***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE The Rhode Isl and Community Alcohol Abuse and Injury Prevention Project ( CAAIPP ) , implemented from 1984 through 1989 , employed the " community gatekeeper " approach to reduce alcohol-related injuries and deaths . Targeting alcohol servers rather than drinkers , community-wide interventions were design ed and implemented to encourage responsible serving behaviors through the adoption of techniques of responsible service . The primary goal of the CAAIPP server intervention evaluation was to assess both short-term and long-term changes in behavior of alcohol beverage servers who were recipients of CAAIPP training . METHOD A 5-hour training curriculum on " Responsible Alcohol Service " was offered to all alcohol servers in a r and omly selected study community . A prospect i ve study design was used to evaluate long-term changes in the self-reported behavior of 321 trainees using three time-points over 5 years . A cross-sectional survey was conducted 4 years posttraining to compare rates of self-reported server behaviors in the intervention community ( n = 106 ) with two comparison communities ( nA = 56 , nB = 49 ) . RESULTS Fifteen months after training , trainees reported significantly higher levels of desired serving behavior than nontrained servers . Though positive effects of server training diminished with time , responsible serving behavior 4 years posttraining remained higher than pretraining levels . The impact appeared greatest for servers with fewer years serving experience , wait-persons , younger servers and servers who worked in establishments without written policies regarding serving practice s. CONCLUSIONS The results with regard to modifying server behavior are positive and indicate that server interventions shown to be efficacious should be implemented . Training programs that target specific serving skills in repeat sessions may be most promising for improving server behavior , particularly among both young and new servers working in establishments without written policies regarding serving practice OBJECTIVES The purpose of this study ws to assess whether a community program begun in March 1988 that organized multiple city departments and private citizens could reduce  alcohol-impaired driving , related driving risks  , and  traffic deaths and injuries . METHODS Trends in fatal crashes and injuries per 100 crashes were compared in Saving Lives Program cities and the rest of Massachusetts from March 1984 through February 1993 . In annual roadside surveys conducted at r and omly selected locations , safety belt use among occupants of 54577 vehicles and travel speeds of 118442 vehicles were observed . Four statewide telephone surveys ( n = 15188 ) monitored self-reported driving after drinking . RESULTS In program cities relative to the rest of Massachusetts during the 5 program years in comparison with the previous 5 years , fatal crashes declined 25 % , from 178 to 120 , and fatal crashes involving alcohol decreased 42 % , from 69 to 36 . Visible injuries per 100 crashes declined 5 % , from 21.1 to 16.6 . The proportions of vehicles observed speeding and teenagers who drove after drinking were cut in half . CONCLUSIONS Interventions organized by multiple city departments and private citizens can reduce driving after drinking , related driving risks , and traffic deaths and injuries OBJECTIVE This article reports the results of the Sacramento Neighborhood Alcohol Prevention Project ( SNAPP ) . SNAPP set as its goal the reduction of alcohol access , drinking , and related problems in two low-income , predominantly ethnic minority neighborhoods , focusing on individuals between the ages 15 and 29 , an age group identified with high rates of alcohol-involved problems . METHOD Two neighborhoods in Sacramento were selected to be the intervention sites because they were economically and ethnically diverse and had high rates of crime and other drinking-related problems . The quasi-experimental design of the study took a " phased " approach to program implementation and statistical examination of outcome data . Outcome -related data were collected in the intervention sites as well as in the Sacramento community at large . Five project interventions included a mobilization component to support the overall project , a community awareness component , a responsible beverage-service component , an underage-access law enforcement component , and an intoxicated-patron law enforcement component . Archival data were collected to measure and evaluate study outcomes and to provide background and demographic information for the study . RESULTS Overall , we found significant ( p < .05 ) reductions in assaults as reported by police , aggregate emergency medical services ( EMS ) outcomes , EMS assaults , and EMS motor vehicle accidents . CONCLUSIONS Results from the Sacramento Neighborhood Alcohol Prevention Project demonstrate the effectiveness of neighborhood-based interventions in the reduction of alcohol-related problems such as assaults , motor vehicle crashes , and sale of alcohol to minors The purpose of this study was to evaluate the effectiveness of Safer Bars , an intervention to reduce aggression in bars . A total of 734 pre - post-intervention observations were conducted by trained observers on Friday and Saturday nights between midnight and 2 a.m. in 18 large capacity ( > 300 ) Toronto bars and clubs assigned r and omly to receive the intervention ( 69 % participation rate of the 26 assigned ) and 12 control bars .  