Interventions that address interpersonal violence experienced by adolescents globally: a systematic review of reviews.

Globally, adolescents experience a significant burden of interpersonal violence, impacting their health, well-being and life trajectory. To address this, decision-makers need reliable evidence on effective interventions across various contexts. OBJECTIVES: Synthesise the evidence for interventions addressing interpersonal violence experienced by adolescents aged 10-25 years. METHODS: Six electronic databases were systematically searched. Systematic reviews and meta-analyses published globally between 2010 and 2022 were included if they reported interventions addressing interpersonal violence experienced by adolescents. Results were synthesised narratively. RESULTS: 35 systematic reviews were included, of which 16 were also meta-analyses. Majority of reviews included interventions set in high income countries (71%) and implemented in educational settings (91%). Effectiveness was reported in majority of interventions measuring victimisation and/or perpetration of intimate partner violence, sexual violence, bullying and/or cyberbullying (90%), majority of interventions measuring improvements in knowledge and attitudes towards violence (94%) and all interventions measuring bystander behaviour and improvements in well-being and quality of life. However, the quality of included reviews as per Assessment of Multiple Systematic Reviews 2 and National Health and Medical Research Council was low, and equity as per PROGRESS-PLUS was seldom considered. There was also a paucity of interventions addressing interpersonal violence in low-middle income countries (12%) and none of the included interventions specifically addressed interpersonal violence perpetrated in the home such as family violence. CONCLUSION: There is some evidence of promising interventions to address interpersonal violence experienced by adolescents, however there are gaps in scope and implementation. There is a need for equity-oriented public health approaches to comprehensively address the disproportionate burden of interpersonal violence experienced by adolescents globally, including those at the highest risk of harm. PROSPERO REGISTRATION NUMBER: CRD42020218969.

Using systems thinking to assess the functioning of an "Age-Friendly City" governance network in Australia.

Age-Friendly Cities (AFC) is a framework for promoting healthy ageing through local actions. We use systems thinking to assess potential outcomes of actions to support older people's mobility, undertaken within an AFC commitment in Greater Sydney. Interviews with 20 informants involved in providing space, infrastructure, or services that affect how older people get around were analysed using causal loop diagrams (CLDs). Four approaches to support older people's mobility were identified and situated to the Multiple Governance Framework: land use, open and public space, supplementary transport, and community transport. Analysis revealed potential for unwanted consequences associated with each, which can be generalised into three generic potential outcomes for other jurisdictions to consider. A recommendation from this research is for policy actors to examine feedback interactions between actions so that they can foresee a wider range of outcomes and take defensive action against those unwanted. By situating CLDs within the Multiple Governance Framework, this research not only identifies what to look for, in terms of potential outcomes, but also where to look, in terms of the level of decision-making. This research offers a new way to assess the functioning of AFC governance networks by their collective outcomes and challenges the standards for the evaluation of AFC.

This study uses systems thinking to assess policy actions for supporting older people's transportation mobility in Greater Sydney. These policy actions pertain to land use, open and public space, supplementary transport, and community transport. Analysis revealed the potential for unwanted consequences, which result from different actions undermining one another, systemic constraints, and failure to account for small, but important, details.

Ironbark: Developing a healthy community program for older Aboriginal people.

ISSUE ADDRESSED: Programs by, with and for Aboriginal older people must be culturally safe and relevant. Successful elements include being Aboriginal specific and group based. Co-design with Aboriginal people and stakeholders is essential. We describe the co-design process of developing the Ironbark: Healthy Community program. METHODS: Aboriginal ways of knowing, being and doing and yarning conversational methods guided the development process, during 2018. A desktop review provided details of current group characteristics and key community stakeholders. Stakeholder engagement regarding views about group operations, participants and benefits also occurred. Aboriginal Elders views of their groups were gathered through yarning circles in New South Wales (NSW). Grounded theory approach was used to ascertain key themes. RESULTS: Initial engagement occurred with 13 different community stakeholders and organisations in three Australian states (NSW, South Australia (SA), Western Australia (WA)). Three yarning circles occurred with Elders from urban (N = 10), regional coastal (N = 10) and regional country (N = 4) groups. Six key themes were organised in three groups according to an Aboriginal ontology. 1. Knowing: groups provide opportunities to share knowledge and connect socially. Adequate program resourcing and sustainability are valued. 2. Being: groups strengthen culture, providing important social, emotional and other forms of support to age well. 3. Doing: previous program experiences inform perceptions for new program operations. Group venues and operational aspects should be culturally safe, acknowledging diversity among Elders, their preferences and community control. Themes were used to develop the program and its resource manual that were finalised with stakeholders, including steering committee approval. CONCLUSIONS: Stakeholder feedback at multiple stages and Aboriginal Elders' perspectives resulted in a new co-designed community program involving weekly yarning circles and social activities. So what?: Co-design, guided by Aboriginal ways of knowing, being and doing, can develop programs relevant for Aboriginal people.

