“keepin’ It REAL”: A Case History of a Drug Prevention Intervention
“keepin’ It REAL”: A Case History of a Drug Prevention Intervention
- Michael L. HechtMichael L. HechtREAL Prevention, LLC
- and Michelle Miller-DayMichelle Miller-DayCommunication Studies, Chapman University
Adolescent substance use and abuse has long been the target of public health prevention messages. These messages have adopted a variety of communication strategies, including fear appeals, information campaigns, and social marketing/branding strategies. A case history of keepin’ it REAL, a narrative-based substance abuse prevention intervention that exemplifies a translational research approach, involves theory development testing, formative and evaluation research, dissemination, and assessment of how the intervention is being used in the field by practitioners. The project, which started as an attempt to test the notion that the performance of personal narratives was an effective intervention strategy, has since produced two theories, an approach to implementation science that focused on communication processes, and, of course, a school-based curriculum that is now the most widely disseminated drug prevention program in the world.
At the core of the keepin’ it REAL program are the narratives that tell the story of how young people manage their health successfully through core skills or competencies, such as decision-making, risk assessment, communication, and relationship skills. Narrative forms not only the content of curriculum (e.g., what is taught) but also the pedagogy (e.g., how it is taught). This has enabled the developers to step inside the social worlds of youth from early childhood through young adulthood to describe how young people manage problematic health situations, such as drug offers. This knowledge was motivated by the need to create curricula that recount stories rather than preaching or scaring, that re-story health decisions and behaviors by providing skills that enable people to live healthy, safe, and responsible lives. Spin-offs from the main study have led to investigations of other problematic health situations, such as vaccination decisions and sexual pressure, in order to address crucial public health issues, such as cancer prevention and sex education, through community partnerships with organizations like D.A.R.E. America, 4-H clubs, and Planned Parenthood.
- Communication Theory
- Communication and Social Change
- Health and Risk Communication
- Interpersonal Communication
keepin’ It REAL (kiR) is a group of drug abuse prevention interventions that bridge basic research and health innovations. kiR is an exemplar translational research endeavor where theory and practice are merged and where teaching, research, and service come together in a perfect blend. The term translational research has been used to reference the multiphased process by which research-generated knowledge directly or indirectly serves the general public. There is a continuum of translation (NIH). The continuum is depicted as beginning with T0 translation, which refers to basic research; T1 translation, which involves the development of programs, practicMulticules, products, and/or policies translated from basic research findings; T2 translation, which is aimed at assessing the efficacy and effectiveness of the intervention; and T3 translation, which addresses dissemination and adoption of the intervention by the target audience and assesses implementation and sustainability of the intervention (Wethington & Dunifon, 2012). kiR research has moved through these stages and has developed and tested theory through practice (Miller-Day & Hecht, 2010). This article tracks the history and evolution of kiR from its roots in basic research to its current implementation.
Every story has a beginning. kiR’s story began in the late 1980s, when most work in health communication was considered applied, with “basic” laboratory and experimental research the most highly valued contributions (Miller-Day & Hecht, 2010). The authors of this article had just begun working together. Michelle was a graduate student and Michael a professor. Michelle Miller-Day first approached Michael Hecht about extending her Master’s thesis research, which was based on the concept of “trigger scripting” (Valentine, 1979), where narratives are scripted and shared with an audience to heighten identification with a social issue, to encourage emotional release, to bring about insights, to foster understanding, and to change attitudes and opinions (Mann, Hecht, & Valentine,1988; Miller-Rassulo,1988; Miller-Rassulo & Hecht, 1988). At this time, Nancy Reagan’s “Just say ‘No’” drug prevention campaign was at the height of its popularity. The program had begun in 1986, and by 1988 it was ubiquitous, with more than 12,000 “Just say No” clubs in the United States (Just Say No, 2010). The authors believed that resistance strategies, such as skills of refusal (just say “No”), were fundamentally about interpersonal communication, so we joined forces to expand interpersonal communication theory and to conduct basic research into the context of adolescent drug offers and refusals. The aim was to understand and to explain problematic interpersonal communication in these contexts, to understand what happens communicatively in adolescent drug offers. This key social-influence process was central to peer-pressure models of drug use (Kandel, 1986) and social-influence models of substance abuse prevention (Tobler, Roona, Ochshorn, Marshall, Streke, & Stackpole, 2000). As we explored the research, it became clear that there was a gaping hole in the literature. Nobody was studying influence processes in drug-offer contexts and nobody was collecting the accounts of actual teens to assess the “in situ” experience of drug offers, acceptance, and/or refusal. Given this gap, first we sought to expand our knowledge of the social-influence process in drug-offer contexts. Second, we sought to use that information to build a performance intervention around the narratives of actual teenagers in order to enhance adolescent social competencies. Third, we sought to evaluate the effectiveness of this communication-based intervention in preventing adolescent substance abuse.
