PHWR Public Health Weekly Report

Depending on the amount, pattern, and duration of consumption, alcohol, a class 1 carcinogen, has a variety of negative effects on the physical and mental health of drinkers. This not only incurs increased healthcare costs but also undermines productivity. It also affects social safety and well-being, contributing to issues such as domestic violence, traffic accidents, and crime. The socioeconomic cost of alcohol consumption exceeds KRW 15 trillion, outweighing the social burden of smoking, which stands at approximately KRW 13 trillion in the Republic of Korea (ROK) [1].

Therefore, the National Health Plan 2030 has selected the high-risk drinking prevalence as one of the key indicators to be addressed.

High-risk drinking refers to consumption levels that can lead to health problems and alcohol use disorders. In ROK, high-risk drinking is characterized by imbibing more than one bottle of soju (or more than five shots for women) at a time more than twice a week [2]. The United States National Institute on Alcohol Abuse and Alcoholism defines high-risk drinking as drinking more than 4 glasses per day or 14 glasses per week for adult men aged ≤65 years and more than 3 glasses per day or 7 glasses per week for women or men aged >65 years [3]. Fortunately, high-risk drinking is a preventable issue, and there has been a substantial amount of research focusing on individual-level interventions to prevent or manage this problem.

However, akin to any other healthy lifestyle aspect, drinking behavior is profoundly influenced by the physical and social environment. Individual-level interventions have limited success in reducing high-risk drinking and its associated harms, particularly in ROK, where a permissive culture of drunkenness prevails. Even when diligently addressing behavior modification for high-risk drinking at the individual level, accomplishing the goals set becomes exceedingly challenging within a social milieu that endorses and fosters drinking [4].

In this context, it is necessary to examine instances where smoking prevalence have been reduced through physical and social environmental alterations. Measures like designating non-smoking areas, raising tobacco prices, and imposing restrictions on advertisements have been advocated to alleviate health issues and social burdens caused by smoking. As these policies persist over time, there is not only a shift in smoking prevalence but also a transformation in societal perceptions of smoking. The once compelling glorification of smoking and smokers gradually loses its persuasive impact [5].

As for alcohol problems, interventions targeting high-risk drinking and alcohol-related harms through environmental change approaches offer a potential avenue to overcome the limitations of individual-level interventions. The environmental change approach focuses on modifying the social, cultural, and economic aspects of the environment to bring about comprehensive changes in the overall drinking behavior and reduce the harms associated with drinking. These measures include increasing taxes on alcohol, raising alcohol prices, restricting advertising, regulating sales (time and location), and limiting access for minors. The evidence supporting the effectiveness of this environmental change approach is unequivocal, with the World Health Organization (WHO) promoting the Strengthen, Advance, Facilitate, Enforce, and Raise (SAFER) initiative. This initiative aims to safeguard against high-risk drinking and minimize its social impacts, advocating for its implementation at the national and local levels [6].

In ROK, finding a comprehensive intervention to induce environmental changes aimed at reducing the prevalence of high-risk drinking and its associated harms has been challenging. In response, Jungnang-gu, Seoul, opted to introduce a community-based environmental change approach to improve the annual high-risk drinking prevalence and related health indicators among residents. This comprehensive intervention has been developed and implemented since 2021.

As the inaugural effort to assess the effectiveness of an environmental change intervention at the basic autonomous district level in ROK, this study aimed to analyze the shifts in the prevalence of high-risk drinking, a variable capable of identifying short-term effects, before and after the intervention.

To assess the impact of community-based environmental change interventions on local high-risk drinking prevalence, a comprehensive intervention was implemented from 2021 to 2022. The focus area for the intervention was Jungnang-gu, one of the autonomous districts of Seoul, with a population of approximately 400,000. As a comparative measure, the remaining 24 autonomous districts served as control areas, where no interventions were implemented, allowing each district to continue with its existing practices.

1. Community-based Environmental Change Intervention Models

The community-based environmental change intervention model used in this study is an intervention aimed at reducing high-risk drinking and its adverse consequences within the community. The core model, derived from the components of Holder et al. [7]’s Community Trial Project and the WHO-led SAFER strategy, was constructed by adopting strategies that can be implemented at the community level. Simultaneously, an extended model was developed to address the additional community-specific needs (Figure 1).

