A Youth Alcohol Reduction Program in Sarajevo, Bosnia and Herzegovina (BIH)

Running head: YOUTH ALCOHOL REDUCTION IN BIH 1

A Youth Alcohol Reduction Program in Sarajevo, Bosnia and

Herzegovina (BIH)

Kelsey Anderson

Skylar Chelton

Lisa Conder

Derek Noland

Rebecca Potter

Erika Reese

PHC 6106: Global Health Program Development and Administration

The University of South Florida

YOUTH ALCOHOL REDUCTION IN BIH 2

Introduction

Effective program planning is a key component in creating,

implementing, and improving health intervention programs.

Program planning provides useful guidelines that outline the

specific steps for an intervention strategy. In particular, the

PRECEDE-PROCEED planning model is a holistic approach that

incorporates ecological aspects of health and health behavior in

developing specific intervention targets (Crosby & Noar, 2011).

The PRECEDE-PROCEED model is comprised of 7 steps, with steps 1-4

taking place during the PRECEDE phase, and steps 5-7

encompassing the PROCEED phase. The following paper utilizes the

PRECEDE-PROCEED model to develop an intervention targeting youth

alcohol abuse in Bosnia and Herzegovina (BIH).

Phase 1: Social Assessment

Historical Background

With the signing of the 1995 Dayton Agreement, Bosnia and

Herzegovina (BIH) emerged from years of conflict as a young,

independent state with enormous social challenges ahead. The

Yugoslav War and Bosnian Wars of the early 1990s weakened the

region’s infrastructure, instilled deep psychological wounds into


society, and displaced more than two million people (Peace

Accords Matrix, 2012; U.S. Department of State, 2013). BIH is a

lower-middle income country (LMIC) with a population of 3,926,000

and is located in Southeastern Europe (WHO, 2014). BIH was one

of six constituent countries of the former Yugoslavia from 1918

until its dissolution in the 1990s. During World War II (WWII),

Yugoslavia was divided in part because of the creation of a Nazi-

allied Croatian state (U.S. Department of State [USDOS], 2013).

Shortly thereafter, the country re-unified under the leadership

of Josip Broz Tito, though the union remained precarious given

deep-seated cultural and religious divisions, WWII memories, and

the mobilization of nationalist forces throughout the region

(USDOS, 2013). Slovenia and Croatia declared formal independence

on June 25, 1991, sparking a war between Croatia and Serbia that

would leave tens of thousands dead and millions displaced (USDOS,

2013). Soon after, BIH declared its independence from Yugoslavia

in May 1992 (U.S. Department of State, 2013). The U.S. and

Western Europe abstained from intervening in what has been cited

as the worst fighting on European soil since the end of WWII

(USDOS, 2013).


BIH is divided into three distinct ethnic and

religious groups, with a population comprised of 43% Muslim

Bosniaks, 31% Orthodox Christian Serbs, and 17% Catholic Croats

(Peace Accords Matrix, 2012). After the collapse of Yugoslavia,

tensions between these groups spurred the subsequent Bosnia Wars.

On April 30, 1992, a war broke out between the Serbian

secessionists, who wished to create an independent Serbian

Republic of Bosnia-Herzegovina, and the Bosnian government (Peace

Accords Matrix, 2012). In Western Bosnia, Croats declared

independence and fought against the Bosnian government, as the

Croatian secessionists aimed to create the Croatian Republic of

Bosnia-Herzegovina (Peace Accords Matrix, 2012). A third

conflict arose in 1993 when the Northwest province of BIH

declared itself the Autonomous Province of Western Bosnia (Peace

Accords Matrix, 2012). Over the course of three years, it is

estimated that 107,000 people were killed, 900,000 became

refugees in neighboring countries, and that roughly 1,290,000

people were internally displaced within Bosnia as a result of

these conflicts, based on a UNHCR report (Peace Accords Matrix,

2012; USDOS, 2013). On October 5, 1995, the U.S. secured a


ceasefire and peace talks initiated soon after. The General

Framework Agreement for Peace in Bosnia and Herzegovina,

otherwise known as the Dayton Agreement, was formally signed on

December 14, 1995 by the Bosnian, Croatian, and Serbian

presidents (Peace Accords Matrix, 2012).

Social Context

Relations between the ethnic groups in the region are

strained, and nationalist sentiments based on ethnic identity

remain strong among some groups and individuals. The city of

Sarajevo, which provided perhaps the most infamous backdrop for

the Bosnian Wars, continues to be a center for the proliferation

of sectarianism. Prejudices held among Muslim Bosniaks, Bosnian

Croat Catholics, and Orthodox Serbs are perpetuated by family,

community, and social networks (French, Kovacevic, & Nikolic-

Novakovic, 2013). Schools remain ethnically segregated, with

each recounting its own version of the Bosnian Wars, exacerbating

ethnic mistrust, and decreasing interethnic discourse among the

postwar generation (Hasanović et al., 2009; French et al., 2013).

Indeed, postwar teens demonstrate nationalistic tendencies in

their expressions of ethnic identity and solidarity (French et


al., 2013). The need to use alcohol and other substances as a

means to escape intergroup tensions has been identified as a

possible factor in adolescent alcohol abuse (French et al.,

2013).