It may have seemed like a lot to take on at the time (and it was!) and we really had no idea it would lead to a partnership that has now lasted over 30 years, that has resulted in over 100 publications, that has been awarded over $12 million in grant support, and that has resulted in the most widely disseminated substance use prevention curriculum in the world (see http://www.dare.org/). Presently, this work has led to the formation of a company, REAL Prevention (www.real-prevention.com) that is rapidly growing through community partnerships.
Basic Research: Communication in Drug-Offer Contexts
Our early research provided a descriptive basis for understanding adolescent’s substance use, the social context of adolescent drug offers and refusals, and early, but promising, findings on the efficacy of a high-school prevention curriculum (Miller, Alberts, Hecht, Trost, & Krizek, 2000). The work revealed that youth primarily use four strategies to refuse drug offers: refuse (simple No), explain (No with an explanation), avoid (verbal or nonverbally), or leave (Alberts, Miller-Rassulo, & Hecht, 1991). Perhaps surprisingly, the strategies were replicated across age groups from elementary school to college students and across the country (Alberts, Hecht, Miller-Rassulo, & Krizek, 1992; Hecht, Alberts, & Miller-Rassulo, 1992). Moreover, when Norris extended our work by asking young Latinas how they resist sexual pressure, she reported very little difference, with the exception of punching the pressurer in the face (Norris, Pettigrew, Miller-Day, Hecht, Hutchison, & Campoe, 2015), and Pettigrew reported the use of these strategies in Nicaragua (Pettigrew, Sohn, Dalton, Castillo, & Allsup, 2015). This early work unpacked other aspects of the social context of drug offers, including revealing that there was less explicit pressure than was commonly assumed (Alberts et al., 1991) and that pressure tended to be applied in a series of moves rather than in a single conversational turn (Alberts et al., 1992). The rich narratives collected in these studies formed the basis of our intervention development.
T1 Translational Research: Intervention Development
Strongly influenced by early research findings on the power of performance in interpersonal persuasion (Boal, 1985; Miller-Rassulo, 1988) and, in particular, the power of personal narratives to shape and reflect attitudes and behaviors (Fisher, 1985; Miller-Rassulo & Hecht, 1988), youth narratives of drug offers, resistance, and acceptance were collected, analyzed, and prepared for adaption into performance scripts (Miller et al., 2000). We worked with a filmmaker to script the narratives for two delivery modalities: live performance and video. The scripts were reviewed by groups of youth and drug prevention educators and were revised based on their feedback. Once the scripts were complete, the live performances had been cast and rehearsed and were ready to perform, and the video had been produced and edited, we conducted a group randomized trial of the intervention’s efficacy. Four treatment conditions (video presentation plus discussion, video presentation only, live performance plus discussion, live performance only) and one control condition were compared as drug prevention interventions. The messages in both the live performance and video production emphasized four communication competencies needed for refusal efficacy: refuse, explain, avoid, and leave. The intervention was delivered in a single session in one high school, with the video projected on a large screen in an auditorium or the live performance performed in that auditorium on a stage. A pretest was administered 1 month before the intervention and a posttest 1 month afterward. Results indicated that both film and live performances were effective in decreasing self-reported use of drugs other than alcohol over a 1-month period. Discussion added to the performance or video screening did not detract from training effectiveness and marginally improved the process (Hecht, Corman, & Miller-Rassulo, 1993).
These findings encouraged our theorizing about health message design. In the tradition of action research, we began testing theories by applying them in the field (Dick, Stringer, & Huxham, 2009). We turned next to integrating more of Hecht’s work on ethnicity and culture by examining if ethnicity and gender played a role in the influence process. Hecht had been looking at similarities and differences in communication among various ethnic groups and our work turned in this direction. The work was influenced by Hecht’s emerging Communication Theory of Identity (CTI; Hecht, 1993), with its emphasis on the complex, multilayered nature of identity. CTI conceptualizes identity on four levels: personal, enacted, relational, and communal. The levels are seen as being “interpenetrated” and intertwined. We conceptualized drug use, drug offers, and drug-offers-to-be, as being an enactment of identities because they express or perform an identity. For example, the term druggy denotes a particular identity group and expression, and others describe their resistance by saying they “are not that type of person.” Our substance use work, however, came to focus on gender and ethnicity. We asked whether the drug-offer process, including resistance strategies, differed among those who identified in various ways with different ethnic or gender groups. In general, the strategies held up (i.e., all groups used all strategies), with some differences in their frequency and execution. All groups are most likely to receive offers from acquaintances and were most likely to use a simple No, with relatively small repertoires of resistance strategies (Moon, Hecht, Jackson, & Spellers, 1999; Moon, Jackson, & Hecht, 2000). Some ethnic differences were observed. Mexican Americans (i.e., youth of Mexican heritage), for example, are more likely to be offered alcohol, marijuana, hard drugs, and inhalants by a brother in a friend’s home or on the street, while European Americans (i.e., youth of European heritage and Caucasian race/ethnicity) are more likely to be offered cigarettes by a male or female acquaintance at a party (Moon et al., 1999). Males are more likely to be offered all types of drugs in public (i.e., at the park or on the street) and to be offered them by a male acquaintance, parent, brother/male cousin, or male stranger, through offers that state the benefits of use. And males resist using explanations, especially involving humor. When females receive offers, they are more likely to be in private (i.e., a friend’s home), by a female acquaintance, boyfriend, or sister/female cousin, through simple offers or offers that minimize the effects of use. We also examined risk and resiliency factors (Moon et al., 2000). We found that for males, risk had a direct effect on use and an indirect effect through age at first use. However, males’ resiliency or their ability to overcome risk and to succeed only affected use through age at first use. For females, resiliency had a stronger and independent effect, while risk had only an indirect effect through first use. Thus, for males, it is important to intervene before first use.
