you’ve got money. We’re on a wing and a prayer at the moment. (KS_7)

The third organisational mechanism identified was being an adaptive learning organisation, seen as critical to San Patrignano’s evolution and sustainability. Although interviewees acknowledged San Patrignano as ‘aspirational’ (KS_7) where ‘the architecture was inspiring’ (KS_1), they disagreed over an expensive architectural plan for the IFDAS site [AGM notes, 25th May, 2017] with four stakeholders emphasising their wish to start the community more ‘humbly’ (KS_7). Along with concern about trying to achieve too much, too quickly, stakeholders highlighted the need for residents’ involvement as part of their recovery process.

I don’t want a solution imposed, because part of the process…I mean even San Pa is still growing and changing and the recovery is in that growing and changing…feeling you’re making an impact and being part of it, rather than moving into something that’s already formed. Does that make sense? So, it’ll be hard when people first move there but you can clean anything up and make it liveable in, and we're not there to raise money for a pretty building, we are there to establish a community. (KS_6)

However, all (ten) stakeholders agreed the new community will need space and time to experiment and evolve, is not ‘set in stone’ (KS_6) and will involve learning for everybody.

One thing I’m absolutely clear about IFDAS is that it needs a bit of room to um, experiment with its adaptations of the San Pa model. (KS_10)

Adaptations from Basta that better suit the Scottish context

Abstinence from alcohol as well as other drugs; smaller, semi-permeable community

Stakeholders identified three adaptations from Basta as more appropriate for the Scottish context than San Patrignano (Figure 1). First, they referred to the context of need which is recovery from addiction to alcohol as well as other drugs (AOD). Stakeholders recalled being served wine with meals in San Patrignano as definitely not transferable and so IFDAS are drawing on Basta which is based on AOD abstinence. This is considered more suitable for Scotland where alcohol poses as much a problem as other drugs and is part of the polydrug culture.

So many of the individuals in Scotland with addiction combine any substance that’s around, including alcohol, prescribed medication, and illicitly obtained drugs. …If we sought to exclude people with an alcohol problem, or a benzodiazepine problem, or cocaine, or whatever, that would be swimming against the tide of need within Scotland because the needs are across different substances. (KS_4)

Second, like Basta, IFDAS are creating a smaller community considered more suitable than one large scale ‘monolithic’ (KS_8) site. Four stakeholders highlighted the risk of institutionalisation inherent in large residential communities where domestic tasks (e.g. laundry) become centralised which is neither in keeping with Scottish local authority care regulations, nor socio-culturally acceptable. IFDAS has decided on a maximum capacity of 40 residents [Business Plan 2016, p. 9] to ensure viability of the business model as well as obtaining planning permission for the site.

I just think that also the level of social acceptability by the local community. If we said we were going to have 1,300 people in recovery on site we might have had a different reaction! (KS_1)

Interviewees (7/10) agreed on the need for structure and routine (like San Patrignano) which should be retained in a smaller unit, though less regimental, and more like Basta.

Third, IFDAS stakeholders thought the semi-permeable nature of Basta would work better in Scotland, compared to the closed San Patrignano model where all services (e.g. hospital, education centre) are internal. They spoke of residents’ need to retain life skills and access key services (e.g. dentist, hospital, 12 step fellowship meetings) available outside.

We want people to leave and be in communication with the outside world and people have to be able to look after themselves. They've got to be able to do their washing, their cooking, their finance and those get lost if people don't do them. But if they go out they have to go with somebody … so they'll be chaperoned initially. But … they may need to go out, you know, for medical help or teeth or they may want to go to AA meetings. There might be a good reason why they go out, because everything can’t be on site so they will have to go out! (KS_6)

In relation to this and in keeping with Basta, IFDAS will implement routine AOD screening. Four stakeholders considered the semi-permeable nature a potential vulnerability due to the entrenched culture of alcohol and methadone in Scotland. However, stakeholders understood the need for residents to develop life skills by linking in with existing recovery and related resources outside in the wider community. The emphasis on reintegration is an integral feature underpinning the model to prepare residents for independent living when they leave and should be enhanced by its location in a pro-recovery region.

