OVERVIEW

Capacity building for health promotion and drug preventionin Croatia

Darko Roviš

Received: 17 February 2010 /Accepted: 29 October 2010# Springer-Verlag 2010

AbstractAim Drug abuse, addictions, and drug-related crime repre-sent one of the major and still rising problems in Croatia.Following the epidemic breakthrough in the 1990s, asystem of prevention and treatment has developed. Theaim of this paper is to analyze substance abuse in Croatiaand its prevention capacities and practice for dealing withthe problem. It analyzes possibilities for capacity buildingfor health promotion and drug prevention in Croatia.Subject and methods This problem analysis and needassessment is based on a planned change model widelyused for health promotion planning and development ofpreventive or health promotion interventions. It includesfour subanalyses: problem description, analysis of deter-minants, network and context analysis, and capacitiesanalysis.Results Croatian prevention practice lacks a comprehensiveand science-based approach in planning, development,implementation, and evaluation of prevention programs.Although our institutional infrastructure is growing, pro-fessionals working with young people still lack specific andup-to-date knowledge and skills in mental health promotionand drug prevention to tackle the problem effectively.Conclusion To improve prevention practice, a capacitybuilding action is necessary. A postgraduate course onhealth promotion and drug prevention can boost ourprofessional capacities and stimulate development of theacademic field at the University of Rijeka.

Keywords Drug addiction . Health promotion .

Prevention . Capacity building

Background

Croatia is faced with a drug abuse and addiction epidemic.As the figures keep rising, so is our need to build aneffective system of prevention. The aim of this paper is toanalyze substance abuse in Croatia, our current preventionpractice, and capacities for dealing with the problem. It willanalyze possibilities for capacity building for healthpromotion and drug prevention at the University of Rijeka,Croatia. It is a call to action for key stakeholders to supportand engage in capacity building aimed at increasing thecompetencies of our health and education professionals andpublic administration and nongovernmental organization(NGO) workers involved in drug prevention and healthpromotion.

The aim of this paper is to analyze substance abuse inCroatia and its prevention capacities and practice fordealing with the problem. It analyzes possibilities forcapacity building for health promotion and drug preventionin Croatia.

Method

For the purpose of conducting a problem analysis and needassessment we will use one of the available planned changemodels. Some of these stepwise planning models such asPRECEDE-PROCEED of Green and Kreuter (1999) andthe ‘Intervention Mapping’ (Bartholomew et al. 2006) arecommonly used for development of preventive or healthpromotion interventions. This problem analysis follows the

D. Roviš (*)Teaching Institute for Public Health of Primorsko-goranskaCounty,Kresimirova 52A,51 000, Rijeka, Croatiae-mail: darko.rovis@zzjzpgz.hr

J Public HealthDOI 10.1007/s10389-010-0385-z

model proposed by Hosman (2007) and includes foursubanalyses: problem description, analysis of determinants,network and context analysis, and capacities analysis. Wewill review the problem epidemiology, etiology as well askey determinants of substance abuse, social networkinginvolved in the problem, and our professional capacity totackle with this problem.

Results

Problem description

Type of problem

Drug abuse, addictions, and drug-related crime representone of the major and still rising problems in Croatia. Untilrecently, cases of drug addiction have occurred onlyoccasionally. They were found only in some subculturegroups and big cities. However, social, political, andeconomic transition associated with the war and postwarperiod in the 1990s created a fertile ground for thefollowing epidemic. We witnessed an increase of drugabuse and drug-related crime as well as street and schoolviolence, family abuse, gambling, and other behaviordisorders in the 1990s. Among these, drug abuse and crimeare the most visible and most devastating.

Until recently, most of the programs related to drugprevention were treatment programs, but now priority hasbeen given to drug prevention programs. Public healthinstitutes are recognized as key partners for development,monitoring, and evaluation of these programs. However, alarge body of programs is implemented outside publichealth institutes by various professionals with different

work experience and background education (e.g., teachers,medical doctors, psychologists, social workers, etc.).Education of these professionals often lacks comprehen-siveness in approach and many of the curriculums areoutdated. Their knowledge and skills are therefore superfi-cial and insufficient for implementation of modern preven-tion interventions. We lack evaluation and implementationstudies as well as policy evaluations which would distin-guish effective from ineffective practice and reinforceevidence-based prevention.

Size: prevalence, incidence, trends

The number of 260 registered drug addicts in 1990 jumpedto 1,340 drug addicts in 1995 and 7,442 drug addicts in2007 (Katalinić et al. 2009). This trend has slowedsomewhat in recent years, but the numbers are still rising(see Fig. 1).

