TRACI L. TOOMEY, PHD * GUDRUN R. KILIAN

JOHN P. GEHAN, MPA MA * CHERYL L. PERRY, PHD

RHONDA JONES-WEBB, DRPH

ALEXANDER C. WAGENAAR, PHD

Qualitative Assessment of Training

Programs for Alcohol Servers and

Establishment Managers

All the authors are with the Division of

Epidemiology, School of Public Health,

University of Minnesota. Dr. Toomey is a

Research Associate, Ms. Kilian is a Com-

munity Program Specialist, Mr. Gehan is

the Project Manager of Project ARM, Dr.

Jones-Webb is a Professor of Epidemiol-

ogy, and Dr. Wagenaar is a Professor of

Epidemiology.

S Y N O P S I S

Objective. In an attempt to reduce the societal burden associated withalcohol-related problems such as underage drinking and drunk driving, some

local communities and state governments mandate training programs foremployees of establishments that serve or sell alcoholic beverages. Thisstudy was designed to assess the available training programs for employeesand managers and to identify states that either mandate training programsor encourage them by reducing establishments' legal liability.

Methods. Training programs were identified through the Internet, key infor-mants, and the research literature. Three researchers independently ratedeach of 22 local and national programs across I0 categories. In addition, theauthors surveyed alcoholic beverage control agencies and legislativeresearch bureaus in the 50 U.S. states.

Results. The results show that training programs are not standardized andvary widely in content, use of behavior change methods, and productionquality. Most programs targeted waitstaff and bartenders. Only one programexclusively targeted owners and managers.

Conclusions. National standards must be developed for training programsfor servers, managers, and owners.

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Violence and injuries are among the leadingcauses of death in the United States.' Alco-hol is implicated in one-third to one-half ofthese deaths, which means that some48,000 deaths per year are due to alcohol-

related injury.2 Because alcohol consumption is influ-enced by a myriad of behavioral, intra- and interpersonal,and environmental factors that are interactive anddynamic,3 4 changes in people and in the environment areneeded to decrease drinking rates and problems relatedto alcohol use.

Server and manager training programs are designed toteach alcohol establishment staff how to sell alcohol inways that avoid sales to underage people and reduce theintoxication levels of patrons. Alcohol servers and sellerscan help support a culture in which high risk drinking isnot acceptable. Responsible alcohol service may involvepreventive strategies-limiting the number of alcoholicbeverages served per customer per hour, promoting thesale of food and non-alcoholic beverages-as well asproactive strategies-preventing alcohol-impairedpatrons from driving and refusing to sell alcohol to obvi-ously intoxicated and underage patrons (both types ofsales are illegal in all states).

EVALUATING TRAININGP RO G R A M S

Server training programs may vary greatly by establish-ment, by community and by state. Some establishmentsvoluntarily participate in training programs, while othersare mandated to do so by local or state governmentalauthorities. Some programs are offered in groups, eitherin the establishment or in a local classroom, and are ledby a professional trainer. In other cases, managers mayconduct training with a staff person one-on-one, show avideo, or provide reading material for employees to look aton their own.

Studies of the effects of server training have shownthat training: (a) increases servers' knowledge andimproves attitudes toward responsible beverage ser-vice;5-9 (b) may increase servers promotion of food andnon-alcoholic beverages;'0 (c) may reduce the risk ofpatron intoxication;54" 1'2 and (d) may decrease alcohol-related traffic crashes.'3

These studies have produced inconsistent findings-in part due to weak research designs but perhaps also dueto the poor quality of the programs being evaluated. Somestudies did not use control groups,9"'0 and some looked atonly a small number of establishments.5-7""l '2

Simply having bartenders and waitstaff watch a 45-minute training videotape at the start of employment isnot adequate. The programs that have been studied havedemonstrated success in increasing the frequency withwhich servers and sellers undertake relatively simple andstraightforward interventions-offering food, soft drinks,and water, checking age identification, and making com-ments about quantity consumed or driving-but notmore difficult ones such as cutting off service of alcoholto an intoxicated patron.6'8

Altering server behaviors that result in refusal of alco-hol sales is clearly a challenge and may require a moreintensive, theory-based curriculum than that needed toreinforce the server behaviors that require less judgment,such as offering food.

COMPONENTS OF A SUCCESSFULP RO G R A M

To increase the likelihood of servers refusing to sell alco-hol to underage and intoxicated patrons, programs mustfirst be designed for the proper audience. Then, regard-less of the target audience, quality programs should coverrelevant content areas, use behavioral change techniquesto increase the likelihood of behavior change, and useappropriate communication methods.