At this point, we were ready to delve back into intervention design, although our focus was on a younger, middle-school population. This move was largely pragmatic. Initiation of drug use was occurring at younger ages, and the prevailing thought in prevention science was to try to reach youth right before they started experimenting. Very early adapters who experiment at younger ages were already using, but for a “universal” intervention” that tries to reach a general audience, most had not yet experienced using illicit substances, though many may have consumed wine in a religious ritual. However, a general audience consists of males and females as well as members of various ethnic groups, so our approach was to target both genders as well as multiple ethnic groups and to compare that to a multicultural approach.
Multiculturalism had become a very popular approach in the educational and social science communities. Often associated with critical and cultural studies and their emphasis on identity politics from a leftist perspective, multiculturalism also had its roots in the more pluralistic view of social relations that characterized anthropology and sociology, for example, for most of their histories (Marsiglia & Hecht, 1998). While social psychology and communicators who followed its lead remained focused on work among white, middle-class, college first- and second-year students in basic courses, others embraced diversity and the complexity and richness it brought to theories, research, and practice. The authors were clearly in the latter camp and our new work reflected that.
So, starting anew, we began to develop an intervention for middle-school delivery, targeting seventh and eighth graders. The prevention field “encouraged” us through grant reviews to consider a longer curriculum—ten lessons was the norm we adopted after initially proposing four lessons. This caused us to think more broadly about prevention and how to influence youth at a critical time when many tend to turn away from authority (Kandel, 1986). We decided to continue the narrative focus in both message content and delivery style, avoiding the fear and morality messages that were common in the prevention field (Tobler et al., 2000). This led to a highly interactive teaching style at a time when the prevention field was coming to the conclusion that this approach was almost a necessary condition for efficacy (Tobler et al., 2000). But interactivity was more than just a pedagogical technique to us. Rather, it was embedded in our narrative approach. Stories are inherently interactive when exchanged and our approach called for the presentation of prototypical narratives to provoke further narrative exchange. Our idea was to approach the prevention intervention from the perspective and experiences of youth while applying prevention science to overall program development. We sought to present stories of the youth we interviewed in each program video, providing behavioral modeling opportunities for each refusal strategy. Additionally, we infused each lesson with role playing, decision-making scenarios, and question-and-answer sessions.
Our curriculum became known as keepin’ it REAL after a group of students suggested the title—a very lucky move on our part, because the expression was vernacular then and retains currency to this day. At the same time, it was our intent to create three versions of the curriculum. The first two versions were to be “targeted” interventions aimed at Latinos and whites, the two largest ethnic groups in the schools with which we were collaborating in south Phoenix, Arizona. Our plan was to mix the two curricula so that we would have a multicultural version. However, when we enlisted a performing arts high school to collaborate on the videos (the “through kids” element of our “from kids, through kids, to kids” approach), the students balked at our plans, saying that African American students had to play a role if they were to work with us. Blacks constituted a smaller minority in the target schools, but after reflecting on the students’ logic, we realized that black pop culture was pervasive in the student population. Moreover, the leading curriculum at the time had two versions—one for whites and one for both Puerto Ricans and African Americans (Botvin, Schinke, Epstein, Diaz, & Botvin, 1995). Since Latinos were the largest group, we decided that the second curriculum would target whites and African Americans and then our multicultural version would include all three groups. (This turned out to be fortuitous when the curriculum was distributed nationally in later years, but we are getting ahead of the story.)
