Reducing Alcohol Problems through Community Action Research Projects: Contexts, Strategies, Implications, and Challenges

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  • Substance Use & Misuse. 35(1&2). 31 52 . 2000

    Reducing Alcohol Problems through Community Action Research Projects: Contexts, Strategies, Implications, and Challenges*

    Norman Giesbrecht t and Judith Rankin

    Addiction Research Foundation Division, Centre for Addiction 8 Mental Health, 33 Russell Street, Toronto, Ontario, M5S 2S1, Canada

    ABSTRACT

    Community-based action research projects may include a number of challenges. The secular context may impede a project; for ex- ample, reducing aggregate rates of drinking-related problems may involve curtailing very popular high-risk drinking occasions. These projects may also embrace important but unrealistic goals, require matching competing goals emerging from multifoci project teams, o r involve convoluted funding arrangements. Attention to team development, priority setting, and project design and evaluation

    *An earlier version of a paper presented at the Fourth Symposium on Community Action Research on the Prevention of Alcohol and Other Drug Problems, Russell Bay. New Zealand, February 8-13. 1998. a thematic meeting of the Kettil Bruun Society for Social & Epidemiological Research on Alcohol. which was organized by the Alcohol and Public Health Research Unit, University o f Auckland, Auckland. New Zealand. The views and opinions expressed in this paper are those of the authors and do not necessarily reflect the policies of the Addiction Research Foundalion Division, Centre for Addiction and Mental Health. ?To whom correspondence should be addressed. Telephone: 416 535-8501 ext 6895. Fax: 416 595-6899. E-mail: norman-giesbrechkr camh.net

    31

    Copyright 0 2000 by Marcel Dekker. Inc uww.dck ker.com

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  • 32 GIESBRECHT AND RANKIN

    issues is essential. Many projects downplay conceptual issues, such as understanding the nature of communities, organizations, systems, their operation, and social change and prevention models. Focus populations, community members and leaders, change agents team members, funding agencies, and policymakers can benefit from these projects.

    Key words. Conceptual groundwork; Effective prevention; Strategic implementation; Evaluation; Feedback

    INTRODUCTION

    This paper analyzes experiences from several community-based preven- tion/research projects, mainly based in North American settings, focusing on: social context and project capacity; goals, objectives, and project roles; project design; alcohol problem identification strategies; social change model(s) and conceptual framing; and outcomes and implications. There is considerable variability across projects on these dimensions, and a number of challenges have persisted over the past decades, as noted in summary accounts from this series of thematic meetings of the Kettil Bruun Society symposia (Giesbrecht etal, 1990b; Hilton, 1993; Holmila, 1995).

    Community-based action research projects provide a unique oppor- tunity of combining the latent with the kinetic, the ongoing and conven- tional with the more novel and innovative. The time-limited nature and often unique combination of players and support groups of these projects paves the way for stepping somewhat beyond the routine and at times ponderous unfolding of bureaucratic processes and institutional responses to alcohol issues, where greater attention might be given to procedural matters than to achieving effective outcomes. If these projects are fully constrained by typical and conventional ways of conducting prevention business, their capacity to reduce drinking-related problems significantly is likely curtailed. Alternatively, if social and institutional contexts are ignored or dramatically challenged, the efforts of these unique endeavors will be thwarted and critical support withdrawn.

    SOCIAL AND POLITICAL CONTEXTS AND PROJECT CAPACITY

    Working with the Secular Context

    Potentially effective policy-oriented initiatives are likely to meet with opposition (e.g., Reynolds, 1993: 1 17). Alternatively, large-scale funding

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  • REDUCING ALCOHOL PROBLEMS 33

    for a number of projects, such as some school-based prevention efforts, may be more a signal of its perceived benign potential and political utility than its potential for change (see Moskowitz, 1989). Initiatives that are supported by community members or leadership may produce modest outcomes or equivalent results, and those that are less popular politically may neverthe- less have a high potential for success (Edwards et al., 1994).

    The secular climate is likely to influence the project design, its imple- mentation, the evaluation of process and outcomes, and dissemination potential. A crucial consideration is whether the state, municipality, or jurisdiction where the project is to be located is oriented to population- based or environmental strategies (Holder et al., 1997b)-which are oriented to reducing aggregate rates of drinking-related problems. If the dominant approach is primarily focused on the individual or the victim, this can create a blockage to broader orientations. If there have been recent movements at the local or regional level to deregulate control or increase access to alco- chol, this may prove to be a challenge to population-based prevention efforts (Giesbrecht and Kruzel, 1996). Or, if in recent years drinking-related problems are perceived to be on the increase, or decrease, this will have varying implications for prevention projects (Greenfield and Room, 1997).

    However, the political regulatory climate and social contexts are much more than umbrella conditions or constants. As noted by Room (1993: 247- 250), many projects interact with broader experiences, using this interchange to enhance their potential to achieve project goals. For example, during a period of countrywide pressures for increasing access to alcohol in New Zealand, and opposition to government intervention in alcohol control, it may be more difficult to develop wide-scale support for policy initiatives (Casswell et al., 1989). On the other hand, this social change provides a resource for generating public awareness of what is at stake. In Ontario the gradual orientation away from regulation and management of alcohol issues at the provincial level has led to constraints at what can be done in municipal contexts, but, in contrast, has also provided an opportunity for local policy development or improved enforcement (McAllister et al., 1997, 1998; Neves et al., 1998). Knowledge dissemination through liquor weeks in Finland (Montonen, 1995) offered a basis for enhancing local awareness and discussion about alcohol issues and likely facilitated a more fertile ground for the Lahti project in one city in Finland (Holmila, 1995; Holmila et al., 1997a, 1997b). In Minnesota and Wisconsin, the high rates of drinking among youth in smaller communities, combined with a general concern about adolescent alcohol use, provided a context for developing multicomponent interventions involving students, teachers, parents, and community business and alcohol-selling policies (Perry et al., 1993). Identification of drinking-related and other risks linked to snowmobiling

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  • 34 GIESBRECHT A N D RANKIN

    in Ontario (Rowe et al., 1993) provided a basis for preliminary policy initia- tives, and eventually provincewide policy work (Caverson et al., 1998). The growth of dram shop liability, high-priced legal action against licensed pre- mises, and emergence of server intervention provided a fertile ground in many Ontario communities for implementing municipal alcohol policies (e.g., Gliksman et al., 1995).

