“I never realized how hard recovery is.” A quasi‐experimental evaluation of a youth participatory action research project for opioid prevention

Abstract

Youth participatory action research (YPAR) has been effectively used for substance use prevention. Yet, YPAR has not been evaluated for opioids, which negatively impact individuals and communities across the United States. The current study evaluated an opioid‐focused YPAR project. YPAR participants (n = 28) completed a pre‐ and post‐survey capturing psychological empowerment and opioid knowledge and behavior. A non‐YPAR comparison group (n = 18) provided post‐survey data. Mean comparisons were conducted to identify changes among participants and between intervention and comparison groups. YPAR participants demonstrated increased psychological empowerment and opioid knowledge and behaviors. In contrast to the comparison group, YPAR participants reported increased psychological empowerment and opioid knowledge, but not behaviors. Evaluation of this opioid‐focused YPAR project indicated positive outcomes. Findings expand research on YPAR effectiveness for substance use prevention. Engaging youth is an effective approach for individual and community change and a promising strategy to address the opioid epidemic.

Highlights

• Youth participatory action research is a valuable approach for community substance use prevention.

• The impact of youth participatory action research on youth opioid use has not been evaluated.

• Findings suggest youth participatory action research is an effective approach to increase youth opioid knowledge and behaviors.

INTRODUCTION

The opioid crisis is one of the most profound modern public health issues and has proven challenging to address due to the complex interplay of individual, social, and environmental factors (Jones et al., 2019). Youth are not immune to the crisis, as evidenced by the one in four adolescents who have engaged in opioid misuse (Robinson & Wilson, 2020) and the sharp increase in adolescent overdose mortality rates (Camenga & Barelli, 2023; Friedman et al., 2022). To combat the negative impact of the opioid crisis on youth and save lives, primary prevention strategies, which are underused (Compton et al., 2019), are necessary (Morton et al., 2021).

Community‐grounded approaches, like youth participatory action research (YPAR), have the potential to directly impact risk factors for opioid use disorder (OUD), such as social norms, attitudes, and awareness in positive ways through community engagement, civic action, and skill development (Ozer, 2017). Adopting a YPAR approach is especially crucial for historically marginalized youth who have been disproportionately and negatively impacted by substance use and whose voices need to be amplified (Linton et al., 2021). Despite the urgency of the opioid crisis, there is limited literature on using YPAR for opioid prevention (Valdez et al., 2020). Therefore, the current study aimed to evaluate the effectiveness of a YPAR project intended to empower adolescents to address opioid misuse in their communities.

YOUTH PARTICIPATORY ACTION RESEARCH

YPAR centers youth‐adult partnerships to learn about and address community issues directly affecting young people (Ozer & Douglas, 2015). In YPAR, adolescents partner with adults as agents of inquiry and analysis, subsequently using findings for social action. On the spectrum of community‐engaged research, participatory action research is often cited as the most intensive form of engagement, with a goal of empowerment (International Association for Public Participation, 2018). YPAR is distinct from other community‐engaged approaches in that adolescents participate in the research process as co‐researchers to achieve both community benefits and individual, developmental benefits like growth in problem‐solving skills, leadership, teamwork, and civic engagement (Suleiman et al., 2021). Achieving these outcomes requires shared power between adolescent and adult participants.

YPAR incorporates critical analysis of issues impacting youth and considers how youth are conceptualized as well as politically and socially marginalized (for a detailed review of YPAR see Malorni et al., 2022). Guided by critical youth theory and theory of relational empowerment, YPAR pulls from interdisciplinary perspectives including developmental science, positive youth development, social justice, and empowerment. Critical youth theory proposes systems and adults thwart youth agency (Quijada Cerecer et al., 2013; Shamrova & Cummings, 2017). YPAR can buffer against this by empowering youth. The theory of relational empowerment emphasizes the importance of relationships in social change (Christens, 2012; Malorni et al., 2022). YPAR may be an amplifier of youth‐led social movements due to its liberation approach, enabling adolescents to take action as a means of social justice (Langhout & Vaccarino‐Ruiz, 2021; Teixeira et al., 2021). In addition, YPAR uses a strengths‐based, positive youth development approach to build on youths' unique talents, interests, and future potential, viewing youth as resources to society rather than problems to be managed (Damon, 2004). Ultimately, YPAR gives youth an outlet to use their voice for shaping policy and systems affecting them (Kennedy et al., 2019).

