Making Drug and Alcohol Prevention Relevant Adapting Evidence-Based Curricula to Unique Adolescent Cultures

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Fam Community Health Supplement 1 to Vol. 31, No. 1S, pp. S52–S60 Copyright c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Making Drug and Alcohol Prevention Relevant Adapting Evidence-based Curricula to Unique Adolescent Cultures

Lori K. Holleran Steiker, MSW, PhD

There is profound value in involving youth in the cultural adaptation of evidence-based drug prevention curricula. Presently, despite the existence of evidence-based programs, few community settings are aware of, utilizing, and following evidence-based curricula in practice. Therefore, to transfer such programs to practice, systematic adaptation procedures should be further developed, utilized, and evaluated. It is recommended that community settings adapt curricula to meet their youths’ unique needs to be effective, particularly with diverse cultures. Key words: adaptation, adolescents, culture, drug prevention

ESIGNERS of prevention curricula have to some youth, the very same activity might D long been aware that, in addition to be considered inappropriate by another,6 and core activities addressing risk and protective similarly videos that “speak to” some youth factors and social and resistance skills, they may bore or offend others.7 Scenarios and ex- must consider other aspects to create effec- amples in a curriculum may or may not cap- tive programs. For example, research shows ture young peoples’ life experiences. As de- that didactic lecture approaches are less ef- signers bear these crucial considerations in fective when compared to interactive, experi- mind, one of the poignant questions they face ential activities for youth.1,2 Videos have also is: How much change or adaptation to a cur- been shown to improve youth interest, and ricula is beneficial for recipients while still therefore engagement in the program.3 Fur- maintaining the core curricula’s effectiveness? thermore, when youth resonate with the cul- There is no such thing as “one size fits tural aspects of a program, this has a strong all” in health interventions.8(p276) Because of impact on interest, retention, and positive the complex nature of implementation in real- outcomes.4,5 Yet, while some activities appeal world settings, as noted by Dr Christopher Ringwalt and his team at the Pacific Institute for Research and Evaluation, “some degree of curriculum adaptation is inevitable.”9(p386) I From the School of Social Work, The University of have discussed the values of cultural adapta- Texas at Austin. tion of drug prevention curricula, related re- This research was funded by the National Institute search, and our cultural adaptation processes on Drug Abuse, a division of the National Institutes of the evidence-based “keepin’ It REAL” pro- of Health, grant K01 DA017276. The author thanks the Drug Resistance Strategies team who developed the gram as an example. original keepin’ It REAL curriculum, and also Laura At the point of implementation, facilitators Hopson, PhD, Jeremy Goldbach, and Dean Sagun for of prevention programs often do not strin- their instrumental work on this study. gently follow the written curricula.10–12 Find- Corresponding author: Lori K. Holleran Steiker, MSW, ings suggest that about one fifth of teach- PhD, School of Social Work, University of Texas, 1 University St, D3500, Austin, TX 78712 (e-mail: ers of substance use prevention curricula did [email protected]). not use a curriculum guide at all, whereas S52 Adolescent Prevention Adaptation S53 only 15% reported they followed one very preliminary research, this researcher found closely.9 Even when host agencies’ workers that agencies on the Texas border were not follow manuals closely, other issues, such as utilizing the videos that are an integral part staffing inconsistency, lack of technical assis- of the keepin’ It REAL curriculum because tance, and the presence or lack of commu- they perceived that the youth would find nity support, complicate technology transfer the videos irrelevant, outdated, and even, on from research to “where the rubber hits the some occasions, offensive.16 Upon further in- road.”13 Many practical limitations that can quiry, social service staff noted that the cur- lead to this lack of adherence include lack of ricula were often perceived as “remedial,”and training and support, inadequate time and re- they felt that their older youth were particu- sources, large class sizes, and low morale and larly untouched by the program information burnout among teachers and school staff.14 and structure. Workers in agencies often contend that pre- This “adaptation-versus-fidelity” discussion vention programs need to be tailored to serve is often referred to as the “local adaptation- their unique, diverse youth.14 fidelity