Keepin' It REAL in Guatemala City: Testing the Applicability of an Evidence-Based Adolescent Substance Use Prevention Program from the USA

Purpose: This pilot study assessed the efficacy of a linguistically adapted version of keepin’ it REAL (kiREAL), an adolescent substance use prevention program originally developed in the USA, among youth in Guatemala City. The study was a collaboration between a local non-profit in Guatemala and university researchers in the USA, with the goal of assessing the relevance, applicability, and feasibility of evidence-based prevention approaches common in resource rich countries for use in poor, violence-prone neighborhoods of Guatemala’s capital.

Methods: The 676 study participants were 6th graders in 12 public middle schools (secundarias), with seven schools randomized to receive the prevention curriculum and five schools serving as a delayed intervention comparison group. Two successive cohorts of students participated at each school, starting at the beginning of the 2013 or the 2014 academic year. The 6th grade teachers in intervention schools received training over two days, and then delivered the manualized kiREAL lessons over a three-month period. Study outcomes were measures of substance use behaviors, an array of antecedents of substance use and the drug resistance skills targeted in kiREAL, other risk behaviors, and self-esteem. We examined changes from pretest to posttest with pairwise t tests, general linear models, and estimated intervention effects sizes (Cohen’s d). All tests employed full-information maximum likelihood (FIML) estimation in Mplus to account for attrition to the posttest (17%), and a robust maximum likelihood estimator (MLR) to adjust for any non-normalities in distributions.

Results: In the kiREAL group all pretest-to-posttest changes in outcomes were in a desirable direction, toward lower levels of substance use, stronger anti-drug attitudes, more use of drug resistance strategies, less susceptibility to negative peer influences, less frequent antisocial behavior, and better self-esteem.  In contrast, changes in the comparison group were generally in an undesirable direction. Tests using baseline-adjusted general linear models demonstrated significantly better outcomes in the kiREAL group for five outcomes: relatively less use of cigarettes and marijuana than the comparison group, less endorsement of positive drug expectancies, more frequent use of drug resistance strategies, a larger repertoire of strategies, and less negative self-esteem.  Effect sizes were strongest for cigarette use (d=.3) and smaller (d=.2) for other outcomes.

Conclusions: Results of this study suggest that kiREAL’s culturally grounded prevention messages –developed originally for a multicultural USA youth population—and its drug resistance training approach resonate well among Guatemala youth from vulnerable neighborhoods, and provide a promising foundation for implementing effective universal prevention programs for early adolescents.