Mobilization of Local Efforts to Reduce AlcoholInvolved Problems: Efforts at Environmental Change

1
Mobilization of Local Efforts to Reduce
Alcohol-Involved Problems Efforts at
Environmental Change
Andrew J. Treno, Ph.D. April 21, 2006 Albuqu
erque, New Mexico

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Presentation

• 1. Environmental Strategies Defined
• 2. Environmental Strategies Contrasted with
  Traditional Approaches
  
• 3. Environmental Strategies in World Context
• 4. Two Studies Presented in Detail (The
  Community Trials Project and the Sacramento
  Neighborhood Alcohol Prevention Project)
  
• 5. Introduce Two New Studies (The Border
  Project and Safer College Studies)
  
• 6. Basic Questions Regarding These Studies
  
  
• a) How are they different?
• b) How are they similar?
• c) How does mobilization work across
  these studies?
  
• d) What is the role of data in these
  studies?
  

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Alcohol Environmental Interventions Defined

• Strategies used to reduce problems associated
  with the use of alcohol through alterations in
  the physical, social, legal or economic alcohol
  environment.

4
Illustrations of Environmental Interventions

• PhysicalRestrictions on Densities of Outlets
• LegalMinimum Drinking Age Laws
• SocialParental Monitoring of Alcohol
  Availability in the Home
  
• EconomicTaxes on Alcohol Sales

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Approaches to the Reduction of Alcohol Problems
Traditional Approaches Environmental
Approaches
Individual Behavioral Change
Goal
Community System Change
Individual Influence
Policy Maker Influence
Use of Media
Individuals At-Risk
Target
Alcohol Environment
Community Role
Information Receivers and Disseminators
Provides Energy for Policy Change
Demand-Oriented
General Approach
Supply-Oriented
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Targets of Environmental Prevention Efforts
Whole populations of geographic areas (e.g.,
states, communities)
Selected sub-populations particularly at risk
(e.g., drinkers at bars)
Small geographic areas containing select
subgroups (e.g., community neighborhoods)
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Why Take an Environmental Approach?

• Higher risk individuals -- more individual
  problems
  
• Lower risk individuals -- more people produce
  more aggregate problems for a community
  
• For example
• Drinkers ? Risk Rate Problem Events
• 100 ? 10 10
• 5,000 ? 1 50

(The Prevention Paradox)
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Policy and Environmental Strategies

• Policy as defined here consists of those effort
  to deliberately alter economic, social, physical,
  and legal dimensions of the alcohol environment.

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Alcohol Policy (Some History)
Alcohol policy---often applied at the
national level. Communities are often passive
recipients.
?
?
Policy approaches with greatest effectiveness
seek to alter the environment
?
Communities have primarily used program
rather than policy strategies.
(But this is changing.)
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6 Community Trial, Sweden
PAKKA, Finland
Paulinia, Brazil Diadema, Brazil
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Examples of International Community Action
Projects for Alcohol Prevention
United States
DUI enforcement Alcohol service News
coverage Underage sales Alcohol outlets
10 reduction in alcohol crashes
California/South Carolina
Reduce alcohol injury and death
?
?
43 reduction in violence
?
Lower alcohol sales to youth
Lower alcohol sales to youth Reduced traffic cras
hes
?
Minnesota
Reduce youth drinking
Local sales policies and enforcement
?
25 reduction in fatal crashes
?
News coverage DUI enforcement Alcohol
outlet surveillance
Massachusetts
Reduce alcohol crashes
12
Examples of International Community Action
Projects for Alcohol Prevention
New Zealand
Public awareness using local news
Highly visible drink/drive enforcement
Investigation of on-license premises based upon
place of last drink data
Fatal alcohol crashes reduced from 22 to 14
Reduce drink/drive problems
?
Waikata Rural Drink/ Drive Project
?
Public perception of risk of being caught
increased
Alcohol positive breath checks decreased by 600
?
New Zealand Six City Project
Local coordinating committee Review of
alcohol availability Local alcohol
advertising limits
Increase local alcohol policy
Greater news coverage
?
Increased public support of local policy
?
13
Examples of International Community Action
Projects for Alcohol Prevention
Canada
Alcohol servingpractices policies
Municipal policies
DUI enforcement
Reduce alcohol problems
Reduced public drinking
?
Ontario (6 Projects)
?
Lower heavy drinking in bars and restaurants
?
Modest effects on overall drinking
?
Reductions in heavy drinking
Primary health care Community education
News
Finland Lathi
Reduce heavy drinking
?
Greater news coverage
Sweden
School education
Reduce heavy drinking and youth drinking
Modest effect on heavy drinking
?
Stockholm--Kungsholmen
Public education
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Examples of International Community Action
Projects for Alcohol Prevention
Sweden
Modest effect in medium strength beer sales to
youth
?
Youth Program Secondary prevention in health c
are
Responsible Beverage Service
Reduce alcohol and drug problems
Stockholm City--STAD
Reduction in sales to intoxicated patrons (5 t
o 47)
?
Violent crime down by 29
?
Stockholm City (18 Districts) Stockholm County
Targets
Local work committees Develop Alcohol
Plan Decrease sales of folk beer to youth
Increase local alcohol policy
Reduced Sales to Youth in 2 target sites (81 to
25 48 to 42)
?
Increased interest in local policy
?
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Examples of International Community Action
Projects for Alcohol Prevention
Sweden
Low effects on problem indicators
Public education Primary health care
screening Reduce alcohol access
Reduce alcohol problems
?
Malmö
?
Reduced male consumption and problems in (a)
screening program and (b) general population
Program adopted by city
?
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Examples of International Community Action
Projects for Alcohol Prevention
Local coalitions Health education Local
alcohol policy concerning public alcohol sale
Australia COMPARI Project
Modest effect on injury
?
Reduce alcohol injury and death
?
Violent events --original site from 9.8 to 4.7
--replication sites from 12.2 to 3.0
Australia Surfers Paradise Safety Action Project

