A systematic review of the effect of the school-based drug prevention program Keepin’ it REAL: translated and implemented in Brazil by PROERD

Valente, Juliana Y.; Galvão, Patricia Paiva de Oliveira; Gusmoes, Julia Dell Sol Passos; Sanchez, Zila M.

doi:10.1590/1413-812320222711.07162022EN

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REVIEW • Ciênc. saúde coletiva 27 (11) • Nov 2022 • https://doi.org/10.1590/1413-812320222711.07162022EN copy

A systematic review of the effect of the school-based drug prevention program Keepin’ it REAL: translated and implemented in Brazil by PROERD

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The Drug Resistance Educational Program (PROERD) is Brazil’s most widespread school-based prevention program; its current curriculum is based on the North American Keepin’ it REAL (kiR) program. There is no evidence of the effectiveness of PROERD in preventing drug use, pointing to the need for further studies to understand these findings. The aim of the study was to synthesis the evidence of the effect of the kiR curriculum (PROERD) through a systematic review. We found 17 studies that reported the effects of different versions of kiR on drug use and/or violence. Except for the Brazilian study, no studies were found that assessed the effect on drug use of the version applied by police officers (DARE-kiR), the same one implemented by PROERD. Favorable evidence of kiR in drug use prevention was found for the 7th-grade curriculum, which contradicts the PROERD’s null-effect results. No international evidence of the effect of kiR was found in the 5th-grade curriculum, in the same line as the PROERD’s study. It is suggested that PROERD’s 7th-grade curriculum should be revised to reflect international results and that the 5th-grade curriculum should be reconsidered in light of the negative international evidence.

