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Northern Dimension Partnership in Public Health and Social Well-being SIHLWA Northwest Russia Stakeholder Analysis REPORT Report prepared by: Mr. Dmitry Titkov, STAKES/THL, Finland Ms. Marja Tuomi, STAKES/THL, Finland Ms. Anna Orlova, St-Petersburg Ms. Natalia Gurina, St-Petersburg 1

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Page 1: Northern Dimension Partnership in Public Health … · Web viewNorthern Dimension Partnership in Public Health and Social Well-being SIHLWA Northwest Russia Stakeholder Analysis REPORT

Northern Dimension Partnership in Public Health and Social Well-being

SIHLWA Northwest Russia Stakeholder Analysis

REPORT

Report prepared by:

Mr. Dmitry Titkov, STAKES/THL, Finland

Ms. Marja Tuomi, STAKES/THL, Finland

Ms. Anna Orlova, St-Petersburg

Ms. Natalia Gurina, St-Petersburg

Ms. Irina Krutikova, Karelia

Ms. Olga Fetisova, Murmansk

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Table of contents

Executive summary..........................................................................................................................................51 Introduction...................................................................................................................................................7

1.1 Background.............................................................................................................................................91.1.1. The Northern Dimension Partnership in Public Health and Social Wellbeing (NDPHS)..................91.1.2. Neighbouring area, Barents Euro-Arctic region and NDPHS co-operation......................................91.1.3. Social Inclusion, Healthy lifestyles and Work Ability (SIHLWA) background.................................10

1.2 Objectives.............................................................................................................................................111.3 Methodology........................................................................................................................................11

2 Realisation...................................................................................................................................................132.1. Personnel.............................................................................................................................................132.2 Desk study............................................................................................................................................13

2.1.1. Review of international policies and strategies............................................................................132.1.2. Review of international projects...................................................................................................20

2.2 Field visits.............................................................................................................................................223 Results.........................................................................................................................................................24

3.1. Federal legislation (policies, strategies, laws) related to health promotion........................................243.2. Federal legislation (policies, strategies, laws) related to alcohol.........................................................253.3. Conclusions for the legislative basis....................................................................................................273.4. Organisation of healthy and socially rewarding lifestyles promotion at governmental level..............283.5. Organisation of risky behavior and alcohol prevention and alcoholism treatment/rehabilitation at governmental level.....................................................................................................................................293.6. Conclusions for governmental arrangements in promotion healthy and socially rewarding lifestyles and alcohol prevention...............................................................................................................................32

4. Overview of the situation in the regions....................................................................................................374.1 Leningradskaya oblast..........................................................................................................................37

4.1.1.General situation...........................................................................................................................374.1.2. Stakeholders.................................................................................................................................384.1.3. Programmes.................................................................................................................................414.1.4. Projects.........................................................................................................................................43

4.2 St Petersburg........................................................................................................................................454.2.1. General situation..........................................................................................................................454.2.2. Stakeholders.................................................................................................................................464.2.3. Programmes.................................................................................................................................524.2.4. Projects.........................................................................................................................................55

4.3 Karelia...................................................................................................................................................584.3.1. General information.....................................................................................................................584.3.2. Stakeholders.................................................................................................................................58

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4.3.3. Programmes.................................................................................................................................614.3.4. Projects.........................................................................................................................................62

4.4 Murmansk oblast..................................................................................................................................654.4.1. General Information.....................................................................................................................654.4.2. Stakeholders.................................................................................................................................664.4.3. Programmes.................................................................................................................................694.4.4. Projects.........................................................................................................................................71

5. Conclusions.................................................................................................................................................745. Recommendations......................................................................................................................................78

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Executive summary

The given Stakeholder Analysis Project is based on the discussions held during the Northern Dimension Partnership for Public Health and Social Wellbeing (NDPHS) Expert Group Meeting "Social inclusion, Healthy Lifestyles Work Ability" SHLWA, Helsinki, 16-17 May 2006.

The SIHLWA, Expert Group under NDPHS agreed that there was a need to have a better picture and understanding of different actors and stakeholders in the sector addressed by SIHLWA. In particular, this means actors and their activities aiming on prevention of negative effects of alcohol use and promotion of healthy lifestyles among young people. Many institutions, incl. research organizations and NGOs, (military and religious/faith-based organizations included) work towards these goals, but we do not always know who they are and what exactly they have done or are doing.

The present project-based work in the neighbouring regions of Finland does not enhance a possibility to survey the field of stakeholders to an adequate extent i.e. the work tends to be limited to the partners who know each other and by the priorities defined in the 1990s. Elaborating a list of most important key stakeholders and their activities in the thematic areas covered by SIHLWA would be an indispensable starting point to enhance and support existing national and international activities. The scope of SIHLWA, non-communicable lifestyle related diseases, is partly new as compared to the priorities set previously in the Finnish-Russian cooperation in the areas of health and social well-being. The proposed work may also for its part prepare some grounds for new international cooperation with Russia in the area of health and social wellbeing.

The present report constitutes an outcome of efforts undertaken by Finnish and Russian experts. The working methods employed in making the present report were desk-studies to review available databases, documents and mass media, interviewing both personally and by phone or email, and field visits. The project progressed quite smoothly, partly due to good communications established between the Finnish and Russian experts.

The present report includes overviews of strategies and policies internationally, followed by deeper insight into the situation in Russia, and particularly in the studied regions of the Northwest Russia. The overall picture of the state-led health promotion activity guided regionally by Centres of Medical Prevention is presented. The key elements and structures of the existing alcohol prevention and treatment system are depicted. Information about recent projects on the issues concerned and stakeholders has been compiled. While the report text bears just few examples of project activity and stakeholders, the attached annexes include wider lists. Yet, it should be borne in mind that there are definitely projects and stakeholders which so far are missing from the lists. The same concerns the most recent developments and changes in the Russian policies with relation to lifestyles among young people in general and alcohol in particular. Such were happening at the moment of the report writing but were not included as this report is not a telephone directory but should be considered as a tool. It is expected that later, in the revised version of the report, amendments will appear in terms of projects, programmes, stakeholders, and, most expected, positive changes in the Russian healthy lifestyles promotion strategies and alcohol policies.

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It may seem that the theme of alcohol is prioritised in the present report, and this impression will be in a way correct. The fact is that alcohol issues have recently been high on the agenda of WHO, European Commission, Northern Dimension Partnership on Public Health and Social Wellbeing, Baltic Sea States Council, and other international structures. Besides, alcohol and healthy and socially rewarding lifestyles are closely interconnected. Promoting healthy and socially rewarding lifestyles implies, among others, non-acceptance of or withdrawal from health risks, and alcohol abuse is one of such risks.

The last chapters carry impressions and conclusions from the work done, as well as recommendations which followed the data and experiences obtained in the course of the project. It should be reinforced that at the moment of reading of this report some of the recommendations may sound out of place due to the rapidly changing situation in Russia, hopefully changing for the better.

The idea in the background of the stakeholder analysis is to create a flexible model or approach to analysing stakeholders and programmes/projects in other regions. This report is the first attempt to gather information about and analyse lifestyle-related stakeholders and programmes/projects, and therefore certain omissions can be detected. It is also obvious that the use of the proposed approach in other regions may require modifications or alterations.

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1 Introduction

Every normal person wants to live a long and happy life. And everyone realizes that a precondition for the dream to come true is good health. No normal person in this world wants to be sick, everyone wants to be healthy, but in most cases people act on the contrary: deliberately or involuntarily they waste their health and think it never ends. At young age a rare person cares about own health; it seems that the whole life is still ahead and the organism is full of energy and will cope with any stress. The price of health becomes known only when it is ruined. And there are thousands of ways to ruin own health.

According to various surveys1, most young people are sure that health is mainly determined by lifestyles, and many people know that their health depends primarily on them themselves. Yet, knowing this, they bend practically no effort to care about their health, which is paradoxical. Health is not considered as a value, into which investments should be made, but health itself is looked upon as an investment, which could be put into achieving other goals.

Childhood and adolescence are the age when consequences of actions are rarely thought about. This is the age for making experiments and rioting against standards and rules. This is the age when peer pressure dominates over the words of parents and teachers. This is the age when demonstration of authority from adults will meet opposition, no matter how reasonable the adults are. The complex development stage at teen age is very sensitive and fragile and may be easily jeopardised by risks in the individual’s environment. The modern time poses a variety of such, which were unknown or not spread so widely before: drugs, tobacco, alcohol, gambling, environmental pollution, junk food, PC games, HIV and sexually transmitted diseases, etc.

The global community has well recognised the threats that have arisen before the young generations and certain steps have been undertaken to ensure their good health and wellbeing. Yet, those steps are not enough to build barriers between the younger generations and the health-related risks, as the practice shows. Therefore, even more resources should be identified to be invested into child and youth health and development to ensure tomorrow’s prosperity and stability.

Such global actors as the United Nations and World Health Organisation have acted as leaders of worldwide initiatives aimed at health promotion among children and young people. The WHO realizes that the young people now are adults tomorrow, and the behavioral patterns they set now in terms of their health will affect how long they will live and how fully they will be able to display their potential as members of society and how meaningfully they will be able to contribute into the economies of their countries. While developing comprehensive strategies for health development, WHO, UN and other institutes also focus on certain risks related to health and wellbeing of children and young people, and one of the risks is alcohol.

1 Белова Н.И. Парадоксы здорового образа жизни учащейся молодежи. Социологические исследования. №4, апрель 2008. с. 84-86. (Belova N.I. Paradoxes of healthy lifestyle among students. Sotsiologitcheskije issledovanija Journal. No 4, April 2008, p. 84-86. Available at http://www.ecsocman.edu.ru/images/pubs/2009/01/13/0000327106/Belova_13.pdf

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High-level recognition of the dangerous alcohol consumption, particularly among young people, came long ago. The world’s largest alcohol consumption is recorded in Europe2 - 11 litres of pure alcohol/adult/year. Such high level leads to frequent occurrence of health disorders, diseases and mortality caused by harmful use of alcohol. According to the Public Health Portal of the European Union 3, “Europe has the highest proportion of drinkers in the world, the highest levels of alcohol consumption per capita and a high level of alcohol-related harm. Harmful and hazardous alcohol consumption is a net cause of 7.4% of all ill-health and early death in the EU”.

Thus, no wonder that most initiatives in reduction of harmful consumption of alcohol were developed in Europe. When looking back at recent times, one can mention the initiative of the WHO EURO to launch a region-wide action plan on alcohol in 1992. This was followed by numerous positive steps to counteract the problem - the year 1995 saw the European Charter on Alcohol, which was adopted at the WHO European Conference on Health, Society and Alcohol. Six years later, in 2001, the WHO EURO held a European Ministerial Conference on Young People and Alcohol. The Conference addressed the issues and possible measures to prevent alcohol abuse by young people. In the following year the WHO EURO put into effect the European Alcohol Information System, which provides country-based data sets on policies and strategies related to alcohol. At the moment the Europe’s guiding policy is the European Alcohol Policy

Framework of 2005.

At the same time it is obvious that alcohol abuse prevention cannot be done through alcohol-related measures. The approach should be taken comprehensively and embrace all unhealthy behavioral risks, like tobacco smoking, drug use, nutrition, physical activity, etc. Although alcohol is a big contributor to mortality amongst young people, especially males, this, unfortunately, is not the only cause for premature mortality among working-age people.

Therefore, activities of global (UN, WHO, etc.) and regional institutes (in our case, Barents Euro-Arctic Council, Baltic Sea

States Council, Northern Dimension Partnership in Public Health and Social Wellbeing, etc.) emphasize a variety of problems specific of the region’s youth, yet provide space for holistic, multi-sectoral and comprehensive approaches as most effective in dealing with today’s concerns.

In this respect it would be important to see what kind of legal and organizational infrastructure is available in Russia and Russian Northwest, keeping in mind that former Soviet time’s institutes, which were responsible for ideological development of children and young people, have been dissolved (Octoberist organisation, pioneer organisation and Komsomol) but new institutes to replace them in taking care of adolescents’ and youth’s lifestyles and behaviour models have not been built. And while we see that the attempts being undertaken by global actors individually or in consolidation are not enough to restrain the problems’ growth, it will be interesting to see what systems are functioning or could be used more extensively in Northwest Russia to tackle the youth-related problems, particularly in terms of health and social inclusion.

2 Anderson, P. & Baumberg, B. (2006) Alcohol in Europe. London: Institute of Alcohol Studies3 http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_factsheet_en.pdf

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Risky behaviors spread increasingly wider, which causes big concerns with such global organizations as United Nations and World Health Organisation. These concerns have led to certain actions to promote health lifestyles, especially among younger generations.

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1.1 Background

1.1.1. The Northern Dimension Partnership in Public Health and Social Wellbeing (NDPHS)

The Northern Dimension Partnership is cooperation between EU, Russia, Norway and Iceland, which are all equal partners. The United States of America and Canada are observer countries. The Northern Dimension

is also linked to the EU-Russia cooperation framework According to the Oslo Declaration 2003 the overall objective of the Northern Dimension Partnership in Public Health and Social Wellbeing (NDPHS) is to promote sustainable development in the Northern Dimension area through improving human health and social wellbeing. The Partnership aims at contributing to intensified co-operation in social and health development and assist partners and participants in improving their capacity to set priorities in health and social wellbeing, as well as to enhance co-ordination of international activities within the Northern

Dimension area. The activities by partners and participants should contribute to greater political and administrative coherence in the area, narrowing of social and economic differences, and to a general improvement of the quality of life.

When the Partnership was built it was stated that it will build on, enhance and support existing national and international activities within its scope. To be able to build on previous experiences there is a need to have actual information about most important key stakeholders as well as projects/programmes in the area. However not much has been systematically done so far to enhance and support this kind information gathering. A reason to this might be that the Partnership mechanisms for the NDPHS are still somewhat premature and the roles and responsibilities of different actors are not clear and the funding for coordination mechanisms of activities is almost non existent.

1.1.2. Neighbouring area, Barents Euro-Arctic region and NDPHS co-operation

Neighbouring area cooperation is an integral part of Finland's foreign policy. The cooperation with Russia is based on an agreement between the Government of Finland and the Government of the Federation of Russia on cooperation in the Murmansk region, the Republic of Karelia, St Petersburg, Kaliningrad and Leningrad region, which was signed in 1992. According to a new Government Programme, Finland's future cooperation in the neighbouring areas will however be reformed. The cooperation in the development of social welfare and health sector in neighbouring areas is very actively ongoing. The working group Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA) will clearly benefit from sharing experience and knowledge about key actors/stakeholders in the above mentioned regions in Russia. The networks created by means of neighbouring area cooperation will, of course, be of vital importance for SIHLWA, based on such themes as prevention of drug abuse among young people, promotion of young peoples health,

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For the Northern Dimension Partnership to effectively build on, enhance and support national and international activities, more information is needed about stakeholders, projects and programmes, and lessons learnt.

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prevention and treatment of communicable diseases (HIV/AIDS, tuberculosis and sexually transmitted diseases), development of family-focused social and health care services and of administrative structures supporting them, as well as strengthening of civil society.

Additionally, within the Cooperation Programme on Health and Related Social Issues in the Barents Euro-Arctic Region 2004-07 significant steps have been made in such priority areas as prevention of and combat with communicable diseases, particularly the HIV/ AIDS sub-programme coordinated by IDC at STAKES (now International Affairs Unit at the National Institute for Health and Wellbeing). Under this sub-programme new contacts have been established e.g. in Murmansk Region, and new stakeholders have been included in Nordic-Russian cooperation, which can directly be utilized also in this stakeholder analysis.

The above described neighbouring area cooperation does not thematically cover the scope of SIHLWA as defined presently and therefore a separate stakeholder analysis is needed.

1.1.3. Social Inclusion, Healthy lifestyles and Work Ability (SIHLWA) background

The new Expert Group (EG) of NDPHS on Non-communicable Diseases and Promotion of Health and Socially-Rewarding Lifestyles was established in December 2004 after consultation in Tallinn Estonia in connection with the Partnership Annual Conference (PAC) and confirmed in April 2005 at the Committee of Senior Representatives (CSR) meeting in Vilnius Lithuania.

The overall structure of this working group is built on three main themes. To better reflect established three sub-groups, the Expert Group's title was changed to "Social Inclusion, Healthy Lifestyles and Work Ability (SIHLWA). The three sub-groups are:

1. Alcohol

2. Adolescent health and socially rewarding lifestyles

3. Work Ability

The overall framework needs to be based on a broad and comprehensive understanding of the problem area in order to make a positive impact on the problems identified and to avoid excluding possible important aspects in the development work. The main priority areas for further development will be defined keeping in mind synergy benefits arising from the three sub-groups. The SIHLWA group started to work on a common strategy and work plans for SILHWA in Helsinki, May 16. - 17. 2006. It was decided to propose a thematic review to identify important SIHLWA stakeholders in order to improve collaboration, networking and capacity building related to the three main themes. A review and analysis of important past/ongoing projects/programmes was also recommended. In this paper we speak about these tasks as stakeholder analysis.

Thematically the stakeholder analysis mainly covers the two first main themes

alcohol

adolescent health and socially rewarding lifestyles.

A better picture and understanding of different important actors and stakeholders in the sector is essential in order to enhance institutional linkages and long term sustainability of developed activities. Many institutions, agencies, organisations, NGOs in the partner countries work with SIHLWA thematic areas but

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we do not always know who they are and what they have done or are doing. It is also important to know Stakeholders whose interests might be in contradiction to SIHLWA's interests when planning any development work. Combating alcohol related problems is, for example, an area of interest for all three SIHLWA sub-groups and most probably also a future challenge for most partner countries.

The availability of "lessons learnt" from past/ongoing projects will enhance and improve the quality of any future efforts and support local capacity building. Support to networking between NDPHS and Russian institutions will benefit all participants in the long-run. We see that the scope of this networking is still at the moment rather limited.

1.2 Objectives

The overall objective and purpose of the stakeholder analysis is to improve the health and wellbeing of the population in the partner countries through providing all interested partner countries with,

a) up to date information on the most important stakeholders and expert organisations and other actors like NGOs and even industries within the project area related to 1) alcohol and 2) adolescent health and socially rewarding lifestyles and up-dated information on 3) workability and

b) a review of most important/successful programmes/projects related to these areas for improved networking and exchange of information and know-how and

c) concrete ideas for future cooperation.

The main result is a report including a list of main stakeholders as well as information about past/ongoing projects (lessons learned) as well as concrete ideas for future cooperation in order to promote sustainable development in the Northern Dimension as well as in the target regions by improving human health, social wellbeing and social inclusion.

Interesting results and experiences from past/ongoing projects can also be presented in expert group seminars.

The NDPHS secretariat and its new web-site www.ndphs.org will provide an excellent platform for the distribution of results. The NDPHS data-base project will also be available for the distribution of project information in English and Russian.

1.3 Methodology

Working methods

Collecting of background information of the NDPHS/SIHLWA work

Collaboration with SIHLWA Coordinator

Social and health policy documents, such as action plans and strategies from target regions will be investigated in order to see how SIHLWA objectives are addressed in each region

Main stakeholders (10-15) will be accepted to the list as of their relevance to the above mentioned themes.

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Establishing contacts with the potential stakeholders, visits to the target regions and stakeholders for collecting documentary information and interviewing them

The key stakeholders will be interviewed about past/ongoing successful programmes/projects in social/health sectors (max 6 per target area) in the thematic areas and about new ideas for possible future development

Also new partner stakeholders having not yet an impressive reference list will be included in the report to the extent needed

Stakeholders whose interests might be in contradiction (antagonistic) to SIHLWA's interests will also be identified and commented (e.g. alcohol and tobacco industry).

Main activities

The work starts as a desk study using existing policy documents, reviews and summaries

The draft template ( annex 1) and questionnaires addressed to the stakeholders for interviews will be finalized

Collection of information will first be done via internet, mail and telephone interviews, supplemented by additional information gathering during visits to the target regions.

Analysis of information and reporting

Categorization of stakeholders in a logical manner will be done (e.g. branches of civil service, research institutes, various types of NGOs etc.)

Relevant programmes/projects will be listed and main lessons learned included in the report

A workshop / seminar will be arranged for key stakeholders to discuss results and further actions

A draft communication plan for dissemination of results will be prepared

The results will be presented and discussed in SIHLWA meetings and the dissemination of the results/report of the review and analysis will be discussed also with the Secretariat in order to reach optimal benefit from the exercise. The NDPHS/SIHLWA provides an already existing forum to discuss the findings at the highest relevant administrative and political level. The results will also be made available for neighbouring area cooperation.

2 Realisation

2.1. Personnel

The project was launched through STAKES/IDC Finland (International Affairs Unit at the National Institute for Health and Welfare starting from January 1, 2009), which has a good record of project implementation and ability to work in the N-W Russian area. Besides, 4 local experts have been selected and hired to work for the Project - two from St-Petersburg (Ms Anna Orlova from the ST-Petersburg NGO Development Centre and Ms Natalia Gurina from St-Petersburg Medical Academy of Post-Graduate Studies), one from Murmansk Region (Ms Olga Fetisova from Murmansk AIDS Centre), and one from Karelia Republic (Ms Irina

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Krutikova from Karelian Resource Centre of NGOs). As for the local experts from St-Petersburg, Ms Anna Orlova was responsible for collecting social sector-related information in St-Petersburg and Leningrad Region, while Ms Natalia Gurina was responsible for collecting health sector-related information from the same area. More local short-term experts may be hired to answer the needs arising in the course of the project implementation but within the budget’s limits.

SIHLWA coordinator acts as a consultant in the project as well as SIHLWA sub-groups chairmen or vice-chairmen as needed.

2.2 Desk study

2.1.1. Review of international policies and strategies

The desk study commenced in Finland was first targeted at scrutinizing policies, strategies and concepts launched internationally, and in Europe in particular to see what attention is drawn to problems of healthy and socially rewarding lifestyles in the first place, and problems of alcohol use in the second place. Linkages with actions in Russia were underlined.