debate.”17(p47) Since there is a gap in As written, many drug prevention curric- the literature clarifying the issue, the preven- ula often fail to be relevant and engaging to tion research field is still in conflict around the youth who receive them.4 As a result, this issue.18,19 In the social sciences, although adaptation can be critical in situations where research is abundant regarding the effective- the culture of the audience is diverse, eth- ness of prevention curricula, research on nically, socially, organizationally, or econom- fidelity of implementation is rare. In fact, ically. In fact, the failure of some prevention many of the highest quality programs’ ad- programs can be traced to their lack of cul- ministrators fail to monitor and verify pro- tural sensitivity.5 Given that teachers in high- gram integrity.20,21 When researchers attempt minority schools were more likely to adapt to measure fidelity, definitions and opera- curricula in response to such characteristics tionalization methods of the concept vary as youth violence, limited English proficiency, widely. Fidelity measures tend to fall into and various racial/ethnic or cultural groups, 5 classifications: adherence, dose, quality of Ringwalt et al15(p61) suggest that curriculum delivery, participant responses, and program developers “make a systematic effort to un- differentiation.22,23 This issue is critical in derstand how (implementers) are adapting drug abuse prevention work, for it is clearly their curricula in high minority schools and established that poor implementation is likely incorporate these modifications, if found ef- to result in a loss of program effectiveness.23 fective, into their curricula.” Agencies have Although some prevention scientists have fortunately become more apt in choosing a maintained that their programs are effective designated “model prevention program,” but regardless of the race, ethnicity, gender, sex- the reality is that many workers at agencies ual orientation, and/or culture of the youth that host such substance abuse prevention who receive them, they often present findings curricula instinctually adapt the programs for from what they call “high-fidelity samples,” the youth whom they serve. This researcher’s which include only the youth who received qualitative research has highlighted how im- a certain number of sessions.24–26 Although plementers at lesbian, gay, bisexual, trans- this makes sense from a research standpoint, gendered, and questioning (LGBTQ) agencies it often fails to capture the high-risk youth add examples of gay youth; agencies serving who tend to need the programs the most (ie, incarcerated youth often add the legal con- youth with poor attendance, truancy, illness, sequences that many universal curricula ig- hiatus at alternative schools, and legal system nore; and agencies serving homeless youth of- involvement). As Botvin14(p69) himself admits, ten omit examples that refer to parents and “Issues related to implementation fidelity and homes. For example, in one instance during adaptation need to be better understood as S54 FAMILY &COMMUNITY HEALTH/SUPPLEMENT 1 TO JANUARY–MARCH 2008 well as factors associated with institutionaliza- lized a systematic adaptation process to create tion of effective prevention programs.” culturally grounded versions of an evidence- based drug abuse prevention program. The CULTURALLY GROUNDED PREVENTION adaptation process incorporated the unique culture of Texas youth at each site into pre- Over the past few decades, social scientists vention curriculum scenarios and videos that have emphasized the role of culture in social accompany the original core curriculum. interventions. “Culture” has been defined as “integrated patterns of human behavior that INVOLVING PARTICIPANTS AS EXPERTS include the language, thoughts, communica- tions, actions, customs, beliefs, values, and As public health experts have long institutions of racial, ethnic, religious, or so- known, and as highlighted by Hopson and cial groups.”27 Substance abuse prevention ef- Holleran, interventions cannot thrive without forts are enhanced and outcomes improved the full participation and commitment— when programs are culturally grounded (ie, ownership, if you will—on the part of the reflect the culture of the youth who are re- host environment.12,34,35,36 Partnerships and ceiving the interventions).4,28 Different dis- collaborations with agency administrators, ciplines and realms utilize varied terminol- staff, youth, and other community members ogy for capturing culture—interchangeably make it possible to adapt and ensure not utilized terms with varied definitions include only that the intervention “talks so youth cultural sensitivity, cultural competence, and can listen” but also that the intervention con- cultural responsiveness.27,29,30 For the pur- tinues beyond the researchers’ presence.37 pose of this article, cultural groundedness is Relationships between program designers utilized since the term is mostly linked with and the facilitators and recipients are critical substance abuse prevention literature.4,28 elements in the utility and effectiveness of Researchers in the field of prevention curricula.38 often emphasize the importance of evidence- The design processes of the original keepin’ based practices. Definitions of “evidence- It REAL curricula captured the complex cul- based” vary widely, but the criterion tural characteristics of participants and in- standard is clearly composed of the assess- corporated them into the research process.39 ment of research findings from randomized A number of substance abuse prevention controlled clinical trials, which constitutes programs (described as “evidence based”) a rigorous research design.31 Preliminary are adopted nationally because of their ef- analyses in this study (a pre-follow-up– fectiveness with certain ethnic populations. post-follow-up designed clinical trial with However, although a program might be in- comparison groups) have found that cultur- digenously grounded (ie, reflecting charac- ally adapted versions of the evidence-based teristics and details of the indigenous group drug prevention curriculum, Keepin’ It REAL, that helped design it), it may not necessar- have better outcomes with high-risk youth in ily be culturally grounded (for ethnicity or community settings than the original keepin’ other cultural aspects) in a way that is gen- It REAL curriculum.28,32 eralizable to other locations and groups of Castro et al33 emphasize the need for rig- youth.40 orous studies of adapted versions of curric- The few programs that claim to be cultur- ula. They suggest the importance of such ally grounded incorporate some cultural val- studies, recommending controlled research ues, practices, and/or beliefs. Still fewer are trials in which cultural adaptations of model designed to capture the norms and mores of prevention program are tested against their organizational cultures such as juvenile jus- original versions.33 Following this suggestion, tice settings. However, when these programs Holleran and colleagues32 designed and uti- are utilized in settings other than those where Adolescent Prevention Adaptation S55 they were developed, there is often a lack of As noted, the purpose of this project was to fit between the package and the host, as has adapt and evaluate a substance abuse preven- been recognized for years.34 Most prevention tion intervention with high-risk youth, with research is conducted in school settings with a particular focus on the impact of organi- students. The original keepin’ It REAL cur- zational and group cultures in prevention ef- riculum targeted middle-school youth. This forts. The intervention employed videos and project utilizes youth as experts in the pro- skills-building exercises to teach adolescents cess of adapting the keepin’ It REAL curricu- about strategies for resisting drug use. This lum’s student workbook and videos, extend- project was conducted in 2 phases. Phase I ing the age target to 14- to 19-year-olds in was designed to engage adolescents in adapt- high-risk, unique community settings. This is ing the curriculum to make it culturally appro- an important age group to target because use priate for their own setting. rates are often higher in these settings and the Phase II evaluated the effectiveness of the initiation of use of so-called “hard drugs”often adapted curriculum in comparison with the takes place during this period.41 original curriculum and a comparison group School-based programs often miss the pop- at each site. This project aimed to assess ulations that need prevention the most. whether adaptations improved the curricu- For example, lifetime rates of alcohol and lum as well as providing opportunities for ado- other drug use are higher among home- lescents to take an active role in making pre- less and street youth than among sheltered vention curricula relevant. or household youth.42 Furthermore, 70% to 80% of street youth report daily use of al- Procedures cohol, and 35% to 55% report weekly or While there are many ways to adapt a pro- higher use of cocaine, crack, heroin, and/or gram culturally, the procedures used in the amphetamines.42,43 keepin’ It REAL adaptation are presented as a Considering adolescents to be experts in simple and systematic option that has proven their own life experiences allows program feasible and advantageous. For the purpose media to portray current and popular ver- of clarity, it is important to note an overview nacular speech, customs, and styles of the of the research process used for both phases target population.16 Current language, ter- of this participatory research project. Phase minology, and slang terms change quickly I employed