That semi-permeable bit, part of that is about re-integration when they leave as well. We have been very clear from the outset that supporting people to prepare to leave is something that is integral to the project. So, I think that's part of … although we don't want a closed environment, we are always supporting people and then trying to reintegrate them into the wider community. (KS_5)

Adaptations drawn from both models and distinctive to the Scottish context

The models of housing and work; the multi-disciplinary stakeholder group

Stakeholders reported three adaptations that draw from both models but are tailored or distinct to, IFDAS (Figure 1). They reported much debate over accommodation since San Patrignano residents’ stay in groups continually, including sharing rooms, meaning they are never alone. In contrast, due to the generous Swedish welfare system, Basta residents have their own furnished room upon arrival. IFDAS will implement a hybrid, step-wise model where residents initially share rooms for reasons of safety with progression to their own space related to progress in recovery.

I think Scottish people would be more tolerant than Swedish about sharing rooms. I think when people come giving them the foundation and someone alongside them. I don’t believe that Scottish people can do the Italian way of always being together. I think they would be up for it in the beginning…before you decide you want to stay….then after three months you get your own room. So they’ll say, ‘Well, three months isn’t so bad.' (KS_9)

San Patrignano’s long-term sharing in dorm-type accommodation was considered neither socio-culturally acceptable nor in keeping with Scottish social care standards and House in Multiple Occupation (HMO) health and safety regulations. However, stakeholders agreed on the need to incorporate social spaces to foster group cohesion and importantly, the whole community will share meals together regularly. Further contextual features shaping the accommodation include practicalities of the site and Scottish housing law which prohibits over development of listed buildings.

We’ve worked hard to have it confirmed we do not need to be registered with the Care Commission. But there is no Care Commission in Italy! There is no HMO, Houses of Multiple Occupation in Italy you know? We have a whole raft of regulations they don’t have. We couldn't put… you've probably heard from your interview with KS_3 he was in a dorm of twenty people, you couldn’t do that here. You would not get that through an HMO inspection! (KS_1)

All interviewees endorsed the role of meaningful work in high quality enterprises as key to successful recovery. San Patrignano contains over 50 social enterprise sectors located within an extensive estate. In contrast, Basta bought over and operates enterprises located in the outside community. IFDAS is drawing on both models, with initial emphasis (like San Patrignano) on horticulture within the 50-acre site, but anticipates business links outside (like Basta) though tailored to the Scottish context enhanced by the local recovery infrastructure.

One of the great things about the site is there’s quite a strong recovery community in [name of town]. So [name of non-residential recovery community] can connect with River Garden and we can make each other stronger because we can facilitate a wider option of things. Like they’ve got a café – so they can go out to the recovery café…and those folk can come and volunteer [here] and do horticultural stuff…(KS_1)

IFDAS plans a step-wise work model with progression from: volunteer, to trainee, to a paid employee when it is expected that residents will make a financial contribution to the community [Business Plan 2016, p. 8]. Although this staged work model also operates in Basta, the Swedish welfare system pays for the resident’s first year of training. Furthermore, in keeping with Scottish social values, five stakeholders spoke of giving residents choice in their work role with emphasis on equality, equal rights and no gender stereotyping of work roles.

I think … building on people's skills, being able to support people with what they're wanting to do. Aye, and I think San Pa was a bit more gender based as well. The women are in the kitchen and the men were doing the … you know? So, none of that nonsense! (KS_2)

River Garden, framed as a ‘Social Enterprise Training and Development Centre’ (KS_1), is a resource that will welcome the public as a visitor destination [opening ceremony notes, 23rd March, 2018] to help address prevailing stigma, which further differentiates it from both San Patrignano and Basta.

The new Scottish model is founded by a multi-disciplinary stakeholder group which differentiates it from San Patrignano which was founded by a visionary entrepreneur and non-specialist volunteers, and Basta, which originated as a partnership collaboration with local municipalities in Sweden. Stakeholders considered the multi-disciplinary nature an essential organisational mechanism since each stakeholder understood the gap in current provision and brought a different necessary skillset.

