This culturally focused youth drug-prevention program is designed to increase resistance skills. The program is rated Promising. The treatment group reported less alcohol and marijuana use 14 months after the intervention. There were no differences in substance resistance strategies, descriptive norms, or intent to accept and self-efficacy. Over time, the control group had more positive views of substance use. The type of cultural version used had an impact on personal norms and substance use.
The keepin’ it REAL program is a video-enhanced intervention that uses a culturally grounded resiliency model to incorporate traditional ethnic values and practices that protect against drug use. The goal is to teach students how to resist substance use through practical, easy-to-remember and -use strategies that are embodied in the acronym REAL (Refuse, Explain, Avoid, Leave).
The curriculum was originally targeted at middle school adolescents in the urban Southwest who were considered at risk of substance use because of poverty and other factors such as immigration status, English acquisition, and acculturation stress. The program was designed to intervene with students before they began to engage in risky behaviors, such as alcohol and other drug experimentation. Although keepin’ it REAL was originally designed as a school-based prevention program for middle school students, it has been implemented with youths ages 11 through 18.
keepin’ it REAL is based on previous work demonstrating that teaching communication and life skills can combat the influence of negative peers and other negative influences (Tobler et al. 2000). The program extends resistance- and life-skills models by using a culturally based narrative and performance framework to enhance antidrug norms and attitudes and facilitate the development of risk assessment, decision-making, problem-solving, and resistance skills. The program is culturally grounded because earlier research shows that the most successful substance use prevention programs reflect aspects of the adolescent’s culture and learning style (Kandel 1995).
Key components of the program draw on numerous theoretical perspectives, including Communication Competence Theory, Narrative Theory, the Focus Theory of Norms, and Ecological Risk and Resiliency. These different perspectives are connected to cultural values and norms which provide a basis for the content and structure of the curriculum.
The program teaches youths to live drug-free lives by building on their existing cultural and communication strengths and the strengths of their families and communities. Using keepin’ it REAL strategies, students learn how to recognize risk, value their perceptions and feelings, embrace their cultural values (e.g., avoiding confrontation and conflict in favor of maintaining relationships and respect), and make choices that support them.
The curriculum includes 10 sequential lessons to be taught in class over a 2- to 3-month period. The curriculum has six core elements: 1) communication competence and ethnic variations thereof; 2) narrative-based knowledge to enhance identification with the prevention message; 3) different types of social norms (personal, injunctive, and descriptive) as motivators in substance use; 4) social learning of life skills and their key role in risk assessment and decision-making; 5) drug-resistance strategies most commonly and effectively employed by adolescents; and 6) the local social context.
Distinct Mexican American, non-Latino, and multicultural versions of keepin’ it REAL were developed so students could recognize themselves in the prevention message and see solutions that are sensitive to their unique cultural environments:
This culture-centered version was created with a concentration on Latino values such as familismo (family orientation), respeto (respect), personalismo (personal treatment), and simpatía (sympathy). For example, in lesson 1 of the Mexican American curriculum, the objective is for the student to recognize that what he or she does affects his or her community, group, and family and to differentiate between simple preference and “wise choice”—a choice that is honorable and can be respected.
This version is a mainstream curriculum, taking values such as goal orientation and individualism from white and African–American culture. For example, in lesson 1 of the black/white curriculum, the objective is for the student to recognize that what he or she does may have favorable or unfavorable consequences on his or her future goals and to differentiate between simple preference and wise choice.
This version was developed by incorporating five lessons from each of the Mexican American and non-Latino versions.
Although all four resistance strategies (Refuse, Explain, Avoid, and Leave) are taught in each version of the curriculum, some strategies receive more stress in one version than in the other. For example, “Explain” is stressed more in the Mexican American version, because explaining confirms cultural values about the importance of dealing with others in a respectful, nonconfrontational manner rather than outright refusal that may seem more disrespectful within the Mexican American culture.
Recent Substance Use
Hecht and colleagues (2003) found that over time the use of alcohol, cigarettes, and marijuana increased for both the intervention group who received the keepin’ it REAL curriculum and the control group. However, the increase was significantly less for intervention students. By wave 4 (14 months after the intervention), intervention group students were reporting significantly less use of alcohol and marijuana, but there was no significant difference in cigarette use.
At wave 2 (2 months after the intervention), intervention group students reported adopting more strategies used to resist marijuana and cigarettes than did control group students. However, by wave 4, no significant group differences emerged.