The addiction rate of 191.1 per 100,000 population aged15–64 is well below most of the EU countries’ rates, whichrange from 200 to 800 (European Monitoring Centre forDrugs and Drug Addiction 2006). Although this mightsound comforting, it actually leaves the door open forfurther increase, if the appropriate measures are not taken.We have not yet seen the peak and the stabilization of thetrend that other European countries have.

The true number of drug users and drug addicts isdifficult to exactly measure, but is assessed through self-reported questionnaires. The European School SurveyProject on Alcohol and Other Drugs (ESPAD) conductedin 2003 (Hibell et al. 2004) investigated the use ofcigarettes, alcohol, and other drugs among 15- and 16-year-old students. As shown in Fig. 2, the 2003 results ofthe Croatian outcomes on selected variables are very close

Fig. 1 Number of treated drugaddicts in the Republic ofCroatia (1995–2007) (Katalinićet al. 2009)

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to average of all ESPAD countries. However, the majorityof risk behaviors were found to be rising, so now weexceed the average for use of marihuana, inhalants, andalcohol plus pills. Experimentation was found to startearlier and the availability of drugs was reported to begrowing.

According to the ESPAD conducted in 2007, Croatiareported upward trends in the use of tobacco and illicitdrugs for both genders, but especially for girls (Kuzman etal. 2008). We now have one third of secondary schoolstudents reporting that they smoke cigarettes every day (inthe last 30 days). Among children in the first and secondgrades, 55–64% of the boys and 43–51% of the girls haveengaged in binge drinking (drinking more than five drinksin consecutive order) in the last month; 20–30% of the boysand 15–23% of the girls reported they have tried marihuanaand up to 5% reported trying ecstasy. These are all veryalarming trends pointing to the possibility for furtherincrease of drug addiction when this population reachesadulthood.

Population at risk

The average age of first drug use (any drug) is slightlydropping and is now 15.9 years for heroin users and theaverage age of treated drug addicts rose from 25.7 in 2001to 29.7 in 2007. This unfortunately means that the timespent on the street is expanding, making drugs moreavailable as well as treatment more difficult. It is astaggering fact that almost 35% of drug addicts are childrenand adolescents in reach of the education system aged up to24, while over two thirds of them are under 30 years old.The Bezinovic (2008, first draft, personal communication)findings show that over 50% of eighth grade students(elementary school) are exposed to risk behaviors of theirpeers such as drinking, smoking, or drug taking. This studyrevealed that experimentation with alcohol and cigarettes isstarting in lower grades, while everyday smoking, drunk-

enness, and drug taking is occurring in seventh grade. Thispopulation is at specific risk for engaging in such riskbehaviors since their social, cognitive, and other develop-mental changes in puberty increase their sensibility toinfluences of their peers and other peer-related socialnetworks. Their egocentrism, overestimated peer confi-dence, and cognitive orientation to find inconsistency andfaults in adults’ arguments, especially regarding drug use,are increasing their risk for acquiring wrong attitudes andengaging in such activities (Botvin 1998).

Expected outcomes

Individual, social, and health impact

The individual, social, and health impact of illicit drug useincludes higher rates of blood-borne diseases such ashuman immunodeficiency virus/acquired immunodeficien-cy syndrome (HIV/AIDS), hepatitis B, and hepatitis C andhigher criminal activities associated with addiction. Smok-ing cannabis also increases the risk of lung disease, and itsuse by adolescents is prone to influence later mental health,conduct, and education problems and increase the risk ofdepression and dependence. All substance use isinterconnected and has a tremendous impact on health. Ayoung tobacco user is more likely to be a heavy drinker, usecannabis, engage in risky sexual activity, have higherantisocial behavior, and—if female—experience symptomsof depression (Loxley et al. 2004). Early school failure,childhood conduct disorder, or aggression are usually notedas early risk behaviors that could later lead to substanceabuse.

Tobacco use is related to death from cancer, respiratorydiseases, vascular diseases, peptic ulcer, and (perhapsconfounded by alcohol use) from cirrhosis, suicide, andpoisoning. There are relationships between alcohol con-sumption and more than 60 types of diseases and injures.According to the Croatian Ministry of Internal Affairs

Any alco

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Fig. 2 Use of cigarettes, alco-hol, and other drugs among 15-and 16-year-old Croatian stu-dents in 2003 (Hibell et al.2004)

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(Ministarstvo unutarnjih poslova 2008), positive associa-tions are found between alcohol and incidence and deathfrom injures, where 30% of all motor vehicle fatalities inCroatia are related to alcohol (Ministarstvo unutarnjihposlova 2008). Alcohol is related to cirrhosis of the liver,cancer, and cardiovascular diseases. Alcohol is found tocontribute to homicides in 35–85% in Canada/Sweden. Anegative impact is found on family, friends, and workwhere alcohol contributes to higher rates of violent crimesand injures in friendship relationships, domestic violence,divorces, work productivity losses, and work injuries. Childabuse, neglect, and isolation coupled with insecurity and allinconsistent parental behavior and demands are much morecommon in families of alcohol abusers and contribute totransgenerational transmission of problematic drinking.

