Community Prevention of Alcohol Problems: A Public Health Approach Harold D. Holder, Ph.D. Prevention Research Center Berkeley, California Observations Rarely are community prevention efforts evaluated we do not know if prevention is having any effect. Across the world, most of what is being done in community prevention will not produce population level effects-- --applying existing scientific evidence Prevention practice tends to implement popular and comfortable strategies--- ---avoiding those with evidence of effectiveness but difficult to implement.
Biggest Current Mistakes in Community Prevention? Doing many things that have little or no effect. 1,000 flowers bloom approach Not incorporating best prevention research into assessment, planning, and evaluation Action Traditional Approach to Prevention Desired Results PUBLIC SCHOOL EDUCATION BLACK BOX OF COMMUNITY BETTER FUTURE CHOICES FOR YOUTH ABOUT SUBSTANCES AND THUS REDUCED ABUSE Search for Action Systems Approach to Prevention Community System Desired Results X Z Y Q REDUCED HIGHWAY DEATHS RELATED TO DRINKING
Just What Is Environmental Prevention, Anyway? Environmental strategies in a community seek: 1. To bring about system-level change (including physical space, local community policies, availability of drugs and alcohol, etc.) in order 2. To reduce substance abuse problems at the population level. That is Public Health. Both conditions must be met. Outcomes-Based Prevention Substancerelated consequences and substance use Intermediate variables Programs/ policies/ practices Implementing the Strategic Prevention Framework Planning, Monitoring, Evaluation, and Replanning
Logic models are composed of: 1. Prevention goal, i.e., specific ATOD outcome to be reduced or changed 2. Intermediate variables or factors, which need to be changed (or considered) in order to achieve the goal 3. Intervention strategies to change intermediate variables. Example Logic Model for Substance Abuse Prevention What is wrong with this picture? Substance- Related Consequences Substance Use Intermediate Variables Strategies Alcohol- Related Traffic Crashes Among 15- to 24-Year-Olds Underage and Young Adult Binge Drinking Underage and Young Adult Driving After Drinking Youth 30-Day Cannabis Use Youth and Young Adult Lifetime Drinking School Bonding for Youth School Drug Resistance Training Awareness of Risk of Drinking Low Personal Self-Esteem Public Education About Drinking and Driving Risks Perceived Risk of Drinking and Driving Enforcement Youth Frequent Exposure to Internet Number of DUI Arrests Highly Visible DUI Enforcement Increased Abstinence Family Training Responsible Beverage Service To Reduce Overserving
Alcohol Sales and Service Regulations, Enforcement, and Sanctions DUI Enforcement Alcohol-Related Motor Vehicle Crash Model Public Awareness of Drinking/Driving Enforcement Price Retail Availability Alcohol Serving and Sales Practices Perceived Risk of DUI Arrest Community Norms Drinking and Driving Drinking Driving After Drinking Alcohol-Related Motor Vehicle Crashes Community Norms Drinking Individual Factors Social Availability Drinking Context Research Evidence Strong Relationship Moderate Relationship Minor Relationship Little Research Evidence but Logical Relationship Review of Research Evidence for Logic Models WWW.PIRE.org Under Featured Websites to Logic Models for the Prevention of Alcohol, Tobacco, and Other Drug Problems, select tab in right-hand hand column.
Underage Drinking Logic Model Retailer training & rewards Compliance checks, citations, license loss Retail sale of alcohol to youth Discount bans Price Underage drinking laws Visible enforcement Party patrol, shoulder taps, beer keg registration Social availability of alcohol to youth (parties, peers, families) Underage drinking Local alcohol policy Community concerns about youth drinking Media advocacy Legal risks for providing alcohol to underage youth Examples of Effective Community Prevention Projects Utilizing Environmental Strategies
National Community Trial To Prevent Alcohol-Involved Trauma - Modesto Salinas.. Orange Oceanside.... Florence Sumter Experimental Comparison Alcohol-Involved Trauma at the Community Level: Logic Model````````` MOBILIZATION MOBILIZATION Local News About Alcohol Problems and Enforcement Local Law Enforcement DRINKING DRINKING AND AND DRIVING DRIVING Perceived Risk of Arrest RESPONSIBLE RESPONSIBLE BEVERAGE BEVERAGE SERVICE SERVICE Alcohol Serving and Sales Practices Social Access to Alcohol UNDERAGE UNDERAGE DRINKING DRINKING Driving After Drinking Local Regulation of Alcohol (density, hours of sale) Retail Alcohol Availability (on- and off-premise) Alcohol Intoxication or Impairment Alcohol-Involved Injury ALCOHOL ALCOHOL ACCESS ACCESS Non-Traffic Risk Activities
Restaurant Service Highly visible and increased actual drinking and driving enforcement
Underage Drinking In Salinas California, 90% of students who drink report attending parties where minors drank.
