Transcript
Page 1: Reducing Alcohol Problems through Community Action Research Projects: Contexts, Strategies, Implications, and Challenges

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

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

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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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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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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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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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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 of specificity, and complexity or degree of interconnectedness of the goals and objectives. This diversity is also reflected in the operational models of these projects-how they are structured and the roles and func- tions of key participants.

From the traditions and experiences of regular programming and pre- vention planning the goals of capacity development are brought to the table-through an emphasis on staffing, resource allocation, training and in-service modules, sustainability, and prevention-oriented activities that meet local needs. To the extent that policy change is a focus of the project, one can expect that interim goals will be oriented to procedures and pro- cesses, and an examination of windows of opportunities where there is a convergence of problem identification, political opportunity, and advice on policy change (Kingdon, 1984).

Different research traditions also bear on the development of project goals. A positivist orientation is likely to stress reduced problem rates as

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outcomes, and measurable “dependent” variables as operationalization of these outcomes. However, traditions oriented to interactive understanding are likely to place greater emphasis on process knowledge, qualitative meas- ures, and the illumination of the richly diverse experiences of project parti- cipants (see Hilton, 1993; Casswell, 1995). A variation in goals is alluded to in Stanley’s (1998:4) listing of “three major outputs from research in the health field: research that tells you who to blame; research that tells you how bad the victims are; and research that gives the oppressed evidence-based options.” The latter has greater relevance to population-based community action research, since it implies that information on procedures, systems, policies, and processes is more highly relevant to effective population-based prevention than is information about perpetrators or victims.

A common admonition to choose a few straightforward goals-which seems both reasonable and sensible at the outset-is easily confounded once project champions, funders, planners, and implementors get down to the business of drawing together perspectives that are probably not fully com- plementary. There is no “off the shelf” solution to matching prevention and evaluation/documentation goals without threatening to take the energy and creativity out of the best of the former, or compromising objectivity and rigor in the latter (see Hilton, 1993; Wagenaar, 1996). Nevertheless, these projects provide the potential for a matrix of complementary goals. Selection or rejection of goals typically involves a balancing act between theoretically and empirically based criteria, including evidence of what is desired and needed in local contexts, interventions that are currently popu- lar although not necessarily proven, and personal agenda of those who have special influence in the goal-setting procedures.

Time. Some will be early stage goals to signal that progress is being made in key areas; others will focus on more immediate postproject out- comes; and still others about longer-range impacts once the formal phase of the project has been completed.

Players and Participants. Community coalition members, community- based practitioners or activists, and researchers or project sponsors are likely involved for different reasons. Some participants will be oriented more to outcomes, others to process experiences during the project (e.g., capacity development), and others to postproject developments (e.g., insti- tutional change arising from the project, impacts of dissemination activ- ities). The ideal arrangement involves participants with different skills and interests taking the lead of certain goals while concurrently supporting all of the goals as members of the project team.

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Type of Knowledge. These goals might include, generically, to under- stand community experiences better, project-community interactions, the application of theory to practice, or utilization and dissemination of project findings. The potential for interaction is great: knowledge in one area has clear implications for another. For example, documentation of the project- community interactions during the project is relevant to a dissemination of project findings.

Commitment to Goals asTeam-Building

Organizing multiple complementary goals and building strong intra- team support for this matrix of project goals requires that sufficient atten- tion be given at the outset to structure, responsibilities, and roles. Function and form interact, and while a simple linear or hierarchical orientation may move things forward quickly, it may only contribute to surprises or mis- perceptions down the road. A priori team-bulding activities include devel- oping a structure and enhancing role definitions that involved appreciation for all the goals, and commitment to whole projects. An explicit discussion of key and secondary goals, and areas of convergence and divergence of the timing of goals or their importance would appear to be an important part of these early deliberations.

A case can be made for having relatively few goals. This will likely require some difficult decisions regarding special interests of local supporters and/or project participants; however, this has the clear advantage of redu- cing the demands on prqject staff with regard to nonessential agenda, facil- itating the measurement of project impact, and increasing the clarity of what can be said post hoc about the project impact. Having relatively few goals will also enhance the linkage between outcomes and process documentation and evaluation, and thus the practical generalizability of project experiences.

PROJECT DESIGN

The development of community action research projects requires a mix of input from researchers, community activists or prevention facilitators, and key community stakeholders. Regardless of the level of involvement of these groups, the development of a project model is an important initial step in project construction. By drawing attention to the rationale and objectives, a program logic model is a powerful tool for developing the project’s overall framework (Rush and Ogborne, 1991; Ogborne and Rush, 1994). This is a generic model that has been shown to be useful in planning and evaluating a wide range of health care and other types of

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programs. It is designed to draw attention to a program’s underlying assumptions. For each of the components of a program or prevention activ- ity, the following five dimensions are specified: implementation/means objectives, outputs, short-term outcoine/ends objectives, intermediate out- come/ends objectives, and, long-term outcome/ends objectives (Ogborne and Rush, 1994:61-62).

