Drug resistance strategies and substance use among adolescents in Monterrey, Mexico

Keepin' It REAL-Mantente REAL in Mexico: Longitudinal Examination of Youth Drug Resistance Strategies and Substance Use Among Early Adolescents

PURPOSE

This study examined if culturally and linguistically adapted versions of a US-developed adolescent substance use prevention intervention, keepin' it REAL (kiREAL), for Mexico increases the use of drug resistance strategies and if increased use of resistance strategies subsequently leads to a reduction in the frequency of substance use (i.e., alcohol, cigarette, marijuana, and inhalants).

METHODS

Students (N = 5,522, 49% female, age range = 11-17) in 36 middle schools across three cities in Mexico were randomized into three conditions: (1) Mantente REAL (MREAL), the culturally adapted version, (2) kiREAL-S, the linguistically adapted version, and (3) Control. Using survey data collected at four time points, random intercept cross-lagged path analyses tested the direct and indirect effects of MREAL and kiREAL-S compared to Control.

RESULTS

At time 2, the number of drug resistance strategies used by students increased in both MREAL (β = 0.103, p = .001) and kiREAL-S (β = 0.064, p = .002) compared to Control. However, only MREAL lead to less frequent use of alcohol (β = -0.001, p = .038), cigarettes (β = -0.001, p = .019), marijuana (β = -0.002, p = .030), and inhalants (β = -0.001, p = .021) at time 4, mediated through increased use of drug resistance strategies.

DISCUSSION

This study provides evidence that MREAL and kiREAL-S are successful in spurring use of the drug resistance strategies that are the core component of the intervention. Only MREAL achieved long-term effects on substance use behaviors, the ultimate objective of these interventions. These findings provide support for the value and importance of rigorous cultural adaptation of efficacious prevention programs as a necessary condition for enhancing prevention benefits for participating youth.

Using Virtual Reality to Create an Observational Assessment of Adolescent Resistance to Antisocial Peer Pressure

Resistance to antisocial peer pressure consistently relates to adolescent adjustment. However, it is typically measured via a mono-method, self-report approach. The current study introduces a virtual reality (VR) protocol to create an observational measure of adolescents' responses to peer pressure to engage in antisocial activities. Data on the reliability and validity of the assessment procedure are presented. Participants (N = 264, 46% male, M_age = 18.17 years, 81% White) provided self-reports of susceptibility to antisocial peer pressure, antisocial behavior, dating violence perpetration, and depressive symptoms. Participants also engaged in 9 VR simulations, 4 of which involved antisocial peer pressure. Participant behavior in the VR simulations was coded for resistance to antisocial peer pressure. Approximately half the sample repeated the VR simulations at a 2-month follow-up. Resistance to antisocial peer pressure in 4 VR simulations evidenced item/simulation-level convergent validity with one another and discriminant validity against scores in 5 VR bystander behavior simulations. When scores from the 4 antisocial peer pressure VR simulations were summed into a total scale score, they demonstrated acceptable internal consistency, 2-month test-retest correlations, convergent validity with self-reports of susceptibility to antisocial peer pressure, and criterion validity with self-reports of antisocial behavior and dating violence perpetration. Associations with antisocial behavior and dating violence perpetration held after accounting for self-reports of susceptibility to antisocial peer pressure and participant gender. Results provide evidence that VR simulations may offer a psychometrically sound addition to self-report measures as a method for assessing responses to antisocial peer pressure.

Traditional gender roles and substance-use behaviors, attitudes, exposure, and resistance among early adolescents in large cities of Mexico

This study investigated the associations between traditional gender roles (TGRs) and substance use among early adolescents in Mexico's largest cities. The sample of seventh grade students (n = 4,932) attended 26 public schools in Mexico City, Guadalajara, or Monterrey in 2014. Outcomes included recent alcohol, binge drinking, cigarette and marijuana use, and lifetime poly-substance use; substance-use intentions, norms, attitudes, and expectancies; and substance-use exposure (peer use, offers) and resistance (refusal confidence, refusal skills, and decision-making skills). A TGR scale assessed endorsement of a polarized gender division of family labor and power. As hypothesized, among males, TGRs were consistently associated with poorer outcomes, and this association was usually stronger for males than for females. In contrast, among females there was no evidence that TGRs were associated with desirable outcomes. Contrary to expectations, TGRs predicted poorer outcomes for both females and males, and to equivalent degrees, for binge drinking, cigarette use, positive substance-use expectancies, and friends' approval of substance use, and they predicted poorer outcomes for females but not for males on parental disapproval of substance use and drug-resistance skills. Interpretations highlight the persisting aspects of TGRs in the family and conflicting messages for females as Mexico undergoes changes in its gender order.