Economic impact

According to WHO, tobacco causes 4.1% of the totalburden of disability. Alcohol causes another 4% and illicitdrugs account for 0.8% of the total burden of disability. Toassess the true impact of drug abuse, the National Center onAddiction and Substance Abuse at Columbia Universitymeasured the impact of substance abuse and addiction onthe US federal state 1998 budgets in 16 budget categories:health, social service, criminal justice, education, mentalhealth, developmental disability, and other programs. Theyfound that a staggering 13.1% of the state budget is relatedto substance abuse and addiction. Of every dollar the statespent, 96 cents went for shoveling up the wreckage ofsubstance abuse and addiction and only 4 cents were usedto prevent and treat it. Prevention, treatment, and researchtogether accounted for only 3.7% of expenditures. Thepercentage of the budget spent by categories is shown inFig. 3.

Need for preventive action

Investing in prevention is an opportunity for possiblesavings in total state spending in combating substancemisuse. The Economist (2001) estimates that drugtrafficking worldwide accounts for over 400 billiondollars annually. Based on the number of drug addicts inCroatia, some estimate that drug trafficking in Croatiaaccounts for over 3 billion Kuna yearly (500 milliondollars). This money comes from various criminalantisocial activities such as selling family belongings,stealing, robberies, etc. Preventing substance abuse andaddictions would increase general public security, trafficsafety, and family integrity, hence increasing the overallquality of life. Reducing substance misuse, drugs andalcohol especially, would increase our transport safety andreduce health costs and the costs due to lost workproductivity. Youth represents our demographic and workforce potential. Preventive interventions in the schoolsetting strengthen the individual’s skills and competencesand boost his academic performance and general achieve-ments. These data call for comprehensive preventionaction aimed at multiple target groups and systems. Thekey stakeholders who should be engaged in prevention ofsubstance abuse should come from education, health, andsocial care sectors, public administration, and NGOs.Schools, hospitals, public health organizations, healthcare centers, social care sectors, NGOs, and local govern-ments share the responsibility for reducing the social,health, and economic burden of substance abuse. In orderto effectively develop, implement, and evaluate compre-hensive prevention interventions, we require well-educated and competent leaders, officials, and workforce.It is the intention of this proposal to deliver suchmeasures.

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Fig. 3 Percentage of the budgetspent by categories

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Analysis of determinants

Theoretical approach

As health promotion and drug prevention is a multidisci-plinary field, the theoretical base for designing, implement-ing, and evaluating its programs is drawn from variousfields and disciplines. However, the most commonly usedand scientifically most intensively researched are a fewmodels and approaches such as the social developmentmodel, risk reduction model, resilience and competencebuilding model, and developmental psychopathology ap-proach, etc. The social development model posits thatdifferent factors influence youth at different ages. Themodel asserts that the most important units of socialization,family, schools, peers, and community, influence behaviorsequentially (Hawkins and Weis 1985). Using a develop-mental pathways approach, we can prevent health problemsby identifying and then modifying the influence of factorsthat lead to development of health behavior disorders. It isan approach commonly used in prevention science, origi-nally drawn from the public health approach (Loxley et al.2004) where risk factors predict the specific behavior andtheir influence can be adjusted and modified throughintervention. On the other hand, protective factors can beseen as independent predictors that moderate and mediatethe effect of risk factors and therefore reduce the likelihoodof substance abuse. Understanding of these influences andprocesses is crucial in order to identify individuals at risk,especially those at high risk, and to target them withadequate prevention interventions.

This rapidly developing field of prevention science isgrowing year after year, delivering us evidence on effectivebut also ineffective prevention practice. The comprehensiveand up-to-date insight into the developing theories andevidence-based programs is therefore necessary for devel-opment of effective policies and programs for drugprevention and mental health promotion in general.According to Hosman (2008, draft paper, personal commu-nication), in order to implement effective policies andprograms to improve mental health and reduce mentaldisorders in populations, we need a range of capacities suchas a competent workforce with relevant knowledge andskills, organizational capacity, coalitions and partnerships,leadership, resources, and public support. It is the intentionof this analysis to provide baseline information for initiatingpostgraduate level education for our health and educationprofessionals, social care officers, local government andadministration officers, and NGOs. Boosting their knowl-edge, skills, and other competences in the field ofprevention science will hopefully influence our preventionpractice and the health outcomes of our preventionprograms.

