Training Program on Addiction Prevention of Turkey (TBM): Content and Process

Training Program on Addiction Prevention of Turkey (TBM) is realized as an effective action plan in combating addictions by taking the country’s sociological structure, needs and current education system into account. It is the first and only measurable and sustainable protective-preventive education program of Turkey. TBM Training program is based on acquisition on 5 different topics listed as Technology, Tobacco, Alcohol and Substance Addiction, together with Healthy Life as a complementary topic. TBM is composed of a total of 18 modules. Each book is prepared taking into account the target age group. TBM has three objectives embracing each other according to its target groups. These are; to train trainer of trainers who will organize and perform trainer trainings, to train ‘trainers’ who will provide training service to the target audience, to transfer the ‘protective-preventive information’ to the target audience. TBM Trainer of Trainers Program were organized with the participation of 500 candidate trainer of trainers nationwide between November and December 2014. At the end of those trainings which were designed as 4 days for each addiction topic, 100 trainer of trainers were trained in each topic. Between March and June 2015, 28.349 school counsellors in whole Turkey were provided in service training including the 5 topics. After the first trainings, they reached 390.000 students countrywide in a month. TBM dissemination trainings are in progress in the whole country in 2015-2016 school year. The target is to reach all students at the end of this school year. Within TBM Dissemination Trainings, assessment and evaluation tools and instructions for use are prepared for primary, secondary and high school, and adult levels.


Introduction
Turkey's population, according to the Turkey Statistical Institute data, is described as 78 million 741 thousand as of December 31, 2015 (http://www.turkstat.gov.tr). It is estimated that the total population of Turkey will nearly be 84 million in 2023. 50% of Turkey's population are young people under the age 30 and 19 million of the population is between the ages 14-29. Although Turkey has lower alcohol and drug use compared with European countries and the United States, several studies revealed that Turkey's alcohol and drug use has increased in recent years [1][2][3][4][5][6]. Especially in recent years, it is determined that there is a rapid growth in substance use in adolescents young population. One of the key findings in the studies is that the age to start to substance use is decreasing gradually [7][8][9]. According to the results of "Survey on Attitude and Behavior Regarding Tobacco, Alcohol, and Substance Use in Schools in Turkey (SPS)", done by Turkish Monitoring Centre for Drugs and Drug Addiction (TUBİM) in 2011, life-long substance use frequency is 2,7% [10]. According to the results of the study, use of drugs at age group of 15-24 is increasing significantly.
It is found that average first drug use age is 14. According to a survey done by Istanbul Directorate of Narcotic Crime Branch in 2012 in 35 high schools in İstanbul-Zeytinburnu, the frequency of adolescents using substance once in their life is 3.5%; however, when the same question is asked in a different way, the frequency reaches to 17%. This result shows that in Turkey when substance use rates increases, first use age decreases on the contrary. The most important risk group is school-age children and adolescents. Considering that these children and adolescents spend most of their time at educational institutions, school oriented demand diminishing studies are getting more important. School focused models in the scope of universal prevention programs which aim to enhance social awareness, aim to develop responsibility in individuals; families and all levels community are the most preferred models in the world.

