The NIfETy method for environmental assessment of neighborhood-level indicators of violence, alcohol, and other drug exposure.

There are limited validated quantitative assessment methods to measure features of the built and social environment that might form the basis for environmental preventive interventions. This study describes a model approach for epidemiologic assessment of suspected environmental determinants of violence, alcohol and other drug (VAOD) exposure and fills this gap in current research. The investigation sought to test the feasibility of a systematic and longitudinal assessment of residential block characteristics related to physical and social disorder and indicators of VAOD exposure. Planometric data were used to establish a stratified random sample of street segments within defined neighborhoods of an urban metropolitan area. Field rater assessments of these neighborhood street segments were conducted using the Neighborhood Inventory for Environmental Typology (NIfETy). This report provides a detailed description of the NIfETy Method, including metric properties of the NIfETy Instrument and outcomes of training procedures and quality control measures. Also presented are block-level characteristics and estimates of observable signs of VAOD activity. This work is a first step toward developing future community-level environmental preventive interventions geared to reduce community VAOD exposure among youthful urban populations and may prove to be useful to other public health research groups as well.

Prevention research and its actual application to health services.

The effectiveness of alcohol abuse programs, whether to treat or to prevent, is of major importance to health services research. Demonstrating effectiveness has been appropriate to establish a sound scientific basis for these programs and to increase public acceptance. Analysis of the costs of prevention efforts in terms of their demonstrated effectiveness in reducing health services demand also is essential. In the end, health services policy deliberations are optimally based on what effect is delivered for the cost of the service, not simply on a determination of which service is the most effective. However, in a time of scarce resources prevention should be studied with the same rigor as treatment in order to determine the best return on investment.

Community prevention trials: a respectful partnership.

OBJECTIVE: To review the theoretical basis for a systems approach to community prevention of alcohol problems and the policy options that this approach suggests. METHOD: A community systems prevention project used 4 environmental strategies to reduce heavy drinking. RESULTS: The Community Trial, using an environmental approach to prevention, achieved a statistically significant reduction in alcohol-involved traffic crashes in addition to lower sales of alcohol to young people and greater number of policies against serving alcohol to intoxicated persons. CONCLUSION: This trial demonstrated that a respectful partnership between researchers and community members is essential. Prevention planners and policy makers must understand how various aspects of the community influence alcohol and other drug use, thereby contributing to alcohol and other drug problems.

Prevention of alcohol problems in the 21st century: challenges and opportunities.

The community is the "new frontier" for alcohol and other drug prevention. New prevention initiatives at the community level suggest that effective strategies will often be quite different from national or state policies and will require a different perspective. Alcohol and other drug use is part of routine community life and must be considered in the context of the community, which is itself a dynamic and self-adapting system. To develop effective community-level interventions, prevention planners and policy makers must understand how various aspects of the community influence alcohol and other drug use and even contribute to alcohol and other drug problems. This paper outlines the basis for a systems approach to community prevention and the policy options that this approach suggests. It also examines the new science of complexity, differentiates between catchment and a systems approach to prevention, describes a public health model within a systems approach, and describes using local policy as a means to produce system changes as well as recent findings from community-based prevention efforts that employed local alcohol policies.

Community prevention of alcohol problems.

Local communities have begun using policy to affect the drinking environment itself as an approach to reducing alcohol involved trauma. That is, policy is used to produce structural changes in the drinking environment. In turn, changes in the environment effect changes in drinking behavior. This paper describes an effort in three communities in two states to reduce alcohol problems at the community level, "Preventing Alcohol Trauma: A Community Trial." This trial was a 5-year research project with a goal to reduce local alcohol-involved injuries and deaths in three experimental communities with populations of approximately 100,000 each (one in northern California, one in southern California, and one in South Carolina). The communities contained racial and ethnic diversity as well as a mix of urban, suburban, and rural settings. Each of these three communities had a control community that did not receive the prevention interventions. The project used an environmental policy approach to prevention and five mutually reinforcing components were implemented: (1) community mobilization to develop community organization and support, (2) responsible beverage service to establish standards for servers and owners/managers of on-premise alcohol outlets to reduce their risk of having intoxicated and/or underage customers in bars and restaurants. (3) a drinking and driving component to increase local drunk-driving enforcement efficiency and to increase the actual and perceived risk that drinking drivers would be detected, (4) an underage drinking component to reduce retail availability of alcohol to minors, and (5) an alcohol access component to use local zoning powers and other municipal controls of outlet numbers and density to reduce availability of alcohol. Results show that the project reduced alcohol-involved crashes, lowered sales to minors, increased the responsible alcohol serving practices of bars and restaurants, and increased community support and awareness of alcohol problems.