Target audience. According to behavior change theoryas well as previous studies of server training pro-grams,3'4"2 it is essential that managers and owners ofalcohol establishments support and model responsiblealcohol service. Even the best server training programswill not be effective without management support. Bar-tenders and waitstaff will be unlikely to serve alcoholresponsibly if owners and managers do not support andreinforce their training or, even worse, if managementthreatens to discipline staff members if they do not serveunderage or intoxicated customers.

Studies have shown that training of managers canlead to changes in policies in alcohol establishments.6'7"0So in addition to training for alcohol servers and sellers,training is needed to help owners and managers identify,implement, and enforce effective alcohol policies fortheir establishments. The alcohol establishment's policiesand the behaviors of the owner and manager(s) mustbe consistent with the messages provided in servertraining 15,16

Content. Effective training programs provide informa-tion about why changing a given behavior is important yet

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"Alcohol servers and sellers can help support a culture inwhich high risk drinking is not acceptable."

do not overwhelm an audience with so many details thatthe audience becomes bored. Key factors that need to beaddressed in server training programs include perceptionsof norms, the policies and practices of the establishment,and understanding of the social support for specific typesof preventive and proactive interventions.4"14 5 Emphasismust be put on refusing service to underage and intoxi-cated patrons as a norm. In addition, managers, owners,and servers need to understand the legal and social con-text in which they serve alcohol. What are the state andlocal laws regulating alcohol sales? What are the socialconsequences of underage and heavy alcohol use in oursociety?

Behavioral change methods. In addition to knowledgeof the laws and policies regarding alcohol sales, both man-agers and servers need specific techniques that they canuse to refuse illegal sales. Managers and servers need toincrease their skills and confidence in refusing service tounderage and intoxicated patrons even in emotional situa-tions such as when a patron is belligerent or when theunderage customer is close to the server's own age. Break-ing down the desired behavior into smaller componentsand having the servers repeat and practice those compo-nents-for example, through role playing-leads togreater skill development and self-efficacy.3 7

Communication methods. Quality server training pro-grams can take lessons from interpersonal communicationtheory. A training program needs to capture and maintainparticipants' attention.'8 A training program is not likely tohave any substantive effect if participants believe that theprogram has little relevance to them, is unrealistic, or isboring. An evaluation of one server training program9showed that some servers found previous programs to beuninteresting. Also, consistent with communication theo-ries, the major points of the server training should berepeated many times through multiple channels such asvideos, lectures, discussions, and in booster sessions at alater time.'9

It is useful to examine the quality of existing programs

to determine whether further development is warranted inprogram design, standards, or implementation. In addi-tion, it is important to identify government jurisdictionsthat mandate server training programs to determine theextent to which server training programs are being man-dated across the country.

M E T H 0 D S

For the present study, we (a) qualitatively evaluated exist-ing server and manager training programs and (b) identi-fied states that legislatively mandate or encouragestatewide server training.

Review of training packages. We conducted a qualita-tive review of server training packages commonly usedthroughout the United States. The authors identified 24server training programs, including state and national pro-grams, by searching the Internet, contacting key infor-mants in the field, and reviewing the relevant research lit-erature. Because a centralized list of manager and servertraining programs does not exist, there may be other localand state programs that the authors did not identify. Someprograms consisted of either a videotape or written mater-ial, some others of a videotape and a trainers' manual. Stillothers included a videotape, a trainers' manual, and writ-ten material for trainees. Trainers' manuals were intendedfor owners and managers training their own staffs or forprofessional trainers.

Eight of the programs were developed by alcoholindustry groups, six by nonprofit or research groups, sevenby for-profit training companies, and one by a state alco-hol beverage control agency.

We limited our review to programs that specificallytargeted establishments that sell alcohol. We excludedtwo programs that addressed responsible beverage servicebut focused on the role of the community and lawenforcement rather than on alcohol establishments. Wecategorized the remaining 22 programs according to theintended audience: (a) bartenders and waitstaff at estab-lishments where alcoholic beverages are sold for on-site

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consumption; (b) owners and managers of establishments(such as restaurants and bars) where alcoholic beveragesare sold for on-site consumption; (c) both owners/man-agers and bartenders/waitstaff at establishments wherealcoholic beverages are sold for on-site consumption; (d)clerks at establishments (such as liquor, grocery, and con-venience stores) where alcoholic beverages are sold foroff-site consumption; and (e) servers and other workerswho interact with customers at stadiums and arenaswhere alcoholic beverages are sold (including securitystaff, parking lot attendants, and ticket takers, amongothers).

Based on the research literature on server training pro-grams8"2 and behavior change theory,3" 4"7 we identified10 categories in which to rate server training programs.

