Adolescent substance-use prevention and legalization of marijuana in Uruguay: A feasibility trial of the keepin’ it REAL prevention program

Types of Offers of Combustible Cigarettes, E-Cigarettes, and Betel Nut Experienced by Guam Youths

The present study examined types of scenarios in which Guam youths are offered tobacco-namely, combustible cigarettes and e-cigarettes-and betel (areca) nut. We conducted 10 focus groups with public middle school students (n = 34) from Guam. Results suggested that the types of offer scenarios of combustible cigarettes, e-cigarettes, and betel nut referenced by the students fall into two categories-direct-relational offers and indirect-contextual offers. The results also suggested that both categories of offer scenarios were more likely to occur in school rather than in other locations such as the home. Family members were more likely to make offers than other types of people. Indirect-contextual offers were more easily avoidable depending on the substance offered, the location where the offer took place, and the person making the offer. Based on the findings, we provide brief suggestions on developing a school-based prevention curriculum focused on training young adolescents from Guam on ways to resist offers of cigarettes, e-cigarettes, and betel nut.

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.

Social Validity in Spain of the Mantente REAL Prevention Program for Early Adolescents

Studies focusing on the relevance or impact of a program, not just on its efficacy or effectiveness, can make important contributions to prevention science. This article documents the social validity (i.e., a construct encompassing feasibility, acceptability, and utility) of a universal substance use prevention program for early adolescents in Spain. The Mantente REAL (keepin’it REAL) program was culturally adapted to the Spanish context, implemented, and evaluated in six public middle schools in two regions of Spain. Participating teachers (N = 15), students (N = 354), and research team members (N = 6) reported on the feasibility, acceptability, and utility of the program implemented with first grade secondary school students. Qualitative and quantitative data about the program, its curriculum, and the implementation process were collected through teachers’ focus groups, students’ surveys, and observation forms completed by members of the research team. Mantente REAL was perceived to be a prevention program that was feasible for implementation in Spanish middle schools, although some logistics related to school structural constraints should be addressed in future implementations. The topics and activities in the curriculum were highly accepted by teachers and students, and they reported that the program was useful in teaching resistance strategies to cope with substance use and other risky situations. The findings support the social validity of the culturally adapted Mantente REAL program for early adolescents in Spain, and highlight how feedback from stakeholders involved in the implementation can improve the dissemination of effective prevention approaches.

The Feasibility, Acceptability, and Utility of Mantente REAL: the Culturally Adapted Version of keepin' it REAL for Mexico

A binational team of investigators culturally adapted, implemented, and tested the efficacy in Mexico of keepin' it REAL, a US-designed prevention intervention for youth. This article reports on the social validity of the adapted intervention by assessing its feasibility, acceptability, and utility, as perceived by participating middle school students, teachers/implementers, and school administrators. Middle schools (N = 36) were randomly assigned to (1) the culturally adapted version for Mexico (Mantente REAL), (2) the original intervention from the USA (keepin' it REAL) translated into Spanish, or (3) a control condition (treatment as usual). Adult and child feedback about the adapted and original versions of the intervention indicate that both are feasible to implement in the Mexican context. Implementation fidelity was equally high for both versions of the manualized intervention. Students, however, were more satisfied with the culturally adapted version than with the non-adapted version. They reported gaining more knowledge, finding it more acceptable, applicable, and authentic, and they reported discussing the program with their family and friends more often. The findings support the feasibility of engaging classroom teachers to implement manualized prevention programs in Mexico. These findings also advance prevention science by documenting the importance of cultural adaptation as a means to increase students' identification with and acceptability of efficacious school-based interventions. The article discusses the practice, policy, and future prevention research implications of the findings for Mexico and their potential generalizability to other middle- and lower-income countries.

Keepin' It REAL-Mantente REAL in Mexico: a Cluster Randomized Controlled Trial of a Culturally Adapted Substance Use Prevention Curriculum for Early Adolescents