Logic models elucidate relationships between project evaluation ques- tions, outcomes, and related project interventions. As the project evolves from basic development by the project team through to implementation in the community, numerous iterations of the logic model should be developed. The development of a project logic model can help project participants operationalize their views about causal relationships and program solutions. Depending on the level of community involvement expected in different stages of the project, the team may consult with the community participants on the entire model or only particular aspects.

Lessons learned from the Midwestern Prevention Project (Pentz, 1994) provides examples of person. situation, and environmental level factors that required attention when developing a project’s model. Problems at the person level include:

The level of use may be too low to detect at the early phases of the evaluation Assumptions about the developmental course of drug use need to be considered when developing an analysis model Maturation of the population may result in transitions in program effec- tiveness Population movement may require adjustments in measurement tech- niques.

Problems encountered at the situational level include:

The changing nature of the environment possess a number of problems including:

Distinguishing between developmental and intervention effects Assessing the true effect of program mediators.

Variation in the readiness of communities to adopt an intervention Different rates of adoption and implementation of interventions by community groups Changes in the demographics of a community and its organizations over time Identifying which community factors may independently contribute to changes in alcohol use.

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Pentz (1994) presents solutions for addressing these problems in the evaluation design. Though these are beyond the scope of this paper, plan- ning a meaningful evaluation requires assessing whether factors such as these will affect the outcome of a program and how appropriate strategies can be used to overcome them. Rush and Ogborne’s (1991) discussion of the role of logic models in program planning and evaluation delineates the stages of model development and application and can help the research identify confounding factors such as those revealed in the Midwestern Prevention Project.

Number and Type of Settings-Context

The number and type of settings is dependent on the scale of the environment for prevention efforts and the time allowed-by funding or bureaucratic support arrangements-to implement, monitor, and evaluate intervention activities. Fewer and smaller setting are more suited to efforts directed toward smaller scope and short-range interventions (Holder and Howard, 1992). Interventions directed toward a whole community require a longer time frame as well as the participation and support of public agencies and institutions (Holder et al., 1997b; Wagenaar et al., 1996, 1998). The introduction of new policies and procedures for preventing alcohol-related problems is suited to longer range and larger projects and also require different organizational structures than targeting a particular problem loca- tion or short term issue. Large demonstration projects such as Community Mobilizing for Change (Wagenaar and Perry, 1994; Wagenaar et al., 1996) and the Community Prevention Trial to Reduce Alcohol Involved Trauma (Holder et al., 1997b) involve not only a wide range of community organi- zations and agencies, but may also involve a large number of communities.

The number of settings targeted for prevention activities is dependent, in part, on the resources available to the project-including financial resources as well as other types of resources, such as social support, volun- teer service by community members, political facilitation, and “in kind” institutional commitment. Recent large-scale demonstration projects have obtained sufficient external funds to enable project participants to involve multiple communities in randomized control trials. Furthermore, the insti- tutionalization of planned interventions has led to the establishment of overhead charges, which can be quite high and benefit the institution apply- ing for public funds-e.g., government agency or private foundation-but may not necessarily benefit the identified focus of the prevention activities.

Comparison across and between intervention and control communities presents many challenges to the analyst and requires sophisticated evalua- tion plans (Pentz, 1994). There are a number of challenges related to match-

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ing: the variables selected for matching at the outset of the project may turn out, in hindsight as the study evolves, not to be the most central to evaluat- ing the unique impact of an intervention; community leaders in “experi- mental” communities may turn out to be particularly interested in interventions that are not amenable to the “reach” of the evaluation proto- col; or “control” communities may develop unique interest in the alcohol- related problems in their jurisdiction once the project gets underway. Due to the complexity of the design. planning, and evaluation components of mul- tiple site projects, single community time series evaluation strategies are also recommended for evaluating the effectiveness of prevention efforts (Holder et al., 1997b).

Selection Methods

Community action research projects for reducing alcohol-use-associated problems are often initiated in response to conditions present in a com- munity. Local leaders or persons active in prevention may seek support for their efforts, and/or outsiders with connections to the community or resources will seek to work in communities where the potential to achieve prevention goals is great. The community has frequently been motivated to become involved in a project in response to a specific alcohol-use-related problem or event. A predetermining factor for community selection may be the interest of local agencies and/or coalitions. These mobilizing conditions not only engage the community but are also necessary for successful plan- ning and development of intervention strategies. Given the responsive nature of many community action research projects to reduce alcohol-use- related problems, it is rarely appropriate or practical to select intervention sites randomly. However, in order to evaluate the effectiveness of projects, researchers may choose to select a control or comparison community based on matching criteria. In such cases it is important that the matching vari- ables are highly correlated with the outcome of the intervention (Koepsell et al., 1995). Nevertheless, at some level there is a somewhat arbitrary aspect to the designations of “intervention” and “comparison” communities since, for example, it is difficult to isolate the intervention of the project from ongoing secular changes or prevention activities that get underway in “con- trol” communities during the time frame of the project.