2.1.1.1. Adolescent health and socially rewarding lifestyles

According to the 2004 Global Burden of Disease report, “the mortality rate due to non-communicable diseases is highest in Europe, where nearly two thirds of all deaths at ages 15–59 years for low- and middle-income countries are associated with cardiovascular diseases, cancers and other non-communicable diseases”. The simple fact is that most of these premature diseases were avoidable, and they could have been avoided by choosing responsible and healthy attitudes to the way of living. Another leading cause of mortality in age span from 15 to 59 is injuries with almost the same 2,5 per 100,000 males as for cardiovascular diseases. So, cardiovascular diseases and injuries together amount to about two thirds of all deaths in age group 15 to 59.

The WHO, a the directing and coordinating authority for health within the United Nations system, realizes that the young people now are adults tomorrow, and the behavioral patterns they set now in terms of their health will affect how long they will live and how fully they will be able to display their potential as members of society and how meaningfully they will be able to contribute into the economies of their countries.

The key structure at WHO EURO responsible for adolescents' health is the Department of Child and Adolescent Health and Development. The guiding document for the Department of Child and Adolescent Health and Development is the European Strategy for Child and Adolescent Health and Development . This document defines central principles as a foundation for making interventions needed to protect health and development of children, young people and their families. One of the areas for action, as prescribed by the document, is adolescents and their behavioral patterns. Many of premature deaths are caused by the lifestyles adopted in adolescence; therefore it is crucial to ensure the right choice by adolescent so that their health-related behavior would affect positively their own lives and the ones of their children. The ultimate goal of the Strategy is to help in formulating national policies and programmes so that they enable the best possible health and development of the current young generation, who are tomorrow's adult

http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html

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generation, too. The Strategy sets seven priority areas fort action, among which are nutrition, injuries and violence, physical environment, adolescent health, and psychosocial development and mental health.

The implementation of the European Strategy for Child and Adolescent Health and Development is supported by SIHLWA and its subgroup on adolescents and socially-rewarding lifestyles.

Activity of the Department of Violence and Injury Prevention at WHO European Office is connected closely with the risky lifestyles and their determinants. The WHO Regional Committee for Europe adopted a Resolution addressing the prevention of injuries in the European Region at its 55th session in September 2005 (EUR/RC55/R9). As stated in the report "Progress in Preventing Injuries in the WHO European Region", the third leading cause of mortality in Europe is injuries, both intentional and non-intentional. One of the biggest risk factor for injuries is alcohol. Thus, the problems of injuries is closely connected with the scope of SIHLWA and the given project.

Besides, Mental Health Action Plan for Europe puts one of the focuses on children and young people as a vulnerable group, which should be given a priority in terms of promotion of mental health and prevention of mental disorders.

Last but not least, another guiding document of WHO, which definitely should be mentioned, is the Action Plan for the Global Strategy for Prevention and Control of Non-Communicable Diseases . The 61st World Health Assembly endorsed a six-year action plan to tackle non-communicable diseases, such as cardiovascular diseases, diabetes, cancers and chronic respiratory diseases, which are a 60% burden in all deaths worldwide every year. The Action Plan urges countries to establish or strengthen multisectoral frameworks and place prevention of non-communicable diseases as intergral part of their national health development programmes . The activity of SIHLWA goes in line with the goals of the Action Plan, since vast majority of cardiovascular diseases, diabetes and other chronic non-communicable diseases take root in unhealthy behavior patterns, like tobacco use, alcohol abuse, unhealthy eating habits, and low physical activity.

WHO supports widely children and adolescents’ health oriented actions and programmes in Russia. Below are few examples of these:

WHO-supported actions/projects in Russia:

According to the European Strategy for Child and Adolescent Health and Development, Russia is one of the countries that asked for intensified support from WHO for developing a national child and adolescent health policy. Yet, according to report "Evaluation of the first implementation phase of the European Strategy for Child and Adolescent Health and Development", Russia did not return a completed questionnaire form which concerned the progress in development of child and adolescent health national policies and strategies.

One of the activity worth being noted is Schools for Health in Europe and its National Programme for Russia coordinated by the Russian Research Federal Institute of Hygiene and Health Protection of Children and Adolescents (Mr. Vladislav Kuchma, vice director of the Institute and national coordinator of Schools

http://www.euro.who.int/Document/MNH/edoc07.pdf

http://www.who.int/nmh/Actionplan-PC-NCD-2008.pdf

http://www.schoolsforhealth.eu/index.cfm?act=landen.state&varland=138

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for Health in Russia,http://www.nczd.ru ). Unfortunately, no information was available about the Russian part of the health surveys among Russian school-children. Besides, the CINDI programme, mentioned below in the alcohol sub-chapter, deals with not only alcohol-related problems, but all non-communicable diseases caused by various risk factors, and is aimed at promotion of healthy lifestyles among young people. One of the CINDI projects, now completed, deserves being mentioned. This is Quit and Win Campaign, which was launched internationally in 1994 based on successful experiences from the North Karelia Project (Finland). Although completed now as an international initiative, this project proved its viability as Karelia Republic (Centre for Preventive Medicine) still conducts regional quit and win campaigns every year. The CINDI Programme in the Russian Federation is managed by the National Centre for Preventive Medicine, Department of Policy and Strategy Development in Disease Prevention and Health Promotion (programme director professor Rafael Oganov, http://www.gnicpm.ru)

Another programme related to the questions of healthy lifestyles is the WHO Healthy Cities Programme, which was started in 1988. Now, the 5th Phase (2009-2013) of the Programme commenced, and one of the three core themes of this period is healthy living, which means that a healthy city, a member of the healthy cities network, provides conditions and opportunities that support healthy lifestyles. The most important issues covered by promotion of healthy lifestyles are alcohol and drugs; prevention of non-communicable diseases; active living; healthy food and diet; tobacco; violence and injuries, etc. Russia is a member of the Programme, with Dr Yulia Abrosimova from the Institute of Public Health and Health Care Management (http://www.hcp.aha.ru/) being the national network coordinator.

Concluding the part concerning WHO activity in Russia it is worth noting that pursuant to the Biennial Collaborative Agreement between the Regional Office for Europe of WHO and the Russian Ministry of Health and Social Development for 2008-2013, certain mid-term priorities for collaboration have been identified, among which were: "Addressed major risk factors with focus on alcohol abuse and tobacco", which means that the problems of avoidable harms will be in the central place within the WHO-Russia cooperation in the near future.

A series of WHO Collaborating Centres operate in the Russian Federation. The following Collaborating Centres are within the interest of SIHLWA and the goals of this project:

WHO Collaborating Centre on Development and Implementation of Non-Сommunicable Disease Prevention Policy and Programs, Department of Development of Policy in Diseases Prevention and Health Promotion at National Research Centre for Preventive Medicine, Ministry of Health, director Rafael Oganov ([email protected])

WHO Collaborating Centre for Research & Training in Mental Health, Bekhterev Psychoneurological Research Institute (http://www.bekhterev.spb.ru), director Prof. Nikolai Neznanov ([email protected])

WHO Collaborating Centre for Occupational Health, Ufa Research Institute of Occupational Health and Human Ecology (http://www.ufniimt.ru), director Mr. Akhat Bakirov ([email protected])

WHO Collaborating Centre for Occupational Health, Russian Academy of Medical Sciences' Institute of Occupational Health (http://www.niimt.ru), director Dr. Nikolai Izmerov ([email protected]),

http://www.euro.who.int/healthy-cities

http://www.euro.who.int/document/bca/rus0809.pdf

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Aside from working through the WHO, the United Nations supports a broad array of other youth programmes and initiatives. The foundation for such programmes and actions is the World Programme of Action for Youth on Health (A/RES/50/81).

A good example of such youth programmes, which is present also in Russia, is the activity of the United Nations Children’s Fund, or UNICEF. One of the principles of UNICEF is that preventive healthcare and promoting healthy lifestyles is more effective and less costly than medical treatment. UNICEF has been present in Russia since 1997. The goal of UNICEF actions in Russia is that every child has the right to have healthy, safe and happy childhood. One of the initiatives undertaken by UNICEF in Russia is establishment of a network of youth-friendly clinics. The youth-friendly clinics work to provide support to adolescents and young people based on their needs, problems and involvement into seeking healthy behavioural patterns. The clinics offer medical and socio-psychological services for free or at minimum price. The services of youth-friendly clinics emphasize promotion of reproductive health among other health promotion services. Youth-friendly clinics are now a powerful tool in promoting health among adolescents, and they are present now in over 30 regions of Russia, including the Russian Northwest.

Apart from the United Nations and WHO, the European Commission is one more key stakeholder on the European continent. Although the EU itself cannot pass laws simply to protect human health (Member States have not conferred this power on the European institutions), the action of the EU may come in the form of “non-binding” resolutions and recommendations urging Member States to act in a certain way. The most prominent international legal obligations that affect alcohol policy are the General Agreement on Tariffs and Trade (GATT) dealing with goods, and the General Agreement on Trade in Services (GATS). Besides, On October 24, 2008, the European Commission adopted a Communication setting out a strategy to support Member States in reducing alcohol-related harm. The priorities identified in the Communication are to:

protect young people and children and the unborn child;

reduce injuries and deaths from alcohol-related road accidents;

prevent harm among adults and reduce the negative impact on the workplace;

raise awareness of the impact on health of harmful alcohol consumption; and on appropriate consumption patterns

Develop a common evidence base at EU level

And again, the European Union is not dealing with harmful and hazardous consumption of alcohol as a lonely reason of ill-health. The Directorate-General on Health and Consumer Protections equally tackles other problems that are related to the question of lifestyles, and certain policies and strategies have been developed on tobacco, physical activity, mental health, etc.

Health determinants, such as alcohol, nutrition, tobacco, physical activity and drug use, as well as social and environmental determinants is one of the objectives of the 2008-2013 Health Programme (2nd Programme of the Community Action in the field of Health) launched by the European Union. For the most part, the Health Programme budget is intended to finance projects and other actions which contribute to increased

http://eur-lex.europa.eu/LexUriServ/site/en/com/2006/com2006_0625en01.pdf

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solidarity and prosperity in the European Union by protecting and promoting human health and safety and by improving public health.

Activity of EU-aided programmes and initiatives related to health of children and youth in Russia is very low at the moment. The reasons are several: Russia is not part of the European Union; the recently launched EU’s Neighbourhood Programme has hampered in Russia; the EU-Russia Cooperation Programme has other priorities than health and welfare of children and adolescents.

So, it is obvious that a series of policies, strategies and other initiatives have been put in place across Europe to oppose the problems of unhealthy lifestyles, with harmful alcohol consumption included. While each of the risk factors is important in itself as it contributes to the prevalence of non -communicable diseases (above all, cardiovascular diseases) in Europe and premature mortality attributable to avoidable causes, and special projects have been designed to deal with it, special attention is focused at the need of a comprehensive and evidence-based approach to tackling the problems as a complex, because it is impossible to tackle the alcohol-related problems and ignore other risk factors, for example, tobacco smoking. Effectiveness of actions depends on multi-sectoral, GO-NGO, parents-school-community cooperation achieved in dealing with these problems, and especially participation of young people is crucial, because the central figure in all the activities is a young person, a very sensitive and vulnerable being, and only when this young person realizes that a healthy lifestyle is part of his/her own attitude, success can be sought.

2.1.1.2. Alcohol

Since one of the tasks of the SIHLWA's sub-group on alcohol is to support the implementation of the alcohol policy framework for the WHO European Region, the key guiding policy for the scope of this Project is Framework for Alcohol Policy in WHO/Europe adopted in 2005 (WHO Regional Committee for Europe resolution EUR/RC55/R1). This is the latest WHO’s policy document on alcohol, which addresses issues previously brought up through other initiatives, like the European Charter on Alcohol (1995), European Alcohol Action Plan (2000-2005), Declaration on Young People and Alcohol (2001). The alcohol policy framework is a foundation for formulating/reformulating national alcohol policies and action plans and a platform for strengthening cooperation at national and international levels in order to reduce the consequences caused by alcohol-related problems.

What is important in terms of this project is that while representing a broad vision on alcohol policy developments and facilitating the further process of developing alcohol policies and programmes, the Framework for Alcohol Policy emphasizes the alcohol-and-youth theme, as youth intoxication remains high across Europe and tends to grow higher.

Being a common problem for the whole Europe in this or that extent, alcohol, aside from this, possesses the multi-sectoral quality, i.e. it affects not only the drinker's health and development, but also the health and wellbeing and development of drinker's environment, it affects the demography and economy of a country. In this regard, the Alcohol Policy Framework calls for close collaboration of three departments - Department of Mental Health and Substance Abuse, Department of Child and Adolescent Health and Department of Violence and Injury Prevention. The Framework is tied with other initiatives of the WHO EURO, inter alia, the European Strategy for Child and Adolescent Health and Development, the Mental

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Health Declaration and Action Plan for Europe, and 2008-2013 Action Plan for the Global Strategy for Prevention and Control of Non-Communicable Diseases11.

It is worth to mention another policy document, which is currently under way. This is a draft global strategy to reduce harmful use of alcohol, which is to be presented in 2010. The WHO Technical Regional Consultation on Global Strategy to Reduce Harmful Use of Alcohol was to be held in Copenhagen from 20 to 23 April 2009 with the main objective on ensuring effective collaboration and consultations with WHO Member States on developing a draft global strategy.

Several WHO-supported alcohol-related development and research projects and programmes have been implemented, wholly or partly, in Russia. Below are some of them:

- WHO Collaborative Project on Identification and Management of Alcohol-Related Problems in Primary Health Care:

- Phase IV: Development of Country-Wide Strategies for Implementing Early Identification and Brief Intervention in Primary Health Care, 2006. - Development and application of country-wide strategies for the widespread, routine and enduring implementation of early identification and brief intervention within primary healthcare in participating countries.

- Phase III: the current practices and perceptions of general medical practitioners (GPs) were assessed (Strand 1), in-depth telephone interviews with GPs and personal interviews with key informants were conducted; and methods for encouraging the uptake and utilization of a screening and brief intervention package by GPs were evaluated in a controlled trial - obstacles to widespread implementation of screening were identified and methods for their initial dissemination and introduction in primary healthcare were evaluated

- Phase II: a clinical trial of screening and brief intervention in PHC was carried out - the effectiveness of a form of brief intervention in primary healthcare was demonstrated in a cross-cultural randomised control trial

- Phase I: a reliable and valid screening instrument for detecting hazardous and harmful drinkers in primary health care (PHC) settings was developed (the AUDIT questionnaire) - an effective screening method was developed for use in brief interventions with primary health care

- Alcohol Use and Sexual Risk Behaviour: A Cross-Cultural Study in Eight Countries, 2005 (a literature review and on-site study in eight countries, including Russia)

- Global Status Report on Alcohol 2004 (an overview and comparative analyses of the alcohol situation on a regional and global basis using indicators such as alcohol consumption and use, prevalence rates and drinking patterns + individual country profiles)

11 http://www.who.int/nmh/Actionplan-PC-NCD-2008.pdf

http://www.who.int/substance_abuse/publications/identification_management_alcoholproblems_phaseiv.pdf. See more about the results of this project in Chapter "Lessons Learnt" http://www.who.int/substance_abuse/publications/alcohol_sexual_risk_crosscultural.pdf http://www.who.int/substance_abuse/publications/global_status_report_2004_overview.pdf

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- Global Status Report: Alcohol Policy, 2004 (review of existing policies in countries worldwide and a brief snapshot of what is known about the effectiveness of alcohol policy measures)

- Global Status Report: Alcohol and Young People, 2001 (an overview of the prevalence of drinking among young people, alcohol-related mortality and other health effects, trends in the alcohol environment surrounding youthful drinking, and prevention policies designed to reduce alcohol-related problems among the young)

- WHO CHOICE (CHOosing Interventions that are Cost-Effective). The project was commenced in 1998 and it assembles regional databases on the costs, impact on population health and cost-effectiveness of key health interventions. The project also provides a contextualization tool which makes it possible to adapt regional results to the country level.

- CINDI (Countrywide Integrated Non-Communicable Diseases Intervention) programme initiated over 30 years ago by WHO EUR. The CINDI network comprises 32 participating countries (31 Member States of the WHO European Region and Canada) and three candidate countries. CINDI provides participating countries with an integrated approach to activities to prevent and control risk factors (such as smoking, high blood pressure, high blood cholesterol, obesity and excessive alcohol consumption) and to address their social and environmental determinants. Among other topics, the CINDI Programme is dealing both with alcohol problems and health promotion among children and adolescents. The Russian web-resource of the CINDI Programme is located at www.cindi.ru (which seemingly does not work).

- Violence and Injury Prevention Programme launched by WHO EUR. Report "Interpersonal violence and alcohol in the Russian Federation", Policy briefing, EUR/06/5063130. The survey looked at how the growth of alcohol consumption in Russia triggered violent behaviors and, consequently, alcohol-related deaths and injuries.

- WHO/UNDCP Programme Global Initiative on Primary Prevention of Substance Abuse, 1998-2003, joint project initiated to support a number of local partners from Central and Eastern Europe, Southeast Asia and Southern Africa in reducing substance use and abuse among young people.

A product of the WHO Healthy Cities Programme/Multi-City Action Plan (MCAP) on Alcohol Project, which draws attention is Guidelines on City Action on Alcohol, which although is relatively old (1998), yet includes examples and good practical tips for making and implementing alcohol policies at local level, including examples from Russia (St-Petersburg). See more about the WHO Healthy Cities Programme above in "Adolescent health and socially rewarding lifestyles" subchapter.

WHO/Europe has established a network with an alcohol counterpart in each of the Member States. These counterparts work together with WHO to facilitate the implementation of the European Alcohol Action Plan 2000-2005 and the Stockholm Declaration on Young People and Alcohol. National counterparts also collect

http://www.who.int/substance_abuse/publications/en/Alcohol%20Policy%20Report.pdf http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.1.pdf http://www.who.int/choice/en/index.html http://www.euro.who.int/CINDI http://www.euro.who.int/Document/E88757.pdf http://www.who.int/substance_abuse/activities/global_initiative/en/ http://www.euro.who.int/document/e60264.pdf

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information on consumption, policies and events in the countries for WHO. The network meets once a year to plan the work for the coming year.

To sum up the findings made on the international (in our case, European) arena, one may conclude that issues of alcohol abuse, particularly among adolescents and young people, have received special concerns in the general context of healthy lifestyle problems. The worries over increasing spread of alcohol use by the younger generations have led to elaboration of special political frameworks and strategies, which on the one hand go in line with overall adolescence and youth health policies and strategies, and on the other hand call for special attention to the problem of alcohol use.

2.1.2. Review of international projects

The next step of the desk study was collection of information and analysis of international projects included in the database of the Northern Dimension Partnership in Public Health and Social Wellbeing. The search yielded 362 projects associated with SIHLWA. The further study of detected projects was subjected to certain limitations: first, geographically projects had to be implemented in the areas concerned, i.e. Murmansk Region, Karelia Republic, St-Petersburg or Leningrad Region. The second limitation regarded timing; a project should have started latest in 2004. The third limitation was the direct focus of a project on the themes of the study, i.e. alcohol or adolescents' lifestyles.

Besides, it was originally assumed to separate projects according to the themes, which caused a rather big problem since many projects that concern alcohol abuse prevention may concern the theme of adolescents' health and lifestyles too. Thus, the first section of the list includes projects related to alcohol and alcohol-lifestyles combination. The second section will cover the lifestyles-related projects. In addition to the database of the NDPHS other sources were employed: external databases linked to the website of the NDPHS Database (BEAR's Health and Social Programme at http://www.barentshealth.org/ with search criteria as: Thematic area: Alcohol, Drugs, Tobacco, Child and Adolescent Health Substate level / administrative units : Karelia Republic, Leningrad Oblast, Murmansk Oblast, St. Petersburg). Another source of information about projects was the website of the East European Committee of the Swedish Health Care Community at www.oek.se. In addition, projects implemented in the regions concerned through EU programmes (Tacis/EU-Russia Cooperation Programme, Interreg, Neighbourhood Programme) have been studied. The database of EU-Russia Cooperation Programme’s projects, projects of other donors, with some Neighbourhood Programmes’ projects included, is posted at the website of project “Support to the National Cooperating Unit, Russia”: http://www.eucoop.ru/TacisPublic/Index.aspx. Then, the catalogue of Finnish-Russian projects ongoing in 2009 and posted at the website of the Finnish Ministry of Foreign Affairs was explored (http://formin.finland.fi/public/default.aspx?nodeid=40161&contentlan=1&culture=fi-FI). In addition, the websites of the local offices of the Neighbourhood Programmes in Murmansk Region, Karelia Republic (www.euregiokarelia.ru ) and St-Petersburg (http://www.southeastfinrusnpi.fi) have been used. Then, project funded by SIDA have been reviewed from SIDA's project catalogue at www.sida.se/shared/jsp/download.jsp?f=Social+sector+Russia.doc&a=4353 -. Last but not least, the database of the International Affairs Unit at the National Institute for Health and Welfare (former International Cooperation Development at STAKES) was examined.

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The complete list of projects is attached in Annex 1. Few projects worth of deeper insight are described in Chapters 3.1 to 3.4

2.2 Field visits

The first visit by the Project manager was undertaken in 16 to 20 January 2009. The first site visited was Petrozavodsk (Karelia Republic), where a meeting was carried out as preliminarily planned with the local expert/organization - Ms Irina Krutikova from the Karelian Resource Centre of NGOs. In addition to the Project manager and local expert the meeting was attended by the director of the Karelian Resource Centre of NGOs Mr. Nikolai Oskin and Centre's expert Ekaterina Lazareva. The agenda of the meeting was to brief the local expert about the Project's goals and purposes, NDPHS' SIHLWA group, tasks of the local expert, etc. The next site visited was St-Petersburg (19-20 January 2009) when a meeting was conducted with local expert Ms Anna Orlova (responsible for collection of Project-related data in the social sector) at the St-Petersburg Development Centre NGOs, where she is currently employed (meeting attended by Centre's Director Ms Anna Skvortsova), and with local expert Anna Gurina (from St-Petersburg Medical Academy of Post-Graduate Studies), who is responsible for collecting Project-related data in the healthcare sector. These two meetings' content was briefing about the Project, SIHLWA, terms of reference, milestones, etc. Besides, a meeting was arranged with one of the Project's key stakeholders - St-Petersburg Public Health Committee (Director of the International Relations Mr. Yuri Petrov and project assistant Ms

21

Highlights of international projects reviewed:

The review of the international projects and programmes implemented in the regions in question shows that:

1) If all the projects are categorized into research and development, then alcohol-related projects are basically research ones as they study effectiveness of various medications or their combinations in treatment of alcohol-based diseases or disorders, i.e. psychopharmacology-oriented,

2) Out of development projects only few ones were targeted at only alcohol problems, and most projects concerned a wider range of problems, where alcohol was just one problem on the list. The reasons for this might be: the target group (children and adolescents) is subjected to various risk factors, therefore it would be most effective to cover most risk factors at a time. Alcohol problems stay often in the shadow of other problems, in the first place drugs. Alcohol abuse has become a so common problem that it is often not seen as a problem by society. The problem of alcohol has only recently started moving into the focus of public authorities.