Key words:
Primary prevention; Substance use; Systematic review

Reference	Country/City/ Study year	Sample (Students/Schools)	Year	Follow up from starting time	Intervention(s) Description	Evaluated outcomes of drug use and violence	Results
Hecht et al.⁹9 Hecht ML, Marsiglia FF, Elek E, Wagstaff DA, Kulis S, Dustman P, Miller-Day M. Culturally Grounded Substance Use Prevention: An Evaluation of the keepin'' it R.E.A.L. Curriculum. Prev Sci 2003; 4(4):233-248.	United States Phoenix, Arizona 1998	6,035 studants 35 schools	7th grade	24 months	1. 10 classes of keepin’ it REAL (kiR) program - Mexican/Mexican American version 2. 10 classes of keepin’ it REAL (kiR) program - Black/White version 3. 10 classes of keepin’ it REAL (kiR) program - multicultural version	Use of alcohol, cigarettes, and marijuana (last 30 days)	1. All interventions had a significant effect on reducing drug use initiation (e.g., alcohol β=-0.23, SE=0.06, and marijuana β=-0.17, SE=0.05 in wave 4; cigarette β=-0.09, SE=0.04 in wave 3)
Kulis et al. ^29a	United States Phoenix, Arizona 1998	3,402 Mexican-origin students 35 schools	7th grade	14 months	1. 10 classes of keepin’ it REAL (kiR) program - Mexican/Mexican American version 2. 10 classes of keepin’ it REAL (kiR) program - Black/White version 3. 10 classes of keepin’ it REAL (kiR) program - multicultural version	Use of alcohol, cigarettes, and marijuana (last 30 days)	1. Latin version effect on reducing use of marijuana (β=-0.24, SE=0.09). 2. Multicultural version effect on reducing use of alcohol (β=-0.24, SE=0.09), and marijuana (β=-0.16, SE=0.08)
Kulis et al. ^31a	United States Phoenix, Arizona 1998	4,622 predominantly Latino students 35 schools	7th grade	2 months	1. 10 classes of the keepin’ it REAL (kiR) program	Use of alcohol, cigarettes, and marijuana (last 30 days)	1. Program effect on reducing use of alcohol (β=-0.10, SE=0.06), and cigarettes (β=−0.09, SE =0.05) for less acculturated Latino boys
Yabiku et al. ^30a	Estados Unidos Phoenix, Arizona 1998	4,622 predominantly Latino students 35 schools	7th grade	2 months	1. 10 classes of the keepin’ it REAL (kiR) program	Use of alcohol (last 30 days).	1. Program effect on reducing use of alcohol among less acculturated Latinos living in poorer regions and among children of single mothers (β=-1.10, EP=-3.75). Greater program effectiveness in immigrant neighborhoods and in higher-crime-levels neighborhoods.
Kulis et al. ^32a	United States city in the southwestern United States 1999	1,364 predominantly Latino drug-taking students 35 schools	7th grade	14 months	1. 10 classes of the keepin’ it REAL (kiR) program	Reduced or discontinued use of alcohol, cigarettes and marijuana (last 30 days); time to reduce or discontinue recent drug taking; severity of drug taking	1. Program effct on the reduction (OR=1.72) and discontinuation (OR=1.66) of use of alcohol among those who already drank. 2. Discontinuation of use among those who reported taking one or more substances before the start of the intervention was higher in the group that had contact with the kiR (OR=1.61)
Hecht et al.²⁰20 Hecht ML, Elek E, Wagstaff DA, Kam JA, Marsiglia F, Dustman P, Reeves L, Harthun M. Immediate and Short-Term Effects of the 5th Grade Version of the Keepin' it Real Substance Use Prevention Intervention. J Drug Educ 2008; 38(3):225-251.	United States Phoenix, Arizona 2004	1,566 predominantly Latino students 23 schools	5th grade	24 months	1. 12 classes of keepin’ it REAL (kiR) program - multicultural version	Use of alcohol, cigarettes, and marijuana (lifetime use and in the last 30 days).	1. The 5th grade curriculum was not effective in altering student drug-taking and other study outcomes.