Determinants

There are many known problem-related behaviors andconditions (risk factors) that influence the onset ofsubstance abuse or are associated with substance abuseitself. We will describe them as they appear in differentdomains of individual’s lives, in the various system levelsin which one is participating, and in a time line of theiroccurrence. An ecological approach or system levelapproach provides a useful framework for grouping bothrisk and protective factors at individual/peer domains,family, school, and community domains (Brounstein et al.2001). These domains are not static in their impact, butinteract with each other and change over time. As anindividual develops, his or her perceptions and interactionswith family, peers, schools, work, and community alter. Forexample, the individual/peer domain is the most influentialin predicting marihuana use, with the strongest predictorsbeing participation in antisocial behavior, friends’ marihua-na use, low perceived risk of marihuana use, and positiveattitude toward marihuana use. Table 1 shows the distribu-tion of risk and protective factors for substance abuseacross the domains.

Relationships between determinants

Using Bronfenbrenner’s ecological model, Durlak (1997)explains that an individual cannot be seen apart from hissurrounding context and the influences the surrounding hason him. The norms, values, other people’s behaviors, andavailability of illegal substances all influence one’s behav-ior. These influences can be organized in different domainsin which the individual is participating in everyday life.Furthermore, an individual behavior is seen as a result ofindividual-environment interaction which can result infavorable or unfavorable behavior outcome. The capacitiesand propensity for the specific surrounding is what makessome individuals do better in a specific situation orsurrounding over another individual or over another setting.This mutually shaping, transactional process of individual-environment interaction can then further reinforce positiveor negative course of actions. So a child’s behavior affects aparent’s behavior, which in turn again affects the child.

The complex series of interactions that occur betweenthe individual and the other domains are shown in Fig. 4. Aweb of influences between the individual and his surround-ing makes it difficult to predict what the behavior outcomewill be for the specific individual. It is the interaction of therisk and the protective factors among different domains andthe individual himself that predict future health outcomes.

The web of influence model makes it clear thatpreventive measures should be taken, in many differentdomains and in different settings. Furthermore, according to

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the developmental psychopathology approach, the risk andprotective factors are located along the development path ofa young person: factors influencing the person prior tobirth, at infancy and preschool, at elementary school andsecondary school, and in early adulthood. So interventionsat multiple domains and multiple settings should beinitiated at multiple time points.

Factors prior to birth usually include maternal smokingand alcohol use, extreme social deprivation, and familybreakdown (Loxley et al. 2004). Brown and Strugeon(Jané-Llopis and Barry 2005) reviewed the differentdeterminants of a healthy start in life, which includephysical, psychological, and socioenvironmental dimen-sions, and found that freedom from poor nutrition,infirmities, injuries, abuse, and neglect or exposure to

drugs prior to birth are conducive to children’s positivedevelopment and their future mental well-being (Jané-Llopis and Barry 2005).

Early childhood risks include child abuse and neglect,early school failure, childhood conduct disorder, aggres-sion, and favorable parental attitudes toward drug use(Loxley et al. 2004). The development of a healthyattachment in the first months of life, positive interactionwith parents, and a stimulating preschool environment areessential for psychological and cognitive development.Exposure during the early start of life to socioenvironmen-tal risk factors such as poverty, violence, armed conflict, orHIV/AIDS in the family have a negative impact on thenewborns’ future mental health (Jané-Llopis and Barry2005).

Table 1 Risk and protective factors for substance abuse (adapted from Brounstein et al. 2001)

Domain Risk factors Protective factors

Individual Rebelliousness Opportunities for prosocial involvement

Friends who engage in the problem behavior Rewards/recognition for prosocial involvement

Favorable attitudes about the problem behavior Healthy beliefs and clear standards for behavior

Early initiation of the problem behavior Positive sense of self

Negative relationships with adults Negative attitudes about drugs

Risk-taking propensity/impulsivity Positive relationships with adults

Peer Association with delinquent peers who use or valuedangerous substances

Association with peers who are involved in school, recreation, service,religion, or other organized activities

Association with peers who reject mainstreamactivities and pursuits

Resistance to peer pressure, especially negative

Susceptibility to negative peer pressure Not easily influenced by peers

Easily influenced by peers

Family Family history of high-risk behavior Bonding (positive attachments)

Family management problems Healthy beliefs and clear standards for behavior

Family conflict High parental expectations

Parental attitudes and involvement in the problembehavior

A sense of basic trust

Positive family dynamics

School Early and persistent antisocial behavior Opportunities for prosocial involvement

Academic failure beginning in elementary school Rewards/recognition for prosocial involvement

Low commitment to school Healthy beliefs and clear standards for behavior

Caring and support from teachers and staff

Positive instructional climate

Community Availability of drugs Opportunities for participation as active members of the community