Everybody that’s in the boardroom, and that’s been a key thing, everybody brings something slightly different to the board. (KS_5)

They were each a leader in their field including: an ADP services co-ordinator; an international social entrepreneur; an international drugs policy expert and ex-residents/managers from San Patrignano or Basta. Stakeholders shared strong commitment to the IFDAS project and understood the need for persistence and skilled flexibility in order to respond to fortuity.

There was vagueness about whether they had or hadn't got rid of the [potential] site and it sounded as if there might be a bit left over … and it turned out the best bit for us was the bit that was left over! So if you're going to do this, you just persist and persist … but you're willing to change. (KS_8)

They reported working pro-bono to help establish the community in the context of funding challenges and scepticism. In addition to these collective features, stakeholders' individual expertise and skillsets have each played a key role.

I'm also part of the sub-group looking at risks that might occur … eh, based on the knowledge that I had from Basta. (KS_9)

KS_5 spoke of the importance of being connected to operations ‘on the ground’ as well as the project aligning with the local pro-recovery policy, vision and infrastructure.

I’ve been leading on that for the past four or five years, to develop a lot of the recovery projects and activities. So it’s given me that balance of the strategic but also very much driving forward development on the ground… (KS_5)

The ‘buy-in’ and support of key ‘brokers’ who understand and support the model was also crucial in the early development stage.

So, meeting people like the Chief Exec of the council, and I work for her, so that helps. And some of the groundwork has been laid in getting people to buy in. The Head of Housing has offered us some potential work and my boss is the Head of Health and Social Care partnership and he's been bought in from the beginning. So, the fact that it happens to be landing in [local authority name] is a complete fluke! However, I'm here and that helps. (KS_5)

Although stakeholders acknowledged their role in the early stages, they expressed their intention (like San Patrignano and Basta) that River Garden ultimately be led and owned by the residents. Finally, stakeholders emphasised the need to stimulate recovery provision which ‘remains a rather marginal aspect of the treatment scene within Scotland’ (KS_9) while highlighting that traditional services still play an essential role. IFDAS River Garden aims to contribute to the landscape of recovery provision, enhanced by the national recovery movement in Scotland.

Discussion

This is one of the first empirical studies to investigate the transferability of a complex intervention across countries that involves prospective adaptations to account for contextual differences between primary and target countries. In Phase 1, we developed the programme theory (Rogers, 2008; Shearn et al., 2017) of San Patrignano, a drug recovery community in Italy, based on stakeholders’ perspectives (Devlin & Wight, 2020). In the present study (Phase 2), we interviewed IFDAS stakeholders involved in planning and early development of a similar model for Scotland to determine which mechanisms they thought should be transferred directly, and adaptations perceived necessary for the Scottish context. It will thus allow us, in the longer term, to examine whether stakeholders can prospectively identify mechanisms to transfer directly, and mechanisms that require intervention adaptation successfully, to suit a new national context.

Stakeholders identified mechanisms for direct transfer including: the need for commitment and motivation; removal to a safe, drug free residential community; peer mentors with lived experience of recovery; visionary leadership and social enterprise. However, stakeholders identified contextual features that required adaptations to the original model. In particular, the entrenched culture of alcohol misuse in Scotland; social care standards; housing regulations related to HMO health and safety; socio-cultural acceptability and funding challenges. These led stakeholders to recommend adopting features of the Basta model, such as extending abstinence to alcohol as well as illegal drugs and creating a smaller, semi-permeable, residential community. Other adaptations go beyond both models, including: a step-wise progressive model of housing and work, and the founding multi-disciplinary IFDAS stakeholder group. Other contextual factors identified include prevailing stigma and scepticism and the national context of great need. Existing recovery infrastructure in the region should enhance the function of the planned adaptations, since the new model is fortuitively located in a proactive recovery region.