Interest in and use of YPAR has increased in youth‐focused health education and programming, and, as a result, empirical research on YPAR has grown as well (Anyon et al., 2018). YPAR is not an intervention on its own but rather an approach. Ozer and Douglas outlined core YPAR components, including:

(a) iterative integration of research and action; (b) training and practice of research skills; (c) the practice of strategic thinking and discussing strategies for influencing change; (d) building of supportive networks by reaching out to school and community stakeholders; and (e) teacher's [adults] sharing of power with students [youth] in the research and action process (2015, p. 31).

Although not all YPAR adheres to these core components, there is a growing body of evidence on the effectiveness of YPAR for positively impacting outcomes of involved communities, adult partners, and youth participants.

Community outcomes

Prior reviews of YPAR studies and other youth‐engaged approaches have identified positive impacts on outcomes related to the setting in which youth operate (e.g., school, neighborhood), the programs offered, the adults present, and research conducted (Anyon et al., 2018; Branquinho et al., 2020; Kennedy et al., 2019; Shamrova & Cummings, 2017).

At a policy‐level, YPAR has been effective in changing school health‐related policies, impacting things like availability of healthy foods, physical activity options, and access to condoms, as well as community policies related to tobacco or alcohol advertising and public transportation (Kennedy et al., 2019). In addition to policies, community infrastructure changes resulted from YPAR, such as the construction of gender‐neutral bathrooms, playground revitalization, and filling old mining pits (Shamrova & Cummings, 2017). Youth advocacy stemming from YPAR led to a greater awareness among policymakers and community members concerning these issues, resulting in policy and infrastructure changes.

Programs delivered in community settings have also benefited from YPAR, including service expansion or enrichment, and space and funding increases. Some programs were created to address unmet needs (e.g., translation services), and often, programs were expanded to intentionally incorporate youth voice going forward (Kennedy et al., 2019). The intentional incorporation of youth represented a shift away from adults making decisions for and about youth and towards a model in which youth voice and contributions were valued like those of adults.

Supportive adult partners are critical in the YPAR process (Pech et al., 2020) and must relinquish control and engage youth as true partners while scaffolding developmental opportunities (Ozer et al., 2010). As a result, there are often benefits to adults such as changes in views, beliefs, and knowledge of youth potential and competency among community adult partners as well as teachers (Kennedy et al., 2019).

From a research perspective, YPAR is associated with positive outcomes related to both process and quality (Kennedy et al., 2019; Mortensen et al., 2014). Engaging youth in the research process resulted in greater access to and recruitment of other youth participants, greater depth of information shared by youth participants, and more nuanced or authentic interpretation of findings by youth co‐researchers.

Youth participant outcomes

Although the term “youth” is used in YPAR phrasing, this approach leverages the developmental changes occurring within adolescence. The developmental stage of adolescence presents unique opportunities to align with developing identity, autonomy, and belonging, including the desire to contribute. We provide a summary of key individual benefits but also refer the reader to Ozer (2017), Ozer et al. (2024), and Suleiman et al. (2021), who focus on YPAR from a developmental perspective. Key individual outcomes of YPAR relate to psychological empowerment, civic engagement, and research self‐efficacy.

Related to YPAR, psychological empowerment spans individual and social domains. Holden et al. (2005) identified key attributes in each domain. In the interpersonal domain, attributes include self‐efficacy, perceived social control, and participatory competence. In the interactional domain, attributes include knowledge of resources, assertiveness, and advocacy. Subsequent research supports these domains and attributes, finding that YPAR‐related empowerment facilitates the development of agency, autonomy, and competence, expansion of social networks, and motivation to influence change within their communities (Means et al., 2021; Suleiman et al., 2021). Ozer and Schotland (2011) developed a measure of psychological empowerment, which was conceptualized as including self‐efficacy related to research and action, general sociopolitical skills, motivation to influence community, engagement in participatory behavior, and opportunities for perceived control.