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ALCOHOL-USE-RELATED PROBLEM IDENTIFICATION STRATEGIES

Relevance of Local Concerns

Large variations exist in the degree of community involvement in iden- tifying problems and in community and problem-appropriate interventions. Such variations stem from different approaches to community action research and a project’s desired outcomes. These variations are evidenced in the extent to which the goals of a project are operationalized along a continuum from mobilizing a community to that of initiating changes intended to reduce alcohol-related problems to that of reducing a specific alcohol-related problem. Regardless of the ultimate goal, program success is dependent upon a cooperative process of problem identification that may require numerous iterations during the course of a project. Where feasible, the identification of local policy arrangements, drinking practices, key dimensions of local “drinking cultures”, and drinking-related problems should be based on several sources such as surveys, interviews with com- munity representatives, archival data, and official statistics as appropriate. This information will be particularly useful in setting priorities and focusing on issues, structures, or arrangements that generate a large number of ser- ious problems related to drinking, and where the potential for measuring impact is high.

Epidemiological Research-Design/Theoretical Basis

Identification of community events and environments that are associ- ated with alcohol-use-related problems offers project participants an empiri- cal basis for what problems exist in the community. Such information supplements views by community members and other project participants since it can provide a basis for reaching consensus on the causes of alcohol- use-related problem(s) and the relevant approaches to reducing the prob- lem(s). Obtaining epidemiological verification provides justification for pro- ject implementation, helps to target program activities to community-based alcohol-use-related problems, and provides baseline data for monitoring the effectiveness of interventions. The data may include archival information that is collected in a routine way by various government agencies. The initiative will likely also require data that are uniquely collected for the project, such as survey data (e.g. Allen et al., 1998; Giesbrecht and West, 1997); special tabulations by law enforcement, emergency service, or health authorities; or ethnographic observations.

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Sources of epidemiological data should be obtained from national, state, and/or local sources. Many factors collectively contribute to alcohol problems, therefore developing solutions requires identifying possible causal factors and the sources of empirical data concerning the causes. A major challenge for the project team is obtaining local data. However, the level of local agency’s cooperation in this facet of project planning can serve as a key indicator of community mobilization.

Gruenewald (1997) provides an extensive review of the types, sources, and management of epidemiological data for community prevention pro- jects. Focusing on areas affected by alcohol use, this author provides details on the sources, expected geographic specificity, expected periodicity, and rational and limitations of using indicators. The major areas included are crime, health, education, the economy, demographics, and politics. Furthermore, consideration is given to community indicators and survey data that will complement archival sources.

Prior to planning the evaluation component of a community action research project. it is critical lo determine the relevant indicator data as well as their range and quality. Where information or resources for collec- tion are limited, i t is critical to evaluate the trade-offs involved in collecting one type of data over another. As one progresses to smaller geographical areas, the uniformity and availability of data decrease, the stability of the measures declines, the ability to measure accurately the impact of interven- tions decreases, and the sensitivity and relative cost of data collection increases. Developing a detailed project plan in which appropriate indica- tors are identified will guide team members in their decisions regarding the level of geographical unit chosen for a given measure.

EDUCATION AND IN FORMATION Dl SSEM IN AT ION

The education and information dissemination components of com- munity action research can be viewed as serving two functions: as an integral component of the intervention and as part of the functional design of the project. As part of the intervention, dissemination of a project’s intentions, goals, and achievements in a community serves to (a) inform the community of alcohol-related problems and how they affect the community; (b) engage Community involvement in project activities; and, (c) counterbias incom- plete or otherwise problematic alcohol-related messages in the media. Education and information dissemination in project design are key to mon- itoring the ongoing activities in the project, for identifying the need for project modifications, and for mobilizing project participants to carry out the project’s activities.

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A substantial part of the information disseminated during the project is likely generated from the evaluation component of the project: formative, process, or outcome evaluation. Therefore, it is important to plan the dis- semination strategies carefully along with the evaluation plan, taking care that the information to be disseminated does not overstate the project’s goals or accomplishments nor reflect poorly on the community or its mem- bers. Identifying appropriate channels and time lines for dissemination should also be a part of developing the project plan. As part of the inter- vention, the appropriate medium will depend upon the number and size of communities participating in the project. Monitoring project time lines deserves special consideration. Providing quick feedback to project partici- pants is critical for keeping the project on track and moving forward.

SOCIAL CHANGE MODELS AND CONCEPTS Developing aTheoretical Base

Community-based action research in the alcohol area is not known for the explicit presentation of social change models and exploration of the same through community trials. Different perspectives of community action are evident, but it is difficult to point to several overarching models of social change that are exemplified in the orientations and action plans, or tested through the trials. This situation likely reflects the diverse traditions of the field, as well as the relatively low priority placed on conceptual work. One signal is the seemingly high priority that is placed on specialization and techniques as solutions, with much less consideration given to concepts and social change models that should guide the application of techniques that are useful to enhance effectiveness, as well as pinpoint measurement of out- comes.