We drew on the realist paradigm which recognises the dynamic interaction between mechanisms and context in a complex intervention (Pawson, 2013; Pawson & Tilley, 1997). While the concept of ‘mechanism’ has been extensively theorised (Lacouture et al., 2015; Shaw et al., 2018), we have adopted the pragmatic, broader definition of Dalkin et al. (2015) that includes resources and reasoning. We have also drawn on an ecological perspective to account for layers of context and mechanism at the individual (agency) and organisational (socio-structural) levels to account for how the intervention works, overall (Westhorp, 2012). Although previous studies have presented comprehensive frameworks with lists of criteria to guide transferability and adaptation of interventions (Cambon et al., 2013; Escoffery et al., 2018; Schloemer & Schroder-Back, 2018; Villeval et al., 2016; Wiltsey-Stirman et al., 2019), we concur with Kislov et al. (2019), that ‘forensically’ mapping every component may, in some cases, be impractical and unwarranted. Others have recently raised similar views (Burchett et al., 2018; Yoong et al, 2020). As Hawe et al. (2004) previously argued, as long as the function of key mechanisms is transferred, their form can be adapted to suit the new context (Hawe, 2015; Hawe et al., 2004). Thus, if their function is not impaired, the specific form of mechanisms, such as meaningful work, can be adapted to suit the new context. This is in keeping with the current concept of 'functional fidelity' (Evans et al., 2021). Therefore, in the present study, we have attempted a balanced, theory-informed approach based primarily on stakeholders’ knowledge of how the intervention works, along with their ability to identify relevant contextual features.

It is important to highlight some limitations of the study. We did not capture the views of any residents since the study was conducted prior to the official opening, when no residents were on site. However, two of the stakeholders involved in establishing the IFDAS community are former addicts in long term recovery: one an ex-resident and peer leader from San Patrignano; the other an ex-resident and manager from Basta. As such, their expertise and roles within the founding group have been captured in this study. This is an important feature of the multi-disciplinary stakeholder group involved in the foundation of the new Scottish model (Table 2). At this stage, we cannot determine whether stakeholders can successfully identify adaptations necessary to transfer an intervention between contexts in advance. This will require a process evaluation (which is presently underway) and, in the longer term, an outcomes evaluation. Also, we could not access some previous research on Basta, which was only available in Swedish. Debate continues around operationalising the realist approach in research studies (Emmel et al., 2018; Lemire et al., 2020). Since we are analysing the transferability of an effective intervention, we drew on realist principles and the socio-ecological model, which best suited the research aims, and the complex nature of the intervention (Bonell et al., 2020). We recognise the important body of frameworks and new guidance (Moore et al., 2021), and refer to recent endorsement of a pluralist approach when analysing complex interventions of this kind (Skivington et al., 2021). Finally, publication of these (Phase 2) findings was delayed partly due to resource constraints, but also because of the need to prioritise the Phase 1 paper (Devlin & Wight, 2020).

These limitations should be balanced by some of the study’s strengths. It is one of the first studies on transferability that articulates the intervention’s implicit programme theory and examines those mechanisms considered transportable and those that are context dependent and need adaptation of the delivery mode. It is also one of the first studies on intervention transfer and adaptation which compares the primary and target context to enhance the likelihood of successful implementation. In keeping with current debate (Kislov et al., 2019), we attempted to synthesise the relational nature of mechanisms and context in our findings, rather than listing components. Therefore, in keeping with updated guidance on development and evaluation of complex interventions (Skivington et al., 2021) our study: (i) takes account of context; (ii) draws on programme theory and; (iii) documents the role of a multi-disciplinary stakeholder group and their decision-making process. Furthermore, this study is one of the first to investigate transfer and adaptation of a therapeutic community (TC) model for drug recovery, since the TC research field has a history of implicit expertise embedded in practice which resists overt codification (De Leon, 1995, 2000). In keeping with best practice (O’Brien et al., 2014), we conducted validation of emerging findings with a sub-group of (four) interviewees. Finally, we have drawn on three sources of qualitative data and triangulated our findings wherever possible to enhance rigour (Patton, 2002).