In building out the rest of our curriculum, based on our theoretical framework, we developed ten lessons for teaching seventh graders decision making and other relational and communicative skills like conflict resolution to increase the power of the intervention. Next, we turned to social cognitive theory (Bandura, 1986), which focuses on the use of role models to develop norms and to create efficacy in performing behaviors, and we found it useful in elaborating our prevention model to include role models of drug-free living in the lessons to enhance resistance self-efficacy and to promote antidrug social norms. As with other moves, this presaged our incorporation of social and emotional learning theory (SEL) when we extended our work to younger children in elementary schools (Durlak, Domitrovich, Weissberg, & Gullotta, 2016). SEL identifies keys skills that promote healthy living and that guide the lessons (e.g., emotion regulation, decision-making, communication). In each case, the following year (eighth grade for middle school and sixth grade for elementary school) we implemented a four-lesson “booster” program designed to reinforce and extend the prevention content.
Structurally, we followed the narrative pedagogical model (Goodson & Gill, 2011; Ironside, 2003). Each lesson began with a story introducing a construct (e.g., decision making, conflict). This was followed by guided discussion during which youth narratives were expected to emerge. A brief, didactic learning session was followed by guided narrative practice, and homework applying the skills. By narrative practice we mean that students were presented with an incomplete or “cliff hanger” story (a story with no ending) followed by application of the designated class skill to resolve the issue. The situations were always problematic (Ironside, 2003), in that they placed the youth in a situation in which something required resolution.
One unique feature of the curriculum was the involvement of youth in developing their own messages. Our motto or theme was “from kids, through kids, to kids” and this was demonstrated in a number of ways. First, as mentioned, youth narratives were scripted into five videos. These were used to introduce the curriculum in Lesson 1 and then to model the REAL resistance skills and confer more positive norms in four additional lessons. Each video told a story—first about the entire curriculum and then a story about one of the situations in which drugs are commonly offered, as well as strategies for resisting or saying No. The videos were central to the curriculum and were created by older, near-peer youth with guidance from the project team. In the original middle-school curriculum, for example, South Mountain High School video classes produced the five videos. Preliminary research among high-school students showed that a video using this approach followed by discussion was effective in reducing substance use 30 days later (Hecht et al., 1993). Later research demonstrated a significant effect for the videos by themselves (Warren et al., 2006).
Second, the narratives were integrated into the lessons to create scenarios used in practice and discussion. Each lesson involved applying the construct being taught to problematic, real-life situations, first as a class, then in small groups, and finally in homework. The scenarios for the situations were drawn from our interviews.
Third, youth receiving the curriculum provided their own narratives during the lessons. Discussions were meant to avoid yes/no responses and to elicit more descriptive narratives. For example, after introducing a concept (e.g., assertiveness), we might have asked students to describe situations in which assertiveness was needed. Then we gave them problematic situations they could face in life and had them describe and role-play assertive solutions.
Finally, the sixth and eighth grade booster programs involved guiding youth to create their own antidrug messages focused on REAL—or how to refuse drug offers. We adopted this message strategy (focusing on REAL) in order to minimize fear or moralistic messages that are unlikely to influence others (Beaudoin, 2002). At the same time, this may involve counter-attitudinal advocacy for those who hold more favorable or prodrug norms and attitudes, a process whereby publicly communicating a belief that runs counter to a belief that the individual currently holds causes a change in behavior (Festinger & Carlsmith, 1959). The eighth grade booster program for our newer rural curriculum is described in greater detail by Krieger, Coveleski, Hecht, Miller-Day, Graham, Pettigrew, and Kootsikas (2013). This “active engagement” strategy, we believe, has great promise in our media-rich environment, where every smartphone is a video camera just a click away from sharing on social media.
T2 Translational Research: Implementation and Evaluation
The original development and evaluation of the keepin’ it REAL program was a massive undertaking (Hecht, Graham, & Elek, 2006). Fortunately, we were able to enlist the enormously talented Dr. Amira de la Garza and her students, Monica Gosin and Amy Drapeau, to develop the curriculum from the model we had created (Gosin, Marsiglia, & Hecht, 2003). We hired others to administer the program. We thought we were set to accomplish the task with a large, interdisciplinary team, but our training had really not prepared us for the complexity of the task. From months and months of door-to-door school recruitment in the sweltering Phoenix summer heat, to dealing with the artistic temperaments of the performing arts students and their teachers, to tensions within the team, almost everything was a challenge. In the end, the challenge was worth the effort, when keepin’ it REAL proved effective, with treatment-group participants reporting significantly less substance use and moderated trajectories of use compared with the control group (Hecht, Graham, & Elek, 2006). The effects persisted 14 months after the intervention, when our posttesting stopped (Hecht et al., 2006), and were even found among youth who reported substance use on the pretest prior to the intervention (Kulis, Yabiku, Marsiglia, Nieri, & Crossman, 2007). That meant that the program worked both as a treatment for youth who were already using substances and as prevention for those who had not yet begun.
