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Department of Social and Preventive Medicine, Southern Clinical School, Princess Alexandra Hospital, Ipswich Road, Buranda, QLD 4102, Australia
In 1993 a rehabilitation program began which aimed to target the issues faced by rural communities in trying to reduce drink driving. The program focused on the social characteristics of small towns and provincial cities. The method used to implement it aimed to; a) create rural communities which were contextual environments that controlled drink driving was modelled on the work of Azrin; b) determine whether courts could act as catchments for systematic controlled drinking interventions and c) provide a model 12 session controlled drinking intervention within communities which had limited alcohol and drug treatment resources.
In the first 18 months of the trial it has successfully screened and educated over 700 offenders and has achieved very high recognition and acceptance levels in the communities in which it has been placed. All key stakeholders in the region have participated in program design and delivery and systematic recruitment of local educators from the widest possible range of backgrounds has meant it has reached all important sectors.
Its impact on the rates of regional drink driving convictions is reported. Comparisons are drawn between rates in the intervention region for the experimental period and the relevant state statistics for the trial period; rates of offending in a control region and re-offence rates over 4 years calculated for the cohort of all drink drivers who offended in the State during 1988.
The differential rates of road fatalities and injuries between rural and urban areas have been a continuing issue in Australian transport safety statistics. A recent analysis of the motor vehicle related mortality rates per 100,000 population in 1990-1992 provides figures which illustrate this systematic variation (Moller, 1994; p4). Using the RaRA classification (RaRA classification, 1994) the study found systematic variations of between 30.3 per 100,000 in remote (other) regions, through 19.4 in remote (major) areas to 11.4 in capital city and 13.1 in other major urban areas.
In much of rural Australia transport is characterised by a variety of environmental and personal hazards that are distinct to or more marked than those that exist in urban settings. Long distances need to be travelled and there is either less, or minimal, availability of alternate public transport. Long road trains, comparatively lower visibility of policing and in particular more restricted use of RT are further external contributors to hazard (Tucker, 1992). Personal driver characteristics including tiredness, increased speeding and decreased compliance with seat belt regulations have been also identified as contributing to the risk (Elliott & Shanahan, 1990). In addition, the prevailing association of recreational activities with alcohol (Brady, 1988) contributes to disproportionately high per capita consumption levels in rural regions (Crook and Kawalski, 1992) and increased risk of alcohol related road crash injury.
The need for a model of the social context of drink driving which moves away from the "individual deficiency" or "killer drunk" explanation has been advocated for a number of years by the American sociologists Ross (1992) and Gusfield (1985). They have stressed the need to examine the historical and normative contexts in which the behaviour occurs. Gusfield paraphrasing Ross writes of the need to examine the "cultural and social organisation in which the daily events of DUI are situated, to support and/or resist DUI".Gusfield 1985, p111). They describe a pressing need to focus on the community context of drink driving.
Azrin (1976) has examined the positive therapeutic benefits for problem drinkers where treatment focuses on modifications to the social contextual aspects of the individual patientís life rather than individualised psychodynamic influences (Brewer, 1992). Basically, this approach, which has evaluated well and appears to have enhanced effectiveness if used with disulfiram, (Azrin, Sisson, Meyers and Godley, 1982) represents an individualised therapeutic intervention which is concerned with the patientís social and relationship environment.
Another model which moves further towards the community is that developed in applied and theoretical research with delinquent offenders. In this criminology literature the role of the interaction between the person and their environment in promoting or reducing recidivism by offenders (Gottfriedson & Taylor, 1986; Geller & Lehman, 1988) is explored. It examines the positive increments to individual behaviour change which can be achieved by varying the community context in which the individual offender has to change their lifestyle patterns whilst trying to cope with pressures to re-offend. Researchers have found that predictive variance in recidivism could be increased by controlling for post release situation characteristics. Individual offenders who are relocated in socially cohesive urban communities are less likely to re-offend than those returning to destabilised or disintegrating suburbs (Gottfriedson & Taylor, 1986, p154).