Out of the silos: embedding injury prevention into the Sustainable Development Goals.

Globally, unintentional injuries contribute significantly to disability and death. Prevention efforts have traditionally focused on individual injury mechanisms and their specific risk factors, which has resulted in slow progress in reducing the burden. The Sustainable Development Goals (SDGs) represent a global agenda for promoting human prosperity while respecting planetary boundaries. While injury prevention is currently only recognised in the SDG agenda via two road safety targets, the relevance of the SDGs for injury prevention is much broader. In this State of the Art Review, we illustrate how unintentional injury prevention efforts can be advanced substantially within a broad range of SDG goals and advocate for the integration of safety considerations across all sectors and stakeholders. This review uncovers injury prevention opportunities within broader global priorities such as urbanisation, population shifts, water safeguarding and corporate social responsibility. We demonstrate the relevance of injury prevention efforts to the SDG agenda beyond the health goal (SDG 3) and the two specific road safety targets (SDG 3.6 and SDG 11.2), highlighting 13 additional SDGs of relevance. We argue that all involved in injury prevention are at a critical juncture where we can continue with the status quo and expect to see more of the same, or mobilise the global community in an 'Injury Prevention in All Policies' approach.

Understanding implementation factors and participant experiences of a cluster randomised controlled trial to prevent falls among older Aboriginal people: a process evaluation protocol.

INTRODUCTION: Process evaluations examining programme implementation are often conducted in conjunction with effectiveness studies. Their inclusion in studies with Aboriginal participants can give an understanding of programme delivery in Aboriginal community contexts. The Ironbark: Standing Strong and Tall programme was codesigned with Aboriginal communities and includes exercise and facilitated 'yarning' discussion about fall risk and prevention strategies. The programme pilot showed favourable outcomes and acceptability for Aboriginal people aged 45 years and over. The Ironbark: Standing Strong and Tall programme is now being compared with a 'Healthy Community' programme in a cluster randomised controlled trial within Aboriginal health and community services. An embedded process evaluation aims to explore relationships between participation and programme outcomes and the quality of programme implementation. METHODS AND ANALYSIS: The process evaluation will use a mixed methods design, guided by Indigenous research methodology. It will evaluate quantitative data (number of completed sessions, site coaching checklist tool, participant and facilitator questionnaire data and a participant habit formation scale), as well as qualitative data (open-ended responses from project and site staff and semistructured interviews using yarning with study participants and site managers). A programme logic model was developed to explain the intended inputs, activities, outputs and outcomes, which guided this process evaluation design. CONCLUSION: This process evaluation of a fall prevention programme for older Aboriginal people using a mixed methods design and data triangulation will allow for a comprehensive understanding of study findings. Multiple study sites allow for generalisability of findings and exploration of variation across sites. TRIAL REGISTRATION NUMBER: ACTRN12619000349145.

The built environment and active transportation safety in children and youth: a study protocol.

