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Drinking on the Dirt Roads of America

NACCHO's Impaired Driving Prevention in Rural Communities Demonstration Site Project

Cox, Erin MSW, MSPH; Fisher, Scott MPH

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Journal of Public Health Management and Practice: May 2009 - Volume 15 - Issue 3 - p 278-280
doi: 10.1097/01.PHH.0000349743.04114.41
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Although alcohol-impaired driving fatalities have declined in many states, impaired driving remains a serious public health threat, especially in rural areas. In 2007, 12 998 people were killed in alcohol-impaired–driving crashes.1 These deaths accounted for nearly one-third of the total motor vehicle traffic fatalities in the United States. In addition, according to the National Survey on Drug Use and Health, an estimated 30.5 million persons aged 12 or older drove under the influence of alcohol at least once in the past 12 months.2

Research suggests that, because of greater distances traveled and increased reliance on automobiles for transportation, a higher prevalence of impaired driving is found in rural areas than in urban areas. Greater distances combined with fewer opportunities for public transportation increase the chances for alcohol-related crashes. In 2006, rural drivers accounted for 62 percent of drivers found to have been drinking, speeding, and unrestrained.3 Rural youth are particularly at risk. According to the National Transportation Board, more than 60 percent of youth alcohol-related crash fatalities in 2005 occurred in rural areas.4 Furthermore, for ages 12–17, the incidence of driving while intoxicated is higher in rural areas than in urban areas.5

Despite such statistics, many rural communities have difficulty implementing driving under the influence/driving while intoxicated enforcement efforts and conducting public health education campaigns because of their sparsely and geographically dispersed populations. Another obstacle to addressing impaired driving in rural communities is that rural America contains almost one of every five Americans on a land base that occupies approximately 80 percent of the nation.6

Role of Local Health Departments

Local health departments (LHDs) play an important role in the prevention of impaired driving in rural communities. As LHDs continue to expand their role in traffic safety through community education, outreach, training, and coordination of high-visibility enforcement initiatives with law enforcement, the National Association of County and City Health Officials (NACCHO) and the National Highway Traffic Safety Administration (NHTSA) have continued to support their efforts. NHTSA collaborated with NACCHO to address impaired driving through the “Impaired Driving Prevention in Rural Communities” project created to help four LHDs enhance their impaired driving prevention activities and identify strategies and approaches most suitable for rural communities. NACCHO's role was to share tools and resources, provide technical assistance to the four communities, disseminate lessons learned to all LHDs, and provide opportunities for shared learning among the demonstration sites.

Demonstration Sites

Through a competitive request-for-proposals process, Carroll and Garrett counties, Maryland; Fillmore and Houston counties, Minnesota; and Fargo Cass, North Dakota, were selected to serve as demonstration sites for the “Impaired Driving in Rural Communities” project. These communities were selected because their innovative programs used community-based approaches to focus on high-risk populations (eg, young drivers, repeat offenders, underage drinkers). These demonstration sites used evidence-based components in their prevention efforts. In particular, mass media campaigns, responsible beverage service training, and educational outreach to high-risk populations conducted in coordination with high-visibility enforcement are strong deterrents to impaired driving.7

Carroll County (Maryland) Health Department

Key elements

Carroll County's “Community Underage Prevention of Impaired Driving” (CUPID) project consisted of underage impaired driving enforcement, impaired driving prevention peer education, an adult impaired driving prevention media campaign, and alcohol screening and brief intervention training.

Lessons learned

Carroll County identified a need to better market alcohol screening and brief intervention training to healthcare providers. Although the training was well publicized and continuing education credits were offered, few providers participated in the training because they did not understand the relevance to their work. It is important to educate healthcare providers about the benefits of alcohol screening and brief intervention and how they can easily incorporate screening and intervention into their work before offering them training on the specific details of how to conduct screening and intervention. In addition, Carroll County found that having strong working relationships with the schools was extremely useful. The LHD would have had difficulty introducing the impaired driving prevention activities to schools and getting approval for the impaired driving knowledge survey without a solid partnership with the schools.

Fargo Cass (North Dakota) Public Health

Key elements

Fargo Cass Public Health's impaired driving prevention activities consisted of court-appointed victim impact panels, responsible beverage service training, and implementation of the Class Action Curriculum in high schools.

Lessons learned

Fargo Cass Public Health identified several lessons learned and suggestions for other rural jurisdictions, including a need to devote a significant amount of time to garner community support for impaired driving prevention through coalition building, education campaigns, and community surveys. Such activities are especially important if community leaders do not acknowledge impaired driving as a priority. In addition, the shortage in law enforcement personnel in rural areas can create difficulties in scheduling prevention activities when trying to coordinate with law enforcement. Therefore, LHDs should schedule activities as far in advance as possible and have several contacts within a particular law enforcement office.