Alcohol disorders are more pervasive in societies that have

experienced trauma, such as war, genocide, political conflict, or

complex emergencies (Sekulic, et al., 2012). BIH following the

Bosnian Wars is one such post-traumatic society that continues to

endure significant social, physical, and psychological damage.

In BIH, the lingering effects of conflict have given rise to the

prevalence of substance use and abuse in the general population

(Sekulic et al., 2012). One long-term follow-up study showed a

high prevalence of post-traumatic stress disorder (PTSD) among

families who had lost a relative to the war, as well as higher

consumption of alcohol and tobacco (Šantić et al., 2006).

Furthermore, children who have experienced war, or who have

family members with PTSD, are at higher risk of developmental

problems related to such substance abuse (French et al., 2013).

People living in societies with corrupt governments also abuse

alcohol and drugs to escape the difficulties of daily life


(Mehic-Basara, 2003). Corruption, especially bribery, is one of

the greatest problems experienced by BIH citizens. The United

Nations Office on Drugs and Crime [UNODC] (2011) ranked

corruption as the fourth most important challenge that BIH faces

today.

Given the turbulent social context in BIH, Bosnians are at

high-risk of developing alcohol disorders. The consequences of

unhealthy drinking behaviors are far-reaching and spread into

many facets of life, including social relationships, employment,

productivity, mood, physical and mental well-being. A public

health intervention targeting adolescents who are at risk of

developing alcohol use disorders will not only improve the life

trajectory of at-risk youth, but also their friends, families,

employers, and other social networks. Ultimately, such an

intervention has the power to improve the quality of life in BIH.

Overall Health Goal

The overarching goal of the proposed intervention is to

improve the quality of life in urban Sarajevo, Bosnia and

Herzegovina by reducing alcohol abuse disorders and the negative

consequences associated with these disorders.


Phase 2: Epidemiologic Assessment

Epidemiologic Assessment Part A: Health

Definition of the health problem. Alcoholism is a chronic

disease that is characterized by difficulty controlling alcohol

consumption, preoccupation with alcohol, and continued alcohol

use even after it causes problems for one’s health or social life

(National Library of Medicine [NLM], 2014). The individual may

also have physical dependence on alcohol, meaning that he/she

needs more and more alcohol to feel drunk. Withdrawal symptoms

may occur if the individual stops drinking suddenly. Alcohol

abuse occurs when an individual’s drinking leads to problems, but

he/she is not physically dependent on alcohol. These problems

may occur at work, school, or home; in one’s personal

relationships; with the law; and/or from using alcohol in

dangerous situations, such as drinking and driving (NLM, 2014).

The debilitating effects of conflict are still being felt among

the people of BIH. For a postwar generation of adolescents,

alcoholism and alcohol abuse represents a significant public

health concern.


Prevalence of the health problem. Prevalence rates of

alcohol use disorders range from 0% to 16% worldwide, with the

highest prevalence rates found in Eastern Europe for both males

and females (WHO, 2004). In BIH, the 12-month prevalence of

alcohol abuse disorders among adults aged 15 or older stands at

5.2% (8.6% among males and 1.9% among females) (WHO, 2014).

Furthermore, 11.7% of males 15 and over engage in heavy episodic

drinking (WHO, 2014). The risk of alcoholism is particularly

high in the BIH student population (Skobic et. al, 2009). Among

all students, 3.9% were alcohol addicts and 11.1% were at high

risk for becoming addicts, compared to 2.1% and 9.9% in the

general population, respectively. One study conducted using the

Michigan Alcohol Screening Test (MAST) to assess a population of

BIH high school students found that 14.4% scored as high risk for

alcoholism (Skobic et. al, 2009). Another study showed that

among adolescents aged 12-17 living in urban and rural areas of

BIH, 15.55% had abused alcohol (Licanin & Redzić, 2005). In the

years following the Bosnian wars, surveillance has detected a

rise in the prevalence of alcohol and substance abuse disorders

in the BIH population Sekulic et al., 2012). These statistics


demonstrate the severity of the health problem, particularly

among adolescent males.

Consequences of the health problem. Alcohol abuse is linked

to a number of negative health and social consequences that not

only affect the individual, but also his/her family, peers,

schools, and communities. For example, adolescents who abuse

alcohol also demonstrated a range of risky behaviors: truancy

(44.1%); suicidal thoughts (36.6%); non-use of seat belts

(24.7%); delinquency (stealing) (22.2%); destructive behavior

(18.9%); unprotected sex (17.7%); low success at school (14.0%);

and, drunken driving (10.0%) (Licanin & Redzić, 2005).

Alcohol abuse also contributes to high mortality and disease

burden, particularly in relation to cirrhosis/liver disease,

traffic accidents and suicide. Globally, alcohol has climbed the

ranks to become the ninth leading cause of disability-adjusted

life years (DALYs), up from twelfth 1990 (GHDx, 2013). Cirrhosis

was ranked the ninth leading cause of death in 2010, up from

tenth in 1990 (GHDx, 2013). In Eastern Europe, alcohol-related

illnesses and deaths continue to increase. Standardized death

rates (SDR) for cause-specific mortality related to alcoholism


are high in BIH: ischaemic heart disease (86 per 100,000);

cirrhosis of the liver (84 per 100,000); alcohol use disorders

(76 per 100,000); and, road traffic accidents (16 per 100,000)

(WHO, 2013). A study of adolescents in Tuzla and Sarajevo found

that the occurrence of suicidal thoughts is more frequent among

alcohol abusers as compared to non-abusers, at 36.6% to 17.6%,

respectively (WHO, 2004). The consequences of alcohol abuse

begin at an early age and, without intervention, have severe

long-term implications.