Content* Legal issues. The legal framework for selling to minors

or intoxicated people (including criminal penaltiesand "dram shop" or civil liability), which identifiesconsequences for servers, managers, and owners.

* Physiological effects. Brief overview of how alcoholaffects the body; skills to recognize cues of intoxication.

* Policy development. Skills to develop and enforceestablishment policies to increase responsible serviceof alcohol.

* Social problems. Health problems associated withalcohol, including traffic crashes, pedestrian injuries,drownings, teen pregnancies, sexually transmitteddiseases, suicide, and violence.

Behavior change elements* Preventing intoxication. Skills to identify obviously

intoxicated patrons; skills to prevent intoxication.* Preventing underage drinking. Skills to identify

minors; strategies for refusing sales to underageyouth.

* Behavior change methods. Methods to build skill leveland self-efficacy, such as peer leadership, role play-ing, and group discussion, instead of a simple lectureformat.

Communication methods* Realism. Use of real life settings, relevant scenarios,

and credible role models.* Respectful ofaudience. Use of a tone that respects the

audience; use of attention-getting techniques such ashumor, montage, and musical soundtracks.

* Production quality. Overall packaging and productionvalues; ease of use; layout and editing.

We scored each program component (videotape, train-ers' manual, managers' manual, and employee materials)on a 4-point scale (0=none, 1 =weak, 2=moderate,3=strong) for each of the 10 categories, based on how wellthey addressed each of the 10 categories. Scores for eachcomponent represent the means of ratings by three of theco-authors, who rated each program independently.Scores were highly consistent across the three raters.Each program component also received an overall score,representing the mean of the scores for each of the 10 cat-egories, with each category receiving equal weighting.

State policies. To identify those states that havestatewide server training policies, we surveyed the 50states' alcohol beverage control agencies and legislativeresearch bureaus. We mailed a 69-item questionnaire toeach beverage control agency, and a longer, 117-itemquestionnaire to each legislative research bureau. The sur-vey response rate was 80% for the alcohol beverage con-trol agencies and 58% for the legislative research bureaus.Overall, we received completed questionnaires fromeither one or both agencies in 46 (92%) states. Highresponse rates were ensured through multiple mailingsand follow-up phone calls.

Respondents from both types of agencies were askedabout changes in their states' alcohol control laws since1967. For the present analysis, we looked at answers to thefollowing question: "Since 1967, has your state enactedlegislation that encourages alcohol establishments to trainalcohol servers?" If staff members responded yes, theywere then asked whether server training was: (a) mandatedby state law or (b) encouraged as a means by which estab-lishments could reduce their legal liability for sales tointoxicated customers that result in injuries to third par-ties. In addition to the surveys, we conducted legalresearch in each of the 50 states to verify the accuracy ofthe completed surveys and to identify the training policiesof states from which we did not receive completed surveys.

RESULTS

Training programs. The ratings of the 22 programs areshown in the Table.

Target audience. Existing training packages varied in termsof intended audiences. Some programs had only oneintended audience, while others had multiple compo-nents, each directed at a different audience. Eight of the22 programs targeted only bartenders and waitstaff. Nineincluded at least one component that addressed owners or

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managers of alcohol establishments. Only one of theseprograms (consisting of a videotape) exclusively targetedowners and managers. Four of the programs had compo-nents that dealt with either off-site alcohol sales or alcoholsales at stadiums and arenas.

Content. Some content areas were more comprehensivelycovered than others. Only six of the programs had at leastone component that were rated as "moderately" to"strongly" covering legal issues related to alcohol sales.Most programs discussed alcohol-related social problemsonly in the context of traffic crashes, if they covered socialproblems at all. Six programs covered several relevantsocial issues, such as traffic crashes and alcohol-relatedviolence. Twelve programs addressed underage youthissues, such as ID checking and underage sales, at leastmoderately well, according to the raters. Two programsexclusively focused on preventing alcohol sales to under-age youth and not on preventing sales to intoxicatedpatrons. Fifteen programs were found to cover issuesrelated to intoxicated patrons moderately well or better.Eight of the programs had at least one component thatappropriately covered physiological issues, providing nei-ther too much nor too little information. Twelve programswere at least moderately successful in covering the impor-tance of establishment policies. Three of these programs,however, did not target owners and managers and aretherefore unlikely to result in policy changes that wouldsupport responsible alcohol service.

Behavior change methods. Few of the programs usedbehavior change techniques. Programs consisting ofaudiovisual tapes alone obviously could not use discussiongroups or role playing. Some videotapes incorporatedbehavior change techniques by using peer leaders-alco-hol servers or owners and managers-as on-screenspokespeople instead of legal or scientific experts.