Fillmore-Houston (Minnesota) Community Health Service

Key elements

The program consisted of a targeted media campaign for 21-to 34-year-olds, development of an impaired driving prevention course for repeat offenders, and a youth underage drinking educational campaign.

Lessons learned

Fillmore Houston Community Health Service identified several lessons learned and suggestions for other rural jurisdictions, including a need to incorporate the faith-based and medical communities in activities because these groups can provide medical, spiritual, and counseling services to youth and adults about alcohol use. Such activities are especially important in rural communities that have few, if any, professional psychologic or treatment services. In addition, engaging individual communities early in activities helps LHDs to determine the specific needs and issues surrounding alcohol use and impaired driving. Developing a rapport with individual communities can serve as an impetus to coalition building. Furthermore, schools should be offered a variety of impaired driving or underage drinking prevention programming options because schools often find developing new programs without the support of other partners difficult and time consuming.

Garrett County (Maryland) Health Department

Key elements

Garrett County Health Department's impaired driving prevention work consisted of responsible beverage service training, expansion of Students Against Destructive Decisions (SADD) chapters, alcohol use awareness and training activities for college students and faculty, and media support for driving under the influence/driving while intoxicated enforcement efforts.

Lessons learned

Through the LHD's impaired driving prevention activities, Garrett County identified the need for frequent alcohol license compliance checks. A high compliance rate during any one particular check did not necessarily carry over to subsequent checks. Personnel changes in establishments serving or selling alcohol and the addition of new licensees created a need for frequent checks. In addition, Garrett County identified a need to work with alcohol distributors and local retailers for any educational campaigns that involve adding prevention messages to alcohol products. LHD staff and SADD members placed alcohol prevention stickers on cases of beer, which local retail establishments were generally receptive to while distributors were apprehensive. LHD staff engaged distributors in project activities to alleviate their concerns.

Several broad themes emerged from the work of the demonstration sites, including the importance of partnerships with community-based organizations, working with law enforcement, and using the media to communicate messages. Other common themes included the importance of peer education and engaging youth in prevention activities, involving the justice and correctional systems, and the importance of health education and training. Although impaired driving prevention activities are similar between metropolitan areas and rural communities, the programs implemented by the demonstration sites differed because of the unique challenges of working in rural communities. Those challenges included large geographic boundaries and discrepancies in funding, personnel, and other resources for impaired driving prevention programs as compared with urban areas. In addition, the demonstration site communities lack many forms of public transportation, such as taxi, bus, and rail service, that LHDs serving urban jurisdictions can widely promote and use in prevention campaigns. LHDs in rural areas looking to build or enhance their impaired driving prevention efforts can learn from the demonstration sites.

NACCHO is sharing findings from the demonstration site project with other LHDs nationwide. The demonstration sites are featured in a recent NACCHO publication, Impaired Driving Prevention in Rural Communities. This compendium profiles select rural LHDs, their approaches to addressing impaired driving, successes they have achieved, and the obstacles they have encountered during program implementation. To download this compendium and to learn more about NACCHO's traffic safety efforts, visit


1. Department of Transportation, National Highway Traffic Safety Administration. Traffic Safety Facts: 2007 Traffic Safety Annual Assessment Alcohol-Impaired Driving Fatalities. Washington, DC: National Highway Traffic Safety Administration; 2008. Accessed February 13, 2009.
2. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The NSDUH Report: Quantity and Frequency of Alcohol Use Among Underage Drinkers. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2008.
3. Department of Transportation, National Highway Traffic Safety Administration. Traffic Safety Facts 2006 Data: Rural/Urban Comparison. Washington, DC: National Highway Traffic Safety Administration; 2008. Accessed February 13, 2009.
4. National Transportation Safety Board. Statement of the National Transportation Safety Board to the Regulated Industries Committee, Florida Senate on Underage Alcohol Consumption Legislation. Published 2007. Accessed February 13, 2009.
5. Substance Abuse and Mental Health Service Administration. Summary of Findings From the 2000 National Household Survey on Drug Abuse. Rockville, MD: Office of Applied Studies, National Household Survey on Drug Abuse; 2001. Series H-13, DHHS Publication No. (SMA) 01–3549.
6. Department of Agriculture. Rural population and migration. Accessed October 2007.
7. Holder H, Gruenewald P, Ponicki W, et al. Effect of community-based interventions on high-risk drinking and alcohol-related injuries. JAMA. 2000;284(18):2341–2347.
© 2009 Lippincott Williams & Wilkins, Inc.