BACKGROUND: Active transportation, such as walking and biking, is a healthy way for children to explore their environment and develop independence. However, children can be injured while walking and biking. Many cities make changes to the built environment (e.g., traffic calming features, separated bike lanes) to keep people safe. There is some research on how effective these changes are in preventing adult pedestrians and bicyclists from getting hurt, but very little research has been done to show how safe various environments are for children and youth. Our research program will study how features of the built environment affect whether children travel (e.g., to school) using active modes, and whether certain features increase or decrease their likelihood of injury. METHODS: First, we will use a cross-sectional study design to estimate associations between objectively measured built environment and objectively measured active transportation to school among child elementary students. We will examine the associations between objectively measured built environment and child and youth pedestrian-motor vehicle collisions (MVCs) and bicyclist-MVCs. We will also use these data to determine the space-time distribution of pedestrian-MVCs and bicyclist-MVCs. Second, we will use a case-crossover design to compare the built environment characteristics of the site where child and youth bicyclists sustain emergency department reported injuries and two randomly selected sites (control sites) along the bicyclist's route before the injury occurred. Third, to identify implementation strategies for built environment change at the municipal level to encourage active transportation we will conduct: 1) an environmental scan, 2) key informant interviews, 3) focus groups, and 4) a national survey to identify facilitators and barriers for implementing built environment change in municipalities. Finally, we will develop a built environment implementation toolkit to promote active transportation and prevent child pedestrian and bicyclist injuries. DISCUSSION: This program of research will identify the built environment associated with active transportation safety and form an evidence base from which municipalities can draw information to support change. Our team's national scope will be invaluable in providing information regarding the variability in built environment characteristics and is vital to producing evidence-based recommendations that will increase safe active transportation.

Older people's out-of-home mobility and wellbeing in Australia: Personal, built environment, and transportation factors associated with unmet mobility needs.

Out-of-home mobility is fundamental to older people's wellbeing and quality of life. Understanding the unmet mobility needs of older people is a necessary starting point for determining how they can be supported to be mobile. This study estimates the extent of unmet mobility needs among older Australians and identifies the characteristics of those most likely to report unmet mobility needs. Analysis was conducted on nationally representative data of 6,685 older Australians drawn from the 2018 Survey of Disability, Aging and Carers conducted by the Australian Bureau of Statistics. Twelve predictor variables from two conceptual frameworks on older people's mobility were included in the multiple logistic regression model. Twelve percent (n = 799) of participants had unmet mobility needs, and associated factors significant in multivariable models included being among the "young-old", having a lower income, having lower levels of self-rated health, having a long-term condition, being limited in everyday physical activities, experiencing a higher level of distress, being unlicensed, having decreased public transport ability, and residing in major cities. Efforts to support older people's mobility must make equity an explicit consideration, reject a one-size-fits-all approach, and prioritize the accessibility of cities and communities.

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents.

INTRODUCTION: Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions. METHODS: A systematic review of peer-reviewed original research published between 2010-2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10-24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status). RESULTS: Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls). DISCUSSION: Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified. CONCLUSION: This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

Independent pharmacist prescribing in Canada.

BACKGROUND: While pharmacists are trained in the selection and management of prescription medicines, traditionally their role in prescribing has been limited. In the past 5 years, many provinces have expanded the pharmacy scope of practice. However, there has been no previous systematic investigation and comparison of these policies. METHODS: We performed a comprehensive policy review and comparison of pharmacist prescribing policies in Canadian provinces in August 2010. Our review focused on documents, regulations and interviews with officials from the relevant government and professional bodies. We focused on policies that allowed community pharmacists to independently continue, adapt (modify) and initiate prescriptions. RESULTS: Pharmacists could independently prescribe in 7 of 10 provinces, including continuing existing prescriptions (7 provinces), adapting existing prescriptions (4 provinces) and initiating new prescriptions (3 provinces). However, there was significant heterogeneity between provinces in the rules governing each function. CONCLUSIONS: The legislated ability of pharmacists to independently prescribe in a community setting has substantially increased in Canada over the past 5 years and looks poised to expand further in the near future. Moving forward, these programs must be evaluated and compared on issues such as patient outcomes and safety, professional development, human resources and reimbursement.

A Systematic Review with Framework Synthesis of the Ways That Urban Environments Influence Opportunities for Healthy and Sustainable Mobility in Older Age.

Supporting older people's use of sustainable transport is important for both population health and sustainable development, especially in the context of global population ageing. This systematic review identifies individual and environmental factors that influence older people's sustainable transport use and synthesises findings using a framework approach. Factors influencing older people's walking (n = 10 studies), bus use (n = 11), community transport use (n = 1), bicycling (n = 1), and e-bicycling (n = 1) were found to be physical, geographical, facility-based, economic, time-based, fear-based, space-based, information-based, or interpersonal. Many factors were common across transport modes. One reason for this is that environmental features designed to facilitate the use of one particular transport mode also influenced the use of other modes (e.g., bus shelters influence not only bus use but also walking as they provide pedestrian seating). Thus, environments need to be considered from the perspective of multiple, different types of road users. Another reason is that many factors related to the ways individuals experienced their environment (e.g., finding information guiding behaviour in public spaces to be unclear), regardless of any specific transport mode. This review highlights the important need for greater cross-sectoral action and input from older people.