Epidemiologic Assessment Part B: Genetic, Behavioral, and

Environmental Determinants

Genetic risk factors. Alcoholism disproportionately affects

males. According to the WHO (2014), the prevalence of alcohol

abuse and disorders in BIH was highest among the male population

aged 15 and older, at 8.6% and 5.5%, respectively. Family

history of alcoholism is one of the strongest predictors for

developing an alcohol abuse disorder (Skobic et. al, 2009). The

risk is amplified among male sons of alcoholic fathers, of which

one in four will become an alcoholic in his lifetime (Simunkovic-

Rocilj & Urlic, 2009).


Behavioral risk factors. Atypical drinking among adolescents

increases the risk of developing alcohol and substance abuse

problems (Groß et al., 2014). It is widely recognized that the

younger a person is when he/she starts to drink, the higher the

chance that they will become addicted to alcohol (Sekulic et al.,

2012). On the other hand, individuals who reach the age of 21

without binge drinking are likely to not become addicted to

alcohol (Sekulic et al., 2012). Many teenagers consume large

quantities of alcohol despite being informed about its effects

(Center for Youth Education, 2012). Public health interventions

seeking to curb alcohol abuse must target alcohol consumption

patterns, including age at which a person starts drinking.

Environmental risk factors. Environmental risk factors for

alcohol abuse disorders in BIH may be further broken down into

subcategories of environmental influence: political/postwar

context, economic stability, access to healthcare,

neighborhood/built environment, cultural/social/community

context, educational and schools, and legal environment.

Political/postwar environment. There exists a strong correlation

between traumatic exposures and alcohol dependency. A study


comprised of primarily Croatian refugees living in camps near

Zagreb, Croatia following the Bosnian/Serbian Wars of the 1990s

found that 50% of men and 35% of women had PTSD. Among those

with PTSD, 60% of men and 8% of women developed alcohol

dependency (Kozariæ-Kovaèiæ, Ljubin, & Grappes, 2000). An

association between early life stress and increased risk of

alcohol dependence has also been reported (Yang et al., 2014).

This association has been demonstrated in Sarajevo, where a study

of 700 citizens found that younger participants (ages 15-27

years) had more stressful life events than older participants

(those over 27 years old). Additionally, it was found that

people with a greater amount of stress in their lives drank more

than those with a lesser amount of stress (Kurspahic-Mujcic et

al., 2014). Therefore, a generation of postwar adolescents in

BIH are at exceptionally high risk for developing alcohol abuse

disorders.

Economic environment. Chronic economic stress is one of the

most robust predictors of alcoholism and problematic drinking

patterns (Brown, Richman, & Rospenda, 2014; Henkel, 2011; UN,

2014). Economic strain is exacerbated by the high unemployment


rates in Bosnia. The youth unemployment rate in BIH is the

highest in the world, standing at 64.1% as of 2013 (CIA

Factbook). This is approximately four times the European Union

average (UN, 2014). Unemployment is a risk factor for many

unhealthy behaviors, including alcohol abuse (Popovici & French,

2013). Males tend to drink more than women in response to

unemployment, a reality for many Bosnian men (Brown et al.,

2014). High rates of youth unemployment increase the risk for

youth binge drinking and binge-induced hospital admissions (Gross

et. al, 2014). Henkel (2011) identifies a cyclical, negative

feedback relationship that exists between unemployment and

alcohol abuse, as unemployment is a risk factor for alcohol abuse

and alcohol/substance abuse is a risk factor for unemployment and

transient employment. Additionally, unemployment is a risk

factor for relapse after alcohol addiction treatment (Henkel,

2011). More recently, in February 2014, youth unemployment gave

rise to the Bosnian Spring (The Week, 2014; Önsoy, nd). The

unemployment rate in conjunction with the distressed economy,

governmental corruption, and social tensions led to a violent

outbreak and protests demanding government officials at the state


level to resign (The Week, 2014). The protest saw the unification

of the three ethnicities under a common goal; however, fear

remains that the continued unrest will take on an ethnic

dimension (The Week, 2014). As described previously, ethnic

tensions contribute to stress and escapist behaviors, such as

increased alcohol consumption. Economic instability creates a

complex web of risk factors and consequences that is compounded

by alcohol abuse.

The healthcare environment. Institutional fragmentation and a

limited capacity for healthcare infrastructure create significant

barriers to accessing care in BIH. In BIH, service delivery is

ineffective and inefficient due to disjointed and strained

service providers, an inefficient provider compensation system,

and inept primary, secondary, and tertiary healthcare sectors

(WHO, 2013). Between 17-35% of the population does not have

health insurance, and for those who do, insurance may not be

transferrable if the individual moves. More than half of total

healthcare expenditures are publicly financed (WHO, 2013).