We followed this original study with two additional efforts. First, we conducted a second study in Phoenix, AZ. This study included an unsuccessful attempt to teach the kiR curriculum to elementary school students (i.e., fifth grade; Elek, Wagstaff, & Hecht, 2010) but did demonstrate additional evidence in support of the middle-school curriculum (Marsiglia, Kulis, Yabiku, Nieri, & Coleman, 2011). This convinced us of the importance of developmental adaptations rather than superficial presentation adaptations (e.g., using more animation for younger children) but supported our original purposes of true cultural grounding.
We then adapted the curriculum to rural settings and carefully described the implementation processes of both the original multicultural kiR and the rural kiR (Colby et al., 2013). Into the 21st century, nearly half of U.S. public schools implemented some form of evidence-based substance use prevention program; therefore, issues of implementation fidelity and adaptation of programs had become an interest to prevention science (Ringwalt et al., 2010). Scholars were asking how adequately evidence-based models were being implemented in the field (Durlak & Dupre, 2008). We sought to understand how teachers actually implemented kiR and how they adapted the program to fit their needs (implementer adaptation; Miller-Day et al., 2013). Moreover, in addition to examining implementer adaptations of the program, we set out to adapt the program ourselves (researcher adaptation) for rural youth, and this program was called Rural kiR (Colby et al., 2013).
Others later reported that kiR returned a cost benefit of 28 to 1 (Miller, Alberts, Hecht, Trost, & Krizek, 2000) and the original group that implemented kiR at Arizona State also continued down their own path of adaptation and successful implementation (Kulis et al., 2007). Perhaps most importantly, kiR was recognized as a “model program” by the federal Substance Abuse and Mental Health Administration’s National Registry of Evidence-based Programs and Practices (NREPP), a registry that proved to be the most influential in school program adoption. Additionally, kiR is a model program listed in the National Dropout Prevention Center and also in Crime Solutions by the National Institute of Justice.
Demonstrating we had an effective evidence-based program, however, was only part of the contribution of the research. A number of theoretical advances also resulted from these efforts. Chronologically, the focus on ethnic and gender cultures led our team to articulate the principle of cultural grounding as an organizing framework for our message design (Hecht & Krieger, 2006). This principle grew out of Hecht’s earlier work on culture and identity and the resulting communication theory of identity (Hecht, 1993) to argue that culture was expressed through a nexus of four layers or frames of identity. This complex view is reflected in the research described above, where, for example, we were concerned with both ethnic labels (personal identity) as well as cultural narratives (enacted identity). We quickly realized that there was an underlying assumption about how we were translating this into health message design—and that became the principle of cultural grounding (Hecht & Krieger, 2006).
While culturally grounded messages (i.e., messages derived from the target audience) were central to our work on health message design, narratives and various narrative theories guided our strategy from its inception through our translation into keepin’ it REAL. As with cultural grounding, we began to realize that the theories did not fully describe how narratives worked and, therefore, were not as helpful as they might have been in guiding narrative message design. Again, our view of narrative emerged with and through our research into what we came to call narrative engagement theory (NET), or more modestly, a narrative engagement framework (Miller-Day & Hecht, 2013). NET argues that narratives work because they engage the audience. Veering away from transportation theory (Green & Brock, 2000), we felt that maintaining some distance from the narrative rather than full immersion was ideal for persuasion (if not for artistic success). Moreover, building on social cognitive theory’s emphasis on modeling (Bandura, 1986), we decided that both mental and behavior models were needed for effect. We argued that a high degree of interest in the message was desirable because it focused attention and led to systematic or central processing that resulted in more enduring change; however, if one became lost in the narrative or transported, heuristic or peripheral processing was likely and thus less enduring influence would be produced (Petty & Cacioppo, 1986). That is, effective narratives model both thought and action. This led us to articulate three elements or dimensions of narrative engagement: interest, realism, and identification. We saw identification as the mental modeling through the connection to the characters, while realism reflected authentic behavioral modeling. We started by developing a self-report scale (Lee, Hecht, Miller-Day, & Elek, 2011) and then used the scale in research supporting both the utility of the model in predicting behavioral change as well as the superiority of this engagement model over the transportation model (Hopfer, 2010).
