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

Binational Cultural Adaptation of the keepin' it REAL Substance Use Prevention Program for Adolescents in Mexico

Sharp increases in substance use rates among youth and the lack of evidence-based prevention interventions in Mexico are a major concern. A team of investigators from Mexico and the USA are actively addressing this gap by culturally adapting keepin' it REAL (kiR)-a former US SAMHSA model program-for Mexico. This paper reports on the processes and outcomes of the cultural adaptation of kiR for adolescents in Mexico. Multiple forms of data informed this cultural adaptation, including focus groups with students about gendered and violence experiences with substance use, feedback from teachers who previously implemented the original versions of kiR, lesson fidelity observations, and external expert reviews. The culturally adapted version of kiR integrates Ecological Validity and Cultural Sensitivity Models in the adaptation process. The process encompassed surface structure adaptations, like updating language, graphics, and videos, as well as deep structure adaptation components including cultural norms, attitudes, and beliefs salient among Mexican adolescents. Youth reported receiving alcohol offers from family members, links between substance use and violence, and that shifting gender norms result in more females initiating substance use offers. In adapted kiR activities, students practice navigating substance use offers in these contexts. This approach to cultural adaptation led to a true collaborative between investigators in two countries. This study advances knowledge about how to undertake cultural adaptations of efficacious US-based prevention programs in international settings.

Substance Use Prevention for Urban American Indian Youth: A Efficacy Trial of the Culturally Adapted Living in 2 Worlds Program

This article describes a small efficacy trial of the Living in 2 Worlds (L2W) substance use prevention curriculum, a culturally adapted version of keepin' it REAL (kiR) redesigned for urban American Indian (AI) middle school students. Focused on strengthening resiliency and AI cultural engagement, L2W teaches drug resistance skills, decision making, and culturally grounded prevention messages. Using cluster random assignment, the research team randomized three urban middle schools with enrichment classes for AI students. AI teachers of these classes delivered the L2W curriculum in two schools; the remaining school implemented kiR, unadapted, and became the comparison group. AI students (N = 107) completed a pretest questionnaire before they received the manualized curriculum lessons, and a posttest (85% completion) 1 month after the final lesson. We assessed the adapted L2W intervention, compared to kiR, with paired t tests, baseline adjusted general linear models, and effect size estimates (Cohen's d). Differences between the L2W and kiR groups reached statistically significant thresholds for four outcomes. Youth receiving L2W, compared to kiR, reported less growth in cigarette use from pretest to posttest, less frequent use of the Leave drug resistance strategy, and less loss of connections to AI spirituality and cultural traditions. For other substance use behaviors and antecedents, the direction of the non-significant effects in small sample tests was toward more positive outcomes in L2W and small to medium effect sizes. Results suggest that evidence-based substance use prevention programs that are culturally adapted for urban AI adolescents, like L2W, can be a foundation for prevention approaches to help delay initiation and slow increases in substance use. In addition to study limitations, we discuss implementation challenges in delivering school-based interventions for urban AI populations.

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.

Cultural Adaptation of Interventions in Real Practice Settings

This article provides an overview of some common challenges and opportunities related to cultural adaptation of behavioral interventions. Cultural adaptation is presented as a necessary action to ponder when considering the adoption of an evidence-based intervention with ethnic and other minority groups. It proposes a roadmap to choose existing interventions and a specific approach to evaluate prevention and treatment interventions for cultural relevancy. An approach to conducting cultural adaptations is proposed, followed by an outline of a cultural adaptation protocol. A case study is presented, and lessons learned are shared as well as recommendations for culturally grounded social work practice.

Resisting pressure from peers to engage in sexual behavior: What communication strategies do early adolescent Latino Girls use?

A content analysis of early adolescent (M=12.02 years) Latino girls' (n=44) responses to open-ended questions imbedded in an electronic survey was conducted to explore strategies girls may use to resist peer pressure with respect to sexual behavior. Analysis yielded 341 codable response units, 74% of which were consistent with the REAL typology (i.e., refuse, explain, avoid, and leave) previously identified in adolescent substance use research. However, strategies reflecting a lack of resistance (11%) and inconsistency with communication competence (e.g., aggression, involving authorities) were also noted (15%). Frequency of particular strategies varied according to offer type, suggesting a variety of strategies may be needed to resist the peer pressure that puts early adolescent girls at risk for engaging in sexual behavior. Findings argue for universality of the REAL typology, building communication competence skills for conflict resolution in dating situations, and including peer resistance strategies in adolescent pregnancy prevention programs.

American Indian cultures: how CBPR illuminated intertribal cultural elements fundamental to an adaptation effort

The ever-increasing numbers of ethnic minority populations in the USA seeking social services suggest that a "multicultural paradigm shift" is underway and gaining speed. This shift will increasingly demand that prevention programs and interventions be more culturally responsive. Interventions that are not aligned with prospective participants' world views and experiences are only minimally effective. Existing models for conducting culturally grounded program adaptations emphasize identifying distinct levels of cultural influences while preserving core elements of the original intervention. An effective adaptation requires competent language translation as well as trained translations of program concepts and principles that will be meaningful to the targeted group, without compromising program fidelity. This article describes how a university research team and curriculum developers worked with American Indian youth and adults in a large southwestern city using a CBPR process to identify cultural elements that became foundational to the adaptation of a prevention curriculum that is a national model program, with the objective of increasing its applicability for urban native youth.

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.

Developing empirically based, culturally grounded drug prevention interventions for indigenous youth populations

This article describes the relevance of a culturally grounded approach toward drug prevention development for indigenous youth populations. This approach builds drug prevention from the "ground up" (i.e., from the values, beliefs, and worldviews of the youth that are the intended consumers of the program) and is contrasted with efforts that focus on adapting existing drug prevention interventions to fit the norms of different youth ethnocultural groups. The development of an empirically based drug prevention program focused on rural Native Hawaiian youth is described as a case example of culturally grounded drug prevention development for indigenous youth; the impact of this effort on the validity of the intervention and on community engagement and investment in the development of the program are discussed. Finally, implications of this approach for behavioral health services and the development of an indigenous prevention science are discussed.

Drug offers as a context for violence perpetration and victimization

Drug use has been linked empirically with and aggression and violence among youth in national and State of Hawai'i samples. However, the nature of this link and its implications for prevention are unclear. Therefore, this article explores the intersection of drugs with aggression and violence by using the drug offer context as the unit of analysis. Native Hawaiian youth are sampled because substance use rates tend to be higher and onset tends to be earlier for them than for their non-Hawaiian peers. Fourteen sex-specific focus group discussions were held with rural Native Hawaiian middle school students (N = 64). Students discussed what they think they would do in terms of drug refusal strategies in a variety of drug offer contexts. Although aggression and violence were perceived to be socially inappropriate, students nonetheless felt drug use would be less socially competent. Narrative analyses indicated that aggression and violence were thought to function as potential drug refusal strategies. As proximal drug resistance, aggression and violence perpetration served as an immediate deterrent to the drug offerer and thus drug use. As distal drug resistance, victimization served as a rationale for avoiding drug using contexts. Implications are discussed in terms of prevention policy and practice, specifically in terms of a school-based prevention curriculum. Future research in Hawaiian epistemology and gendered approaches are warranted.