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Reducing alcohol use among adolescents through a community-based multicomponent intervention: an implementation research approach

Abstract

Alcohol consumption is a component cause of many non-communicable diseases (NCDs), including several types of cancers, cardiovascular diseases, diabetes, and substance use disorders. According to World Health Organization, harmful use of alcohol is considered one of the four major risk factors responsible for the worldwide rise of NCDs. In this way, acting to prevent and reduce harmful alcohol consumption during the life course is an important approach to reduce NCDs burden. One of the most effective strategies to reduce alcohol consumption and harm later in life is to delay alcohol use onset among adolescents through evidence-based interventions. Recurrent scientific evidence shows that community-based initiatives promote more consistent and long-term effects in reducing adolescent alcohol use than individual programs implemented as a one-off intervention. These strategies are multicomponent and usually composed of a school prevention program (adolescent), a family program (family), and environmental strategies (community). Another main characteristic is that they are implemented in a context in which stakeholders are an active part of the implementation strategy and have a central role in all stages of the implementation process. In Brazil, a partnership between the United Nations Office for Drugs and Crimes (UNODC) and the Ministry of Health allowed the country to adapt and implement programs with proven international evidence of effectiveness to prevent alcohol and other drug use. Two of them were Unplugged, named Tamojunto 2.0 in Brazil, a school-based intervention with multiple components, including life skills training, normative beliefs, and drug information for adolescents (12-14 year-old) and Strengthening Families Programme 10-14 (SFP 10-14), named Familias Fortes in Brazil, family skills training program for families with children aged 10-14 years old. After adaptation, these programs were supposed to be disseminated by municipalities with the federal government's support. However, despite being highly promising on the national scene, the programs have been mostly discontinued in the municipalities where they have been initially implemented due to lack of "know-how to do" that should be answered through implementation research and a lack of stakeholders involvement. Then, there is a gap to be fulfilled in Brazilian alcohol prevention public policy: the implementation of a community based multicomponent intervention that can integrate the existing, evaluated and not disseminated programs already adapted in Brazil, with community environmental strategies, proved to be effective worldwide, taking into account the appropriate stakeholders' participation in all decision process. We will conduct implementation research with a hybrid design, that is, considering the diad implementation-effectiveness, through the implementation research cycle proposed by the WHO framework to guide implementation research. Phase 1 - Identification of an appropriate intervention; Phase 2- Adaptation and piloting the intervention; Phase 3 - implementation and evaluation of the intervention (including here the core outcomes of the implementation research such as reach, adoption, and fidelity and a pragmatic trial to assess the real-life effect of the community intervention on the delay and reduction of adolescent alcohol use); Phase 4 - Scale-up, describing how the knowledge will be translated, disseminated, sustained with quality in the studied community and in similar ones. The study will use a mixed-methods approach to evaluate the following outcomes: readiness, appropriateness, acceptability, feasibility, fidelity, adoption, reach, sustainability, and effectiveness (real-world efficacy). The proposal will involve two small municipalities in the State of São Paulo, with authorization and involvement of the executive and legislative power of the cities. (AU)

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