3) The most common themes of a project are: prevention of psycho-active substance use (drugs, alcohol, tobacco), promotion of healthy lifestyles, support actions for vulnerable groups of population.

4) The Russian counterparts in projects represent both the governmental and non-governmental sector. Formal commitment from governmental bodies is preferable regardless to who implementing parties of a project are from the Russian side.

5) The most active international actors in the regions in question are from Finland. Swedish and Norwegian organizations concentrate their project activity in Murmansk Region

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Ekaterina Kuznetsova) to present information about the Project and agree possible cooperation. It was agreed to establish information sharing between the Project and the Committee.

The second field visit was conducted on 23 to 26 February. The visited sites were Murmansk and St-Petersburg. In Murmansk, the Project manager met with Mr. Boris Lyangazov from Murmansk Regional Centre for Medical Prevention, one of the regional key stakeholders in prevention of alcohol abuse prevention and healthy lifestyles promotion. Mr. Lyangazov told about the activities, trainings and research conducted by the Murmansk Centre for Medical Prevention. Besides, the most burning problems in terms of alcohol-youth relationship were discussed. The next meeting was with Mr. Igor Zaplatkin, acting director of Murmansk Regional Narcology Clinic, who shared information about the current narcological situation in Murmansk Region, biggest problems, structure, networking and existing programmes of the Murmansk Narcological Clinic. This meeting was arranged in the premises of the Murmansk Regional Medical Information and Analysis Centre, and the chief of the international operations of the Centre was present at the meeting. The following stakeholder visited was Murmansk Regional Youth Department. The meeting was attended by Mr. Aleksei Pisarev, vice chief of the Committee, Ms Olga Pokrovskaja, senior expert of the Committee. Besides, the meeting was participated by the local expert Ms Olga Fetisova, who is currently working for Murmansk Regional AIDS Centre. The Project manager received a considerable amount of information about the activities of the Murmansk Youth Department, and particularly largest and most successful projects and programmes targeted at adolescents and young people of the Region. Besides, information was presented about the structure, international experiences of cooperation and networking of the Committee. The local expert was briefed about her assignment.

The next destination in this trip was St-Petersburg, where meetings were held with local experts Ms Natalia Gurina and Ms. Anna Orlova. The aim of the meetings was to discuss the progress of the work, share information and update the assignments. Besides, a meeting was held with representatives of St-Petersburg Committee for Social Policy Ms. Galina Kolosova, vice-chief of the Committee, and Ms Albina Andrianova, senior expert of the Committee. Through them, contact information of Ms Marina Zhukova, responsible for implementation of St-Petersburg City Demographical Concept/Action Plan was obtained. The St-Petersburg City Demographical Concept seemed to be a crucial policy document, which is very much relevant to SIHLWA priorities and objectives.

On May 21-24 a trip was undertaken to Petrozavodsk (Karelia Republic) to get more information about local stakeholders. To this end a meeting was organized with the local expert, who had helped organized meetings with the personnel of Karelian Addictions Clinic (Ms Aleksandra Lubnina) and the Sociological Survey Laboratory at Karelian Pedagogical University (Ms Svetlana Goranskaja). Besides, a meeting was arranged with the local AA organization.

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3 Results

The chapters below are dedicated to the results obtained through the desk study and field visits to the Russian regions and collection of information, and overview of the Russian federal and regional laws, programmes and policies related to healthy and socially rewarding lifestyles and alcohol prevention.

3.1. Federal legislation (policies, strategies, laws) related to health promotion

The federal legislation related to health promotion is based on the following policies:

- Long-term Russian National Priority Project "Health" ("Zdorovje"), which sets off health promotion as a new direction of the Priority Project for the years 2009 to 2012. The tasks defined by the Project are reduction in alcohol abuse (2012 goal - by 5,1% among adults if compared with 2007 figures) and tobacco smoking (the share of the smoking population from 45% down to 37% by 2012). Another key direction of the Priority Project is improvements to the disease prevention system, where one of the tasks is to increase the share of health-examined working population from 50% to 90% and to increase the number of visits to doctors for preventive purposes from 37% to 40%.

- Concept of Russia's demography policy to year 2025 (approved by Decree of Russia's President No 1351 on 9.10.2007). One of the major tasks of the Russian demography policy is, pursuant to the document, establishment of conditions and development of motivation towards healthy lifestyle among the population. The first phase of the Concept's implementation (2007-2010) stipulates development of regional demography policies to be streamlined with measures of the Russian national priority projects.

- Concept of Russian healthcare development up to 2020. This is probably the most important document from the viewpoint of health lifestyles development as it places enormous attention on fostering healthy lifestyles. In many ways the concept is founded on Russian Priority Project "Health". One of the ultimate goals is to increase life expectancy rate in Russia to 75 years and build up healthy lifestyles among the population, particularly through reduction of alcohol use and tobacco smoking. The problem of healthy lifestyle development is caused by: identity crisis, loss of life perspectives and goals with most population; mass poverty; wide spread of harmful habits (smoking, drinking, drug use, etc.); low physical activity; unhealthy nutrition. Thus, health promotion should, according to the Concept, be based on: improved health education; an effective system of measures aimed against unhealthy habits; healthy nutrition; enhanced physical activity; reduced effect of environmental risk factors. To achieve this, three motivation systems should be set up. First, motivation of school administrations to health promotion amongst schoolchildren; second, motivation of people towards healthy lifestyles and involvement into preventive actions; third, motivation of employers to take care of their employees' health. The health promotion programme requires efforts from the healthcare and social welfare sector, educational sector, cultural sector and mass media.

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To sum up the health promotion-related policies and strategies one may conclude that in the recent years the federal government has paid increasing attention to health promotion and disease prevention initiatives, particularly among young people. The key targets of the government are reduction of tobacco smoking, drug and alcohol use. The today's accents are made on drugs and to some extent to anti-tobacco campaigns.

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- Strategy of Physical Culture and Sports Development in Russia (draft). The problem is that some 85% of the population and 65% of children and adolescents do not systematically practice physical exercises. The goal is to have 30% of the population involved in mass physical culture by 2015 and 50% - by 2020. The key proposed measures are: to upgrade the system of physical culture at educational institutions, to build the infrastructure of sports facilities, to develop a system of incentives for PE teachers and instructors.

- Strategy of Youth Policy in the Russian Federation (approved by Decree of the Russian Government on 18.12.2006 No 1760-p). The Strategy is estimated till 2016 and maps out youth-targeted (14-30 years old, young people at risk and young families) prioritized directions. The youth-related challenges suggested by the Strategy are high political indifference, absence of ethnical/national tolerance, unemployment, housing problems, and low status of the family institute among young people. The goal of the Strategy is development and realization of the youth's potential for the interests of Russia. The strategic directions are involvement of the youth into social practices and increasing awareness about the development potential, development of creativity among young people, and integration of young people at risk into society. The Strategy's implementation assumes a project-based approach. The expected results are better situation of the youth, which specifically is expressed in better health, better educational services, and higher incomes of young people.

- There are more federal laws and programmes that in this or that way are related to health promotion and healthy lifestyles. For example, federal law on sanitary well-being of population No 52-FZ of 30.3.1999 (Article 5 - one of the powers of federal authorities is public health education and health promotion) and federal law No 120-FZ "Basics of Child Neglect and Juvenile Delinquency Prevention" of 24.6.1999 (with amendments) which is targeted at vulnerable groups of children and adolescents and ensures prevention of their social isolation. The year 2009 was officially declared a Year of the Youth in Russia, and a string of youth-targeted programmes and plans have been started. Programme "League of Nation's Health" was launched in Russia to reduce tobacco smoking.

3.2. Federal legislation (policies, strategies, laws) related to alcohol

At the moment the alcohol policy in Russia is built on few laws:

- Federal Law No 171-FZ "State Control of Production and Turnover of Ethyl Alcohol, Alcohol and Spirit-Containing Products", 22.11.1995, Article 16 par.2 sets out that "alcohol products shall not be sold in retail at children's healthcare,

educational institutions, sports facilities, culture organizations. Retail sales of alcohol products shall not be done to minors". Paragraph 3 of the same article limits the eligible sites for selling alcohol products with proof at over 15%. Paragraph 3.1 of Article 16 states that "regional authorities of the Russian Federation

24

The Russian Federation lacks at the moment any comprehensive alcohol policy or strategy, although such were put into effect in the Soviet time Russia. None of the three were a success, and probably for this reason the Russian Government has taken a very cautious position. Yet, causes for this may be many more: i) Taxes on alcohol products bring considerable profits to the budget, ii) Catherine II said once: "It is easier to manage a drunk nation", iii) Strong lobby of alcohol manufacturers' interests in the federal government and Parliament, iv) The Government realizes that repressive measures alone will not help, yet resources for a comprehensive strategy are not adequate.

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are authorized to limit the time for sales of above-15% proof alcohol products". According to Russian Law No 120-FZ "Principles of the Child Neglect and Juvenile Delinquency Prevention System", 24.06.1999, Article 1 Chapter I, "a minor is a person aged under 18 years"

- Russia's Code on Administrative Offences, No 195-FZ, 30.12.2001, Article 12.8. Driving a motor vehicle in alcohol intoxication state, or takeover of a motor vehicle to an alcohol-intoxicated person for driving purpose. The article stipulates driving license revocation for 1,5 to 2 years for drunk driving or transfer of a motor vehicle to an intoxicated person for driving purposes. Drunk driving with no driving license or revoked driving license may lead to an administrative arrest for up to 15 days or a RUR 5,000 penalty. Such amendments to the Code were made in 2004 and 2007.

- Federal Law No 38-FZ "Advertising", 13.3.2006, Articles 21 and 22 about advertising of alcohol products and beer. Advertising of beer products is prohibited on TV from 7 am till 10 pm, and advertising of alcohol products is entirely prohibited. Besides, advertising of alcohol and beer is banned at healthcare, educational, cultural and many other institutions as well as within 100 meters towards such buildings.

- Russia's Code on Administrative Offences, No 195-FZ, 30.12.2001, Articles 20.20-20.22. Consumption of beer and alcohol products under 12% proof in children's, healthcare, educational, cultural institutions, in sports facilities and in public transport leads to an administrative fine at RUR 100 to RUR 300, while consumption of alcohol products above 12% proof leads to RUR 300-500 fines. Appearance in public (streets, stadiums, parks, squares, public transport) in alcohol intoxication state that offends human dignity and societal morale may lead to a fine at RUR 100 to 500, or administrative arrest of up to 15 days. Doing the same (consumption and appearance) by under-aged individuals means a fine for their parents or legal representatives at RUR 300 to 500.

- Federal Laws No 102-FZ and 114-FZ of 21.7.2005 increase the statutory capitals for manufacturers and dealers of ethyl spirit and vodka and for alcohol sellers. By this mean the government tries to regulate the alcohol market, to oust small players and leave big players only in the alcohol industry.

Yet, new anti-alcohol initiatives and bills regularly emerge within the walls of the State Duma (Russian Federal Parliament), but none of them ever reached hearings. Besides, usually concepts of alcohol policy in many ways pursue interests of alcohol manufacturers. For instance, the alcohol policy concept prepared in February 2008 by the Drug Addiction and Alcoholism Working Group at the State Council of the Russian Federation is, according to many all-out alcohol opponents, too mild and guided by alcohol producers' interests as it presumes not decreases in alcohol sales but replacement of hard alcohol with high-quality wines and beer. Besides, the concept states that the measures of Russian alcohol laws should "ensure balance between the interests of the state, manufacturers and consumers".

Out of the recent initiatives and events several are worth mentioning:

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Summing up the above mentioned federal acts one may conclude that the Russian national legislation sets out limits in terms of age at which alcohol and beer can be purchased legally, places from where it may be bought and where it should not be consumed, drunk driving, advertising of alcohol and beer, and legal minimum age at which consumption of such products is allowed. As the reality shows, tools for monitoring the implementation of the laws should be developed further.

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- Roundtable "Priorities of National Alcohol Policy in Russian Federation" at the Federation Council of the Russian Federal Assembly, 23 October 2008. The Roundtable recommended to facilitate the development of the concept of national alcohol policy, to support the establishment of a single authorized body - Rosalkogol - which would be responsible for implementation of the national alcohol policy, elimination of illegal production and sales, development of tax and excise tools fostering manufacturing of high-quality alcohol products

- Bill on criminal responsibility for selling alcohol and tobacco to minors, submitted to the State Duma in March 2009. According to the bill, amendments should be made to Russia's Criminal Code to provide for fines from RUR 2,000 to RUR 4,000 imposed on officials and from RUR 20,000 to 40,000 imposed on those legal bodies found guilty of selling alcohol or tobacco to the underaged to up to 90-day suspense imposed on shops found guilty of doing so.

- Another bill submitted to the State Duma in February 2009 suggests increase of age at what alcohol may be sold from 18 years to 21 years.

- One more bill, which is under preparation now by Archangelsk and Moscow bill-writers, regards return to the compulsory treatment of drug addicts and alcoholics. At the moment treatment procedures can mainly be applied at free will of a patient. The new bill will provide mandatory therapy if a drug addict or alcoholic commits at least 2 administrative offences within a year.

3.3. Conclusions for the legislative basis

Russia has adopted a youth strategy but meanwhile lacks any clear programme for implementing the strategy. So far no nationwide health promotion policy or strategy has been prepared for young generations. Different aspects of health promotion or risk prevention are fragmented in different laws and strategies. The existing laws are not always followed or implemented because of lack in tools which would guarantee the implementation. Another reason for not following the laws is lack of resources, financial and human. The recent years have demonstrated vivid efforts of the Russian government on the arena of health promotion. The examples of the efforts include a health promotion block in National Priority Project "Health" (which is meant for the whole generation and not just young people), declaration of the year 2009 as the Year of the Youth, which prioritized youth-related actions at federal and regional levels (with accent on morale and patriotic issues and involvement of young people into social life). The country leaders have many times brought the theme of the youth and their lifestyles in speeches and reports, which gives hopes that shortly a comprehensive programme of actions will appear for young people, which will take into account the issues connected with young people's health and the issues connected with young people's social inclusion. There are also hopes that the existing and come-to-be laws will be supported by monitoring and control tools, which will ensure their implementation.

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3.4. Organisation of healthy and socially rewarding lifestyles promotion at governmental level

Both Russia's President Dmitry Medvedev and Prime Minister Vladimir Putin underline the importance of healthy lifestyle and consider as a priority of the nationwide social policy. Upon Putin's initiative real funding was allocated for health promotion interventions starting from 2009. Besides, one of the four Russian national priority projects - Health (Zdorovje) Project - was enlarged to include a health promotion component, which particularly targets physical activity, healthy nutrition, reduction of alcohol, and tobacco use, regular health checkups, and disease prevention. It is quite predictable that since Putin said at the government's meeting in late June 2008 that "it is important to fight with such a national disaster as drinking and smoking" the health promotion programmes will focus on these two issues. In addition, on 25 February 2009 at a meeting of the Board of the National Priority Projects Implementation and Demographic Policy, Vladimir Putin drew attention to the need of developing sports and physical exercise infrastructure and facilities for children and young people. Another comment regarded healthy nutrition at schools. Thus, most crucial components for promotion of healthy lifestyles have been brought up. The presentation of Ms Tatiana Golikova, Russian Minister of Health and Social Development, at the same meeting, covered the same unhealthy habits and health promotion needs as well as the problem of public attitude towards own health.

By and large, the current national health promotion policy bends efforts at the following issues: 1) to make every individual an active actor in keeping own heath through development of responsible attitude towards own health, provision of information about how to strengthen health and prevent diseases, 2) to facilitate development of infrastructures related to health promotion, 3) to shift from expensive medical services to cost-effective preventive measures and regular public health checkups to ensure early detection of health problems, 4) to make changes to the legislation to limit alcohol use and tobacco smoking, 5) to start developing healthy nutrition programmes for population22.

Young person as a core of preventive work

If we look at both promotion of healthy and socially rewarding lifestyles and alcohol prevention among young people, the following circle of actors of impact can be drawn. It is obvious that different actors have different impact on the object. Such actors of impact as the family, friends, peers, classmates, colleagues may have the strongest impact as they reach the object at its closest, schools and NGOs may have the second rating, and the others have likely the same effect on the object. See Figure 4 for the circle of actors of impact.

22 Summary of the presentation by Russian Minister of Health and Social Development Ms. Tatiana Golikova at a meeting of the Board of the National Priority Projects Implementation and Demographic Policy

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The federal authorities have been very much concerned in the recent time about prevalence of unhealthy behavior patterns prevailing increasingly in Russia, particularly among young people. These concerns have been explicitly expressed by the country leaders in speeches as well as emphasized in national plans and programmes.

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Fig. 1 Actors of impact on a young person

3.5. Organisation of risky behavior and alcohol prevention and alcoholism treatment/rehabilitation at governmental level

General (or non-specific) prevention is the job done by non-medical professionals. This may include a variety of governmental organizations, of which the key ones are regional youth committees/departments, if we target at children and young people. The general task of a youth committee is to propose to young people alternatives to unhealthy lifestyles, specifically the prominent tasks of a youth committee are: to draft statutory acts, programmes, proposals aimed at supporting young families, prevention of child neglect and juvenile delinquency, support of healthy lifestyles, moral and patriotic upbringing of young people, etc.; to provide support to operations of children's and youth's NGOs and associations; to provide methodical and counseling support to municipal authorities in terms of the youth policy; fosters inter-sectoral and international cooperation in the youth sector. A regional youth authority is subordinate to the regional government and the federal agency on youth matters (Rosmolodezh') established under the Russian Ministry of Sport, Tourism and Youth Policy.

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Special prevention is the responsibility of centres of medical prevention23, which are established in each region of Russia and big cities. Besides, smaller units - departments and offices of medical prevention - function at healthcare institutions. One of their primary functions is to run health promotion and risk factor prevention programmes and projects, particularly among children and adolescents, based on prevailing risk factors identified. The current prevailing risk factors are common for most Russian regions: tobacco smoking, alcohol use, drug use, unhealthy nutrition, low physical activity. Centres for medical prevention coordinate and guide the work of medical prevention offices, which operate at municipal outpatient healthcare institutions, and carry out monitoring of risk factor prevalence across the region. Centres for medial prevention are subordinate to regional healthcare authorities. In big cities they are subordinate to city healthcare authorities.

The scientific and methodical guidance in the medical prevention structure belongs to the Federal Research Institute of Medical Problems in Health Promotion.

The head institution in the medical prevention service is the Federal Centre of Medical Prevention. This is an independent institution of practical healthcare. The Federal Centre of Medical Prevention organizes the operations of healthcare bodies and institutions, coordinates the work of other agencies and institutions aimed at enhancing the health culture level and health promotion. The tasks of the Federal Centre are as follows:

• to define, in cooperation with other research institutes, directions in primary and secondary prevention of diseases, and also priorities in promotion of medical and health knowledge and information;

• to identify and assess casual relations between public health and lifestyle. Based on this, to develop prevention actions and practical recommendations with regards to changes of behavioral patterns among different population groups.

• to coordinate the work of healthcare, education, culture authorities and institutions, other structures and institutions with regards to disease prevention and health promotion within federal and special health promotion programmes

The next level in the hierarchy is occupied by regional centres of medical prevention (republican, inter-district, oblast, krai, city). The key tasks of the centre of medical prevention are:

• organization and conduct of evidence-based actions aimed at primary and secondary prevention of non-communicable diseases, health education, dissemination of health information and knowledge, and

23 Centre of Medical Prevention - Tsentr meditsinskoj profilaktikiDepartment of medical prevention - otdelenije meditsinskoj profilaktikiOffice of medical prevention - kabinet meditsinskoj profilaktikiFederal Research Centre of Preventive Medicine - federalnyj nauchno-issledovatelskij tsentr profilakticheskoj meditsiny

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When talking about how risky lifestyle-related and alcohol problems are dealt by governmental organisations, the picture will be as follows: lifestyle and alcohol related problems can be roughly divided into the following segments: 1) general/nonspecific prevention, 2) special prevention, and 3) treatment and rehabilitation.

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assistance to other structures and institutions in implementation of such actions regardless to their form of ownership;

• analysis of casual relations between public health and lifestyles, level of healthcare services and environmental situation; based on this, development of specific measures of disease prevention;

• provision of health-related information to professionals and population groups;

• organization and analysis of the activity of the offices of medical prevention (kabinet meditsinskoj profilaktiki) and healthy child offices (kabinet zdorovogo rebenka) (in questions of health education and health promotion) at healthcare institutions, control of their work;

Administratively, a centre of medical prevention is subordinate to a regional healthcare authority. Organizational, scientific and methodical guidance of medical prevention centres is executed by the Federal Research Centre of Preventive Medicine. See the structure of Russia's medical prevention services in Figure 1 below.

Usually, the structure of a centre of medical prevention has the following divisions: methodical division, campaigning division, publishing division, counseling division.

The primary health promotion units are health promotion departments (offices). They are established within policlinics, outpatient services of hospitals, other out-patient healthcare settings. Administratively they are subordinate to the administration of the institutions, but counseling and methodical guidance is done by regional centres of medical prevention. The activity of a department (office) of medical prevention is based on annual plans approved by the chief doctor of the healthcare institution and agreed with the centre of medical prevention.