Intermediate Variable and Strategy Data
Newspaper Factor Score - Local Stories 4 3 Organizational Development and Planning Training, Additional Planning Training and 1st Media Events Ongoing Advocacy Efforts 2 1 0-1 -2 J F MAM J J A S OND J FMAM J J ASOND J FMAM J J A S OND J F MAM J J ASOND J FMAM J 1992 1993 1994 1995 1996 Experimental Sites Comparison Sites Underage Alcohol Prevention Activities 160 140 120 100 80 60 40 20 0 Q2 Q3 Q4 Q1 Q2 ENFORCEMENT VISITS CITATIONS ISSUED OUTLETS TRAINED
Mountain of Beer Underage Alcohol Purchase Survey Experimental and Comparison Communities 60 PRETEST POSTTEST Percent Selling 50 40 30 20 10 53 47 45 35 19 16 0 Comparison Experimental No Training Experimental Training Comparison Experimental No Training Experimental Training Holder, et al., J. American Medical Association, 2000
Outcomes What were final results?
Community Trials Cost/Benefits Total Savings = $2,032,590 (injury, death, property damage) $1.00 Investment $2.03 Savings Based upon traffic crashes alone
EXAMPLES OF COMMUNITY ACTION PROJECTS FROM AROUND THE WORLD Minnesota, USA California, USA South Carolina, USA 6 community trial, Norway Ontario, Canada Ireland Massachusetts, USA Stockholm, Sweden Malmo, Malmȯ..., Sweden 6 Community Trial, Sweden U K PAKKA, Finland Lahti,, Finland Florence, Italy Israel Queensland Diadema & Paulinia, Brazil Western Australia New Zealand COUNTRY United States Sacramento, California Minnesota Massachusetts Examples of Community Action Projects for Environmental Prevention GOALS Reduce drinking and problems for 15-29 youth and young adult Reduce youth drinking Reduce alcohol crashes STRATEGIES local news Alcohol service (RBS) Underage sales enforcement Drunk patron enforcement community mobilization Local sales policies and enforcement News coverage DUI enforcement Alcohol outlet surveillance RESULTS 3.9% reduction in reported assaults 43% reduction in violence 33.7% Lower emergency care Lower alcohol sales to youth Reduced traffic crashes 25% reduction in fatal crashes
COUNTRY Sweden STAD Project Stockholm Australia Surfers Paradise Safety Action Project Examples of International Community Action Projects for Alcohol Prevention GOALS Reduced local alcohol and drug problems Lower alcohol- involved violence STRATEGIES Responsible Beverage Service Joint parent/police enforcement of sales to youth Club policy and drug recognition by door security Community forum and alcohol safety audit Model house policies Increased enforce- ment of alcohol- licensed premises RESULTS Reduction in sales to intoxicated patrons (47% to 5%) Violent crime down by 29% Refusals of drug impaired patrons increased by 300% Reduction in violent events: original site from 9.8 to 4.7 and replication sites from 12.2 to 3.0 COUNTRY Sweden Trelleborg Project Malmö Examples of International Community Action Projects for Alcohol Prevention GOALS Reduce alcohol problems STRATEGIES Public education Primary health care screening Reduce alcohol access RESULTS Low effects on problem indicators Reduced male consumption and problems in (a) screening program and (b) general population
Evaluation
Evaluation and Monitoring = Measuring changes in outcomes and intermediate variables to determine if changes are going in desired directions. Provides management information (MIS) Determines strength (dosage) of intervention Enables changes in strategies and improvement Is good politics let local and State leaders see success Data and Effective Local Prevention Local prevention data is only useful if it directly helps improve local assessment, planning, and evaluation. Currently, few communities have the resources, technical ability, or skills to collect, analyze, and make full use of data to improve local prevention. How do we know what is needed for assessment, planning, and evaluation?
Summary Local environmental prevention can produce measurable results. Logic Model in environmental prevention must be based on empirical evidence about intermediate variables. Environmental strategies must be selected that have been shown to work that is, impact key intermediate variables. Do few things well. High dosage dosage to be effective.