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Keepin' it REAL
Date of Review: December 2006

Keepin' it REAL is a multicultural, school-based substance use prevention program for students 12-14 years old. Keepin' it REAL uses a 10-lesson curriculum taught by trained classroom teachers in 45-minute sessions over 10 weeks, with booster sessions delivered in the following school year. The curriculum is designed to help students assess the risks associated with substance abuse, enhance decisionmaking and resistance strategies, improve antidrug normative beliefs and attitudes, and reduce substance use. The narrative and performance-based curriculum draws from communication competence theory and a culturally grounded resiliency model to incorporate traditional ethnic values and practices that protect against substance use. The curriculum places special emphasis on resistance strategies represented in the acronym "REAL" (Refuse offers to use substances, Explain why you do not want to use substances, Avoid situations in which substances are used, and Leave situations in which substances are used).

Descriptive Info Outcomes Ratings Study Populations Studies/Materials Contacts

Descriptive Information

Topics	Substance abuse prevention
Areas of Interest	Alcohol (e.g., underage, binge drinking), Tobacco/smoking
Outcomes	Outcome 1: Alcohol, cigarette, and marijuana use Outcome 2: Anti-substance use attitudes Outcome 3: Normative beliefs about substance use Outcome 4: Substance use resistance
Study Populations	Age: 6-12 (Childhood), 13-17 (Adolescent) Gender: Female, Male Race: Black or African American, Hispanic or Latino, White (See Study Populations section below for percentages by study)
Settings	School
Implementation History	Keepin' it REAL has been implemented in schools in Delaware, Indiana, Maryland, Michigan, Ohio, Pennsylvania, Tennessee, and Texas. It also has been implemented in Monterrey, Mexico.
Replications	No replications were identified by the applicant.
Adaptations	Keepin' it REAL is a culturally grounded intervention that incorporates ethnic values to enhance resilience to substance use. Mexican American (Spanish- and English-language versions), African American, and multicultural versions of keepin' it REAL are available.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the applicant.
Public or Proprietary Domain	Proprietary
Costs	The curriculum manual, including five videos, is available for $99, and a set of materials for five participants can be purchased for $18.50. An online version of the curriculum is available from Discovery Health at http://www.discoveryhealthconnection.com. The 12-month license per school is $1,695 for access to the full site and $500 for access to the Alcohol and Other Drugs Module (which includes keepin' it REAL, Here's Looking at You, STARS for Families, and Youth Matters), as well as a library of more than 500 videos. The price for a 1-day training session is $1,000, plus expenses. A sample youth questionnaire can be downloaded free from the Drug Resistance Strategies Web site: http://drugresistance.la.psu.edu/index.html. Data analysis of questionnaires is available for a fee of $2.50 per student.
Institute of Medicine Category	Selective, Universal

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Outcomes

Outcome 1: Alcohol, cigarette, and marijuana use

Description of Measures	Substance use was compared using self-reported quantity and frequency of use before the program and at 2, 8, and 14 months after students completed the curriculum. Questionnaires asked how often and how much students used alcohol, cigarettes, and marijuana (e.g., "On how many of the past 30 days did you use alcohol?" and "How many drinks have you had in the past 30 days?").
Key Findings	Curriculum participants reported lower alcohol, marijuana, and cigarette use than students who did not receive the program. Effects lasted up to 14 months for alcohol use and marijuana use and up to 8 months for cigarette use. Matching students' language preference to a particular version of the curriculum (i.e., Spanish or English curriculum) did not improve outcomes for reported substance use. Intervention students who received the Mexican American or the multicultural versions of the curriculum reported lower alcohol use than control students (p = .0018 and p = .0001, respectively). Students who received the multicultural version of the curriculum also reported a slower increase in marijuana use over time compared with control students (p = .0061). Forty percent of participants who used alcohol at baseline reported reductions in alcohol use after receiving the curriculum, compared with 30% of control students who were baseline users (p < .001). Thirty-two percent of intervention students who used alcohol at baseline reported discontinuation of use, compared with 24% of control students who were baseline users (p < .01). Positive outcomes occurred primarily among students who saw four or five of the curriculum videos. For example, compared with control students, intervention students who saw four or more intervention videos reported fewer days of alcohol use (p < .001), fewer drinks consumed (p = .029), fewer days of marijuana use (p = .007), and fewer "hits" of marijuana (p = .007). Curriculum participants who saw fewer than four videos did not report lower rates of substance use.
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 2: Anti-substance use attitudes

Description of Measures	Anti-substance use attitudes were measured with a questionnaire that asked students about their intention to accept offers to use alcohol, cigarettes, or marijuana in the future. It also addressed their beliefs about the positive consequences of substance use and their confidence that they could refuse offers to use substances from an acquaintance, a friend, or a family member.
Key Findings	At the 8- and 14-month follow-ups, students who received the curriculum reported lower expectations of positive consequences of substance use compared with students who did not receive the intervention. Students who received the Mexican American version of the curriculum reported increases in their perceived ability to refuse offers to use substances and smaller increases in intentions to use substances in the future compared with students who did not receive the intervention.
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.6 (0.0-4.0 scale)

Outcome 3: Normative beliefs about substance use

Description of Measures	Antidrug normative beliefs were measured with a questionnaire that asked students what they believed and what their parents and peers believed was right or wrong about substance use. For example, students were asked if they believed it was "OK" for someone their age to use alcohol, cigarettes, or marijuana; how angry their parents would be if they used substances; and how their best friends would act toward them if they used substances. Students were also asked to estimate how many friends or peers in their school used drugs regularly or experimented with them occasionally.
Key Findings	Compared with control students, students receiving the curriculum reported lower personal acceptance of drug use 2 and 8 months after the intervention (but not 12 months afterward). The intervention group also reported smaller increases in estimates of the number of peers who experimented with drugs occasionally and used drugs regularly at 2, 8, and 12 months after the intervention compared with the control group. The intervention had no effect on perceptions of parental or peer norms. Researchers found that students who received the Mexican American version of the curriculum, compared with control students, reported smaller increases in estimates of the number of their friends and peers who used drugs.
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.5 (0.0-4.0 scale)