There has been only very limited application of broadly based community change models to reducing drink driving in either urban or rural regions. One attempt to address the problem at a community level was conducted in New Zealand (Community Alcohol Action Programme, 1987). This involved an intensive law enforcement programme coordinated by Transport and Police Department personnel and integrated with alcohol education components run by the local health board and community action groups. This intervention was supported by the Alcoholic Liquor Advisory Council. Evaluations have been mixed (DeJongh and Bailey, 1987; Duignan and Casswell, 1987) but suggest that the intervention encountered organisational difficulties in establishing an effective coordination of the involved intersectoral agencies.
This paper describes an intervention which was based on the assumption that a collaborative social contextual approach to the problem of drink driving would have particular relevance to small rural communities with relatively closed networks.
The intervention was designed to establish and strengthen those positive influences in the community that could limit the likelihood of drinking and driving. It aimed to augment traditional rehabilitation by implementing a programme which would: a) create a contextual environment that controlled drink driving in a rural community; b) determine whether courts could act as catchments for systematic controlled drinking interventions; c) provide a model 12 session controlled drinking intervention within a community which had limited alcohol and drug treatment resources.
The issues of what is a "community", and how meaningful is the concept of "community development" are recognised as being the focus for continuing debate. In the present study community has been defined geographically and socially. It is concerned with the Central region of Queensland and it includes those persons whom Rogers (Rogers, 1983) describes as "innovators" or "early change agents", and other relevant stakeholders. There is a pervasive Australian belief that in rural communities "everyone knows everyone". What is the case is that populations are small, there are active local media outlets, stakeholders and opinion leaders are relatively easy to identify and it is possible to conscribe the area or jurisdiction which is encompassed within the socially experienced community. The model describing the key stakeholders concerned with drink driving is presented in Figure 1.
The Central region of Queensland is the Australian rural community in microcosm in that it includes both dry inland and coastal farming areas, a number of very large mines, a mining related industrial centre and port. It has regional offices for Police, Health, Education and Corrective Services, a University College and an established Technical and Further Education system (TAFE). It has a relatively small and widely dispersed population, limited professional resources and comparatively high rates of motor vehicle accidents and drink driving convictions. It has a population of approximately 281,783 on the 1991 census and in 1988 approximately 1,040 drink driving offenders at >.15 were convicted. (Sheehan, Steadson, Davey and Schonfeld, 1993).
The design of the programme actively involved community representatives in the following tasks which were designed to influence community mores:
Local Police, Transport staff, Magistrates and Corrective Services staff were actively involved in the development and the specification of the examples and stimulus materials used in the programme. The audio-visual and video resources for the programme were produced at the regional T.V. station by the local T.V. personnel. Materials and advice given by the local Transport and Police staff and Magistrates and the local staff of the State Emergency Service were used in the production of the completed resources.
Systematic feed-back sessions were held with the local facilitators who taught the programme at all stages of the development of the package. Feedback was also obtained from offenders on the content of the programme and both groups were encouraged to see themselves as participants working to reduce drink driving in the community.
The process of implementation was discussed and developed in close consultation with the Magistrates and staff from the Corrective Services, Police Service and Transport Department officials. In addition discussions were held with all local legal officers and solicitors. These people and all police stations in the region were sent continuing up-dates on progress and posters and informative material for waiting rooms etc. All major employers were visited and their support for work shift changes for employees who elected to complete the programme sought and obtained. All active regional Union Officers were advised about the programme and sent up-dates as it progressed. The television and print media were consistently involved in all stages via press releases, interviews, ministerial launchings etc. It is also the case that all court outcomes are reported in the local papers in the Central region so that the advent of an innovative sentencing initiative was well publicised.
The programme is taught through the local TAFE Colleges in the region which have a highly visible profile in the small rural communities. The programme is conducted in regular class rooms so that offenders and facilitators are rubbing shoulders with other students and staff working on other courses. This TAFE involvement is an important component, because it coincidentally raises the issue of drink driving and its aftermath to the young persons who make up the majority of TAFE students. It also reintroduces most of the offenders to an educational environment which may stimulate their interest in continuing education.