This study assesses the efficacy of a version of the keepin' it REAL (kiREAL) substance use prevention curriculum for middle school students that was culturally adapted for Mexico, renamed Mantente REAL (MREAL), and tested in a cluster randomized controlled trial in Mexico's three largest cities. Student participants were in 7th grade in public middle schools (N = 5523, 49% female, mean age = 11.9). A representative sample of 12 schools from each city, stratified by whether they held morning or afternoon sessions, was randomized to three conditions: culturally adapted MREAL, original kiREAL translated into Spanish, or a treatment-as-usual control group. Regular classroom teachers were trained to deliver the adapted MREAL or the kiREAL manualized curricula. Students with active parental consent completed pretest and post-test questionnaires, 7-8 months apart, at the beginning and end of the 2017-2018 academic year. We assessed the MREAL intervention, relative to kiREAL and controls, with general linear models adjusted for baseline, attrition (24%), non-normal distributions, stratification by city, and school-level clustering. Among students already using the substance more often at pretest, MREAL students had relatively more desirable outcomes, compared to kiREAL and/or to controls, in recent use of alcohol, cigarettes, "hard drugs," heavy episodic drinking, and intoxication. MREAL students reported relatively less violence victimization and perpetration of bullying and relatively more use of three of the intervention's REAL drug resistance strategies (Explain, Avoid, Leave). The adapted version of kiREAL for Mexico showed numerous desired outcomes in areas deliberately targeted in the cultural adaptation. Full protocol can be accessed through Clinical Trials.gov. ID: NCT03233386, "'Keepin' It REAL in Mexico: An adaptation and multisite RCT".

Testing a Culturally Adapted Youth Substance Use Prevention Program in a Mexican Border City: Mantente REAL

Background: This article reports on a test of a youth substance use prevention program conducted in Nogales-Sonora, a Mexican city on the US border. Objective: The study tested the efficacy of a version of the keepin' it REAL curriculum for middle school students that was culturally adapted for Mexico and renamed Mantente REAL. Methods: Students in 7th grade classrooms in four public schools participated in the study (N = 1,418, 49% female, mean age = 11.9). Using a clustered randomized design, two schools received the intervention and two served as a treatment-as-usual control group. Regular classroom teachers were trained to deliver the twelve-lesson Mantente REAL manualized curriculum. Parents provided active consent and students gave written assent to collect pretest and posttest questionnaire data, 7 months apart, at the beginning and end of the 2017-2018 academic year. We assessed the Mantente REAL intervention with general linear models adjusted for baseline, attrition, non-linear distributions, and school-level clustering. Results: Students who participated in Mantente REAL reported relatively less frequent use of alcohol and illicit drugs other than marijuana, compared to students in control schools. Males alone reported desirable intervention effects for marijuana use. These desirable effects were especially strong among students who reported higher initial levels of involvement in risky behaviors. Among students more at risk, both females and males receiving the program reported relative reductions in the frequency of use of alcohol and illicit drugs. Conclusions: These promising results within the Mexico-US border context support a further dissemination of the intervention and additional youth prevention research in the region.

Testing the keepin' it REAL Substance Use Prevention Curriculum Among Early Adolescents in Guatemala City

This article describes a test in Guatemala City of Mantente REAL, a linguistically adapted version of the keepin' it REAL universal substance use prevention curriculum for early adolescents that teaches culturally grounded drug resistance, risk assessment, and decision making skills. Academic researchers collaborated with a local non-profit to recruit and randomize 12 elementary schools in Guatemala City to intervention and comparison conditions. Regular classroom teachers were trained to deliver the ten-lesson Mantente REAL (MR) manualized curriculum to sixth-grade students. Parents provided passive consent and students gave active assent for data collection, which occurred between February 2013 and September 2014. Two academic year cohorts of students participated (n = 676; 53% male; M age = 12.2). All students completed a pretest questionnaire before the curriculum lessons began in intervention schools and a posttest (87% matched) 4 months later, 1 month after the final lesson. We assessed the MR intervention with paired t tests, effect sizes (Cohen's d), and general linear models adjusted for baseline, attrition, non-linear distributions, and school-level clustering. Results indicated that MR can be an effective school-based prevention approach in Guatemala. The MR participants reported pretest-to-posttest changes in desirable directions on substance use behaviors, attitudinal antecedents of substance use, and acquisition of drug resistance skills. The comparison group generally changed in undesirable directions. In linear models, the MR participants, relative to the comparison group, reported less cigarette and marijuana use, less positive drug use expectancies, and greater use of drug resistance skills. Intervention effect sizes were between .2 and .3.

The Intersection of Men's Sexual Violence Perpetration and Sexual Risk Behavior: A Literature Review

According to the Confluence Model of Sexual Violence, men with a strong impersonal sex orientation (i.e., greater engagement in sexual activities with more casual sexual partners) are at increased risk of perpetrating sexual violence. Research from a variety of countries and samples has supported this proposition, finding that men who perpetrate sexual violence are also more likely to engage in risky sexual behavior. The present article reviews this literature, synthesizing research findings from both psychology and public health domains utilizing both domestic and international samples. In particular, this review focuses on the associations between men's perpetration of sexual violence and their sexual partners, condom use, and sexually transmitted infection status, as well as provides recommendations for future research directions and prevention and intervention programming.