The project addresses a critical evidence gap in how to comprehensively address alcohol initiation, use and abuse amongst adolescent boys and young men (ABYM) in sub Saharan Africa (SSA). The most recent survey of global health found that alcohol is the biggest risk factor for death among 15-49 year old men in the world. Death from preventable causes in Africa, such as interpersonal violence among male adolescents (aged 10-19 years) is higher than in any other region. Adolescent alcohol use is an important cause of these problems and predominantly amongst boys and young men. Drinking at an early age makes it more likely that you will be an alcoholic in adulthood, and causes poor adult health and bad effects on family, employment, and society. Interventions to decrease alcohol use among male adolescents could decrease death and illness in Africa and let boys reach their full potential. Some studies in rich countries have shown that these interventions might work, but very few have been tested in sub Saharan Africa. The way young people drink in Tanzania is like many other places in East and Central Africa. Our research will therefore be useful to other African settings. Also, our research team has experience and skill in adolescent health research in Tanzania with in-country partnerships and networks already in place. Local teachers, people who work with young people and key people from the ministries of health and education have asked us to help develop interventions for their male adolescents, in recognition that current international focus has been on the girl-child. Our research also supports the World Health Organisation (WHO) Global Strategy to Reduce the Harmful Use of Alcohol and will help fill gaps in alcohol policy in East Africa. The project is a partnership between two leading UK and Tanzanian research and learning institutes, a Tanzanian referral hospital and research centre, three Tanzanian based community based organisation, and local government authorities nationally and within two districts of Tanzania. Our overall aim is to co-create a package of school and community interventions and develop strategies to optimise the interplay between them in order to prevent, delay and reduce alcohol use among adolescent males in high alcohol use settings in Tanzania. This will be achieved through 4 specific objectives: OBJECTIVE 1: To understand what people in the community think about what makes adolescent boys and young men drink and how and where that drinking happens OBJECTIVE 2: To work with people in the community do design activities in the community and schools that will prevent and decrease alcohol use among adolescent boys and young men. OBJECTIVE 3: To assess the whether the relevant people like the intervention and believe that it will work OBJECTIVE 4: To collect information to help design a bigger study that will see if the intervention actually works. Our research project will directly benefit Tanzanian adolescent boys and young men, their communities, teachers and school officials as well as local and national government. We will discover new ways to develop complex interventions to decrease drinking amongst young people, especially those who are vulnerable. What we learn will be shared with politicians, people who work with with young people and researchers. It will also help us plan a larger study to test how the intervention works on a large scale.

BACKGROUND AND AIMS: Alcohol is the leading risk factor for death among men aged 15-49 years in Sub Saharan Africa and accounts for more deaths in this Region than any other. Because of harmful norms of masculinity, much of this increase risk begins in adolescence. Prevention or delay of alcohol initiation and decreased alcohol use among adolescent boys and young men (ABYM) (10-25 years) could profoundly impact morbidity and mortality in Africa. Schools and community interventions have the potential to address the social norms such as masculinities that drive harmful alcohol use, however evidence about intervention design and impact in Africa is lacking. Our overall aim is to co-create a package of school and community interventions and develop strategies to optimise the interplay between them in order to prevent, delay and reduce alcohol use among adolescent males in high alcohol use settings in Tanzania. We will achieve this through 4 specific objectives: OBJECTIVE 1: To gather evidence about key stakeholder (including adolescent girls and young women AGYW) perspectives on drivers and contexts of alcohol use among ABYM. To do this we will conduct a scoping review to explore and map alcohol related laws, policies and statutes in Tanzania and a stakeholder analysis in order to identify local actors and stakeholders committed to supporting implementation of the alcohol interventions. We will use participatory techniques among adolescents, families, community leaders, stakeholders to explore the drivers, cultural practices and risk factors influencing adolescent male alcohol initiation and heavy use and to identify potential structural approaches toward mitigating male adolescent alcohol use and harm. We will then use ethnographic methods to garner a more nuanced understanding of the behaviour of ABYM in high risk settings and particularly identify vulnerable groups, such as adolescents out of school. Finally, we will collaboratively map assets to enable a strengths-based approach to intervention design; assets might include safe spaces, existing activities, and structures to promote scale and sustainability. OBJECTIVE 2: To co-develop a theory of change (ToC) and collectively assemble and refine community and school interventions, assess the validity of outcomes and build stakeholder ownership to underscore the design, and future implementation and evaluation. In order to achieve this, we will facilitate three participatory and iterative workshops with key stakeholders identified in the stakeholder analysis. In the first we will build on our ToC by identifying and addressing individual and contextual factors and potential interactions and conflicts between them that influence alcohol use amongst ABYM. In the second workshop we will propose, discuss, prioritise and select refinements to existing interventions based on the ToC, and a map of available assets and existing services, WHO best practice and existing evidence. We will develop and support joint working groups which will bring together community, researchers and policy makers to develop theintervention. In the final workshop we will iteratively refine the intervention tools. OBJECTIVE 3: To assess the acceptability of the candidate interventions Within the groups we will assess stakeholder and participant satisfaction, adequacy of community resources for larger scale implementation and willingness of communities to proceed in the intervention development and evaluation. OBJECTIVE 4: If progression criteria are met, to design the a intervention feasibility study which will also collect data to support design of the main impact evaluation trial.