Lacking access to health care inhibits an individual’s ability to

seek treatment for alcohol-related disorders.


Neighborhood/built environment. A study has demonstrated that

adolescents living in the urban areas of Sarajevo (comprising

56.6% of this age group) consume significantly more alcohol than

those living in rural areas (43.4%) (Licanin & Masic, 2009). It

is possible that the ethnic diversity in Sarajevo, in addition to

high rates of displaced persons following the Bosnian Wars,

contributes to alcohol-related health disparities between urban

and rural dwellers.

Cultural/social environment. Alcohol consumption among

Bosnians is recognized as a cultural custom or “social heritage”

(Center for Youth Education, 2012, p. 1). On average, a BIH

citizen aged 16 years and older drinks about 9.6 liters of pure

alcohol each year (Quandl, 2014). Drinking is accepted and even

expected in certain circumstances, such as get-togethers or

celebrations, leading to the probability that young people,

particularly teenagers, will start consuming alcohol at an early

age (Center for Youth Education, 2012). This is particularly

true for Bosnian males, for which it is customary to drink during

dinner or special occasions (Sujoldzic et al., 2006).


Educational/school environment. Primary school children in BIH are

ubiquitously at low-risk for alcoholism; yet, more than 14%

become high-risk during high school (Skobic et. al, 2009). A

negative association has been demonstrated between alcohol

consumption and important educational measures such as school

absenteeism and behavioral grades (Sekulic et al., 2012). The

association between poor academic performance and alcohol abuse

has been well documented; however, the cyclical vs. causal nature

of this relationship remains unclear (Licanin & Redzić, 2005).

Namely, it is uncertain whether educational failure advances

substance abuse or vice versa. A study by Sekulic et al. (2012)

conducted with a population of BIH students aged 17 to 18-years

old found that almost half of males and one-fifth of females

practiced harmful drinking. The study also noted a correlation

between drinking and academic underperformance: 50% of males and

22% of females who failed to meet academic benchmarks also

practiced harmful drinking behaviors. The school environment is

also a social environment for students, whose drinking patterns

are highly influences by their peers.


Legal environment. The WHO (2014) reports the legal drinking

age in BIH as 18 years; yet, this is disputed among various

sources. For example, some sources list the country as not

having a drinking age; other sources list it as 16 or 18

(ProCon.org, 2011; World Country Facts, 2014; WHO, 2014). There

are no legal restrictions on the hours or days when alcohol can

be purchased on- or off-premises, nor on the density of pure

alcohol per volume (WHO, 2014); however, there are restrictions

on places alcohol can be consumed and purchased, such as schools.

While there is an excise tax on sprits/wine/beer, it is

reportedly lower than that of Western countries (WHO, 2014). At

present, health warning labels are not required on alcohol

advertisements or containers. Though the national government

supports community action against alcohol, there is no national

monitoring system in place. The lack of surveillance creates a

challenge for alcohol-related interventions, and is likely a by-

product of weakened infrastructure following years of conflict.

PRECEDE-PROCEED Objectives

Epidemiological: At the one year follow-up assessment, the

percentage of students who abuse alcohol will decrease to


10% or lower (compared to the 15.55% alcohol abuse rate

among adolescents in BIH cited by Licanin & Redzić (2005).

Behavioral. At the one year follow-up assessment,

consumption of alcoholic beverages among the high school

students who participated in the educational intervention

will decrease by 25%.

Environmental. At the end of the educational intervention

(i.e. end of the school year for 8th grade students who

received intervention from beginning of school year), the

mean value of the perceived proportion of first-year

students who drink alcohol will be within 5% of the actual

value, as perceived by those students who participated in

the intervention.

Phase 3: Education and Ecological Assessment

Phase 3 Sub-Objectives. The following sub-objectives were

identified as critical in meeting the main epidemiological,

behavioral and environmental objectives:

Predisposing: Upon completing the intervention, at least 75%

of students will self-report that they believe they have

control over their decision to abstain from alcohol.


Reinforcing: As a result of completing the educational

intervention, at least 75% of students will self-report that

they have identified a group, physician, or individual

source of support in maintaining their decision to abstain

from alcohol.

Enabling: At the end of the educational intervention, 75% of

the participants who successfully complete the program will

be able to describe three stress-coping strategies that do

not involve alcohol, tobacco, or other substances/drugs. At

the conclusion of intervention, at least 50% of students

will be able to identify mental health resources that they

can utilize for help in achieving their goals related to

alcohol abstinence.