Community laws, norms favorable toward drug use Decreasing substance accessibility

Extreme economic and social deprivation Cultural norms that set high expectations for youth

Transition and mobility Social networks and support systems within the community

Low neighborhood attachment and communitydisorganization

Society Impoverishment Media literacy (resistance to pro-use messages)

Unemployment and underemployment Decreased accessibility

Discrimination Increased pricing through taxation

Pro-drug use messages in the media Raised purchasing age and enforcement

Stricter driving while under the influence laws

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From adolescence, low involvement in activities withadults, the perceived and actual level of community druguse, availability of drugs in the community, parent-adolescent conflict, parental alcohol and drug problems,poor family management, school failure, deviant peerassociations, delinquency, and favorable attitudes towarddrugs were all identified as risk factors. Communitydisadvantage and disorganization, positive media por-trayals of drug use, adult unemployment, and mentalhealth were further factors strongly associated withharmful drug use. Some research points to attentiondeficit hyperactivity disorder (ADHD), intelligence, anx-iety, and depressive symptoms as risk factors as well, butthe evidence on these factors remains open to question(Loxley et al. 2004).

As mentioned, protective factors moderate and medi-ate the effect of the risk factors. They appear to balanceand buffer the negative impact of existing risk factors,reducing the likelihood of substance abuse throughdevelopmental phases. Early age protective factorsinclude having an easy temperament, social and emo-tional competence, and shy and cautious temperament.Protective factors in adolescence include family attach-ment, parental harmony, and religious involvement, andin adulthood, well-managed drinking environments andmarriage (Loxley et al. 2004).

The risk reduction model posits that if the risk factorsoutweigh the protective factors, then one is more likely tostart abusing drugs. The risk factors stack and cluster,enhancing their cumulative strength in time and influencinga range of negative health outcomes (Loxley et al. 2004;Brounstein et al. 2001). Figure 5 shows the number of high-risk individuals (five and more risk factors present) whoremained drug free in the short and long term in relation tothe number of protective factors they had. It is obvious thatprotective factors stack and cumulate their protectivepower, reducing the probability for drug abuse even amonghigh-risk individuals (Smith et al. 1995).

Network analysis

The social network

As a universe of social groups, networks, systems, andinfluences exists around each of us, each one of themcarries the potential for positive and negative influences onthe range of protective and risk factors that contribute to theindividual’s substance use and addiction. Initially, a child islocated in a few social systems like family and preschoolcenters. As a child is growing, it engages in more and moresocial networks and systems, but it also falls under theinfluence of other systems in which it does not participatedirectly. This broadening of circles of influences isdescribed in Bronfenbrenner’s ecological model. Itdescribes child development in an ecological approachwhere the relationship between individuals and the envi-ronment is viewed as “mutually shaping.” At the microlevel, a child experiences immediate interactions at home,at a child care center, preschool, school, or neighborhood.At the meso level, we find interrelationships among settings(i.e., the home, a day care center, the schools). The exolevel describes the forces that influence the quality of the

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Fig. 5 Drug abuse among high-risk individuals (Loxley et al. 2004)

Fig. 4 Web of inf luence(Brounstein et al. 2001)

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interrelationships among different settings in which thechild participates. These may include the parental work-place, school boards, social service agencies, and planningcommissions. The macro level forces shape the overallsystem and human development. For example, an economicrecession, a war, or technological changes represent suchinfluences that could result in major changes in othersystem behavior. Filling this model with the real life socialactors gives us a possibility to better understand what wecan do at which level and by whom a particular risk/protective factor for substance abuse can be tackled.Figure 6 shows the network of influences and possibletarget groups for prevention programs.

Supportive and harmful functions

During the early period of life there is intense developmentin mental, social, and physical functioning of a child. Thehealthy, secure, and supportive environment has a hugeinfluence on the development of a child. All types of familydysfunction should later be compensated for by differentorganizations such as preschool centers or schools. Theschool, as a setting for health promotion and drugprevention, has been endorsed in a number of major policydocuments in recent years (Jané-Llopis and Barry 2005). Itis described as “the major setting” for health promotion andpositive mental health development in various documentsof the WHO and USA. The European Parliament andEuropean Council have recognized personal skills devel-opment like communication, planning, decision making,conflict resolution, and coping with stress in its frameworkfor key competences for lifelong learning (EC Directorate-General for Education and Culture 2006). According toSylva as interpreted by Durlak (1997), the quality of schoolcan be up to five times more important than the individualfamily socioeconomic background. Schools provide a ready

