Keepin' It REAL-Mantente REAL in Mexico: Longitudinal Examination of Youth Drug Resistance Strategies and Substance Use Among Early Adolescents.

PURPOSE: This study examined if culturally and linguistically adapted versions of a US-developed adolescent substance use prevention intervention, keepin' it REAL (kiREAL), for Mexico increases the use of drug resistance strategies and if increased use of resistance strategies subsequently leads to a reduction in the frequency of substance use (i.e., alcohol, cigarette, marijuana, and inhalants). METHODS: Students (N = 5,522, 49% female, age range = 11-17) in 36 middle schools across three cities in Mexico were randomized into three conditions: (1) Mantente REAL (MREAL), the culturally adapted version, (2) kiREAL-S, the linguistically adapted version, and (3) Control. Using survey data collected at four time points, random intercept cross-lagged path analyses tested the direct and indirect effects of MREAL and kiREAL-S compared to Control. RESULTS: At time 2, the number of drug resistance strategies used by students increased in both MREAL (ß = 0.103, p = .001) and kiREAL-S (ß = 0.064, p = .002) compared to Control. However, only MREAL lead to less frequent use of alcohol (ß = -0.001, p = .038), cigarettes (ß = -0.001, p = .019), marijuana (ß = -0.002, p = .030), and inhalants (ß = -0.001, p = .021) at time 4, mediated through increased use of drug resistance strategies. DISCUSSION: This study provides evidence that MREAL and kiREAL-S are successful in spurring use of the drug resistance strategies that are the core component of the intervention. Only MREAL achieved long-term effects on substance use behaviors, the ultimate objective of these interventions. These findings provide support for the value and importance of rigorous cultural adaptation of efficacious prevention programs as a necessary condition for enhancing prevention benefits for participating youth.

Inflammatory Mediators and Type 2 Diabetes Risk Factors before and in Response to Lifestyle Intervention among Latino Adolescents with Obesity.

Obesity is associated with chronic inflammation that may contribute to T2D among youth. We examined the association between inflammatory biomarkers and insulin sensitivity and ß-cell function and response to lifestyle intervention among Latino youth with obesity. Latino youth (n = 64) were randomized to six months of lifestyle intervention (INT, n = 40) or usual care (UC, n = 24). INT included nutrition education and physical activity. UC involved meeting with a pediatric endocrinologist and registered dietitian to discuss healthy lifestyles. At baseline, multiple linear regression assessed fasting serum interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), high-molecular weight adiponectin (HMW Adpn), IL-10, IL-1 receptor antagonist (IL-1ra) as predictors of insulin sensitivity (whole-body insulin sensitivity index, WBISI) and ß-cell function (oral disposition index, oDI). Changes in outcomes between groups were assessed using covariance pattern models. At baseline, MCP-1 (ß ± SE, -0.12 ± 0.05, p = 0.027) and IL-1ra (-0.03 ± 0.01, p = 0.005) were negatively associated with WBISI. Treatment effects were not observed for inflammatory markers. WBISI was significantly increased among both INT (from 1.8 ± 0.2 to 2.6 ± 0.4, p = 0.005) and UC (from 1.6 ± 0.2 to 2.8 ± 0.5, p = 0.002) with no significant differences between the groups. Obesity-related inflammatory mediators were associated with T2D risk factors but were unaffected by lifestyle intervention among Latino youth.

Perception of Parental Knowledge by Parents and Adolescents: Unique Effects on Recent Substance Use in a Latinx Sample.

The main objective of the current study is to analyze how the unique perspectives from both parents and children in regards to parental knowledge of the child's whereabouts, activities, and friendships are related to the adolescent's recent substance use four months later. Differences between parents and children, as well as between male and female adolescents are examined. Data come from a Latinx sample (mostly Mexican-origin) of 523 parent-adolescent dyads from Arizona (US) using a multi-informant approach (parent and adolescent reports). The results indicate that parents, especially mothers, report higher levels of parental knowledge than adolescents do. The structural equation modeling (SEM) results for the total sample indicate that both parents' and adolescents' unique perception of the level of parental knowledge is negatively related to the adolescents' recent alcohol and cannabis use four months later. Further, multi-group SEM results split by gender indicate that parents' unique perception of higher levels of parental knowledge is only marginally related to lower alcohol use for both males and females, whereas adolescents' unique perception is negatively related to alcohol and cannabis use (significantly) and tobacco use (marginally) for both males and females. No significant gender differences were found in the effects of parental knowledge on substance use. Findings suggest that parents' and adolescents' perceptions seem to be quite distinctive and independent from each other. Implications of these results regarding intervention programs for preventing substance use are discussed.