T3 Translational Research: The Story Continues
At this point the story branches, as successful stories will. Dr. Anne Norris read about the work, and she adapted it to understanding, first, how adolescent Latinas resist sexual pressure (Norris et al., 2015) and then to guide the development of an innovative, interactive video game to improve resistance skills, to increase self-efficacy, and, ultimately, to reduce risky sexual behaviors (Norris et al., 2013). It is interesting to see that Latinas basically use REAL as their repertoire of resistance strategies, with one notable addition— if they experience too much aggression, they will punch the person pressuring them in the nose. The video game provides an original tool for utilizing narratives for health promotion. Norris’s approach employs avatar-based virtual reality (AVR) technology as a powerful alternative to role play; it is an interactive simulation experience in which a player can literally (but not actually) talk with an adolescent avatar in private (Wirth, Norris, Mapes, Ingraham, & Moshell, 2011). In this application of REAL in the context of sexual pressure, a 3D avatar is created through digital puppetry to create verbal and nonverbal behaviors that mirror the youth playing the game (e.g., hair flip, eye roll). Verbal and nonverbal responses of the avatar in the actual interaction are triggered by a human puppeteer. The synchronous interaction in real time allows the live actor/puppeteer to tailor the game play experience to the youth player’s skill level and to adapt responses to the exigencies of the interaction. In this game play, the adolescent player is presented with a series of novel interpersonal situations (i.e., peer-pressure situations) and points are earned for socially competent and effective responses to the situations. The challenge of finding the best way to respond to a novel and changing interpersonal context makes game play fun and engaging (Koster, 2005). This promising intervention strategy is now being tested throughout the public-school system in Miami, FL.
A second path has been taken by Dr. Suellen Hopfer, who was trained in narrative intervention practice by her teachers, Drs. Parrott, Miller-Day, and Hecht, as well as the by broader narrative literature. She has focused on the prevention of human papilloma virus (HPV) infection, a cause of cancer and sexually transmitted disease, by promoting the HPV vaccine. Hopfer, realizing that there was an effective vaccine for the virus that was vastly underutilized, decided to focus on decision narratives, or how women decide to get the vaccine (Hopfer & Clippard, 2010). The work revealed characteristics of vaccine-acceptance and vaccine-resistance narratives of college-age women, and Hopfer converted the narratives into scripts portraying women overcoming resistance and making the decision to vaccinate. Amazingly, the videos almost doubled vaccination rates among the college students in her study (Hopfer, 2012). Continuing this work with Hecht and Miller-Day, the approach of identifying narratives and adapting the narratives into health messages framed as “women’s stories” is now being tested among Planned Parenthood clients and at eight universities throughout the United States.
A third path was followed by Dr. Kathryn Greene in adapting her media literacy, substance use prevention curriculum for broader use. Greene and Hecht received a grant to create a web-based curriculum for use by 4-H clubs that re-stories advertising that promotes tobacco and alcohol use, and engages youth in creating their own antidrug stories and in sharing them among their peers and family. The new curriculum, REAL messages, is highly interactive, attempting to engage youth in analyzing and critiquing the story being told by advertisers and then in planning and executing counter-messaging among their peers. Results have been promising, with a face-to-face version demonstrating effects on proximal outcomes, such as substance use intentions (Banerjee, Greene, Magsamen-Conrad, Elek, & Hecht, 2015) while the web-based e-learning version proved feasible and was well received in preliminary research.
Another path, pursued by Dr. Linda Larkey, who worked with both Hecht and Miller-Day during her doctoral training, diverged from substance use prevention and kiR, but extended the narrative approach into the realm of cancer screening and prevention (Larkey & Hill, 2012). Dr. Larkey and her colleagues developed a variety of narrative health promotions to address colorectal cancer (Larkey et al., 2009; Robillard & Larkey, 2009) and osteoporosis (Larkey, Day, Houtkooper, & Renger, 2003).
The furthest path took the kiR story to Nicaragua. Dr. Jonathan Pettigrew, while visiting a friend in that country, learned that the U.S. Embassy was looking to extend its outreach to youth enhancement. Pettigrew obtained funding to develop a “Nica” version of keepin’ it REAL and a Nica version of the Fourth R, which focuses on healthy relationships, for delivery in private schools and community organizations (Wolfe et al., 2009). Politics, unfortunately, kept the project out of the public schools. Enlisting Miller-Day and Hecht as consultants, Pettigrew set out to reground kiR through the stories of Nicaraguan youth (Pettigrew et al., 2015) and these formed the adapted Nicaraguan kiR. There were both surface and deep structure changes to this version of the kiR program. The new youth narratives and experiences were woven into the lessons in terms of examples, role-play scenarios, and skill application activities, and new Spanish language videos were developed using the narratives to introduce the program and to illustrate and model the resistance strategies of refuse, explain, avoid, and leave.
The widest path, however, was the adoption and adaptation of keepin’ it REAL for delivery by police officers in D.A.R.E.’s wide-ranging program. Drug Abuse Resistance Education (D.A.R.E.) is an international substance abuse prevention education program that seeks to prevent use of controlled drugs, membership in gangs, and violent behavior. D.A.R.E., after several curriculum attempts, decided that it would adopt an evidence-based curriculum and it chose kiR in 2009. Adaptation of the program for D.A.R.E., or what we call “DARE-ifying,” involved clarifying the lesson plans for delivery by officers rather than teachers and producing new sets of videos for a national audience, including rural, suburban, and urban REAL videos. Based on the successful implementation of the D.A.R.E. keepin’ it REAL program, what followed next was an adaptation for elementary-school students. The D.A.R.E. EkiR (elementary keepin’ it REAL) program was developed along the same principles and procedures as all previous versions of kiR, following the theoretical and conceptual model of kiR and integrating the foundational concepts of social and emotional learning (SEL). Targeting children in fifth grade, this curriculum is designed to engage the youth through peer stories and videos that merge live action with animation. The animated characters are then integrated into the lessons, illustrations, workbooks, and supplemental materials. One supplemental material designed to augment the program is REAL Adventures, a comic book that offers an illustrated version of the stories in the videos and the situations posed in the lessons. The original kiR program in its many adaptations—mostly surface changes in terms of integrating regional narratives—has to date reached almost 2 million youth in the United States and in 52 countries around the world. This has been quite a journey (http://www.dare.org/).