Outcome 4: Substance use resistance

Description of Measures	Substance use resistance was measured using a questionnaire that asked students if they had used any of the intervention strategies to turn down an offer to use substances: Refuse ("just say no"), Explain ("giving an explanation or some other excuse"), or Leave ("just leaving the situation").
Key Findings	Students in the intervention group reported greater use of these strategies to resist marijuana use 2 months after the intervention and to resist cigarette use 2 and 8 months after the intervention. The effect was not found 12 months after the intervention.
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	1.7 (0.0-4.0 scale)

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Ratings

Quality of Research Ratings by Criteria (0.0-4.0 scale)

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
Outcome 1: Alcohol, cigarette, and marijuana use	3.0	3.0	2.0	2.8	2.5	3.0	2.7
Outcome 2: Anti-substance use attitudes	2.5	3.0	2.0	2.8	2.5	3.0	2.6
Outcome 3: Normative beliefs about substance use	2.5	2.5	2.0	2.8	2.5	3.0	2.5
Outcome 4: Substance use resistance	0.0	0.5	2.0	2.5	2.3	3.0	1.7

Study Strengths: The measures were developed and pilot tested with members of targeted ethnic groups to ensure cultural sensitivity. The psychometric properties were adequate and demonstrated stability over four waves of data collection. Students responded anonymously, which has been shown to enhance the validity of self-report.

Providing teachers with training and a standardized curriculum manual enhanced implementation fidelity, and the observation of 76% of teachers implementing the curriculum demonstrated high fidelity ratings (average fidelity ratings were 5.8 on a scale of 1.0-7.0).

Although attrition was high (only one in four students completed all four waves of the survey), it did not vary significantly by ethnic group, so attrition bias does not appear to be a significant concern. Moreover, missing data were handled appropriately, with multiple imputation using methods developed by Rubin and Little, along with generalized estimating equations (GEE).

Most analyses were sophisticated and appropriate, with large sample sizes and appropriate covariates.

Study Weaknesses: Tests of cultural matching may have suffered from low statistical power caused by including so few African American and White students. There was no examination of the cultural content of programming received by control students.

Despite the use of sensitivity analyses and plans to address attrition, there was a high level of attrition, with two schools not participating in data collection 8 and 14 months after the intervention.

Confounding variables present some concerns. In addition, some of the participants that were at higher risk had stronger outcomes. Consequently, it is unclear if their risk status explains the results better than the success of the intervention.

Approximately 30% of participants saw all five videos; those who did not see at least four videos may have a problem with school attendance, a condition associated with numerous other negative outcomes. In addition, they probably did not receive other aspects of the curriculum at the same level as those who viewed four or five videos.

The resistance strategy measure was developed specifically for this study, and no evidence of reliability was presented. The items are face-valid, yet the scales are limited to yes/no reports of using three strategies. (The program acronym "REAL" reflects four resistance strategies; only Refuse, Explain, and Leave were evaluated, and it is unclear why Avoid was not included.) The emphasis on resistance strategies, which were a key component of the curriculum, varied between the different culturally grounded curricula.

Baseline self-reported use of strategies was controlled in the GEE analyses. However, it is impossible to discern whether the outcomes reflect an increase in the ability to use the strategies (i.e., an increase in skill level) or simply reflect a greater motivation to use the strategies.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

Implementation Materials	Training and Support	Quality Assurance	Overall Rating
3.5	0.5	0.5	1.5

Dissemination Strengths: The program manual is scripted and easy for teachers to use with limited preparation. The video segments are well done, providing a stimulus for dialog and discussion. Materials reflect urban teen culture and realistically present situations that teens might encounter. Program materials are also available in Spanish.

Dissemination Weaknesses: Program materials state that they are effective for students 10-17 years old, but most of the scenarios described in the manual and video seem most appropriate for high school-aged students. Training appears to be available according to the program Web site, but no detailed information is provided on training content or support resources available for implementers. Though the teacher guide provides a basis for measures of fidelity and outcomes, no actual measures or protocols are provided to support quality assurance.

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Contact Information

Web site(s):

http://www.kir.psu.edu/index.html
http://www.discoveryhealthconnection.com

For information about implementation:

Michael Hecht, Ph.D.
Professor and Department Head
Department of Communication Arts and Sciences
Pennsylvania State University
234 Sparks Building
University Park, PA 16802-5201
Phone: (814) 865-3461
Fax: (814) 863-7986
E-mail: mhecht@psu.edu

Brannan Kenny
Discovery Education
One Discovery Place
Silver Spring, MD 20910
Phone: (800) 323-9084
E-mail: brannan_kenny@discovery.com

Michael Bryant
Discovery Education
One Discovery Place
Silver Spring, MD 20910
Phone: (800) 323-9084
E-mail: michael_bryant@discovery.com

For information about studies:

Michael Hecht, Ph.D.
Professor and Department Head
Department of Communication Arts and Sciences
Pennsylvania State University
234 Sparks Building
University Park, PA 16802-5201
Phone: (814) 865-3461
Fax: (814) 863-7986
E-mail: mhecht@psu.edu

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The NREPP review of this intervention was funded by the Center for Substance Abuse Prevention (CSAP).