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

CONTEXT: High-risk alcohol consumption patterns, such as binge drinking and drinking before driving, and underage drinking may be linked to traffic crashes and violent assaults in community settings. OBJECTIVES: To determine the effect of community-based environmental interventions in reducing the rate of high-risk drinking and alcohol-related motor vehicle injuries and assaults. DESIGN AND SETTING: A longitudinal multiple time series of 3 matched intervention communities (northern California, southern California, and South Carolina) conducted from April 1992 to December 1996. Outcomes were assessed by 120 general population telephone surveys per month of randomly selected individuals in the intervention and comparison sites, traffic data on motor vehicle crashes, and emergency department surveys in 1 intervention-comparison pair and 1 additional intervention site. INTERVENTIONS: Mobilize the community; encourage responsible beverage service; reduce underage drinking by limiting access to alcohol; increase local enforcement of drinking and driving laws; and limit access to alcohol by using zoning. MAIN OUTCOME MEASURES: Self-reported alcohol consumption and driving after drinking; rates of alcohol-related crashes and assault injuries observed in emergency departments and admitted to hospitals. RESULTS: Population surveys revealed that the self-reported amount of alcohol consumed per drinking occasion declined 6% from 1.37 to 1. 29 drinks. Self-reported rate of "having had too much to drink" declined 49% from 0.43 to 0.22 times per 6-month period. Self-reported driving when "over the legal limit" was 51% lower (0. 77 vs 0.38 times) per 6-month period in the intervention communities relative to the comparison communities. Traffic data revealed that, in the intervention vs comparison communities, nighttime injury crashes declined by 10% and crashes in which the driver had been drinking declined by 6%. Assault injuries observed in emergency departments declined by 43% in the intervention communities vs the comparison communities, and all hospitalized assault injuries declined by 2%. CONCLUSION: A coordinated, comprehensive, community-based intervention can reduce high-risk alcohol consumption and alcohol-related injuries resulting from motor vehicle crashes and assaults. JAMA. 2000;284:2341-2347.

Alcoholism treatment and medical care costs from Project MATCH.

AIMS: This paper examines the costs of medical care prior to and following initiation of alcoholism treatment as part of a study of patient matching to treatment modality. DESIGN: Longitudinal study with pre- and post-treatment initiation. MEASUREMENTS: The total medical care costs for inpatient and outpatient treatment for patients participating over a span of 3 years post-treatment. SETTING: Three treatment sites at two of the nine Project MATCH locations (Milwaukee, WI and Providence, RI). PARTICIPANTS: Two hundred and seventy-nine patients. INTERVENTION: Patients were randomly assigned to one of three treatment modalities: a 12-session cognitive behavioral therapy (CBT), a four-session motivational enhancement therapy (MET) or a 12-session Twelve-Step facilitation (TSF) treatment over 12 weeks. FINDINGS: Total medical care costs declined from pre- to post-treatment overall and for each modality. Matching effects independent of clinical prognosis showed that MET has potential for medical-care cost-savings. However, patients with poor prognostic characteristics (alcohol dependence, psychiatric severity and/or social network support for drinking) have better cost-savings potential with CBT and/or TSF. CONCLUSIONS: Matching variables have significant importance in increasing the potential for medical-care cost-reductions following alcoholism treatment.

Introduction: community action research and the prevention of alcohol problems at the local level.

Many community action projects from around the world exist to reduce alcohol problems at the local level. The role of research within this international movement is discussed within this introduction for the entire special issue on community action research in alcohol problem prevention. Previous community prevention programs have utilized a variety of prevention strategies: (a) an educational approach which focuses on changing behavior through changes in knowledge, attitudes, and information; and (b) an environmental approach which focuses on changing behavior through changes in the social and economic systems within a community. Many projects have used both approaches. This special issue provides a current overview of many types of community action projects from different countries and summarizes what has been learned to date from these experiences.