The treatment and rehabilitation are the responsibility of addiction clinics and, when it comes to mental disorders, of psychiatric clinics.

The Narcologic Service was designated as an independent service in 1975-1976, and before this it was part of the Psychiatric Service. The Narcologic Service was established to provide therapeutic, preventive, medico-social and medico-legal support to chronic alcoholics, drug addicts and substance abusers.

The Narcologic Service encompasses narcologic institutions and narcologic units at psychiatric and general somatic healthcare settings. The basic special narcologic institution is an addiction clinic (narkologicheskij dispanser), which acts as a methodical centre and care provider. In each Russian region there is a central addiction clinic and/or addiction hospital, which is subordinate to the regional healthcare authority. Usually, a regional addiction clinic has a network of narcology offices/wards/professionals located in municipal outpatient and inpatient healthcare settings, including, in some cases, psychiatric and psycho-neurological institutions. See the structure of Russia's narcological services in Figure 3 below.

Provision of care is founded on voluntary principle, except for cases stipulated by the Russian laws.

The major tasks of an addictions clinic is early detection and putting on records of patients with chronic alcoholism, drug addiction or substance abuse; therapeutic and preventive, counseling and psycho-preventive assistance to such patients in inpatient and outpatient settings; surveying of incidence rates related to chronic alcoholism, drug addiction and substance addiction; analysis of effectiveness of therapeutic and preventive services provided; participation in anti-alcohol and anti-drug measures along with other agencies, organizations and institutions; medical examination of convicts referred to mandatory

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therapy courses due to chronic alcoholism or drug addiction, and examination of temporary disability, alcohol intoxication and other examinations; keeping contacts with psycho-neurological clinics about hospitalizations; counseling and methodical support to narcologic offices (narkologicheskij kabinet) established at outpatient institutions and to hospitals and policlinics; making of therapeutic and preventive plans for patients with alcoholism, drug addiction and substance addiction in the coverage area based on statistical analysis of records.

Structure of an addiction clinic: an admission ward with registry and primary examination office; an outpatient ward with offices of psychiatrist-narcologists, including children's psychiatrist-narcologist, therapist, neuropathology doctor, psychologist, other specialists; inpatient ward; diagnostic ward with laboratory facilities; X-ray examination facility; therapeutic offices and facilities; administrative offices.

Other important structures of the Narcologic Service are addiction hospitals and departments. The narcologic departments may be part of narcologic and psychiatric institutions.

The leading methodical and coordinating centre of the Russian Narcologic Service is the Russian National Addiction Research Centre subordinate to the Federal Healthcare and Social Development Agency (Roszdrav). Formally the addiction clinics are networked as they are coordinated and counseled by the Russian National Narcology Research Centre (Moscow), and chief narcologists gather together for conferences of the Russian Narcology Research Centre approximately twice a year.

A more complete circle of stakeholders on the healthy lifestyle and alcohol field includes also other actors, which are listed in Figure 4 below.

3.6. Conclusions for governmental arrangements in promotion healthy and socially rewarding lifestyles and alcohol prevention

It is evident that the state possesses a network of organizations called to roll out general (non-specific) prevention and health promotion – regional and local youth authorities. To conduct primary prevention the centres of medical prevention have been established across the country. Those are to become coordinators of health promotion and risk prevention activities in respective regions. For secondary and tertiary prevention of certain health disorders and risky behaviors (in our case, alcohol and other psychoactive substance) regional and city centres for addictions have been created. Of course, there are many more state institutes which bear responsibility for promotion of healthy habits and socially rewarding lifestyles – schools, social care centres, centres for working with families and children, etc.

Despite the fact that broad institutional infrastructures exist in Russia to eliminate behavioral risks and bring up healthy and socially active young people, the current situation does not look brilliant. Out of all mentioned structures the youth authorities and organizations seem to be most active at the moment, which may be the effect of the Year of the Youth 2009 and government’s commitment to the youth issues. Regional authorities have to be on the ball in such situation and prove loyalty to federal initiatives. The cross-cutting theme in the activity of youth authorities and organizations is morale and patriotism of the youth. Besides, this active work may be a consequence of political parties’ efforts to draw over politically

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indifferent adolescents and young people, because young people are not just a labour resource but also political support.

The activity of centres of medical prevention (as well as centres of addictions) is hampered due to resource constraints. Lack of resources and a clear mandate does not allow centres of medical prevention to become real coordinators and facilitators of health promotion work regionally.

The recent initiatives and speeches of the country leaders signal about closer attention of the government to the problem of people’s health and behavioral risk factors.

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Fig. 2. Structure of the medical prevention services in Russia

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Federal Research Institute of Medical Problems in Health Promotion

scientific and methodical guidance

Federal Research Centre of Preventive Medicine

Centre of Medical Prevention: regional, oblast, republican, krai, city

отделения/кабинеты профилактики в составе ЛПУотделения/кабинеты профилактики в составе ЛПУDepartments/offices of medical prevention at healthcare settings

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Fig. 3. Structure of Narcological Service in Russia

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Fig. 4. Stakeholders on the alcohol field

tax policy Federal government, finance ministry, tax authority

illegal trafficking, inappropriate quality Law enforcement authorities and Rospotrebnadzor (Consumer Rights and Human Welfare Agency)

offences/crimes in alcohol intoxication state Law enforcement agencies, social services and NGOs (e.g. victims of domestic violence)

treatment/rehab/sec. and tertiary prevention Narcology services, psychiatric services, NGOs

primary special prevention Medical prevention services, narcology services, mass media, NGOs

non-specific prevention Youth authorities, social authorities, educational authorities, culture authorities, mass media, NGOs

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4. Overview of the situation in the regions

The next step in the work was studying of the situation in the regions of the Stakeholder Analysis. Since alcohol is taken in the Stakeholder Analysis as a theme of special attention, the regional chapters will give brief information about alcohol situation in the regions and overview of regional key stakeholders, programmes and projects.

4.1 Leningradskaya oblast

4.1.1.General situation

Leningrad Region is located in the Northwest Russia with the City of St-Petersburg inside the Leningrad Region. Yet, while St-Petersburg, alike Moscow, is considered a federal-level city, it has its own executive and legislative authorities, and Leningrad Region has its own government of Leningrad Region with relevant regional authorities and the Regional Legislative Assembly. The population of Leningrad Region as of January 2008 was 4,568,000 people27. The graph below is related to prevalence of alcoholism and alcohol psychoses based on figures calculated by the Statistics Office of St-Petersburg and Leningrad Region "Petrostat"28.

Alcoholism and alcohol psychoses per 100,000 population, Leningrad Region

Besides, according to the Statistics Office, in 2007 in Leningrad Region, 2,446 people were put onto preventive records due to "harmful use", altogether 8,411 were on these records as of the end of 2007. According to booklet "Basic figures of performance of the Russian Narcologic Service in 2006-2007" prepared by the National Addictions Research Centre29, the total number of cases recorded in 2007 with diagnosis "harmful use" in Leningrad Region amounted to 10,642.

Below is some data related to access to sports, leisure and cultural infrastructure in Leningrad Region:

27 Основные показатели демографических процессов в Санкт-Петербурге и Ленинградской области (сборник) / Key demographic figures for St-Petersburg and Leningrad Region (collection), http://petrostat.gks.ru/public/DocLib2/2007.HTM

28 http://petrostat.gks.ru/public/DocLib2/SF_07.HTM

29 Кошкина Е.А. и др. Основные показатели деятельности наркологической службы в Российской Федерации в 2006-2007 годах. Краткий статистический сборник. М., 2007 /Koshkina E.A. et al. Key performance figures of the Russian narcology service in 2006 to 2007. Concise collection of statistics. M., 2007

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2007 2008

Sports facilities info n/a info n/a

Professional theatres 5 5

Museums 33 37

Public libraries 282 277

Cultural leisure facilities 298 292

Cinema houses 31 31

4.1.2. Stakeholders

Based on the general approach used in this report, the key public-sector stakeholders in Leningrad Region will be as follows:

- Healthcare Committee of Leningrad Region (with the network of addictions clinics and centres of medical prevention subordinate to the Healthcare Committee of Leningrad Region)

Contact information: 113, Nevski Prospekt, St-Petersburg, 191024, Russia. Phone +7812 717 65 01, fax +7 812 717 65 40, email: [email protected]. Director of the Committee: Mr Aleksander Okunev

The Healthcare Committee of Leningrad Region is the chief executive authority of the public healthcare sector in Leningrad Region. All state-owned healthcare institutions located in Leningrad Region are subordinate to the Committee. The Committee is responsible for development and implementation of special regional programmes on healthcare development and disease prevention. Specifically, the Committee is responsible for organization of special health services at most state-owned narcologic settings in Leningrad Region.

- Leningrad Regional Addictions Clinic

Contact information: 19/1 Novo-Devyatkino Village, Vsevolozhski Rayon, Leningrad Region, 188661. Chief Doctor Ms Tatiana Slavina. Phone: +7 812 296-99-02, fax: + 7812 296-99-09

The Leningrad Regional Addictions Clinic is the coordinator of the narcologic services related to treatment, rehabilitation, preventions and surveys through Leningrad Region. The functions of the Addictions Clinic are the same as of the other addictions clinics in Russia.

- Youth, Sports and Tourism Committee of Leningrad Region

Contact information: 3, Street Smolnogo, St-Petersburg, 191311. Director of the Committee: Mr Aleksander Sobolenko, phone: +7182 576-79-22, chief of youth policy division Mr Ilja Prokofjev, phone +7182 576-77-93, Committee's email: [email protected]

The Committee is responsible, among other tasks, for implementation of the governmental youth policy across Leningrad Region. Russia's President declared the year 2009 as the Year of Youth in Russia, which implies a series of actions specifically targeted at young people countrywide. The Leningrad Regional Youth Committee is to implement such actions in Leningrad Region, several of which are targeted at prevention of antisocial behavior and use of psychoactive substances. In addition to actions bent to prevent psychoactive substances use, a Committee's task is to ensure alternatives to unhealthy and antisocial patterns of behavior.

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- Educational Committee of Leningrad Region (with Leningrad Regional Centre for Leisure, Health and Educational Programmes "Molodezhniy")

Contact information: 14, Fontanki Quay, St-Petersburg, 191028. Director of the Committee: Mr Sergei Tarasov, phone +7812 273-33-78, fax +7812 272-60-04.

The Regional Educational Committee, as a managing structure of the educational network in Leningrad Region, is a key stakeholder in the sense that it in many ways answers for health promotion and encouragement of socially rewarding lifestyles among schoolchildren through teaching health skills, involvement of children into health-supportive actions, development and support of sports amateur circles, support of children’s creative initiatives. Conducting surveys and other actions at schools presumes, first of all, negotiations with the school’s overseeing structure, i.e. Educational Committee. The educational sector plays an important role in upbringing healthy generations as schools should pay much attention to health education and health promotion within educational processes, including extra-curricula activities. Besides, the Educational Committee oversees the operations of children’s summer camps, one of functions of which is to promote health and responsible behavior among children.

- Leningrad Regional Committee for Social Protection

Contact information: 6, Zamshina Street, St-Petersburg, phone +7 812-225-33-20/+7 812 225-26-40, fax: +7 812 225-24-60, Committee's email [email protected], Director of the Committee Ms Zinaida Bystrova. The Committee has a person, who is responsible for international cooperation - at the moment this is Ms Tatjana Terehova. Besides, a relevant person/department is Ms Julia Emeljanova, head of the family and children department at the Committee.

The relevance of the Committee is defined by the tasks and scope of responsibility. The Committee oversees the public children's homes, shelters, rehabilitation centres, etc., i.e. the places where at-risk children and adolescents stay. Besides, the Committee is responsible for working with and supporting to families at risk through the network of public centres of social care and centres for support to families and children. Last but not least, the Committee makes decisions about social welfare benefits and other forms of material and non-material social support to various population groups, including families at risk, families at difficult life situations, orphans, etc. Representatives of the Committee are members of the regional and municipal commissions on minors' issues (komissija po delam nesovershennoletnih), which are inter-sectoral boards established to deal with children's rights, their rights' advocacy and protection. Technically, the most crucial moment is political commitment and endorsement of any project activity which is related to the responsibility of the Committee, for example, promotion of life skills among children staying at children's homes, etc. The Committee is to be regularly advised about progress of a project activity, as this enables commitment and support to a project, and ensures that project's goals, objectives and priorities go in line with Committee's tasks and priorities. Although the Committee may be unseen in the whole course of a project implementation, it makes or contributes to very rather important project-related decisions, for instance, selection of pilot areas/institutions.

- Centre for Social Rehabilitation of Alcoholics and Drug Addicts "New Life"

Contact Information: Organisation's office: 5, Street Dresdenskaja, St-Petersburg. Centre's locations: former mental hospital in Preobrazhenka Village of Kingisepp District/Leningrad Region; former military base in Kotly Village of Kingisepp District/Leningrad Region. Phones: +7 (812) 585 0707 or +7 905 288 44 70, email: volonters @ list . ru , website http://newliferus.ru, contact person Mr Aleksei Fomichev.

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The Centre was established in 1995 and its operations concentrate on the following areas of prevention: social rehabilitation and adaptation of addicts; social rehabilitation and adaptation of people with no place of living; prevention of drug use and promotion of healthy lifestyles; working with groups at social risk, including street children and problem adolescents. The Centre has two rehabilitation centres, one in Preobrazhenka Village, and the other in Kotly Village. Any person may come to the Centre, the rehabilitation course lasts for 1 year. The fundamentals of the rehabilitation are resurrection, labour, and creativity. The content of rehabilitation is in many ways founded on religious aspects.

- Leningrad Regional Youth Centre of Drug Use Prevention "Lotsman"

The establishment of Leningrad Regional Youth Centre of Drug Use Prevention "Lotsman" was initiated by the Leningrad Regional Committee on Youth, Physical Culture, Sports and Tourism in early 2002. The Lotsman Centre is the leading co-implementer of activity related to primary prevention of psychoactive substance use in the youth environment in Leningrad Region. The mission of the organization is health promotion, building up of life skills with young people, arrangement of leisure actions. The activity of the Lotsman Centre is focused on the following areas: training for personnel (psychologists, social teachers, specialists from youth committees, etc.) dealing with primary prevention of drug use among adolescents; development of volunteer movement "Peer to Peer" through recruitment and training of volunteers out of adolescents and parents; awareness raising and teaching for school teachers in order to enhance effectiveness of preventive work in educational settings; conduct of preventive actions for parents in order to improve their competence in primary prevention; publication of informational material and guidelines for parents and teachers on primary prevention of drug addiction, and informational booklets for adolescents.

Below are few of the projects completed or being implemented by the Lotsman Centre.

2005-2008 - project "Health of the Youth is Responsibility of Adults", awareness raising and competence building among parents. The key goals of the project were: 1. Development of mindsets towards healthy lifestyles and responsible behavior with parents and adolescents, 2) Enhancement of psychological and informational competence with parents about addictive behaviors, 3) Assistance to volunteer movement in Leningrad Region. Within the project, the Lotsman Centre conducted weekly classes for parents titled as "Family Impact on Development of Recognised Attitude to Healthy Lifestyle with the Young Generation". The purpose of the classes was to improve parents' psychological competence and parent-to-child relations. Videos were employed in the classes, both documentaries and fiction movies. In addition, a series of articles was released in local mass media of Leningrad Region and Hatsina District on alcoholism issues in the context of family influence. Psychological counseling was rendered to parents and adolescents - altogether 115 consultations for parents and 83 consultations for adolescents were carried out in 2006.

In 2007, the Lotsman Centre concluded a cooperation agreement with Foundation "Centre for Social Development and Information" on implementation of project "Youth Centre" in Hatsina District of Leningrad Region. The purpose of the Project was to contribute to reduction of psychoactive substance use and HIV spread amongst young people through increased access to rewarding social activity, which covers spare time of young people and prevent them from risky behavioral practices. The leading components in the project's activity were leisure actions for adolescents, measures of primary prevention of psychoactive substance use, HIV and promotion of safe sexual behavior, volunteer training, peer-to-peer trainings on psychoactive substance use and HIV prevention, medico-social counseling, and family counseling and family therapies to

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prevent psychoactive substances use. Although the project ended in the end of 2008, negotiations are being held to extend the cooperation.

2008 - the personnel of the Centre designed programme "5 Steps to Yourself" which is employed in working with children and young people in Leningrad Region. 5 Steps to Yourself is a set of active exercises and logic tasks aimed at discovering various group and individual qualities, namely team-working skills, leadership skills, overcoming one's own complexes and fears, respect to other's opinion, empathy. When an exercise is completed, either successfully or not, it is discussed in the group. The integral part of the Programme is parables, when trainers both narrate and make scenes. The programme is a success at schools, universities and companies.

2009 - Pursuant to Decree of the Leningrad Regional Government about conduct of the Year of the Youth in Leningrad Region, the personnel of the Centre designed project "Step Ahead" in order to create a network of volunteers working in drug use prevention, HIV prevention and promotion of life skills. The project is being implemented through 2009 and is based on peer-to-peer education methods. The project seeks to involve active young people into preventive work among their peers and parents.

4.1.3. Programmes

The following regional programmes stand out as relevant to the project’s theme:

- Regional Special Programme “Prevention of Law Offences in Leningrad Region in 2007 to 2009”.

One of the overall goals that the Programme pursues is to reduce the use of drugs and reduce the criminality level caused by drug use and drug trafficking. The Programme’s goals are to be achieved to a series of tasks, some of which are: to rehabilitate the system of social prevention of law offences, which would be closely aimed at fighting with excessive drinking, alcoholism, criminality, child neglect, etc. Another task is to establish a system of early diagnostics of chemical dependence among at-risk groups and professionals whose work is connected with ensuring safety and health of people.

The implementation of the Programme implies a multi-sectoral approach. The key implementing parties of the Programme are the Committee on Law and Order of Leningrad Region and Chief Interior Department of St-Petersburg and Leningrad Region. The secondary implementing are, among others, Leningrad Regional Healthcare Committee, Leningrad Regional Educational Committee, and Leningrad Regional Social Welfare Committee.

The person responsible for the Programme’s implementation is Mr Vladimir Kirillov, chairperson of the Committee on Law and Order of Leningrad Region, phone +7812 274-37-72.

The Programme is connected with other socio-economic measures of the Leningrad Regional Government. The Programme includes actions from such regional programmes as “Youth of Leningrad Region in 2005 to 2008”, “Development of Physical Culture and Sport in Leningrad Region in 2005 to 2010”, etc.

The whole Programme is split into seven sections, and one of the sections (Section No 6) is dedicated to comprehensive measures on prevention of drug use. The measures in Section No 6 of the Programme are as follows: measures on prevention of drug use within Regional Programme “Development of Social Services System for Families and Children in Leningrad Region in 2007 to 2010”; measures on prevention of

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psychoactive substance use among adolescents and young people within Regional Programme “Youth of Leningrad Region in 2005 to 2008”; informational support to drug addiction preventive measures within Federal Programme “Complex Measures on Drug Abuse and Drug Trafficking Prevention in 2005 to 2009”; measures in the cultural sector aimed at promotion of healthy lifestyles; arrangement of leisure activities for children and young people, support of creativity initiatives in order to prevent drug abuse, alcoholism, legal offences; conduct of seminars to share experiences; medico-social prevention of offences in order to detect addictions. The outputs of the activity is publications on addictive pathology and anti-drug propaganda, purchase of medical diagnostic equipment for healthcare institutions dealing with drug addicts and drug abusers, assistance to social adaptation of adolescents and young people who are apt to using psychoactive substances, popularization of youth initiatives and stimulation of societal activity.

Comments: Section No 6 includes actions on primary, secondary and tertiary prevention, but certain weak spots stand out in terms of the content: 1) Although primary prevention actions are being held to build up negative attitudes towards psychoactive substance, it is very hard to assess their effectiveness. Effectiveness can be assessed though surveys among young people about their attitudes. In 2007, in the outset of the Programme such a survey was carried out, and a follow-up survey is planned for 2010, which means that only then it will be possible to assess efficacy of the accomplished actions on primary prevention, 2) Resources reserved for secondary prevention are obviously not enough. The most likely reason is that the system of detection of secondary addiction to psychoactive substances is not developed. To adequately implement secondary prevention mechanisms of detection and build-up of groups of secondary addicts are needed, 3) While certain positive changes are seen in tertiary prevention, resources allocated to this activity is not adequate. As a result, more actions for treatment and rehabilitation are needed in addition to actions aimed at improving quality of medical and rehabilitation services for addicts. The lack of resources is compensated by NGOs working in this field (rehabilitation centre “New Life”, NGO “Lotsman”).

An extension of the Programme for 2010 to 2012 is now under development, where weak places will be taken into account.

- Regional Programme “Youth of Leningrad Region in 2005 to 2008”

The implementing party of the Programme is the Committee on Physical Culture, Sport, Tourism and Youth Policy of Leningrad Region, and the co-implementing parties are Centre of Leisure, Health Supporting and Educational Programme “Molodezhnyi”, NGOs implementing youth policy in the Region, youth policy divisions at municipal administrations, youth NGOs, etc. The person responsible for the Programme is Mr Aleksander Sobolenko, chairperson of the Committee on Physical Culture, Sport, Tourism and Youth Policy of Leningrad Region, phone +7814 576 79 22.

Comments: The extension of the Programme for 2009 through 2011 was prepared in September 2008, and the new Programme was accepted in February 2009. The new Programme, alike the previous one, goes in line with the federal youth policy and covers practically the same directions as the federal and municipal youth programmes. The goals of the 2005-2008 Programme were practically all achieved.