Some adaptations are particularly topical to discuss. IFDAS River Garden is a semi-permeable, residential community which aims to integrate with the surrounding recovery infrastructure and reciprocate by providing a resource for the external community, through welcoming visitors. In this way, residents will be able to link in and build the recovery capital required to progress towards a drug free lifestyle (Cloud & Granfield, 2008; White & Cloud, 2008) and address prevailing stigma. River Garden (http://www.rivergarden.scot/) is located in a beautiful, restorative, rural setting and will emphasise excellence in terms of products, like San Patrignano and Basta. Previous studies highlighted the need for recovery to be better integrated within communities and more visible within a wider system (Best et al., 2014, 2017; Best & Colman, 2019; Collinson & Best, 2019) to foster a ‘therapeutic landscape of recovery’ (Wilton & De Verteuil, 2006). Similarly, Ashford et al. (2019) recently developed an ecological framework to assess levels of recovery ‘readiness’ in keeping with current systems approaches to developing effective public health interventions (Meadows & Wright, 2008; Rutter et al., 2017; Sniehotta et al., 2017).

There is a growing recovery movement in Scotland, including recovery communities (Anderson et al., 2021; Campbell et al., 2011; Rome, 2019; Rome et al., 2017). However, the River Garden model, inspired by San Patrignano, is one of the first in Scotland which is long term, residential, and based on social enterprise. Stakeholders recognised the essential role services play, but emphasised the need to broaden provision to better support recovery. In relation to this, a recent scoping review indicates limited residential provision in Scotland along with recommendations to improve access (Scottish Government, 2020a, 2020b). River Garden is based on empowering residents with the aspiration that it ultimately be user-led and governed democratically (Zimmerman, 2000). In keeping with Basta, the potential vulnerability of the semi-permeable configuration will be addressed by regular AOD testing but this model is intended to place ownership with those in recovery (Carlberg, 2006, Vamstad, 2015). This aligns with a recent review that indicates increased interest in user- and/or community-led solutions, including recovery enterprises (EMCDDA, 2017b). Despite funding challenges reported in these early stages, an economy based on social enterprise is considered essential for ownership and to ensure key elements (e.g. long term, residential nature) are retained. River Garden resonates with a contemporary vision of pre-figurative politics in circumnavigating current restrictions by building a new structure to attempt to address an identified gap in provision (Beckwith et al., 2016). It has done so by drawing on best practice models in other countries in a theory-informed manner (Devlin & Wight, 2020). As we already intimated, further evaluation will be required to determine whether or not this has been successful.

Conclusions

This is one of the first empirical studies of the international transfer and adaptation of a complex intervention that analyses key stakeholders’ theory-informed decision-making in the early development of a novel drug recovery model: River Garden, Scotland. This practical example contributes to developing principles on intervention transferability, namely: drawing on the programme theory and a realist informed approach, with stakeholders articulating key mechanisms and prospective adaptations to suit the local context. Therefore, an intervention’s underlying programme theory may be the most useful information for decision-makers tasked with its transferability. In this way, our work contributes to the field of implementation science, and also informs the broadening of recovery provision to align more closely with the current ‘Rights, Respect and Recovery’ (Scottish Government, 2018) alcohol and drugs strategy in Scotland.

Author contributions

DW initiated the study and determined its aims. AD liaised with stakeholders and carried out data collection. Data analysis and synthesis was conducted by AD and DW. AD drafted the article with significant input from DW. Both authors have read and approve of the final version.

Acknowledgements

We express our sincere thanks to the Founder of Independence from Drugs and Alcohol Scotland (IFDAS) and River Garden. We are grateful to all other stakeholders for participating in research interviews and sharing their knowledge and insight on the early development of the River Garden community. We thank Dr. Emily J. Tweed of the MRC/CSO Social and Public Health Sciences Unit, for providing valuable feedback on an earlier version of the manuscript. Finally we wish to thank the anonymous reviewers whose comments helped improve the article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research study was funded by the Complexity in Health Improvement Programme of the Medical Research Council (MRC) United Kingdom (UK) Grant number: MC_UU_12017/14 and CSO (SPHSU14).