Lower alcohol involved violence
Community Forum alcohol safety
audit Model House Policies Increased enfor
cement of alcohol licensed premises

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Examples of International Community Action
Projects for Alcohol Prevention
Australia Partysafe project Carnarvon, We
stern
Australia
Reduce harm from private drinking (males 25-4
5 years)

local media peer cartoon character ser
ver training
?
Heightened local awareness of alcohol issues
?
Unknown effects on drinking
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Community Systems that Support Alcohol Use
Abuse are Complex Systems
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Community Action and Prevention Lessons from
International Projects
We are just beginning to learn how to intervene
in these systems to prevent problems related to
alcohol.
?
Value of Evaluationdetermine effects
?
Environmental strategies are most effective
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COMMUNITY TRIALS TO PREVENT ALCOHOL-INVOLVED
TRAUMA
1991-1997
Prevention Research Center Berkeley, CA
Sponsors National Institute on Alcohol Abuse an
d Alcoholism Center for Substance Abuse Preve
ntion
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National Community Trial to Prevent
Alcohol-Involved Trauma
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Overall Project Goal Reduce Alcohol-involved
Trauma
Traffic Crashes
Unintentional Injuries
Violence
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Five Prevention Components
1. Community Mobilization
2. Responsible Beverage Service
3. Risk of Drinking and Driving
4. Underage Drinking
5. Alcohol Access
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INTERVENING IN A COMPLEX SYSTEM . . .

Chronic Outcomes
Alcohol DependenceCirrhosis
Drinking Levels
Population Growth
Outlet Growth
Alcohol Sales
Drinking Contexts

Acute Outcomes
Drunken DrivingAlcohol-Related CrashesDrowning,
Burns, and FallsAlcohol-Related Violence
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. . . THE COMMUNITY TRIALS INTERVENTIONS
Chronic Outcomes
Alcohol DependenceCirrhosis
Drinking Levels
Responsible Beverage Service Component
Population Growth
Outlet Growth
Alcohol Sales
Drinking Contexts
Access Component (Availability)
Youth Component (Sales to Youth)
Drinking and Driving Component
Media Component