4.1.4. Projects

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- Project: Quality to Child Welfare, 2008-2010

The partners of the international Project are the Leningrad Regional Social Welfare Committee from the Russian side and State Provincial Office of Southern Finland from the Finnish side. The main objective of “Quality to Child Welfare” Project is to carry on co-operation between State Provincial Office of Southern Finland and Social Welfare Committee of Leningrad Region in child welfare issues. The aim of the Project is to improve the quality of child welfare in social and health services and enhance distribution of tools and models of quality care to public officials. The Project aims to utilize the information obtained from the prior Neighbouring Area projects (Face-to-Face 2002–2004; Family in child welfare 2005–2007). The main target is to enhance child and youth services in Leningrad Region by integrating the results and good practices from the three projects. The Project's primary working tools are workshops/seminars for relevant professionals and officials in Russia and Finland, and piloting of identified best practices.

- Project: Promotion of Health Education in Child Care Institutions in St. Petersburg and Leningrad Oblast 2007–2009

The partners in this international project are the International Affairs Unit at the Finnish National Institute for Health and Welfare and the Russian side is represented by the Healthcare Committees of St-Petersburg and Leningrad Region. The implementing organisation of the project from the Russian side is NGO Stellit. The time frame is from 2007 through end of 2009.

The overall goal of the project is to contribute to decreased risk behavior and improvement of health of children and adolescents in child care institutions in St. Petersburg and Leningrad oblast, due to better awareness concerning health risks and less risky life styles. The purpose of the project is improved capacity of specialists and personnel of child care institutions to promote healthy life styles and prevent risk behavior. The project seeks to achieve the following results: 1) Information on methodology and best practices of health promotion and prevention of risk behaviour disseminated, 2) Personnel of child care institutions trained in methods of health promotion and prevention of risk behavior, 3) Pilot groups of children residing in child care institutions educated in healthy life styles and prevention of risk behavior, 4) Network between relevant local organizations formed. Out of project's 7 pilot sites three are located in Leningrad Region - Lodejnoje Pole Town, Boksitogorsk Town, and Pikalevo Town.

Comment: The reason for including this project into the chapter lies with the certain characteristics of the project: firstly, the partners' commitment, enthusiasm and qualification, which ensures its sustainability, and secondly, the classic method of the project implementation with innovative inclusions. In the initial stage of the project all necessary meetings were held to inform interested parties about the project's goal and objectives, then the awareness level and qualification of the personnel from the pilot institutions on health promotion and risk behavior prevention aspects were surveyed. Based on obtained data and available experiences a curriculum was drafted and then presented at a seminar attended by all relevant organizations, which enabled to receive further ideas and topics for health promotion training. The trainees suggested by the pilot institutions underwent special psychological testing to find out their compliance with the training's requirements, which was an innovative aspect as usually trainees are simply selected by organizations and their motivation to attend trainings is never studied. Another innovation of the project was establishment of so-called health teams within the pilot institutions, which became the core of the health promotion activity at the respective institutions. The health team concept was a combination of Finnish experiences and experiences gained at project ”Support to School Health Education in St. Petersburg 2004–2006”. The further

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classic steps were preparation of leaflets, booklets and other informational material plus to training packages intended for the trainees. After the training is completed and plans of preventive work are compiled and put into effect at each institution, a follow-up survey will be made to examine changes. The final phase of the project will focus on exchanging experiences, participatory discussions of "bottlenecks" in the practical work, and dissemination of successful experiences through roundtables.

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4.2 St Petersburg

4.2.1. General situation

St-Petersburg is one of the two federal cities in Russia and the second largest in Russia with the population estimated at 4,584,000 as of 1 April 20093. Although administratively St-Petersburg and Leningrad Region are separated from each other, in real life the areas are closely interrelated. Many residents of Leningrad Region have their job-places or study in St-Petersburg . When it comes to psychoactive substances, including alcohol, a lot of those having Leningrad Region as place of residence, go out to St-Petersburg because: access to substances is better; they have friends there with whom they party together; St-Petersburg offers better conditions for entertaining. Many of those people who got into hard life situations for various reasons, including hard drinking and alcoholism, end up selling their apartments in St-Petersburg and moving to suburbs of the city or areas of Leningrad Region.

Below is some statistics related to alcohol consumption in St-Petersburg.

Alcoholism and alcohol psychoses per 100,000 population. St-Petersburg

Besides, according to the Statistics Office, in 2007 in St-Petersburg, 699 people were put onto preventive records due to "harmful use", altogether 1,621 were on these records as of the end of 2007. According to booklet "Basic figures of performance of the Russian Narcologic Service in 2006-2007" prepared by the National Addictions Research Centre4, the total number of cases recorded in 2007 with diagnosis "harmful use" in St-Petersburg amounted to 2,167.

Besides, below is some data related to access to sports, cultural and leisure infrastructure in St-Petersburg.

2006 2007

3 Statistic Authority for St-Petersburg and Leningrad Region, http://petrostat.gks.ru/digital/region1/2007/01dem-G.htm

4 Кошкина Е.А. и др. Основные показатели деятельности наркологической службы в Российской Федерации в 2006-2007 годах. Краткий статистический сборник. М., 2007 /E.A. Koshkina et al. Basic Performance Figures of the Russian Narcological Service in 2006-2007. Concise Collection of Statistics. M., 2007

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Sports facilities 4336 4858

Professional theatres 43 42

Museums 71 68

Public libraries 281 265

Cultural leisure facilities 51 55

Cinema houses 46 42

4.2.2. Stakeholders

St-Petersburg is an active actor in the field of alcohol use prevention and promotion of healthy lifestyles. Various programmes and projects, both domestic and international, have been implemented in St-Petersburg City. Therefore, stakeholders are numerous, too. Yet, following the general structure of the stakeholders relevant to alcohol use prevention and promotion of healthy and socially rewarding lifestyles, the following stakeholders would stand out in St-Petersburg:

- St-Petersburg City Public Healthcare Committee

Contact information: 1, Malaja Sadovaja Street, St-Petersburg, 191011. Chair of the Committee is Mr. Yuri Scherbuk.

Likewise in other regions of Russia, the City Public Health Care Committee oversees the operations of the city centre of medical prevention and city narcology clinics and hospitals. Thus, cooperation ties with narcology or medical prevention institutions presuppose certain support and commitment from the overseeing structure, i.e. city Public Health Care Committee. Besides, the Public Health Care Committee is widely and actively involved into Russian and international cooperation projects and programmes, from government-to-government through institution-to-institution levels. A special department has been established within the Committee to guide cooperation links with national and international partners and medical institutions. The head of the department is Mr. Yuri Petrov (email: [email protected]), another important expert and contact person with the department is Ms Ekaterina Kuznetsova ([email protected], phone +7 812 5958911). The department is very easily accessible by communication means and always eager to assist and advise. Being an active partner is diverse programmes and projects, the department tries to run its own database of relevant projects and programmes.

Besides, as health promotion has become in 2009 an important component in the national priority healthcare project "Zdorovje", Governor of St-Petersburg Ms Valentina Matvienko assigned in February 2009 the City Healthcare Committee to design a city healthy lifestyle promoting programme.

- St-Petersburg City Committee of Social Policy

Contact information: 6, Antonenko Street, St-Petersburg, 190000. Chair of the Committee is Mr. Aleksander Rzhanenkov.

The Committee of Social Policy is responsible, among other matters, for social support to socially vulnerable groups; for coordination of the work of St-Petersburg Administration's bodies in development and implementation of social programmes; for collaboration with NGOs and charity organizations, which provide

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social support to people; for social payments and benefits to people. Specifically, the Committee is one of the key parties responsible for working with families and children, including neglected and street children, and for development and implementation of the city's demographic policy. Alike in Leningrad Region, any project activity aimed at families with children, families at risk, neglected and street children, children staying at children's homes and shelters, supposes involvement, at least politically, of the Committee of Social Policy, as these groups are the targets of the Committee's work. Besides, the Committee of Social Policy performs overall coordination and management of the city's demographic policy, which in many ways is related to reduction of alcohol use and promotion of healthy lifestyles in the city. See the overview of the St-Petersburg Demographic Policy below in subchapter Projects/Programmes.

The most appropriate contact persons at the Committee of Social Policy of St-Petersburg may at the moment be: Ms Galina Kolosova, vice chairperson of the Committee (phone + 7 812 576-2453, [email protected]), Ms Marina Zhukova, a senior expert from the family and demographic policy department of the Committee (phone: +7 812 315-3106, email: [email protected]).

- St-Petersburg Committee on Youth Policy and Cooperation with NGOs

Contact information: 31 A, Bolshaja Morskaja Street, St-Petersburg, 190000. Chair of the Committee is Mr. Sergei Grishin.

The St-Petersburg Committee on Youth Policy and Cooperation with NGOs is one of the key stakeholders as it does primary prevention of risk factors, including alcohol use. The Committee bears responsibility for the implementation of the state youth policy in St-Petersburg and for coordination of other state executive bodies of St-Petersburg in the youth policy sector. The Committee is authorized to draft St-Petersburg City youth programmes, to ensure implementation of federal programmes related to the youth policy, to coordinate and finance the activity of organizations subordinate to the Committee, to carry out measures to support youth's creative and research initiatives, to arrange recreation and health promotion of children and young people, to contribute to prevention of delinquency and drug addiction among the youth, to coordinate and support activities of children's and youth clubs and centres, and to contribute to development of youth's leisure options. The Committee's activities are based on federal and city programmes. The Committee's municipal guiding document relevant to working with young people is St-Petersburg City Law on Basic Directions of Youth Policy in 2006 to 2010 (some of the basic directions are support to children's and youth organizations through training, seminars, study stages, roundtables, camps; teaching of youth leaders; broad propaganda of healthy lifestyles among the youth; establishment of a network of youth social workers to run individual and group prevention of juvenile delinquency, development of a system of youth organizations, etc.).

The Committee is currently running a variety of programmes, which are aimed at support of youth and children's clubs and centres, summer vacation and recreation of children, support to talented youth, support to youth's patriotism and societal responsibility, support to youth's initiatives and organized leisure, prevention of HIV, drug use and delinquency, and encouragement of tolerance. The Committee is very active in international and inter-regional cooperation and runs projects with over 20 countries. The main forms of cooperation are exchange programmes for professionals and youth, arrangement of volunteer youth camps, international youth camps, trainings on various aspects (juvenile law system, prevention of drug use, etc.). The St-Petersburg Committee has district-level youth committees in each district of St-Petersburg, and also the Committee operates a network of subordinate institutions, among which the following are relevant to this

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stakeholder analysis because these are organizations, with which practical cooperation could be established with support and commitment from the Committee on Youth Policy:

- House of St-Petersburg Youth (www.dom-molodej.spb.ru, email: [email protected], or [email protected]). The Youth House has two locations: one is 22B, 13 line of Vasilievski Ostrov, and the other is 48, Novoizmailovski Prospekt. The Youth House carries out front-level work with its activities targeted mainly at: working with young people (leisure, mass events, support to youth's initiatives, etc.), working with youth leaders, teachers, other appropriate professionals (trainings, attestation, methodical support), running a database of youth and sports clubs and centres, informational support. The Youth House also has a department responsible for inter-regional and international cooperation.

- St-Petersburg Centre for Prevention of Child Neglect and Drug Use among Minors "CONTACT" located at 4, Frunze Street (www.profcenter.spb.ru, email: [email protected]). The Centre was established in 1998 by St-Petersburg Youth Policy Committee to seek three goals: to prevent child neglect, to reduce the number of street children, and to prevent drug use. The operations of the CONTACT Centre, unlike the House of St-Petersburg Youth, are closer to children at risk and include both primary and secondary prevention. At the moment the structure of the Centre consists of 6 services: support to and development of local programmes; youth personnel; social support to juvenile delinquents; working with informal youth groups; drug use prevention; information and analysis. The drug prevention service assists all interested parties in monitoring of drug situations in their areas, in assessment of current drug preventive interventions, in preparing of informational materials for clients and mass media and guidelines for professionals. Another special target of the Centre is support to youth's initiatives, which suggest prevention of psychoactive substances use and promotion of healthy lifestyles through networking of youth organizations and promoting "healthy-lifestyle-is-a-fashion" programmes. Much emphasis is placed on volunteers. The Centre monitors the street situation and places of youth gatherings ("social patrolling") to identify neglected/street children and adolescents inclined to offences and crimes and to offer them support. The environment and causes for neglect are investigated.

- St-Petersburg V.M. Bekhterev Research Psycho-Neurological Institute, Department for Addictions

Contact information: 3, Bekhtereva Street, St-Petersburg, 192012. Contact person: Mr Evgeny Krupitsky, MD, PhD (email: [email protected], phones: +7-812-365-2217, +7-901-300-5811 mobile, +7-911-748-9989 mobile)

The primary task of the Department is research in drug and alcohol dependence, and post-graduate medical training, i.e. the organisation is a stakeholder very much relevant to alcohol problems, particularly to alcohol-related secondary and tertiary prevention, as most of the research projects are linked to clinical features and treatment of co-morbid conditions, alcohol-dependent affective disorders, assessing effectiveness of medications in treating addictions and preventing relapses, besides behavioral patterns are examined with Russian addicts. Most of the research projects were supported by US National Institute of Health. And, of cource, in addition to research, the Department provides therapy and care to addicts, and trains new clinicians and re-trains certified professionals. The Department was the country's pioneer in promoting rehabilitation care and psychotherapeutic approaches to alcoholics and drug addicts. Many of the Department's developments have been put into effect in the narcologic service nationwide. This stakeholder is obviously

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linked to alcohol issues, as said above, and what is more importantly, the geographic coverage is not limited to St-Petersburg City only, as Dr. Krupitsky is, along with being the chief of the Addictions Department at the Bekhterev Institute, is the chief addictions doctor/narcology doctor of Leningrad Region, i.e. connected to another region of the given project.

- Regional Non-Governmental Organisation of Social Welfare Projects "Stellit"

Contact information: 9, Bumazhnaja Street, St-Petersburg, phone: +7 812 445-28-93, 445-28-94, fax: + 7 812 445-28-93, 445-28-94, email: [email protected] , website: www.ngostellit.ru Contacts persons: Ms Maja Rusakova, director, Ms Olga Kolpakova, preventive programmes manager

The organization has been formed in 2002 by sociologists and psychologists from the Sociological Institute of Russian Academy of Sciences. The goal of the organization is to support the solving of the problems of deviant behavior (crime, drug and alcohol use, risk sexual behavior). Specialists of the organization have implemented more than 50 projects in four major areas: social research, preventive programs, social work and organizational consulting. In particular, there were projects and programs directed to the system of complex systematic work in health promotion and prevention of risk behavior in different institutions (schools, boarding schools, and women’s prison).

The NGO develops and implements risk behavior prevention and health promotion programmes, including school-oriented programmes. A model for systematic health promotion and risk behavior prevention with adolescents and young people at educational institutions has been designed as a result of prior developments and experiences. Now this model is successfully applied at secondary and professional schools.

Another interesting approach tested and implemented by the Stellit NGO is the Health Team Method, which originally was proposed by WHO. A Health Team combines 8 to 14 people, i.e. school's principal, vice principal, psychologist, social teacher, teachers, healthcare workers, representatives of parents and schoolchildren. The functions of the Team include planning and implementation of actions aimed at schoolchildren's health promotion and prevention of risk factors. To this end, federal, regional and municipal programmes are employed in addition to the multi-sectoral approach. The approach was probed within a USAIDS-funded project at seven educational institutions of St-Petersburg.

One more relevant product of Stellit's activity was publishing of monograph "Alcohol Use in Russia: History, Statistics, Psychology" with support from Psychology Faculty of St-Petersburg State University and STAKES (Finland).

By and large, Stellit NGO is a good example of science-practice combination in the social sector.

Geographically, the operations of the Stellit are not limited to St-Petersburg as it is an active player in the social sector across Northwest Russia and other regions of Russia.

Other projects of NGO “Stellit” on promotion of healthy lifestyle and prevention of risk behaviors among adolescents and young people:

Project “Children as the Basis for a Healthy Society” has been implemented since 2005 by the staff of “Stellit” together with representatives of Public Health Department of Bergen Municipality and support of Ministry of Welfare and Health Care of Norway. The project’s objective is to develop cooperation between experts of health care of children and adolescents in St. Petersburg, Archangelsk, Kaliningrad, Murmansk and Bergen, and exchange of prevention experiences. In 2008 a manual with the best experiences of Norwegian and North-

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West Russian experts will be issued within the project. The manual may be distributed among personnel of social rehabilitation centers.

Project “Prevention of Alcohol and Drug Addiction of Young People in St. Petersburg” was implemented with support of Ministry for Foreign Affairs of Finland and Information Office of Nordic Council of Ministers in St. Petersburg in 2007-2008. It was coordinated by Information and Analysis Center of Medical and Social Non-Governmental Organizations. The project involved experts of ”Stellit”, NGO ”Peer to Peer”, NGO ”Look into the Future”. It was aimed at activities on prevention of alcohol abuse of school students for adolescents and youngsters, population in general, mass media and school personnel. Within the project the experts of RPO ”Stellit” developed a package of handouts on drug abuse for school personnel, and arranged a training seminar on prevention of drug abuse of school students. The package may be used for development of handouts for the staff of the pilot child care institutions.

- Regional Non-Governmental Organisation “Look into the Future”

Contact information: 18/2, Metallistov Prospect, St-Petersburg, phones: +7 812 248-11-78, 248-34-27, email: [email protected] , Kmyrova @ list . ru , website: www . vvb . spb . ru , contact persons: Mr. Aleksei Khmyrov, Ms Anna Khmyrova.

The mission of the organization is health promotion and involvement of young people into tacking of social problems

The key areas of activity are:

- Development and implementation of programmes/projects aimed at prevention of high risk behaviors among adolescents and young people based on “peer-to-peer” principle;

- Development and implementation of communication projects on health promotion;

- Organisation of conferences and seminars on promotion of healthy lifestyles;

- Creative developments: mass preventive and social actions, PR actions, youth festivals;

- Comprehensive support to research projects.

- Own publishing house: development and release of printed material targeted at prevention of alcohol use, tobacco smoking, drug use, and at health promotion;

- Video studio “Look into Future”, making flash cartoons targeted at promotion of healthy lifestyles and socially rewarding behaviors.

The organization is working actively throughout Northwest Russia. Youth-friendly clinics were established with the support of the Look into the Future in Petrozavodsk, Great Novgorod, Severodvinsk, Tosno, Svetogorsk (14 clinics altogether).

Professionals and volunteers in many cities in Northwest Russia completed training programme “PRO Healthy Choice” aimed at prevention of high risk behaviors among young people.

The organisation is one of the leaders in “peer-to-peer” education in Russia, and in 2004 became an official representative of the international volunteer network Y-PEER.

Completed and ongoing programmes/projects:

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From 1999 – Counseling and methodical guidance to “13” and “13+” projects to establish youth volunteer-aided counseling centres across St-Petersburg. The projects were implemented together with the St-Petersburg Public Healthcare Committee and Stockholm District Board (Sweden).

2000-2001 – Echo Project: Establishment and training of over 10 volunteer groups at youth clubs, leisure centres and medical organizations of St-Petersburg for further implementation of “peer-to-peer” prevention of high risk behaviors. The project was supported by the UN Children’s Fund.

2001-2003 – Echo Network Project for establishment of a coordinating and information preventive system in St-Petersburg, which would coordinate activities of various youth organizations. Volunteer teems and organizations were integrated into a humanitarian non-political volunteer-based youth movement ECHO. Over 10,000 of adolescents from St-Petersburg and Leningrad Region were involved into 20 large and many more small actions dedicated to health promotion over two years of the project. The project supported training of youth group «Narva Noored Noortele» from Estonia.

2003-2008 – A series of preventive mass actions with the themes of health promotion and particularly reproductive health, prevention of alcohol use, tobacco smoking, drug use.

2004-2005 – Project “Welcome” to establish and develop a network of medico-social youth-friendly services and volunteer groups in 11 Russian regions, and conduct of an International Master Forum together with other organizations and institutions and with support of the Russian Ministry of Healthcare and Social Development and UN Children’s Fund.

2007-2008 – Project “Welcome-2” to establish and develop a network of medico-social youth-friendly services and volunteer groups in Karelia Republic with the support from Karelian Ministry of Healthcare and Social Development and UN Children’s Fund.

2007-2008 – Project “Prevention of Alcohol and Drug Use among Youth in St-Petersburg” with support from the Finnish Foreign Ministry and Information Bureau of the Nordic Council of Ministers in St-Petersburg. The basic activity of the Look into Future within the project was organization and conduct of mass events at educational institutions of St-Petersburg aimed at health promotion and prevention of risk factors, and involvement of young people into social life. The activities were mainly conducted among senior schoolchildren. An interactive programme of preventive seminars was prepared, on the base of which dozens of seminars were conducted. Besides, printed materials (leaflets and posters) were released.

2008-2009 – Independence Day. Implementation of comprehensive actions aimed at health promotion and prevention of psychoactive substances use among young people of St-Petersburg. The project was funded from a grant allocated by the President’ Fund.

Though the years of its activity, the Look into Future carried out actions and projects along with international partners from the United Nations, American organizations and institutions, Sweden, Lithuania, etc.

Internet links to the organisation’s projects:

http://www.adolesmed.ru/partner-vvb.html

http://vestnik.ulsu.ru/issues/723/7/

http://uchastie.narod.ru/kuda6.htm

- Inter-regional Association of NGOs in the drug and alcohol prevention sector “NORTH-WEST”

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Contact information: 34, Podjacheskaja Street, St-Petersburg, phones + 7812 570-22-52, +7 921 916-68-08, email: [email protected], website: http://mranko-nw.web-box.ru/, contact person: Mr. Yakov Godovikov, director of the Association

The mission of the NORTH-WEST is to pool together efforts of NGOs to enhance effectiveness of drug and alcohol prevention in St-Petersburg, Leningrad Region, Northwest Russia, partnerships with government and business in dealing with these problems.

The key activities of the Association include: healthy lifestyles promotion, primary prevention of drug and alcohol use, socio-psychological support, various forms of rehabilitation. The Association includes 26 non-governmental and non-for-profit organizations, which cover a wide range of preventive services from health promotion and primary prevention to support to clients and their families and socio-psychological rehabilitation.

All members of the Association adhere to one criterion – drug and alcohol addiction is a bio- psycho- socio- spiritual disease of a personality, and recovery may take a long time, from 3 to 7 years.

