AAA PREVENT WP7 NATIONAL REPORT GOOD PRACTICES AND INTERVENTIONS FOR THE PREVENTION OF ALCOHOL USE AMONG JUVENILES IN CYPRUS Prof. Andreas Kapardis (University of Cyprus) & Dr. Zina Poulli (Ministry of Education and Culture) INTRODUCTION Cyprus, like other European countries, faces a number of social and health-related problems that include increasingly high reported rates of alcohol, smoking and violence by juveniles (Papadopoulos and Constantinopoulos, 2005; Stylianou, 2007). Findings from the ESPAD 2011 survey of students aged 16 years in 36 european countries show that the level of alcohol use in Cyprus is alarmingly high. More specifically, while for 75% and 66% respectively getting beer and wine was easy to get hold of if they wanted it, the majority of boys (87%) and girls (78%) had used alcohol during the past twelve months; 72% of boys and 62% of girls had done so the past 30 days, making Cyprus the fifth highest among the countries surveyed; Cyprus was raked 13 th highest in terms of the estimated average alcohol consumption; the dominating beverage during the last alcohol drinking day was beer (42%) for boys and spirits (40%) for girls; almost one in five 19% of the boys and 10% of the girls had been were drunk the past 30 days; and, finally, over half (56%) of boys and one third (34%) of the girls had 5 or more drinks on one occasion during the past 30 days. Widespread alcohol abuse among juveniles has a serious impact on society, the economy and public health. In order to obviate the consequences of alcohol abuse, state and local the Ministry of Education and Culture has been implementing a national prevention strategy which is described next.adopted various prevention programs which have not been evaluated. In Cyprus, alcohol prevention programs are offered primarily by the Ministry of Education and Culture and by the Anti Drugs Council but, also, by the Youth Board of Cyprus which runs antiaddictions campaigns. More recently, following private initiatives and outside funding, two local authorities in Nicosia have implemented the Communities That Care substance abuse and antisocial behavior prevention program in close collaboration with the local secondary schools with very positive results among high risk individuals (see below). 1. National Alcohol Prevention Strategy at the Meso and Micro Level in Cyprus The consumption of alcohol by juveniles is tackled in Cyprus in the broader context of juvenile deviance. To this end, a national strategy has been implemented by the Health Promotion Programmes Office within the Ministry of Education and Culture (the Ministry ). The last few years, the Ministry has moved from the traditional health education approach in dealing with such deviant behaviours as alcohol use by juveniles to health promotion, reforming the health education curriculum in schools in the process in order to encourage teachers to work in a health promoting way. In the words of Ioannou, Kouta and Charalambous (2012:153), 1
The central goal of this curriculum is to enable students and schools to act as health agents, addressing the structural determinants of health and promoting environmental changes. The optimum level for all topics of the curriculum is achieved through learning objectives, which concern three interconnected levels. These are: investigating determinants of health, practising action competency skills for health and achieving changes in favour of health. All levels are means as well as end products in terms of the curriculum objectives. Drawing on Ioannou et al. (2012), this curriculum, based on health promotion and counteracting a individualistic perspective on alcohol use prevention and taking into consideration local sociocultural and political conditions, is innovative and has the potential to be implemented in other European countries (see Figure-1). Levels of the curriculum Level 1: Investigating the causes and correlates of health The national curriculum s point of departure is the social learning that occurs in the lives of young people. Thus, students have the opportunity to critically articulate their personal experiences, carry out small-scale research projects and, also, to express their views on a broad variety of factors that impact on, inter alia, alcohol use by young people. Level 2: practicing action competence for health (see the middle circle in Figure-1) By being able to act, to use their own initiative, students are empowered to bring about changes in their own health habits, working with parents or their teachers and community groups. Level 3: achieving changes that favour health The third level addresses the potential of schools, through a structural approach of the curriculum, to act as health agents and to be instrumental for change as far as the students health habits such alcohol use are concerned.. Regarding the content of the curriculum, all topics of the curriculum are classified into four thematic areas, namely: (1) Development and empowerment of one s self. (2) Development of a healthy and safe lifestyle. (3) Development