Elek et al. ^8b	United States Phoenix, Arizona 2004	1,984 students 29 schools	5th and 7th grades	48 months	1. 12 classes of keepin’ it REAL (kiR) program - kiR-Plus version 2. 12 classes of keepin’ it REAL (kiR) program - kiR-Acculturation Enhanced (kiR-AE) version	Use of alcohol, cigarettes, and marijuana (lifetime use and in the last 30 days)	1. kiR curricula have not been shown to be effective in altering proposed outcomes 2. Students who had contact with either version of kiR only in the 5th grad reported an increase in substance-taking (from 23% to 71%, SE =0.48)
Marsiglia et al. ^21b	United States Phoenix, Arizona 2004	1,670 Mexican-origin students 29 schools	5th and 7th grades	48 months	1. 10 lessons of keepin’ it REAL - original multicultural version for 5th grade 2. 12 classes of keepin’ it REAL (kiR) program - kiR-Acculturation Enhanced (kiR-AE) version for 5th grade 3.10 lessons of keepin’ it REAL - original multicultural version for 7th grade 4. 10 classes of keepin’ it REAL (kiR) program - kiR-Acculturation Enhanced (kiR-AE) version for 7th grade	Use of alcohol, cigarettes, and marijuana (last 30 days)	1. The results do not provide evidence that intervening only in the 5th grade was effective in altering drug use trajectories 2. Implementing the program only in the th grade changed the use trajectories of all drugs (cigarette β=-0.01; marijuana β=-0.02; inhalants β =-0.02)
Marsiglia et al.²⁴24 Marsiglia FF, Booth JM, Ayers SL, Nuño-Gutierrez BL, Kulis S, Hoffman S. Short-Term Effects on Substance Use of the Keepin' It REAL Pilot Prevention Program: Linguistically Adapted for Youth in Jalisco, Mexico. Prev Sci 2014; 15(5):694-704.	Mexico Guadalajara Study year not informed	432 students 2 schools	7th and 8th grades	8 months	1. 10 lessons of Mantente REAL (MR) program: kiR version translated into the Spanish language	Use of alcohol, cigarettes, and marijuana (last 30 days)	1. Program effect on decreasing the frequency of use of alcohol (β=-0.22), and tobacco (β=-0.18)
Marsiglia et al. ^25c	Mexico Guadalajara Study year not informed	431 students 2 schools	7th and 8th grades	8 months	1. 10 lessons of Mantente REAL (MR) program: kiR version culturally adapted to the Spanish language	Use of alcohol, cigarettes, and marijuana (last 30 days)	1. Long-term desired effects were found for use of alcohol (β=0.08 for amount and β=0.06 for frequency), and marijuana β=0.02 for amount and β=0.02 for frequency)
Kulis et al.²³23 Kulis SS, Ayers SL, Harthun ML. Substance Use Prevention for Urban American Indian Youth: A Efficacy Trial of the Culturally Adapted Living in 2 Worlds Program. J Prim Prev 2017; 38(1-2):137-158.	United States Phoenix, Arizona 2009	107 indigenous-origin students 3 schools	7th and 8th grades	3 months	1. 10 classes of keepin’ it REAL (kiR) program - Living in 2 Worlds (L2W) version 2. 10 classes of the keepin’ it REAL (kiR) program	Use of alcohol, cigarettes, and marijuana (lifetime use and in the last 30 days); fighting, stealing or carrying a firearm	1. L2W version effect, compared to the kiR version, on reducing use of cigarettes (t test=2.56)
Hecht et al.²²22 Hecht ML, Shin Y, Pettigrew J, Miller-Day M, Krieger JL. Designed Cultural Adaptation and Delivery Quality in Rural Substance Use Prevention: an Effectiveness Trial for the Keepin' it REAL Curriculum. Prev Sci 2018; 19(8):1008-1018.	United States Pennsylvania and Ohio 2009	2,781 students 39 schools in rural areas	7th grade	36 months	1. Original kiR (developed for urban areas) 2. kiR adapted for rural areas	Lifetime use of alcohol, cigarettes, marijuana, and chewing tobacco; high and low implementation quality	1. Effect of kiR adapted to rural areas on reducing use of cigarettes (regardless of quality of implementation: high quality β=-0.09, SE=0.02; low quality β=-0.06, SE=0.02)
Kulis et al.²⁸28 Kulis SS, Marsiglia FF, Porta M, Arévalo Avalos MR, Ayers SL. Testing the keepin' it REAL Substance Use Prevention Curriculum Among Early Adolescents in Guatemala City. Prev Sci 2019; 20(4):532-543.	Guatemala Guatemala 2013	676 predominantly Latino students 12 schools	6th grade	4 months	1. 10 lessons of Mantente REAL (MR) program: kiR version translated into the Spanish language	Use of alcohol, inhalants, cigarettes and marijuana (last 30 days); stealing; getting into a physical fight; fighting at school	1. MR participants reported a reduction in use of in cigarettes (β=-0.13, SE=0.06) and marijuana (β=-0.10, SE=0.05) compared to the control group. 2. MR non-effect on violence outcomes