Development of psychological empowerment through YPAR often occurs alongside increased civic engagement. YPAR supports the development of a sense of collective efficacy among youth participants by providing awareness of community systems, inequalities, and worldviews beyond their personal experience (Ozer, 2017). Youth engagement in YPAR was associated with opportunities to learn about policy‐making and how to positively influence systems within their communities (Kennedy et al., 2019). As communities, programs, and adults value youth voice in decision‐making, it presents youth with opportunities to serve on boards, councils, and other roles in a position to enable policy change. These new skills enrich a sense of political empowerment, collective efficacy, connection to the youths' community, and improved awareness of social justice (Branquinho et al., 2020). Given the centrality of psychological empowerment and civic engagement to YPAR, these constructs were assessed in the current study.

YPAR and substance use

YPAR approaches engage youth and the structures and systems in which they are embedded, making such approaches ideal for addressing complex, multiply determined health behaviors like substance use (Helm, 2015; Valdez et al., 2021). Youth have a unique insider perspective on developmental phenomena that enhances the validity of research. They offer essential insights on issues facing adolescents and their community (Mortensen et al., 2014).

Valdez et al. (2020) conducted a systematic review of YPAR addressing substance use prevention and identified both individual and community outcomes specific to substance use. Individual outcomes mirrored those found generally in the literature, such as a sense of empowerment, efficacy, and motivation for advocacy and change. Yet, YPAR also demonstrated impacts on youth substance use knowledge, attitudes, and behaviors. These impacts include increased knowledge of tobacco and alcohol, decreased approval of peer substance use, and decreased frequency of alcohol and cannabis use. Youth participants also increased their dialog with community members regarding substance use, offering an elevated awareness of community issues and collective efficacy. At the community level, there was increased awareness of substance use, valuing of youth voice, and development of community resources specific to substance use. As a result, communities received youth‐specific data on substance use, programs, and materials tailored to the community, as well as resources for future implementation. Collectively, findings suggest benefits at the individual and community level and indicate how YPAR can be a valuable tool in addressing substance use prevention among adolescents.

Much of the prior research on YPAR and substance use prevention has focused on tobacco, alcohol, and cannabis, not opioids, missing a critical opportunity to address the dearth of youth‐focused opioid prevention, treatment, and recovery approaches. Linton et al. (2021) summarized this issue by saying, “adolescent opioid use occurs within the context of structural inequalities that require the establishment of youth‐centered and youth‐driven prevention, treatment and harm reduction programs and procedures” (p. 630). YPAR approaches are ideal for putting youth voice at the center of addressing the critical issues impacting them, those around them, and the places they live.

CURRENT STUDY

The limited literature on using YPAR for substance use prevention demonstrates positive individual and environmental outcomes associated with participation, as well as impacts on risk and protective factors influencing adolescent substance use, knowledge, and dialog. However, this study has predominantly focused on alcohol, cannabis, or tobacco use, and not on opioids, which continue to negatively impact individuals, families, and communities across the United States. To help address this knowledge gap, the current study evaluated a YPAR project to assess change in youth participant outcomes of psychological empowerment and opioid‐related knowledge, attitudes, and behaviors. Specifically, we hypothesized post‐survey measures would be significantly improved compared to pre‐survey measures (Hypothesis #1). Additionally, post‐survey measures were collected from a comparison group of peers. A post‐only comparison was made between the YPAR participants and comparison group participants. We hypothesized post‐survey measures of YPAR participants would be significantly higher than those of comparison group participants (Hypothesis #2).

MATERIALS & METHODS

The current study, Take‐PART (Participatory Action Research with Teens), implemented YPAR in three communities in Washington state focused on opioids. Sites were spread across the state with one in Eastern, Central, and Western Washington state. The design was a quasi‐experimental pre‐/posttest design with a posttest comparison.

Sample

Thirty‐nine youth participated in YPAR across three sites and completed the pre‐test survey. Of these, 28 completed a posttest survey (71.8%) and served as the sample for the current study. Youth were predominantly female (86.2%) and White (46.4%), Hispanic/Latino (34.5%), or multi‐racial (7.1%), and, on average, 16.4 years old. Youth were primarily from medium metro (28.6%), small metro (39.3%), or micropolitan (28.6%) communities, based on the National Center for Health Statistics classification urban‐rural classification scheme (Ingram & Franco, 2014). See Table 1 for participant and comparison group descriptives. Comparison group participants (n = 18) were recruited from youth who expressed interest but, primarily due to scheduling conflicts, did not participate in YPAR and from enrolled 4‐H youth members within Eastern, Central, and Western Washington state locations. The comparison group youth were predominantly female (72.2%) and White (72.2%), Hispanic/Latino (16.7%), or multi‐racial (11.2%), and, on average, 16.6 years old. Youth were from medium metro (50.0%), small metro (33.3%), and micropolitan (16.7%) communities.