audience and an excellent setting for systematic promotionof health and positive development of young people. It is asource of friends and social networks and an opportunityfor young people to engage in these interactions with theirpeers. Peers exert great influence on an individual’sdevelopment. As one gets older, the influence of one’sparents weakens and the influence of one’s peers, themedia, and other socialization factors get bigger (Botvin1998). An adolescent’s egocentrism and overestimatedconfidence in his peers grows as well as the cognitivedevelopment that allows him to find inconsistency andlogical flaws in adult advice. This makes space forrationalization and neglect of parent’s advice, especiallyregarding substance use. The need for experimenting andfilling the content in newly discovered freedom is oftenfound in bars and clubs surrounded by other peers alreadyengaged in some high-risk activities such as smoking,drinking, and drug use. With the Internet, there is acompletely new social arena in which our youngsters areparticipating. It is a place for socializing, forming andmaintaining relationships, exchanging ideas, and meetingnew people. A Pew Research Center study (Lenhart et al.2007) has shown that over 93% of children aged 12–17 usethe Internet, two thirds of them are content creators, and forthe majority of them social networking sites such asFacebook, MySpace, etc. are hubs for these teen contentcreation activities. It appears that this new tech age socialarena is taking the place of some more traditional ones,such as youth organizations, clubs, or even sport. Acomprehensive prevention intervention would thereforeaim at these social networks as well.

Although a workplace should be experienced as acontribution to health, it often becomes a source of individualand family distress. Work stress and the lack of work alsocreate social and economic burdens on health, such as loss ofproductivity, increases in health care welfare system costs,

Education

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Public Health & Social Affairs

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Fig. 6 Systems, organizations,and stakeholders havingcontrol over risk and protectivefactors (Hosman 2008, draftpaper, personal communication)

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increased crime rate, traffic accidents, divorce, and a variety ofother social consequences (Jané-Llopis and Barry 2005).

Community opportunities for access to positive socialactivities, community disorganization, crime rates, andalcohol and tobacco sale policies all influence youngpeople. Social cohesion, social networks, and activeinvolvement in the community add to quality of life: apowerful social determinant of health (Naidoo and Wills2000). However, building social capital is possible onlywhen certain threats to the community are eliminated.Policies such as education, child care, employment,housing, environment, and equality/social inclusion have ahuge impact on the individual’s functioning. Barry andJenkins (2007) call for an effective mental health promotionembedded in these policies as a wider health developmentagenda for tackling the broader determinants of poor mentalhealth such as poverty, social exclusion, exploitation, anddiscrimination.

What needs to be changed?

This complex interaction of risk and protective factors andtheir mapping across domains and the life span raises aquestion: when there are so many risk factors in existence, onwhat grounds should we select specific factors as the focus ofintervention?We need a kind of selection framework and a listof selection criteria to weigh the importance of the differentfactors for selecting them as the prevention target. Further-more, an integration of health promotion and drug preventionefforts across a range of health and social agencies andpolicies is a crucial element of prevention system develop-ment. In order to effectively tackle various determinants ofhealth nested in different systems and levels, a multidisciplin-ary and multisectoral approach is required. Aside frombuilding the institutional and organizational infrastructure,we need to build partnerships and cooperation acrossagencies, organizations, and community groups within andbeyond the health sector. Health promotion strategies, asdescribed in the 1986 Ottawa Charter for Health Promotion,call for development of healthy policies aside from the healthpolicy, reorienting the health service, building the supportingenvironments, strengthening the community, and buildingpersonal and social competencies within the framework ofcommunity action. It underscores the importance of actionacross levels, highlighting the need for a top-down policyapproach, as well as bottom-up community and practice-driven initiatives (Barry and Jenkins 2007). The mostsuccessful actions prove to be those employing multiplehealth promotion strategies that operate at multiple systemlevels and include a combination of actions to support eachstrategy.

Drug prevention cannot be undertaken by a single sector,profession, or discipline on its own. Effective policy and

practice requires that the different sectors and organizationswork together. However, bringing these different back-ground sectors, organizations, and professions togethercould prove to be a difficult job. In order to work together,we must speak the same language. Building a commonlanguage in terms of knowledge, competences, skills, andprocedures is therefore a conditio sine qua non. Followingthe national mental health policy recommendations onbuilding a competent workforce, Ireland has developed astrong infrastructure for health promotion with over 300dedicated health promotion specialists working in healthpromotion and mental health promotion (Barry 2007). Alsoin the Netherlands a strong infrastructure for preventionexists in health promotion, prevention, and mental healthpromotion, with 1,433 experts in this field working inorganizations such as public health services, addictionclinics, mental health services, and primary care (Fransenet al. 2009). Mostly these professionals are working inspecialized health promotion, prevention, or health educa-tion teams. We must do the same here in Croatia.

