Guide to community preventive services
Effectiveness of Multicomponent Programs with Community Mobilization for Reducing Alcohol-Impaired Driving

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Abstract

A systematic review was conducted to determine the effectiveness and economic efficiency of multicomponent programs with community mobilization for reducing alcohol-impaired driving. The review was conducted for the Guide to Community Preventive Services (Community Guide). Six studies of programs qualified for the review. Programs addressed a wide range of alcohol-related concerns in addition to alcohol-impaired driving.

The programs used various crash-related outcomes to measure their effectiveness. Two studies examined fatal crashes and reported declines of 9% and 42%; one study examined injury crashes and reported a decline of 10%; another study examined crashes among young drivers aged 16–20 years and reported a decline of 45%; and one study examined single-vehicle late-night and weekend crashes among young male drivers and reported no change. The sixth study examined injury crashes among underage drivers and reported small net reductions. Because the actual numbers of crashes were not reported, percentage change could not be calculated.

According to Community Guide rules of evidence, the studies reviewed here provided strong evidence that carefully planned, well-executed multicomponent programs, when implemented in conjunction with community mobilization efforts, are effective in reducing alcohol-related crashes. Three studies reported economic evidence that suggests that such programs produce cost savings. The multicomponent programs generally included a combination of efforts to limit access to alcohol (particularly among youth), responsible beverage service training, sobriety checkpoints or other well-defined enforcement efforts, public education, and media advocacy designed to gain the support of both policymakers and the general public for reducing alcohol-impaired driving.

Introduction

Alcohol-impaired driving continues to be a major public health problem in the U.S. In 2007, there were 12,998 people who died in crashes in which at least one driver had a blood alcohol concentration (BAC) of at least 0.08 grams per deciliter (g/dL), the level at which adult drivers in the U.S. are legally drunk.1 The estimated economic cost of alcohol-related crashes in 2000 was $51 billion,2 or approximately $64 billion in 2008 dollars based on the annual average Consumer Price Index.a

Attempts to address alcohol-impaired driving through law enforcement date back to New York's impaired driving law of 1910.3 More than 50 years later, the National Highway Safety Bureau's 1968 Report to the Congress on Alcohol and Highway Safety stimulated official and public concern regarding alcohol-impaired driving.3, 4 Since then, individual states and communities have implemented a broad range of strategies to reduce alcohol-impaired driving. Other systematic reviews in this series have summarized the effectiveness of some of the common single-component interventions, including various laws,5, 6 sobriety checkpoints,5, 6, 7 mass media campaigns,8 designated driver programs,9 and school-based programs.10 In practice, individual interventions are combined to form multicomponent programs.

Among the earliest multicomponent community-based programs to address alcohol-impaired driving were the Alcohol Safety Action Projects (ASAPs), funded by the U.S. Department of Transportation (DOT) and conducted from 1969 through 1975. These programs were based on a “systems approach,” later called a “health–legal” approach that focused on health-related interventions, such as alcohol-problem screening and referral to treatment, on the one hand, and on legal interventions, such as legislation, enforcement, adjudication, and penalties, on the other. Each of these programs also had a public information and education component made up primarily of public service media campaigns, speakers bureaus, local education programs, and other informational activities. Approximately $84 million was expended over a period of 5–6 years on 35 individual ASAPs. Evaluation results reported by the National Highway Traffic Safety Administration (NHTSA) indicated that about one third of these projects (12 of 35) resulted in significant reductions in nighttime fatal crashes, compared with zero in matched comparison sites.11

Although all of the ASAPs involved multiple community agencies and organizations, and several were implemented at the community (county) level, they did not specifically focus on community mobilization to implement and sustain the programs. A multicomponent program was defined for this review as one that implemented interventions, policies in multiple settings (e.g., responsible beverage service in bars and sobriety checkpoints), or both to alter the community environment to directly or indirectly reduce alcohol-impaired driving. Programs satisfied the community mobilization criterion if a community coalition or task force was actively involved in making decisions about the type of interventions implemented or methods for implementation and the group remained engaged in the program throughout the period of implementation. The multicomponent programs included in this systematic review are summarized below.