Intent to Accept and Self-Efficacy
The intervention had no significant impact on students’ intent to accept alcohol, tobacco, and other drug (ATOD) offers or on student confidence in resisting such offers (self-efficacy) at any of the follow-up periods.
The control group students reported significantly greater increases in positive expectations regarding alcohol, cigarette, and marijuana use at waves 3 and 4. This means that over time the control group students had more positive views of substance use, compared with the intervention students.
Overall, there were no significant differences in the degree of change in intervention and control group students’ reports of their parents’ or friends’ anti–ATOD injunctive norms over the follow-up periods. However, at waves 2 and 3, intervention students reported significantly less erosion in their attitudes against someone their age using substances (although this difference disappeared by wave 4). Also, across all three follow-up periods, intervention students reported perception of their peers’ substance experimentation and use increased significantly less than among control students (descriptive norms).
The Mexican American and multicultural versions of the curriculum both affected personal norms and alcohol and marijuana use. Students who received the Mexican American version performed significantly better than control students on cigarette use, self-efficacy, intentions to accept ATOD offers, and descriptive norms. Students who received the multicultural version performed significantly better on resistance strategies, positive substance use expectancies, and friend’s injunctive norms. However, the non-Latino (black/white) version of the curriculum had a significant impact only on students’ alcohol use and did not have an impact on any other measure.
The keepin’ it REAL evaluation conducted by Hecht and colleagues (2003) looked at program effectiveness at participating public schools in Phoenix, Ariz. The study was conducted over 4 time periods: wave 1 was baseline/preintervention; wave 2 was approximately 2 months after the completion of the intervention; wave 3 was 8 months after intervention completion; and wave 4 was 14 months after intervention completion.
Year 1 of the evaluation stratified 35 sample middle schools by enrollment and ethnicity and used block randomization to assign to one of four conditions: the Mexican American version of the curriculum, the non-Latino (black/white) version of the curriculum, the multicultural version of the curriculum, or the control. Year 2 administered a preintervention questionnaire to all participants (wave 1), implemented the curriculum in seventh grade classes in treatment schools, and followed this with a wave 2 postintervention questionnaire. Teachers used English or Spanish materials (or both), available with each version. During the summer, a bilingual television public service announcement and outdoor billboard campaign was conducted. Year 3 delivered school-based booster sessions with students in the treatment schools and administered follow-up questionnaires (wave 3) and final questionnaires (wave 4) to students in all schools.
The study sample consisted of 3,318 Mexican or Mexican American students (47 percent female), 1,141 students of other Latino or multiethnic Latino origin (e.g., Mexican and white, Mexican and American Indian; 50 percent female), 1,049 non-Hispanic white students (48 percent female), and 527 African American students (44 percent female). Students ranged in age from 11 to 18, with an average of 12.53 years of age at wave 1. A large proportion of the students spoke Spanish as their native language. In fact, about 10 percent of all participating students chose to complete the study questionnaire in Spanish, about 10 percent specified they speak mostly Spanish with their friends, and 13 percent stated they speak mostly or only Spanish with their families.
The questionnaires used a three-form design that employed planned “missingness” to limit the number of items each individual student received in the questionnaire, while maximizing the total number of items included for analysis. At each wave, students responded to the items used to obtain information about behavioral and psychosocial variables, including recent alcohol, cigarette, and marijuana use; resistance strategies; self-efficacy; intentions to accept substances; positive expectations; and norms. The questionnaire assessed how much (amount) and how often (frequency) students drank alcohol, smoked cigarettes, and smoked marijuana in the past 30 days. Resistance strategies were measured by students’ response to three items for each substance (alcohol, cigarettes, and marijuana). Students received one point for each strategy they indicated that they used (such as “just saying no”). Self-efficacy was assessed through three items measuring the students’ confidence in saying no to alcohol, tobacco, and other drug (ATOD) offers. A three-item measure assessed students’ intentions to accept offers of ATOD. Positive substance use expectancies represented the students’ perceptions of the positive consequences of substance use. Finally, the Focus Theory of Norms was used to identify and measure three types of norms: personal (what the individual thinks is right or wrong); injunctive (what the individual believes that others think is right or wrong); and descriptive (how many of their peers use drugs).
The analyses of outcomes include generalized estimating equations and marginal regression models. The models used to assess treatment impacts included condition and time main effects, and the condition x time interaction. Instead of conducting an omnibus test of the interaction, the study used single-degree-of-freedom contrasts to test mean differences among treatments at each follow-up time point.