Experiences of Older Aboriginal People in Navigating Transport Systems in an Urban Setting: An Indigenous Perspective on Transport Access, a Social Determinant of Health.

BACKGROUND: In Australia, Aboriginal people are underserved by the transport system and are less able to easily get to places they need to go than others. This is a part of a larger pattern of exclusion and inequity for Aboriginal people which affects their health, wellbeing, and social participation. Guided by a decolonising framework, this research explored how older Aboriginal people, whose pivotal roles in their families and communities require their mobility, experience the transportation system, providing an Indigenous-centred view of the accessibility of transportation options in society. METHODS: Interviews drawing from the yarning technique were conducted with ten older Aboriginal people living in Greater Western Sydney and analysed qualitatively. RESULTS: In addition to the cognitive labour required to decipher the rules of the transport system and organise commitments to match the scheduling of transport services, older Aboriginal people in this study experienced stigmatising attitudes and condescending treatment from service professionals and the public when traveling. CONCLUSIONS: This study suggests three potential ways that the current trajectory that underserves older Aboriginal people could be disrupted, relating to service design, the diversity and inclusion agenda, and the social determinants of Indigenous health.

Impact of medical fitness to drive policies in preventing property damage, injury, and death from motor vehicle collisions in Ontario, Canada.

INTRODUCTION: Drivers with medical conditions and functional impairments are at increased collision risk. A challenge lies in identifying the point at which such risk becomes unacceptable to society and requires mitigating measures. This study models the road safety impact of medical fitness-to-drive policy in Ontario. METHOD: Using data from 2005 to 2014, we estimated the losses to road safety incurred during the time medically-at-risk drivers were under review, as well as the savings to road safety accrued as a result of licensing decisions made after the review process. RESULTS: While under review, drivers with medical conditions had an age- and sex-standardized collision rate no different from the general driver population, suggesting no road safety losses occurred (RR = 1.02; 95% CI: 0.93-1.12). Licensing decisions were estimated to have subsequently prevented 1,211 (95% CI: 780-1,730) collisions, indicating net road safety savings resulting from medical fitness to drive policies. However, more collisions occurred than were prevented for drivers with musculoskeletal disorders, sleep apnea, and diabetes. We theorize on these findings and discuss its multiple implications. CONCLUSIONS: Minimizing the impact of medical conditions on collision occurrence requires robust policies that balance fairness and safety. It is dependent on efforts by academic researchers (who study fitness to drive); policymakers (who set driver medical standards); licensing authorities (who make licensing decisions under such standards); and clinicians (who counsel patients on their driving risk and liaise with licensing authorities). Practical Applications: Further efforts are needed to improve understanding of the effects of medical conditions on collision risk, especially for the identified conditions and combinations of conditions. Results reinforce the value of optimizing the processes by which information is solicited from physicians in order to better assess the functional impact of drivers' medical conditions on driving and to take suitable licensing action.

Advanced vehicle technologies and road safety: A scoping review of the evidence.