both qualitative methods (focus and constantly.44 Youth are the richest re- groups and naturalistic process evaluation) source for securing accurate portrayals of to study adolescents’ process of adapting the drug-related culture. curriculum to suit their culture and setting as well as the specific mechanisms of adap- THE KEEPIN’ IT REAL ADAPTATION tation and the behavioral impact of partici- PROJECT pating in this process and quantitative measures to assess the impact, if any, on their Recent research findings support the use drug use and attitudes. Participants created of a cultural adaptation intervention for high- 4 new videos (1 for each prevention strat- risk adolescents between 14- and 19-year-olds egy; refuse, explain, avoid, and leave) to ac- in community settings.32 The data were gath- company the curriculum and rewrote scenar- ered at 4 alternative schools and 1 public high ios used in the workbooks. While no changes school, a homeless youth shelter, a juvenile were made to the core curriculum, the partic- justice day program setting, a YMCA-run pro- ipants adapted the workbook and remade the gram for youth at low-income housing cen- videos to include such local nuances as drugs ters, a drop-in center for GLBTQ youth, and a of choice, settings, language, styles, drug of- youth advocacy group on the US-Mexico bor- fer particulars, and relevant clothing and mu- der in Texas. sic in videos. Adaptations to the curriculum S56 FAMILY &COMMUNITY HEALTH/SUPPLEMENT 1 TO JANUARY–MARCH 2008 were structured so that the videos and sce- use, participants in phase I were adminis- narios covered the same topics as the original tered questionnaires before and after adapt- curriculum. Adaptation sessions were super- ing the curriculum. Participants participated vised by voluntary staff at the project site in in a focus group before and after develop- collaboration with a member of the research ing the videos and scenarios to learn about team. their beliefs, attitudes, and experiences re- This systematic adaptation utilizes agency lated to substances and prevention curricula. facilitators to orchestrate the youth process They were given monetary incentives, and of changing the scenarios, wording, and de- it was noted that they were being recruited tails in the student workbooks as well as creat- as expert consultants in youth and the cul- ing 4 new videos to accompany the core cur- ture in which youth use substances. Phase II riculum. First, the agency facilitator is given consisted of the implementation of original group ground rules to help the group set some and adapted curricula, along with comparison expectations and to structure the process:45 groups. Data are presently being analyzed and (a) each member of the group should have preliminary findings are discussed. an equal opportunity to contribute to the process; (b) each participant should be respectful PRELIMINARY FINDINGS of everyone in the group; (c) what is discussed in the group stays in the group (ie, confiden- In preliminary analyses, we found that tiality); and (d) if someone is not fulfilling the (1) adaptation processes engage youth who expectations listed, the group and facilitator are often oppose to prevention programs and will decide whether that person can continue messages, and (2) by engaging older adoles- to participate. cents (who often have already used or even Next, facilitators are given clear written abused drugs) as experts, the curricula can directions on how the adaptation should be transformed into culturally grounded ver- proceed.45 For example, the youth are in- sions for younger youth and peers of the structed as follows: adapters. These findings support adaptation processes to improve the curriculum, and it The scenes/scenarios chosen to appear in the has emerged that the actual act of adapting workbook and/or videos should be decided upon the evidence-based program for others shifts by the WHOLE YOUTH GROUP. Videos should not attitudes and behaviors regarding drugs and show extreme consequences such as injuries or fa- alcohol. Specifically, the overall model includ- talities that result from drug use because such illus- ing all substance use variables indicates the trations are not effective due to youth’s tendency groups differ significantly in substance use to assume “this won’t happen to me.”Scenarios de- < = < picted in workbooks and videos should be events over time (P 0.05; F(36,292) 1.889, P that at least 75% of group members have witnessed 0.05). The following variables had indepen- or experienced to assure that common scenarios dent significant effects: beer, wine, liquor, are being captured. marijuana, hallucinogens, and ecstasy. Youth receiving any version of the curriculum re- These instructions confine the process to ported less beer, wine, and liquor use over reality-based details. In the experience of the time in