El objetivo principal de este estudio es analizar cómo las perspectivas únicas de padres e hijos con respecto al conocimiento de los padres sobre el paradero, las actividades y las amistades de su hijo/a se relacionan con el consumo reciente de sustancias del adolescente cuatro meses después. Se examinan las diferencias entre padres e hijos, así como entre adolescentes chicas y chicos. Los datos provienen de una muestra de latinos (en su mayoría de origen mexicano) de 523 díadas de padres y adolescentes de Arizona (EE.UU.) utilizando un enfoque de múltiples informantes (informes de padres y adolescentes). Los resultados indican que los padres, especialmente las madres, reportan niveles más altos de conocimiento parental que los adolescentes. Los resultados del modelo de ecuaciones estructurales (SEM) para la muestra total indican que tanto la percepción única de los padres como la de los adolescentes del nivel de conocimiento parental está relacionada de forma negativa con el consumo reciente de alcohol y cannabis por parte de los adolescentes cuatro meses después. Además, los resultados de SEM multigrupo divididos por género indican que la percepción única de los padres de niveles más altos de conocimiento parental está únicamente relacionada de forma marginal con un menor consumo de alcohol, tanto para chicos como para chicas, mientras que la percepción única de los adolescentes está relacionada de forma negativa con el consumo de alcohol y cannabis (significativamente) y el consumo de tabaco (marginalmente), tanto en chicos como en chicas. No se encontraron diferencias de género significativas en los efectos del conocimiento parental sobre el uso de sustancias. Los resultados sugieren que las percepciones de padres y adolescentes parecen ser bastante distintas e independientes entre sí. Se discuten las implicaciones de estos resultados con respecto a los programas de intervención para prevenir el consumo de sustancias.

Testing a Culturally Adapted Youth Substance Use Prevention Program in a Mexican Border City: Mantente REAL.

Background: This article reports on a test of a youth substance use prevention program conducted in Nogales-Sonora, a Mexican city on the US border. Objective: The study tested the efficacy of a version of the keepin' it REAL curriculum for middle school students that was culturally adapted for Mexico and renamed Mantente REAL. Methods: Students in 7th grade classrooms in four public schools participated in the study (N = 1,418, 49% female, mean age = 11.9). Using a clustered randomized design, two schools received the intervention and two served as a treatment-as-usual control group. Regular classroom teachers were trained to deliver the twelve-lesson Mantente REAL manualized curriculum. Parents provided active consent and students gave written assent to collect pretest and posttest questionnaire data, 7 months apart, at the beginning and end of the 2017-2018 academic year. We assessed the Mantente REAL intervention with general linear models adjusted for baseline, attrition, non-linear distributions, and school-level clustering. Results: Students who participated in Mantente REAL reported relatively less frequent use of alcohol and illicit drugs other than marijuana, compared to students in control schools. Males alone reported desirable intervention effects for marijuana use. These desirable effects were especially strong among students who reported higher initial levels of involvement in risky behaviors. Among students more at risk, both females and males receiving the program reported relative reductions in the frequency of use of alcohol and illicit drugs. Conclusions: These promising results within the Mexico-US border context support a further dissemination of the intervention and additional youth prevention research in the region.

Sex as a moderator of body composition following a randomized controlled lifestyle intervention among Latino youth with obesity.

BACKGROUND: Body composition differences between males and females emerge during adolescence and continue throughout adulthood; however, whether sex moderates body composition changes in adolescents with obesity after an intervention is unknown. OBJECTIVE: To examine sex as a moderator of changes in adiposity following lifestyle intervention. METHODS: A total of 136 Latino youth with obesity (BMI% 98.2 ± 1.3) aged 14 to 16 years old were randomized to either a 12-week lifestyle intervention (27 males/40 females) or control (35 males/34 females) group. The intervention included nutrition education (1 h/wk) and moderate-to-vigorous physical activity (3 h/wk). Anthropometric data (body mass index [BMI], BMI%, waist circumference, total body fat, and fat-free mass) were obtained pre- and post-intervention. Sex differences were examined by general linear models with significance determined at P < .05 for the F-statistic. RESULTS: Sex did not moderate changes in BMI (F1,115 = 0.01, P = .9), BMI% (F1,115 = 0.14, P = .7), or waist circumference (F1,117 = 1.1, P = .3). Sex significantly moderated changes in body fat percent (F1,117 = 5.3, P = .02), fat mass (F1,116 = 4.5, P = .04), and fat-free mass (F1,116 = 4.3, P = .04). Intervention males compared with females had greater relative reductions in fat percent (-4.1 ± 0.8% vs -1.2 ± 0.7%, P = .02) and fat mass (-5.0 ± 1.1 kg vs -1.5 ± 0.9 kg, P = .02) and gained more fat free mass (3.6 ± 0.9 kg vs 0.5 ± 0.8 kg, P = .02) when compared with same sex controls. CONCLUSION: Males and females exhibited a differential response to lifestyle intervention for percent fat, fat mass, and fat-free mass indicating that sex-specific improvements in body composition favours males over females.