Drunken DrivingAlcohol-Related CrashesDrowning,
Burns, and FallsAlcohol-Related Violence
Acute Outcomes
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Community Mobilization
Goal Provide support for other project
interventions
Actions
?
Increase general community awareness and concern
about alcohol-involved unintentional trauma
?
Increase community support for environmental
prevention
?
Mobilize community to support specific
interventions
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Responsible Beverage Service
Goal Reduce alcohol intoxication or impairment
for patrons of bars and restaurants
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Drinking and Driving
GoalReduce the number of community drinking and
driving events
Actions
?
Increase law enforcement efficiency
?
Increase perceived risk of DWI detection
?
Increase community support of DWI enforcement
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Underage Drinking
GoalDecrease underage drinking
Actions
?
Increase community awareness of underage drinking
?
Reduce physical availability of alcohol to minors
?
Increase awareness of retail establishments and
adults of the legal and social risks of
providing
alcohol to minors
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Access Intervention
Goal Decreased physical availability of alcoho
l
Actions
?
Reduction in outlet densities
?
Changes in planning and zoning laws
?
License challenges
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COMMUNITY TRIALS SIGNIFICANTLY REDUCED
ALCOHOL-RELATED PROBLEMS
49 -- self- reported over-consumption
51 -- self-reported driving over limit
10 -- nighttime injury crashes
6 -- self-reported drinking per occasion
6 -- crashes involving drinking drivers
43 -- assault injures in emergency rooms
Source Holder, H.D., Gruenewald, P.J., Ponicki,
W.R., Treno, A.J., Grube, J.G., Saltz, R.F.,
Voas, R.B., Reynolds, R., Davis, J., Sanchez, J.,
Gaumont, G., and Roeper, P. Effect of
Community-Based Interventions on High-Risk
Drinking and Alcohol-Related Injuries, Journal of
the American Medical Association. 2000
182341-2347.

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The Follow-up

• Community Trials Project was awarded model
  program status by the Center for Substance Abuse
  Prevention.
  
• Communities across the country are adopting this
  program and receiving federal support under the
  State Incentive Grants program.

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Sacramento Neighborhood Alcohol Prevention
Project (SNAPP)2000-2003

• La Familia Counseling CenterStanford Settlement
  House
  
• Prevention Research Center
• Funded by the National Institute on Alcohol Abuse
  and Alcoholism, the Center for Substance Abuse
  Prevention, and The California Endowment

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Project Goals
Reduce

• Youth and young adult drinking
• Youth access to alcohol
• Drinking- related problems (i.e., crime,
  automobile crashes, and alcohol-involved
  injuries).

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The intervention components were phased in over a
4 year period
1. A neighborhood in the southern part of the
city, and
2. A similar neighborhood in the northern part,
2 years later.
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Project Interventions
1. Community mobilization increases
neighborhood support for all components.
2. Community awareness disseminates
information about youth and young adult
alcohol access and use.
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Project Interventions
3. Responsible Beverage Service program
focuses on service to minors and
intoxicated patrons
4. Underage Access Component supports
increased police enforcement of underage
sales laws and laws regarding provision of
alcohol to minors by social hosts
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Project Interventions

• Enforcement component regulating sales
  to intoxicated persons in alcohol
  establishments and at special events

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Types of Evaluation

• Process What happened and when, i.e. dosage
• Intermediary Measures What effect did it have?
• Outcomes Did it reduce problems?

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Process Timeline of Intervention Activities
(South Area Only)
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Intermediary Measures Purchase/Service Rates
for Waves 1 and 2
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Intermediary Measures Purchase/Service Rates for
Waves 2 and 3
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SNAPP OUTCOMES

• Fewer calls to Police for Assaults Fewer calls
  to Emergency Medical Services Fewer Motor
  Vehicle Accidents

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Unique Contributions of SNAPP

• Focusing on the neighborhood contexts of alcohol
  problems
  
• Developing environmental interventions in
  different ethnic minority contexts
  
• Understanding geographically appropriate levels
  at which to implement such interventions

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Next Steps

• Determine the relative importance of training,
  enforcement, and mobilization components
  
• Determine the most cost effective "dosage" of
  environmental interventions
  
• Develop environmental strategies appropriate to
  communities within different cultural contexts

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The Border Project

• Preventing alcohol-related problems at the
  US/Mexico Border

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Current sites

• San Diego -Tijuana
• El Paso Juarez
• Laredo Nuevo Laredo
• Brownsville - Matamoros

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The Problem

• Mexicos drinking age is 18
• Some border towns provided plentiful, cheap
  sources of alcohol

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The Problem

• Mexicos drinking age is 18
• Some border towns provided plentiful, cheap
  sources of alcohol
  
• Beverage service is not always responsible

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The Problem

• Mexicos drinking age is 18
• Some border towns provided plentiful, cheap
  sources of alcohol
  
• Beverage service is not always responsible
• Heavy drinking occurs
• Sometimes resulting in problems in Mexico

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Implementing the Project

• The nature and scope of the problem were
  explained to groups and agencies on both sides of
  the border
  
• Media advocacy brought the problem to the
  attention of the public through compelling news
  coverage

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The Change Strategies

• Earlier bar closings
• Stepped up DUI enforcement efforts on the US side
  of the border
  
• Highly publicized enforcement of laws against
  crossing by youth under 18
  
• New restrictions on Marines from Camp Pendleton

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The Results

• Dramatic decline in number of nighttime crossings
  by young people
  
• Reduction in nighttime crashes involving drivers
  under 18
  
• 90 reduction in number of Marines driving back
  from the border
  

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The Safer California Universities ProjectA risk
management approach to college student drinking
problems

• Goal To evaluate the efficacy of a Risk
  Management approach to alcohol problem
  prevention

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What is Risk Management?