There are intercontinental differences, as well as differences related to the size and source of funding of projects. European projects seem to place greater emphasis on conceptual positioning of their work (Giesbrecht and Rankin, 1997), and projects that are largely funded by granting agencies requiring elaborate research proposals, such as the US National Institute of Alcoholism and Alcohol Abuse (NIAAA), will require the team to provide considerable detail about the proposed intervention, the rationale for and expected interrelationships of specific components, and offer a logical and literature-linked basis for expecting the intervention to work. However, if effective action is perceived to be somewhat detached from theory, or even hampered by theory, then theoretical-based approaches may be considered a liability (see Stoil and Hill, 1996:7).

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Nevertheless, some interesting tendencies are emerging. There is increas- ing evidence of efforts to move beyond individually oriented and educa- tional or information dissemination-dominated approaches that were strongly in evidence in the earliest community trials focusing on cardiovas- cular risks (see Shea and Basch, 1990; Hyndman et al., 1992; Holder and Howard, 1992). The drinking context and selling distribution environments have become central foci in number of projects as well as in routine com- munity-based programming (see Giesbrecht et al., 1990a; Greenfield and Zimmennan, 1993).

Second, interventions are oriented not only to the “heavy drinkers” per se, but to the regulations, procedures, and interinstitutional arrangements that allow for illegal distribution of alcohol to minors or intoxicated per- sons, or encourage “high-risk’’ drinking. Thus, recently community-based research places a much greater importance on the impact of policy changes than was the case some years ago, particularly in North American trials (Gliksman et al., 1995; Hingson et al., 1996; Holder et al., 1997a, 1997b; Wagenaar and Perry, 1994; Wagenaar et al., 1996).

A third tendency involves the elaboration of possible independent and intervening variables. particularly among large-scale community-based pro- jects (e.g., Romelsjo et al., 1993; Holmila, 1997b; Holder et al., 1997a; Wagenaar et al., 1996). In some cases this involves a range of levels of specificity (individual, small group, community, and extracommunity levels). It also reflects an evolving appreciation of the range of factors that contribute to population level drink-related risks, and at the same time offers a rationale for more extensive and fine-tuned evaluation.

The first two developments noted above have been informed, in part, by the distribution of the consumption model and research pointing to the relevance of alcohol availability and control policy to drinking rates and levels of problems (see Bruun et al.. 1975).

Variation in Community Action Models

The projects also differ with regard to community action models. For example, several models of community action were in evidence in papers presented at the second symposium in this thematic series of symposia of the Kettil Bruun Society: a “grass-roots” model linked to revolution or protest; a second approach involves working through the existing community struc- ture such as the mayor and elective representatives; a third is oriented to working with local professionals “in which the ordinary community mem- bers tend to be defined in a passive role”; and a fourth involves the use of “money from the outside as the crystallizer of community action” (Room, 1993; 247-249). In practice. these are not mutually exclusive orientations. In

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some large-scale projects one can see implicit combinations of such approaches: for example, public protest of servinglselling practices to minors, working with existing power structures to bring about a change in problem control, and using “outside” money to cover some of the coordi- nation and development costs.

Other conceptual work has focused on some specific aspects of preven- tion activities. Social marketing has been used as a way of defining the focus/target group and promoting the prevention activity, and more recently media advocacy has been increasingly included as part of a general preven- tion strategy (see Reynolds, 1993; Holder et al., 1997a).

Suggested Foci for Conceptual Work

A critical look at the concepts and theories used would seem to be an important priority in this field. Conceptual grounding will facilitate prepara- tion for project implementation, enhance our interpretation of impacts and implications, focus dissemination efforts, and position the generalization of project results. Given the contexts and goals of these efforts, project teams might be expected to provide a conceptual perspective about the (a) the nature of communities; (b) the nature of organizations, systems, and their operation; (c) perceived causes of alcohol-use-related problems under con- sideration; and (d) social change and prevention. With regard to the topic of social change and prevention, a particularly useful undertaking at the outset of a project is to explicate the following:

What model of community action is under consideration? Which organizations, groups, or types of individuals are expected to play key roles in facilitating or blocking the community action under considera tion? What combination of players or coalitions is expected greatly to enhance the potential for achieving the desired goals? Who/what is likely to interfere with and/or inhibit planning, implemen- tation, and assessment; and Under what conditions are there ways for preventing, limiting, or neu- tralizing these confounding factors? What are the main components of the intervention and their relation- ship? What is the proposed optimum sequence of intervention activities? On what theory, empirical work, or other rationale is this sequence based?

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a What rationale (logic. empirical evidence. hunch) is there for expecting changes in one arena of activity (sometimes called independent or inter- vening variables) to lead to the outcomes desired (dependent variables)? What type, size, and timing of effort is expected to bring about the social/environmental changes desired?

Community-based prevention projects with an alcohol focus might also benefit from a closer look at the experiences in other arenas: cardiovascular trials, prevention and control of tobacco use or problems, and community- based improvements in the physical environment (air, water, land-use). The concepts, interventions, and action models used in these contexts offer direc- tion for the conceptual work required in the alcohol arena.