Institutionalization of community action projects to reduce alcohol-use related problems: systematic facilitators.

This article reviews papers from a recent conference on community action research in order to identify factors that contribute to long-term maintenance, sustainability, or institutionalization of community project interventions. The descriptions of long-term outcomes and aftereffects of projects that emerged in the conference are valuable because relatively few instances of institutionalization have been documented in the scientific literature. After a general theoretical discussion of institutionalization in communities, the article identifies characteristics of successful community action programs that outlived their original funding. These characteristics include honoring community values and cultural relevance, cultivating key leader support, and utilizing indigenous staff. They also include developing local resources, maintaining flexibility, and leveraging prior success. The paper concludes by noting that aiming for policy and structural changes is a goal for an institutionalization of measures positively affecting desired health outcomes, even if the programs which created them are not themselves sustained.

Alcoholism treatment offset effects: an insurance perspective.

This study investigates whether alcoholism treatment costs are offset by reductions in other medical treatment costs by comparing people treated for alcoholism with a matched comparison group. The alcoholism treatment group is defined by diagnoses of alcohol dependence, abuse, or psychoses from health insurance claims field between January 1980 and June 1987. A comparison sample was matched on age, gender, and insurance coverage. In this primarily methodological study, expected costs for nonalcoholism treatments were calculated from standardized regressions. Offset effects were measured from the insurer's perspective through differences in expected total nonalcoholism treatment costs in the periods preceding and following alcoholism treatment. Members of the alcoholism treatment group were more likely than the comparison group to be hospitalized and to need other (nonalcoholism) medical treatment, thus incurring higher total costs. Offset effects emerged for patients with alcohol abuse and without mental psychosis comorbidities.

The alcohol supply: its importance to public health and safety, and essential research questions.

This paper seeks to identify the main questions which have emerged from the preceding papers concerning the supply side of alcohol. On any rational analysis these issues are of thoroughly legitimate concern to public health researchers. We list them under seven headings: (1) what drives the alcohol supply side? (2) What is the impact of alcohol supply on demand? (3) What are the benefits and risks to health and safety stemming from deregulation and what are the possibilities to avoid negative effects? (4) What is the size and significance of the alcohol supply which may derive from other than the officially approved channels? (5) Who are the important actors in the alcohol supply system? (6) What are local influences on alcohol supply and its distribution throughout communities? (7) What is to be learned from tobacco and other risky commodities about the importance of supply? Finally, we outline a series of possible next steps for a supply side initiative.

The cost offsets of alcoholism treatment.

While the effectiveness of alcoholism treatment is an important concern in alcohol research, the cost of such treatment and its benefits are also important research matters. There is substantial research that examines the possible benefits of alcoholism treatment in reducing the cost of all medical care, including the cost of alcoholism treatment itself. This is referred to as cost offsets. This chapter reviews the research evidence of alcoholism treatment cost offset, that is, the ability of alcoholism treatment to reduce the cost of medical care of persons participating in such treatment. The chapter gives an overview summary of the cost offset findings for alcoholism treatment and concludes with an identification of future research needs and opportunities, especially surrounding the popular increase in the use of managed care.

Actual and estimated replication costs for alcohol treatment modalities: case study from Project MATCH.

OBJECTIVE: As a first step in a thorough cost-effectiveness analysis of a randomized alcohol-treatment-matching trial (Project MATCH), the present study examines the relative costs of three manual-guided, individually delivered treatments and the costs of replicating them in nonresearch settings. METHOD: Costs of delivering a 12-session Cognitive Behavioral Therapy (CBT), a 4-session Motivational Enhancement Therapy (MET) and a 12- session Twelve-Step Facilitation (TSF) treatment over 12 weeks were assessed for three treatment sites at two of the nine Project MATCH locations (Milwaukee, WI, and Providence, RI). Research cost calculations included clinical, administrative and training/supervision variables in determining total treatment costs, average cost per contact hour and average cost per research participant. Investigators from all nine MATCH locations estimated direct clinical costs, administrative overhead costs and training/supervision costs for replicating these treatments. RESULTS: For Project MATCH, MET cost twice as much or more per patient contact hour (mean = $498) than CBT (mean = $198) and TSF (mean = $253) but was less costly per research participant (mean = $1,700) than both CBT (mean = $1,901) and TSF (mean = $1,969). For clinical replication, high end per patient costs ranged from $512 for MET to $750 for TSF to $788 for CBT: a cost savings for MET of $238 (32%) over TSF and $276 (35%) over CBT. CONCLUSIONS: As part of a randomized clinical trial, MATCH treatments are costly to produce. However, when estimates are used to project these costs to nonresearch clinical settings, the costs are greatly reduced. Whereas MET appears to be much less costly to deliver in nonresearch settings than the other two treatments, the estimated cost differentials are less than the 1:3 treatment session ratio for MET versus TSF or CBT.