comparison with youth. The adapted researchers, these directions frame the pro- versions yielded greater reductions in wine cess well. Facilitators also provide page-by- and liquor use than the original version.32 page instructions on how to have students Youth adaptations of the drug prevention change the student workbook and how to cre- curriculum “student workbooks” yielded in- ate their versions of the videos.45 teresting products. At some sites, the youth Because the process of developing videos made basic changes such as updating the and adapting the workbook was hypothe- popular names of substances such as “weed” sized to impact youth attitudes toward drug for “pot.” Youth had different opinions about Adolescent Prevention Adaptation S57 which drugs were best targeted with their version; even finding it funny was engaging. peers, and some sites’ youth felt that it was (“In da Club”was a popular hit by US rap star important to aim at “harder drugs”rather than 50 Cent’s from his 2002 album, Get Rich or cigarettes, marijuana, and alcohol (which they Die Tryin’.) tended to minimize as problematic). Some The video adaptation also yielded power- youth groups made changes to the popu- ful products. The ownership and involvement lar youth activities (eg, basketball instead of of youth in the creation of the videos cultur- soccer) and names of frequented locations. ally grounds them in a way that no other pro- Many sites made changes to the specifics cess can.46 Each of the sites had the youth par- of drug offer scenarios (eg, who made the ticipants conceptualize, script, act, and film offer, where, and how). Another trend in- four drug prevention videos. A drug preven- cluded population-specific changes: home- tion video was created for each of the keepin’ less youth took out scenarios with parents, It REAL resistance strategies (ie, refuse, ex- GLBTQ youth made the workbook more gen- plain, avoid, and leave, thus the acronym der neutral, incarcerated youth added drug REAL).28 Each site filmed the videos at its court scenarios, and low-income youth por- agency ground, so the location is recogniz- trayed scenarios in their homes and friends’ able to the youth and their peers who would homes because they did not have transporta- receive the adapted curricula. The scenarios tion options elsewhere. range from drug deals gone awry to decisions Some participants, such as the homeless to leave or avoid a party. The youth incor- youth, made more drastic changes to the text. porated specific experiences. One youth de- Some youth included curse words when ad- picted the story of a friend who was given ministrators would allow it, because, as they pills in her drink at a party and came to con- stated, “This is how we really talk.”Even when sciousness the next morning without know- the facilitators said curse words could not ing what happened. Another group depicted be used, the youth often opted to include a peer’s experience of taking a drug offer and representations faithful to their actual com- winding up in the hospital. The group of in- municating (eg, using a euphemism “@!%$”). carcerated youth depicted getting caught in Many of the groups infused the workbooks relapse and winding up in drug court with with slang terms and popular culture phrases: sanctions. for example, “slacker” for the original “(a The most effective mechanism, however, student who) never pays attention or does according to the youth in focus groups (across his homework”; “blowing up your phone” for sites) was the “explain” video that simply “keeps calling you”; “chillin”’ for “are at the filmed youth talking candidly about their house”;“get throwed”for “get drunk”;“home- drug perceptions, beliefs, and experiences. boy” for “friend”; and “blazin’ KB” for “smok- The “testimonial” was perceived as the most ing pot.” One of the most illustrious exam- grounded portrayal of their real-life experi- ples came from the groups facilitated by the ences. Different sites, as noted, had differ- YMCA for youth in a low-income housing ent perceptions about effective drug preven- complex. They changed the I-statement exer- tion strategies. Some of the sites considered, cise because they felt that they would never for example, that the abstinence model (ie, identify with the original version that read, “Just say no”)was unrealistic and that a harm- “I feel when I dance in front of reduction model would be more effective. In people. . . .” They opted to change it to a pop- these testimonials, youth note that although ular hip-hop tune lyric, “I feel in they choose to use certain substances (espe- ‘da club with a bottle full of bub.” At first, cially marijuana), they absolutely would not the facilitator thought that they were not tak- use other substances (eg, crack and heroin), ing the exercise seriously, but they soon real- and they note their reasons. Several sites had