Predisposing factors. Predisposing factors encompass the self-

efficacy, knowledge, attitudes and beliefs necessary to change

health behaviors (Crosby & Noar, 2011). Empowering people to

form a positive attitude and believe in their ability to abstain

from alcohol increases self-efficacy. People who believe that

they have control over their choice to abstain from alcohol may

be more likely to achieve long-term success. Blagojevic-Damasek


et al. (2012) found strong evidence of this relationship in their

study on Croatian men, in which they found an individual’s belief

in their ability to abstain from alcohol was a better predictor

of success than peer support. In regards to ability to abstain

from alcohol, they found that “persons who hold themselves

responsible for their alcohol related problems and believe that

successful abstinence depends solely on their decision to stop

drinking . . . manage to abstain for a longer period of time”

(Blagojevic-Damasek et al., 2012, p. 9). In light of these

results, instilling intervention participants with the belief

that they have the ability to control their alcohol consumption

is paramount to success. Regardless of whether an individual has

or had a drinking problem, or has never had any sort of drinking

problem, impressing this belief upon the BIH intervention

participants is critical. Furthermore, students in BIH need to

gain knowledge about alcohol consumption and its short- and long-

term consequences. Attitudes and beliefs are difficult to

change; however, it is the hope of program planners that by

increasing knowledge and self-efficacy, as well as instilling


realistic perceptions of peer alcohol consumption, these

attitudes and beliefs can be shaped over time.

Reinforcing factors. Reinforcing factors are primarily

environmentally engineered and steeped in perceived social norms

(Crosby & Noar, 2011). Peer support groups in which participants

feel closely connected and accountable to one another is an

effective form of reinforcing abstinence from alcohol. Giguère,

Lalonde, and Taylor (2014) determined that under these

conditions, group participants are more likely to adhere to the

social norm within the group, as they have access to a reference

that exemplifies normal behavior. When individuals transgress

from normative behavior, feelings of guilt prompt them to assess

their actions and seek to return to the standard set within the

group (Giguère et al., 2014). Thus, creating alcohol abstinence

groups in which the majority of the participants exhibit the

desired healthy behavior, will lead to improved behavior on the

part of those who may struggle, and provides a form of security.

Furthermore, this research highlights the need to formulate

groups that stimulate participant buy-in, leading them to feel

motivated and obligated to achieve normative behavior. Giguère


et al. (2014) illuminate this phenomenon by stating that “[the

results] suggest that individuals who strongly identify as group

members may respond in a constructive manner to [norm-based]

interventions” (p. 630).

Primary care physicians also have the opportunity to

positively contribute to the reduction of alcohol consumption

among their patients. Fleming et al. demonstrated that physicians

who show support and offer advice to their patients also reduce

overall alcohol use, and that they can be “trained to conduct and

successfully implement brief alcohol interventions” (p. 29).

Without access to a primary care provider who can deliver this

information, adolescents in BIH are at higher risk of developing

alcohol use disorders and not receiving treatment.

Research indicates that parents are highly influential in

the lives of youth in regards to principles and expectations, and

in particular, issues relating to alcohol use. Likewise, it has

also been theorized that teachers exert a similar degree of

influence on students (Youniss and Smollar, 1985; Keefe, 1994;

Perkins, 2003). Having regularly accessible support of this


nature is will be paramount to the success of the BIH

intervention.

Enabling Factors. Enabling factors encompass the skills,

resources, and conditions necessary for a change in behavior to

occur (Crosby & Noar, 2011). For adolescents in BIH who are under

tremendous amounts of social and economic stress, one of the key

skills needed for reducing alcohol consumption is developing

healthy coping strategies for stress management. Special

consideration must also be given to mental health issues and

depression, which are closely linked to alcohol use disorders.

Studies have identified a high comorbidity of alcoholism and

mental health disorders, particularly depression; and,

comorbidity of PTSD and alcoholism is especially high among

displaced persons (Kozariæ-Kovaèiæ, Ljubin & Grappes, 2000).

Access to mental health services increases the likelihood of

diagnosing and treating alcoholism or common comorbid conditions,

such as PTSD. Identifying and developing resources to aid in

positive support, for addressing both alcohol abuse and its

correlated issues will increase the success of the educational

intervention. Because the healthcare environment in BIH is


fragmented and access to care issues abound, the school

environment can serve as a substitute for students who need to

talk to someone about mental health and substance abuse concerns.

Furthermore, school programs can help to prevent development of

alcohol use abuse disorders through health promotion and stress

management activities.

Phase 4a: Intervention Alignment

The proposed intervention is grounded in social norms

theory. The theory posits that the perception of the behavior of

one’s peers, and specifically what is perceived as ‘normal’ among

peers, has a direct influence on one’s own health behaviors

(Bertholet et al., 2011). This is particularly true regarding

alcohol and substance use (Bertholet et al., 2011; Larimer et

al., 2009; Neighbors et al., 2010). Many adolescents

overestimate how much their peers drink (Bertholet et al., 2011;

Neighbors et al., 2010). This misperception of normal drinking

behavior increases one’s own alcohol consumption (Larimer et al.,

2009). Conversely, underestimation of peer drinking habits is

associated with decreased personal drinking habits (Bertholet et

al., 2011). These associations were found independent of socio-


demographic variables, education level, occupation, living

environment, and a family history of alcohol problems (Bertholet

et al., 2011); therefore, this theory can be applied to the

student population in BIH with a reasonably high probability of

success. It is crucial that the health education intervention

reinforce healthy social norms as they relate to alcohol

consumption among adolescents.