Table 1.

YPAR participant and comparison group demographics.

Demographics	YPAR (N = 28)		Comparison (N = 18)
	n	% or M (SD)	n	% or M (SD)
Gender
Female	25	89.3%	13	72.2%
Male	1	3.6%	4	22.2%
Gender identity not listed	0	0.0%	1	5.6%
Prefer not to answer	2	7.1%	0	0.0%
Race
White	13	46.4%	13	72.2%
Hispanic or Latino	10	35.7%	3	16.7%
Multi‐racial	2	7.1%	2	11.2%
American Indian or Alaska Native	1	3.6%	0	0.0%
Asian or Asian American	1	3.6%	0	0.0%
Black or African American	1	3.6%	0	0.0%
Grade level
9th Grade	4	14.3%	2	11.1%
10th grade	1	3.6%	2	11.1%
11th grade	12	42.9%	5	27.8%
12th grade	11	39.3%	9	50.0%
Age	28	16.4 (1.1)	18	16.6 (1.4)
Urban–rural classifications
Large Central Metro	1	3.6%	0	0.0%
Large Fringe Metro	0	0.0%	0	0.0%
Medium Metro	8	28.6%	9	50.0%
Small Metro	11	39.3%	6	33.3%
Micropolitan	8	28.6%	3	16.7%
Noncore	0	0.0%	0	0.0%
Geographic location
Central/Virtual	12	42.9%	6	33.3%
Eastern	8	28.6%	9	50.0%
Western	8	28.6%	3	16.6%

Note: Urban–rural classifications based on the National Center for Health Statistics 2013 classification scheme for counties (Ingram & Franco, 2014).

YPAR implementation

Adult partners included Washington State University 4‐H faculty and staff with prior experience in youth program facilitation. Youth were recruited by adult partners by word of mouth, advertisements on social media, and emailing school‐based educators and counselors in the geographic area served. Each site implemented YPAR with some variation in their implementation, such as in the number and cadence of meetings (e.g., weekly vs daily) and meeting format (i.e., online vs. in‐person). However, all adult partners were trained in and used the YA4‐H! Youth Advocates for Health: Youth Participatory Action Research curriculum (Arnold & Gifford, 2015) to facilitate the YPAR process. This curriculum is intended for adults who are supporting youth through a YPAR process. It includes lessons and activities separated into categories focused on: team building, asking research questions, collecting and managing data, analyzing data, communicating research, taking action within the community, and reflecting on the experience.

All sites addressed YPAR topics including: team building, deciding on the research question, designing the research and choosing methods, preparing the research instruments, identifying and recruiting participants, collecting data, analyzing data and drawing conclusions, producing a report, producing a final project, and implementing a final project. Groups supplemented the curriculum with educational videos on opioid topics (e.g., addiction, neurobiology) and guest lectures from community speakers to discuss opioids (e.g., paramedics, physicians, addiction counselors, youth advocates). To ensure YPAR fidelity, Ozer and Douglas' (2015) five core components of YPAR were applied, as described in Table 2. The study was reviewed and approved by the first author's affiliated Institutional Review Board, and parental consent was obtained before program implementation and data collection. The study was conducted in accordance with the Declaration of Helsinki.

Table 2.

Program fidelity to YPAR core components.

Core YPAR component	General description	Application in current study
Iterative integration of research and action	Combined a youth‐centric learning environment with curriculum activities to flow between research and action	Use of manualized curriculum to engage in iterative process of identifying a research question, data collection, and action (Arnold & Gifford, 2015)
Training and practice of research skills	Youth identified research questions, assessed and developed research tools, and practiced data collection and analysis	Selected curriculum activities to develop data collection and analysis skills, which were practiced during data collection through interviews and surveys, as well as the use of secondary data
The practice of strategic thinking and discussing strategies for influencing change	Youth discussed root causes to social problems and considered how to influence rules and policy	Selected curriculum activities to facilitate discussion of topics and social structures contributing to the development of opioid use disorder and potential solutions (e.g., trauma and the role it plays in opioid use disorder)
Building of supportive networks by reaching out to community partners	Youth, supported by adults, engaged community members, local professionals, and peers	Networking with community members as invited guest speakers, as well as organizations, as partners in disseminating projects (e.g., permission to have a booth at a local farmer's market)
Adult's sharing of power with youth in the research and action process	Power was shared between youth and adults in decisions about YPAR project and in everyday climate	Before program, adults received training in the development of youth‐adult partnerships, scaffolding learning experiences, and engaging in mutually respectful ways.
		Adults shifted from providing more structure and guidance earlier in the program to less structure to support youth leading projects; increasingly sharing power with youth.