Communication methods. The programs varied in terms ofmode of presentation. Eleven consisted of only a video-tape, with no supplemental written material to guidetrainers or trainees. One program was delivered by aninteractive computer program. Six of the programs usedvideotapes and a trainer. The remaining programs used acombination of trainers and written material.

Fewer than half the programs had one or more compo-nents that, in the raters' opinion, adequately used realisticscenarios and recommendations. On the whole, themajority of the programs were respectful of the audience;however, eight had at least one component that we felt

could be improved by incorporating realistic scenarios,such as a busy and loud bar scene, or by being morerespectful of the audience, not talking down to them.Thirteen of the 22 programs had at least one componentthat had poor production quality.

Overall scores. Overall scores ranged widely across compo-nents and programs, from 0.83 to 2.87. Only two pro-grams (numbers 16 and 17) received an overall rating of2.5 or better. However, both of these programs targetedonly bartenders and waitstaff.

State laws on server training. As of 1994, 13 states hadenacted some form of legislation on alcohol server training.Eight states (Alaska, Delaware, Maryland, New Mexico,Oregon, Utah, Vermont, and Wisconsin) require servers toreceive training. Florida, Maine, New Hampshire, andTexas have legislation that encourages but does not man-date server training. Instead, in these states alcohol estab-lishments' potential liability for negligent alcohol sales iseither diminished or abolished if the establishments pro-vide server training for their employees. Michigan requiresinsurance companies to give discounts to establishmentsthat mandate employee server training. Eight states have alegislatively mandated system for reviewing and certifyingserver training programs; however, in our review of statelaws, we found that the level of monitoring and the certifi-cation process vary across these states.

DISCUSSION

Although several states mandate server training and othersreduce establishments' liability if employees are trained, astandardized server training curriculum has not yet beendeveloped. Of the many programs that do exist, some havebeen designed by private, for-profit companies, some arepart of publicly funded research projects, and some havebeen developed by organizations that have close ties to thealcohol industry.

Our review of 22 existing programs shows great vari-ability across programs in terms of coverage of essentialcontent areas, use of behavior change techniques, andcommunication methods.

Many of the programs were rated strongly in one cate-gory or had one highly rated component, but only a fewprograms received high scores across all categories andcomponents. No single program was outstanding in allrespects. The two programs that scored highest in ourreview (numbers 16 and 17) covered all content areas, hadgood production values, and employed behavior change

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techniques. These programs, however, like most of theothers, focused solely on alcohol bartenders and waitstaff,with no attention given to managers or owners.

The purpose of server training programs is to alteralcohol serving practices to reduce intoxication levels ofcustomers and prevent illegal sales to underage people, allwith the ultimate goal of reducing alcohol-related prob-lems. Training programs that do not cover essential con-tent areas, have few behavior change components, or arepoorly produced are unlikely to achieve these goals. Ourresults indicate that existing server training programs needfurther refinement.

Recommendations. Based on this qualitative review, werecommend that national standards should be developedfor server and manager training programs. A national con-sensus conference should be held, with participants froma wide range of organizations and backgrounds, including:representatives from the National Institute on AlcoholAbuse and Alcoholism, the Centers for Disease Controland Prevention, the National Highway TransportationSafety Association, the Center for Substance Abuse Pre-vention, and interested foundations such as the RobertWood Johnson Foundation; public health and behavioralchange researchers; specialists in curriculum develop-ment; representatives of organizations that offer servertraining packages; representatives of alcohol retailers and

the hospitality industry; representatives of insurance agen-cies that issue dram shop insurance; and experts in statealcohol laws.

The standards developed at the consensus conferenceshould include criteria for (a) content areas that must becovered, (b) use of scientifically based behavior changetechniques, and (c) use of theoretically based communica-tion methods. State policy makers could then require thattraining programs in their states meet these standards. Anational consensus conference could also aid in the devel-opment of guidelines for establishing state systems forevaluating and certifying quality training programs.

One recommendation may be that states set up stan-dard training programs in neutral institutions such astechnical colleges. Once programs using the identifiedstandards and systems are developed, researchers shouldevaluate the programs to assess their effectiveness inreducing sales to intoxicated and underage customers anddecreasing alcohol-related problems such as trafficcrashes, homicides, and other forms of violence.

These approaches should significantly improve thequality of server training nationally so that good intentcan be followed by effective action.

Preparation of this paper was assisted by grants from the Robert WoodJohnson Foundation and the National Institute on Alcohol Abuse andAlcoholism.

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