• Risk Assessment using data to identify
  intervention targets (settings, events)
  
• Risk Reduction interventions aimed at reducing
  alcohol-related problems
  
• Risk Monitoring using data to assess
  intervention effectiveness and modify
  interventions if necessary

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Risk Assessment

• Brief interviews with key personnel
• Archival data sources
• Student survey data

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What are we trying to prevent?

• Intoxication at particular settings/events
• Harm related to intoxication at particular
  settings/events

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Selecting A Problem Setting

• Using assessment data to target prevention efforts

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Web-based Student Survey, Fall 2003

• Administered to 14,000 students at 14 California
  universities
  
• Established baseline levels of student drinking
  and alcohol-related problems
  
• Identified settings where the majority of
  alcohol-related problems are occurring

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Survey Modules for Specific Settings

• Residence hall parties
• Greek parties
• Campus events (e.g., concerts, sporting events)
• Off-campus parties (houses, apartments)
• Bars/restaurants
• Outdoor settings (e.g., parks, beaches)

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Drinking Problems in Past Semester/Quarter
Source Safer California Universities Survey, 2003
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Percentage of all Alcohol Problems by Setting
(Fall 2004)
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Why?
Off-Campus Parties are Causing the Most Problems

• Over 9,000 students in survey sample went to at
  least one off-campus party, 3-4 times as many as
  other settings
  
• Statistical analyses indicate that off-campus
  parties carry a higher risk for frequent
  intoxication and alcohol-related problems than
  other settings

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Effects of Survey Data on Decision Making

• Consensus to target interventions to off- campus
  settings (e.g., house parties)
  
• Support for long-term implementation of
  interventions
  
• Great interest in continued surveillance to
  assess intervention effects

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• Interventions for Off-Campus Settings
• Educational campaign to support safe social
  gatherings and encourage responsible hosting of
  social activities
  
• Fair but firm enforcement of existing laws
• DUI enforcement
• Party patrols to disperse dangerous crowds
• Enforce laws prohibiting alcohol sales or
  informal provision of alcohol to minors
  
• Placing the burden of costs to those who
  repeatedly require community or police response
  a response cost ordinance.

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Current Project Summary

• Student survey, archival and key informant data
  provide an assessment of where and when
  alcohol-related problems are occurring
  
• These data can be used to help college prevention
  specialists, administrators, campus police and
  others to focus intervention efforts on a
  particular setting and sustain those efforts
• Data can also be used to monitor the effects of
  interventions targeted to specific settings
  

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What have we learned from these Environmental
Prevention Programs?
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Environmental Strategies Myths Mistakes
1
Effects take a long time to demonstrate.
2
Environmental strategies are programs
3
All prevention programs are environmental.
4
Only youth are targeted.
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Important Questions
What are minimum factors for success?


What partnerships are necessary between
community
coalitions and researchers?

What works? Which combinations of strategies are
most cost-effective?

How can coalitions demonstrate that their home
grown efforts are effective, e.g., in 1-3 years?
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Similarities across Programs

• Comprehensive and Multi-component
• Address the Specifics of the Local Alcohol
  Environment
  
• Research Based
• Rely Largely on Local Energies for
  Implementation
  
• Evaluation Addressing Process, Intermediary
  Environmental Conditions, and Outcomes

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Differences between Programs

• Tailored to the Specific Needs and Conditions of
  their Respective Communities
  
• Targeting Different Outcomes
• Differing Instruments Used to Evaluate Based on
  these Needs and Conditions

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Mobilization across Programs

• Use of Local Existing Groups are Key to Program
  Success
  
• Mobilization is Used in Support of Environmental
  Change
  
• Scientific Findings Play a Key Role in in Program
  Development and Implementation as Well as
  Evaluation.
  

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Role Played by Research Across Programs

• Development of Specific Targets and Strategies
• To Mobilize Communities by Increasing Awareness
  and Concern, Acceptance of the Environmental
  Approach
  
• For Purposes of Program Evaluation

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Mobilization of Local Efforts to Reduce
Alcohol-Involved Problems Efforts at
Environmental Change
Andrew J. Treno, Ph.D. April 21, 2006 Copenh
agen, Denmark