and improvement of one s social self. (4) Development of an active citizen. In conclusion, as Ioannou et al (2012) convincingly argue, the benefits of the curriculum are: overcoming victim blaming, achieving in-depth knowledge, and, finally, empowering the students themselves and the school as health agents. Of course, as will be seen below, whilst the Ministry of Education and Culture is the main provider of alcohol consumption prevention programmes, other agencies are also involved. Such programmes also tackle, at the same time, use of other addictive substances such as tobacco and illicit drugs. As far as evaluation of the programmes mentioned below is concerned, with the exception of Fred goes to school, all others that are implemented in collaboration with the Anti-Drugs Council of Cyprus, are approved by the said Council before being implemented but no systematic evaluation of them has been reported. 2. Inventory of good alcohol consumption preventive programs for juveniles in Cyprus: i. Micro initiatives: Individual level Intervention Type 1 Age Period 2 Dimension 3 Main Sources 4 1 Universal (for everyone in an eligible population), selective (for members of population subgroups at higher risk), or indicated (for those with existing alcohol problems). 2 Year when the intervention was started. 2
name targeted results Mentor educational 7 12 years 1997 All primary Not substance (primary and junior evaluated abuse prevention school) and 12 16 secondary schools program (junior using well secondary) equipped mobile units Report By the Committee on School Violence (2008), Ministry of Education The program Mentor involves a series of activities in both the Primary and Secondary Education that aim in providing relevant information so as to promote attitude and behavior which will keep students away from substance abuse. It is coordinated by primary and secondary education teachers specially trained in the UK who they offer the specific program to groups of students in elementary schools and gymnasiums, using well equipped mobile units. The purpose of the program is said to be achieved through offering information and knowledge, taught skills and self esteem enhancement to teach and inspire positive life attitudes while cultivating respect for one s self and others. ii. Family level Intervention Age targeted Period Dimension Main results Sources Mikri Arktos 7 18 years 2005 All primary Not available Cyprus Ani (Little bear and parents and Drugs Council star) secondary school pupils Mikri Arktos/Small Bear Star is a Youth Board of Cyprus Prevention and Ministry of Education Counseling Services Section program. Its activities are included in the Cyprus Anti Drugs Council National Strategy. It offers prevention programs that address the student and general population, including parents, aiming at the prevention of drugs and alcohol abuse and other 3 Number of individuals, schools or communities involved. 4 Articles, reports, documents, etc. 3
harmful behaviors. In schools, the program carries out educational activities, seminars and workshops in Primary as well as Secondary Education which are addressed to students, teachers, school counselors and parents. The programs can be in the form of lectures or workshops to groups of 8-15 participants and are coordinated by staff specifically trained. The duration of the workshops can be from 5 to 8 meetings (80 90 minute sessions). iii. Meso initiatives: school level Intervention Age targeted Period Dimension Main results Sources FreD Goes to 12 16 years 2011 present All junior Not evaluated Office of School secondary schools yet Health Promotion Programmes in Ministry of Education The program Fred goes to School is an intervention and prevention programme for alcohol abuse and smoking and follows the successful model of the FreD Goes Net program (Frühintervention bei jungen Drogenkonsumenten). According to the program s protocol, when a student is reported for smoking or alcohol use in the school premises or during a school event he/she is referred to the school counselor. Through an intake interview, the school counselor (who is trained for the program) verifies whether the student is ready and willing to go through the program that will provide him/her with the support he/she needs and thus avoid being punished by the school for defying the school regulations. The course comprises eight hours in total which is subdivided in 4 sessions of 2 hours each. Based on the principles of motivational interviewing and psycho-educational methods, the intervention covers the following contents which are developed interactively with the course participants: knowledge on the effects and risks of alcohol and smoking and legal aspects; reflecting on personal patterns and motives of consumption; and practical tips for limiting consumption or quitting altogether. iv. Community level Intervention Age targeted Period Dimension Main results Sources Communities that care 12 16 years 2006 present Junior secondary Significant reduction of Kapardis (2010) 4
