'Keepin' It REAL in Mexico: An Adaptation and Multisite RCT

The need for more effective prevention efforts in Mexico is clear and increasingly urgent, with important ramifications for the US. In the US immigrant adolescents from Mexico historically have had lower drug use rates than US-born Mexican Americans, but these trends are changing rapidly. To fill the gap in evidence-based universal prevention programs in Mexico, this study proposes to adapt, implement, and test the efficacy of kiR-a school-based substance use prevention program in use in the US and several other countries-among a sample of youth from the three largest urban areas in Mexico. This study will directly impact factors influencing sustainability - leadership, capacity, and relationship building. The research team is partnering with Dr. Medina-Mora and the National Psychiatric Institute of Mexico, which oversees substance use prevention nationwide. This study will build long-term relationships with Mexican scientists, educators, government agencies, social workers, and community stakeholders; demonstrate the feasibility of coordinated strategies for implementing school-based prevention programs involving national and local stakeholders; and will increase the capacity of schools and communities to deliver future interventions to additional students.

keepin' it REAL (kiR), a SAMHSA recognized model program on the National Registry of Effective Programs and Practices (NREPP), is a school-based, manualized curriculum for substance use prevention among middle school students. The kiR curriculum includes: 10 weekly classroom lessons; 5 videos demonstrating drug resistance strategies that were scripted, acted and filmed by students; and school-wide booster activities (e.g., replaying the videos) to reinforce the classroom lessons. The curriculum is implemented by regular classroom teachers who receive a two-day long training.

The curriculum includes the mix of elements found to have the largest effect sizes in school-based prevention interventions: those that teach comprehensive life skills to increase knowledge of substance use, address affective and motivational aspects of substance use (e.g., anti-drug attitudes, beliefs and values) and build risk assessment, decision making, and drug refusal skills. kiR emphasizes the mastery and expansion of a repertoire of the drug resistance strategies most commonly and effectively employed by adolescents: to refuse substance offers with a simple "no", to explain or provide an excuse to decline the offer; to avoid situations where substances might be offered; and to leave when substances are offered. kiR teaches a variety of communication techniques to reject risky or undesirable influences, and the flexibility to select appropriately from a repertoire of strategies in different situations. Youths equipped with multiple strategies can assess situations where substances are offered, decide which resistance strategies will be most effective, and try additional strategies (repertoire) if the first one does not work.

There are several reasons the original kiR curriculum is an appropriate foundation for developing efficacious school-based prevention approaches in Mexico: its attention to Mexican American cultural and social contexts of substance use; evidence of the applicability of kiR's core components in Mexico; and its ideal developmental timing for implementation. There are also theoretical and empirical reasons that additional adaptation to the cultural and social contexts of Mexico is needed. The cultural communication patterns of youth and the context of substance use offers needs to be incorporated when adapting it for use in Mexico.

Cross-sectional studies in Mexico show that kiR's core elements and approach are relevant and effective for Mexican youth from different regions. Surveys of Mexican high school youth found that kiR strategies were not only used in Monterrey and in Guanajuato State, but that the use of these strategies is associated with decreased alcohol and tobacco use. A longitudinal randomized pilot field trial of kiR in two Guadalajara middle schools reported significant effects in reducing use of alcohol, cigarette, and marijuana use, but in ways that differed for males and females, suggesting that additional tailoring of the curriculum to gendered substance use cultural and social contexts may be needed.