The proliferation of Advanced Vehicle Technologies (AVTs) has generated both excitement and concern among researchers, policymakers, and the general public. An increasing number of driver assistance systems are already available in today's automobiles; many of which are expected to become standard. Therefore, synthesizing the available evidence specific to the safety of AVTs is critical. The goal of this scoping review was to summarize this evidence with a focus on AVTs that require some driver oversight (i.e., Levels 0-3 as per the Society of Automotive Engineers (SAE) levels of automation taxonomy). A scoping review of research literature on AVTs was conducted for studies up to March 2018. Inclusion criteria consisted of: any study with empirical data of AVTs that included male and female drivers aged 16 years and older, healthy people (i.e., without impairments), passenger vehicles, driving simulators and/or large databases with road safety information that could be analyzed for the purpose of examining AVTs (SAE Levels 0-3), as well as measures of driving outcomes. A total of 324 peer-reviewed studies from 25 countries met the inclusion criteria for this review with over half published in the last 5 years. Data was extracted and summarized according to the following categories: measures used to evaluate the effect of AVTs on road safety (objective) and driver perceptions of the technology (subjective), testing environment, and study populations (i.e., driver age). The most commonly reported objective measures were longitudinal control (50 %), reaction time (40 %), and lateral position (23 %). The most common subjective measures were perceptions of trust (27 %), workload (20 %), and satisfaction (17 %). While most studies investigated singular AVTs (237 of 324 studies), the number of studies after 2013 that examined 2 or more AVTs concurrently increased. Studies involved drivers from different age groups (51 %) and were conducted in driving simulators (70 %). Overall, the evidence is generally in favour of AVTs having a positive effect on driving safety, although the nature and design of studies varied widely. Our examination of this evidence highlights the opportunities as well as the challenges involved with investigating AVTs. Ensuring such technologies are congruent with the needs of drivers, particularly younger and older driver age groups, who are known to have a higher crash risk, is critical. With automotive manufacturers keen to adopt the latest AVTs, this scoping review highlights how testing of this technology has been undertaken, with a focus on how new research can be conducted to improve road safety now and in the future.

Assessing the impact of the 2015 introduction of increased penalties and enhanced public awareness and enforcement activities on texting while driving among adults in Ontario, Canada.

Objective: Texting while driving (TWD) is considered a particularly hazardous form of distracted driving. It is highly prevalent among young drivers, but fewer studies of TWD among adult drivers exist and these prevalence rates may approach those of younger drivers. The effectiveness of measures to prevent distracted driving, and TWD specifically, is unclear. On September 1, 2015, Ontario introduced increased penalties for distracted driving accompanied by public education programs to increase public awareness of the new regulations. Provincial police also introduced enhanced enforcement efforts. The current study examined self-reported TWD in a representative sample of Ontario adults before and after introduction of the new legislation and the enhanced public education and enforcement efforts.Methods: Data were based on telephone interviews with 1,846 respondents who reported having driven in the past year. Data were derived from the 2015-2016 cycles of the Centre for Addiction and Mental Health (CAMH) Monitor, an ongoing cross-sectional telephone survey of adults aged 18+ years in Ontario, Canada. A binary logistic regression analysis of TWD in the previous 30 days was conducted, adjusting for demographic characteristics (sex, age), driving exposure, and introduction of the legislation (before versus after).Results: The proportion of the sample reporting TWD declined significantly from 37.6% before the law was introduced to 24.2% after the law was introduced. The impact appeared to be most pronounced among drivers who reported TWD more frequently. Adjusted odds of TWD declined 42% following introduction of the legislation and associated enhanced public education and enforcement.Conclusions: These results identify a decrease in TWD following the introduction of enhanced penalties with corresponding public education and enforcement efforts, adding to the existing evaluative evidence base to inform transportation safety policy. These results also support the need to examine TWD and its determinants among all age groups.

Vehicle impoundments improve drinking and driving licence suspension outcomes: Large-scale evidence from Ontario.

Although vehicle impoundment has become a common sanction for various driving offences, large-scale evaluations of its effectiveness in preventing drinking and driving recidivism are almost non-existent in the peer-reviewed literature. One reason is that impoundment programs have typically been introduced simultaneously with other countermeasures, rendering it difficult to disentangle any observed effects. Previous studies of impoundment effectiveness conducted when such programs were implemented in isolation have typically been restricted to small jurisdictions, making high-quality evaluation difficult. In contrast, Ontario's "long-term" and "seven-day" impoundment programs were implemented in relative isolation, but with tight relationships to already existing drinking and driving suspensions. In this work, we used offence data produced by Ontario's population of over 9 million licensed drivers to perform interrupted time series analysis on drinking and driving recidivism and on rates of driving while suspended for drinking and driving. Our results demonstrate two key findings: (1) impoundment, or its threat, improves compliance with drinking and driving licence suspensions; and (2) addition of impoundment to suspension reduces drinking and driving recidivism, possibly through enhanced suspension compliance.

Evaluation of the general deterrence capacity of recently implemented (2009-2010) low and Zero BAC requirements for drivers in Ontario.

