From Unplugged to Tamojunto: Changes in the Content of a Preventive Program Could Justify a Negative Effect on the Initiation of Alcohol Use in Early Adolescence?

Introduction: From 2013 to 2017 a national prevention system was implemented by the Brazilian Ministry of Health (BMH), disseminated through the structure of local State and Municipal Secretariats of Health and Education in at least 10 Brazilian states. The BMH conducted transcultural adaptation and implementation of three evidence-based prevention programs that had positive results in Europe and North America. The only program that during this period was submitted to an effectiveness study was Unplugged, named #Tamojunto in Brazil, after transcultural adaptation. The aim of the present study is to investigate, through mixed methods, possible explanation for a negative result obtained in an effectiveness study.

Methods: A three wave school-based cluster randomized controlled trial was conducted in 2014/2015 among 6,391 students in 7th and 8th grades in 72 public schools in 6 Brazilian cities. The intervention evaluated was #Tamojunto, the adapted version of Unplugged. Baseline data were collected prior to program implementation and follow up data were collected 9 months and 21 months later. Content analysis of the Tamojunto Teacher and Students’ Book and of BMH internal documents was performed. Semi-structured interviews with 19 implementers was also included on the analysis. Axis of the qualitative analysis were fidelity and adaptation.

Results: Mean age of the students was 12.5 (SD 0.7). After 9 months, the program seemed to increase first alcohol use, since students in the experimental group had a 30% increased risk of initiating alcohol use (aHR = 1.30, 95%CI 1.13–1.49). The effect decreased after 21 months (aHR=1.13, 95%CI 1.01-1.27). Content analysis of the Program Books identified that the original format and topics was retained, but with several adapted activities and a new visual identity. Changes on core activities were found in 3 lessons. The larger change was on lesson 3, in which content that reinforced non-use of alcohol was replaced by content that emphasized non-intoxication/drunkenness, moving to a harm reduction approach. Teachers discourse presented evidence of exclusion of some activities and the impossibility to complete several lessons. Aspects such as indiscipline of the students, lack of time and enthusiasm in improving the program were reasons for the changes.

Conclusion: Changes in the content concerning alcohol use, from an approach of non-use to a harm reduction approach, seems to be a predictor of the increase in alcohol initiation among 12 y.o Brazilian adolescents. In parallel to this, low fidelity of implementation in some lessons may also have compromised the content.