Interventions in the alcohol server setting for preventing injuries

 

Abstract

Background

Injuries are a significant public health burden and alcohol intoxication is recognised as a risk factor for injuries. Increasing attention is being paid to supply-side interventions that aim to modify the environment and context within which alcohol is supplied and consumed.

Objectives

To quantify the effectiveness of interventions implemented in the server setting for reducing injuries.

Search methods

We searched the following electronic databases to November 2008; Cochrane Injuries Group's Specialised Register, CENTRAL, MEDLINE, EMBASE, PsycINFO, PsycEXTRA, ISI Web of Science, Conference Proceedings Citation Index - Science, TRANSPORT and ETOH. We also searched reference lists of articles and contacted experts in the field.

Selection criteria

Randomised controlled trials (RCTs), non-randomised controlled trials (NRTs) and controlled before and after studies (CBAs) of the effects of interventions administered in the server setting that attempted to modify the conditions under which alcohol is served and consumed, to facilitate sensible alcohol consumption and reduce the occurrence of alcohol-related harm.

Data collection and analysis

Two authors independently screened search results and assessed the full texts of potentially relevant studies for inclusion. Data were extracted and methodological quality was examined. Due to variability in the types of interventions investigated, a pooled analysis was not appropriate.

Main results

Twenty-three studies met the inclusion criteria. Overall methodological quality was poor. Five studies used an injury outcome measure; one of these studies was randomised, the remaining four where CBA studies.

The RCT targeting the alcohol server setting environment with an injury outcome compared the introduction of toughened glassware (experimental) to annealed glassware (control) on the number of bar staff injuries; a greater number of injuries were detected in the experimental group (relative risk 1.72, 95% CI 1.15 to 2.59).

One CBA study investigated server training and estimated a reduction of 23% in single-vehicle, night-time crashes in the experimental area (controlled for crashes in the control area). Another CBA study examined the impact of a drink driving service, and reported a reduction in injury road crashes of 15% in the experimental area, with no change in the control; no difference was found for fatal crashes. In a CBA study investigating the impact of an intervention aiming to reduce crime in drinking premises, the study authors found a lower rate of all crime in the experimental premises (rate ratio 4.6, 95% CI 1.7 to 12, P = 0.01); no difference was found for injury (rate ratio 1.1 95% CI 0.1 to 10, P = 0.093). A CBA study investigating the impact of a policy intervention reported that pre-intervention the serious assault rate in the experimental area was 52% higher than the rate in the control area. After intervention, the serious assault rate in the experimental area was 37% lower than in the control area.

The effects of such interventions on patron alcohol consumption is inconclusive. One randomised trial found a statistically significant reduction in observed severe aggression exhibited by patrons. There is some indication of improved server behaviour but it is difficult to predict what effect this might have on injury risk.

Authors' conclusions

There is insufficient evidence from randomised controlled trials and well conducted controlled before and after studies to determine the effect of interventions administered in the alcohol server setting on injuries. Compliance with interventions appears to be a problem; hence mandated interventions may be more likely to show an effect. Randomised controlled trials, with adequate allocation concealment and blinding are required to improve the evidence base. Further well-conducted, non-randomised trials are also needed when random allocation is not feasible.

 

Plain language summary

Are interventions that are implemented in alcohol server settings (e.g. bars and pubs) effective for preventing injuries?

Injuries are a significant public health burden and alcohol intoxication (i.e. drunkenness) is recognised as a risk factor for injuries; indeed the effects of alcohol lead to a considerable proportion of all injuries. Alcohol-associated injuries are a problem in both high- and low-income countries.

Many interventions to reduce alcohol-related injuries have a demand-side focus and aim to reduce individuals' demand and consequently consumption of alcohol. However, there is increasing attention on supply-side interventions, which attempt to alter the environment and 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.

This systematic review was conducted to examine the evidence for the effectiveness of interventions implemented in the alcohol server setting for reducing injuries. The authors of this systematic review examined all studies that compared server settings which received an intervention aimed at facilitating sensible alcohol consumption and/or preventing injuries, to server settings which did not receive such an intervention.

The authors found 23 studies; only five of these measured the effect on injury, the remaining 18 measured the effect on behaviour (by the patrons and/or the servers of the alcohol within the premises). The studies investigated a range of interventions involving server training, health promotion initiatives, a drink driving service, a policy intervention and interventions that targeted the server setting environment.

The authors concluded that there is insufficient high quality evidence that interventions in the alcohol server setting are effective in preventing injuries. The evidence for the effectiveness of the interventions on patron alcohol consumption was found to be inconclusive. There is conflicting evidence as to whether server behaviour is improved and it is difficult to predict what effect this might have on actual injury risk.