As part of the intervention , owners/managers completed the  risk assessment workbook  to identify ways of reducing environmental risks , and 373 staff and owners/managers ( 84 % participation rate ) attended a 3-hour training session focused on preventing escalation of aggression , working as a team and resolving problem situations safely . The main outcome measures were rates of severe aggression ( e.g. punching , kicking ) and moderate physical aggression ( e.g. shoving , grappling ) . Hierarchical linear modelling ( HLM ) comparing pre - post aggression for intervention versus control bars indicated a significant effect of the intervention in reducing severe and moderate aggression . This effect was moderated by turnover of managers and door/security staff with higher post-intervention aggression associated with higher turnover in the intervention bars . The findings indicate the potential for a st and -alone relatively brief intervention to reduce severe and moderate physical aggression in bars Clear policies and expectations are key to increasing responsible service of alcohol in licensed establishments . Few training programs focus exclusively on owners and managers of alcohol establishments to reduce the risk of alcohol service . Project ARM : Alcohol Risk Management is a one-on-one consultation program for owners and managers . Participants received information on risk level , policies to prevent illegal sales , legal issues , and staff communication . This nonr and omized demonstration project was implemented in five diverse bars . Two waves of underage and pseudo-intoxicated purchase attempts were conducted pre- and postintervention in the five intervention bars and nine matched control bars . Underage sales decreased by 11.5 % , and sales to pseudo-intoxicated buyers decreased by 46 % . Results were in the hypothesized direction but not statistically significant . A one-on-one , outlet-specific training program for owners and managers is a promising way to reduce illegal alcohol sales , particularly to obviously intoxicated individuals Objective —To evaluate the effectiveness , in terms of injury prevention , of toughened pint glassware in bars . Design —R and omised controlled trial . Setting —A r and om sample of 57 bars in South Wales , West Midl and s , and West of Engl and . Subjects — A total of 1229 bar workers . Intervention — Complete replacement of pint glasses with annealed ( control ) or toughened ( intervention ) glassware . Main outcome measures —Bar  staff injuries recorded monthly : number , site , and severity ( lifestyle impact ; treatment need ) of injuries . Results —Ninety eight bar staff experienced 115 injuries : 43 in the control group , 72 in the intervention group . Adjusting for people at risk gave a relative risk ( RR ) of 1.48 ( confidence interval ( CI ) 1.02 to 2.15 ) . Similarly , adjusting for hours worked gave RR 1.57 ( CI 1.08 to 2.29 ) . Thus , injury rate was 60 % higher in the intervention group ( p<0.05 ) , with no significant difference in severity . Most were h and injuries requiring first aid . Injuries tended to occur simultaneously in more than one body part in the intervention group , reportedly caused by spontaneous disintegration of toughened glassware . Impact resistance testing showed the energy required to break annealed glass ( 1.8 ± 0.2 J ) was greater than that for toughened glass ( 1.4 ± 0.2 J ) , though the difference was not significant . Conclusions —Glass with lower impact resistance caused more injuries . “ Toughened ” glassware had lower impact resistance . St and ards for toughening need to be developed Sometimes interventions in r and omized clinical trials are not allocated to individual patients , but rather to patients in groups . This is called cluster allocation , or cluster r and omization , and is particularly common in health services research . Similarly , in some types of observational studies , patients ( or observations ) are found in naturally occurring groups , such as neighborhoods . In either situation , observations within a cluster tend to be more alike than observations selected entirely at r and om . This violates the assumption of independence that is at the heart of common methods of statistical estimation and hypothesis testing . Failure to account for the dependence between individual observations and the cluster to which they belong can have profound implication s on the design and analysis of such studies . Their p-values will be too small , confidence intervals too narrow , and sample size estimates too small , sometimes to a dramatic degree . This problem is similar to that caused by the more familiar " unit of analysis error " seen when observations are repeated on the same subjects , but are treated as independent . The