Combating drug abuse studies in Turkey
Turkey is a country that is fully corresponding with the international agreements about combating drug abuse and applying decisions and recommendations of United Nations and European Union with caution. In order to reach the desired success in the fight against drug use and addiction, it is decided that action plans will be carried out with a strategy and policy document which is given by institutions determining Turkey's combating drug policy. Considering the fact that causes and outcomes of drug abuse and addiction concern many disciplines and sectors; "National Policy and Strategy Document on Drugs" (2013) [11] and the National Action plan on Drugs (2013) [12] were created in order to ensure a systematic and holistic approach that will direct the preventive, protective and therapeutic studies. These documents administer legal regulations about substance abuse prevention, ensure that activities and studies are carried out which encourage the cooperation between institutions like the ministry of education, ministry of health, youth and sports, ministry of family, universities and nongovernmental organizations.
It is aimed to work with holistic and multidisciplinary system in all areas with participation and cooperation of central administration, local government and nongovernmental organizations to prevent drug use and addiction. Substance abuse prevention legislation are made by government, demand diminishing plans and strategies have been created, and liabilities and tasks are given to various state institutions. For this reason, many institutions and organizations, do some work about their own liabilities and scope. However, when all these studies are examined closely, it is noteworthy that all these prevention programs are done as seminars but the number of comprehensive training programs is very low [13]. Even though these programs work devotedly, until Training Program on Addiction Prevention (TBM) was developed, it is seen that all prevention programs didn't form a country wide contend yet and their target groups were only certain regions and were all small scale studies. With its quite large area, individual studies carried out in Turkey are generally independently committed, unaware of each other, lacking in assessment and evaluation systems, not holistic nor sustainable. When contend of the prevention studies are evaluated, it is seen that they are generally at non-pedagogical level and even contain uncontrolled and risky content/ visuals. Thus Turkish Green Crescent Society created TBM as a program that can be performed at national level and can be used in all parts of Turkey, with consideration of all these risk factors Turkish Green Crescent Society was founded in Istanbul on March 5, 1920. It works for the protection of society and particularly of young people from tobacco, alcohol, drugs, gambling and technology addictions and has 40 branches and 101 representative agencies in Turkey. Turkish Green Crescent Society is a nongovernmental organization that, on the premise of human honor and respect, endeavors to protect society and youth from harmful habits without discrimination. Guided by national and moral values, and using scientific methods, the Green Crescent struggles against tobacco, alcohol, drug, technology, gambling and other addictions by engaging in preventive and rehabilitative public health, and advocacy work. Turkish Green Crescent Society, has developed Training Program on Addiction Prevention of Turkey, with realization of lack of prevention activities in Turkey, based on the current scientific practice of prevention studies in order to start a society based fight by mobilization all layers of society, and putting school and family based techniques together.

Contend of training program on addiction prevention of Turkey
Training Program on Addiction Prevention of Turkey is developed by Green Crescent Society in order to start a society based fight by mobilization in all layers of society, and putting school and family based techniques together with realization of lack of prevention activities in Turkey, based on the current scientific practice of prevention studies. When fight against addiction taxonomy is approached as environmental, developmental and informational [14], TBM is informational in terms of prevention taxonomy. But it is the previous step of Green Crescent Life Skill Training Program which is still on preparation process and will be the second step as developmental intervention. Also these programs has the feature of primary prevention with its preventive and protective effective academic instructive structure and contend designed for individuals who have serious problems with substance abuse [15,16]. TBM, is implemented as an effective action plan against addiction based on our country's social structure and needs. It has aimed to contribute a safer and a healthier life for youth and children away from the risks of addiction and increase the awareness of rising generation about dependency types. This program is a scientific training program which has various applied examples in different parts of the world and devoted to minimizing the risks of addiction of non-addictive individuals.
TBM is a three year training project applied between the years 2013-2015. With its preventive and protective contend, TBM has the aim to give preventive education services to all related parties especially youth and children. TBM, which offers the most comprehensive practice in the fight against addiction was developed with support of specialists in the field of addiction, by taking in to consideration of the needs, sociological structure and current education system in Turkey and can be applied all over the country.
TBM started with an analysis of deficiencies in prevention works in Turkey, and current scientific exercises regarding prevention works. In sequence of information obtained from this study, the main aim of developing TBM can be summarized as follows: 1. To reach a common language in combating addictions.

To gather the concerned institutions and organizations
around the same objective.
3. To start Public -NGO Cooperation in combating addictions.
4. To create a science-based resource for a nationwide combat.

