Implementing prevention interventions Prevention paradox Diffusion of preventive interventions

Here we see the continuum of alcohol involvement represented again. Note that the notions of Problem Drinking, and alcohol-related disabilities extend into the moderate drinker group. The Institute of Medicine, in a 1990 report, estimate the ratio of problem drinkers to alcohol dependent individuals to be 4:1. As it turns out, a large part of the social burden from alcohol use comes from moderate drinking. . . Let me show you how that plays out in a couple of ways.

Alcohol costs American businesses billion per year in productivity losses Mangione et al. (1999): 60% of the negative impact of alcohol at the workplace is caused by moderate drinkers, the 80% of workers who are not dependent on alcohol but who maybe drink too much at lunch, or drink heavily the night before work

Percent of + BACs by drinker type, and absolute numbers of + BACs This is a graph representing a sample of people who went to an Emergency room in CA with an injury. The BARS group people into drinker types (infreq, light, mod, heavy) and show the percentage of each drinker type that came in with an injury and a positive reading on the breathalyzer test. As you can see the likelihood of a positive blood alcohol concentration (BAC) increases as you move from infrequent drinkers to heavy drinkers. However, the line indicates that absolute numbers of injuries that were associated with positive BACs, and the largest number of them came from the moderate drinking group. Note that 15% of 440 people is a lot more than 21% of 201 people. One inference that can be drawn here is that individual risk of alcohol-related injury increases with heavier consumption patterns, but the greatest impact of alcohol-related injury on this Emergency Room came from the many more moderate drinkers.

At age 17 binge drinking was common: Romelsjo & Danielsson (2012): Does the prevention paradox apply to various alcohol habits and problems among Swedish adolescents? European Journal of Public Health. The bottom 90% accounted for the majority of alcohol problems reported (61%-77%) At age 17 binge drinking was common: 89% boys 82% girls Many in the bottom 90% reported binge drinking

Prevention Paradox Heavier drinkers are responsible for large numbers of problems per person, but they are a relatively small group Heaviest drinkers account for a small fraction of the total alcohol problems experienced in a population The majority of problems can be attributed to light- moderate drinkers Prevention efforts should target light-moderate drinkers Media : raise awareness of link between low levels of consumption and harms and promote harm reduction Environmental strategies: limit access to and availability of alcohol, increase price, limit advertising Harm reduction/prevention strategies to reduce risk of harm despite drinking .. .

Rose’s theorem "a large number of people at a small risk may give rise to more cases of disease than the small number who are at high risk". Corollary: small changes by many people can have population impact Geoffrey Rose, 1992 book "The Strategy of Preventive Medicine". Small intervention on large numbers (vaccinations) can have big impact on PH a preventive measure that brings large benefits to the community may offer little to each participating person. For example, to prevent one death due to a motor vehicle accident, many hundreds of people must wear seat belts.

Prevention interventions are adopted slowly because: rewards are delayed risks are probabilistic rewards are intangible

Diffusion of preventive innovations (Rogers, 2002, Addictive Behaviors) uptake of new interventions more likely if: perception of advantage relative to alternatives   compatible with context simple to understand and implement options for pilot testing effects are observable

Dissemination suggestions (Rogers, 1995, 2002; Sobell, 1996) ask questions that are informed by campus partners (community-based participatory research, market analysis) make a case for the relative advantage of prevention interventions find/develop champions or opinion leaders who use personal influence to encourage adoption package evidence base to facilitate use by adopters (reviews, fact sheets, manuals, websites like EBBP.org) mobilize peer networks to change system norms regarding prevention interventions conduct dissemination research (e.g., Implementation Science)