Testing the keepin' it REAL Substance Use Prevention Curriculum Among Early Adolescents in Guatemala City.

This article describes a test in Guatemala City of Mantente REAL, a linguistically adapted version of the keepin' it REAL universal substance use prevention curriculum for early adolescents that teaches culturally grounded drug resistance, risk assessment, and decision making skills. Academic researchers collaborated with a local non-profit to recruit and randomize 12 elementary schools in Guatemala City to intervention and comparison conditions. Regular classroom teachers were trained to deliver the ten-lesson Mantente REAL (MR) manualized curriculum to sixth-grade students. Parents provided passive consent and students gave active assent for data collection, which occurred between February 2013 and September 2014. Two academic year cohorts of students participated (n = 676; 53% male; M age = 12.2). All students completed a pretest questionnaire before the curriculum lessons began in intervention schools and a posttest (87% matched) 4 months later, 1 month after the final lesson. We assessed the MR intervention with paired t tests, effect sizes (Cohen's d), and general linear models adjusted for baseline, attrition, non-linear distributions, and school-level clustering. Results indicated that MR can be an effective school-based prevention approach in Guatemala. The MR participants reported pretest-to-posttest changes in desirable directions on substance use behaviors, attitudinal antecedents of substance use, and acquisition of drug resistance skills. The comparison group generally changed in undesirable directions. In linear models, the MR participants, relative to the comparison group, reported less cigarette and marijuana use, less positive drug use expectancies, and greater use of drug resistance skills. Intervention effect sizes were between .2 and .3.

The Role of Culture of Origin on the Effectiveness of a Parents-Involved Intervention to Prevent Substance Use Among Latino Middle School Youth: Results of a Cluster Randomized Controlled Trial.

The purpose of this study was to assess the combined effectiveness of a parenting intervention, Families Preparing the New Generation (FPNG), and a youth curriculum, keepin' it REAL (kiR), on substance use prevention for middle school students in a large urban metro area of the southwest USA. The study aimed to generate usable knowledge on what works in adolescent substance use prevention and how it works best-a combined parent and youth programming or parent-only programming. A total of 532 adolescents in the 7th grade from 19 participating middle schools were randomly assigned into three intervention conditions: parent-youth (PY), parent-only (PO), and comparison (C). This article focuses on the comparison between PY and PO in order to determine which intervention strategy works best to reduce adolescent substance use including alcohol, inhalant, cigarette, and marijuana uses. A generalized estimating equation (GEE) model examined the longitudinal data. The results for alcohol use show that PO yielded better results than PY and that PY outperformed C after 20 months. Further, PO showed a decreasing trajectory in any substance use over time since the implementation of the intervention. The effect sizes based on Cohen's h indicate small effects in any substance use and alcohol use for PO condition and smaller effects for the PY condition. These findings have implications for the design of future culturally specific parenting and youth prevention interventions with Latino families.

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.

Substance Use Profiles of Urban American Indian Adolescents: A Latent Class Analysis.

UNLABELLED: A growing majority of American Indian adolescents now live in cities and are at high risk of early and problematic substance use and its negative health effects. OBJECTIVE: This study used latent class analysis to empirically derive heterogeneous patterns of substance use among urban American Indian adolescents, examined demographic correlates of the resulting latent classes, and tested for differences among the latent classes in other risk behavior and prosocial outcomes. METHOD: The study employed a representative sample of 8th, 10th, and 12th grade American Indian adolescents (n = 2,407) in public or charter schools in metropolitan areas of Arizona in 2012. Latent class analysis examined eight types of last 30 day substance use. RESULTS: Four latent classes emerged: a large group of "nonusers" (69%); a substantial minority using alcohol, tobacco, and/or marijuana [ATM] (17%); a smaller group of polysubstance users consuming, alcohol, tobacco, marijuana, other illicit drugs, and prescription or OTC drugs in combination (6%); and a "not alcohol" group reporting combinations of tobacco, marijuana, and prescription drug use, but rarely alcohol use (4%). The latent classes varied by age and grade level, but not by other demographic characteristics, and aligned in highly consistent patterns on other non-substance use outcomes. Polysubstance users reported the most problematic and nonusers the least problematic outcomes, with ATM and "not alcohol" users in the middle. CONCLUSIONS: Urban AI adolescent substance use occurs in three somewhat distinctive patterns of combinations of recent alcohol and drug consumption, covarying in systematic ways with other problematic risk behaviors and attitudes.

Bullying among Urban Mexican-heritage Youth: Exploring Risk for Substance Use by Status as a Bully, Victim, and Bully-Victim.