ized that the youth resonated with the new youth who used to abuse substances and now S58 FAMILY &COMMUNITY HEALTH/SUPPLEMENT 1 TO JANUARY–MARCH 2008 are “sober”or “clean”(which meant that they curriculum and make the program resonate no longer use drugs and alcohol.) with those who will receive it. Although fi- Although initially the researchers were con- delity to the core program is important, com- cerned that the youth would feel guarded or plex, and reality-based interactions cannot be intimidated about the video process, it is note- scripted.46 Therefore, clinicians should hesi- worthy that the youth not only were willing tate to stray too far from the scripted program to express their drug beliefs and histories but manuals, but allow for natural and true inter- also welcomed the opportunity to share with actions with youth. By engaging the youth in their peers. Overall, preliminary data suggest adapting the curricula first, it may prevent a that participating in adaptation processes may sea of blank faces and glances at watches that genuinely change attitudes about drug use, are so common in high-risk youth receiving suggesting that more research needs to be drug prevention curricula.48 done on consideration of the adaptation pro- A critical issue to consider is the reality por- cess as an intervention in and of itself. trayed by the programs. Many high-risk youth in community settings are already using sub- IMPLICATIONS FOR RESEARCH, stances, sometimes at high rates. It is impor- PRACTICE, AND POLICY tant to avoid presenting the “Just say no”mes- sage without considering nonabstinence and A commitment to the cultural adaptation harm-reduction frames.49 In addition, it is the of prevention curricula is not a vote against instinct of many implementers to try to scare fidelity—especially in light of the emphasis youth with worst possible scenarios, but this on technology transfer from research to prac- is not an effective mode of intervention.23 The tice, it is important to see that these two com- bottom line is that when presenting drug pre- mitments are not mutually exclusive. It is a vention messages, it is important to honor the travesty to make the two distinct merely to true life experiences of the youth recipients. perpetuate the debate. Similar to the field’s The policy implications for cultural adap- “qualitative versus quantitative” debates, the tation drug prevention curricula include the two are best seen as complementary and both need to illuminate health agencies, funding necessary. Although agencies struggle to en- agencies, and communities about the im- gage and retain adolescents in varied settings, portance of youth voices in the creation of it is critical that prevention scientists consult curricula and the most effective means of with the experts to capture the emic (or in- implementing such programs. Also, the uni- sider) perspective, the language, the style, and versal implementation (ie, administration of the needs of the youth being targeted by the curricula to all youth in a broad scope, such intervention. as the DARE program) of model drug preven- As noted in this article, the best mecha- tion programs in schools may not only miss nism to achieve a truly culturally grounded the highest risk youth but also ostracize them curriculum is to enlist youth as experts. Prac- in iatrogenic ways, making them even less titioners should go beyond perusing the Sub- amenable to change. School settings should stance Abuse and Mental Health Services Ad- consider more targeted means of prevention. ministration “model programs”list and engage Second, administering nationally marketed key stakeholders in the process of choosing versions of drug prevention curricula that the prevention intervention that is likely the have been named “culturally grounded” may best fit, and creating a structure for youth be problematic (if not unethical) due to the and staff input on the intervention’s adapta- perception that they are effective with diverse tion process. Although the core of the cur- youth across the board. They may be foreign, riculum needs to be preserved, the scenar- and possibly even offensive, to youth who do ios, language, music, culture, and videos in not fit the mean, such as LGBTQ youth, in- the project can be recreated to enhance the carcerated youth, homeless youth, youth in Adolescent Prevention Adaptation S59 unique regions (eg, border towns, rural ar- with directions on how to culturally ground eas), and youth of low socioeconomic status. them for the youth served. This will allow for For these reasons, this author maintains the vi- a systematic means for transforming preven- sion that at some point in the near future, all tion programs into the real world, and as true drug prevention curricula will be distributed mechanisms for change.

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