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Published in final edited form as: Health Promot Pract. 2022 Jan 19;23(4):609–618. doi: 10.1177/15248399211070547

Using Community–Academic Partnerships and a Creative Expression Contest to Engage Youth in the Development of Communication Materials for Promoting Behaviors That Prevent COVID-19

Jacob Szeszulski 1,2, Ghadir Helal Salsa 3, Paula Cuccaro 1, Christine M Markham 1, Mary Martin 4, Lara S Savas 1, Melissa Valerio-Shewmaker 3, Timothy J Walker 1, Andrew E Springer 2
PMCID: PMC12466313  NIHMSID: NIHMS2094977  PMID: 35043711

Abstract

Youth can transmit COVID-19 to adults, but few communication materials exist for engaging youth in COVID-19 prevention behaviors. We describe the process of leveraging a community–academic partnership in a rapid response initiative to engage youth in a contest (i.e., Youth-Led Creative Expression Contest to Prevent COVID-19 across Texas) to develop creative public health messaging centered on the prevention of COVID-19 transmission and infection for their peers. Core activities included developing a request for applications that solicited submission of creative expression materials promoting the use of COVID-19 prevention behaviors (mask-wearing, social distancing, handwashing, not touching the face) from Texas youth in elementary, middle, and/or high school; sending the request for applications to 48 organizations in Austin, Brownsville, Dallas, El Paso, Houston, and San Antonio in summer 2020; and recruiting a youth advisory board to score submissions and award prizes. We report on youth engagement in the COVID communication contest across Texas and use statistics (chi-square and t-tests) to characterize and compare youth participants and their creative expression artwork. The contest resulted in 3,003 website views and 34 submissions eligible for scoring. Each submission averaged >2 prevention behaviors. On average, winning submissions included a higher number of prevention behaviors than nonwinning submissions. The prevention behavior “not touching the face” was included more often in winning submissions than nonwinning submissions. Elementary school children were less likely to include a mask in their submission compared with older youth. Existing community–academic networks can engage youth in the development of geographically and age-tailored communication materials.

Keywords: information dissemination, project, pilot, health communication, coronavirus disease 2019, child and adolescent health

BACKGROUND

Between January 21, 2020, and January 11, 2021, more than 22.3 million people in the United States suffered from COVID-19, resulting in more than 373,000 deaths (Centers for Disease Control and Prevention [CDC], 2021). Fewer COVID-19 deaths occurred in youth below the age of 18 years old, and hospitalization rates were as low as 8.0 per 100,000; however, in early 2021, youth only accounted for about 10.8% of all people with COVID-19 (CDC, 2021; Kim et al., 2020). When youth contract COVID-19, they are typically asymptomatic or show mild symptoms, but they can still spread the virus to adults, some with preexisting health conditions (CDC, 2020). In fact, 7.3% of all school-age children live with someone above the age of 65 years, and this proportion is up to 19% for some racial/ethnic groups (Kaiser Family Foundation, 2020b). Furthermore, one in four school teachers are at risk of serious illness or death if infected with COVID-19 (Kaiser Family Foundation, 2020a).

Texas is the second largest U.S. state by size, total population, and number of youth below the age of 18 years old, and Texas has substantial geographic, economic, and racial/ethnic diversity (U.S. Census Bureau, 2020). Almost one tenth of all people in the United States with COVID-19 are located in Texas, which was one of the last states to issue a stay-at-home order, and one of only four states where the governor ordered schools to reopen (“Map: Where Are Schools Closed?” 2020; Moreland et al., 2020; U.S. Census Bureau, 2020). Thus, numerous opportunities exist for Texas youth to acquire and transmit COVID-19, and regional- and age-related differences in knowledge of COVID-19 and/or engagement in prevention behaviors may necessitate tailored messaging (Haischer et al., 2020). Accordingly, engaging Texas youth in COVID-19 prevention behaviors is an urgent public health priority.

During the peak of the pandemic, there were few tailored communication strategies or public health campaigns that engage youth in COVID-19 prevention behaviors (e.g., wearing a mask), and because COVID-19 is a novel virus, the need to identify the best dissemination channel to reach youth (i.e., in-person, online) became apparent. Public health research consistently shows that messages are more effective when they are designed using structured methods and engage community members in the development process (Bartholomew Eldredge et al., 2016; Minkler et al., 2003). Furthermore, participatory approaches that engage youth typically target routine behaviors that occur in school or community settings (Anyon et al., 2018; Larsson et al., 2018). As youth should engage in prevention behaviors routinely to prevent COVID-19 transmission, their involvement is critical to the development of communication materials targeting these behaviors (Flores et al., 2014).

