Treating drunk drivers with moral reconation therapy: a one-year recidivism report

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Study protocol: a hybrid effectiveness-implementation trial of Moral Reconation Therapy in the US Veterans Health Administration

Background

Moral Reconation Therapy (MRT) is a cognitive-behavioral intervention aimed at reducing risk for criminal recidivism by restructuring antisocial attitudes and cognitions (i.e., “criminogenic thinking”). MRT has empirical support for reducing risk for criminal recidivism among civilian offenders. Recently, a version of MRT was developed for military veterans; however, no randomized controlled trials (RCT) have been conducted with the veteran-specific protocol, and the effectiveness and implementation potential of MRT outside of correctional settings has not been established.

Methods

Using a Hybrid Type 1 RCT design, this study will test the effectiveness of MRT to reduce risk for criminal recidivism and improve health-related outcomes among justice-involved veterans entering mental health residential treatment at three US Veterans Health Administration (VHA) Medical Centers. Upon admission to the treatment program, justice-involved veterans will complete a baseline assessment, be randomized to usual care (UC) or UC + MRT, and be followed 6 and 12 months post-baseline. A process evaluation will also be conducted to identify barriers and facilitators to implementation of MRT in residential treatment.

Discussion

The primary aim of this study is to evaluate the effectiveness of MRT with justice-involved veterans. If MRT proves effective in this trial, the findings can provide large healthcare systems that serve veterans with an evidence-based intervention for addressing criminogenic thinking among justice-involved adults, as well as guidance on how to facilitate future implementation of MRT in non-correctional settings.

Trial registration

This trial is funded by the VA Health Services Research & Development Program (IIR 14–081) and is registered with ClinicalTrials.gov (ID: NCT02524171).

A meta-analysis of moral reconation therapy

This study reports on a meta-analysis of moral reconation therapy (MRT). Recipients of MRT included adult and juvenile offenders who were in custody or in the community, typically on parole or probation. The study considered criminal offending subsequent to treatment as the outcome variable. The overall effect size measured by the correlation across 33 studies and 30,259 offenders was significant (r = .16), indicating that MRT had a small but important effect on recidivism. Moderator analyses were conducted to detect the possible factors affecting the relationship between MRT and recidivism. Moderators included setting, age, gender, research design, sample size, type of recidivism, follow-up period, publisher, and year of publication. Moderator analysis demonstrated that MRT was more successful with adult than juvenile offenders in institutional settings as opposed to the community, and where researchers in the primary studies used randomization to allocate participants to either a treatment or control condition. The treatment effect size was greater when the type of recidivism used was rearrest rather than rearrest followed by conviction or reincarceration. The benefits of MRT were strongest with a relatively short follow-up period. MRT was more successful for relatively small samples and for large samples rather than medium-sized samples. The effect size was smaller for studies published by the owners of MRT than by other independent studies. The effect size was also smaller for studies published after 1999.

Treating drug offenders with Moral Reconation Therapy: a three-year recidivism report

70 male felony offenders treated with the cognitive behavioral approach of Moral Reconation Therapy during and after incarceration were assessed for rearrests and reincarceration 38 months after their release. They were compared to a nontreated control group of 82 male felony offenders. Recidivism in the treated group was 24.3% as compared to 36.6% for the control group. Analysis showed that steps completed significantly correlated with rearrests and recidivism and that the correlation between number of aftercare sessions and recidivism approached significance.

Treating drunk drivers with Moral Reconation Therapy: a three-year report

115 DWI-convicted male inmates were treated with the cognitive behavioral system of Moral Reconation Therapy during their incarceration. Three years after their release, subjects' postrelease arrest and reincarceration records were collected. In the treated group, 24 subjects participated in an extended aftercare program and were compared to a control group of 65 DWI-convicted inmates who did not enter treatment due to limited bed space. Analysis showed reincarceration rates of 36.9% for the 65 controls, 22.6% of the 115 treated subjects, and only 16.7% of the 24 aftercare clients.

Treating drunk drivers with Moral Reconation Therapy: a two-year recidivism study

115 DWI-convicted male inmates were treated with Moral Reconation Therapy during incarceration. Nearly two years after their release, subjects' postrelease arrest records were collected. Treatment group data were compared to a control group of 65 inmates who applied but did not enter treatment as bed space was limited. Analysis showed that 10.4% of the treatment group obtained additional DWI arrests after release compared to 15.6% of the control group. 14.3% of treated subjects received additional sentences compared to 21.5% of nontreated controls. Results were also analyzed for a group of 24 treated subjects who continued to participate in treatment after release. This aftercare group showed a postrelease DWI rate of only 4.2% and reincarceration rate of 8.3%.

Relationship of DUI recidivism to moral reasoning, sensation seeking, and MacAndrew alcoholism scores

115 convicted male DUI offenders were treated with Moral Reconation Therapy during their incarceration. Postrelease recidivism status (arrests) was correlated with the pretest, posttest, and change scores on the MacAndrew Alcoholism Scale, Sensation Seeking Scale, Life-purpose scores, and Moral Reasoning scores. Analysis showed that recidivism correlated positively and significantly with the pretest scores on the MacAndrew scale and approached significance with both pre- and posttest scores on the Sensation Seeking Scale. Recidivism status correlated negatively and significantly with scores on the highest levels of moral reasoning (Scale 6 pretest and posttest and Principled Reasoning pretest).