Primary prevention

Most members of the Association deal with primary prevention. In 10 years the members of the Association conducted 260 big anti-drug actions in concert halls of large cities in Russia, Ukraine, Belorus, Baltic States and Helsinki.

Social rehabilitation of drug and alcohol addicts

The members of the Association have 22 centres for socio-psychological and socio-labour rehabilitation in St-Petersburg, Leningrad, Pskov, Vologda and Yaroslavl Regions. A rehabilitation course take from 42 days to one year. Over 500 people are under rehabilitation at the moment.

Completed/ongoing projects include meetings and pickets to collect signatures against tobacco and beer advertising; numerous anti-drug actions; exhibitions; roundtables; press-conferences; sports events; festivals, newspaper “Free Land” and supplement “Sober League”, etc.

Internet links to activities of the Association: http://www.ecad.ru/mn-pl4_51.html

4.2.3. Programmes

- 2015 Demographic Development Concept for St-Petersburg City

(full text available at http://gov.spb.ru/gov/admin/otrasl/trud/demogr)

The goals of the demographic concept are longer life expectancy, higher birth rate, and optimal migration traffics for the social and economic benefit of St-Petersburg.

The objectives in the demographic development are:

- establishment of a system of health promotion for the sake of active professional, social and personal life;

- reduction of mortality, particularly men of working age, from external causes – injuries, poisoning (with psychoactive substances included), murders and suicides.

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The following priorities have been identified in terms of health promotion and life expectancy growth:

- development of a system of healthy rewarding values, settings and models of everyday behavior;

- development of new and expansion of available health-promoting and disease-preventing measures to ensure lifelong support to healthy life;

- improvements to medical services;

- ensured access to physical education and sports for all residents of St-Petersburg;

- reduced marginalization and enhanced motivation to socially rewarding and healthy lifestyles among all groups of people.

To this end, the following measures have been documented: to establish a comprehensive system of health propaganda; to put incentives in place to promote healthy behaviors; to effect campaigns and actions in order to involve young people and other age groups to PE and sports; to continuously counteract administratively, legally, publicly and ideologically the propaganda of tobacco smoking, drug use, and other deviant behaviors; to raise awareness on reproductive health and STD prevention among the population, to improve infrastructure for physical exercises and sports activities; to prepare and put into effect a system of measures on prevention of tobacco smoking, alcohol and drug use; to develop a system of medico-social rehabilitation for addicts and their family members, etc.

The concept presupposes two phases and serves as foundation for making demographic projects and programmes in St-Petersburg. The inception phase of the concept is 2006 to 2008, and the implementation phase is from 2009 to 2015.

Comment: In 2006 and 2007 no funds were allocated to the concept. In 2008, 42 million rubles were allocated to all implementing structures.

Within the allocated grant, the Social Policy Committee of St-Petersburg announced a tender for training programmes aimed at health promotion among different age groups. The Psychology Faculty of St-Petersburg State University won the tender, established an expert board with representatives from city committees, universities, prosecutor’s office, medical institutions, NGOs to define target groups for training programmes. Senior schoolchildren and freshmen from universities were selected for the first phase, and 12-14 year old adolescents with the parents for the second phase. The training programmes include, among other topics, prevention of risk behaviors, promotion of physical exercises and healthy nutrition. In 2009, the programmes will be put into effect – Stellit NGO was contracted for this job.

Other activities were also implemented in 2008 – “Tobacco-Free Classes” and “I Choose Health” programmes in the City Centre for Medical Prevention, establishment of consultations on alcohol and drug addiction in policlinics of Moskovski District of the city, establishment of mini-stadiums and sports grounds, etc.

Secondary prevention is hampered by weak collaboration between addictions clinics and social services as data about patients does not reach the social services, and medical services are not supported by social services. Besides, there are few professionals who are trained and motivated to work with these categories, as many questions have to be settled at clients’ homes, which is not always safe for social workers.

In 2009, only one million roubles is allocated under the concept – all this money will be spent to do a comprehensive monitoring of the demographic situation in St-Petersburg.

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On 25 February 2009 the Russian Government decided to expand the National Priority Project “Health” with a new subprogramme called “Healthy Lifestyle”. As a result, the Governor of St-Petersburg assigned St-Petersburg Public Healthcare Committee to make a similar programme for the city. It is likely that some of the measures from the demographic concept will be included into the new healthy lifestyle programme.

- St-Petersburg Programme “Complex Measures to Counteract Drug Use and Drug Turnover in 2006 to 2008” (full text is available at http://www.gov.spb.ru/law?d&nd=8429136&prevDoc=8429136&mark=00000000000000000000000000000000000000000000000000TLT607#I0)

In the first glance the programme may seem irrelevant to the project’s coverage, but the activities and outcomes of the programme make a considerable input into alcohol prevention and health promotion.

The goal of the programme is to reduce drug use and rug trafficking in St-Petersburg and to reduce the level of drug-related crimes.

The implementing parties of the programme are the Committee on Law, Order and Safety of St-Petersburg, Education Committee of St-Petersburg, Public Healthcare Committee of St-Petersburg, Mass Media Committee, Social Policy Committee, Physical Culture and Sports Committee, Youth Policy Committee, etc.

The components of the programme are classic: 1) training and awareness (for relevant specialists, teachers, mass media, etc.), 2) information (leaflets, posters, guidelines, manuals, social advertising, TV and radio programmes and features, articles in the press, press conferences), 3) preventive activities in educational institutions, youth clubs, student dorms, among working youth, i.e. primary prevention-oriented actions, 4) cooperation encouraging (roundtables for stakeholders to ensure their involvement), 5) socio-psychological support, assistance in employment for former addicts, and rehabilitation in in-patient settings for addicts, i.e. tertiary prevention.

Comment: The emphasis of the programme was made on prevention of drug use and drug trafficking, but the activities in 2008 were enlarged to include alcohol and tobacco prevention.

Expertise of NGOs was widely employed in the programme implementation.

One of the biggest outcomes of the Programme was real coordination and integration of efforts of all relevant parties – the functions were clearly distributed and actions were well-coordinated.

Another achievement of the programme is appearance of new preventive technologies, for example, new format of social advertising not only on conventional carriers but also on souvenirs.

The new programme for 2009 through 2012 will likely be adopted in summer 2009 but no extra funds will be allotted to the new programme’s actions. The new programme will probably focus even wider the aspects of primary prevention and include health promotion.

- Programme for development of a system of youth centres in St-Petersburg in 2008-2010

The Programme for development of a system of youth centres in St-Petersburg in 2008-2010 is a set of measures to be undertaken by executive authorities of St-Petersburg to achieve the following objectives:

- establishment of conditions for leisure activities of children and young people in St-Petersburg;

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- youth centres have better capacities to offer diverse opportunities for personal self-realization, spiritual and moral development as foundations for better life quality of children, young people and society in general.

The objectives of the Programme are: to develop infrastructure of community-based youth centres in line with the needs of children and young people; to upgrade qualification of personnel working at youth centres; to update the content and tools of the social clubs' work; and to build up common information space in community-based activities.

The Programme's completion requires about 849 million roubles within three years.

According to the Programme, needs should be studied in each District of St-Petersburg to find out the most optimal solutions for community-based youth leisure and activities, all existing premises should be remodeled to fit the requirements of construction and sanitary standards, and the needs of young people, staff should be recruited and trained, services should be of high quality in demand, informational support to the operations of the centres should be ensured.

In 2008, premises for several clubs were repaired, equipment purchased, a series of youth and sports facilities constructed (Youth Houses in Kolpinski, Admiraltejski, Kalininski and Primorski Districts, sports centre in Kalininski District, rowing-boat centre on Krestovski Island, winter sports centre in Toksovo).

4.2.4. Projects

- Project name: Alcohol and drug abuse prevention among youth in St. Petersburg

Project's start and completion: January 2007 – December 2009

Objectives, target group, methods:

· To influence risk-behaviour of young people towards responsible, sustainable relationship with alcohol, and towards abstinence vis-à-vis drugs.

· Development of modern preventive programs based on peer-to-peer methods and “Health Teams” in schools; training for volunteers; interactive public actions; media seminars; seminars for local decision makers

· 3-4 pilot districts (in cooperation with the Nordic Council of Ministers Information office (NCM) in St. Petersburg).

Budget: 111,000 euros, Finnish Foreign Ministry and Nordic Council of Ministers

Partners: National Public Health Institute (Finland), A-Clinic foundation (Finland), Mechnikov Medical Academy (St-Petersburg), Information and Analyses Centre for Social and Health NGOs, Stellit, “Look to the future”, Drug abuse prevention centre (“Rovesnik”)

Contact persons:

Information and Analyses Center for Social and Health NGOs: Anna Skvortsova, [email protected]

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Stellit: Olga Kolpakova, [email protected]

Look into Future: Anna Khmyrova, Khmyrov a @ list .ru

Drug Abuse Prevention Center: Marina Orlova, [email protected]

Comment: The project encompassed all important parties: training for teaches was set up, activities and classes for schoolchildren and students arranged, awareness-raising seminars for mass media arranged, roundtables for decision-makers conducted. The project succeeded to tighten up links among relevant Russian stakeholders, and between Russian and international experts and organisations.

- Project name: Development of Country-Wide Strategies for Implementing Early Identification and Brief Intervention in Primary Health Care, Phase IV

Project's start and completion: 1998 - 2002

Objectives: to customize the screening and brief alcohol intervention technique to the Russian context, pilot and further disseminate to other Russian regions

Budget: two grants from Know-How Fund in London and a grant from the European Union (ECATOD project)

Partners: St-Petersburg Medical Academy of Post-Graduate Studies, Department of Adolescent Medicine (prof. Vladislav Medvedev and assistant professor Tatiana Krishtal), Centre for Alcohol and Drug Studies, Newcastle, North Tyneside (prof. Nick Heather)

Comments: The Russian arm of the project was carried out in St-Petersburg in 1998 to 2002 with Kalininski District as the principal pilot site. The project included a survey of primary healthcare institutions' visitors with the AUDIT questionnaire. The survey revealed that one fourth of male visitors are "harm drinkers" or "alcohol dependent" according to the ICD-10. Then, attitudes of health professionals to EIBI implementation in primary healthcare settings were investigated. By and large, healthcare professionals displayed a negative attitude to EIBI for various reasons. Besides healthcare professionals (GPs, pediatricians, healthcare managers, nurses), social workers and psychologists. The outcome of the interviews was neither encouraging for EIBI implementation. Another component of the project was to establish new or modify existing training courses on health promotion. Such was done as part of the post-graduate course at the Medical Academy of Post-Graduate Studies and intended for GPs, pediatricians, family nurses, school nurses, social workers. In addition, training of volunteers for peer-to-peer education was held together with Look into the Future NGO. An interesting output of the activities in Kalininski District of St-Petersburg was establishment of a Strategic Alliance in Kalininski District of St-Petersburg. The Strategic Alliance is centered around the Health Authority of the District, which has direct links with healthcare institutions and GP offices, while linkage to the Educational Authority of the District was never established, therefore links with educational institutions were made via NGOs (Look into the Future). Also attempts to contact other municipalities and mass media failed. The Strategic Alliance for some reason completely ignores the social sector. Last but not least, an exit poll was carried out in St-Petersburg at a policlinic for students. The survey covered almost 500 young people. The results showed that majority had never been asked by doctors about their drinking habits, and majority would never like to have such conversations with doctors. To sum up the project's conclusions, one may say: EIBI implementation is a big challenge in the Russian context as many various obstacles are on the way to clear which many years will be needed.

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- Project name: Feasibility of Hazardous and Harmful Use of Alcohol: Early Identification and Brief Intervention 'EIBI' in Leningrad Region

Project's start and completion: January 2008 – December 2008

Objectives: The main purpose of the feasibility project is to prepare a well thought through project plan for a 3-year pilot with defined activities and budget for EIBI piloting in the Leningrad region, with a long term aim to disseminate the methodology in North-West Russia and elsewhere in collaboration with MoHSD/RF

Budget: 79,000 euros

Partners: STAKES/IDC, Medical Academy of Post-Graduate Studies in St-Petersburg (MAPS), Information and Analysis Centre for Social and Health NGOs, Bekhterev Psychoneurological Research Institute, St. Petersburg

Contact person: Mr Sviatoslav Plavinski, vice rector St-Petersburg Medical Academy of Post-Graduate Studies (MAPS), [email protected]

Comment: The overall objective was to advance the introduction of early identification and brief intervention (EIBI) for harmful and hazardous alcohol consumption in Russian health and social services as a potentially cost-effective approach to secondary prevention of alcohol-related problems. The project's purpose was to provide stakeholders, particularly the medical community and healthcare authorities, with evidence-based information about the cost-effectiveness of EIBI as a method for curbing harmful and hazardous alcohol use. The project was also to assess the viability of EIBI in the Russian context, and, if found viable, to prepare an EIBI testing project. Despite certain difficulties related to the project's management, weak commitment and involvement of all interested parties into the project's activities, feeble communications, and the project achieved certain outcomes. The current alcohol situation in Russia was analysed, stakeholders identified, plans for further advance of EIBI in the health and social sectors prepared, seminars were held for stakeholders to present the EIBI concept. The EIBI idea still remains a novelty in Russia and few decision-makers ever heard about it. But all project partners agreed that EIBI may be implemented in Russia, be it properly modified and supported by laws, funds and, last but not least, authorities.

According to information from St-Petersburg Medical Academy of Post-Graduate Studies (MAPS), the St-Petersburg City Centre for Medical Prevention got interested in the EIBI idea and asked to present materials that were prepared and translated into Russian within the Project. The interest is connected with the recent federal initiative to include the component of health promotion and risk factor prevention into Russian National Priority Project “Health”. Subsequently, certain same-directed initiatives should appear at local level. While conventional awareness-raising through lectures about bad effects of alcohol brings about next to no outcome, the St-Petersburg City Centre for Medical Prevention started looking for innovative approaches to tackling the alcohol problem. For this reason information and the plan of EIBI training for general practitioners in St-Petersburg was asked from the MAPS. It is assumed that, provided the idea of EIBI training for GPs is found reasonable, federal money is allocated to start the training. It might be advisable to keep an eye on the progress with EIBI training in St-Petersburg. Should the training be launched, space might be looked at for support through international projects.

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4.3 Karelia

4.3.1. General information

Karelia Republic is a Russian Region in northwest Russia, it borders on Murmansk Region in the north, Leningrad and Vologda Regions in the south, and Finland in the west. The population of Karelia Republic is 690,700 people (Karelian Statistical Authority at http://krl.gks.ru/default.aspx). The capital of Karelia Republic is Petrozavodsk City where over one third of the republic's population lives.

In terms of alcohol use, the Karelian figures are higher than on average in the Northwest Russia, and Karelia is the third alcohol consumer in the Northwest Russia after Nenets Autonomous District and Novgorod Region. According to E.A. Koshkina et al. (2007), the cumulative number of cases diagnosed with alcoholism and alcohol psychoses was 18,402 in 2007 (and 19,825 in 2006), of whom adolescents of 15-17 years old were 6 (and 10 in 2006). The cumulative number of patients diagnosed with harmful alcohol use was 2,647 in 2007 (and 2,838 in 2006) of whom adolescents of 15 to 17 years old amounted to 318 (and 388 in 2006). The number of newly diagnosed cases of alcoholism and alcohol psychos in 2007 was 1,396 (and 1,663 in 2006), of whom 15-17-year-olds amounted to 3 (and in 2006 they were 7), and as for new cases of harmful alcohol use, such were 469 in 2007 (and 523 in 2006), of them adolescents of 15-17 years old were 125 (and 185 in 2006). In addition, according to the Karelian Statistical Authority, deaths caused by alcohol poisoning dropped from 510 in 2003 down to 298 in 20075.

Comment: Being one of the leaders in the Russian northwest in terms of alcohol consumption, Karelia Republic steadily tends to improve the situation, particularly the situation among newly diagnosed cases among adolescents in looking up, which may mean that risk factors take a leg over health-rewarding factors at some time after young people end schooling. Another assumption is that harmful alcohol use is under-diagnosed or not documented for some reasons among under-aged teenagers. Besides, the picture with high alcohol consumption is generally characteristic for regions with low drug use rates.

4.3.2. Stakeholders

The circle of stakeholders in Karelia Republic is similar to other regions under the project's consideration.

- Karelian Ministry of Health and Social Development

Contact information: 6, Lenina Prospect, Petrozavodsk, 185035. Minister Mr. Valeri Boinitch. Phone: +7 8142 792900, email: [email protected]

The role of the Ministry is defined by its managing and coordinating functions in the Karelian healthcare system, and, therefore, the healthcare's services to do health promotion and alcohol prevention are ultimately subordinate to the Ministry. Health promotion has for a long time been on the agenda of the Ministry, and certain effort and resources are put by the Ministry into this direction, while alcohol problems specifically are not among the issues the Ministry explicitly addresses. The most appropriate person in the Ministry, with who is likely better to establish contacts and start negotiations to get support, commitment and interest is First Vice

5 http://krl.gks.ru/digital/region1/DocLib/dem8.htm

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Minister Mr. Ervand Hidishjan (+7 8142 792902), who oversees, among others, Ministry's international relations.

Comment: The Ministry seems now to be overburdened with its primary functions, particularly within National Priority Project "Zdorovje", that it may have little time and resources, including staffing resources, to do anything else. Should a development idea or project proposal be streamlined with Russian national priorities or regional programmes and plans, then this will facilitate the process, i.e. as mentioned above, while health promotion and disease prevention, especially cardiovascular disease prevention, questions remain on the Ministry's to-do list, specific alcohol prevention may be beyond the Ministry's expectations. The functions of the Ministry include such responsibilities: - the Ministry develops proposals on health education and health promotion among population, - the Ministry develops measures aimed at protection of family's health (protection of children and parents), - the Ministry coordinates operations of public, municipal and private healthcare organizations in terms of public health protection, - organizes provision of special health services at special healthcare clinics and institutions (medical prevention and narcology services included), etc. Last but not least, the Ministry combines the healthcare and social welfare functions, which may help smoother and more effectively implement a development programme/project, which integrates healthcare and social aspects.

- Karelian Centre for Medical Prevention

Contact information: 3, Kirova Street, Petrozavodsk, 185035. Director Ms Marina Markelova. Phone: +78142 767501, fax: +7 8142 768140, email: [email protected], [email protected] . Contact person: Ms Anastasia Partanen, sociologist and PR expert, email: [email protected]

The Centre for Medical prevention was established in 2001 after restructuring of the Karelian Republican Therapeutic and Physical Exercise Clinic. The Centre is subordinate to the Karelian Ministry of Health and Social Development. The chief task of the Centre for Medical Prevention is to carry out primary prevention and disease prevention among population, in the first place at pre-school and other educational institutions. The Karelian Centre for Medical Prevention designed a regional healthy lifestyle programme in 2001-2002, which was later adopted by the Karelian Parliament and Karelian Government, and since on the activity of the Centre is based on the provisions of the regional healthy lifestyle programme, which is now valid till 2010. The focuses of the Centre's work are on the most common risk factors, like, tobacco smoking, alcohol, drugs, nutrition, physical activity, sexual health, stresses, etc. The personnel of the Centre have developed prevention programmes for various risk factors, which they implement at educational institutions for pre-school children, schoolchildren, students, working youth. Besides, training programmes are developed for teachers and other staff of educational institutions, who deal with healthy habits of children and adolescents. Trainings are arranged also for personnel of healthcare institutions, who are responsible for health promotion and disease prevention activity. TV and radio regularly invite experts from the Centre to talk about health, behavioral risk factors, and healthy lifestyles. Along with other organizations or alone the personnel of the Centre make surveys of risky behaviors amongst children and young people, arrange roundtables and seminars for decision-makers to raise their awareness and expedite further concerted actions against alarming situations. As many prevention offices and healthy child offices are established now in outpatient settings across Karelia, the personnel of the Centre help them in their activity with advice, methodical guidance, information support. The Centre has a department responsible for making leaflets, booklets, posters and other informational and educational materials. The Centre runs a page at the livejournal about risk factors and healthy habits. The Centre has gained good international contacts and experiences within EU's and bilateral international projects.

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At the moment the Centre is involved into Finnish-Karelian Project "Support to Implementation of Health Promotion Policy in Karelian Republic 2007-2009".

- Karelian Narcology Clinic

Contact information: 18, Fedosovoi Street, Petrozavodsk. Director Ms Galina Matveeva, phone +78142 784020 and +7 8142 762437, email: [email protected] / [email protected]. Contact person: Ms Aleksandra Lubnina, chief of prevention and child services

The Karelian Narcology Clinic is subordinate to the Karelian Ministry of Healthcare and Social Development. Pursuant to the Clinic's regulations, the Clinic is established to deliver special medical and prevention services, particularly consultations, diagnostics, therapy, medico-social rehabilitation and prevention of addictions. The Clinic delivers inpatient and outpatient care in the form of medicine-aided, psycho-therapeutic, psycho-correctional and social services. A department responsible for addictions prevention and child narcological care was set up in early 2006. The activity of the prevention and child department is directed at: one-to-one counseling for children and parents on psychoactive substance prevention (tobacco, alcohol, drugs, toxicants, games, internet); trainings and group talks on narcologic issues in educational settings; mass events together with law enforcement agencies, NGOs, other healthcare institutions; trainings for health workers and other professionals; field trips to rural areas for therapeutic and methodical assistance; prevention actions at companies and enterprises; inter-regional and international cooperation; counseling through internet (www.molod.karelia.ru); surveys.

The Clinic participated in a series of international projects together with Finnish and Swedish partners on such themes as client-centered treatment of addictions (as a result a multi-professional team was established at the Clinic to deliver higher quality services), prevention of HIV and TB among addicts, development of narcologic services for deaf people (together with the Finnish Association of Deaf People). At the moment the Clinic is implementing a pilot school-based survey of the UN Office on Drug and Crime (Global Assessment Programme on Drug Abuse). About 1000 schoolchildren of 15 to 17 years old have been interviewed about their behaviors towards narcotic substances. The outcome of the project must be regular monitoring of alcohol, drug and tobacco situation in this age group, which will help plan further prevention work.