schools in a municipality high risk factors v. Multi component Intervention Age targeted Period Dimension Main results Sources Feet to walk: prevent, educate, socialize 7 18 years, families & parents 2010 Schools and community groups all over Cyprus Effective with children, youth and family members in the short term Anti Drugs Council The Feet to walk: prevent, educate, socialize programme aims to reduce high risk behaviors (including alcohol use) by teaching children, youth, and parents social skills, encouraging them to adopt a healthy lifestyle, and to form positive relationships. 3. Description of two models of good practices in Cyprus One major difficulty in compiling this national report has been the afct that, even though alcoholconsumption prevention programmes have been implemented in Cyprus for at least 16 years, the effectiveness of only two has to some extent been ascertained. Lack of systematic evaluation of prevention/interventions programmes implemented by both the Ministry of Education and Culture and the Anti drugs Council is an endemic problem. Therefore, only the two programmes could be selected. 3.1.1. Example 1 Name: Communities That Care (CTC) Even though listed above a multiple component programe, in essence it could be equally justifiably be classified either as a micro (because of its emphasis on both individual students and especially those with serious behavioural problems, including alcohol etc consumption, as well as their parents. Goals: The implementation of the Communities That Care intervention program encourages a community-based-partnerships approach in the area of prevention to foster multi-agency partnerships on a local level. Community-based partnerships are forced to develop a shared knowledge-base about local crime issues to establish a common action-plan in the community. The 5
Communities That Care (CTC) approach was originally developed in the U.S. to assist and guide community prevention coalitions. The CTC operation system is a field-tested and evaluated strategy for activating communities to use prevention science to plan and implement community prevention services systems. Epidemiological research on risk- and protective factors, working with effective prevention programs, community ownership of local implementation, proactive training as well as technical assistance and evaluation of local results are the core elements of CTC. The CTC Survey uses self-report technique and measures 16 risk and 11 protective factors, derived from longitudinal research, as well as 6 youth problem behaviours. The CTC Youth Survey was developed as a tool to provide community-based partnerships with reliable information about the prevalence of youth behaviour problems (anti-social behaviours as well as alcohol and drug use) as well as the prevalence of underlying factors (risk- and protective factors). The CTC approach was originally developed in the U.S. to assist and guide community prevention coalitions. Domain (individual, family, school, neighborhood): school Age targeted: juveniles of 12 16 years old and their parents The Methodology: Using the CTC questionnaire, a survey of 519 junior secondary school students aged 12-15 years in the Latsia Municipality in Nicosia were surveyed in 2007 in order to identify risk and protective factors relevant to a broad range of anti-social behaviors, including alcohol and drugs. Utilizing the survey findings and in close cooperation with the school itself and the school counselor in particular, the local community, and the Municipality, an intervention program was drawn up and implemented by a team of CTC-trained team during two afternoons a week, totaling 4 contact hours. The team included physical education instructors, a specialist counseling psychologist who offered their services in the context of after-school sport and other activities that were open to all the students at the school. The psychologist was tasked with approaching, in the play context students with a history of alchohol, drugs and violence, befriend them and work also with their parents after hours in order to impact positively on their general behavior. The implementation of CTC continued until the end of 2010. The survey was repeated in 2009 with 495 students at the same school. Evaluation: Using data from the school authorities pertaining to antisocial behaviours dealt with by the school during the period concerned, a composite index of effectiveness was constructed with the local police station incident reports of referrals of students from the school and visits to the school to investigate complaints of criminal damage to property, theft, violence etc, a questionnaire survey of parents, teachers, and the participating students themselves. It was found that the use of alcohol and drugs at the school had dropped significantly as had the level of violence in the school. 6