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 methodology of future evaluations needs to be improved. 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.

 

摘要

背景

在酒精提供環境的介入來預防傷害

意外傷害是公共衛生的一大負擔且酒精中毒被認為是受傷的危險因子.對於供應方面的介入增加,目的在調整酒精供應與消耗的環境.

目標

評估在供應處的介入手段對於降低受傷的效果.

搜尋策略

我們搜尋Cochrane Injuries Group Specialised Register (九月 2004), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), MEDLINE (January 1966 to September 2004), EMBASE (1980 至 2004, 第 36週), 其他專科資料庫及文章的參考文獻. 我們也與此領域的專家接洽.

選擇標準

對於供應方面的介入增加來調整酒精供應與消耗的環境及促進合宜的酒精消耗及降低與酒精有關的傷害的產生的Randomised controlled trials (RCTs) 及 nonrandomised controlled studies (NRS).

資料收集與分析

兩位作者獨立審查研究結果且評估可能相關研究的全文. 節錄數據併檢驗方法的品質. 因為被研究的介入型態變異性大,聯合的分析並不合適.

主要結論

有二十個研究符合含括標準. 所有的方法品質均不良. 有五個研究使用傷害結果測量 只有一個檢查是隨機分配. 這些研究隨介入方式粗略分成幾種.一個NRS研究供應者的訓練及預估於試驗地區單一夜間車禍下降 23%(已控制地區車禍為控制組). 另一個 NRS 檢驗代喝酒者開車服務的效應並且報告在實驗地區道路車禍受傷下降15%, 而控制地區沒有變化死亡車禍並沒有差別. 一個NRS 評估警察介入的效應, 報告指出於介入前,在實驗地區的嚴重傷害比率為52%,較控制地區高. 在介入後,在實驗地區的嚴重傷害比率為37%,較控制地區低.唯一的RCT 著重於供應設置環境的受傷結果比易碎的玻璃器皿(實驗組)及強化玻璃器皿(控制組)於吧台人員受傷人數 在實驗組受傷的人數較多 (relative risk 1.72, 95% CI 1.15 to 2.59). 一個NRS評估介入目的為降低喝酒場所遭遇的犯罪行為發現於實驗場所所有犯罪率較低(rate ratio 4.6, 95% CI 1.7 to 12, P = 0.01), 受傷方面並無不同(rate ratio 1.1. 95% CI 0.1 to 10, P = 0.093)對於酒精消耗的老顧客的介入效應並無結論. 一隨機的實驗發現觀察老顧客嚴重暴力表現有統計學上明顯的降低.這顯示改善供應者的表現,但很難評估這在於傷害危險的效應.

作者結論

並沒有可信的證據顯示酒精供應設置的介入對於傷害的降低有效果. 對於介入的順應性可能會有問題 因此強制性的介入可能更能顯現效果. 需有足夠配置隱密及人力不可控制的Randomised controlled trials來促進證據基礎. 當隨機配置是不可行時, 需有進一步良好指導的nonrandomised trials.

翻譯人

本摘要由高雄榮民總醫院王曉萍翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

意外傷害是公共衛生的一大負擔且酒精中毒(酒醉)被認為是受傷的危險因子的確酒精造成所有傷害的大部分. 酒精相關的傷害在高及低收入國家都是問題.許多對於降低酒精相關的傷害的介入聚焦於需求方面,目標在於降低個人需求和必然的酒精消耗. 然而, 現在對於供應方面的介入注意增加,這企圖改變那些酒精供應環境目的是去調整喝酒和或喝酒的環境以減低可能的傷害.此系統性的回顧是去檢查酒精供應設置面執行介入來降低傷害的證據. 此系統性回顧的作者檢驗所有比較暴露於促進明智的酒精消耗及或避免受傷的介入措施的供應設置,相較於沒有暴露於如此措施的設施的研究.作者們發現有20個研究 只有五個評估傷害的效果, 其他15個評估行為的效果(經由老主顧及或經營場所的酒精供應者). 這些研究評估介入範圍包含供應者訓練, 健康促進行動, 代喝酒者開車的服務, 警察的介入及主要目標為供應設置環境的介入.作者們結論並沒有可信的證據顯示酒精供應設施的介入可以預防傷害.對於酒精消耗的老主顧介入的效果發現並無結論. 這稍顯示改善供應者的行為但很難預測這對實際傷害危險性有何效果.缺乏對於介入的順應性可能會有問題 因此強制性的介入或對配合者有獎勵可能更能顯現效果. 進一步評估的方法需改進. 研究的焦點可能廣泛為評估其他不是供應者訓練的介入,那之前的研究已經是佔有主要地位. 當收集傷害結果的資料是不可行時, 研究需界定最可能有效取代物指標.