Figure 1. A Community-based environmental change intervention model for reducing high-risk drinking and alcohol-related harm
SBIRT=Screening, Brief Intervention, and Referral to Treatment; DUI=driving under the influence.

This model underscores the critical role of collaborative efforts among various community resources as an essential prerequisite for implementing effective interventions. Each intervention was strategically guided by a specific community resource. To ensure access to Screening, Brief Intervention, and Referral to Treatment services, executive boards of the local medical, dental, and pharmacy associations played pivotal roles in reaching out to their respective members and encouraging them to participate in the program to increase the number of participating organizations, rather than dispatching a separate staff member to each health center for conducting a community health center high-risk drinking screening and counseling program. Participating organizations received program implementation guides and screening instruments used for identifying individuals engaged in high-risk drinking and providing recommendations based on the results of the screening.

In the intervention area, some of the components of the intervention model were launched in 2021, with the full spectrum of intervention components activated in 2022 within the designated intervention area. Additional details on the content of the intervention have been outlined by Kim et al. [8].

2. Participants

The study was conducted in Jungnang-gu, one of the 25 autonomous districts in Seoul, an urban area with a population of approximately 400,000. In 2018, the high-risk drinking prevalence in Jungnang-gu, which was reviewed during the planning phase of the intervention, was 21.6% among drinkers, ranking as the third highest among the 25 districts in Seoul. Notably, this figure significantly differed from that of Gangdong-gu, which had the lowest high-risk drinking prevalence at 13.0% among drinkers [2]. Given the sustained occurrence of this indicator in Jungnang-gu over an extended period, an intervention plan was formulated as a countermeasure.

3. Study Content and Data Collection

The independent variable in this study was either the implementation or absence of a community-based environmental change intervention, designating Jungnang-gu, where the intervention was executed, as the intervention area, and considering the remaining districts of Seoul as the control area. No interventions were implemented in the control area.

The dependent variable was the prevalence of high-risk drinking among annual drinkers at the community level. The annual high-risk drinking prevalence among drinkers was defined as the percentage of individuals who consumed alcohol in the past year, with an average of 7 or more glasses (or 5 cans of beer) for men and 5 or more glasses (or 3 cans of beer) for women, and drank at least twice a week in the past year. In this study, the term ‘high-risk drinking prevalence’ or ‘high-risk drinking prevalence among drinkers’ referred to the prevalence of high-risk drinking rate among annual drinkers [2].

Data on the high-risk drinking prevalence were collected from the annual Korea Community Health Survey (KCHS) conducted by the Korea Disease Control and Prevention Agency. Starting in 2022, the majority of community health surveys have been conducted from August to October of each year, with results release around June of the following year. For this study, gender- and age-specific standardized high-risk drinking prevalence from the KCHS collected in 2020 served as the baseline measure, while the prevalence of high-risk drinking in 2022 served as the post-intervention measure. Furthermore, data on high-risk drinking were collected for all years from 2008 to 2022, encompassing the period when the KCHS was initially conducted. This comprehensive dataset allowed for the examination of the time series of high-risk drinking prevalence for each of the 25 autonomous districts [2].

Although the interventions in this study aimed at reducing both high-risk drinking and its associated harms, unpublished national-level data on drinking harms were unavailable. This limitation emerged because the study focused on the short-term outcomes within <2 years following the implementation of the interventions. Consequently, the study exclusively utilized high-risk drinking as an outcome variable.

4. Statistical Analysis Methods

To examine the time series of high-risk drinking prevalence across the 25 autonomous districts in Seoul from 2008 to 2022 and assess the changes in Jungnang-gu’s ranking among these districts before and after the intervention, a boxplot was generated to depict the distribution of high-risk drinking prevalence among annual drinkers by year.

Given the limited number of observations available from the initiation of the intervention in the intervention area and beyond, two in 2021 and two in 2022, it was deemed inappropriate to apply double-difference analysis or interrupted time series analysis regression models [9]. Therefore, to indirectly assess the impact of the intervention, the difference in mean high-risk drinking prevalence between the intervention and control areas was analyzed using a t test, stratified into pre-intervention and post-intervention periods.

Additionally, the prevalence of high-risk drinking for the intervention and control areas were plotted at baseline in 2020 and 2022 after the intervention to observe the changes. The percentage change from baseline was then calculated and compared in each area. This was defined as the % change in high-risk drinking prevalence, which was calculated for each of the 24 districts in the control area. And the average % change in the control area was computed and compared with the % change in the intervention area. The data were analyzed using the SAS Institute software version 9.4 (SAS Institute).