In 1984, planning began for a multicomponent program to be implemented by the Rhode Island Department of Health, with funding from the CDC and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The Rhode Island Community Alcohol Abuse and Injury Prevention Project introduced an approach referred to as the “gatekeeper model,” which targeted key individuals who influence community drinking practices (e.g., alcohol servers and enforcement agencies) rather than targeting drinkers themselves. This was also one of the first documented programs designed to mobilize broad community support for actions by these gatekeepers to reduce alcohol-related injuries and deaths.12

Then, in the late 1980s, the Massachusetts Saving Lives Program was implemented as a multicomponent effort, addressing traffic safety issues including impaired driving, speeding, and pedestrian injuries in six moderate-size communities. These programs were designed more specifically to organize city departments and private citizens to address the impaired driving issue.13

At the same time, the IOM recommended the implementation of such multicomponent community efforts to address the more general problems posed by alcohol use and abuse.14 Following that recommendation, several large-scale, multicomponent community-based programs were implemented. From 1992 through 1996, for example, the Community Trials Project was funded by the Center for Substance Abuse and Prevention (CSAP) and NIAAA and implemented in three communities in northern California, southern California, and South Carolina. In addition to community mobilization activities, the project sought to reduce rates of alcohol-related injuries by means of interventions involving enforcement of drinking and driving laws, publicity, responsible alcohol beverage service, and reducing access to alcohol. These interventions were implemented in stages, forming intervention “pulses.”15

Also in 1992, the Robert Wood Johnson Foundation (RWJF) funded a large-scale, multimillion-dollar community intervention program to reduce substance abuse problems in 14 communities across the U.S. Five of these 14 communities implemented interventions that focused on reducing alcohol availability, particularly among youth, as well as on expanding treatment and referral activities. This program, called Fighting Back, began with 2-year community planning efforts through which local task forces developed multicomponent interventions involving combinations of publicity, referral, treatment, and aftercare; efforts to reduce access to alcohol; responsible alcohol service; “sting” operations at alcohol retail stores to reduce underage purchases; and reduced marketing of alcohol. One community also included enhanced enforcement of drinking and driving laws.16

In 1993, another large, community-based program was funded by the CSAP and NIAAA. The Communities Mobilizing for Change on Alcohol (CMCA) program focused on community organizing to change policies and practices to reduce youth access in seven Minnesota and Wisconsin communities. Interventions included enforcement to reduce underage purchasing of alcohol, publicity, and reduced access to alcohol via efforts to change alcohol service practices and community norms.17

In 1997, with funding from the NIAAA and RWJF, the Operation Safe Crossing program was implemented in San Diego (CA) County to reduce the number of young people crossing the U.S. border to drink in Tijuana, Mexico, then driving to destinations in and around San Diego on their return. It focused extensively on community mobilization, strong media advocacy, and publicized driving-under-the-influence law enforcement efforts to meet its objectives.18

These six community-based programs provided the research base for examining the potential for multicomponent programs with community mobilization to reduce alcohol-impaired driving and associated crashes and injuries.

This systematic review was conducted on behalf of the Task Force on Community Preventive Services (Task Force) for inclusion in the Guide to Community Preventive Services (Community Guide, www.thecommunityguide.org). The general methods used to conduct systematic reviews and economic evaluations for the Community Guide have been described in detail elsewhere.19, 20

An economic evaluation is conducted only if the systematic review indicates that a strategy is effective according to Community Guide rules of evidence, and economic data are available. Economic evaluations use the societal perspective, which considers all costs and benefits, regardless of who bears the costs or receives the benefits.19

To be included in this review, a study had to (1) be primary research published in a peer-reviewed journal, technical report, or government report; (2) be published in English between January 1, 1980, and June 30, 2005; (3) meet minimum Community Guide quality criteria for study design and execution19; and (4) evaluate the effects of a multicomponent program with community mobilization to reduce alcohol-related crashes.