The future will bring several expansions. We are currently developing an online version of the elementary curriculum that we call EkiR mobile. This version of the program will allow officers and students to access the curriculum through computers, tablets, and smartphones. A unique feature of the project is the developer’s augmented reality technology, which allows a student to scan an image to experience a talking, 3-D version of the various characters who tell their stories throughout the curriculum. The app for the program is free and available for download on a variety of mobile devices. The app offers a variety of features, including a portal to the lessons for students, officers, and teachers, games, and a decision-making activity for youth to navigate decisions made in their daily life both inside and outside the classroom. The application also has a parent portal that provides a variety of resources in substance use prevention for parents, including information on how to communicate with youth about substances and substance use. Additional online education enhancements also are planned.
As our story unfolds, we also are in the process of expanding the age ranges reached by the kiR program. In addition to the middle-school kiR programs and the elementary kiR, we are in the midst of developing programs for a new D.A.R.E. high-school curriculum. DARE HS will have three components. First, the media literacy work described above will be adapted for online or face-to-face delivery by officers. Second, we will partner with David Wyrick and his organization Prevention Strategies to adapt their “myPlaybook” curriculum for delivery by D.A.R.E. officers to student athletes. Finally, we developed “Celebrating Safely" a brief intervention for officers to access and implement during annual homecoming, prom and graduation events. Integrating youth stories along with legal information and advice for youth, the intervention offers a range of resources, including a classroom or assembly presentation, a video used to analyze and critique the decision-making of a prom-going female student, and tip sheets for parents and for schools pertaining to hosting pre- and post-event parties and transportation issues.
As we have been expanding the keepin’ it REAL program across international borders and have collaborated with a variety of agencies, the visibility of the program has increased. We are consistently approached by school districts without D.A.R.E in their community who ask to access the program. Therefore, we developed a small business, called REAL Prevention, to provide the original kiR program to schools and other youth organizations, to train and support the implementation of kiR in the programs, and to provide consultation in prevention programming (www.real-prevention.com). We have been able to develop an e-commerce website so that youth organizations can access the program easily, purchase it, and coordinate training for teachers and other implementers.
In this case history of the keepin’ it REAL (kiR), we provide the history and evolution of kiR from its roots in basic research to its current implementation. The story of kiR is complex, but with consistent characters and plotlines. The foundation of the program is communication theory and research integrated with prevention research and health education. kiR is an example of translational research—translating research into programs and practice, ensuring that research knowledge reaches the people and populations for whom it can make a difference, and ensuring that programs and practices are implemented correctly. At the same time, it also is an example of action research, where theory is generated and tested through practice. From basic research and the pilot study of a curriculum, to a middle-school curriculum, an elementary-school program, and now a high-school program, kiR has been disseminated within and outside the United States and is still being developed and applied for a variety of audiences. To us, that is a story worth telling.
Discussion of the Literature
Narrative theory has guided the keepin’ it REAL series of programs since its inception. Narrative theory suggests that human experience is organized, stored, and communicated in narrative form. Thus, narratives have a special power in unlocking interpretations and influencing thought and behavior. Through this work, we have developed a narrative engagement theoretical framework (Miller-Day & Hecht, 2013). This framework asserts that narratives are central to health promotion and risk prevention efforts because they enhance narrative knowledge, promote engagement, and provide mental and behavioral models. The appeal of narrative lies in the pervasive nature of this kind of discourse in everyday life. Human beings are storytelling animals and narrative is the means by which we make sense of our experiences and ourselves, organize and understand events, and recount experiences (Clandinin & Connelly, 2004). There is evidence that first-person narratives might be most effective in affecting health outcomes. A meta-analysis of narrative interventions revealed that employing first-person narratives (i.e., those told using “I” or “me”) in prevention efforts (e.g., campaigns) is twice as likely to have an effect as employing no narrative or third-person narratives (i.e., those told about other people’s experiences). Narratives are particularly useful in health message design because of the populations they enable us to reach. Hopfer and Clippard (2010) identify five qualities of narrative messages that make them particularly promising for health interventions. Narrative messages can:
Overcome resistance to the advocated health behavior
Engage less-involved audiences
Reach low-knowledge audiences
Render complex information comprehensible
Ground messages in the culture and experiences of the target audience
Hence, in our program development we utilize a “from kids, through kids, to kids approach” that relies on collecting and examining target-audience narratives to inform implementation design and message development. The underlying assumption is that humans make health decisions based on the narrative story lines available to them (socially, locally, and personally) and that they embrace stories that cohere and resonate with their experiences (Hecht & Miller-Day, 2009). Thus, the stories people tell about their experiences (e.g., drug offers and resistance strategies) reveal how they see the health issue, the choices they make, and what can be done to influence them to make healthy choices.