1. Status of Community Environmental Change Interventions (Outputs of the Implementation of the Community Environmental Change Interventions)

1) Establishment and operation of a regional council

To facilitate the implementation of community-based environmental change interventions, memorandums of understanding were signed by pertinent stakeholders in the local community, and a council was organized to conduct launching ceremonies and annual meetings. In addition, ongoing discussions occurred periodically with each participating institution or organization throughout the year to refine the intervention strategy and allow each institution or organization to take ownership of the project. The council was named the , and the participating organizations were as follows:

― For the interventions included in the core model: Jungnang-gu Office (Health Center), Jungnang-gu Council, Jungnang Police Station, Korean Foodservice Industry Association Jungnang-gu Branch, Jungnang-gu Medical, Dental, and Pharmacy Associations, Jungnang-gu Mental Health and Welfare Center, and three emergency healthcare centers in the area.

― For the interventions included in the extended model: Seoul Dongbu District Office of Education, Residents’ Association, and Jungnang Council for Improving Drinking Culture.

2) Intervention status

As of October 31, 2023, an overview of the interventions categorized by intervention strategy is presented in Table 1.

Table 1 Summary of the implementation status of community-based environmental change interventions

	Participating entities	Intervention	Implementation status
Main model	District council	Restrictions on alcohol accessibility	Amendment of the ordinance completed. Designation of Zone 1 as a alcohol-restricted area (penalty imposition scheduled).
	Police station	Drinking-driving prevention	Developing measures to strengthen enforcement against drunk driving and aiding and abetting drunk driving. Extension of drinking-driving enforcement hours until 4 a.m.. Enforcement of drinking-driving for kick scooters/bicycles. Promotional banners placed at 17 major intersections.
	Korea foodservice industry association	Responsible beverage service	314 restaurants or pub/bar participated. Incorporated video training for alcohol providers into the mandatory hygiene education program for restaurant operators.
	Healthcare facility	Access to SBIRT	57 local clinics, dental clinics, and pharmacies participated. 4 health center and branch offices participated.
Expanded model	Public or workplace	Access to SBIRT of general population	Completed mobile self-report AUDIT-C screening for 521 individuals. 51 individuals completed the program.
	Schools	Underage drinking prevention	Pilot project for all students in one school. Annual education sessions planned for 2nd-grade students at one elementary school.
	Homes	Public awareness	Broadcasting campaign videos on monitors in elevators across 611 units in 61 apartment complexes. Year-round broadcast of shortened versions on 19 unmanned public service kiosks.

SBIRT=Screening, Brief Intervention, and Referral to Treatment; AUDIT-C=Alcohol Use Disorders Identification Test - Concise..

2. Change in the Prevalence of High-risk Drinking Rates

1) Distribution of high-risk drinking prevalence in 25 districts of Seoul, 2008–2022

Based on the box plot of the distribution of annual high-risk drinking prevalence among drinkers in 25 districts of Seoul (Figure 2), a noticeable decrease in the high-risk drinking prevalence across all districts in Seoul was observed in 2020, before the intervention. This decline coincided with the strong promotion of social distancing measures in response to the coronavirus disease 2019 (COVID-19) pandemic, which served as the baseline for this study. This decline continued in 2021 due to the impact of social distancing measures.

Figure 2. Distribution of high-risk drinking prevalence in the 25 districts of Seoul and the position of Jungnang-gu (Community Health Survey, each year)
^a)High-risk drinkers among 1-year drinkers.

Upon reviewing the placement of the intervention area, Jungnang-gu, on the boxplot, it consistently appeared near the top among the 25 districts in all but 3 years throughout the 13-year period (from 2008 to 2020). As a point of reference, the locations of Dongdaemun-gu, which has similar characteristics to the intervention area in terms of social indicators, and Gangnam-gu, which has the highest number of bar establishments among the 25 districts in Seoul, were presented.

When the three communities were compared, Dongdaemun-gu and Gangnam-gu exhibited a decline in the prevalence of high-risk drinking rates from the baseline in 2020 to 2021, followed by a notable increase in 2022, coinciding with the relaxation of social distancing measures amid the COVID-19 pandemic. In contrast, the high-risk drinking prevalence in Jungnang-gu remained relatively stable from 2022 to 2021. The intervention area ranked 3rd in 2020, 6th in 2021, and 8th in 2022 among the 25 districts in high-risk drinking prevalence, positioning it within the middle 50% group.