The number of injuries and fatalities associated with drinking and driving continues to decline in the province of Ontario. However, this behavior remains as one of the major contributors to collision-related injuries and fatalities. Few large-scale studies of blood alcohol concentration (BAC) <0.08% limits exist in the literature, necessitating additional investigation. Here we evaluate the general deterrent effectiveness of three Ontario countermeasures implemented during 2009 and 2010, two of which impose lower allowable BAC on drivers in the province. Using ARIMA-based interrupted time-series analysis we found that Warn-range sanctions, which include immediate roadside suspension for the previously un-targeted BAC range of 0.05-0.08%, were associated with a 17% decrease in the number of people injured or killed in drinking and driving collisions (relative to the number injured or killed in other collisions). Similarly, we found that Zero BAC requirements newly applied to young drivers (<22y.o.) were associated with a reduction in the numbers of two other dissimilar drinking and driving sanctions received by young drivers (relative to the number of these sanctions received by non-young drivers). A roadside seven-day vehicle impoundment for BAC>0.08%, which was added to an already existing roadside 90-day license suspension, was not found to produce general deterrence. Taken together, our results suggest that sanctions which target previously untargeted groups, specifically via lower BAC requirements, are effective as general deterrents against drinking and driving.

Program design for incentivizing ignition interlock installation for alcohol-impaired drivers: The Ontario approach.

INTRODUCTION: Drinking and driving is a major risk factor for traffic injuries. Although ignition interlocks reduce drinking and driving while installed, several issues undermine their implementation including delayed eligibility for installation, low installation once eligible, and a return to previous risk levels after de-installation. The Canadian province of Ontario introduced a "Reduced Suspension with Ignition Interlock Conduct Review" Program, significantly changing pre-existing interlock policy. The Program incentivizes interlock installation and an "early" guilty plea. It also attempts to reduce long-term recidivism through behavioural feedback and compliance-based removal. This evaluation is the first in assessing Program impact. METHODS: Ontario drivers with a first time alcohol-impaired driving conviction between July 1, 2005 and November 25, 2014 comprised the study cohort. Longitudinal analyses, using interrupted time series and Cox regression, were conducted in which exposure was the Program and the outcomes were ignition interlock installation (N=30,200), pre-trial elapsed time (N=30,200), and post-interlock recidivism (N=9326). RESULTS: After Program implementation, installation rates increased by 54% and pre-trial elapsed time decreased by 146 days. Results suggest no effect on post-interlock recidivism. CONCLUSIONS: Through an incentive-based design, this Program was effective at addressing two commonly cited barriers to interlock implementation- delayed eligibility for installation and low installation once eligible. Results reveal that installation rates are responsive not only to incentivization but also to other external factors, thus presenting an opportunity for policy makers to find unique ways to influence interlock uptake, and thereby, to extend their deterrent effects to a larger subset of the population. This study is one of the few that do not rely on proxy measures of installation rate.

Working in tandem: The contribution of remedial programs and roadside licence suspensions to drinking and driving deterrence in Ontario.

In 1998, Ontario implemented a remedial program called "Back On Track" (BOT) for individuals convicted of alcohol-impaired driving. Drivers convicted before October 2000 were exposed to a single-component program ("Edu BOT"); those convicted after participated in a multi-component program ("Full BOT"). We evaluated the impact of BOT, and the preceding 90-day roadside licence suspension, on drinking and driving recidivism, an outcome yet to be examined, using population-wide driver records. A Chi Square Test was used to compare the three-year cumulative incidence of recidivism between three historically-defined cohorts: No BOT, Edu BOT, and Full BOT. Stratified analyses by completion status and by age were also conducted. Analyses of the roadside suspension were conducted using an interrupted time series approach based on segmented Poisson/negative binomial regression. The roadside suspension was associated with a 65.2% reduction in drinking driving recidivism. In combination with indefinite suspensions for non-completion, the BOT program was also associated with a 21% decrease in drinking and driving recidivism in the three years following a CCC driving prohibition, from 8.5% to 6.7%. This reduction cannot be explained by pre-existing trends in recidivism. Conversion of the BOT program from the single-component version to the multi-component program further reduced the three-year cumulative incidence of recidivism to 5.5% (a total reduction of 35% from pre-BOT). Results provide strong converging evidence that remedial alcohol education/treatment programs in combination with other sanctions can produce substantial increases in road safety.