To disseminate prevention messages to youth, it is important that we use familiar channels. Almost 90% of youth ages 13 to 17 years have used social media; 75% have at least one social media account (American Academy of Child and Adolescent Psychiatry, 2018). Youth commonly use social media to engage in political activism or conversations where they are typically excluded, in many cases, through art- or music-based messaging (Lee, 2018; Schwan et al., 2018). For example, youth from one study reported that looking at artistic messages could affect their health behaviors, but that designing these messages can also help them to cope with life’s challenges, enhance self-esteem, and manage stress (Schwan et al., 2018). Furthermore, creative expression is commonly used by youth to promote community health initiatives (Glik et al., 2002; Gray et al., 2010; Jacquez et al., 2013; Malm & Löfgren, 2007; Suleiman et al., 2006). Consequently, allowing youth to develop COVID-19 prevention messages for their peers may have multiple benefits, including the creation of effective messages, benefits to youth associated with their design, and regional tailoring of prevention messages.

PURPOSE

The purpose of this article is twofold. First, this article describes the process of leveraging existing networks of academic institutions, community agencies, and schools to engage youth across Texas in a contest (i.e., Youth-Led Creative Expression Contest to Prevent COVID-19 Across Texas) to develop rapid response creative public health messages centered on the prevention of COVID-19 transmission and infection for their peers. This article also describes recruitment channels, characteristics of youth participants reached, and the types of creative expression artwork submitted.

METHODS

Design and Setting

In April 2020, in response to the COVID-19 pandemic, the University of Texas Health Science Center at Houston’s School of Public Health formed a COVID-19 communications team to support the development and delivery of health communication materials that promote COVID-19 prevention behaviors in Texas. The team identified a need for new materials to promote COVID-19 prevention behaviors and disseminate support resources tailored to local communities (e.g., medically underserved and vulnerable communities, youth, day laborers, clinical care providers). Consequently, we developed a list of priority prevention behaviors, via a brainstorming session that incorporated Intervention Mapping processes, and split into several subcommittees to develop tailored resources promoting those behaviors (Bartholomew Eldredge et al., 2016).

In May 2020, the school subcommittee began meeting to generate communication materials tailored for Texas youth. To improve the salience and impact of those materials, we chose to engage youth in the development of materials through a creative expression contest. We created a request for applications (RFA) inviting Texas youth to submit creative expression projects that promoted four priority prevention behaviors: handwashing, wearing a mask, social distancing, and not touching the face. We also developed a youth advisory board (YAB) to score contest submissions. The YAB awarded three tiers of five prizes (i.e., US$300, US$100, and honorable mention) to the top 15 submissions. The contest ended in August 2020, and we notified the winners in October 2020 (Figure 1). All activities were completed virtually using videoconferencing software.

FIGURE 1. Timeline of Youth-Led creative Expression contest in Texas during Summer 2020.

FIGURE 1

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Note. RFA = request for applications; UTSPH = University of Texas Health Science Center at Houston’s School of Public Health; YAB = youth advisory board.

Participants

Engagement of Community Partners and Youth Contest Participants.

To disseminate the RFA to youth across Texas, the COVID-19 communications team and the school subcommittee identified existing partnerships with youth-serving organizations and shared the creative expression contest with them. Specifically, committee members sent the RFA to their community partners in July 2020 along with a social media template, which partners could use to disseminate the contest via their own social media channels. In addition, we disseminated the RFA through several of our center’s social media channels and listservs. All correspondence directed youth to visit our website for contest rules and materials’ submission. To be eligible for the contest, youth had to (a) be in elementary, middle, or high school; (b) live in Texas; and (c) have parental permission. The school subcommittee screened all submissions, and exclusions were made if submissions (a) exceeded 120 s in length, (b) used materials protected by copyright, or (c) did not include one of the four priority prevention behaviors.

YAB.

