ABSTRACT

To encourage development of negative attitudes toward alcohol use and thus prevent early onset of alcohol use, an intersectoral intervention was conducted from 2014 to 2015 among Cuban adolescents in 14 schools in Havana. The intervention included 312 students (189 girls and 123 boys) aged 14 to 15 years in 10th grade of high school or vocational school. Workshops were conducted using participatory techniques and group dynamics. Qualitative methods were applied, including narrative, desiderative and projective techniques. Indicators included attitudes, motivation, interests and perception of risk. Following the intervention, 82.7% (258/312) of participants reported healthy cultural and recreational interests and 61.9% (193/312) reinforced negative attitudes toward drinking. Such interventions can help prevent early onset of alcohol use in school settings. Given the positive results, the intervention is slated to be reproduced in other Cuban provinces.

Adolescents; prevention; alcoholism; attitudes; Cuba

INTRODUCTION

Alcohol is one of the psychoactive substances most commonly consumed by adolescents and young adults[¹1. Londono Pérez C, Vinaccia S. Prevención del abuso en el consumo de alcohol en jóvenes universitarios: lineamientos en el diseno de programas costo-efectivos. Psicologia y Salud. 2005 Jul-Dec;15(2):241-9. Spanish.] and its use is a major public health problem. Harmful use of alcohol—which includes irresponsible and inappropriate use, use against medical advice, and drinking to the point of intoxication—presents a serious threat to health, well-being and life.[²2. Gonzalez Menéndez R, Galan Beiro GM. El alcohol: la droga bajo la piel del cordero. Rev Hosp Psiquiatrico de la Habana [Internet]. 2007 [cited 2016 Feb 7];4(3). Available from: http://www.revistahph.sld.cu/hph0307/hphsu0307.html. Spanish.
http://www.revistahph.sld.cu/hph0307/hph... ] According to the World Health Organization (WHO), harmful use of alcohol is a causal factor in more than 200 diseases and leads to 3.3 million deaths worldwide (5.9% of all deaths) annually.[³3. World Health Organization [Internet]. Nota descriptiva No. 349 Alcohol. Geneva: World Health Organization; 2015 Jan [cited 2016 Feb 16]. Available from: http://www.who.int/mediacentre/factsheets/fs349/es/. Spanish.
http://www.who.int/mediacentre/factsheet... ]

Alcohol is a central depressant and can cause psychological and physical dependency.[⁴4. Lopes RMF, Menezes RC, Farina M, Moraes A, Bastos AS. [Alcoholism and cognitive interferences in attention and perception processes]. Panam J Neuropsychol. 2015;9(3):15-23. Portuguese.] The biological, psychological and social effects of early-onset alcohol use can be dramatic and irreversible,[⁵5. Zaldivar Basulto F, López Rios F, Garcia Montes JM, Molina Moreno A. Consumo autoinformado de alcohol y otras drogas en población universitaria espanola. Electronic J Res Educ Psychol. 2011;9(1):113-32. Spanish.] and the developing adolescent brain is particularly vulnerable to the addictive effects of alcohol and other drugs.[⁶6. Steinberg L. Risk taking in adolescence. New perspectives from brain and behavioral science. Curr Dir Psychol Sci. 2007 Apr;16(2):55-9.,⁷7. Spear LP, Varlinskaya EI. Adolescence alcohol sensitivity, tolerance, and intake. Recent Dev Alcohol. 2005;17:143-59.]

Modern society has seen a rise in recreational drinking, affecting individuals from a wide range of ethnic, cultural, and sociodemographic groups. In addition, drinking is associated with many aspects of social and cultural life, and is taken for granted as a part of festive celebrations and social gatherings.[⁸8. Sarasa-Renedo A, Sordo L, Molist G, Hoyos J, Guitart AM, Barrio G. Principales danos sanitarios y sociales relacionados con el consumo de alcohol. Rev Espanola Salud Pùblica [Internet]. 2014 Jul-Aug [cited 2016 Feb 20];88(4). Available from: http://dx.doi.org/10.4321/S1135-57272014000400004. Spanish.
http://dx.doi.org/10.4321/S1135-57272014... ] Even at levels not normally considered excessive, alcohol can cause serious harm,[⁹9. Gonzalez Menéndez R. Mensaje a multiplicadores comunitarios sobre la repercusión social global del uso excesivo de drogas. Rev Cubana Salud Pùblica. 2010 Jan-Mar;36(1):165-84. Spanish.] but its deep cultural roots hinder implementation of public policies to curb its consumption.