OUTCOMES AND IMPLICATIONS

A number of the challenges and lessons from these projects are drawn together in the remarks that follow, organized by referent group: popula- tion, community leaders and change agents, project team members, funding agencies, and policymakers. These groups are not mutually exclusive.

A number of projects have reported that a reduction or perceived decline in drinking-related problems is feasible in the course of several years, and that the efforts of the specific project likely had an impact on the change monitored (e.g., Hingson et al., 1996; Holder et al., 1997b, Stout, 1992; Wagenaar et al., 1996). Others reported unique changes in orientation or experiences in the intervention contexts that are concurrent with the project goals (e.g.. Casswell et al., 1989; Gliksman et al., 1995; Holmila, 1997). These changes were only achieved through a significant outlay of resources, either involving direct funding of research and coordi- nation components, or indirect support in kind through the mobilization of professional staff and/or community coalition members. It is feasible to reduce drinking-related problems in medium-sized communities through concerted, organized efforts that build on previous research and experience and involve multiple interventions with a few goals. However, we have limited information about the stability of the changes and how best to maintain the changes achieved (see Bush, 1997). Postproject evaluations also need to be conducted some years after the formal end of the project in order to see whether the initial outcomes persisted, if some were eroded, and if new positive changes emerged.

A central rationale for a potentially effective project is that the conventional ways of doing business are not sufficient in curtailing drinking-related problems. Thus, a project at

Populations.

Community Leaders and Change Agents.

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least implicitly provides a critique of the local status. A proposal to reorient how alcohol-use-related problems are managed will be rejected in some jurisdictions, and willingly accepted by others. The challenge for the com- munity leadership is to step ahead of the crowd. For the community activist the project may provide an opportunity to move from the role of critic to that of partner in the change process, including participating in task groups or committees with representatives of organizations considered to be part of the problem, and finding opportunities for honorable solutions. Projects create opportunities for new alliances and coalitions, and at least a modest fine-tuning of the conventional power landscape; thus they provide an opportunity for dialogue, collective planning, and new ways of thinking about alcohol-use-related problem management in the local community.

Many pages have been written over the past decade since the 1989 Scarborough thematic symposium (Giesbrecht et al., 1990a) about the challenges facing project teams in defining goals, combin- ing complementary perspectives and expertise, and developing effective working relationships. The implications for team members from the experi- ence to date is really not much different than it is for community leaders, although the demands on the relationships are likely more intense. The experiences from these projects point to the need to give special considera- tions to the following: a-priori planning of expectations, working relation- ships, roles, and utilization of expertise; interim arrangements for making adjustments as the team learns from practical field experience; and develop- ing a strong team commitment to all aspects of the project, even those where others take the lead or are the experts. It is unlikely that these projects can operate effectively by just bringing different people together to do business in their conventional ways. These projects demand a partial suspension of the usual ways of conceptualizing and conducting work by all key partici- pants, and require unique skills in participating in constructive ways in multidisciplinary teams.

Funding Agencies. Projects are demanding both in the resources required and in the flexibility in fiscal arrangements. Monitoring and accountablity are important, but they may also be out-of-step with the main agenda of the project, unnecessarily detracting from achieving the community-based project goals. To the extent that the projects are treated like routine work, and similarly evaluated, their potential will likely be compromised. Priority setting and community mobilization may seem arti- ficial and out-of-step with local experiences and social change models, if externally imposed time lines and conventional milestones take precedence. Single source external funding is the preferred arrangement. Multiple source funding with sponsors that have distinct agenda may require that project

Project Team Members.

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staff invest a great deal of time to trying to please multiple masters and still keep focused on the goals of the project for the community.

Current or recent projects place considerable emphasis on alcohol policy as a potentially strong lever in reducing drinking-related problems. As part of their experience, these projects point. on the one hand, to the inadequacies of the current operationalization, enforcement, or resource allocation with regard to many policies. Alternatively, they signal the potentially strong role that policymakers play in managing alcohol issues in their community. A high priority is exploring ways to increase this awareness of the potential of policies, and furthermore to develop the capacity of policymakers for making wise choices with regard to alcohol- specific policies and their enforcement.

Whether these costly and human capital intensive efficacy trials warrant further elaboration or expansion is an open question. However, encouraging national state, and provincial alcohol policies to be more responsive to public health and safety agenda is also likely to be a challenge. The advan- tages of working at the community or municipal level are several. This is where the problems of excessive drinking become real-neighbors, friends, relatives, or colleagues will likely know the family that was victimized by an assault, car crash, snowmobile, or boating tragedy linked to drinking. Also, access to levels of power, although never easy, may be less complicated and more direct at the local level. And, where national or regional governments continue to drift toward deregulation in the alcohol arena, there may be increasing pressures and expectations that the local jurisdiction must carry the lion’s share of managing and preventing drinking-related problems in our societies. This brings us back to our opening remarks about the iniport- ance of social context. A demonstration of effective local action provides a resource for adjacent cities and communities faced with similar problems. It will hopefully also provide reminders to policymakers at other administra- tive levels that prevention-oriented population-based policies are timely, effective, and relevant.