Capacities, strengths, and existing services

The National Strategy for Prevention and Suppression ofDrug Abuse in the Republic of Croatia was first acceptedby the Croatian Parliament in 1995. Following the drugstrategy of the European Council and guidelines of theUnited Nations International Drug Control Program, Cro-atia upgraded its national drug strategy for 2006–2012, aswell as its action plan for 2006–2009 (Drug strategy 2006).It is based on the continuous and balanced implementationof organized measures to decrease the drug supply (drugavailability on the illegal market) and drug demand amongthe population at risk. The new strategy is comprehensive,focusing on illegal drugs, and covers: coordination, supplyreduction, demand reduction, international cooperation, andinformation/research/evaluation.

Until recently, most of the programs related to drugprevention were treatment programs, but now priority hasbeen given to drug prevention programs. Public healthinstitutes are one of the key organizational elements in drugprevention. They have a leading role in outpatient treat-ment, but also in drug prevention. They are recognized asthe key partners for development, monitoring, and evalua-tion of these programs.

Drug prevention at the universal level is mostlyorganized and implemented within the education systemand is primarily aimed at reducing the interest of youngpeople in experimenting with addictive substances. Theseefforts lack monitoring, supervision, and coordination andare often completely missing. On a community level,campaigns targeted at the general media are organizedoccasionally as well as lectures at forum discussions on

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addiction problems and educational programs on theconsequences of drug misuse.

Selective and indicated prevention is undertaken withinthe educational context and outpatient counseling servicesof public health sector and NGO sector. The existingcounseling psychotherapeutic services are maybe the bestelement in the spectrum of prevention interventions,probably due to the high standards for achieving thepsychotherapy certificate.

The University of Rijeka, together with working pro-fessionals, has numerous experts in different fields relatedto this set of problems (medical doctors, psychiatrists,psychologists, educators) that could tackle drug preventionissues with great competence. The University of Rijeka iskeen to establish a university at the same level as modernEuropean universities in terms of organization and qualityof teaching and research. With its institutions located infour different cities and three counties, the University ofRijeka covers a vast area and there is an unambiguousimportance of raising professional awareness and compe-tence of experts working with youngsters. Furthermore, itsacademic and professional community has a rich experiencein health promotion, especially throughout the Institute forPublic Health.

The Teaching Institute for Public Health of Primorsko-Goranska County has been actively working in the field ofhealth promotion for more than 100 years. Its professionalexperience in conducting health promotion programs aswell as its academic staff serves as a teaching base for theMedical Faculty, University of Rijeka. The Departments ofSocial Medicine and Health Ecology have the highestnumber of scientific publications that are put to practicaluse in teaching.

There is a gap between the Croatian and global level ofknowledge related to prevention science; we lack compre-hensive experience in planning and general approaches aswell as prevention research, effectiveness studies, andevaluation of prevention interventions (Bašić 2009). Mostof the evaluation studies available involved gathering datafor process evaluation and presenting information on whathas been done, where, when, and on what scale. We aremissing outcome and effectiveness evaluations, cost-effectiveness studies, and randomized controlled trials, etc.

The global experience however shows that it is possibleto significantly improve mental health through universalinterventions and to prevent mental disorders by selectiveand indicated interventions in populations at risk. However,outcomes studies have revealed a large variation in theefficacy of programs, ranging from large effects to noevidence-based effects and even negative effects (Durlak1997). According to Hosman (2008, draft paper, personalcommunication), the evaluation of implementation ofmental health promotion and prevention programs in the

last decade has shown serious limitations in currentprevention practice ranging from lack of evidence ofprogram effectiveness, lack of any effect or negative effectsin some programs, uneven quality of implementation,limited reach in population, (un)availability of policiesand resources to support prevention and promotion inmental health, and finally a limited spectrum of available“programs that work.” This would be a suitable descriptionof Croatia reality as well.

Comparing needs and capacities

A comprehensive and well-structured legislative frameworkis not fully and consistently implemented due to theinadequate institutional and organizational mechanisms.Difficulties arise from unclear responsibilities and account-ability for conducting national strategy activities. We lackadequate professional staff and not enough is invested inprofessional training. A huge issue is epidemiological datagathering and the evaluation of program effectiveness.

As the substance abuse and addiction problem began togrow in the 1990s, a number of drug prevention and healthpromotion professionals grew with it. With years, ourprofessionals’ experience grew, but they still lack thespecific and most recent knowledge and skills to tacklethe problem effectively. Staff working with children andyoungsters often lack the basic knowledge and skills tocope with these themes and problems. There is an evidentinsufficiency in the just described comprehensive knowl-edge of substance abuse, health promotion, and preventionamong different professionals involved in everyday healthpromotion and drug prevention (e.g., teachers, medicaldoctors, psychologists, and social workers, etc.). Universityprograms offer only general medical and psychologicaleducation with little, if any, curriculum related specificallyto health promotion and drug prevention.