Successful intervention programs grounded in social

norms theory combine a social norms approach with personalized

normative feedback (PNF) to educate participants on the actual

proportion of peers that drink (Bertholet et al., 2011; Neighbors

et al., 2010). Consistent with the social norms theory, PNF

specifically aims to respond to the participants’ perceptions of

peer drinking behavior by educating them on the actual drinking

patterns of their peers (Neighbors et al., 2011). Gender-

specific PNF has also been shown to have greater success in

reducing the drinking habits of female over-drinkers (Neighbors

et al., 2011). Another study by Larimer et al. (2009) likewise

highlighted the importance of a more specific PNF approach,

finding that success in reduced drinking was higher when at least


one aspect of the PNF (i.e. gender, ethnicity, and residence) was

personalized. Planners should be cognizant of considering the

patriarchal culture in BIH, which includes gender-specific

drinking norms.

Phase 4b: Administrative and Policy Assessment

Currently, there is no formal national policy or public

health plan for alcohol disorders in BIH (WHO, 2014). BIH has a

state monopoly on all alcoholic beverages, including the

production of alcoholic beverages. Health warning labels on

alcohol containers and alcohol advertisements are not legally

required; there are few regulations on alcohol advertisements;

and, a national monitoring system is lacking. Youth events,

healthcare establishments, educational facilities, and workplaces

all have a ban on alcohol. However, there are no restrictions on

public consumption of alcohol in many public spaces such as

parks, streets, public events, concerts, etc. Furthermore, age

restrictions on alcohol sale may not be firmly enforced. WHO

(2014) has indicated national support for community action;

however, the level of commitment from the government and


infrastructural capacity for undertaking a policy-driven

intervention is unclear.

In this light, non-governmental organizations (NGOs) working

with local communities to reduce the burden of alcohol disorders

represent a key community resource for advancing a health

education policy intervention in BIH schools. For example, IOGT-

NTO has partnered with the Center for Youth Education (CEM) in

BIH with the goal of decreasing alcohol use among youth and

increasing awareness of its harmful consequences. CEM works in

the areas of school education, advocacy, campaigns, and diverse

activities (IOGT-NTO Movement, 2014). The proposed intervention

will build upon the groundwork laid by IOGT-NTO and CEM.

Furthermore, a strategic partnership with CEM can incorporate and

leverage the organization’s activities and resources to bolster

the in-school health education intervention. The following CEM

programs represent possible channels for alignment with the

intervention: 1) ‘Lifestyle without Alcohol’ program, an informal

network of socially responsible civil society organizations; 2)

‘Alcohol-free Lifestyle’ project, which delivers peer

presentations in high schools throughout BIH; and, 3) Healthy


mobile bar in Travnik, in which volunteers and peer educators

share information about alcohol consumption consequences

alongside free fresh fruit juices for passengers and youth.

Incorporating fun activities such as the Healthy Mobile Bar into

a school-based education program can help to motivate students to

take alcohol education more seriously, or even inspire them to

become peer educators themselves.

Phase 5: Implementation

In depth research shows that successful health interventions

tend to be theory-driven, focus on school norms around alcohol

use, and assist students in social and personal skill-building to

withstand the pressures of consuming alcohol (Stigler et al,

2011). In addition to incorporating components of social norms

theory, the BIH alcohol education program uses the Social

Ecological Model (SEM). The SEM involves five hierarchical

levels, including individual, interpersonal, community and

enabling environment. Public health interventions that target

multiple levels are more successful than those that target only

one (CDC, 2013).


Target population. The health education intervention will

target first-year high school students in urban Sarajevo. The

average age for starting eighth grade is 14 years old in BIH.

This is an opportune window for intervention because studies have

shown that high-risk factors for alcohol abuse emerge during high

school (Skobic et al., 2009). However, it is important to

deliver the intervention prior to the end of compulsory education

at age 15. Male adolescents are one of the highest risk groups

for developing first-time alcohol abuse disorders. Females will

also be included in this health education intervention because

the burden of alcohol disorders among women is also significant.

Program implementation signals the beginning of a series of

evaluations. In order to determine which high school will

receive the pilot intervention, program planners will conduct a

preliminary needs assessment by administering the Michigan

Alcohol Screening Test (MAST) to last-year compulsory school

students at three high schools within a 20 mile radius of

Sarajevo. The pilot intervention will then be administered to

the school with the highest percentage of students at-risk for

alcohol abuse as measured by MAST indicators. The intervention


will test several basic assumptions, including (1) that not

consuming alcohol is the actual norm among students; (2) that

students, teachers, and parents overestimate the consumption of

alcohol by students; and (3) that student alcohol consumption is

associated with the over-estimation by these three groups

(Perkins, 2003).

Program planners will identify key stakeholders such as

Parent Teacher Associations, school staff/administration,

community partners (i.e. CEM), and a contingent of students to

give their input on the specific needs that should be addressed

by this health education program. Research indicates that parents

and teachers influence students’ principles and expectations,

which extend to alcohol-related behaviors (Youniss & Smollar,

1985; Keefe, 1994; Perkins, 2003). A final program proposal will

be presented to the stakeholders and school board for approval

prior to implementation of the education intervention.

Stakeholders will be involved throughout the program

implementation, and information such as assessment results will

be shared at monthly meetings.