Policymakers.

ACKNOWLEDGMENTS

Suggestions by Robert Bush, Marja Holmila, and Stanley Einstein on an earlier version of this paper are gratefully acknowledged.

ALLEN, B., ANGLIN. L.. and GIESBRECHT, N. (1998) Effects of others’ drinking as per- ceived by community members. Ctm. J . Public Health 89: 337-341.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Mcg

ill U

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rsity

on

10/2

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onal

use

onl

y.

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BRUUN, K., EDWARDS, G., LUMIO, M., MAKELA, K., PAN, L., POPHAM, R. .E., ROOM, R., SCHMIDT, W., SKOG 0.-J., SULKUNEN. P., and OSTERBERG, E. ( I 975). Alcohol Control Policies in Public Health Perspective. Helsinki: Finnish Foundation for Alcohol Studies, Volume 25.

BUSH, R. (1997). Can we achieve sustainable reductions in harm in local communities? Drug Alcohol Rev. 16: 109-11.

CASSWELLS, S. (1995). Reftections on Section I . Commentary presented at the Kettil Bruun Society’s Thematic Meeting Third Symposium Action Research, Grave, Italy.

CASSWELL, S., and GILMORE, L. (1989). An evaluated community action project on alcohol. J . Stud. Alcohol 50: 339-346.

CASSWELL, S., GILMORE, L., MAGUIRE, V., and RANSOM, R. (1989). Changes in public support for alcohol policies following a community-based campaign. Br. J . Addict. 84: 515-522.

CAVERSON, R., SMYTHE, C.. DOUGLAS, R., and MITCHELL, B. (1998). Challenges Faced in Managing an Alcohol Policy Intervention in a Complex Internal and External Environment. 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.

DOUGLAS, R. (1993). Discussion. In T. K. Greenfield and R. Zimmerman (Eds.), Experiences with Community Action Projects: New Research in the Prevention of Alcohol and Other Drug Problems (CSAP Prevention Monograph). Rockville, MD: US Department of Health and Human Services.

EDWARDS, G., ANDERSON, P., BABOR, T. F., et al. (1994). Alcohol Policy and the Public Good. Oxford: Oxford University Press.

GIESBRECHT, N., CONLEY, P., DENNISTON, R. W., et al. (1990a). Research, Action, and the Community: Experiences in [he Prevention of Alcohol and Other Drug Problems (OSAP Prevention Monograph). Rockville. MD: US Department of Health and Human Services.

GIESBRECHT, N., CONLEY, P., DENNISTON, R. W.. et al. (1990b). Lessons from com- munity action research: Experiences and suggestions for future prevention projects. In N. Giesbrecht, P. Conley, R. W. Denniston, et al. (Eds.), Research, Action, and the Community: Experiences in the Prevention of Alcohol and Other Drug Problems. Rockville, MD: US Department of Health and Human Services.

GIESBRECHT, N., and FERRIS, J . (1993). Community-based research initiatives in preven- tion. Addiction 88: 83s-93s.

GIESBRECHT, N., and KRUZEL, K. (1996). The Proposed Privatization of Retail Alcohol Sales in Ontario: An Analysis of Research, Public Discussion and Policy Deliberations. Paper presented a t the Kettil Bruun Society 22nd Annual Alcohol Epidemiology Symposium, Edinburgh, Scotland, June.

GIESBRECHT, N., and RANKIN, J. (1997). Implementation and Evaluation of Community- Based Prevention Programmes-Diflerences and Similarities from European and North American Perspectives. Presented at the First European Symposium on Community Action Research Programmes to Prevent Alcohol Problems, Malmo, Sweden, December 4-6.

GIESBRECHT, N., and WEST, P. (1997). Drinking patterns and drinking-related benefits, harm and victimization experiences: Reports from community-based general population surveys. Contemp. Drug Probl. 2 4 551-519.

GLIKSMAN, L., DOUGLAS, R. R., RYLETT, M., and NARBONNE-FORTIN, C. (1995). Reducing problems through municipal alcohol policies: The Canadian experiment in Ontario. Drugs: Educ. Prev. Policy 2(2): 105-1 18.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Mcg

ill U

nive

rsity

on

10/2

6/14

For

pers

onal

use

onl

y.

Page 21: Reducing Alcohol Problems through Community Action Research Projects: Contexts, Strategies, Implications, and Challenges

REDUCING ALCOHOL PROBLEMS 51

GREENFIELD. T. K., and ROOM. R. (1997). Situational norms for drinking and drunken- ness in the U.S. adult population. 1979-1990. Addictiut7 92: 3 3 4 7 .

GREENFIELD. T. K., and ZIM MERMAN. R. (Eds.) ( 1993). Esp~rirnrxr nith Community Action Prujects: NPII. R~~.serndr in the Prrivnrion of Alcohol and O//JeV Drug Prublems (CSAP Prevention Monograph) Rockville. MD: US Department of Health and Human Services.