Building the capacity of professionals and organizationsto assure the best quality implementation of the preventionprograms is a necessity and priority. The ultimate aim is toimprove the mental health of the population and theindividual, as well as social and environmental conditionsthat have an impact on health.

According to Hosman (2008, draft paper, personalcommunication), in order to implement effective policiesand programs to improve mental health and reduce mentaldisorders in populations we need a range of capacities suchas a competent workforce with relevant knowledge andskills, organizational capacity, coalitions and partnerships,leadership, resources, and public support. The capacitybuilding should be aimed at citizens, communities andpopulations, the non-health sectors (e.g., NGOs, education,industry, social services, justice, media), the health sector(e.g., primary health care, mental health care, hospitals), as

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well as the specialized health promotion, prevention, andpublic health sector and the research sector. To do this, wecan use a range of strategies such as staff education andtraining, consultation and advice, personnel managementand quality management, research and evaluation projects,national and international conferences on prevention, andpromotion in mental health.

The core issue is, especially at the beginning of theprocess, building the competent workforce who will deliverthe effects at the organizational, institutional, program, andcommunity levels. To that aim, we should incorporatetraining in mental health, health promotion, and preventioninto core education programs of health, social care, andeducation professionals (e.g., general practitioners, nurses,social workers, psychiatrists, psychologists, public healthofficers). We should develop pre- or postgraduate leveleducation and training in health promotion, public andmental health, community psychology as well as postgrad-uate courses and workshops for leaders and workers inhealth and other societal sectors. International exchange ofstudents and scholars should be endorsed and Interneteducation and long distance learning. For Croatia, whichlacks basic knowledge in the field, strengthening the bodyof professionals already working in the field is essential, sodevelopment of postgraduate specialist level educationcould be an excellent start. However, the mere availabilityof such programs is not enough. For successful transition ofmental health promotion and prevention knowledge intopractice, other conditions need to be realized also, such asreaching an agreement with policy-makers, financingagencies, and professional organizations about qualitystandards of professional work in this field, regulatorynorms or protocols in which these standards are defined asobligatory or at least as norms for quality evaluation ofprofessionals, and financial incentives or support to make itpossible for professionals or students to invest time in suchtraining opportunities.

Conclusion

Drug abuse and addictions represent a major and still risingproblem in Croatia. Social, political, and economic transi-tion associated with the war and postwar period in the1990s created a fertile ground for the following epidemic.The average age of first drug use (any drug) is stilldropping and is now 15.9. We are faced with upwardtrends in the use of alcohol, tobacco, and illicit drugs bysecondary school children. Until recently, most of theprograms related to drug prevention were actually drugtreatment programs, but now priority has been given todrug prevention programs. However, we lack evaluationstudies and the implementation of prevention programs has

shown serious limitations in current prevention practice.University programs offer only general medical andpsychological education with little, if any, curriculumrelated specifically to health promotion and drug preven-tion. Public health institutes are recognized as key partnersin health promotion and drug prevention and carry hugeresponsibility for setting quality standards.

The priority should be to build, strengthen, and developa competent workforce, organizations, and institutions atvarious levels. Expertise in health promotion and preven-tion is a key issue for achieving improvement in drugprevention practice. This expertise should be up to date onthe vast body of scientific knowledge in the field ofprevention science. Learning from global experience,educational opportunities need to be integrated into regulareducational programs and into an institutional frameworkthat will guarantee its sustainability and institutionalization.To achieve this, it is necessary to strengthen the capacity ofthe University of Rijeka and Public Health Institute andbring them together to provide a new interdisciplinarycourse for health and education professionals, publicadministration and NGO workers, and those working ondrug prevention and health promotion. Providing a post-graduate level course on “health promotion and drugprevention” will boost our professional capacities, enhancecommunity cooperation, improve prevention practice, andultimately produce a positive impact on the health of ourchildren and young. But the development of such a coursewould also boost our academic development in this field. Itwould aid in establishing the University of Rijeka as theleading center with respect to health promotion and drugprevention education and training in this part of the countryand nationwide.

Acknowledgments This paper was prepared for the purpose of a Ph.D. study in Prevention Science during 2008/2009 under thementorship of Prof. Dr. C.M.H. Hosman. This paper serves as acontribution to the project of development of a postgraduate course onhealth promotion and drug prevention financed by the EuropeanCommission (Tempus project 41030-2006).

Conflict of interest The author is engaged in the project ofdevelopment of a postgraduate course on health promotion and drugprevention financed by the European Commission (Tempus project41030-2006). The author has no other conflict of interest.

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