Keepin’ It Real (Mantente REAL) in Mexico: Short-Term RCT Effects of a USA Substance Use Prevention Program Culturally Adapted for Middle Schools in Mexico’s Three Largest Cities

Purpose: Despite sharp increases in substance use rates among its youth and a narrowing gender gap, Mexico has few school-based universal prevention programs that are culturally grounded and evidence-based. Funded by a NIDA R01, a bi-national team of researchers from four universities addressed this gap by culturally adapting the keepin’ it REAL (kiR) prevention intervention, and testing it in an RCT in Mexico’s largest cities. KiR is a prevention program for middle school students shown to be efficacious and cost-effective in reducing substance use among large multi-ethnic and Mexican American samples in the USA. The multiphase adaptation process refashioned kiR’s core prevention elements and accompanying videos—training in drug resistance, risk assessment, and communication skills—to address gender differences in exposure to substances in Mexico and common connections between violence and substance use. This presentation focuses on tests of the short-term intervention effects in the areas targeted by the adaptation: use of an expanded set of specific drug resistance skills and effects on violence perpetration.

Methods: Local research teams in Mexico City, Guadalajara, and Monterrey recruited a stratified probability sample of 36 middle schools, 12 in each city. We randomized schools to three conditions: Culturally adapted kiR (kiR-A), Original kiR translated into Spanish (kiR-O), and a Control condition with treatment as usual. Regular teachers were trained over two days to implement the kiR-A and kiR-O curricula to their students over 3-4 month period. All students with parental consent completed pretest and posttest questionnaires during the 2017-2018 school year (n=5,524 at pretest). The relative effectiveness of kiR-A versus both kiR-O and Controls was analyzed through baseline adjusted regression models in Mplus using FIML estimation to adjust for attrition (24%) and accounting for school-level random effects.

Results: Compared to kiR-O and to Controls, kiR-A students reported relatively more use of the central kiR drug resistance strategies from pretest to post-test (Explain why you decline a drug offer, Leave the situation, Avoid drug offers) as well as closely related alternatives used in Mexico (Change the subject, Ignore the offer). KiR-A students also reported using an expanding repertoire of different drug resistance skills. In addition, kiR-A students reported relative declines in perpetrating bullying and aggression, compared to kiR-O and controls. The direction of relative changes in recent use of alcohol, cigarettes and marijuana showed more desirable trends for kiR-A than for kiR-O or controls, but these effects were non-significant.

Conclusions: The culturally adapted version of kiR for Mexico produced expanding use of effective drug resistance strategies and less reliance on bullying in the short-term, areas deliberately targeted in the cultural adaptation. Longer-term tests may be needed to show significant effects on substance use behaviors.