We recruited seven YAB members to score the submissions and identify contest winners. We recruited YAB members by sending out a flyer to community partners (process as described above) and via a targeted recruitment approach. Our goal was to recruit a YAB that was diverse in age and location. For targeted recruitment, we identified communications team members and other faculty who had school-age children or adolescents and sent them a flyer and application to complete. We also identified youth who were currently engaged in other research projects and sent them the flyer and application. We invited all youth who completed the application to participate. To be eligible, youth had to be (a) between the ages of 9 and 18 years old, (b) live in Texas, (c) have parental permission, and (d) have a working computer and internet connection. Youth met online three times over the course of a month to develop review criteria, complete a reviewer training, and score/select contest winners. Final review criteria developed by the YAB included (a) promotion of COVID-19 prevention behaviors, (b) quality, (c) effort, (d) creativity and inspiration, (e) originality, (f) likelihood of going viral, and (g) overall impression. Each criterion was worth 20 points for a total of 140 points.

Data Sources, Variables, and Statistical Methods

To summarize the delivery of this creative expression contest, we utilized data from three sources. First, to assess the composition of our partnership, we tracked distribution of the contest flyer to our community partners via a spreadsheet and categorized their type and locations. Next, to determine project reach, we identified the number of times and people (i.e., unique views) who viewed our website, sources that linked each person to the website, the city from where the website was viewed, and the amount of time spent on the website. We graphed the views day-by-day to determine how views coincided with dissemination strategies. Finally, to identify who engaged with the contest and the types of submissions received, we classified each submission by its city, grade level (i.e., elementary, middle, or high school), number of youth who contributed to each submission, type of submission, and the targeted behavior(s). We used chi-square and t-tests to compare characteristics related to the inclusion of specific prevention behaviors, the total number of prevention behaviors included in each submission, and characteristics of winning and nonwinning submissions. As we had limited funding for this project, we did not evaluate changes in youth’s psychosocial outcomes (i.e., attitudes, knowledge) or behaviors that resulted from participation in this study. Protocols for the Youth-Led Creative Expression contest were reviewed and approved by the institutional review board at the University of Texas Health Science Center at Houston (HSC-SPH-20–0913).

RESULTS

Community Partners

We sent the RFA to 55 partners from 48 unique organizations in San Antonio (n = 18), Houston (n = 12), El Paso (n = 8), Austin (n = 4), Brownsville (n = 4), and Dallas (n = 2) and their surrounding areas. Organization types included schools (n = 17), community nonprofits (n = 9), government agencies (n = 5), a collaborative or coalition (n = 4), internal university research centers (n = 3), external university faculty (n = 3), faith-based organizations (n = 2), foundations (n = 2), a university project (n = 1), a city health organization (n = 1), and a for-profit company (n = 1).

Website

From July 7 to October 31, the Youth Creative Expression Contest website was viewed 3,003 times (2,599 unique views). The average time spent on the website was 4 min 27 s. The website was viewed statewide (Figure 2), including 1,536 views (1,315 unique views) from Houston, 505 views (407 unique views) from Brownsville, 196 views (173 unique views) from San Antonio, 189 views (162 unique views) from Austin, 121 views (109 unique views) from Dallas, and 28 views (26 unique views) from El Paso or their surrounding areas. In addition, 428 views (407 unique views) occurred outside of the major cities with University of Texas Health Science Center at Houston campuses or did not have a location associated with viewer’s internet protocol address. Most views occurred through direct links to the page (59.6%; n = 1,791), but views also occurred via social media (11.9%; n = 358), search engines (9.7%; n = 291), school listservs or message boards (9.6%; n = 288), news websites (7.4%; n = 223), and other sources (1.7%; n = 52). Most views occurred during the contest period and increased following the use of a new dissemination strategy, including the promotion of the contest by a news station (Figure 3).

FIGURE 2. Locations Where the contest Website Was accessed in Texas during Summer 2020.

FIGURE 2

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Note. Austin (green), Brownsville (brown), Dallas (yellow), El Paso (blue), Houston (purple), San Antonio (red), and other locations (black).

FIGURE 3.

FIGURE 3

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Contest Website Views by day in Texas during Summer 2020

Submissions and Contest Winners

We received 54 submissions to the contest, including nine duplicate submissions. Eleven submissions were excluded for using music under copyright protection (n = 5), not including a specified prevention behavior (n = 4), and exceeding the 120-s limit (n = 2). The YAB scored the remaining 34 submissions from elementary (n = 7), middle (n = 12), and high schools (n = 10), as well as five elementary and middle school collaborations.