Although public policies can sometimes encourage drinking (e.g., unrestricted retail access), they can also be a resource to prevent alcohol abuse and addiction. The most effective are those related to financial policy and pricing, regulation of availability and accessibility, and policies on drinking and driving.[¹⁰10. World Health Organization. European action plan to reduce the harmful use of alcohol 2012–2020. [Internet] Copenhagen: World Health Organization; 2011 Sep [cited 2016 Feb16]. Available from: http://www.euro.who.int/data/assets/pdf_file/0006/147732/RC61_wd13E_Alcohol_111372_ver2012.pdf
http://www.euro.who.int/data/assets/pdf_... ] Other effective tools for controlling alcohol-related problems are education programs for minors, modifications to drinking settings (for example responsible beverage service training), and (properly designed and implemented) public information campaigns.[¹¹11. Foxcroft DR, Tsertsvadze A. Universal alcohol misuse prevention programmes for children and adolescents: Cochrane systematic reviews. Perspect Public Health. 2012 May;132(3):128-34.] For example, in the first decade of the 21st century, public health policies in Spain led to a decline in frequent consumption of wine and liquor among adolescents (although incidence of episodic intoxication rose).[¹²12. Sanchez-Queija I, Moreno C, Rivera F, Ramos P. Tendencias en el consumo de alcohol en los adolescentes escolarizados espanoles a lo largo de la primera década del siglo XXI. Gac Sanit. 2015;29(3):184-9. Spanish.]

In Cuba, 45.2% of the population aged >15 years consumes alcohol, with a 7%–10% alcoholism prevalence (one of the lowest in Latin America).[¹³13. Gonzalez Menéndez R. La atención integral al alcoholismo: experiencia cubana. Rev Cubana Med [Internet]. 2008 Apr-Jun [cited 2014 Nov 14];47(2). Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75232008000200012. Spanish.
http://scielo.sld.cu/scielo.php?script=s... ] On average Cubans begin to drink at about age 15.[¹⁴14. World Health Organization. Informe sobre el Sistema de Salud Mental en la Repûblica de Cuba. Havana: World Health Organization; Pan American Health Organization; 2012. 62 p. Spanish.] In 2014, approximately 23% of adolescent boys and 11% of adolescent girls started to drink before age 15 years.[¹⁵15. National Health Statistics and Medical Records Division (CU). Encuesta de indicadores mùltiples por conglomerados, Cuba, 2014. Havana: Ministry of Public Health (CU); 2014. 12 p. Spanish.]

The Ministry of Public Health’s (MINSAP) prevention and treatment programs in community mental health services, psychiatric hospitals and primary health care cannot by themselves fully address the problem of alcohol harm in Cuba.[¹⁶16. Ministry of Public Health (CU). Programa Nacional de Salud para la Atención Integral Diferenciada a la Adolescencia 2012-2017. Havana: Ministry of Public Health (CU); 2012. 36 p. Spanish.] We also need concerted intersectoral actions. Intersectorality in health is defined as the coordinated intervention of institutions from more than one social sector through actions focused totally or partially on treatment of problems related to health, well-being and quality of life.[¹⁷17. Castell-Florit P. La intersectorialidad en la practica social. Havana: Editorial de Ciencias Médicas; 2007. p. 14-22. Spanish.]

Education is one key sector in this area. The Ministry of Education (MINED)’s Health Promotion and Education Program makes antismoking, antidrinking and antidrug education part of core curriculum.[¹⁸18. Ministry of Education (CU). Programa Director de Promoción y Educación para la Salud en el Sistema Nacional de Educación. Havana: Ministry of Education (CU); 1999. Spanish.] According to the program, by the end of ninth grade, students should have learned about the negative effects of excessive alcohol use, and by the end of twelfth grade, they should express negative attitudes to alcohol, in light of its harmful effects.

