When transferring an evidence-based programme across national frontiers, a simple language translation may not be enough. Results from a substance use prevention programme in Mexico suggest that wider cultural adaptations are necessary to maximise effectiveness.
The importance of taking cultural differences into account is reinforced by the report from a pilot study where American researchers translated their Keepin’ it REAL intervention for Hispanic American young people for use across the border in Mexico. Although results from a randomised controlled trial involving two schools in the city of Guadalajara showed promise, there was evidence to suggest they could have been better if a comprehensive cultural adaptation had been made.
After they completed Manténte REAL, the programme translated into Spanish, five classrooms of 7th grade students (average age 13) at one of the schools showed no significant self-reported changes in the frequency of their alcohol consumption or cigarette use. However, the control group of non-participating peers at the other school reported increases, making differences between the two groups statistically significant.
While the “dampening” effect observed on the frequency of substance use was a promising outcome, it fell short of stronger, more consistently positive effects when the Keepin’ it REAL curriculum was evaluated ten years earlier in Arizona.
In addition, when results from the Mexican pilot were split by gender, the statistically significant treatment effects remained for female participants but not males. This suggested that the programme’s positive impact depended on substance use changes made by girls.
Interactive lessons as part of the Keepin’ it REAL curriculum seek to increase young people’s ability to resist offers of alcohol, tobacco and illegal drugs while promoting anti-substance attitudes and norms of behaviour. REAL is an acronym for “Refuse”, “Explain”, “Avoid” and “Leave”, reflecting the emphasis on modeling a repertoire of communication techniques for rejecting undesirable influences.
Focus groups held with students and teachers who had implemented the programme provided further, qualitative, evidence that a more careful cultural adaptation might have improved its impact, especially among boys. For example, videos used to promote strategies for resisting peer pressure had been dubbed, but Mexican students said they found the American-accented Spanish distracting and did not identify with some of the scenarios being presented.
In addition, the average class size in the American schools where Keepin’ it REAL was tested had been 25. This compared with around 50 in the Mexican schools, making the curriculum’s small group activities more challenging for teachers. Access to technology and equipment also inhibited teachers' efforts to deliver the curriculum as originally developed.
The researchers note that societal norms in relation to alcohol are more lenient in Mexico than the United States and that increasing concerns are being expressed about problem drinking among Mexican young people. Reported use of illicit drugs by young people is low, but 9 per cent of young people are active smokers, with boys more likely to smoke than girls.
In that context, the researchers argue that the pilot study results are encouraging enough to conclude that the core components of Keepin’ it REAL offer an effective tool for teaching drug resistance strategies in Mexican schools. Nevertheless, they accept that more extensive cultural adaptation may be needed and that a simple translation into Spanish was not enough. Including examples and scenarios relating to the day-to-day experiences and cultural norms of Mexican young people would be an obvious first step.
These are issues that resonate beyond the immediate question of whether Keepin’ it REAL is a suitable programme for replication in Mexico. Programme providers, service planners and researchers around the world can learn from its conclusions about the importance of matching evidence-based interventions that are being imported to local cultures.
Marsiglia, F.F., Booth, J.M., Ayers, S.L., Nuño-Gutierrez, B.L., Kulis, S. & Hoffman, S. (2013). Short-term effects on substance use of the Keepin’ It REAL pilot prevention programme: linguistically adapted for youth in Jalisco, Mexico. Prevention Science. DOI: 10.1007/s11121-013-0421-7.
Hecht, M.L., Marsiglia, F.F., Elek, E., Wagstaff, D.A., Kulis, S., Dustman, P. et al. (2003) Culturally grounded substance use prevention: An evaluation of the Keepin’ it REAL curriculum. Prevention Science, 4, 233-248.Return to Features