Kulis et al.²⁶26 Kulis SS, Garcia-Perez H, Marsiglia FF, Ayers SL. Testing a Culturally Adapted Youth Substance Use Prevention Program in a Mexican Border City: Mantente REAL. Subst Use Misuse 2021; 56(2):245-257.	Mexico Nogales, Sonora 2017-2018	1,418 Mexican students 4 schools	7th grade	7 months	1. 12 classes of Mantente REAL (MR): kiR version culturally adapted for Mexican population	Use (frequency and amount) of alcohol, inhalants, cigarettes, marijuana, and other illicit substances (last 30 days)	1. MR participants reported relatively less frequent use of alcohol (β=-0.04), and other illicit drugs (β=-0.02) compared to students in control schools. 2. Only men reported desirable intervention effects for use of marijuana (frequency β=-0.09; amount β=-0.03). 3. Program effects were shown to be greater among students at higher risk (alcohol frequency β=-0.38; amount of alcohol β=-0.47; illicit drug use β=-0.02)
Kulis et al.⁴⁷47 Kulis SS, Marsiglia FF, Medina-Mora ME, Nuño-Gutiérrez BL, Corona MD, Ayers SL. Keepin' It REAL-Mantente REAL in Mexico: A Cluster Randomized Controlled Trial of a Culturally Adapted Substance Use Prevention Curriculum for Early Adolescents. Prev Sci 2021; 22(5):645-657.	Mexico Mexico City, Guadalajara-Zapopan Monterrey-Apodaca-San Pedro 2017-2018	5,523 Mexican students 12 schools	7th grade	7.8 months	1. 12 classes of Mantente REAL (MR) culturally adapted for Mexico 2. 10 classes of the original kiR translated into the Spanish language	Use of alcohol, cigarettes, marijuana, inhalants and other illicit substances (last 30 days); violence practiced and suffered	1. Among students who already used drugs, the MR proved to be effective in reducing the frequency of use of alcohol (β=0.19) and excessive alcohol consumption (β=0.12) compared to the control and kiR. 2. Students who had contact with the MR reported fewer cases of bullying compared to controls (β=0.10, SE=0.49) and fewer cases of victimization compared to those who had contact with the original Kir (β=0.06, SE=0.02)
Cutrín et al.³³33 Cutrín O, Kulis S, Maneiro L, MacFadden I, Navas MP, Alarcón D, Gómez-Fraguela JA, Villalba C, Marsiglia FF. Effectiveness of the Mantente REAL Program for Preventing Alcohol Use in Spanish Adolescents. Psychosoc Interv 2021; 30(3):113-122.	Spain Santiago de Compostela and Sevilhe 2018-2019	755 Spanish students 12 schools	1st grade of secondary education*	4 months	1. 12 classes of Mantente REAL (MR) culturally adapted for Spain	Frequency and levels of use of alcohol, frequency of heavy use of alcohol, and episodes of alcohol intoxication (last 30 days)	1. The group that had contact with MR reported significantly lower frequency of use of alcohol (ß=-0.04) and intoxication episodes (ß=-0.11) compared to the control group 2. It was observed that the desired MR effect on reducing the levels of use of alcohol was greater in those adolescents who were already involved in heavier use of alcohol before the intervention (ß=-0.40)
Sanchez et al.⁴⁸48 Sanchez ZM, Valente JY, Gusmões JDP, Ferreira-Junior V, Caetano SC, Cogo-Moreira H, Andreoni S. Effectiveness of a school-based substance use prevention program taught by police officers in Brazil: Two cluster randomized controlled trials of the PROERD. Int J Drug Policy 2021; 98:103413.	São Paulo Brazil 2019	4,030 Brazilian students 30 schools	5th and 7th grades	9 months	1. 10 classes of PROED/Caindo na Real (D.A.R.E.-kiR translation	First use of alcohol, tobacco, marijuana, inhalants, and binge drinking	1. No evidence was found that the program is effective in reducing drug-taking initiation in both curricula (5th and 7th grades)