Little is known about adolescent bullying behavior and its relationship to substance use in ethnic minority populations. In a sample of youth of Mexican heritage, the current study aimed to examine the prevalence of bullying behavior subtypes and its co-occurrence with recent alcohol, cigarette, and inhalant use. Data come from a school-based substance use prevention study in the Southwestern U.S. (n=809). We explored the prevalence of bullying behavior by status among youth classified as bullies, victims, bully-victims, and rarely-involved bully-victims in an urban context. We also investigated risk of past 30-day use of alcohol, cigarettes, and inhalants by bullying behavior status. Compared to non-involved youth, rarely-involved bully-victims were more likely to use alcohol, bullies were more likely to engage in alcohol and cigarette use, and bully-victims were more likely to use alcohol, cigarettes, and inhalants. In contrast, victims were not significantly at risk of substance use compared to non-involved youth. Chronic bullies and bully-victims are particularly at risk for substance use, with chronic bully-victims reflecting the greatest risk of using multiple substances. Prevention and early intervention programs aimed to reduce bullying can also work to decrease other risky behaviors, such as substance use, and should attend to the growing ethnic diversity among youth.

Short-term effects on substance use of the keepin' it real pilot prevention program: linguistically adapted for youth in Jalisco, Mexico.

This article presents the short-term effects of a pilot study of keepin'it REAL (Manténte REAL) conducted in central Mexico by a binational team of investigators. This middle school-based model program for preventing substance use was adapted for Mexico linguistically but not culturally. Two Guadalajara public middle schools were recruited and randomly assigned to either implement the prevention program or serve as a control site. The program was implemented in the treatment site by the students' regular teachers, who were trained by the research team. Seventh graders in ten classrooms in the treatment and control schools (N = 432) completed a pretest and posttest survey in Spanish similar to the survey utilized in the original efficacy trial of keepin'it REAL in the US. T-tests and OLS regressions were conducted to determine the effects of the intervention on substance use outcomes. Differences between treatment and control groups in frequency of use of alcohol and tobacco, the two substances of choice in this sample, were significant and in the desired direction. Differences in amount of use were also in the preferred direction but were not significant for alcohol and only marginally significant for tobacco. When the sample was split by gender, statistically significant treatment effects remained for females but were not observed among males. Effects of the linguistically adapted version of keepin'it REAL appears to be driven by the change in female use; however, the difference in male and female outcomes was not statistically significant. Implications for cultural adaptation and prevention in Mexico are discussed from a communication competency perspective. The promising results of the pilot study suggest that the linguistic adaptation was effective, but that a comprehensive cultural adaptation of keepin'it REAL in partnership with Mexican investigators and communities may be warranted.

Religiosity and adolescent substance use in central Mexico: exploring the influence of internal and external religiosity on cigarette and alcohol use.

This study explores the multidimensional nature of religiosity on substance use among adolescents living in central Mexico. From a social capital perspective, this article investigates how external church attendance and internal religious importance interact to create differential pathways for adolescents, and how these pathways exert both risk and protective influences on Mexican youth. The data come from 506 self-identified Roman Catholic youth (ages 14-17) living in a semi-rural area in the central state of Guanajuato, Mexico, and attending alternative secondary schools. Findings indicate that adolescents who have higher church attendance coupled with higher religious importance have lower odds of using alcohol, while cigarette use is lower among adolescents who have lower church attendance and lower religious importance. Adolescents are most at risk using alcohol and cigarettes when church attendance is higher but religious importance is lower. In conclusion, incongruence between internal religious beliefs and external church attendance places Mexican youth at greater risk of alcohol and cigarette use. This study not only contributes to understandings of the impact of religiosity on substance use in Mexico, but highlights the importance of understanding religiosity as a multidimensional phenomenon which can lead to differential substance use patterns.

Gender differences in drug resistance skills of youth in Guanajuato, Mexico.

Research is limited or absent on Mexican adolescents' exposure to substance offers, ways of dealing with these offers, and possible gender differences in responses to offers. Extending U.S.-based research, this study examines how youth living in the Mexican state of Guanajuato employ the four drug resistance strategies-refuse, explain, avoid, and leave-that are part of the Keepin' It REAL evidence-based drug prevention intervention. The analysis uses cross-sectional survey data from 702 students enrolled in eight alternative secondary education sites in 2007. Participants reported the drug resistance behaviors they used to deal with offers of alcohol, cigarettes, and marijuana. Using multivariate regression, findings indicate most youth had developed repertoires of drug resistance strategies that involved multiple REAL strategies and some other strategy as well. For those receiving offers, the most common strategy was to refuse the offer with a simple "no." However, males used all the strategies significantly more often than females for situations involving cigarettes and marijuana as well as when using refuse and non-REAL strategies for alcohol. Possible reasons for the gender difference in use of strategies are discussed. The findings can help inform effective prevention programs based on teaching culturally appropriate drug resistance and communication skills.