Cuba has a long tradition of alcohol production, and alcohol producers and manufacturers constitute another important sector in prevention of alcohol-related harm. This group has taken an interest in preventing underage drinking, based on a policy of corporate social responsibility,[¹⁹19. Carroll AB. The pyramid of corporate social responsibility: toward the moral management of organizational stakeholders. Business Horizons. 1991 Jul-Aug;34(4):39-48.] defined as a company’s ongoing commitment to adhering to ethical guidelines and contributing to economic development while improving the quality of life of its employees, their families, local communities and society at large.[²⁰20. Belhouari A, Buendia Martinez I, Lapointe MJ, Tremblay B. La responsabilidad social de las empresas: ^un nuevo valor para las cooperativas? CIRIEC-Espana. 2005;53:191-208. Spanish.] Historically, discussions of corporate social responsibility have centered on corporate ethics and the degree to which companies support society with contributions of money, time, and talent (including support for sustainable development and collaboration with governments, the public health sector, and scientific and academic communities).[²¹21. World Commission on the Environment and Development. Informe Brundtland. Nuestro futuro comûn. Oxford: Oxford University Press; 1987. Spanish.,²²22. Argandana A, Fontrodona J, Garcia P. Libro blanco del consumo responsable de alcohol en Espana. Barcelona: Universidad de Navarra; 2009. p. 61-2. Spanish.] Companies in the beer–wine–liquor sector have promoted a new global platform on responsible drinking based on explicit commitments, especially to reducing alcohol use by minors and drivers.[²³23. Pringuet P. Compromisos de la industria (20132018). Washington, D.C.: International Center for Alcohol Policies; 2012. Spanish.] Cuba’s leading alcohol producer, Havana Club International S.A. (HCI), has had a corporate social responsibility policy aimed at reducing alcohol harmful use since 2013.[²⁴24. Carrillo Ortega V. Havana Club empenada en reducir consumo nocivo de alcohol. Agencia Cubana de Noticias [Internet]. 2014 Jun 8 [cited 2016 Feb 17]. Available from: http://www.acn.cu/titulares/1821-havana-club-empenada-en-reducir-consumo-nocivo-de-alcohol. Spanish.
http://www.acn.cu/titulares/1821-havana-... ]

This paper describes an intersectoral intervention to reduce alcohol consumption in a group of Cuban adolescents, a collaboration among the Medical University of Havana’s Academic Development Center on Drug Dependency (CEDRO; representing the academic sector), MINED (representing the education sector), and HCI (representing the business sector).

INTERVENTION

Objective, justification and population

The objective was to promote adolescents’ awareness of alcohol-related risk, negative attitudes to alcohol, and alcohol-free lifestyles and behaviors. The intent was to respond to adolescents’ need to empower themselves to choose healthy behaviors with respect to drinking, in accordance with MINSAP’s National Comprehensive Adolescent Health Program 2012–2017[¹⁶16. Ministry of Public Health (CU). Programa Nacional de Salud para la Atención Integral Diferenciada a la Adolescencia 2012-2017. Havana: Ministry of Public Health (CU); 2012. 36 p. Spanish.] and MINED’s Health Promotion and Education Program.[¹⁸18. Ministry of Education (CU). Programa Director de Promoción y Educación para la Salud en el Sistema Nacional de Educación. Havana: Ministry of Education (CU); 1999. Spanish.] Activities were based on identifying the learning needs of ninth-grade students, through a pilot study of 23 adolescents who began their technical training in Havana’s Manuel Fajardo Medical Faculty in the 2012–2013 academic year (in Cuba, middle-level health technicians receive their training at medical schools, where they have separate facilities and teachers). Included were students considered vulnerable to developing habitual use of alcohol or other drugs, by virtue of coming from dysfunctional homes, having poor academic records and being unmotivated by the specialty they were studying. Participants proposed that the intervention be called “You Decide,” since they saw it as providing them with the skills to make correct decisions about drinking.

Following the pilot study, we recruited 312 10th-grade students (189 girls and 123 boys aged 14–15 years) in 14 educational institutions (high schools or vocational technical schools) in Havana during the 2014–2015 academic year (4 high schools and 10 medical faculties).

Activities

The intervention, conducted from September 2014 through July 2015, involved various activities: 1) lectures on early onset of alcohol use and its consequences, in order to increase perception of risk; 2) cultural and sports activities to enrich lifestyles and develop personal resources and recreational activities not involving alcohol consumption; and 3) activities to encourage development of life plans.

CEDRO was responsible for coordinating the project and implementing activities to demonstrate alcohol’s harmful health effects. MINED facilitated access to students, programmed biweekly project activities during regularly scheduled classes, and supported vocational and sports activities. HCI collaborated with cultural activities and organized workshops on nonalcoholic drinks, financed the printing of evaluation instruments and educational materials, and contributed resources for student transportation, an awards contest, and a concert for the program finale. Educational activities included workshops using participatory techniques and group exercises. The workshops, objectives and activities are presented in Table 1.