Subsequently, in April 2011 a second municipality in Nicosia (Aglandjia) introduced CTC in collaboration with the two local junior secondary schools but evaluation of that intervention is not yet available due to lack of funding in the conextof he financial crisis that has recently plagued Cyprus. More recently, a CTC survey of 392 students from 19 classess in years 7-9 (aged 12-15 years) was carried out and risk and protective facors identified by SPSS data analysis in the local (and regional) junior secondary school in Klirou during school hours in November 2011. 1n May 2012, CTC was introduced in the aforementioned school, in collaboration with the local junior secondary school, the local authority (consisting of 24 villages) and the local church authorities. The success of CTC in Nicosia junior secondary schools is in support of numerous positive evaluations reported internationally. 3.1.2. Example 2 Name: Feet to walk: prevent, educate, socialize This programme is largely school based and, as such, it has been chosen as a meso project because it is one of two programmes generally which have in some way been evaluated. Goals: By strengthening a person s inter personal skills, improving within family relationships, and encouraging participation in community activities and in sport, this program in effect also aims to re educate those participating so as to impact on their values and social norms, to equip them with cognitive behavioral strategies that help them strengthen their self control, thus being in a better position to control their drug use behavior. Evaluation: of the program found that while a broad range of activities was introduced and taken up by the vulnerable participants, 90% of the participating children/youths remained in the occupational skills educational program, by the 4 th month 90% of the vulnerable children and youths were able to recognize illegal addictive substances and knew their harmful effects. The same was found for the relatives of the participants. It was also found that 40% of those children/youths participating in sport activities remained in the program more than three months. However, 12months into the program, most left it. Finally, as new children and youth joined the program, their integration into existing groups proved very difficult. 4. Conclusions In the Republic of Cyprus, alcohol consumption prevention programmes have been implemented primarily by the Anti-Drugs Council, the Ministry of Education and Culture and, more recently, by local authorities in collaboration with local schools. Of the Anti-Drugs Council s prevention programmes, the Feet to Walk, Prevent, Educate and Socialize intervention programme has yielded results that demonstrate the challenge of retaining vulnerable individuals exhibiting vulnerable individuals long enough (i.e. more than one year) for them to benefit substantially from the programme s activities. More promising is Fred Goes Net that has been shown to equip youths better in order to be able to deal with the problems that arise as a result of alcohol abuse. Other 7
promising alcohol consumption prevention programmes implemented by the Ministry of Education are Mentor and Fred Goes to School but, unfortunately, they have not yet been evaluated. Similarly, while popular with students and teachers alike, anti-drugs education seminars provide those participating with abroad range of antidotes to substance abuse, their proper evaluation is long overdue. Little is known about the generalizability of the risk and protection approach in Europe. Interestingly enough, however, since 2005 and following the initiative of a group of individuals, two local authorities in Nicosia have implemented the Communities That Care (CTC) prevention programme with documented positive results. It is encouraging to note in this context that CTC is about to be introduced an a ye another suburb of Nicosia with the full collaboration of the local secondary schools. In conclusion, a range of substance (including alcohol) use prevention programmes have been and are being implemented in the Republic of Cyprus. Some of them have been shown to have positive results. However, the need for systematic evaluation of their impact on those that participate in them cannot be overemphasized. At a time of financial crisis and budgetary constraint, evidencebased substance abuse prevention programmes must be the ones being funded. List of References ESPAD (2011). The 2011 ESPAD Report: Substance Use Among Students in 36 European Countries. Ioannou, S., Couta, C. and Charalambous, N. (2012). Moving from health education to health promotion: developing the health education curriculum in Cyprus. Health Education, 112 (2), 153 160. Kapardis, A. (2010). Implementing Communities That Care delinquency intervention programme in Nicosia, Cyprus. Paper presented at the CTC Session, European Forum for Urban Security, International Congress Center, Berlin, May 9-12 May. Papadopoulos, M. and Constantinopoulos, K. (2005). Pancyprean Research on the use of Legal and Illegal Substances Among Students in Lyceums in Cyprus. Nicosia, Ministry of Education and Culture. Stylianou, S. (2007). Juvenile Delinquency and Cypriot Society. Nicosia : University of Nicosia Press. 8