Once the high school has been chosen to receive the pilot

intervention, program planners – with input from community

stakeholders – will develop a survey tool to examine the

perceptions of peer drinking among students entering the eighth

grade. Based on the social norms theory and personalized

normative feedback, the intervention will be gender-specific to

allow for maximum results. Both the MAST and perceptions of

alcohol use survey will be administered to all incoming first-

year high school students at the targeted school at the beginning

of the school year. A mail-home survey will be sent to parents

to determine their perceptions of alcohol use among students,

helping to measure Assumption Two.

Based on the data collected during the strategy development

phase, various alcohol education messages and communication

channels will be developed to relay accurate information

regarding student norms of nonuse of alcohol to students,

parents, and school staff. The educational intervention will

incorporate the following key components: (1) information

regarding the actual peer drinking behavior of Bosnian primary

students; (2) healthy ways to cope with stress that do not


include alcohol or substance use; (3) advice on building healthy

personal and social skills to help students resist peer pressure;

(4) offering other alternatives to drinking; (5) using peers as

leaders to conduct sessions; and (6) integrating teachers and

parents into the intervention. Participation in certain

interactive classes and peer-led workshops (i.e. stress

management, coping strategies) on alcohol education will be

mandatory for all first-year students. Content will be reinforced

by messages incorporated into direct mailings sent to parents;

professional development for teachers; and posters, promotional

postcards, flyers, radio spots on youth-based stations. Posters

will be displayed around schools and places where young people

and adults frequent, such as churches, banks, libraries, and bus

stops. These messages and graphics will also be printed on

youth-related items, including stickers, frisbees, and hacky

sacks. The messages will be changed each month to keep the

information fresh.

Phase 6: Process Evaluation

To measure program fidelity, program staff will track – at

each step – to what extent the program is being administered in


the way it was planned. Any changes will be documented and

adjusted as necessary. This iterative, ongoing feedback will

improve the program while in its pilot stage, and inform future

program decisions. The intervention implementation will be

evaluated via staff notes and checklists, which will be sent for

review to the steering committee. The biweekly intervention

evaluation will take particular note of student attendance,

budget and timeline adherence, incorporation of student and

teacher feedback and recommendations, and the ability to adjust

the intervention accordingly. All peer educators, school

staff/administration and health program educators will be given

an opportunity to express their feedback about how certain

activities and messages performed. This feedback can be used to

improve messaging on a monthly basis (as health education

campaign messages revolve month-to-month) and improve

implementation of workshops and mandatory education sessions.

Phase 7: Impact and Outcome Evaluation

Baseline data on students’ risk of alcohol abuse will be

collected through the administration of the MAST to all students

prior to participating in the health education intervention. The


MAST is one of the most widely-validated methods for assessing

the risk of developing alcohol use disorders. The test has been

effectively applied to diverse populations in varied environments

(Buddy, 2014), and will be translated/back-translated into

Bosnian by a community partner familiar with the local language

and culture. The MAST will be administered to three schools in

the Sarajevo area as part of the initial needs assessment, with a

completion rate goal of at least 50 MASTs from each school.

In order to evaluate changes in students’ knowledge,

perceptions and attitudes toward alcohol consumption, a

customized survey tool will be created by a contingent of program

planners, specialists and community members. A child

psychologist will be engaged for this phase to ensure the survey

is appropriate for students with past trauma. The perceptions

survey will be designed for dissemination alongside the MAST

surveys to all incoming eighth graders at the target school.

Data will be analyzed in order to assess the drinking behaviors

and perception of the students. The steering committee will call

on the results of the initial MAST and perception surveys to

design specific aspects of the health education intervention.


At the end of eighth grade, students receiving the

intervention will be re-evaluated and given the MAST and

perception surveys again to determine how many students are at

high risk for developing alcohol use disorders. Post-

intervention evaluations will be compared to baseline assessments

to show whether the intervention changed knowledge, attitudes,

and perceptions of alcohol use; and, whether actual alcohol use

and risk for alcohol abuse decreased. MAST data from the two peer

schools that did not receive the intervention can serve as a

control. These results would be further validated if the peer

schools also re-administered the MAST test at the end of the

school year. Any changes in risk of alcohol abuse at the peer

school can be measured against changes in the target school to

determine whether the results are a result of the program, or a

natural progression of ‘coming-of-age.’ A follow-up assessment

will be administered one year later to 9th grade students (e.g.

the end of compulsory education) who participated in the pilot

program in 8th grade. Results of this pilot program will inform

whether or not the intervention may be implemented in other

schools.


At the end of the educational intervention, the behavioral

objective will have been met if consumption of alcohol among high

school students decreases by 25% (as measured by MAST). The

environmental objective related to perceptions of drinking

behaviors and social norms of alcohol will be evaluated based on

the assessment of the post MAST/perception surveys. This

assessment will determine if the perceived proportion of first-

year students who drink alcohol is within 5% of the actual

proportion of first-years who drink alcohol. The epidemiological

objective will be evaluated based on a one-year follow up

assessment of This objective will be met if the percentage of

students who abuse alcohol is 10% or lower after the

intervention, as compared to the starting point of a 15.55%

alcohol abuse rate among adolescents in BIH (Licanin & Redzić,

2005).