The method of motivational interviewing is employed by psychologists of the Clinic. The Clinic developed a 10-class training programme on motivational interviewing, and in February 2009 started training doctors. Yet, more advice on teaching is needed.

Comment: As the biggest current problems, representatives of the Clinic mentioned the following: clients get to the Clinic with already developed addictions, and therefore personnel of the Clinic started in late 2008 training activities with doctors and mid-level staff from primary healthcare settings but there are not enough materials that could be handed out to professionals and particularly clients (self-administered questionnaires, leaflets on early symptoms of alcohol addiction, norms of alcohol use, etc.). Another problem is too little anti-advertising on all risk factors. And prevention activities at educational institutions should be systematized. And, last but not least, healthcare institutions/healthcare professionals are generally not motivated to do prevention of psychoactive substances in their everyday work.

As possible themes for cooperation the following were underlined: training on motivational interviewing and EIBI; piloting of a primary-secondary prevention system in a policlinic/outpatient clinic.

- Karelian Youth Committee

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Contact information: 5, Kujbysheva Street, Petrozavodsk, 185610. Chairperson Mr. Maksim Mazurovski, phone: +7 8142 784638, email: [email protected] . Contact person: Mr. Evgeni Lobski, chief of relations with NGOs, inter-regional and international cooperation, phone: +7 8142 781740

The functions of the Karelian Youth Committee prescribe to implement the federal youth policy in Karelia Republic, i.e. to implement federal plans and projects in the youth sector; develops proposals for the Karelian Government on governmental support to young families, on working with neglected and street children, on promotion of healthy lifestyles, moral and patriotic education, etc.; to participate in inter-regional and international cooperation in the youth sector; to prepare guidelines for municipal authorities on youth policy implementation, and so on.

Comment: Recently appointed minister, Mr Maksim Mazurovski, a son of Karelian businessman and member of Karelian Parliament Mr Andrei Mazurovski. The minister is young, active, ambitious and has good relations with regional decision-makers in Karelia and Moscow. The Committee has organised numerous mass actions for children and young people in Karelia, both small and large-scale, it participates at exhibitions and mass actions held by other organisations. Many of the actions are aimed at health promotion and prevention of risk factors (tobacco, alcohol, HIV). A very interesting and ambitious forthcoming project of Mr. Mazurovski is Hyperborea 2009: Fight of Ideas to be held in Karelia in August 2009. The Hyperborea Project will gather together 10 teams of young people from 10 northwest Russian regions added by international teams from the Baltic Region (Finland, Sweden, Denmark, Germany, Latvia, Lithuania, Estonia). The goal of the project is to establish a creative and innovative platform for active young people. Within a week the participants of the camp (1,500-2,000 people) will be searching for innovative solutions of the key problems in the Northwest Russia and Baltic Region. Two of seven priority problems to be tackled will be creation of conditions for demographic improvements, and dealing with national threats (alcohol, tobacco smoking, drugs). The expected outcomes include prepared project proposals and ideas, contribution to socially rewarding and healthy lifestyles, and expansion of relations among young people and organisations regionally and internationally. Interesting background information related to the Hyperborea 2009 Project is how money was allocated from the Karelian budget to this Project (3 million roubles, or about 70,000 euros). The Minister was absent at the ministerial meeting in early 2009 when budget proposals were discussed and, thus, no money was envisaged. Nonetheless, later, after the budget was approved by the Karelian Governor, an amendment was made to the budget and the needed money was assigned from the budget. This speaks a lot about the pushing capacity and good connections of the Minister. Needless to say, that the total budget of the Project is roughly 17 million roubles (or about 400,000 euros) and the Minister promised to find it from other sources.

4.3.3. Programmes

- Youth of Karelia 2009-2011

The Programme was prepared by the Karelian Youth Committee. The overall goal of the Programme is to create conditions for youth’s integration into societal processes in Karelia. The Programme pursues 14 specific objectives, some of which are: development of mechanisms and models for involving young people into diverse social practices and rewarding societal activity though support to NGOs; health promotion among young people and support to different forms of leisure and recreation for young people; support to youth

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initiatives; development and implementation of effective models for working with young people at risk. The total cost of the Programme is 46 million roubles (over 1 million euros) for three years.

Comment: As 2009 is the first year of the Programme’s implementation it is hard to assess now the progress and financial implementation of the Programme. The first year’s progress report will be prepared in February 2010.

- Healthy Lifestyle in Karelia 2005-2010

The overall goal is to develop with people an ideology of healthy lifestyles, strengthening of physical and spiritual health, involvement of people into systematic physical exercises, sports and tourism, in other, simpler, words, to make a healthy lifestyle a fashion . The Programme presents a comprehensive plan for health promotion activity in Karelia Republic based on an inter-sectoral approach. Besides, the Programme heavily employs cooperation among the public sector, private sector and the third sector. While the key implementing and overseeing structures of the Programme are the Karelian Ministry of Health and Social Development and Karelian Ministry of Education, the programme provides tasks for other relevant parties, for example, Ministry of Culture, Karelian Department of the Federal Consumer Protection and Human Welfare Agency, municipal authorities, etc. The Programme has a Coordinating Board established under the Governor of Karelia. The Board usually gets together in February or March each year to discuss outcomes of a previous year and coordinate actions for the forthcoming year. The total cost of the Programme in the year 2004 prices was about 40 million rubles (roughly 1,200,000 euros in the prices of 2004)

Comment: Formally, the Programme is successfully achieving the planned outcomes. It was planned originally that the death rate in Karelia would go down to 17,6% and natural loss of the population would be as high as 7,6%. According to statistics of the Karelian Statistical Authority, as of the end of 2007 the mortality rate was 15,9% and natural loss of population was 5,3%. The Programme effectively used international cooperation to streamline projects with the objectives of the Healthy Lifestyle Programme, while from the regional and municipal budgets the Programme seemed to be underfinanced. Besides, the recent changes in the federal healthcare policies (development of high-tech capacities for treatment of cardiovascular conditions, health promotion as a priority) allowed advancing the Programme more vigorously. Yet, there is a lot of space left for improvements. For example, a lot of surveys are conducted by different organizations in Karelia among different groups of population on issues related to health behaviors and risk factors, particularly at schools. The results of such surveys seem to be little used for further actions, i.e. surveys are conducted for the sake of surveys. Such results and analyses could be fed into a common databank with administered access. This could help more effectively use resources of projects, including international, when more surveys are conducted to collect data, which is already available somewhere.

4.3.4. Projects

- Project name: Strategies to Tackle Alcohol and Drug Abuse in the Workplace

Project's start and completion: 2004 - 2010

Objectives: The overall objective of the project is to establish and encourage local preparedness to deal effectively with problems related to alcohol and drug abuse in the workplace in Karelia through formulation of alcohol and drug abuse policy for Petrozavodsk City Administration, Onego Tractor Plant and other

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stakeholders. The focus is on working with the Petrozavodsk City Administration and the Onega Tractor Plant. The services provided include workplace and public policies, stakeholder networking, occupational health and treatment perspectives, Prime for life lifestyle risk reduction model, gender and family aspects, information and education as prevention methods. The project is also providing the basis for a possible second phase, the purpose of which would be to spread the method to a larger region.

Achieved results: Due to know-how and technology shared by Swedish experts and experiences learnt from a study tour to Sweden the work with young people on risk factors received a new impulse. Numerous trainings, seminars, games, consultations and interventions were held for children, adolescents, parents and professionals. A series of community-based mini-projects were arranged at different parts of Petrozavodsk City; volunteers were trained to peer-to-peer education technology; leisure and other mass events were arranged to young people, informational and methodical materials prepared and released. The activities launched at companies also allowed to reduce alcohol use at working time.

Budget: app. 336,000 euros

Partners: Scanagri Sweden AB, Petrozavodsk City Administration, Onego Tractor Plant

Contact person: Ms Vera Meshko, international relations department at Petrozavodsk City Administration, [email protected]

Comments: New and ambitious team of managers came to Onego Tractor, and they were eager to float new management approaches in the operations of the Plant, including interventions into alcohol behavior of the personnel. Unfortunately, the production operations never improved since and the products remained out of demand, and the project fell out of the vision of the Plant’s administration, who were more concerned about the economic situation at the Plant than alcohol use. Another problem is that the project is hardly visible or promoted. Specialists from the Karelian Narcology Clinic never heard about the project, although this institution would likely fit as a stakeholder or partner in the project.

- Project name: Youth House Karelia

Project's start and completion: 2007 - 2008

Objectives: Applying a model of interactive web-portal of youth e-participation. Applying digital video for strengthening the youth NGOs’ activities. Developing a model of new special structure – Guarantor for youth participation. Summarizing the experience and disseminating the applied methods to 3 regions of Russia. The project activities and results are posted at: http://eco.karelia.ru

Budget: 227,000 euros

Partners: Petrozavodsk City Administration, Association of Karelian Children's and Youth NGOs, Segezha Municipality, Sortavala Municipality – Joensuu City Administration, Nuokka hanke

Contact person: Mr. Denis Rogatkin, project coordinator, [email protected]

Comments: detailed information about the project is available in English at http://eco.karelia.ru/en/about/. This is just one example of successful projects carried out by the Karelian Association of Children and Youth Organisations. The project achieved all its objectives and could be looked at as a project fostering socially rewarding lifestyles among young people through environmental educational and involvement into nature-friendly actions, from ecocamps to making environment-oriented videos.

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- Project name: Support to Implementation of Health Promotion Policy in Karelia Republic

Project’s start and completion: 2007-2009

Objectives: to develop a model of inter-sectoral cooperation in health promotion and risk factor prevention and test the model in a pilot area.

Budget: 285,000 euros

Partners: Karelian Ministry of Healthcare and Social Development, Karelian Centre for Medical Prevention, Segezha Municipal District – National Institute for Health and Welfare (former STAKES), international affairs unit

Contact person: Mr Dmitry Titkov, project manager, [email protected]

Comments: As now the project advances to its end, certain results can already be formulated. Inter-sectoral collaboration in Segezha District, a pilot area of the project, was established among the stakeholders horizontally and with District authorities vertically. In addition to this, partnership links were reinforced between Segezha District and regional healthcare institutions. And one of the results is that the model of inter-sectoral cooperation in risk factor prevention and health promotion has been prepared and is being put into everyday practice. This model was last year under preparation as a District Strategy for Alcohol Prevention, but later was reconsidered and widened into a District Strategy for Psychoactive Substance Use Prevention. The Strategy uses the best developments gained in Russia and Finland, it clearly defines tasks and responsibilities for all relevant organizations and sectors. The Strategy is now to be accepted by the Municipal Council and put into effect. Poor economic situation may negatively affect the implementation of the Strategy as the authorities may be more concerned about other issues. Yet, experiences of partnering with Segezha authorities allow assuming that they will keep the eye on the ball and do their best to have the Strategy running. Besides, Segezha authorities are an active player in international cooperation in general, and few other projects related to children, youth and health promotion are under realization in Segezha District.

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4.4 Murmansk oblast

4.4.1. General Information

Murmansk Region is located in the outmost northern region of Northwest Russia and covers the territory of Kola Peninsula. The population of Murmansk region is 864,600 people (2006). In the west, Murmansk Region borders on Norway and Finland, in the south – on Karelia Republic, in the west – on Archangelsk Region. The capital of Murmansk Region is Murmansk City with population at over 300,000 people.

According to information from Murmansk Regional Addiction Clinic, the recent alcohol tendencies in Murmansk Region look as follows: in 2008, totally 8,955 people in Murmansk Region had diagnose “alcoholism” or “alcohol psychosis” (2007 – 10,593, and 2006 – 10,631), and 2,512 had diagnose “alcohol harmful use” in 2008 (2007 – 3,365, and 2006 – 3,366), of whom 587 were children. Most patients placed on records of Murmansk Addictions Clinic are diagnosed with alcoholism, alcohol psychosis or alcohol harmful use (80,7% of all patients).

The growth of women in the structure of addicts causes concerns. In the alcohol picture, out of 8,955 diagnosed chronic alcoholics 1,873 are women, with the correlation at 3,7 : 1 (in 2000, the correlation was 4,9: 1).

Due to more active detection of people with harmful alcohol behaviors, growth of harmful drinkers is also observed among adolescents.

Total diagnosed harmful drinkers among adolescents in Murmansk Region

Alcohol psychoses, as indicators of alcoholization, tend to fall in the last 2-3 years, but prevalence still overruns the Russian average figures (143,3 per 100,000 population). The level of newly diagnosed cases of alcohol psychosis is also high (in 2007 the figure was 48,2 per 100,000 population, and the Russian average level was 40,8 per 100,000 population). Also, newly diagnosed chronic alcoholism grows in Murmansk Region (in 2000, the figure was 52,3, in 2007, it was 80,4 per 100,000 population). Newly diagnosed harmful drinking was 130,7 per 100,000 population (in 2000, newly recorded harmful drinking was 122,3 per 100,000 population).

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Despite the tendencies of the last 2-3 years in reduction of incidence and prevalence of alcohol-related disorders, the problem remains burning, and the tendencies may change the direction if no adequate measures are taken. The biggest problems in terms of alcohol in Murmansk Region are: 1) growth of alcohol use (and psychoactive substances in general) among children and young people, 2) lower age of first drinking, 3) growth of women in the structure of addicts, 4) growth of beer alcoholism. When speaking about the spread of alcohol use among children and young people, the factors contributing to this growth are: 1) absence of a complex inter-sectoral programme of alcohol prevention among young people, 2) youth-oriented aggressive advertising, 3) alcohol problems are often missed in view of wide spread of drugs, 4) insufficient resources, including staffing resources (for example, there are only three children’s addictions-specialised psychiatrists in Murmansk Region, of who two work at Murmansk Regional Addictions Clinic), 5) inadequate controls of alcohol sales, 6) lack of a regional law on time restrictions for alcohol sales, 7) neglect and provocations from parents’ side (often they themselves offer alcohol to their children thinking “They’d better drink at home and under control than somewhere else”).

Besides, unlike Karelia Republic, St-Petersburg and Leningrad Region, alcohol may be purchased from shops 24/7 as there is no regional law to restrict time for alcohol sale.

4.4.2. Stakeholders

- Murmansk Regional Ministry of Health Care and Social Development

Contact information: 20, Profsojuzov Street, Murmansk City, 183038. Minister Mr Arkady Rubin. Email [email protected], phone: +7 8152 48 89 55

The Murmansk Regional Ministry of Healthcare and Social Development acts very actively on the international field. This active position is in the first place accounted for by activity of Minister Mr. Rubin, who is interested in international know-how, experiences and developments, which may give an extra impulse to development of the healthcare system in Murmansk Region and help cope with problems in public health. Mr. Rubin is a co-chair of the Barents HIV Programme. Although the main international effort is aimed at the problem of HIV and drugs in Murmansk Region, this does not hamper Mr. Rubin to see the picture wider, supports new initiatives and employs possibilities of international cooperation in other issues of Murmansk Region. As an example, a letter by e-mail sent by the project manager of this project to Mr. Rubin with a request to help organize meetings with the stakeholders was answered operatively and positively. Contacts are best established or kept through the chief of the international cooperation department at Murmansk Information and Analysis Centre, Ms Olga Fedulova (+7 8152 47 62 50, [email protected]) who is reporting directly to the Minister.

- Murmansk Regional Addictions Clinic

Contact information: 16, Volodarskogo Street, Murmansk City, 183038. Contact person: Mr. Igor Zaplatkin, vice chief doctor, phone: +7 8152 45-28-17, email: omko @ m 51. ru

The Murmansk Regional Addiction Clinic is subordinate to the Murmansk Regional Ministry of Healthcare and Social Development. The main functions of the Addiction Clinic, likewise anywhere in Russia, is identification of patients with chronic alcoholism, drug addictions and substance addictions; therapeutic, diagnostic, counselling and psycho-preventive assistance to such patients in outpatient and inpatient settings; surveying of alcoholism, drug abuse and substance abuse incidence, analysis of effectiveness of provided therapies and

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assistance; participation in alcohol and drug prevention measures together with other sectors, organisations and institutions, etc. The operations of the Murmansk Regional Addiction Clinic are funded from the regional budget.

The Addiction Clinic has had wide international long-term contacts in addictions issues with the Netherlands, Sweden, Finland, and Norway. The Addictions Clinic took part in a project to support women with psychoactive substance addictions (introduction of the 12 steps programme) in early 2000, which was implemented in cooperation with the Swedish East-European Health Committee. At the moment the Clinic runs no projects.

According to Mr. Igor Zaplatkin, ideas for potential projects could be focused at the current biggest problems: 1) growth of women among patients of the Addiction Clinic, 2) earlier age of starting using psychoactive substances, 3) growth of beer alcoholism, which can be considered as the first stage in chain “low alcohol drinks – strong alcohol – drugs”.

Comments: Murmansk Addiction Clinic has experiences of disseminating the technique of motivational interviewing. Narcology psychiatrists, who possess this method, train and consult healthcare professionals of other specialties, particularly therapists and pediatricians, and school health workers, which helps to broader identify alcohol-related problems. Besides, the Addiction Clinic works close with Murmansk Regional Centre for Medical Prevention, for example in running actions among schoolchildren and young people. Another potential point of interest is the Complex Programme for Prevention of Alcoholism, Drug Abuse and Substance Abuse in Severomorsk Municipality of Murmansk Region in 2009-2010. The Programme and its practical implementation require closer investigation. One more interesting experience in Murmansk Region is a programme of alcohol prevention among children, which was designed by the Murmansk City Centre of Social Services for Young People (Mr. A. Pechenjuk). Last but not least, schools in Kolski District of Murmansk Region implement complex programmes aimed at prevention of psychoactive substances (alcohol included) among teenagers.

- Murmansk Regional Centre for Medical Prevention

Contact information: 55, Lenina Street, Murmansk City, 183038. Director Mr. Vladislav Dvornikov. Contact person Mr Boris Lyangazov, psychologist, phone: +7 8152 449675, mobile: +7 921 2767262

Murmansk Regional Centre for Medical Prevention performs the same functions as the other centres for medical prevention across Russia. Murmansk Centre for Medical Prevention is accountable to Murmansk Regional Ministry of Healthcare and Social Development.

Specialists of the Centre are actively involved in surveying of risk factors and lifestyles among children and young people. Usually, such surveys are conducted within regional, city or international programmes and projects. The Centre for Medical Prevention collects data, analyses situation with prevalence of risk factors in Murmansk Region, Murmansk City, other districts, areas, and schools. On the base of situation analyses recommendations are prepared to programme’s or project’s owner for further actions. Besides, the Centre for Medical Prevention itself develops interventions aimed at the most prevalent risk factors identified, for example, at a school, then agrees with the educational authority and school administration possibilities for running proposed interventions, involves other organizations and institutions (often Murmansk Regional Addictions Clinic acts as a partner in such interventions), and eventually carries out interventions/actions.

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Murmansk Centre for Medical Prevention is an active partner in international cooperation. At the moment, for instance, Mr. Boris Lyangazov acts as a local coordinator in Russian-Finnish project " Strengthening of inter-sectoral action to fight drug abuse and drug related harm in Murmansk Region 2008–2009".

Comment: The problem of drug abuse seems to lap over the alcohol problem in Murmansk Region, thus most efforts are bent on drug prevention (and HIV prevention, of course).

The Centre for Medical Prevention is using its own questionnaire form to collect data about prevalence of various risk factors in the youth environment (see Annex). Unfortunately, not every survey results in interventions by surveys’ customers, and sometimes surveys may be conducted for the sake of surveys. But this problem is characteristic of many regions, not only Murmansk.

It is planned to establish 4 health centres in Murmansk Region, one of which will be founded in Murmansk Regional Centre for Medical Prevention. Most funding for the establishment will be allocated from the federal budget. At the moment a list of standard equipment is being completed. Soon the regulations for such health centres will be prepared and healthcare workers trained.

Such health centres will offer primary diagnostics of risk factors and recommendations for healthy lifestyles: to measure cholesterol, to measure nicotine level in blood, to measure stress effects on organism, to control hypertension, to set up dieting recommendations, to optimize physical activity.

- Murmansk Regional Youth Authority

Contact information: 25a, K. Marksa Street, Murmansk City, 183025. Director Mr. Leonid Mostovoj. Contact person: Mr. Aleksei Pisarev, vice director, phone: +7 8152 441422, email: [email protected]

Like other youth authorities in Russia, Murmansk Regional Youth Authority is responsible for the practical implementation of the governmental youth policy in Murmansk Region. One of the functions of the Youth Authority is to arrange measures aimed at protection of youth’s rights, employment and leisure for young people, prevention of law offences and use of drugs, alcohol, toxic and psychotropic substances by children and young people. In other words, one of the major functions of the Youth Authority is to ensure primary prevention of risk factors among the youth.

Comment: Young, enthusiastic, ambitious and qualified personnel of the Youth Authority is an important prerequisite for successful activity. A meeting with specialists of the Youth Authority Mr. Aleksei Pisarev and Ms Olga Pokrovskaja gave plenty of information about youth initiatives being implemented by the Youth Authority. Some of them look innovative and really effective from the viewpoint of involving young people into socially rewarding life. One of the regional programmes is called SOS Programme, which is aimed at prevention and treatment of drug abuse and HIV, and prevention of drug trafficking in Murmansk Region. The Programme includes three components: informative, educational, and creative. The information component implies production of preventive audios and videos, purchase of video- and printed materials, making of manuals, leaflets, posters. One of the developments prepared under the information component is internet resource www.4erdak.ru – a website of Murmansk youth. The FAQ section allows to ask any question related to risk factors. The answering experts are an narcology doctor, HIV counselor, gynecologist, and a drug police officer. The educational component of the Programme is aimed at training youth leaders and qualification upgrade for personnel from the youth sector. And the creative component is purposed at arranging various events and actions, which would oppose addictions and risky behaviors and would promote healthy lifestyles. An example of creative initiatives launched by Murmansk Regional Youth Authority is open regional festival of creativity

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“TRASSA” (Freeway). The first festival was conducted in 2005 and gathered some 7,300 participants and audience. The 2008 festival gathered 20,000 people. The festival covers several cities of Murmansk Region and the time period is from late January to late May. The festival allows young people to realize their creative ideas and initiatives in any sphere of life.

