Injuries are a major public health problem worldwide and the global burden of injury is predicted to increase. Injuries rank amongst the leading causes of mortality and morbidity in all regions, affecting people of all ages and income groups.
Alcohol is an important risk factor for injury. It has been estimated that alcohol is responsible for around 47% of assault deaths, 38% of drowning, 33% of fall deaths, 44% of fire deaths, 26% of road deaths and 29% of suicides.
Many interventions to reduce alcohol-related injuries have a demand-side focus and aim to reduce individuals’ demand and consequently consumption of alcohol. However, increasing attention is being given to supply-side interventions, which attempt to alter the environment and the context within which alcohol is supplied and consumed; the aim being to modify the drinking and/or the drinking environment so that potential harm is minimised.
A systematic review carried out by the Cochrane Injuries Group examined the evidence for the effectiveness of such an approach. Systematic reviews are important for demonstrating areas where the available evidence is insufficient and where further good quality trials are required.
The authors carried out an extensive search for all controlled trials of interventions administered in the server setting that attempt to modify the conditions under which alcohol is served and consumed, to facilitate sensible alcohol consumption, and reduce the occurrence of alcohol-related harm.
They found twenty studies meeting the inclusion criteria, of which five had been conducted in Australia, ten in the USA, two in Canada, two in Sweden and one in the UK.
Fourteen studies compared a “responsible server training intervention” with no training. Two studies investigated the effectiveness of delivering health promotion information in serving establishments. Two studies examined interventions that targeted the server setting environment. One study focused on the management policies of serving premises, and one study investigated the effectiveness of a driving service for intoxicated patrons.
Five studies had an injury outcome. Fourteen studies collected data on behaviour (of servers and/or of patrons) and six studies collected data on changes in knowledge.
Overall, the methodological quality of the studies included in this review was judged to be poor. This may be a reflection of the numerous challenges posed by conducting research in this area. However, there are opportunities to improve methodology, which should be considered for future evaluations.
There was no reliable evidence that interventions in the alcohol server setting are effective in preventing injuries. Only one randomised trial with an injury outcome was identified and this did not find a beneficial effect.
The effectiveness of the interventions on patron alcohol consumption is inconclusive. One trial found a statistically significant reduction in observed severe aggression by patrons.
There is an indication of improvement in server behaviour, however, the extent to which this translates into a reduction in injury risk is uncertain.
There is no reliable evidence that interventions in the alcohol server setting are effective in reducing injury. Lack of compliance with interventions seems to be a particular problem; hence mandated interventions or those with associated incentives for compliance, may be more likely to show an effect.
The compliance problem is likely to have implications for the success of proposed strategies outlined in the Alcohol Harm Strategy for England, in which there is a preference for voluntary agreements with the alcohol industry in regard to intervention implementation. It is likely that such voluntary interventions will suffer
limited uptake and thus have limited effect. The findings of this systematic review suggest that the UK Government should consider taking a firmer stance with the alcohol industry in the adoption of harm prevention policy, if any discernible effect is to be seen.
The methodology of future evaluations needs to be improved. Randomised controlled trials, with adequate allocation concealment and blinding, are needed to improve the evidence base. Further well conducted non-randomised trials are also needed, when random allocation is not feasible.
The focus of research should be broadened to investigate the effectiveness of interventions other than server training, where previous research dominates.
When the collection of injury outcome data is not feasible, research is needed to identify the most useful proxy indicators.
Finally, future studies should be designed with the aim of contributing to the evidence base, not simply as stand alone evaluations.
It was carried out by Katharine Ker and Paul Chinnock, under the guidance of Ian Roberts (Cochrane Injuries Group, London School of Hygiene 6: Tropical Medicine).
This work was supported by the Alcohol Education Research Council and the Cochrane Health Promotion 6: Public Health Field.