Drug-Resistance Strategies of Early Adolescents in Mexico: Gender Differences in the Influence of Drug Offers and Relationship to the Offeror

To address increases in substance use among Mexican adolescents, particularly females, US prevention programs are being adapted to the Mexican cultural context. Understanding how responses to substance offers by Mexican adolescents are shaped by gender and relationships to those making offers is an important step in the adaptation process. Using data from Guadalajara, Mexico middle schools (N = 431), this pilot study tested for gender differences in the use of several drug resistance strategies commonly taught in US substance abuse prevention interventions. Results indicated that the drug-resistance strategies of Mexican early adolescents differ by gender, type of substance offered, and the youth's relationship to the offeror. Contrary to previous research on older Mexican adolescents, in this sample, females received more substance offers from age peers than males did, and employed a wider repertoire of drug-resistance strategies, including active strategies such as direct refusals. Gender differences in use of the strategies persisted after controlling for number of offers received. There were gender differences in the conditional effects of greater exposure to offers. A larger volume of alcohol and cigarette offers predicted females' use of direct strategies more strongly than for males, but less strongly than males for marijuana offers. Females' use of drug resistance strategies was more strongly associated with offers from family adults, siblings, and cousins, while males' use of strategies was predicted more strongly by offers from nonfamily adults. Interpretations and prevention implications are discussed in light of changing gender norms in Mexico and gendered patterns of substance use.

Long-term effects of the keepin' it REAL model program in Mexico: substance use trajectories of Guadalajara middle school students

In the face of rising rates of substance use among Mexican youth and rapidly narrowing gender differences in use, substance use prevention is an increasingly urgent priority for Mexico. Prevention interventions have been implemented in Mexico but few have been rigorously evaluated for effectiveness. This article presents the long term effects of a Mexico-based pilot study to test the feasibility of a linguistically specific (Mexican Spanish) adapted version of keepin' it REAL, a school-based substance abuse prevention model program. University affiliated researchers from Mexico and the US collaborated on the study design, program implementation, data collection, and analysis. Students and their teachers from two middle schools (secundarias) in Guadalajara participated in this field trial of Mantente REAL (translated to Spanish). The schools were randomly assigned to treatment and control conditions. The sample of 431 students reported last 30 day substance use at three times (one pretest and two posttests). Changes in substance use behaviors over time were examined using growth curve models. Long term desired intervention effects were found for alcohol and marijuana use but not for cigarettes. The intervention effects were greater for girls than for boys in slowing the typical developmental increase over time in alcohol use. Marijuana effects were based on small numbers of users and indicate a need for larger scale studies. These findings suggest that keepin' it REAL is a promising foundation for cultural program adaptation efforts to create efficacious school-based universal prevention interventions for middle school students in Mexico.

Preadolescent drug use resistance skill profiles, substance use, and substance use prevention

The aims of the current study were threefold: (1) specify the skills component of social influence prevention interventions for preadolescents, (2) examine the relationship between resistance skill profiles and substance use among preadolescents, and (3) evaluate whether subgroups of preadolescents based on their resistance skills and refusal confidence may be differentially impacted by the kiR prevention program. Latent class analysis showed a four-class model of 5th grader resistance skill profiles. Approximately half of preadolescents (53%) were familiar with four prototypical resistance skills and showed confidence to apply these skills in real-world settings (highly competent profile); 15% were familiar with resistance skills but had little confidence (skillful profile); 18% were confident yet had little knowledge (confident profile); while 15% had low knowledge and confidence (low competence profile). These skill profiles significantly predicted 8th grade recent substance use (2LL = -2,262.21, df = 3, p = .0005). As predicted by theory, the highly competent skill profile reported lower mean recent substance use than the population sample mean use. Latent transition analysis showed that although patterns of transiting into the highly competent skill profile over time were observed in the expected direction, this pattern was not significant when comparing treatment and control. Identifying skill profiles that predict recent substance use is theoretically consistent and has important implications for healthy and substance-free development.