GRUENEWALD. P. J . ( 1997) M C ~ I . S ~ I J ' ~ J I ~ ~ f W J J f 7 7 U J l i I ~ lirdicators: A SJ..S/OJI.S Approach to Drug and Alcohol frohletJ1.Y. Thousand Oaks, CA: Sage.

HINGSON, R.. McGOVERN. T.. HOWLAND. J.. et al. (1996). Reducing alcohol-impaired driving in Massachusetts: The Saving Lives Program. A m . J . Puhlic. Health 86: 791-797.

HILTON, M. (1993). Tension in community action research: Reflections on the Conference. In T. Greenfield and R. Zimmcrman (Eds.). E.\periences n.ir/r C'omnuinir!~ Action Projects: New R~seurch in the Prcwntion ( ~ / ' . 4 I ~ ~ f i h i i / ~ i n d Other Drug Pvoh~KnJs. Rockville. MD: U s Department of Health and Human Services.

HOLDER, H. D.,. and HOWARD. .I, M. (Eds.) (1992). Comrtntnit~ Prnwi t ion Trials ,for Alcohol Pruh1eni.v: ~ e t / J f i ~ / o / ~ i , ~ i ~ ~ i i / l , w w . y . Westport, CT: Prdeger.

HOLDER, H.. SALTZ. R. F.. GRUBE. J . W., et al. (1997a). Summing up: Lessons from a comprehensive community prevention trial. Addiction 92: S253-S302.

HOLDER, H.. SALTZ. R. F., GRUBE. J. W.. ct al. (1997b). A community prevention trial to reduce alcohol-involved accidental injury and death: Overview. Arklition 92:. S155-Sl7 I .

HOLMILA, M. (1995). Community action on alcohol: Experiences of the Lahti Project in Finland. Hcu/ /h Pron?otiori In/ . 10: 283-291.

HOLMILA. M . (1997a). Introduction. In M Holniila (Ed.), Con7nlunif~. PrciieniicwJ of Alcohol Problenis (pp. 1-14). London: Macmillan.

HOLMILA. M. (Ed.) ( 1997b). C O J ? I I > J U J J ~ ~ ~ ~ Pr~vention of' Alcolrul Proh~ef1l.Y. London: Macmillan.

HYNDMAN, B., GIESBRECHT. N.. BERNARDI, D. R., et al. (1992) Preventing substance abuse through multi component community action research projects: Lessons from recent and past experiences and suggestions for future initiatives. Coiitmip. Drug Prohl. Spring: 133-164.

KINGDON, J. W. (1984). Agetulm, Al/c~rircitii~c~.\. mid Prthiic Polici~s Boston. MA: Little, Brown. KOEPSELL. T. D., DIEHR. P. H.. CHEADLE. A, , and KRISTAL. A. (1995). Invited

commentary. Symposium on community intervention trials. A H J . J . Epidenziol. 142(6): 594-599.

LANGDON, N., LANGE. McALLISTER. J. , GIESBRECHT. N.. HER. M.-H.. KOBUS-MATTHEWS, M.,

~ c l / J J ~ ? i U l ? ~ ? ~ ~ AIc(>hol Pol iq P.. and WALSH, G. (1997). Solutions Project. Re,wirch Pf~o /~muI . Toronto. ON: Addiction Research Foundation.

McALLISTER. J., GIESBREC'HT. N., RANKIN, J., LANGDON. N., and KOBUS- MATTHEWS, M. ( 1998). C(n~mutniti~ .Il/cohol Policy Soluticms. Paper presented at the Fourth S ~ ~ r ~ ~ p o s i u n i on ~ o n n ~ ~ u n i t ~ ' .-lc~lion R<J.\-ea,-ch oti the Preoentiorr ( J f ' Alcohol and Other Drug Prohlenis, Russell Bay. New Zealand, February 8-13.

MONTONEN, M. (1995). T/JP Liquor Wccks: Loml Collaboration to In/iwni the Public about Alcohol. Paper presented at thc Kettil Bruun Society's Third Symposium on Community Action Research, Grave. Italy. September.

MOSKOWITZ, J. M. (1989). Primary prevention of alcohol problems: A critical review of the research literature. J . Srutl. Alwhol 50: 54-88.

NEVES, P., DE PAPE, D.. GIESBRECHT. N.. KOBUS-MATTHEWS. M.. KRUZEL, E., et al. (1998). Comn?unities Tuke Action! Toronto. ON: Addiction Research Foundation and Ontario Public Health Association.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Mcg

ill U

nive

rsity

on

10/2

6/14

For

pers

onal

use

onl

y.

Page 22: Reducing Alcohol Problems through Community Action Research Projects: Contexts, Strategies, Implications, and Challenges

52 GIESBRECHT AND RANKIN

OGBORNE, A. C., and RUSH, B. (1994). Program logic models: Tools for program planning and evaluation. In J. Lloyd-Jones and F. Simyar (Eds.), Strategic Planning, Program Evaluation and Public Accountability ,for Health Service Professional.? (pp. 61-72). Ottawa, ON: CHA Press.