Prices for a set of keepin’ it REAL curriculum materials range from $269 to $580. Curriculum materials can be purchased from the ETR Associates Web site (please see Additional References for a link).
The keepin’ it REAL curriculum set includes the following materials:
- Teacher guide
- Student books
- Drug facts pamphlets and posters
- Spanish-language materials
Curriculum materials can be purchased from the ETR Associates Web site (please see Additional References for a link).
Evidence-Base (Studies Reviewed)
These sources were used in the development of the program profile:Study 1Hecht, Michael L., Flavio Francisco Marsiglia, Elvira Elek, David A. Wagstaff, Stephen Kulis, Patricia A. Dustman, and Michelle Miller–Day. 2003. “Culturally Grounded Substance Use Prevention: An Evaluation of the keepin’ it R.E.A.L. Curriculum.” Prevention Science 4(4):233–48.
These sources were used in the development of the program profile:Elek, Elvira, David A. Wagstaff, and Michael L. Hecht. 2010. “Effects of the Fifth and Seventh Grade Enhanced Versions of the keepin’ it REAL Substance Use Prevention Curriculum.” Journal of Drug Education 40(1):61–79.ETR Associates. 2012. “Home.” http://www.etr.org/home Harthun, Mary L., Patricia A. Dustman, Leslie J. Reeves, Flavio Francisco Marsiglia, and Michael L. Hecht. 2009. “Using Community-Based Participatory Research to Adapt keepin’ it REAL: Creating a Socially, Developmentally, and Academically Appropriate Prevention Curriculum for Fifth Graders.” Journal of Alcohol and Drug Education 53(3):12–38.Hecht, Michael L., Elvira Elek, David A. Wagstaff, Jennifer A. Kam, Flavio Francisco Marsiglia, Patricia A. Dustman, Leslie J. Reeves, and Mary L. Harthun. 2008. “Immediate and Short-Term Effects of the Fifth Grade Version of the keepin’ it REAL Substance Use Prevention Intervention.” Journal of Drug Education 38(3):225–51.Hecht, Michael L., John W. Graham, and Elvira Elek. 2006. “The Drug Resistance Strategies Intervention: Program Effects on Substance Use.” Health Communication 20(3):267–76.Kandel, Denise B. 1995. “Ethnic Differences in Drug Use: Patterns and Paradoxes.” In Gilbert J Botvin, Steven Schinke, and Mario A. Orlandi (eds.). Drug Abuse Prevention With Multiethnic Youth. Thousand Oaks, Calf.: Sage.Kulis, Stephen, Tanya A. Nieri, Scott T. Yabiku, Layne K. Stromwall, and Flavio Francisco Marsiglia. 2007. “Promoting Reduced and Discontinued Substance Use Among Adolescent Substance Users: Effectiveness of a Universal Prevention Program.” Prevention Science 8:35–49.Kulis, Stephen, Scott T. Yabiku, Flavio Francisco Marsiglia, Tanya A. Nieri, and Ashley Crossman. 2007. “Differences by Gender, Ethnicity, and Acculturation in the Efficacy of the keepin’ it REAL Model Prevention Program.” Journal of Drug Education 37(2):123–44.Marsiglia, Flavio Francisco, Stephen Kulis, Scott T. Yabiku, Tanya A. Nieri, and Elizabeth Coleman. 2011. “When to Intervene: Elementary School, Middle School, or Both? Effects of keepin’ it REAL on Substance Use Trajectories of Mexican Heritage Youth.” Prevention Science 12:48–62.Tobler, Nancy S., Michael R. Roona, Peter Ochshorn, Diana G. Marshall, Andrei V. Streke, and Kimberly M. Stackpole. 2000. “School-Based Adolescent Drug Prevention Programs: 1998 Meta-Analysis.” Journal of Primary Prevention 20(4):275–336.Warren, Jennifer R., Michael L. Hecht, David A. Wagstaff, Elvira Elek, Khadidiatou Ndiaye, Patricia A. Dustman, and Flavio Francisco Marsiglia. 2006. “Communicating Prevention: The Effects of the keepin’ it REAL Classroom Videotapes and Televised PSAs on Middle School Students’ Substance Use.” Journal of Applied Communication Research 34(2):209–27.Yabiku, Scott T., Stephen Kulis, Flavio Francisco Marsiglia, Ben Lewin, Tanya A. Nieri, and Syed Hussaini. 2007. “Neighborhood Effects on the Efficacy of a Program to Prevent Youth Alcohol Use.” Substance Use & Misuse 42:65–87.