The number of youth who contributed to a submission ranged from one to 16, but most submissions were an individual effort (75%). Submissions came from Houston (n = 21; 61.8%), Brownsville (n = 12; 35.3%), and Austin (n = 1; 2.9%), or their surrounding areas, and included drawings/paintings (n = 14; 41.2%), videos (n = 13; 38.2%), photos (n = 3; 8.8%), digital art (n = 3; 8.8%), and a website (n = 1; 2.9%). All but one submission (Spanish) was in English. Most submissions targeted wearing a mask (n = 30; 88.2%) as a COVID-19 prevention behavior, just over half of the submissions targeted social distancing (n = 20; 58.8%) and handwashing (n = 19; 55.9%), and less than a quarter of the submissions targeted not touching the face (n = 6; 17.6%). Each submission targeted an average (mean ± standard deviation) of 2.21 ± 1.04 prevention behaviors. Elementary school children were significantly less likely to include a mask in their submission compared with older youth, but other descriptive characteristics did not relate to the inclusion of a prevention behavior or total number of prevention behaviors (Table 1).

TABLE 1.

Inclusion of Prevention Behaviors by descriptive characteristics in Texas, 2020

Descriptive characteristic Mask Handwashing Distancing Not touching face Number of prevention behaviors
Yes Yes Yes Yes 1 2 3 4
Age group 14.8 (.001) 0.2 (.976) 2.9 (.406) 2.2 (.535) 6.7 (.669)
 Elementary school 42.9% (3) 57.1% (4) 57.1% (4) 14.3% (1) 57.1% (4) 14.3% (1) 28.6% (2) 0.0% (0)
 Middle school 100.0% (12) 58.3% (7) 41.7% (5) 16.7% (2) 33.3% (4) 33.3% (4) 16.7% (2) 16.7% (2)
 High school 100.0% (10) 50.0% (5) 70.0% (7) 10.0% (1) 30.0% (3) 20.0% (2) 40.0% (4) 10.0% (1)
 Elementary/middle school 100.0% (5) 60.0% (3) 80.0% (4) 40.0% (2) 0.0% (0) 40.0% (2) 40.0% (2) 20.0% (1)
Number of youth 1.5 (.217) 0.4 (.533) 2.8 (.092) 0.3 (.601) 4.9 (.176)
 1 83.3% (20) 62.5% (15) 54.2% (13) 16.7% (4) 37.5% (9) 20.8% (5) 29.2% (7) 12.5% (3)
 2+ 100.0% (8) 50.0% (4) 87.5% (7) 25.0% (2) 0.0% (0) 50.0% (4) 37.5% (3) 12.5% (1)
Location 0.4 (.820) 1.3 (.520) 3.1 (.214) 3.2 (.202) 4.4 (.618)
 Austin 100.0% (1) 0.0% (0) 0.0% (0) 0.0% (0) 100.0% (1) 0.0% (0) 0.0% (0) 0.0% (0)
 Brownsville 91.7% (11) 58.3% (7) 75.0% (9) 33.3% (4) 16.7% (2) 25.0% (3) 41.7% (5) 16.7% (2)
 Houston 85.7% (18) 57.1% (21) 52.4% (11) 9.5% (2) 38.1% (8) 28.6% (6) 23.8% (5) 9.5% (2)
Submission type 2.2 (.704) 4.6 (.329) 5.3 (.260) 1.9 (.754) 12.7 (.392)
 Digital art 100.0% (3) 100.0% (3) 66.7% (2) 0.0% (0) 0.0% (0) 33.3% (1) 66.7% (2) 0.0% (0)
 Drawing/painting 85.7% (12) 50.0% (7) 64.3% (9) 21.4% (3) 35.7% (5) 21.4% (3) 28.6% (4) 14.3% (2)
 Photo 66.7% (2) 33.3% (1) 0.0% (0) 0.0% (0) 100.0% (3) 0.0% (0) 0.0% (0) 0.0% (0)
 Video 92.3% (12) 61.5% (8) 61.5% (8) 23.1% (0) 23.1% (3) 30.8% (4) 30.8% (4) 15.4% (2)
 Website 100.0% (1) 0.0% (0) 100.0% (1) 0.0% (0) 0.0% (0) 100.0% (1) 0.0% (0) 0.0% (0)
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Note. Gray rows are chi-square statistics and (p value). Bolded values are significant (p < .05). Percent (n) are for within rows.