Note: Core components identified by Ozer and Douglas (2015) with language adapted to community environment.

Site descriptions

YPAR was implemented in 2020–2021 and followed state and local COVID‐19‐related policy and guidance. Descriptions of site implementation are presented below and with additional details included in Table 3.

Table 3.

YPAR site descriptions.

Location	Central	Eastern	Western
Number of youth	15	9	8
Number of adults	4	3	2
Meeting cadence	Weekly, 90‐min meetings, plus separate meetings for individual or group work	Weekly, 90‐min meetings, plus separate meetings for individual or group work	Daily, 1‐h meetings, four days a week
Delivery format and location	Virtual with two in‐person culminating activities	Hybrid – zoom for weekly lessons and in‐person for planning meetings at an Extension office in an urban city	In‐person based at a local, public community college in a rural city
Timeframe	Nov 2020–May 2021	Jan 2021–June 2021	June 2021–July 2021
Incentive	$600 stipend, free 4‐H enrollment	$500 stipend, free 4‐H enrollment	$770 stipend for completion of YPAR and partner program
Guest speaker background	Emergency services (e.g., EMT), chemical dependency counselor, emergency department physician, youth experienced in opioid‐awareness advocacy	Local prevention coalition, emergency services, law enforcement, pharmacist, youth health services, youth serving organizations	Public health nurse, addiction studies professor, addiction counselor, physician
Focus of research	Risks of opioid misuse and use disorder	Safe storage and disposal of opioids	Connection between trauma, addiction, and resilience
Data collection methods	Observations, interviews	Interviews, secondary data	Survey, interviews, secondary data
Project	Coordinated social media and printed poster marketing campaign highlighting the dangers associated with opioid misuse and addiction shared through local 4‐H communication channels and public bulletin boards.	Designed and delivered a 1‐h health course for middle school students at a local school; created a traveling medicine cabinet display teaching safe storage practices used at a local farmer's market and fair.	Advocacy campaign and call to action shared at local county courthouse and county fair.

Note: All sites included YPAR phases including: team building, deciding on the research question, designing the research and choosing methods, preparing the research instruments, identifying and recruiting participants, collecting data, analyzing data and drawing conclusions, producing a report, producing a final project, and implementing a final project.

Central

Fifteen youth and four adults met virtually once a week for 90‐min sessions from November 2020 to May 2021. Youth participated in 25 h of structured meetings with additional time outside of team meetings to complete work independently and in small groups, including two in‐person events to distribute educational materials and celebrate the team's accomplishments. Each youth contributed an average of 32 h to the project. The youth chose to focus their research on the dangers associated with opioid misuse and addiction. Project outputs included a coordinated social media and printed poster campaign highlighting the dangers associated with opioid misuse and addiction, which generated over 2505 engagements. The youth participants received a $600 stipend and a 1‐year 4‐H membership at no cost.

Eastern

Nine youth and two adults met virtually once a week for 90‐min sessions from January to June 2021. Youth participated in 27 h of structured meetings with additional time outside of team meetings to complete work independently and in small groups, including four in‐person events to engage local partners in opioid‐related events (e.g., Medication Take Back Day) and share project materials. Each youth contributed an average of 45 h to the project. The youth chose to focus their research on opioid awareness, prevention, and safe storage and disposal of opioid medications. Project outputs included (a) fundraising for non‐profits that provide addiction and mental health treatment for youth as well as healthcare, housing, and support to individuals in need; (b) designing and delivering a 1‐h opioid awareness course for middle school students; and (c) creating a medicine cabinet that taught safe storage and opioid awareness, which was displayed at a county fair for community members. Youth participants received a $500 stipend and a 1‐year 4‐H membership at no cost.