- Complex Centre of Social Service for Young People

Contact information: the Centre has three locations in Murmansk City: 21, Marata Street; 25, Maklakova Street (preventive programmes); 3, Orlikovoj Street. Contact person: Ms Ekaterina Presnukhina, chief of preventive programmes, phone: +7 8152 27-57-87, email: [email protected]

The Centre consists of 5 departments (psycho-pedagogical support, preventive programmes, outreach work with children and young people, support to employment, training and production). The Centre works in the following directions:

- prevention of asocial phenomena among teens and young people (including support to youth initiatives, and working with parents and teachers);

- health promotion;

- support to volunteer movement in health promotion;

- support to employment and leisure for young people;

- support to young families;

- establishment of conditions for solving social and psychological problems (including a helpline service);

- professional and extra-curricula training programmes for teens and young people;

- social and psychological adaptation of children in difficult life situations.

The activity of the Centre is funded from the budget of Murmansk City.

The preventive programmes department takes part in AWARD programme together with the Karelian Centre for Development of Youth and Societal Initiatives. Besides, the department implements own programmes on promotion of reproductive health and prevention of STIs among young people, on prevention of tobacco smoking, on prevention of psychoactive substance use, on alcoholism prevention, on prevention of aggressive behavior with young people, etc. Besides, the preventive programmes department runs projects on training of volunteers (Tomorrow Starts Today), prevention of alcoholism and tobacco smoking and health promotion (Stationary Games, Friday Party, Quit and Get a Sweet), etc. The outreach department runs programmes targeted at developing responsible behaviors among young people.

The Centre has produced a series of printed materials (brochures, leaflets, posters) dedicated to prevention of alcoholism, tobacco smoking, drug use, HIV, and to health promotion for various target groups (young people, parents). Besides, the Centre has prepared a manual for volunteer-promoters of healthy lifestyles. The manual was reprinted in early 2009 as it is very popular among young people and NGOs.

4.4.3. Programmes

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- Murmansk Regional Law on Complex Prevention of Drug Abuse, Substance Abuse and Alcoholism (of 04.07.2001 N 287-01-ZMO; with amendments of 11.05.2005 N 633-01-ZMO)

The goals of the law is to establish comprehensive prevention of drug abuse, substance abuse and alcohol addiction across Murmansk Region and to consistently reduce illegal use of narcotic, toxic and psychotropic substances in the Region. The objectives of the Law are: to define the key directions of activity for state authorities of Murmansk Region, for local authorities, for organisations and individuals in terms of prevention of narcologic diseases spread in Murmansk Region; to improve the infrastructure of the narcological service in Murmansk Region, to ensure availability of necessary medication, equipment, and conditions for qualified personnel.

Comment: The practical implementation of the Law seems to prioritise drug and substance abuse, which are huge problems for Murmansk Region. Yet, the Law clearly describes the stakeholders of the prevention and their competences. The circle of stakeholders includes: 1) Murmansk Regional Parliament, whose competence is to legally regulate the prevention activity, to control implementation of laws, and to approve of regional programmes/plans, 2) Government of Murmansk Region, whose competence is to define priorities for prevention activity, to prepare special narcologic prevention programmes, to regularly inform population about the epidemiological situation and measures undertaken, 3) law enforcement agencies, whose competence is to detect under-aged children at risk and refer them to relevant social, educational or healthcare institutions, to detect adults who involve children into offences or who ignore their parenting responsibilities, 4) Murmansk Regional Ministry of Health and Social Development, whose competence is to arrange narcological services in the Region, to provide social services to children at risk, to provide social services aimed at prevention of child neglect and child homelessness, and to provide measures of post-therapy social rehabilitation to children referred to social institutions, 5) Murmansk Regional Educational Authority, whose competence is provide educational and upbringing services targeted at prevention of addictions and to build up activity targeted at health promotion among children and adolescents, 6) Murmansk Regional Youth Authority, whose competence is build up primary prevention of addictions and juvenile delinquency in Murmansk Region. Besides, the Law defines the role of municipal authorities and non-governmental organisations in prevention of addictions. In addition, the Law fully describes the levels of the complex prevention with splitting it into primary, secondary and tertiary prevention.

- Long-Term Special Programme “SOS 2008-2010” (measures for complex prevention of drug abuse and psychoactive substance addictions in Murmansk Region)

The Programme is coordinated by the Murmansk Regional Youth Authority. The Programme presents in inter-sectoral effort of such actors as the Murmansk Regional Anti-Drug Commission, Murmansk Regional Drug Control Authority, Murmansk Regional Ministry of Healthcare and Social Development, Murmansk Regional Youth Authority, Murmansk Regional Ministry of Education, Murmansk Regional Interior Affairs Authority, etc.

The goal of the Programme is to minimize the effects of the second wave of the drug epidemic, prevent crisis in the demographic situation in Murmansk region, and to enhance people’s safety on the Kola Peninsula. The objectives of the Programme is to improve the quality of drug prevention activity in municipalities, to further develop complex prevention of drug and psychoactive substance abuse, to support and stimulate targeted preventive work among children and young people, and to stimulate societal resistance to spread of drugs.

The Programme is financed from the regional budget.

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The expected results are consistent reduced demand for drugs among teens and young people; increased attractiveness of healthy and socially rewarding lifestyles for teens and young people; better awareness of parents about the problem of drug addiction and preventive measures; conserved and improved labour and intellectual potential of Murmansk Region.

Comment: The Programme seems to be really working in the Region, and more young people are involved in socially rewarding activities. Yet, demand for drugs remains high. Besides, the problem of alcohol seems to stay out of the Programme’s focus, and it may happen so that the reduced demand for drugs will result in higher demand for alcohol, and the problem of addictions will not be solved.

- Complex Programme for Prevention of Drug, Substance and Alcohol Abuse in Severomorsk Municipality in 2009-2010

The programme is designed for Severomorsk Municipality of Murmansk Region (27 km of Murmansk city) and goes in lien with Murmansk Regional Law on Complex Prevention of Drug and Substance Abuse and Alcoholism in Murmansk Region. The programme is funded from the municipal budget and extra-budgetary funds. The programme provides for a series of actions, some of them are: update of databanks and information exchange about minors using narcotic and toxic substances and about adults involving teens into drug trafficking; field seminars in villages of Severomorsk Municipality for teachers, psychologists, other specialists on methods of preventive work among teens and young people; a series of seminars for school psychologists and schools’ vice principals on secondary prevention (early identification of drug users and early intervention); training of preventive work instructors at volunteer camps; organizations of camps for teens at risk; publication and dissemination of youth-oriented leaflets, brochures, booklets, posters, audios and videos.

Comment: The programme is a result of active work of the municipal authorities, municipal youth department, and Regional Inter-Sectoral Drug Prevention Commission. The population of the municipality is primarily connected with the military fleet (Severomorsk is a naval base of submarines). From the viewpoint of the project, one of the most interesting moments is training on early identification and intervention for school personnel. Schools may prove to be a good platform for such activity. And practical implementation may be guided and added by healthcare professionals.

4.4.4. Projects

- Project name: Arctic Children I, II and III (Health and Wellbeing of Children in the Arctic Region)

Project's start and completion: 2002 - 2008

Objectives: development of the psycho-social well-being of children and young people living in the Arctic area. Development of a multifunctional model of co-operation aimed at health care and preventing exclusion from the social environment. The project description and results are available at www.arctichildren.net

Partners: Murmansk Pedagogical University, Murmansk School No 3, Lovozero School-University of Lapland (Finland), Luleå University of Technology, Department of Health Science and Faculty of Educational Sciences

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(Sweden), Finnmark University College, Department of Education and Liberal Arts, and Department of Culture and Social Sciences (Norway)

Contact person: Eiri Sohlman, [email protected], Eva Alerby, [email protected], Ole-Martin Johansen, [email protected], Inna Ryzhkova (Russia), +7 921 27 57 607

Results: The project consisted of three phases: inception phase in 2002-2004, research phase in 2004-2006, development phase in 2006-2008. In the first phase, parameters of psycho-social wellbeing were defined for children and adolescents of the Arctic Region. This work was carried out in four countries (Russia, Finland, Sweden, Norway). In the second phase the psychosocial wellbeing was measured based on various methods (express test of psycho-emotional stress – a Russian development, QPS-Nordic questionnaire, WHO’s Health Behavior in School Age Children). The survey revealed many common problems. As a result a joint transnational programme for support of school education to improve health and wellbeing in children of Arctic Region was prepared. The training programme was tested in pilot sites. Another product of the project was a manual prepared by the project’s partners “Crystals of Schoolchildren’s Wellbeing”.

- Project name: Support New Beginning

Project's start and completion: 2004

Objectives: to build up strong NGO-aided alcoholism rehabilitation activities

Budget: app. 70,000 euros

Partners: "Sami Mission" (Sigfred Giskegjerde), "New Beginning" Fund (Ms Natalia Vetsko), +7 8152 428818

Contact person: Sølvi Endresen ([email protected])

Comment: The Fund “New Beginning” seems to be a very active NGO in Murmansk Region involved in many projects, ao international, in such problems as support to victims of domestic abuse, prevention of HIV, drug abuse, alcohol problems.

- Project name: Competence building for prevention and rehabilitation of children and youth with drug- and alcohol problems

Project's start and completion: 2006-2008

Objectives: to provide knowledge and experience , consultations and follow-up of the existing and prospective activities for children and youngsters who abuse drug/alcohol in the Murmansk Region. To contribute to the re-integration of children who abuse drug/alcohol into society.To involve civil society into the problems of children who are drug/alcohol abusers. To strengthen the co-operation in the Barents region in solving common tasks concerning rehabilitation of children who abuse drug/alcohol

Budget: app. 60,000 euros

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Partners: SOS-barnebyer Norge, Murmansk Regional Administration, “Save the Children – Norway” in Russia

Contact person: Berit Bakkane, [email protected]

Comment: The Norwegian partner acts rather arduously in Murmansk Region through projects aimed at groups at risk, for example through outreach working with street children in Murmansk City and Apatity City.

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5. Conclusions

The conclusions drawn up below result from the overview of the Russian legislation in force, national strategies, policies and plans, and regional laws, policies and plans being realized in two thematic areas: 1) healthy and socially rewarding lifestyles, 2) alcohol. The conclusions are also supported by the overview of international and local programmes and projects related to the two thematic areas formulated above. Besides, activity of local stakeholders in promotion of socially rewarding and healthy lifestyles and alcohol prevention was considered in estimating regions' efforts to address problems related to lifestyles among children and young people. The situation in the regions with lifestyles and alcohol use was taken into account, too.

The investigations made in the project's areas in terms of promotion of healthy and socially rewarding lifestyles among young people and alcohol prevention revealed a lot of common features among the regions:

Firstly, the problems of lifestyles among the youth in all investigated regions are very much serious. All the regions undergo now economically hard times, which does not allow governments or people concentrate adequately on health issues, particularly of the younger generations. Likewise, alcohol-related problems are common everywhere in the regions. Indicators of this are: 1) increasing number of women among narcologic patients, 2) initiation of alcohol consumption at younger age, 3) beer alcoholism, 4) high public acceptance of alcohol consumption, including medical community, 5) low early detection rate of alcohol-related problems, 6) official statistics is only a peak of the iceberg, 7) quality criteria and monitoring for the narcological service are missing.

Secondly, low health culture and low responsibility for own health generally is historically characteristic for most Russian regions, including the regions in questions.

Thirdly, the regional governments address the issues of lifestyles and young people as a priority in regional policies and programmes (e.g. Republic of Karelia has a regional healthy lifestyle programme, Murmansk Region - a law on complex prevention of drug, substance and alcohol abuse, St-Petersburg - 2015 Demographic Development Concept. Regional strategies are to be funded from the regional budgets). In part, the priority setting is own regional initiative and, in part, existing federal initiatives and programmes (2009 Year of the Youth, National Priority Project "Zdorovie", League of Health) make Russian regions follow federal policies and strategies because of political and financial reasons.

Fourthly, In view of strong centralization of power and lack of specific alcohol strategies or plans at the national level, no such clear alcohol strategies or plans have either been developed locally in the studied regions of Russia. As soon as the federal government and State Duma prepare and adopt a national-level alcohol strategy with real funding, similar programmes and strategies can be expected to start appearing at regional level because it will then be possible to get funding for them from the federal budget, and because regional initiatives will then go in line with federal initiatives.

Fifthly, the problems of lifestyles are not dealt exclusively by healthcare or social welfare authorities. Practically every ministry or agency is involved in so-called complex programmes, or in own sectoral programmes and plans have special chapters dedicated to youth issues. In complex programmes the lead role still belongs to healthcare, youth and educational authorities.

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Sixthly, the government-funded network of Centres for Medical Prevention and Addictions Clinics is present in every Russian region. Regional centres for medical prevention and regional addictions clinics are subordinate to respective regional healthcare authorities, funded from respective regional budgets, have similar functions and responsibilities.

Seventhly, although the issues of healthy and socially rewarding lifestyles are taken gravely by decision-makers, and a number of governmental structures have been assigned to incorporate the lifestyle-and-youth issue into their activity, the coordination and coordination of efforts from various responsible actors is still weak - health promotion and youth support activity is in need of systematic arrangements.

Eighthly, addressing lifestyle-related issues in strategies and policies does not automatically mean success. Resources - staff, infrastructure and facilities, funding - are scarce to implement the intentions and to control the existing laws. For example the laws related to alcohol (minimum legal age for buying alcohol, drinking in public places, restricted hours of alcohol sales) are hardly observed.

Ninthly, in each project's pilot area there are NGOs who play extensively on the field of alcohol prevention and health promotion. They use internationally supported development projects in their activity. Although NGOs constitute an active stakeholder in all the examined regions, the biggest and to some extent most advanced NGOs are located in St-Petersburg, which often expand their activities to other regions of Northwest Russia and beyond.

Tenthly, combining two topics in one stakeholder analysis posed big challenges as it was not easy to find a balance between two closely inter-related themes - healthy and socially rewarding lifestyles, on the one hand, and alcohol issues on the other hand. The theme of lifestyles is rather broad and includes various aspects and risk factors, one of which is alcohol.

Eleventhly, the following algorithm in analyzing stakeholders was used: 1) overview of the national and regional legislative basis related to the theme, 2) overview of national and regional strategies and policies and supportive programmes/action plans. These two overviews will give information about the relevance of the problem nationally and regionally, and give information about relevant key stakeholders, at least in the public sector. Besides, available systems and structures, including stakeholders' interaction, will become visible. 3) study of thematically and geographically related international programmes and projects and their results. This work yields further data about key stakeholders both in the public and non-public sector. Besides, prioritized areas tied with the studied theme and taken into projects become clear.

The most significant results of the study may be formulated as follows:

1. The Russian federal and regional governments have in the recent years started paying increasing attention to the issues of risky behavior and promotion of healthy and socially rewarding lifestyles among children and young people, since the demographic situation in Russia is so bad that it threatens the national security. While the federal government tries to enhance accessibility, quality and effectiveness of medical care to, for instance, cardiovascular patients, it also looks into the roots of cardiovascular diseases prevalence, i.e. risky behavioral factors.

2. Policies and strategies for health promotion are available at federal, regional and municipal levels but at the same time Russia lacks specific health promotion programmes, which would

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support the implementation of the developed policies and strategies. Programmes are available for certain risk factors (socially significant diseases, drugs, HIV and some others)

3. On the one hand, promotion of healthy and socially-rewarding lifestyles has become part of many agencies and ministries. On the other hand, there is no prime responsible body, i.e. when it comes to a problem with healthy and socially active behavior of young people, there is no one to ask from.

4. Russia lacks alcohol-targeted policies or strategies. Availability of such might, in view of the strongly developed axis of power in Russia, trigger similar processes at regional and municipal levels.

5. The circle of stakeholders relevant to alcohol- and lifestyle related themes is much wider that the healthcare and social care sectors. If we take a young person as the core object, the subjects of impact in terms of disease prevention and health promotion might be as follows:

6. Governmental and especially non-governmental organizations have implemented dozens of projects, domestic and international, in the sector of healthy and socially rewarding lifestyle promotion and support to groups at risk, and disease prevention. Still the focus of most projects was on primary prevention of risk factors, which may seem right, as emphasis of a certain risk factor may lead to the oblivion of the others, which may come out instead.

7. The most common themes of projects are: promotion of healthy and socially rewarding lifestyles among young people, support to vulnerable groups of population, prevention of psychoactive substances use (tobacco, drugs, alcohol).

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8. Alcohol-related projects are basically of research nature (psychopharmacology); few development projects have been implemented on this arena.

9. The method of early identification and brief intervention of hazardous and harmful use of alcohol (EIBI) was tested in a couple of projects. Although they were not very much successful, this does not mean they method has no right for life. Sweden and Finland have been implementing the method with large resources for decades and they are still halfway. More EIBI-related activities, in the first place collection of evidence to support effectiveness and efficiency of the method application, should be carried out.

10. No matter who or what organisation is an implementing party of a project from the Russian side, formal commitment from governmental bodies is preferable. This may facilitate the practical advance of a project and ensure the sustainability of its results.

11. The interviewed stakeholders are keenly interested in strengthening their activities oriented at promotion of healthy and socially rewarding lifestyles in general, and prevention of alcohol and other risk factors in particular.

12. The effect of multiple projects and actions might be bigger, should these efforts be coordinated and integrated. Sometimes organizations are not aware about similar actions or projects that other organizations run. Such collaboration should rather be operative than formal within working groups or coordinating boards that gather together once a year.

13. Synergy of and communication between projects is still an issue. It is not a rare occasion that projects related to the same or similar problem and running in the same region are not aware about one another.

The possible other themes, in addition to EIBI, for international cooperation might be:

- lifestyle-related: arrangement of systematic promotion of healthy and socially rewarding lifestyles; key risk factors and how they are dealt with; practices of cardio-vascular disease prevention and management; practices of health promotion among young people; building up responsible attitudes towards own health; joint youth initiatives, actions, camps.

- alcohol-related: tax and price policies in western countries/EU; control of alcohol sales to under-aged; reporting, statistics, information exchange, surveying; piloting of a system of primary and secondary prevention of psychoactive substances in outpatient setting; development of educational and informational materials; working with at-risk groups, introduction of the motivational interviewing.

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5. Recommendations

1. The causes of high levels of alcohol consumption and low adherence to healthy and socially rewarding lifestyles lie, in the first place, in high demand for alcohol, and, secondly , low motivation and access towards healthy lifestyle-related conditions. And the high demand for psychoactive substances, low motivation and low access for effective healthy promotion are believed to be caused by the economic and social situation in Russia, lack of sustainable life-long goals and uncertainty in what tomorrow will be.

2. Based on the conclusion that at the moment Russia lacks a clearly formulated alcohol policy but has a well-established (but not so well implemented) health and wellbeing promotion strategies for young people, it may be reasonable to support governmentally recognized priorities. Although, judging by recent news, alcohol may soon come to the agenda of national programming finally.

3. Many sectoral programmes provide for health promotion activities (health sector, educational sector, social care sector, youth sector, mass media, law enforcement, etc.). In some regions special health promotion coordinating bodies have been established to coordinate efforts of different sectors. In might be advisable, in addition to such coordinating bodies which discuss and settle questions at high level once or twice a year, to have region-level working groups on health promotion, which might operatively decide about joint actions at the practical level.

4. It might be advisable to also think about better coordination of projects (including international) whose objectives are fully or partially aimed at lifestyle-connected and health aspects, such as health promotion, prevention of non-communicable diseases, prevention of alcohol, drug and substance abuse, prevention of HIV and STIs, support to reproductive health and sexual education, etc. And again, region-level working groups operating at grass-root level could technically coordinate concerted action of different projects.

5. It seems most effective to initiate primary prevention actions through regional youth authorities, while regional addictions clinics may act as effective coordinators of secondary and tertiary prevention activity. Youth authorities might coordinate their primary preventive actions with other state authorities and sectors (healthcare, social welfare, education, etc.), and the narcological service might broader involve other healthcare specialties (psychotherapy, psychology, general practice, pediatrics, school healthcare), social workers and teachers into early detection of drug and alcohol problems and rehabilitation for children and young people.

6. The third sector (NGOs and volunteers) seems to be active in all four regions where the stakeholder analysis has been done, and it definitely has to be taken into account and employed for risk prevention and healthy lifestyle promotion programme and projects. NGOs have good networking contacts, and experienced and qualified personnel. Capacity of NGOs might be applicable in any direction of alcohol prevention and health promotion work, particularly support to families and children, support to at-risk groups, training and workshops, networking, capacity building for peer-to-peer counseling, etc.

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7. Awareness raising campaigns alone bring very limited effect. Knowing does not mean doing. Information should be added by other actions, for example trainings and workshops based on interactive techniques, one-to-one counseling, which seem to be most effective methods in preventive work.

8. For alcohol problems’ prevention, EIBI should be further tested. The regional addictions clinics in Murmansk and Petrozavodsk seem to be interested in piloting the EIBI method and motivational interviewing. The same interest displayed St-Petersburg City Centre for Medical Prevention towards EIBI Feasibility Study Project and a plan prepared by St-Petersburg Medical Academy of Post-Graduate Studies about EIBI training for general practitioners. However, it should always be borne in mind that EIBI should in the first place be introduced in primary healthcare, in somatic and mental health settings and by social workers. When clients get to narcologist counseling their alcohol problems have already got out of control and EIBI is not a method of choice then. Alcohol and drug addicts need different therapies.

9. Possibilities should be explored to ensure more extensive support to community-based initiatives. The problems that require special attention in this regard are lack of resources, inadequate access to resources/services, information about resources/services, inadequate communication tools between community-based initiatives and resources.

10. For further stakeholder analyses it looks feasible to apply the suggested and tested analysis route: overview of relevant legislation, overview of policies/strategies and respective programmes/plans, overview of international and local projects. Of course, this work should be supported by field visits and interviews face-to-face, by phone or by email.

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