The submissions that the YAB selected as winners included three elementary, eight middle, and two high school submissions, as well as two elementary and middle school collaborations. Winning submissions were equally distributed between Houston (46.7%; n = 7) and Brownsville (46.7%; n = 7). One submission was from Austin (6.7%). Winning submission types were equally distributed between videos (46.7%; n = 7) and drawings/paintings (46.7%; n = 7). One winning submission was digital art (6.7%). On average, winning submissions scored more points (mean ± standard deviation = 105.8 ± 12.1 vs. 65.7 ± 13.6) and included a nonsignificantly higher number of prevention behaviors than nonwinning submissions (mean ± standard deviation = 2.4 ± 1.1 vs. 2.1 ± 0.97; t = −0.968; p = .340). The prevention behavior “not touching the face” was included more often in winning submissions (χ2 = 4.5; p = .033), but winning and nonwinning submission were not significantly different in any other way (Figure 4).

FIGURE 4.

FIGURE 4

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A collage of Submissions From Summer 2020 in Texas

DISCUSSION

This rapid response youth-led creative expression contest engaged 48 unique community agencies throughout six of Texas’ major metropolitan areas to develop regional- and age-tailored communication materials for engaging youth in COVID-19 prevention behaviors. These partners also had ties to rural communities through standing community advisory boards to ensure that the effort was advertised broadly. Regional and age-specific tailoring of prevention messages is an important part of creating an effective public health campaign, as messages delivered from a person who looks or sounds like the recipient may be more effective than messages delivered by an outsider (Bartholomew Eldredge et al., 2016; Noar et al., 2007). Contest submissions included images of both White and non-White people and materials in both Spanish and English. We received an almost equal number of submissions from elementary, middle, and high school youth, with some age-specific elements. Furthermore, the use of Intervention Mapping processes in the design of the RFA and the use of exclusion criteria in the scoring process ensured that the final submissions included evidence-based recommendations. However, we need further research to test the efficacy of these materials in changing psychosocial constructs (e.g., attitudes and knowledge) and promoting COVID-19 prevention behaviors.

We found that elementary school children were significantly less likely to include a mask in their submission compared with older youth, a finding that may suggest that younger children may not be as familiar with masks and may wear them less frequently than older children. A review by the World Health Organization found that very young children—below the age of 5 years—often lack the motor skills to wear a mask correctly when not supervised by an adult (World Health Organization, 2020). Moreover, environmental factors such as poor parental modeling of mask-wearing in children’s homes or lower level of mask-wearing in settings where elementary children spend much of their time (e.g., outdoor play) may contribute to these findings. However, further studies are needed to test these hypotheses.

Our creative expression initiative demonstrates how existing academic–community partnerships can efficiently respond to public health crises. Within 2 months, we engaged 48 stakeholders across Texas to help disseminate this RFA. Organizations included schools, community nonprofits, government agencies, collaboratives/coalitions, internal university research centers, external university faculty, faith-based organizations, foundations, a university project, a city health organization, and a for-profit company. By sending a simple request to disseminate an RFA, we were able to leverage existing partnerships to reach more than 2,500 people in Texas and generate 54 submissions. A previous systematic review reported that the median number of contest submissions for health contests is 73 (Pan et al., 2017). Given that our contest occurred during the early stages of COVID-19, it is positive that we generated a similar number of submissions using only online and media-based dissemination channels. We also generated media attention (i.e., new stories) and media content (i.e., social media posts) around an important public health initiative. Almost all youth use social media channels as a source of information, but these same channels are rampant sources of COVID-19 misinformation (American Academy of Child and Adolescent Psychiatry, 2018; Pennycook et al., 2020; Tasnim et al., 2020). Thus, to increase the dissemination of evidence-based information to youth on social media channels, it is important to create media content in a manner that coincides with the way that youth consume it and to have youth-specific partnerships to facilitate its dissemination. This pilot rapid response initiative provides evidence that existing community–academic partnerships can be leveraged to disseminate contest information and generate COVID-19 prevention materials.