Regional liquor outlets were also advised about the programme and a campaign initiated to encourage as many of these as possible to introduce breathalyser machines to their premises to assist offenders and reduce community offending. This component has had only limited success though the proprietors are aware of the programme.
The facilitators of the programme are selected from persons who respond to advertisements placed by the project team in the local regional newspapers. At the time the programme commenced there were very few qualified counsellors or professionals with psychological qualifications in the region and those available were heavily over-committed to other areas of mental health work. A decision was made to design the programme within a tightly structured framework and to enlist persons with past experience in group work or community service as facilitators. Selection criteria were developed which effectively screened people into these positions who might be characterised as "opinion leaders". Almost without exception facilitators have had experience in club or sport administration or have been or are in active community service positions. Most have degrees though only a minority to date would have qualifications in psychology or social work. Many are high school teachers or health workers. The work backgrounds of some of the 60 facilitators employed to date are: Community Health Nurse; TAFE Teacher; Principal Secondary School; Retired Police Officer; Taxi Driver; Family Services Officer; Proprietor - Small Business Driving School Proprietor; Director - Day Care Centre; Secondary School Teacher; Primary School Teacher; University Lecturer; Youth Worker; Tax Officer Defensive Driver Trainer; Physical Education Teacher; Physical Therapist; Community Development Officer; Computer Programmer; Drug and Alcohol; and Counsellor
Facilitators feel strong ownership of the programme and have considerable investment in its success. The recruiting method has provided the opportunity to influence a very wide range of persons in varying occupational groups towards more healthy attitudes. Within the social contextual model this is hypothesised to provide an opportunity to modify community mores. In order to ensure maximum community penetration of the ideas and information contained in the programme facilitators are only employed for three consecutive programmes before being given an extended break and replaced by other recruits. In this way the modified knowledge and attitudes that they have gained from the programme are disseminated more widely and ownership of drink driving prevention is spread through the community.
The model for implementation was developed in liaison with the regional magistrates. Continuing contact was maintained with magistrates during the first stages of implementation and contact and feed-back continues. The magistrate describes the programme and its requirements to all offenders and offers them the option to complete the programme at the time of sentencing. The offender is required to pay a standard tuition fee in substitution for the recommended fine. Licence suspension is unaffected and offenders are suspended for at least the statutory minimum period of time. Payment can be made in full at sentencing or over the duration of the course through the clerk of court. Courses need to be completed within the suspension period which is at least six months.
The programme has been well received by magistrates and offenders and a summary of attendances is shown in Table 1.
Programme Summary Jan 93 - May 95
Systematic checks indicate that approximately one quarter of offenders across the region will elect to complete the programme. There is considerable variation between magistrates in referring rates. Attendance rates are very high and it does provide a major health related impact on this relatively small community.
The key themes of the programme involve: a) controlled drinking; and b) separating drinking from driving; It builds on current best practice models in the areas of problem drinking and drink driving. It is not an abstinence programme though abstinence is available as an option. The programme is taught over 12 weeks in one and a half hour sessions and provides alcohol to persons who are by definition "drinkers with problems". The majority of these people would not have presented for help with their drinking if the programme did not exist. In reality it has provided a major treatment outreach to over 800 people in a rural community with limited professional resources.
The outcome evaluation of the project is still at a relatively early stage. The model for evaluation includes; a) monitoring recidivism rates over the period of the intervention in control and intervention regions; b) following up participants in the programme to monitor their recidivism rates against expected state - wide and regional rates; c) monitoring community awareness through a staged series of telephone interviews of a representative sample of community members in the control and intervention areas.
At this time data is still being collected and analysed. Regional offence rates are not available as yet. Preliminary findings from a follow up of those offenders who commenced the programme in 1993 have been obtained and compared with the re-offence rates calculated for the same period of time for the 1988 cohort of drink drivers in Queensland. Caution should be exercised because there are important methodological limitations on these comparisons which will not be discussed here. No first offender (n=139) had re-offended by October 1994. Over the same period of time 12 of the 97 multiple offenders had re-offended. Compared with estimates based on an analysis of the cohort of 1988 drink driving offenders in Queensland the programme reduction is approximately half those expected.