“Community mobilization” or “community organization” has been broadly defined as the organization and activation of a community to address local problems.21 The concept has been defined as “a planned process to activate a community to use its own social structures and any available resources to accomplish community goals that are decided on primarily by community representatives and that are generally consistent with local values.”22 The community mobilization model, which emphasizes community-level actions over individual behavior change strategies,23, 24 is well suited to addressing alcohol misuse for at least two reasons. First, communities exert some local control over the sale and public consumption of alcohol through enacting and enforcing local ordinances, and second, many of the costs associated with alcohol misuse are borne not only by the individual drinker but also by other members of the community, for example, through motor vehicle crashes and alcohol-related violence.25

Section snippets

Conceptual Model

The figure below shows the conceptual model that guided the review. The model reflects that community mobilization efforts can facilitate changes in alcohol-impaired driving through both direct and indirect pathways. For example, policy and environmental changes implemented in these programs can either directly target alcohol-impaired driving, usually by increasing the perceived risk of arrest for alcohol-impaired driving, or they can focus on reducing high-risk alcohol consumption, thereby

Evidence Synthesis

Six studies were identified that evaluated changes in alcohol-related crashes following implementation of a multicomponent program with community mobilization.12, 13, 15, 16, 17, 18 All six of these programs were conducted in the U.S. between 1988 and 2001. They addressed a variety of outcomes in addition to alcohol-impaired driving, including underage drinking, other risky driving behaviors such as speeding, disorderly conduct, alcohol-related injuries and violence, access to alcohol

Discussion

The studies reviewed here indicate that carefully planned, well-executed multicomponent programs with community mobilization can reduce alcohol-related crashes. They also suggest that such programs produce cost savings.

None of the studies provided unequivocal evidence that a given program reduced alcohol-related crashes; there is consistent evidence, however, of an impact across the body of evidence reviewed. This pattern is unlikely to be an artifact of methodologic flaws within the studies

Conclusion

The community-based programs evaluated in this review tended to be well-funded, multiyear efforts with outside technical assistance and evaluators. Additionally, each of the programs implemented at least some individual interventions with proven effectiveness. These characteristics probably maximized their effectiveness. Because these programs represent a highly select sample of multicomponent community-based programs addressing alcohol problems and alcohol-related driving injuries and deaths,

References (45)

  • Alcohol and Highway SafetyReport to the U.S. Congress 1968

    (1968)
  • R.A. Shults et al.

    Reviews of evidence regarding interventions to reduce alcohol-impaired driving

    Am J Prev Med

    (2001)
  • S. Zaza et al.

    Motor vehicle occupant injury

  • R.W. Elder et al.

    Effectiveness of sobriety checkpoints for reducing alcohol-involved crashes

    Traffic Inj Prev

    (2002)
  • National Highway Traffic Safety Administration. Alcohol Safety Action Projects evaluation methodology and overall...
  • Final report of the Rhode Island Community Alcohol Abuse and Injury Prevention Project: Volume I, technical report

    (1994)
  • R. Hingson et al.

    Reducing alcohol-impaired driving in Massachusetts: the Saving Lives Program

    Am J Public Health

    (1996)
  • Prevention and treatment of alcohol problems: research opportunities

    (1990)
  • H.H. Holder et al.

    Effect of community-based interventions on high-risk drinking and alcohol-related injuries

    JAMA

    (2000)
  • R.W. Hingson et al.

    Effects on alcohol related fatal crashes of a community based initiative to increase substance abuse treatment and reduce alcohol availability

    Inj Prev

    (2005)
  • A.C. Wagenaar et al.

    Communities Mobilizing for Change on Alcohol (CMCA): effects of a randomized trial on arrests and traffic crashes

    Addiction

    (2000)
  • R.B. Voas et al.

    Operation Safe Crossing: using science within a community intervention

    Addiction

    (2002)
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