5.
To enable school counsellors to conduct prevention works at schools appropriate for each age group TBM was conducted to start a grassroots combat by combining school and family-based methods to mobilize all layers of society in fighting against addiction. TBM is valued as an effective action plan in combating addiction by taking the country's sociological structure, needs and current education system into account. TBM has been developed by taking into consideration the basic preventative needs of students. It is based on acquisition on 5 different topics listed as Technology, Tobacco, Alcohol and Substance Addiction, together with Healthy Life as a complementary topic. It is composed of a total of 18 modules. Each book is prepared taking into account the target age group. The training modules available for each age group in the training plan are as follows: Apart from 18 modules, there is an additional material (Activity Book) which consists of activities that address TBM acquisitions [17]. In order to create a standard between developed materials within the scope of TBM, and praxis, "TBM Practitioners Guidebook" was prepared [18]. The book included the features of target groups, and the terms of how to use the material and activities developed for each target group. All contend used in the training program has been prepared by professional staff including Turkey Green Crescent Society.
About contend: 1. It has been prepared in accordance with science-based approaches.
2. The program is designed as a modular program which consists of 18 modules.
3. Each module has their own book prepared.
4. Each book is designed and written to be appropriate for the age level of target group.
5. Information texts, activities and pictures used in the book are prepared by experts in the field studiously.
TBM especially aimed to correct false information that is known as true and spread the correct information about addiction to the target group with trainings prepared in 5 areas. Particularly preventing youth and children from normalizing addictive substances like alcohol, tobacco etc. through media or friend zone and hinder them to be rigged with false information in this respect is one of the prior aims of TBM. TBM distance learning system and website: Since it is decided not to train through only classroom interaction, but also with implementation of distance education format, an interactive content as well as the book has also been prepared. For these purpose activities, videos etc. prepared by experts in the field were converted into interactive content. While developing the distance learning program, the Green Crescent cooperated with Istanbul University. Distance Education Systems those are created in order to serve the continuity of knowledge though country, accomplished only in 22 universities and implemented as Learning Management System (ALMS). Interactive contents are developed starting from pre-school level through high school level. Contend, prepared taking into consideration of the developmental characteristics of the age group, aimed to catch target group's attention and provide a positive contribution to the learning process. The Distance Learning System includes interactive content which was prepared with consideration of the learning characteristics of the new generation. This is the first and only program in Turkey in the field of combat against addiction. Created to serve the aim of maintaining the continuity of the knowledge and extending it countrywide, the Distance Learning System is implemented through a Learning Management System. TBM has a training pack of 13 modules which was created by transforming activities and videos into interactive contents. There are interactive contents until high school level now; and  The web site is prepared in a structure that includes information about trainers and information practitioners who will work in extensification activities, all training materials including posters and brochures used from the level of kindergarten to the adult level, additional training materials which includes expert interviews, training videos of related issues, and also music videos for preschool and elementary school age children. The web site is the only place where relevant source and it is also possible to get in to distant learning system through this web site. It serves as a resource and an announcement portal for all practitioners within the scope of TBM extensification studies.
After opening the website, the user should choose his/her age group; only then s/he can see the content. With this way, everyone sees only the content suitable for his/her age group. All printed and electronic contents related to the modules can be downloaded from the website. In addition to that, related materials are sent to the users for free. For this purpose, material requests are again received through the website. Moreover, in the website one can find the current news linked to TBM, and planned trainings as well as training videos and interviews with field experts. TBM gives importance to sustainability of knowledge; therefore, through webinars, TBM trainers meet with field experts as well.
TBM preparation and application process: Project implementation and dissemination process is designed to be in 3 stages. As the first stage 2013-2014 academic year pilot scheme is planned to be done, in 2014-2015 TBM practitioner and training instructor training is planned to be done and students and their families are planned to be reached by practitioners and trainers. In the final stage it is planned to prepare activities suitable for Ministry of Education curricula and carry on the necessary work for implementation of those activities in to the schools. In the final stage of preparation activities suitable for all Ministry of Education curricula scanned curriculum and the implementation of the necessary work has been planned for implementation in their schools.
In this regard, TBM has three objectives embracing each other according to its target groups. These are; 1. To train trainer of trainers who will organize and perform trainer trainings.
2. To train 'trainers' who will provide training service to the target audience.
3. To transfer the 'protective-preventive information' to the target audience.
The program was started by the pilot scheme. Activities of pilot scheme are given below.

