The cultural adaptation of evidence-based drug use prevention programs: Is it necessary?

Flavio F. Marsglia wrote this article for the International Consortium of Universities for Drug Demand Reduction (ICUDDR)’s monthly newsletter. It was originally posted in the August newsletter. 

The use and misuse of alcohol, tobacco and other drugs among preadolescents and adolescents is of universal concern. In the prevention field, there is consensus about the severity of the problem and about the paucity of evidence-based programs to address it (Liu, Guo & Wang, 2023). Designing and evaluating the efficacy of prevention interventions requires methodological capacity and other resources that often are not accessible to preventionists in many parts of the world. Evidence-based drug use prevention programs overwhelmingly tend to originate in the USA, selected European countries, and other highly developed nations and regions of the world and the proven interventions rarely reach middle and low-income countries (Rabadán-Diehl, 2024). Access to evidence-based interventions (EBIs) that are culturally congruent is not only uncommon in low-and-middle income countries but if it happens, it is not equitably distributed (Momanyi, 2023).

To increase access to EBIs, a limited number of programs are being implemented in low- and middle-income countries. Although commendable for their effects in increasing access, they generate ethical and methodological questions. For example, does the urgency of the matter justify the transfer of an EBI into a new sociocultural context without adapting it first? A possible answer is that, in a globalized world, cultural differences are not as conspicuous as they were in decades past. Others may say that implementing an unadapted intervention is better than not implementing an intervention at all. The lack of equity in accessing prevention science can lead some countries to import efficacious prevention interventions without considering their cultural appropriateness. This type of rushed implementation could compromise the same effectiveness that they are seeking to achieve.

Cultural adaptation is an emerging science defined as the “systematic modification of an evidence-based treatment or intervention protocol to consider language, culture, and context in such a way that is compatible with the participants’ cultural patterns, meanings, and values” (Bernal et al. 2009, p. 362). Although there is a need for more efficacy and effectiveness investigations on culturally adapted EBIs (Castro, Barrera & Holleran, 2010), there is sufficient evidence supporting it, especially about its effects on increasing the acceptability and feasibility of EBIs (Li et al., 2024).

Conducting a cultural adaptation is costly and time-consuming; it can significantly delay implementation, and in some cases, it can make the implementation unfeasible. Not doing it can have negative consequences for the end-users (often children and youth). For example, low levels of identification with the program (i.e., it is not about me or for me, it is for other children). Such a lack of identification can make the program ineffective, or worse it can produce iatrogenic (adverse) effects (Marsiglia & Booth, 2015). Thus, a rushed technological transfer is methodologically and ethically questionable.

We propose that the transfer of EBIs follow certain basic protocols. First, assess the cultural appropriateness of the prevention program in the new sociocultural context. Second, if cultural adaptation is needed, conduct the adaptation with local implementers and participants as they are the experts in their own culture. Third, test its efficacy through a Randomized Controlled Trial, comparing the adapted version of the program and to a control condition. Fourth, assess the value added of the culturally adapted version and the feasibility of taking the modified version of the program to scale.

The optimal implementation of the described steps necessitates research infrastructure, methodological know-how, and financial resources. In-country academic partners and their international collaborators can provide the needed scientific back-up. Local governments, international organizations, foundations and research award granting organizations can provide the funding. Initially, the process might feel overwhelming but taking small steps and having a clear sense of direction and a long-term goal will help.

Our team’s experience in conducting a comprehensive cultural adaptation of Keeping it REAL in partnership with schools and investigators in the three largest cities in Mexico offers an example of such a process (e, g., Marsiglia et al, 2019; Kulis et al, 2021). In other countries, we have conducted smaller cultural adaptation studies, gathering the necessary evidence to inform larger studies (e.g. Cutrin et al, 2023; Marsiglia et al, 2018). These examples provide support to the popular Spanish language saying: “si se puede” (yes, it is possible).

Acknowledging the need to assess cultural appropriateness is an important first step. The participants and the implementers in the field are the best source of knowledge about what feels comfortable, natural and useful. Cultural adaptation is all about listening. Participants at times may not communicate perceived cultural mismatches verbally, but dropping out from a program or exhibiting a passive attitude can be louder than words. Let’s listen.

Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40(4), 361–368.

Castro, F. G.,Barrera Jr, M., & Holleran Steiker, L. K. (2010). Issues and challenges in the design of culturally adapted evidence based interventions. Annual Review of Clinical Psychology, 6(1), 213-239.

Cutrín, O., MacFadden, I., Marsiglia, F. F., & Kulis, S. S. (2023). Social validity in Spain of the Mantente REAL prevention program for early adolescents. Journal of Prevention, 44(2), 143-164.

Kulis, S. S., Marsiglia, F. F., Medina-Mora, M. E., Nuño-Gutiérrez, B. L., Corona, M. D., & Ayers, S. L. (2021). Keepin’ it REAL – Mantente REAL in Mexico: A cluster randomized controlled trial of a culturally adapted substance use prevention curriculum for early adolescents. Prevention Science, 22 (5), 645-657.

Liu, X. Q., Guo, Y. X., & Wang, X. (2023). Delivering substance use prevention interventions for adolescents in educational settings: A scoping review. World Journal of Psychiatry, 13(7), 409.

Li, A., Miller, F. G., & Williams, S. C. (2024). Cultural adaptations to social–emotional learning programs: A systematic review. School Psychology.

Marsiglia, F. F., Medina-Mora, M. E., Gonzalvez, A., Alderson, G., Harthun, M., Ayers, S., Nuño Gutiérrez, B., Corona, M. D., Mendoza Melendez, M. A., & Kulis, S. (2019). Binational cultural adaptation of the Keepin’ it REAL substance use prevention program for adolescents in Mexico. Prevention Science, 20, 1125-1135.

Marsiglia, F. F., Kulis, S., Kiehne, E., Ayers, E., Libisch Recalde, C., & Barros Sulca, L. (2018). Adolescent substance use prevention and legalization of Marijuana in Uruguay: A feasibility trial of the Keepin’ it REAL prevention program. Journal of Substance Use, 23(5), 457-465.

Marsiglia, F. F & Booth, J. (2015). Cultural adaptation of interventions in real practice settings. Research on Social Work Practice, 25, 423-432.

Momanyi, A. (2023). Effectiveness of School-Based Health Education Programs in Preventing Substance Abuse among Adolescents. International Journal of Public Health Studies, 1(1), 45-57

Rabadán-Diehl, C. (2024). Public health approaches to address substance use: An urgent need for multisectoral engagement. In Principles and Application of Evidence-based Public Health Practice (pp. 165-185). Cambridge, Massachusetts: Academic Press.