Western

Eight youth and two adults met in person 4 days a week, 1 h per day, for 5 weeks from June to July 2021. Youth participated in 20 h of structured meetings and group work sessions. The Western cohort participated in YPAR as a component of another youth leadership program in which they were enrolled. Each youth contributed an average of 120 h to the project. The youth chose to focus their research on the relationship between trauma and addiction and how resilience science may be able to reduce addiction risk. Project outputs included a tri‐fold presentation board that communicated a call to action to (a) increase funds for mental health care, (b) provide trauma‐informed training to all youth‐serving professionals, and (c) offer comprehensive health education in schools including education on healthy relationships. Their presentation was displayed in the local county courthouse for 2 years and at the local fair, where it was viewed by county leaders and community members. Youth participants received a $770 stipend for participating in the program that hosted the 5‐week YPAR program, but did not receive an additional stipend for participating in YPAR.

Measures

Psychological empowerment

Psychological empowerment was assessed on the pre‐ and post‐survey using four subscales adapted from the Psychological Empowerment and Self‐Efficacy for Research Measure (Ozer & Schotland, 2011). These subscales included research action and self‐efficacy (e.g., “I can explain guidelines for conducting research to another person”), motivation to influence (e.g., “It is important for youth to try to improve our community even if we can't always make the changes we want”), participatory behavior (e.g., “I have led a group of young people working on an issue we care about”), and perceived control (e.g., “Youth have a say in what happens in my community”). Items were adapted to reflect the community, rather than the school context. Response options ranged from one (“Strongly disagree”) to four (“Strongly agree”) and averaged such that a higher number reflected greater empowerment. See Tables 4 and 5 for subscale reliability.

Table 4.

Wilcoxon signed‐rank test for YPAR participant pre‐ and post‐survey outcomes.

Outcome	Pre‐survey		Post‐survey		Z	p	Effect size
	M (SD)	α	M (SD)	α
Psychological empowermenta
Research and action self‐efficacy	3.1 (0.4)	.83	3.6 (0.3)	.83	−3.97	<.001	0.53
Motivation to influence	3.4 (0.5)	.83	3.6 (0.5)	.77	−2.03	.042	0.27
Participatory behavior	2.7 (0.5)	.67	3.4 (0.4)	.64	−4.22	<.001	0.56
Perceived control	2.7 (0.7)	.83	3.0 (0.8)	.89	−2.14	.032	0.29
Opioid knowledge, behavior, and stigma
Opioid use and safetyb	2.9 (1.5)	.60	4.3 (2.0)	.87	−2.45	.014	0.33
Harm to one's healthc	4.6 (0.5)	.77	4.8 (0.4)	.71	−2.14	.032	0.29
Prescription safety behaviorsc	3.9 (0.7)	.66	4.3 (0.7)	.81	−2.89	.004	0.39
Substance use stigmac	4.0 (0.9)	.75	4.1 (0.8)	.71	−1.48	.138	0.20

Note: Bolding indicates significant p‐value based on p < .05. Different response options are indicated with superscript.

^a 1 = Strongly Disagree to 4 = Strongly Agree.

^b 0 = No 1 = Yes.

^c 1 = None to 5 = A Great Deal or 1 = Not at all to 5 = Extremely or 1 = Definitely Not to 5 = Definitely.

Table 5.

Mann–Whitney U test for YPAR participant and comparison group posttest outcomes.

Outcome	Participant N = 28		Comparison N = 18		Z	p	Effect size
	M (SD)	α	M (SD)	α
Psychological empowermenta
Research and action self‐efficacy	3.6 (0.3)	.83	3.1 (0.4)	.86	−3.32	.001**	.49
Motivation to influence	3.6 (0.5)	.77	3.3 (0.4)	.67	−2.45	.014*	.36
Participatory behavior	3.4 (0.4)	.64	2.8 (0.5)	.70	−3.48	<.001***	.51
Perceived control	3.0 (0.8)	.89	2.4 (0.7)	.91	−2.68	.007**	.40
Opioid knowledge, behavior, and stigma
Opioid use and safetyb	4.3 (2.0)	.87	3.2 (1.6)	.62	−2.13	.033*	.31
Harm to one's healthb	4.8 (0.4)	.71	4.3 (0.6)	.86	−2.95	.003**	.43
Prescription safety behaviorsb	4.3 (0.7)	.81	4.1 (0.5)	.59	−1.68	.092	.25

Note: Bolding indicates a significant p‐value. Different response options are indicated with superscript.