purpose of this paper is to provide an introduction to the problem of  clustered data in clinical research . It provides guidance and examples of methods for analyzing clustered data and calculating sample sizes when planning studies . The article concludes with some general comments on statistical software for cluster data and principles for planning , analyzing , and presenting such studies CONTEXT High-risk alcohol consumption patterns , such as binge drinking and drinking before driving , and underage drinking may be linked to traffic crashes and violent assaults in community setting s. OBJECTIVES To determine the effect of community-based environmental interventions in reducing the rate of high-risk drinking and alcohol-related motor vehicle injuries and assaults . DESIGN AND SETTING A longitudinal multiple time series of 3 matched intervention communities ( northern California , southern California , and South Carolina ) conducted from April 1992 to December 1996 . Outcomes were assessed by 120 general population telephone surveys per month of r and omly selected individuals in the intervention and comparison sites , traffic data on motor vehicle crashes , and emergency department surveys in 1 intervention-comparison pair and 1 additional intervention site . INTERVENTIONS Mobilize the community ; encourage responsible beverage service ; reduce underage drinking by limiting access to alcohol ; increase local enforcement of drinking and driving laws ; and limit access to alcohol by using zoning . MAIN OUTCOME MEASURES Self-reported alcohol consumption and driving after drinking ; rates of alcohol-related crashes and assault injuries observed in emergency departments and admitted to hospitals . RESULTS Population surveys revealed that the self-reported amount of alcohol consumed per drinking occasion declined 6 % from 1.37 to 1 . 29 drinks . Self-reported rate of " having had too much to drink " declined 49 % from 0.43 to 0.22 times per 6-month period . Self-reported driving when " over the legal limit " was 51 % lower ( 0 . 77 vs 0.38 times ) per 6-month period in the intervention communities relative to the comparison communities . Traffic data revealed that , in the intervention vs comparison communities , nighttime injury crashes declined by 10 % and crashes in which the driver had been drinking declined by 6 % . Assault injuries observed in emergency departments declined by 43 % in the intervention communities vs the comparison communities , and all hospitalized assault injuries declined by 2 % . CONCLUSION A coordinated , comprehensive , community-based intervention can reduce high-risk alcohol consumption and alcohol-related injuries result ing from motor vehicle crashes and assaults . JAMA . 2000;284:2341 - 2347 AIMS To evaluate effects of a training program for owners/managers of alcohol establishments-Alcohol Risk Management (ARM)-on : ( i ) propensity to sell alcohol to obviously intoxicated patrons ; and ( ii ) changing establishment-level policies/ practice s. DESIGN We assigned alcohol establishments r and omly to intervention ( full-ARM ) and delayed-intervention/control ( ARM Express ) conditions . SETTING One large metropolitan area in Midwestern United States . PARTICIPANTS Owners and managers at 231 on-premise alcohol establishments ( i.e. bars , restaurants ) .  INTERVENTION Training programs consisted of one-to-one sessions with the owner/manager at each establishment . The goal of training was to help owners/managers to select and implement alcohol control policies in their establishments . The full-ARM training consisted of four one-to-one sessions and the ARM Express was a single session . MEASUREMENTS We measured intervention effects through baseline and follow-up pseudo-intoxicated alcohol purchase attempts ( i.e. feigning intoxication while attempting to purchase alcohol ) and telephone surveys of owners/managers at alcohol establishments . FINDINGS Sales rates to pseudo-intoxicated patrons reduced 23 % ( relative to delayed-intervention/control condition ) at the first follow-up purchase attempt ( P = 0.06 ) but returned to baseline levels 3 months later . On average , establishments selected 13 of 18 recommended policies , but in multivariate models we observed no significant differences at follow-up in reported policies/ practice s across establishments . CONCLUSIONS Reliance on manager training to promote responsible establishment alcohol policies is not sufficient to prevent illegal alcohol sales to obviously intoxicated patrons and to reduce alcohol-related problems AIMS To decrease alcohol consumption among patrons in student pubs by server-training programmes . DESIGN R and omized controlled trial . SETTING University campus . PARTICIPANTS A total of 1322 students visiting local student pubs during ordinary pub evenings .  INTERVENTION Educational programmes were given to b 
    Output:
    
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 no reliable evidence that interventions in the alcohol server setting are effective in reducing injury .
Compliance with interventions appears to be a problem ; hence m and ated interventions may be more likely to show an effect .