Expanding urban American Indian youths' repertoire of drug resistance skills: pilot results from a culturally adapted prevention program

This article examines changes in the drug resistance strategies used by urban American Indian (UAI) middle school students during a pilot test of a substance use prevention curriculum designed specifically for UAI youth, Living in 2 Worlds (L2W). L2W teaches four drug resistance strategies (refuse, explain, avoid, leave [R-E-A-L]) in culturally appropriate ways. Data come from 57 UAI students (53% female; mean age = 12.5 years) who participated in L2W during an academic enrichment class for Native youth at two Phoenix schools. Students completed a pre-test questionnaire before the L2W lessons and a post-test 7 months later. Questions assessed the use of R-E-A-L and alternative strategies commonly reported by UAI youth (change the subject, use humor). Tests of mean differences from pre-test to post-test showed significant increases in use of refuse, explain, and leave, and an expanding R-E-A-L repertoire. Use of more passive strategies (avoid, use humor) did not change significantly, except for change the subject, which increased. Changes in the use of strategies did not differ significantly by gender, age, school grades, parental education, or length of urban residence. The L2W curriculum appears effective in teaching culturally relevant communication strategies that expand UAI youths' repertoire of drug resistance skills.

Drug resistance and substance use among male and female adolescents in alternative secondary schools in Guanajuato, Mexico

OBJECTIVE

Research is limited on the strategies that Mexican adolescents use to resist use of alcohol, cigarettes, and other drugs. Cultural norms and gender socialization patterns concerning the acceptability of use of various substances by women and men influence Mexican youths in their responses to offers of substances. This study explored the drug-resistance strategies used by youth in the central Mexican state of Guanajuato, how their use predicted patterns of substance use, and how these associations differed by gender.

METHOD

The analysis used cross-sectional survey data from 702 (60% male) students enrolled in eight alternative secondary education school sites in 2007. Participants reported the drug-resistance behaviors they used to deal with offers of alcohol, cigarettes, and marijuana. Past-12-month use of the four drug-resistance strategies employed most often by U.S. youth-refuse, explain, avoid, and leave (R.E.A.L.)-and any other strategies were measured. Composite measures of lifetime and recent use of alcohol, cigarettes, and marijuana were predicted in multivariate ordinary least squares regression analyses. Models were tested with and without controls for the frequency that respondents were offered substances and introduced gender interaction effects.

RESULTS

Controlling for substance use offers, more frequent use of a wide repertoire of R.E.A.L. strategies predicted less consumption of alcohol and cigarettes, and using non-R.E.A.L. strategies predicted less marijuana consumption. All of these relationships were either stronger for males than for females or significant for males only.

CONCLUSIONS

Gender differences exist in the impact of R.E.A.L. strategies on substance use among youth in Mexico. Despite a narrowing gender gap in substance use in Mexico, large exposure to and susceptibility of substance use remains. Developing effective prevention programs in Mexico based on teaching appropriate drug-resistance strategies and enhancing communication skills could aid in reducing substance use among Mexican adolescents.

Religiosity and adolescent substance use in central Mexico: exploring the influence of internal and external religiosity on cigarette and alcohol use

This study explores the multidimensional nature of religiosity on substance use among adolescents living in central Mexico. From a social capital perspective, this article investigates how external church attendance and internal religious importance interact to create differential pathways for adolescents, and how these pathways exert both risk and protective influences on Mexican youth. The data come from 506 self-identified Roman Catholic youth (ages 14-17) living in a semi-rural area in the central state of Guanajuato, Mexico, and attending alternative secondary schools. Findings indicate that adolescents who have higher church attendance coupled with higher religious importance have lower odds of using alcohol, while cigarette use is lower among adolescents who have lower church attendance and lower religious importance. Adolescents are most at risk using alcohol and cigarettes when church attendance is higher but religious importance is lower. In conclusion, incongruence between internal religious beliefs and external church attendance places Mexican youth at greater risk of alcohol and cigarette use. This study not only contributes to understandings of the impact of religiosity on substance use in Mexico, but highlights the importance of understanding religiosity as a multidimensional phenomenon which can lead to differential substance use patterns.

Gender differences in drug resistance skills of youth in Guanajuato, Mexico

Research is limited or absent on Mexican adolescents' exposure to substance offers, ways of dealing with these offers, and possible gender differences in responses to offers. Extending U.S.-based research, this study examines how youth living in the Mexican state of Guanajuato employ the four drug resistance strategies-refuse, explain, avoid, and leave-that are part of the Keepin' It REAL evidence-based drug prevention intervention. The analysis uses cross-sectional survey data from 702 students enrolled in eight alternative secondary education sites in 2007. Participants reported the drug resistance behaviors they used to deal with offers of alcohol, cigarettes, and marijuana. Using multivariate regression, findings indicate most youth had developed repertoires of drug resistance strategies that involved multiple REAL strategies and some other strategy as well. For those receiving offers, the most common strategy was to refuse the offer with a simple "no." However, males used all the strategies significantly more often than females for situations involving cigarettes and marijuana as well as when using refuse and non-REAL strategies for alcohol. Possible reasons for the gender difference in use of strategies are discussed. The findings can help inform effective prevention programs based on teaching culturally appropriate drug resistance and communication skills.