The community survey data is also positive. In June 1994 just over a quarter (27%) of the intervention sample approved of the use of breathalysers compared with 16% of the control sample. Approximately one fifth (19%) of the intervention region knew about a drink driving rehabilitation programme compared with 6% of the control community. Although these figures are only preliminary they are supportive.
Australian Bureau of Statistics. Unpublished figures 1991 Census (Personal Communication Brisbane office).
Azrin, N.H. (1976), Improvements in the Community - Reinforcement Approach to Alcoholism, Beha. Res. and Therapy, 14: 339-348.
Azrin, N.H., Sisson, R.W., Meyers, R. and Godley, M. (1982), Alcoholism Treatment by Disulfiram and Community Reinforcement Therapy, Beha. Res. and Therapy, 13: 105-111.
Brady, M. (1988) When the Beer Truck Stopped: Drinking in a Northern Australian Town, Australian National University, North Australian Research Unit Monograph.
Brewer, C. (1992), Controlled Trials of Antabuse in Alcoholism: the importance of supervision and adequate dosage. Acta Psychiatr. Scand. 86:51-58
Community Alcohol Action Programme (1988), Wanganui (May/July 1987); Final Report, Ministry of Transport, April 1988, Auckland.
Crook, C. and Kowalski, E. (1992), Per Capita Consumption of Alcohol across Queensland Health Regions (1989-1990); Alcohol and Drug Branch, Queensland Health.
DeJongh R. and Bailey, J.P.M. (1987), The Evaluation of Two Drink-Driving Campaigns in Wanganui, Wellington: Dept of Scientific and Industrial Research, Report No. CD2385.
Duignan, P. and Casswell, S. (1987), Wanganui Community Alcohol Action Programme. A Retrospective Process Evaluation (1988), Alcohol Research Unit, Dept of Community Health, University of Auckland, New Zealand.
Elliott, B. and Shanahan, P. Research (1990), Rural Male Drivers under 30 and Road Safety. Unpublished Manuscript, Elliott and Shanahan, Sydney.
Gottfriedson, S.D. and Taylor, R.B. (1986), Person-environment interaction in the prediction of recidivism, in Byrne, J.M. and Sampson, R.J. (eds), The Social Ecology of Crime, Springer-Verlag, New York.
Gusfield, J.R. (1985), Social and Cultural contexts of the drink driving event, Journal of Studies in Alcohol, Supplement 10.
Moller, J. (1994), The Spatial Distribution of Injury Deaths in Australia: Urban, Rural and Remote Areas. Issue 8, Australian Injury Prevention Bulletin. National Injury Surveillance Unit, Adelaide.
RaRA classification (1994). Department of Primary Industries and Energy and Department of Human Services and Health, Rural Remote and Metropolitan Areas Classification System (1991 Census), Canberra.
Rogers, E.M. (1983), Diffusion of Innovations (3rd. ed) New York, The Free Press.
Ross, H. L. (1992), Confronting Drink Driving: Social Policy for Saving Lives, Yale University Press, Connecticut.
Sheehan, M., Steadson, D., Davey, J. and Schonfeld, C. (1993), A model for an innovative community based approach to drink driving prevention and rehabilitation pp 1391-1401 in Utzelmann, Berghaus, and Kroj (eds) Alcohol, Drugs and Traffic Safety - T92 3, Springer-Verlag, Koln.
Sheehan, M. Siskind, V., Woodbury, D., and Reynolds, A. (1992), The systematic trial of an innovative community based drink driving rehabilitation programme, Report to FORS, April 1991, Drink Driving Prevention Programme, University of Queensland, Qld.
Tucker, A. (1992), Regional Director of Transport, Rockhampton. Personal Communication.
Unpublished statistics based on Queensland Transport Department records 1988, Dept of Social and Preventive Medicine, Queensland, Australia.