    Thus an initial, as well as ongoing, challenge of these projects is posi- tioning the project within the sociopolitical context and evolving priorities with regard to alcohol management in the jurisdiction. This includes finding a balance between, on the one hand, having project agenda being over- shadowed or controlled by secular change to, on the other, challenging local vested interests to the point where support for the proposed unique prevention efforts is eroded.

    Of critical importance is appreciating how community-based action research fits with or complements local and regional political and social developments. As noted by Stanley (1998), issues of ownership, power, degree of sensitivity to local approaches, and expertise are not only legit- imate in their own right, but how they unfold can positively or negatively impact the outcome of the project. Project participants, local supporters, funders, and other champions should be interested in what the project is all about, and are encouraged to ask questions such as the following:

    How does the proposed initiative fit with other ongoing or previous local efforts addressing alcohol issues? Have the prevention plans under consideration been shown to be more effective and relevant than what we have here already? What specific aspects of the proposed prevention have been shown to be most beneficial in other contexts? If the orientation seems to be contrary to popular views on managing alcohol problems, what is the justification? Is the proposed prevention effort based, in part, on previously evaluated interventions? Why is this being proposed at this time? Who will manage the project and what will the relationships be with local experts and leaders?

    The positioning of the project involves directing attention to three dif- ferent levels: (1) the provincial, state, or regional developments with regard to drinking promotion and alcohol problem management; (2) local orienta- tions and experiences related to both the commercial promotion as well as safety or harm reduction aspects of alcohol management, including the composition and interconnectedness of committees and informal networks or power relationships bearing on alcohol issues; and (3) the drinking cul-

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  • REDUCING ALCOHOL PROBLEMS 35

    ture in the community, or region, particularly heavy drinking patterns and practices. Different persons will have special knowledge or insight with regard to some aspects. Preliminary deliberations, planning and fact-finding that devote special attention to these topics will avoid some challenges along the way, as well as providing guidance with regard to organizing and focus- ing team efforts as the project begins to unfold.

    Developing Realistic Perspectives on Capacity

    By ignoring, or downplaying, social context, i t is likely that capacity will be underestimated. In the social and political change arena, estimating capacity is far from an exact science, and it is heavily influenced by cultural, place, and time considerations. One needs to be aware the concurrent local changes can inflate or reduce the resources needed to achieve measurable harm-reduction goals. Estimating capacity (both intraproject and through partnership arrangements) is therefore a primitive art. First, routine preven- tion programs are typically not oriented to population-level behavior change goals, which are typically more demanding to achieve than, for ex- ample, disseminating information or informing public groups. Population- level behavior change goals are those oriented to overall rates of social problems in a jurisdiction, such as reduction of drinking and driving crashes, incidents of violence, or admissions to emergency hospital services. Therefore, previous routine prevention efforts provide an incomplete and inadequate referent for estimating capacity.

    Second, even projects that are oriented to population-level changes do not typically have a tradition of process documentation, and hence do not provide a strong post-hoc resource for estimating capacity. Previous experi- ences that are most relevant are those that have documented the capacity (project participants and other resources) required in order to achieve a desired level of reduction of specific drinking-related problems in a medium-sized community over the course of several years, and an estimate of the disaggregation of the capacity for main phases or tasks of the inter- vention and the type of expertise involved. Completed projects provide a very useful reference point (Holder et al., 1997b; Holmila et al., 1997a, 1997b; Wagenaar et al, 1996, 1998) for assessing capacity. Of particular utility is systematic process documentation and evaluation about the com- munity planning, mobilization, and implementation aspects of a project. This information can provide estimates of person-days spent on specific tasks over a specific period of time with concrete results, thus offering a step forward by using empirically based methods for estimating capacity. Nevertheless, in light of cultural. temporal, and site-specific aspects of

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  • 36 GIESBRECHT AND RANKIN

    capacity, estimates derived from one setting may be unrealistic if mechani- cally projected to another context.

    Project planners have underestimated capacity in a number of ways: the length of time to achieve project goals; the demands of project implementa- tion and coordination; team commitments required; the time to develop local networks and establish partnership arrangements; and the resources required to facilitate mobilizing this potential. Capacity has many dimen- sions-for example, maintaining funding, intervention planning, training and, implementation, various types of evaluation and research activities, and dissemination activities. Some of these experiences also relate to build- ing postproject or longer-term capacity, so that the initial achievements can be more effectively sustained. Looking across to other initiatives, such as cardiovascular trials, we see that large-scale efforts do not fully achieve the desired outcomes: Finally, we must acknowledge that, despite intensive intervention efforts, the empiric evidence of program effects in these studies is quite modest was the comment by Koepsell et al. (1995:598) in reviewing several major community intervention trials.

    GOALS, OBJECTIVES, STRUCTURES, AND ROLES Finding a Complementary Matrix

    These projects draw on several traditions and typically involve planners, funders, team members, and facilitators representing a wide range of per- spectives on alcohol issues, their management and control, as well as the intersection of community action and research (e.g., Room, 1990; 1993; Hilton, 1993). This diversity contributes to the variation in the scope, level...

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