	Selection Bias		Attrition bias	Reporting bias	Other biases	Total score (5-15)
	Proper random sequence generation	Allocation concealment	Incomplete results data	Selectivity in reporting results	Biases not previously reported	Total score (5-15)
Hecht et al.⁹9 Hecht ML, Marsiglia FF, Elek E, Wagstaff DA, Kulis S, Dustman P, Miller-Day M. Culturally Grounded Substance Use Prevention: An Evaluation of the keepin'' it R.E.A.L. Curriculum. Prev Sci 2003; 4(4):233-248.	2	2	3	2	3	12
Kulis et al.²⁹29 Kulis S, Marsiglia FF, Elek E, Dustman P, Wagstaff DA, Hecht ML. Mexican/Mexican American Adolescents and keepin' it REAL: An Evidence-Based Substance Use Prevention Program. Child Sch 2005; 27(3):133-145.	3	2	3	2	3	13
Kulis et al.³¹31 Kulis S, Yabiku ST, Marsiglia FF, Nieri T, Crossman A. Differences by Gender, Ethnicity, and Acculturation in the Efficacy of the keepin' it Real Model Prevention Program. J Drug Educ 2007; 37(2):123-144.	2	2	3	2	3	12
Yabiku et al.³⁰30 Yabiku S, Kulis S, Marsiglia FF, Lewin B, Nieri T, Hussaini S. Neighborhood Effects on the Efficacy of a Program to Prevent Youth Alcohol Use. Subst Use Misuse 2007; 42(1):65-87.	2	2	3	2	3	12
Kulis et al.³²32 Kulis S, Nieri T, Yabiku S, Stromwall LK, Marsiglia FF. Promoting Reduced and Discontinued Substance Use among Adolescent Substance Users: Effectiveness of a Universal Prevention Program. Prev Sci 2007; 8(1):35-49.	2	2	3	2	3	12
Hecht et al.²⁰20 Hecht ML, Elek E, Wagstaff DA, Kam JA, Marsiglia F, Dustman P, Reeves L, Harthun M. Immediate and Short-Term Effects of the 5th Grade Version of the Keepin' it Real Substance Use Prevention Intervention. J Drug Educ 2008; 38(3):225-251.	1	2	3	2	3	11
Elek et al.⁸8 Elek E, Wagstaff DA, Hecht ML. Effects of the 5th and 7th Grade Enhanced Versions of the Keepin' it Real Substance Use Prevention Curriculum. J Drug Educ 2010; 40(1):61-79.	1	2	1	2	1	7
Marsiglia et al.²¹21 Marsiglia FF, Kulis S, Yabiku ST, Nieri TA, Coleman E. When to Intervene: Elementary School, Middle School or Both? Effects of keepin' It REAL on Substance Use Trajectories of Mexican Heritage Youth. Prev Sci 2011; 12(1):48-62.	2	2	3	2	3	12
Marsiglia et al.²⁴24 Marsiglia FF, Booth JM, Ayers SL, Nuño-Gutierrez BL, Kulis S, Hoffman S. Short-Term Effects on Substance Use of the Keepin' It REAL Pilot Prevention Program: Linguistically Adapted for Youth in Jalisco, Mexico. Prev Sci 2014; 15(5):694-704.	1	2	3	2	1	9
Marsiglia et al.²⁵25 Marsiglia FF, Kulis SS, Booth JM, Nuño-Gutierrez BL, Robbins DE. Long-Term Effects of the keepin' it REAL Model Program in Mexico: Substance Use Trajectories of Guadalajara Middle School Students. J Prim Prev 2015; 36(2):93-104.	1	2	3	2	1	9
Kulis et al.²³23 Kulis SS, Ayers SL, Harthun ML. Substance Use Prevention for Urban American Indian Youth: A Efficacy Trial of the Culturally Adapted Living in 2 Worlds Program. J Prim Prev 2017; 38(1-2):137-158.	3	2	3	2	1	11
Hecht et al.²²22 Hecht ML, Shin Y, Pettigrew J, Miller-Day M, Krieger JL. Designed Cultural Adaptation and Delivery Quality in Rural Substance Use Prevention: an Effectiveness Trial for the Keepin' it REAL Curriculum. Prev Sci 2018; 19(8):1008-1018.	1	2	3	2	1	9
Kulis et al.²⁸28 Kulis SS, Marsiglia FF, Porta M, Arévalo Avalos MR, Ayers SL. Testing the keepin' it REAL Substance Use Prevention Curriculum Among Early Adolescents in Guatemala City. Prev Sci 2019; 20(4):532-543.	1	2	3	2	1	9
Kulis et al.²⁶26 Kulis SS, Garcia-Perez H, Marsiglia FF, Ayers SL. Testing a Culturally Adapted Youth Substance Use Prevention Program in a Mexican Border City: Mantente REAL. Subst Use Misuse 2021; 56(2):245-257.	1	2	3	2	1	9
Kulis et al.⁴⁷47 Kulis SS, Marsiglia FF, Medina-Mora ME, Nuño-Gutiérrez BL, Corona MD, Ayers SL. Keepin' It REAL-Mantente REAL in Mexico: A Cluster Randomized Controlled Trial of a Culturally Adapted Substance Use Prevention Curriculum for Early Adolescents. Prev Sci 2021; 22(5):645-657.	1	2	3	2	1	9
Cutrín et al.³³33 Cutrín O, Kulis S, Maneiro L, MacFadden I, Navas MP, Alarcón D, Gómez-Fraguela JA, Villalba C, Marsiglia FF. Effectiveness of the Mantente REAL Program for Preventing Alcohol Use in Spanish Adolescents. Psychosoc Interv 2021; 30(3):113-122.	2	2	3	2	3	12
Sanchez et al.⁴⁸48 Sanchez ZM, Valente JY, Gusmões JDP, Ferreira-Junior V, Caetano SC, Cogo-Moreira H, Andreoni S. Effectiveness of a school-based substance use prevention program taught by police officers in Brazil: Two cluster randomized controlled trials of the PROERD. Int J Drug Policy 2021; 98:103413.	3	2	3	2	3	13

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[1] Collaborations

JY Valente was responsible for writing the first version of the article and for the selection and analysis of articles included in the systematic review. ZM Sanchez, PPO Galvão and JDSP Gusmoes also contributed to the selection process and analysis of articles included in the systematic review. ZM Sanchez was also responsible for reviewing the final version of the manuscript. All authors read and approved the article.