Community Prevention II Design and Implementation of Strategies Harold D. Holder, Ph.D. Prevention Research Center Berkeley, California USA Associação Brasileira de Estudos de Álcool e Outras Drogas, Sao Paulo September 5, 2003

Traditional Approach to Prevention Action Desired Results BETTER FUTURE CHOICES FOR YOUTH ABOUT SUBSTANCES AND THUS REDUCED ABUSE BLACK BOX OF COMMUNITY PUBLIC SCHOOL EDUCATION Systems Approach to Prevention Search for Action Community Systems Model Desired Results X Z Y Q REDUCED HIGHWAY DEATHS RELATED TO DRINKING

One might say a “systems output” Systems Principle 1 Substance abuse problems are not simply the actions of high-risk individuals— -- rather, the result of complex social, cultural, and economic factors within the overall community-system. One might say a “systems output”

Systems Principle 2 Community systems by nature are: 1. adaptive—adjust to changes including local prevention efforts 2. transformational—create new results and outcomes 3. unpredictable—do not follow expected courses, i.e., are counter-intuitive

Prevention Intervention and Outcome Direct Effect on Outcomes Dose or Strength of Intervention

Prevention Intervention and Outcome “Barrier” “Threshold” Direct Effect on Outcome “Step” Dose or Strength of Intervention

Public Health Model of Substance Abuse Problem Prevention Individual (User) Environment (Context) Agent (Substance)

Individual Approaches 1. School-Based Education 2. Mass Communication and Public Education 3. Family Education/counseling 4. Alcohol and Tobacco Warning labels 5. Deterrence: Possession or sale of drugs, Drinking and driving Laws, Sale of tobacco or alcohol to minors. 6. Brief Intervention in health care or workplace

Public Health Model of Substance Use Prevention Individual(User) Agent (Substance) Environment (Context)

Environmental Approaches 1. Retail Access to substances, e.g., price, outlet locations, minimum purchase laws. 2. Restrictions or constraints on the Drinker’s or Smokers Behavior, e.g., drinking & smoking locations, drink drive 3. Reduce Risk or Problem Severity

Public Health Model of Substance Use Prevention Individual(User) Environment (Context) Agent (Substance)

Agent Approaches 1. Low or No Alcohol Beverages or lower tar tobacco products 2. Alcohol container size or tobacco package restrictions 3. Restrictions on Product Advertising

Alcohol-involved Trauma at the Community Level: Conceptual Model````````` MOBILIZATION DRINKING AND DRIVING Local News about Alcohol Problems & Enforcement Perceived Risk of Arrest Local Law Enforcement RESPONSIBLE BEVERAGE SERVICE Social Access to Alcohol Driving after Drinking Alcohol Serving and Sales Practices UNDERAGE DRINKING Local Regulation of Alcohol (Density, Hours of Sale) Retail Alcohol Availability (On and Off-premise) Alcohol-involved Injury Alcohol Intoxication or Impairment ALCOHOL ACCESS Non-Traffic Risk Activities

General Timeline of Program Implementation Community Trials Project 1991 - 1996 1992 1993 1994 1995 1996 Funding Secured Evaluation Data Collection Mobilization & Media Advocacy Component Drinking and Driving Component Responsible Beverage Service Component Underage Drinking Component Access Component

Community Mobilization Goal: Community Awareness of Alcohol Problems and Support for Local Policy Actions Community Organizing Local News (Media Advocacy)

Community Mobilization  Increase general community awareness and concern about alcohol-involved unintentional trauma  Increase community support for environmental prevention  Mobilize community to support specific interventions

Community Mobilization Question: Who should be included in a community project to prevent alcohol-involved trauma? What is their interest or investment in such a local problem? What political, social, or economic resource can they bring?

Friday, December 10, 1993

Five Prevention Components 1. Community Mobilization 2. Responsible Beverage Service

Restaurant Service

Responsible Beverage Service Goal: Reduce alcohol intoxication or impairment for patrons of bars and restaurants Actions:  Server and manager training  New alcohol serving policies (price promotions, reduce serving sizes, promote non-alcoholic beverages and food)  Enforcement of no service to underage and obviously intoxicated patrons

Responsible Beverage Service Policy: Refuse Service to Intoxicated Patrons 5 10 15 20 25 Pretest (1993) Posttest (1995) Experimental Comparison Mean % Yes Northern California Communities Southern California Communities South Carolina Communities

Five Prevention Components 1. Community Mobilization 2. Responsible Beverage Service 3. Risk of Drinking and Driving

Source: Prevention Research Center Community Survey

Drinking and Driving Goals:    Reduce number of community drinking and driving events  Increase perceived risk of DWI detection  Increase community support of DWI enforcement

DRINKING AND DRIVING COMPONENT ACTION MODEL Enforcement News Perceived Risk Of DUI Arrest Drinking & Driving Driver BAC Crashes

Enforcement & News to Perceived Risk DRINKING AND DRIVING COMPONENT ACTION MODEL Enforcement & News to Perceived Risk California Sites Enforcement: F 11.65, p < .076* Publicity: F 9.04, p < .095* Enforcement News Perceived Risk Of DUI arrest South Carolina Site Enforcement: F 4.25, p < .287* Publicity: F .03, p < .891* *Analysis of variance

Perceived Risk to Drinking and Driving DRINKING AND DRIVING COMPONENT ACTION MODEL Perceived Risk to Drinking and Driving All 6 Sites Experimental and Comparison Enforcement News Self-Reported Driving after drinking: t -14.25, p < .001* Driving while intoxicated: t -6.04, p < .001* *Tobit regression Perceived Risk Of DUI arrest Drinking & Driving Driver BAC

Drinking and Driving vs. Crashes DRINKING AND DRIVING COMPONENT ACTION MODEL Drinking and Driving vs. Crashes Northern California: G2 15.96, p < .001* Enforcement News Southern California: G2 58.86, p < .001* Perceived Risk South Carolina: G2 10.17, p < .006* *SURE Analysis Drinking & Driving Driver BAC Crashes

Enforcement and News vs. Crashes DRINKING AND DRIVING COMPONENT ACTION MODEL Enforcement and News vs. Crashes All Communities: G2 10.08, p < .025* Enforcement News California Communities: G2 9.74, p < .025* Perceived Risk South Carolina Communities: G2 1.37, p < .711* *SURE Analysis Drinking & Driving Driver BAC Crashes

DRINKING AND DRIVING COMPONENT ACTION MODEL Enforcement News Increased enforcement & news = -10% injury crashes Perceived Risk Of DUI arrest Drinking & Driving G2 10.08, p < .025* *SURE Analysis Crashes

Five Prevention Components 1. Community Mobilization 2. Responsible Beverage Service 3. Risk of Drinking and Driving 4. Underage Drinking

Underage Drinking Goals:     Increase community awareness of underage drinking  Reduce adolescent drinking, especially in risky situations  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

Sunday, February 27, 1994

Current Access Intervention Status  All experimental communities have intervened to reduce alcohol access  Community-wide changes in availability have occurred  Major neighborhood-specific changes in availability have occurred. For example: New alcohol outlets denied

What have we learned? Evaluation Results