2) Comparing the differences in high-risk drinking prevalence between the intervention and control sites: results of stratification analysis

Table 2 presents the results of the t test analysis of the difference in the mean values of high-risk drinking prevalence between the intervention and control areas, stratified by pre-intervention and post-intervention periods. In 2020, prior to the intervention, the prevalence of high-risk drinking rate in the intervention area was significantly higher than that in the control area (p<0.001). However, the analysis showed no significant difference in high-risk drinking prevalence between the intervention and control areas during the intervention period (2021–2022) (p=0.378).

Table 2 Differences in mean high-risk drinking prevalence between intervention and control areas before and during the intervention period

	Pre-intervention period (2008–2020)				Intervention period (2021–2022)
	Mean±SD	t	p-value		Mean±SD	t	p-value
Control area	16.7±3.1	–4.38	<0.001		13.1±2.8	–0.87	0.387
Intervention area	20.5±2.7				14.8±0.0

SD=standard deviation..

3) Changes in the pre- and post-intervention high-risk drinking prevalence and % change

Figure 3A illustrates the prevalence of high-risk drinking in the intervention and control areas. Prior to the intervention, in 2020, the prevalence of high-risk drinking in the intervention area was 16.6%, decreasing to 14.8% in 2022. In contrast, the control areas experienced a slight increase in high-risk drinking prevalence, rising from 12.9% pre-intervention to 13.5% post-intervention.

Figure 3. Changes in high-risk drinking prevalence and percentage of change
^a)High-risk drinkers among 1-year drinkers. ^b)Average % change across the 24 Districts in Seoul.

After calculating these changes as a percentage of the baseline for each district and then averaging the percentage changes for the control areas, the high-risk drinking prevalence in 2022 increased by 7.0% from the baseline. Conversely, the intervention neighborhoods experienced a 10.8% reduction in high-risk drinking prevalence in 2022 from baseline (Figure 3B).

This quasi-experimental study analyzed the impact of a community-level environmental change approach on the high-risk drinking prevalence among annual drinkers. The findings indicate that the environmental change approach intervention led to a reduction in the high-risk drinking prevalence compared with the absence of intervention.

The intervention model in this study included a variety of strategies that could be implemented at the local level, including public drinking restrictions, impaired driving prevention, responsible alcohol service, and screening and counseling for high-risk drinkers at the local clinics, dental clinics, and pharmacies. There is no precedent for such a multisectoral environmental approach in ROK. To the best of our knowledge, this study is the first to evaluate the effectiveness of such an approach in this country.

It is not difficult to identify studies conducted in other countries that have employed environmental change approaches to address high-risk drinking prevalence and related harmful drinking behaviors. A systematic review assessing the effectiveness of key strategies used in environmental change approaches found that organizing and activating community resources, implementing various interventions falling under the umbrella of environmental approaches to drinking (including community mobilization, responsible alcohol provider training, and strict enforcement of laws governing impaired driver licensing), impaired driving interventions such as increased police enforcement patrols and the use of car ignition interlocks, restricting alcohol advertising, limiting the density of restaurants and bars as well as wholesale and retail establishments that sell alcohol, increasing alcohol prices, and increasing alcohol taxes were more likely to be effective in reducing harmful alcohol use [10].

With regard to the mechanism underlying this effect, Holder et al. [7] evaluated the effects of implementing an intervention falling under the ‘utilizing multiple interventions’ category of the evidence-based interventions mentioned above. Furthermore, a theoretical model of how such interventions can reduce the prevalence of high-risk drinking and harmful drinking was presented. According to this model, restricting access to alcohol through strengthening licensing requirements for alcohol retail outlets and providing responsible serving training for alcohol servers can reduce the opportunity to drink, subsequently reducing the amount of alcohol consumed. This reduction in turn mitigates high-risk drinking, leading to a decrease in alcohol-related issues such as violence and injury. In terms of police countermeasures against impaired driving, increasing impaired driving patrols and simultaneously publicizing them to the community increases the fear of being caught, thereby discouraging impaired driving.