Previous literature also highlights creative expression as a powerful method of engaging youth in research and that youth can be effective change agents in promoting community health initiatives (Glik et al., 2002; Gray et al., 2010; Jacquez et al., 2013; Malm & Löfgren, 2007; Suleiman et al., 2006). However, elementary school children are only included in about 11% of youth-engaged research, and few studies allow youth to share power and responsibility in intervention development (Jacquez et al., 2013; Larsson et al., 2018). We specifically empowered youth to develop COVID-19 prevention materials and developed a YAB to score and select contest winners, while actively discussing the role of adultism in the decision-making process (Bettencourt, 2020). Results from this study show that when empowered, youth can play a vital role in creating and evaluating public health communication materials. Furthermore, our study adds to the literature by showing that it is feasible to engage youth, including elementary school youth, in rapid response initiatives, and that engaging youth is possible even with limited time (<2 months), financial resources (<$2,000), and in conjunction with existing community–academic partnerships.

Limitations

Some challenges encountered during this creative expression initiative were the use of copyrighted materials (e.g., songs, images), profanity suggestive wording within messages, and the display of anger in messages as a means to change COVID-19 prevention behaviors. These characteristics rendered messages inappropriate for university media platforms and younger children, and may polarize audiences if disseminated (Skurka, 2019). Future contests should emphasize RFA wording that discourages copyright infringement and specifies a priority population for the contest submissions to help ensure that all messages are appropriate for dissemination throughout various organizations. In addition, future studies should identify additional ways to incorporate behavioral theory when content is being generated via public-engaged contests or when disseminating that content after the contest period.

Strengths

We found that creative expression is a viable method of engaging youth in the development of materials that promote COVID-19 prevention behaviors to geographically diverse audiences. It also allowed youth opportunities to integrate their culture, lived-experience, and passion into media content to share with their peers. Previous research shows that creative expression positively influences individual/community identity through serving as a voice of strength, allows youth to reflect on personal and historical experiences, and fosters a sense of belonging (Glik et al., 2002; Gray et al., 2010; Jacquez et al., 2013; Malm & Löfgren, 2007). Although we did not assess these or other psychosocial outcomes, anecdotal interactions with youth participants, the YAB, and youth’s parents suggest that positive psychosocial benefits were present. For example, several parents reported that their child enjoyed participating in the contest and that it was exactly what they needed during their summer break. Although these anecdotal reports were not part of our study design, future research studies should evaluate if these anecdotal findings represent real effects from this contest. Furthermore, materials generated through this study may need to be evaluated, refined, and packaged using behavioral theory before they are used as an intervention to promote behaviors that can prevent COVID-19.

IMPLICATIONS FOR PRACTICE AND RESEARCH

This 2-month pilot experience resulted in the development of 34 pieces of media content that promote COVID-19 prevention behaviors for geographically diverse youth ages 6 to 18 years old. We found that contests are a tangible method of engaging youth in the development of prevention messages. Researchers should test the efficacy of these messages for improving COVID prevention behaviors prior to widespread dissemination. The engagement of youth in this COVID-19 prevention project resulted in multiple benefits to our research team, including support in the rapid generation of materials, a better understanding of how youth view the pandemic, and the generation of geographically diverse, youth-specific products. The engagement process may be useful for rapid engagement of youth in tailoring of messages to other health needs, such as obesity prevention, vaccination, or mental health. Consequently, schools, health departments, and other community groups could benefit by engaging youth in future health promotion initiatives. Furthermore, existing university–community networks may be an effective means of engaging youth in public health projects and disseminating information across large geographically diverse locations.

Acknowledgments

We would like to acknowledge all of the community partners, youth participants, youth advisory board members, and university students, faculty, and staff who made this project possible. Specifically, we would like to acknowledge Rachel Atterstrom and Aaron Nieto for all of their guidance navigating the complexities of a communication campaign. Preparation of this manuscript was funded in part by The National Cancer Institute/NIH Grant T32/CA057712, awarded to the University of Texas Health Science Center at Houston School of Public Health Cancer Education and Career Development Program. Partial funding was provided by the Michael & Susan Dell Center for Healthy Living for Jacob Szeszulski for his contribution. None of the funding agencies played any role in the design, data collection, analysis, interpretation, or reporting of data from this paper. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute, the National Institutes of Health, or the Michael & Susan Dell Center for Healthy Living.

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