title: Increasing compliance with alcohol service laws in a developing country: intervention trial in the Kingdom of Bhutan.
abstract: OBJECTIVE
  Bhutan is a low-middle income country that, like many others, experiences significant alcohol-related harm and low compliance with laws restricting availability and promotion. This study assessed changes in compliance of alcohol outlets with sales restrictions following a multi-sector programme aimed at improving this.
  
  
  METHODS
  Pre-post design with covert observation of service practices.
  
  
  METHODS
  Thimphu, Bhutan, June-November 2013. Alcohol is not permitted for sale except from 1 to 10 p.m. Wednesday-Monday. Serving minors (< 18 years old) or intoxicated patrons is illegal.
  
  
  METHODS
  Seventy-one outlets selected randomly from all 209 on-premises outlets in downtown Thimphu.
  
  
  METHODS
  Multi-sector programme involving visits to outlets, education of owners and staff, a toolkit and implementation checks.
  
  
  METHODS
  Ten mystery-shopper visits were made to each outlet both before and after the intervention. We assessed compliance in five purchasing scenarios: (1) before 1 p.m., (2) after 10 p.m., (3) on Tuesdays and (4) shoppers who appeared to be underage or (5) intoxicated. Changes in compliance rates were assessed using multi-variable logistic regression models.
  
  
  RESULTS
  Overall compliance increased from 20 to 34% [difference: 14%; 95% confidence interval (CI) = 7-22%]. Improvement was found in refusals of service before 1 p.m.: 10-34% (difference(adj) = 24%; 95% CI = 12-37%) and on Tuesdays: 43-58% (difference(adj) = 14%; 95% CI = 1-28%). Differences in refusal to serve alcohol: after 10 p.m. (difference(adj) = 15%; 95% CI = -8 to 37%); to underage patrons (difference(adj) = -5%; 95% CI = 14 to 4%); and to intoxicated patrons (difference(adj) = 7%; 95% CI = -7-20%) were not statistically significant. Younger servers, stand-alone bars and outlets permitting indoor smoking were each less likely to comply with the alcohol service laws.
  
  
  CONCLUSIONS
  A multi-sector programme to improve compliance with legal restrictions on serving alcohol in Bhutan appeared to have a modest effect but even after the programme, in two-thirds of the occasions tested, the laws were broken.
authors.affiliation: School of Public Health, Boston University, USA.|School of Medicine and Public Health, University of Newcastle, Australia.
authors.forename: Gampo
authors.initials: G
authors.lastname: Dorji
authors.affiliation: School of Public Health, Boston University, USA.
authors.forename: William
authors.initials: W
authors.lastname: DeJong
authors.affiliation: School of Public Health, Boston University, USA.
authors.forename: Jacob
authors.initials: J
authors.lastname: Bor
authors.affiliation: School of Public Health, Boston University, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Bachman DeSilva
authors.affiliation: School of Public Health, Boston University, USA.
authors.forename: Lora
authors.initials: L
authors.lastname: Sabin
authors.affiliation: School of Public Health, Boston University, USA.
authors.forename: Frank Rich
authors.initials: FR
authors.lastname: Feeley
authors.affiliation: Faculty of  Nursing and Public Health, Thimphu, Bhutan.
authors.forename: Pema
authors.initials: P
authors.lastname: Udon
authors.affiliation: Faculty of  Nursing and Public Health, Thimphu, Bhutan.
authors.forename: Nima
authors.initials: N
authors.lastname: Wangchuk
authors.affiliation: Ministry of Health and National Statistical Bureau, Bhutan.
authors.forename: Ugyen
authors.initials: U
authors.lastname: Wangdi
authors.affiliation: Ministry of Health and National Statistical Bureau, Bhutan.
authors.forename: Tshering
authors.initials: T
authors.lastname: Choden
authors.affiliation: Ministry of Health and National Statistical Bureau, Bhutan.
authors.forename: Mongal Singh
authors.initials: MS
authors.lastname: Gurung
authors.affiliation: Ministry of Health and National Statistical Bureau, Bhutan.
authors.forename: Tandin
authors.initials: T
authors.lastname: Chogyel
authors.affiliation: Ministry of Health and National Statistical Bureau, Bhutan.
authors.forename: Dorji
authors.initials: D
authors.lastname: Wangchuk
authors.affiliation: School of Medicine and Public Health, University of Newcastle, Australia.
authors.forename: Kypros
authors.initials: K
authors.lastname: Kypri
mesh_terms: D000428:Alcohol Drinking / Q000331:legislation & jurisprudence*; D000434:Alcoholic Beverages; D000435:Alcoholic Intoxication; D001631:Bhutan; D003132:Commerce / Q000331:legislation & jurisprudence*; D003906:Developing Countries; D004493:Education; D005246:Feedback; D006801:Humans; D035846:Law Enforcement / Q000379:methods*; D008004:Licensure / Q000331:legislation & jurisprudence; D000066608:Underage Drinking / Q000331:legislation & jurisprudence*
keywords: Alcohol; community intervention; covert observation; education; mystery shopper; policy; service