Pilot scheme
The first leg of the program was initiated under the protocol signed with the Ministry of National Education of Turkey on January 03, 2014. The pilot project was conducted in high schools in Istanbul. Program development process, was started with the initiation of a pilot scheme. It is intended to continue to the pilot program with the voluntary training instructors and announcements were made in this regard to counselors who are willing to work as training instructors. 197 applicants from different districts were assessed and one applicant from each district is invited to a face to face interview. After the interviews, volunteer counselors from 33 different districts were invited to attend the trainings to be training instructions, and Provincial Directorate for National Education was requested to appoint counselors for 6 districts that didn't have any volunteer counselors for training. With attendees from public health, general doctorate of lifelong learning, Ministry of family and social policies and the green crescent to the trainings, the number of attendees has reached to 58. After pilot scheme was implemented, the program is updated based on the problems faced during pilot scheme and prepared for 2014-2015 academic year. 41 training instructors from 39 districts of Istanbul were given a 6 day combating addiction training between 17-22 February in 2014. 42.5% of attenders were male, 57.5% were female and 90% of attenders were 20-39 years old. In these trainings, right along with TBM Core Area trainings like tobacco addiction training, alcohol addiction training, substance abuse training, technology addiction training, and healthy living training, TBM management learning area and TBM education learning area trainings are also provided in order to provide greater efficiency from these trainings. Expert Educators Questionnaire was conducted to participants at the end of the training. The results showed that participants were satisfied with their learning, they don't have any self-esteem problems in presenting the program to other people and they rely on what they learned from the training. With this determination, it is believed that with these trainings, a high quality and important number of training instructors' pool for Green Crescent was created.
Fallowing the training instructor education, a necessary evaluation has done and it decided to make one day workshop with training instructors. In the workshops information about the process was given and they were requested to share their opinions and suggestions. Thereby the way to be fallowed in the training process and also things to be done during the trainings is decided with the joint decision of participants. Thereafter training instructors were divided in to 5 groups based on subject areas and were asked to try out activities based on their subject areas. Groups shared their activities with each other at the workshops in order to share thoughts and comments. In this process material that will be used in the trainings were prepared with necessary revisions. Within the frame of the problems that are faced during the workshops, contend and High school counselors were appointed with co-operation of district national education directorate for trainer education. 41 training instructors has given 2 day combating addiction training to high school counselors from their districts and reached to 890 counselors from 39 districts. In this context, by impending program 8 districts every week, 5 weeks after with participation of high school counselors from all 39 districts, trainings were completed. Education and training materials were sent to 515 high schools throughout Istanbul after trainings. As the final step of the training, counselors who had taken executive education training informed high school students about addiction by applying TBM program to first their schools then to schools at the neighborhood. Training of students in 515 schools in 39 districts was carried out in this context. Training is given approximately 60 thousand students in 5 core areas.
At the trainings that are offered at schools pre-test and posttests to assess effectiveness of the program is conducted, the results were input in an excel file and sent to the green crescent district training instructors. District trainers collected all survey results from their districts and conveyed these results to Green Crescent. In order to evaluate effectiveness of the program at schools, a 5 point Likert scale that assess misconceptions about addiction in the society is used in pre and posttests. The results showed that misconceptions were corrected between 5% to 10%, and in some questions correct answer rate rises to 50%. In the light of information gained from pilot scheme of TBM training instructor education, trainer education, prevention education and workshops, training materials, and program had been evaluated, necessary arrangements were done and training program had been revised. Thus problems that may arise during the implementation of the program across the country were eliminated and program became more productive and effective.
TBM implementation process TBM Trainer of Trainers Program was conducted on November 2014 with participation of 494 training instructors from Turkey and 12 training instructors from Turkish Republic of Northern Cyprus and with the help of Ministry of Education to disseminate TBM throughout the country. Candidate training instructors from school counsellors were selected through interviews on a voluntary basis. At the end of this training which is designed as 4 day training program for each dependency area, 102 training instructors for "Addiction" field, 102 training instructors for "Alcohol Addiction" field, 102 training instructors for "Tobacco Addiction" field, 102 training instructors for "Technology Addiction" field and 98 training instructors for "Healthy Living" area were trained. TBM trainers were specialized in one area but also equipped with knowledge and skills for other four other addiction area.
Between March and June 2015, 28.349 school counsellors in whole Turkey were provided in service training including all 5 topics. An 18 hour training program was prepared for training instructors hence they can provide Practitioners Training for school counselors in their district. In this context, 20.000 school counselors throughout Turkey were provided training covering 5 general area of addiction and they were all equipped with knowledge and skills in the fight against addiction. In the trainings, school counsellors were informed about addiction and addiction types. At the end of the 3-day in service training, as being TBM Trainers, it was the school counsellors' responsibility to transfer TBM contents first to students, and then to adults. In the third step of TBM, school counselors who had finished practitioner training are expected to give that training about 5 core areas about addiction to the students at their own schools. Through student training, it is aimed to create awareness and give information about addiction to the target group. First trainings were organized between April and June 2015, and they reached 390.000 students countrywide in a month. TBM dissemination trainings are in progress in the whole country in 2015 -2016 school year. The target is to reach all students at the end of this school year.
Distribution of all published educational materials and assessment tools for required implementation steps performed across the country is carried out by Turkey Green Crescent Society. In every step of this program, implementation process was conducted with continuous information exchange between coordinator training instructors and Turkey Green Crescent Society. Coordinator training instructors report about trainings that are conducted in their cities to Turkey Green Crescent Society on a regular basis. TBM assessment and evaluation tools consist of two sections where knowledge level and perceptional change evaluations are carried out. Within TBM dissemination trainings, assessment and evaluation tools and instructions for use are prepared for primary, secondary and high school, and adult levels. Assessment tools within TBM can be accessed by public at the web site. Teachers download assessment tools from that page and apply it to students. Then they send the tools to Green Crescent via cargo and Green Crescent assess them.
As can be seen from the table (Figure 1 and Figure 2), TBM Training Instructor Training Program and Trainer Training Program pretest and posttest results indicate that there is a significant increase in post-test application [19].
There is still an ongoing testing and evaluation of the program especially about the impact of the study on students.