Indicators, data collection and analysis

The main indicators were attitudes, motivation, interests and perception of risk; also examined were peer relations, academic performance, development of personal resources, and sense of health and well-being. Qualitative procedures (specifically narrative, desiderative and projective techniques) were used.[²⁵25. Gonzalez Llaneza FM. Instrumentos de evaluación psicológica. Havana: Editorial de Ciencias Médicas; 2007. p. 375-83. Spanish.] The narrative element consisted of an essay on the topic of alcoholic beverages, to elicit attitudes (positive, negative or neutral). The desiderative technique involved having each student list and rank their ten main goals and aspirations, to identify information concerning “Healthy cultural and recreational interests” and “vocational interests and future plans.” The projective technique called for students to complete phrases concerning key indicators (coping resources, social relationships, family conflicts, health problems, perception of risks and motivation to modify risky behaviors).

Before and after the intervention, participants received printed questionnaires or instructions and responded in writing. Teachers provided information on academic performance. All information was entered into a database and the results were presented in percentages. Content analysis was done of the material gathered through the various techniques.

Ethics

The study was approved by the Scientific Research Ethics Committee of the General Calixto García Medical School, and authorized by MINED and the directors of participating institutions. Participants were assured of confidentiality; they and their parents provided written informed consent.

RESULTS

Prior to the intervention, 62.2% (194/312) of participants had initiated occasional drinking. No additional students initiated drinking during the intervention, and after it, there was a rise in indicators suggesting a shift toward healthy cultural and recreational activities (from 40.7% to 82.7%) and formulation of vocational aspirations in life plans (from 30.4% to 69.5%). Perception of the risks involved in drinking and drug use increased appreciably (from 42.3% to 77.9%). There was a concomitant increase in negative attitudes toward drinking (from 26.9% to 61.9%) (Table 2).

At the cognitive level, participants were better informed about risks associated with early-onset alcohol use, allowing them to understand the effects of alcohol on the human body and develop their perception of alcohol-related risks. At the behavioral level, interests were promoted that encouraged behaviors not associated with alcohol use, such as visits to cultural centers for exhibits and performances, and community activities related to vocational interests. We observed that students developed motivation and experiences that empowered them to reject alcohol use during adolescence.

Participants’ willingness to enrich their lifestyles also increased through development of various cultural, sports and recreational activities. Motivation to modify risky behaviors (such as limited participation in social activities and little time devoted to individual study and personal development) increased from 42% to 63.5% (Table 2), suggesting that reinforcing negative attitudes towards drinking can help students steer clear of unhealthy behaviors. The proportion of students with satisfactory academic results (passing grades) also improved (from 56.7% to 75%) (Table 2). While other educational activities besides the intervention may have come into play, it is plausible that the development of vocational interests and future projects also helped nurture academic performance.

There were only modest increases in the remainder of the indicators. For example, good peer relationships were already common before the intervention, and this type of intervention could not be expected to modify domestic conflicts or students’ preexisting health problems. Substantial changes in personal resources were also unlikely, since adolescent brains have not yet fully developed the capacity to effectively manage complex environmental contingencies.

The 312 direct beneficiaries launched social communications activities in their schools and invited their peers to activities that reinforced negative attitudes toward drinking, such as a contest in which students expressed their views on the issue through drawings, photography and stories. The grand finale of these activities was a concert, with a band chosen by the students. The levels of participation in the contest and concert revealed the relative impact of the intervention in the 14 schools in which it was applied.

Study participants thus became health promoters for addressing the problem of harmful alcohol use and had a positive impact on their classmates: Close to 1500 of these were indirect beneficiaries of the intervention.

In each school, permanent groups were formed to work on prevention of alcohol and drug use, in which intervention participants presented their experience. These groups were a resource that helped influence straggling participants whose results were less satisfactory. In addition, psychological counselling was provided to individual adolescents with family and social problems that negatively affected either their results during the intervention or their academic performance.

Although most participants had already begun drinking occasionally at the beginning of the intervention, indicators of negative attitudes toward drinking increased after the intervention, with the strengthening of new interests and projects.

LESSONS LEARNED

The intervention stimulated adolescents’ interest in participating in organized activities and learning more about the issue, and raised their awareness to the point of changing their behavior, with concomitant improvement in most indicators examined. Providing essential information on the risks of harmful use of alcohol and other substances during adolescence helped generate decisionmaking autonomy among both direct and indirect beneficiaries.

Direct participation by two other sectors in the interventions’ conception and implementation highlights intersectorality’s potential as a resource to address complex health situations. In light of these positive results, MINSAP’s School Health Division and MINED approved extension of the intervention to several Cuban provinces—with a view to eventual coverage throughout the country—as part of a strategy to improve the health and wellbeing of children and adolescents.

REFERENCES

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