PENTZ, M. A. (1994). Adaptive evaluation strategies for estimating effects of community- based drug abuse prevention programs. J . Community Psychol. Special Issue: 26-51.

PERRY, C. L., WILLIAMS, C. L. et al. (1933). Background, conceptualization and design of a community-wide research program on adolescent alcohol use: Project Northland. Health Educ. Res. 8: 125-136.

REYNOLDS, R. I. (1993). Policy initiatives and public health research: Commentary and reflections on the day. In T. Greenfield and R. Zimmerman (Eds.), Experiences with Community Action Projects: New Reseurch in the Prevention of Alcohol and Other Drug Problems. Rockville, MD: U S Department of Health and Human Services.

REYNOLDS, R. I. (1995). Rejections on Section 2. Presentation at the Kettil Bruun Society's Thematic Meeting Third Symposium on Community Action Research, Grave, Italy, September.

ROMELSJO, A,, ANDREN, A,, and BORG, S. (1993). Design, implementation and evalua- tion of a community action program for prevention of alcohol-related problems in Stockholm City: Initial experiences. In T. Greenfield and R. Zimmerman (Eds.), Experiences with Community Action Projecrs: New Research in the Prevention of Alcohol and Other Drug Problems. Rockville, MD: U S Department of Health and Human Services.

ROOM, R. (1990). Community action and alcohol problems: The demonstration project as an unstable mixture. In N. Giesbrecht, P. Conley, R. W. Denniston, et al. (Eds.), Research, Action. and the Community: Experiences in the Prevention of Alcohol and Other Drug Problems. Rockville, MD: US Department of Health and Human Services.

ROOM, R. (1993). Tailoring programs to communities: Commentary and reflections on the day. In T. Greenfield and R. Zimmerman (Eds.), Experiences with Community Action Projects: New Research in the Prevention of Alcohol and Other Drug Problems. Rockville, MD: U S Department of Health and Human Services.

ROWE, B. H., CAVERSON, R., THERRIEN, S., BOTA, G., GIESBRECHT, N., and SMYTHE, C. (1993). Snowmobilers in a Northeasrern Ontario Community: A Survey of Characteristics. Injury ProJiles and Strategies for Injury Prevention. Report prepared by the Addiction Research Foundation and Sudbury General Hospital.

RUSH, B., and OGBORNE, A. C. (1991). Program logic models: Expanding their structure for program planning and evaluation. Can. J . Program. Eval. 6: 9S-105.

SHEA,, and BASCH, C.E. (1990). A review of five major community-based cardiovascular disease prevention programs. Part 1: Rationale, design, and theoretical framework. Am. J . Health Promotion 4: 203-213.

STANLEY, P. (1998). You Can't Liberate the Oppressed from the Castle of the Elite. Paper presented at Fourth Symposium on Community Action Research on the Prevention of Alcohol and Other Drug Problems, Russell Bay, New Zealand, February 8-13.

STOIL, M. J., and HILL, G. (1996). Preventing Substance Abuse: Interventions that Work. New York, NY: Plenum Press.

STOUT, R. L. (1992) Prevention experiments in the context of ongoing community processes: Opportunities or obstacles for research. In H. Holder and J. Howard (Eds.), Community Prevention Trials.for Alcohol Problems (pp. 121-136). Westport, CT: Praeger.

WAGENAAR, A. (1 996). Making Changes: Communities and Underage Drinking. Paper pre- sented at the Research Society on Alcoholism Annual Meeting and the International Society for Biomedical Research on Alcoholism Joint Scientific Meeting, Washington, DC. June.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Mcg

ill U

nive

rsity

on

10/2

6/14

For

pers

onal

use

onl

y.

Page 23: Reducing Alcohol Problems through Community Action Research Projects: Contexts, Strategies, Implications, and Challenges

REDUCING ALCOHOL PROBLEMS 53

WAGENAAR, A. C., JONES-WEBB. R., and TOOMEY, T. L. (1996). Communities Mobilizing /or Change on Alcohol. Paper presented at the Annual Meeting of the International Society for Biomedical Research on Alcoholism Joint Scientific Meeting, Washington, DC. June 22-27.

WOLFSON, M., and MURRAY. D. M. (1999). Communities mobilizing for change on alcohol: Lessons and results from a 15-community randomized trial. J . Community

WAGENAAR, A. C., and PERRY, C. L. (1994). Community strategies for the reduction of youth drinking: Theory and application. J . Res. Adolesc. 4: 3 19-345.

WEBER, T. R., WERELEY, T.. MclNTOSH, L., and GIESBRECHT, N. (1994). Charting Prevention Opportunities in Local Watrrwavx: A Study of Roaring Behaviour in the Greater Kingston Area) (Report). Toronto. ON: Addiction Research Foundation.

WAGENAAR, A. C., GEHAN, J. P., JONES-WEBB, R., TOOMEY, T. L.. FORSTER, J. L.,

P~~ychol. 27(3): 315-326.

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t Use

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care

.com

by

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pers

onal

use

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