The community-based environmental change intervention employed in this study introduced a novel component to Holder et al. [7] model: screening and counseling for high-risk drinking in the local clinics, dental clinics, and pharmacies. This element is the only aspect of the WHO’s five strategies on SAFER that does not overlap with the model proposed by Holder et al. [7]. Conducting screening for high-risk drinking and providing advice to reduce or abstain from drinking in primary healthcare settings can help connect individuals in need of professional assistance to treatment settings, subsequently mitigating the physical and mental health consequences of drinking [10].

Despite the evidence supporting the effectiveness of community-based environmental change approaches in reducing high-risk drinking and alcohol-related harms, the adoption of such approaches appears to face challenges in ROK. This is attributed to the fact that environmental change necessitates the active involvement and collaboration of diverse community resources. Achieving cross-sectoral consensus proves to be a demanding process, and the foundation of engaging and collaborating with diverse communities relies on the awareness of the drinking problem and fostering the determination to address it. However, these efforts seem to be hindered by the pervasive culture of binge drinking in ROK.

Although acknowledging the short-term nature of this impact evaluation, the results of this study suggest the potential of community-based environmental change interventions to positively influence the environment. This potential lies in the collaboration of various local resources within the intervention area, with this collaboration being an ongoing and structured endeavor, not a one-time occurrence. To facilitate the widespread adoption of this model in ROK and the attainment of its objectives, it is imperative to establish a sustainable collaborative structure for organizing community resources.

In particular, considering the spread of the intervention area in this study to other autonomous districts in Seoul, the institutions and organizations involved in the intervention project (such as the council, police department, Korean Foodservice Industry Association branch, and healthcare practitioner organization branch in Jungnang-gu) also exist in other autonomous districts in Seoul. In essence, the basic local resources needed for expansion to other municipalities are already in place. In addition, this study has delineated the intervention’s content, specifying the roles and methods for each of these community resources, thereby providing a blueprint for implementation in other areas.

In the end, the community environmental change interventions proposed in this study can be implemented by securing the workforce in charge of collaborative networking among local resources in each autonomous district. This necessitates the allocation of the equivalent of one full-time worker, and a review by the Seoul Metropolitan Government is imperative to ensure that the departments currently in charge of sobriety projects in each local government designate a responsible personnel.

In this study, interventions were conducted focusing on environmental change approaches applicable at the basic local government level. However, community-level environmental change approaches will show more tangible results if they are accompanied by policy approaches at the higher levels of local governments and the national level, such as regulations on various forms of indiscriminate advertising and interventions on alcohol availability, such as restricting the time and place of alcohol consumption and sales or introducing pricing policies.

Further studies should be conducted to evaluate the medium- and long-term effects of the community-based environmental change interventions implemented in this study, and a variety of alcohol-related variables other than high-risk drinking prevalence could be included as outcome variables. This requires administrative and financial support to ensure that implementation of the community-based environmental change interventions can be sustained in the intervention area.

In conclusion, a community-level environmental change intervention, conducted for the first time in ROK, was observed to be effective in improving the local high-risk drinking prevalence. Although this is a short-term impact evaluation at this stage of the intervention, it is important to note that the results suggest that community-level environmental change approaches may be able to reduce high-risk drinking and, most of all, that the intervention was implemented through collaboration between local resources.

In the future, environmental change approaches that can improve the prevalence of high-risk drinking should be attempted at the local government level to improve the health of the entire Seoul Metropolitan Government, including the intervention area, which are anticipated to play a significant role in mitigating high-risk drinking across ROK.

Ethics Statement: The study was approved by the Institutional Review Board of the Catholic University of Korea (IRB no. MC22QISI0089).

Funding Source: This work was supported by the Research Program funded by the Korea Disease Control and Prevention Agency (fund code 2021-11-023).

Acknowledgments: The authors extend our heartfelt appreciation to Jungnang-gu Public Health Center and the local community resources that participated in the for their continuous dedication and contributions to ongoing activities aimed at enhancing the health of the local community.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: SJJ, BCS, HKL, HAB. Data curation: SBL, JTK, SYH. Formal analysis: BCS. Funding acquisition: SJJ. Investigation: SYH, YJS, MHB, SBL, MHK, JRK, JTK. Methodology: SJJ, BCS, HKL. Project administration: SYH. Resources: JRK, JTK, MP. Software: BCS. Supervision: SJJ, HKL, HAB, MP. Validation: HKL, MHB, YJS. Visualization: BCS, MP. Writing – original draft: SJJ, BCS. Writing – review & editing: SJJ, BCS, HKL.