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Appendix A

Program Timeline

Action Steps

Responsibilities

Timeline Resources PotentialBarriers

Step 1: Initial Needs Assessment to select target school

-AdministerMAST to three schools-Identify school withthe highestMAST score

-May 1, 2015(2-4 weeks)

-Funding-Staffing-MASTs-Students

-Disapproval and lack of cooperation by schools and students-Lack of funding

Step 2: Survey Design & StakeholderEngagement

-Identify stakeholders (CEM)-Form contract with a child psychologist-Form proposal-Approval by stakeholders-Rent nearby office space

-June 1, 2015(2-4 weeks)

-Funding-Staffing-Psychologist-Office space

-Disapproval of proposal by stakeholders-No cooperation with psychologist-Lack of support and funding-No nearby office space available


Step 3: Baseline Assessment &Survey Implementation

-DisseminateMAST & drinking perception survey -Compile data-Statisticalanalysis

-August 1, 2015(4 weeks)

-Funding-Staffing-School resources (i.e. classrooms)

-Limited participation-Lack of parental approval-Lack of supplies

Step 4: Program Design & Development

-Design intervention based on needs assessment and survey-Design andcollection of educationalmaterials

-September 1, 2015(8 weeks)

-Collected data-Public healthworkers-Psychologist-Educational materials

-Time constraint-Lack of funding-No contract with psychologist-Lack of supplies

Step 5: Program Approval ByAdministrators & Stakeholders

-Intervention approval by stakeholders- Revisions

-November 1, 2015(4 weeks; optional 8 weeks if needed)

-Staff-Stakeholders

-Disapproval-Disputes

Step 6: Implementation of Intervention

-Module preparedness-Engage intervention with

-January 1, 2016 - March 1, 2016(Fixes & updates duringbreak)

-Staff -Psychologist-Students-Classroom space-Education

-Lack of participation-Lack of parent approval


students -Continuation April 1, 2016 - June 1, 2016-Intervention method done biweekly

materials-Equipment (i.e. survey materials, etc.)-Funding

-Studentsdropping out-Lack of equipment

Step 7: Process Evaluation

-Evaluationof intervention during off weeks of intervention-Continuousimprovementof intervention-Collect feedback from stakeholders

-January 1, 2016 - March 1, 2016(Fixes & updates duringbreak)-Continuation April 1, 2016 - June 1, 2016-biweekly

-Staff-Stakeholders-Supplies-Funding

-Lack of funding-Lack of Stakeholder participation-Disputes

Step 8: Intervention Evaluation

-Post intervention survey & MAST administered at end of8th grade-Assess progress ofintervention-Post

-June 2, 2016(2 weeks)

-June 2, 2017(2 weeks)

-Staff-Funding-Stakeholders-Students-Assessment tools -Office space and follow-up office space

-Lack of funding-Lack of participation-Time constraints-Student drop out


intervention survey & MAST administered at end of9th grade-Assess overall effectiveness of the intervention


Appendix B

Program Budget

Resources (All Bosnians)

Estimated Cost (USD)*

Total Cost (USD)

Program Administrator/Manager

2 year contract - $12,000/yr

$24,000

Public Health Workers - 3

2 year contract - $9,000/yr

$54,000

Child Psychologist 1 year contract - $15,000

$15,000

Office Space 2 year contract - $6,000/yr - $24,000/yr (program staff will seek in-kind donation of office space)

$12,000 - $48,000(possible in-kind)

Materials-Laptop Computers (4)-Office Supplies-Training Materials-Projector and Screen (for trainings, presentations, etc.)-Gifts (stickers, hacky sacks, frisbees, etc.)

$4,000 $4,000

Advertising-Radio, Mailings, Flyers, Posters

$2,000(program planners will seek in-kind contribution via

$2,000


strategic media partnership)

Miscellaneous $2,000 $2,000

Total $113,000 - $149,000

* The estimated cost was based on an assumption of 200 children in the eighth grade and ten stakeholders.


Appendix C

Source: Green, L. W. & Kreuter, M. W. (2005). Health Program

Planning: An Educational and Ecological Approach. 4th edition. NY: McGraw-

Hill Higher Education.


Appendix D

Group Member Contributions

Each member was involved in the initial phase of the project(i.e. deciding on topic and country)

Phase 1: Historical Background and Social Assessmento Skylar Cheltono Kelsey Anderson

Phase 2: Epidemiologic Assessmento Lisa Condero Erika Reeseo Rebecca Potter

Phase 3: Education and Ecological Assessmento Derek Nolando Rebecca Potter

Phase 4a+4b: Intervention Alignment and Administrative and Policy Assessment

o Lisa Condero Erika Reese

Phase 5-7: Implementation, Process Evaluation, Impact and Outcome Evaluation

o Skylar Cheltono Kelsey Andersono Lisa Condero Erika Reese

Budget/Timeline:o Skylar Cheltono Kelsey Anderson

PPT:o Lisa Conder


o Skylar Cheltono Erika Reeseo Kelsey Andersono Derek Nolando Rebecca Potter

Paper edits, compilation, formatting, and final editing:o Derek Nolando Rebecca Potter

A Youth Alcohol Reduction Program in Sarajevo, Bosnia and Herzegovina (BIH)

Documents