TBM corporate cooperation model:
TBM Corporate Cooperation Model is created to transfer TBM contend directly to the target group by training occupational group that in direct relationship with the target group ( Figure 3). Hence the scope of the prevention studies is tried to be extended to start a total fight against addiction with cooperation of all institutions and organizations. It is also aimed at ensuring social participation and cooperation through a countrywide social communication campaign by using all channels. There are close cooperation especially with the national and local media representatives.

Results and conclusion
TBM is the first and only national prevention program in Turkey. The content and methodology of implementation and dissemination of TBM was designed both by examining preventive program taking part as successful examples around the world, and by including strategy and principles of preventive programs and "International Standards on Drug Use Prevention" published by United Nations Office on Drugs and Crime (UNODC). On the other hand, program designed as a training   program in accordance with country's needs and socio-cultural properties. In general terms, the program has rich structure including addictions in various areas. The program which has an interactive methodology and spiral structure, was designed as appropriate for age groups from beginning preschool and to adulthood.
Structure with taught-provoking content and visual materials aimed at enhancing information and capacity of both trainers and target groups. It emphasizes that substance addiction is a treatable health problem. All content of implementation has changed into a standard structure. Participation of trainers is based on voluntariness. NGO-Public Body involves coordination and cooperation and public body with integration structure increases sustainability. The program has been continually updated as a result of an up-to-date training program. TBM has met experts' , especially psychological counselors, needs via reliable and rich educational materials for new generation in the studies of fighting against addiction of throughout the country.
The challenges and difficulties faced by TBM is listed below; 4. Conducting the program with school counsellors who have already too many responsibilities related to their job.

Lack of communication between public body units.
6. The attitudes of public bodies which are legally obliged to do these activities.
7. The attitudes of NGOs which work in this field at the local level for years.
8. The support of the political will -ideological approaches to the combat. For long-termed and standard information, entering TBM into curriculum of The Ministry of Education will increase the impact and success of program. However, despite all, TBM has drawn attention as an example of wide scale implementation throughout the country. The program has own assessment and measurement system. Reports for examining effectiveness of ongoing program will clearly show success of TBM. Nevertheless, TBM has become successful to spread all over the country and attained crucial achievement as creating mutual goals with significant institutions and organizations of the country. The program has embraced by institutions and organizations in the district, especially by school counselors. TBM which has been successful to be known and accepted countrywide, is a preliminary preparation for next most important step after itself, Green Crescent Life Skill Training Program. Green Crescent Life Skill Training Program which is currently prepared in a spiral structure and will be grounded on awareness and training created by TBM, is a preventive program based on skills of school and life [20]. In this way, protective and preventive structure based on providing information of TBM and functional structure for acquiring skills and behaviors of LST, will together serve for longitudinal context in structure of formal education. The purpose of the Green Crescent Life Skills Training Program is to prevent tobacco, alcohol, and drug use among children and adolescents. YLST program goals are; to prevent adolescents from starting drug use, to delay the age to start using drugs, to prevent those who have experimented with drugs from becoming regular users, to prevent or curb the risk factors demonstrated to predict drug use; and to enhance protective factors, and reduce risk in the family environment.