Planning for alcohol-problem prevention through complex systems modeling: results from SimCom.

This article describes a computer-based model of alcohol use and misuse intervention called SimCom. This generic model, based on the best available scientific knowledge, incorporates eight interaction subsystems. When loaded with actual data from a locality, the model has the ability to "act like" this location and can be used to forecast the future effects of alternative prevention strategies. The article describes benchmark testing of a model for the state of California, including projected prevention strategies for that state.

Science and alcohol policy at the local level: a respectful partnership.

This paper describes the working exchange between scientists who designed a three-community prevention trial in the United States (1990-95) to reduce alcohol-involved injuries at the community level, and community organizers and local policy-makers in the experimental sites. We found that researchers brought scientific knowledge of potentially effective alcohol policies but had no experience with the local culture, priorities or processes; conversely, community organizers understood the local situation but were not knowledgeable about prevention strategies which, based on prior evidence, could work. We also found that communities are interested in science to aid the selection of local alcohol policies, but scientists do not understand local dynamics well enough to direct the implementation of these policies. This case study showed that both groups must respect each other and seek ways to work together for the mutually desired outcome of effective local prevention.

Altering alcohol price by ethanol content: results from a Swedish tax policy in 1992.

In July 1992, the Swedish alcohol retail monopoly reset the taxes for alcohol sold in state stores according to absolute alcohol content. This provided a unique opportunity to examine the effects on alcohol sales within the three beverage classes (beer, wine and spirits) in a situation where price is purposely linked to alcohol content. The most notable effects of the taxation change were a substantial compression of the range of prices for spirits and wine and a corresponding expansion of the price spectrum for beer. Consumers appear to have responded to these tax changes by shifting away from beverage brands that became relatively more expensive. These results suggest that alcohol policy strategies to reduce total alcohol consumption should consider the entire price/quality spectrum as well as differences in absolute alcohol per volume across the three alcohol beverage types.

A community prevention trial to reduce alcohol-involved accidental injury and death: overview.

The 5-year "Preventing Alcohol Trauma: A Community Trial" project in the United States was designed to reduce alcohol-involved injuries and death in three experimental communities. The project consisted of five mutually reinforcing components: (1) Community Mobilization Component to develop community organization and support, (2) Responsible Beverage Service Component to establish standards for servers and owner/managers of on-premise alcohol outlets to reduce their risk of having intoxicated and/or underage customers in bars and restaurants, (3) Drinking and Driving Component to increase local DWI enforcement efficiency and to increase the actual and perceived risk that drinking drivers would be detected, (4) Underage Drinking Component to reduce retail availability of alcohol to minors, and (5) Alcohol Access Component to use local zoning powers and other municipal controls of outlet number and density to reduce the availability of alcohol. This paper gives an overview of the rationale and causal model, the research design and outline of each intervention component for the entire prevention trial.

Community mobilization: evaluation of an environmental approach to local action.

"Community mobilization" in the Community Trials Project refers to organizing community members to support and implement policies to reduce alcohol-involved trauma. This paper defines the conceptual model of mobilization used in the project. In evaluating the project, we were guided by the conceptual model and we used structured materials from interviews with local staff in all three experimental communities; we found that the overall goal of mobilization (implementation of policies) was achieved. Additional observations based on naturalistic case studies of the communities include: (1) the importance of an established research base, (2) the varying role and problematic nature of coalitions, (3) the strategic advantage of early project support among the general population, (4) the role played by key leaders in mobilization, (5) the advantages of a multi-component design, and (6) the key role played by media advocacy.