Preferred drug resistance strategies of urban American Indian youth of the southwest

This study explored the drug resistance strategies that urban American Indian adolescents consider the best and worst ways to respond to offers of alcohol, cigarettes, and marijuana. Focus group data were collected from 11 female and 9 male American Indian adolescents attending urban middle schools in the southwest. The youth were presented with hypothetical substance offer scenarios and alternative ways of responding, based on real-life narratives of similar youth. They were asked to choose a preferred strategy, one that would work every time, and a rejected strategy, one they would never use. Using eco-developmental theory, patterns in the preferred and rejected strategies were analyzed to identify culturally specific and socially competent ways of resisting substance offers. The youth preferred strategies that included passive, non-verbal strategies like pretending to use the substance, as well as assertive strategies like destroying the substance. The strategies they rejected were mostly socially non-competent ones like accepting the substance or responding angrily. Patterns of preferred and rejected strategies varied depending on whether the offer came from a family member or non-relative. These patterns have suggestive implications for designing more effective prevention programs for the growing yet underserved urban American Indian youth population.

Migration intentions and illicit substance use among youth in central Mexico

This study explored intentions to emigrate and substance use among youth (ages 14-24) from a central Mexico state with high emigration rates. Questionnaires were completed in 2007 by 702 students attending a probability sample of alternative secondary schools serving remote or poor communities. Linear and logistic regression analyses indicated that stronger intentions to emigrate predicted greater access to drugs, drug offers, and use of illicit drugs (marijuana, cocaine, inhalants), but not alcohol or cigarettes. Results are related to the healthy migrant theory and its applicability to youth with limited educational opportunities. The study's limitations are noted.

Strategies to resist drug offers among urban American Indian youth of the southwest: an enumeration, classification, and analysis by substance and offeror

This study explores the drug resistance strategies of urban American Indian adolescents when they encounter people offering them alcohol, cigarettes, and marijuana. Data were collected in 2005 from 11 female and 9 male adolescents who self-identified as American Indian and attended two urban middle schools in the southwestern United States. In two focus groups-one at each school site-the youth described their reactions to 25 hypothetical substance offer scenarios drawn from real-life narratives of similar youth. Qualitative analysis of their 552 responses to the scenarios generated 14 categories. Half of the responses were strategies reported most often by nonnative youth (refuse, explain, leave, and avoid). Using ecodevelopmental theory, the responses were analyzed for indications of culturally specific ways of resisting substance offers, such as variation by specific substance and relationship to the person offering. Study limitations are noted along with suggestive implications for future research on culturally appropriate prevention approaches for urban American Indian youth.

Exploring Culturally Specific Drug Resistance Strategies of Hawaiian Youth in Rural Communities

This qualitative study examined the drug resistance strategies of Hawaiian youth residing in rural communities in Hawai`i. Forty seven youth participated in 14 focus groups which focused on the social and environmental context of drug use for these youth. The findings indicated that there were 47 references to resistance strategies used in drug offer situations. These strategies fell within two different categories: (1) overt/confrontational drug resistance strategies, and (2) non-confrontational drug resistance strategies. These strategies occurred within the community context of relational networks of ascribed and biological family members, and differed in frequency of use by gender. Implications for culturally grounded drug prevention programs for rural Hawaiian youth are discussed.

Assessing adolescents' anticipated behavioral and emotional responses to offers of alcohol and marijuana

The Adolescent Responses to Alcohol and Drug Offers Scale (ARADOS) is a self-report questionnaire designed to assess a respondent's anticipated emotional reactions and intended use of cognitive-behavioral refusal skills in response to an offer of alcohol or other drug. A sample of 267 students enrolled in the 11th and 12th grades of four public high schools located in northwest Ohio completed four versions of the ARADOS. Factor analyses of the 27 listed resistance responses suggested five clusters of items comprising internally consistent though inter-correlated subscales (Inform others, Aggression, Verbal or nonverbal refusal, Deflection, Deception). Psychometric analyses revealed that ARADOS subscale scores often differed significantly as a function of drug type (alcohol or marijuana) and offerer (close friend or acquaintance), that resistance scores were generally consistent with participants' pre-existing decision to accept or reject offers of alcohol or marijuana, and that anticipated use of resistance responses was significantly correlated with resistance responses used in the past. The ARADOS is a relatively short, easily-scored, contextually-sensitive, self-administered questionnaire that could be used to evaluate education/prevention programs (and clinical interventions) designed to enhance adolescents' refusal of alcohol and drugs.