Also guiding this work is the model of communication competence (Spitzberg & Cupach, 1984; Spitzberg & Hecht, 1984), which argues that competence is a relational phenomenon and identifies four necessary components: knowledge, motivation, skills, and outcomes. The components of relational communication competence mirror elements of successful drug prevention. In order to competently resist offers of drugs, teens need adequate knowledge, appropriate motivation, and skills to produce desirable outcomes. Our formative work was, we believe, influential in guiding our understanding of drug offers and resistance as a social process. Studies of smoking, for example, revealed three general strategies of resistance: appropriateness (fear of disapproval), consistency (personal convictions), and effectiveness (fear of effects; Reardon et al., 1989). More recent extensions are found in the work of Harrington in developing substance use prevention messages (Harrington et al., 2003).
Building on a narrative and communication competence foundation, a second line of work focused on the role of culture. Based on our early findings and prevention research indicating that cultural sensitivity enhances school-based prevention and that ethnic matching maximizes impact (Botvin, Schinke, Epstein, & Diaz, 1994), our work took a turn toward creating what we called “culturally grounded” curricula that reflected cultural sensitivity and appropriateness (Airhihenbuwa, 1995; Castro, Barrera, & Martinez, 2004; Kreuter, Lukwago, Buchholts, Clark, & Sanders-Thompson, 2003; Resnicow, Barononski, Ahluwalia, & Braithwaite, 1999).
A third major line of theoretical influence on our work was translational and implementation science. Translational science refers to the study of translating research into practice, ensuring that basic research knowledge actually reaches populations who can benefit from that knowledge in the form of innovative programs, practices, products, or policy, and assessing if the innovations are implemented correctly. Since the turn of the 21st century, NIH has made translational science a priority (Woolf, 2008). Not only is it important to translate research from basic science into programs that can be used for the public good, but also Bosworth’s (2015) recent edited volume has given voice to an emerging emphasis on the importance of how programs are actually being disseminated and implemented in the field. In our case, the focus is how a curriculum is being taught by instructors, and not just its development and overall impact. The prevailing model for implementation science has been the construct of “fidelity,” or strict adherence to the curriculum (Botvin, 2004). More recently, fidelity has been reconceptualized more broadly as “implementation quality,” or how well the curriculum is implemented, and this includes adherence to the prescribed program, but also engagement of the target audience with the program, the amount of exposure the target audience has to the program (or dosage), and the degree to which the program is adapted by implementers in the field (Berkel, Mauricio, Schoenfelder, & Sandler, 2011; Durlack & DuPre, 2008).
Finally, there has been a move toward a prevention approach called social emotional learning (SEL; Durlak, Domitrovich, Weissberg, & Gullotta, 2016). The SEL approach argues that there are five basic competencies that youth need to develop healthy lives: self-awareness, self-management, social awareness, relationship skills, and responsible decision-making. Social and emotional learning involves the processes through which children acquire and effectively apply the knowledge, attitudes, and skills necessary to understand and manage emotions, set and achieve positive goals, feel and show empathy for others, establish and maintain positive relationships, and make responsible decisions (CASEL, 2012). SEL programming is based on the understanding that social and emotional skills are critical to being a good student, citizen, and worker, and many different risky behaviors (e.g., drug use, violence, bullying, and dropping out) can be prevented or reduced when integrated efforts develop students’ social and emotional skills (Domitrovich et al., 2011). The SEL approach has a strong empirical base, with a growing body of research linking SEL to improved prosocial behavior and academic achievement and reductions in aggression and substance use (Greenberg et al., 2003). Schools across the United States have established student learning standards that emphasize social and emotional competence (Dusenbury, Zadrazil, Mart, & Weissberg, 2011). Given the growing evidence in support of the SEL approach, recent work by our team is integrating SEL principles throughout program development for children and youth.
Links to Digital Materials
- www.real-prevention.com (Provides project overview and description of various curricula.)
- www.kir.la.psu.edu (Provides project history.)
- www.casel.org (Provides overview of social and emotional learning theory.)
- www.dare.org (Describes D.A.R.E. programs.)
- www.samsha.gov/nrepp (An external evaluation of keepin’ it REAL.)
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