^* = p < .05.

^** = p < 01.

^*** = p < .001.

^a 1 = Strongly Disagree to 4 = Strongly Agree.

^b 1 = None to 5 = A Great Deal or 1 = Not at all to 5 = Extremely or 1 = Definitely Not to 5 = Definitely.

Opioid knowledge, behavior, and stigma

Opioid knowledge was assessed on the pre‐ and post‐survey using measures adapted from the Adolescent Opioid Safety and Learning scale (Abraham et al., 2022). Constructs assessed include familiarity with topics about opioid use and safety (six items; e.g., “Have you already learned about how to safely store opioids?”), perceived degree of harm opioid use does to one's health (five items; e.g., “How much harm does opioid use do to one's mental health?”), and likelihood of engaging in opioid prescription safety behaviors (six items after dropping one item due to low reliability; e.g., “If you or your family member are prescribed an opioid medication, how likely are you to share the medication with others if they are in pain?”). Familiarity with opioid use and safety items were dichotomous Yes/No items and summed. Response options for other constructs were averaged and ranged from 1 to 5 with differing labels, as noted in Tables 4 and 5. Response options were recoded as needed so higher numbers reflect more desirable outcomes.

Stigma towards substance use was assessed using the four‐item Adolescent Stigma Scale (e.g., “Would you feel embarrassed or ashamed if your friends knew that someone in your family was addicted to drugs?”; Adlaf et al., 2009). Response options ranged from 1 (“Definitely”) to 5 (“Definitely not”) and were recoded as needed so higher numbers reflect more desirable outcomes. See Tables 4 and 5 for scale reliability. One item was dropped from the stigma scale, “Would you make friends with someone who is addicted to drugs?” to improve reliability.

Analytic approach

Data management, descriptive statistics, and analyses were conducted in SPSS Version 27. Responses were matched with a unique identification code. Analyses of pre‐ and post‐survey means were conducted with a Wilcoxon Signed‐Rank test for two related samples and YPAR participant and comparison group post‐survey means were analyzed using a Mann–Whitney U due to some items having a non‐normal distribution and small sample size (Damian Riina et al., 2023). For all analyses, significance was assessed at the p = .05 level. Effect sizes were calculated by dividing the Z statistic by the square root of the sample size.

RESULTS

Findings of YPAR participant changes from pre‐ to post‐survey indicated significant improvement in both psychological empowerment and opioid knowledge and behavior, therefore supporting Hypothesis #1 (see Table 4). Specifically, all psychological empowerment subscales increased related to research and action self‐efficacy (Z = −3.97, p < .001), motivation to influence (Z = −2.03, p = .042), participatory behavior (Z = −4.22, p < .001), and perceived control (Z = −2.14, p = .032). Related to opioid knowledge, behavior, and stigma, we observed significant increases in three subscales of familiarity with topics about opioid misuse and medication safety (Z = −2.45, p = .014), perceived degree of harm of opioid misuse to one's health (Z = −2.14, p = .032), and the likelihood of engaging in prescription opioid safety behaviors (Z = −2.89, p = .004). There was a nonsignificant increase in substance use stigma (Z = −1.48, p = .138).

Testing the means of participant post‐survey and comparison group indicated significant differences in both psychological empowerment and opioid knowledge and behavior, therefore supporting Hypothesis #2 (see Table 5). YPAR participants showed significant differences in all psychological empowerment measures, including research and action self‐efficacy (Z = −3.32, p = .001), motivation to influence (Z = −2.45, p = .014), participatory behavior (Z = −3.48, p < .001), and perceived control, (Z = −2.68, p = .007). Participants demonstrated differences in two measures of knowledge of and engagement in opioid safety behaviors, although substance use stigma was not assessed due to poor comparison group reliability. In contrast to the comparison group, YPAR participants showed significant differences in familiarity with topics about opioid misuse and medication safety (Z = −2.13, p = .033) and perceived degree of harm of opioid misuse to one's health (Z = −2.95, p = .003) but no significant difference in the likelihood of engaging in opioid safety behaviors (Z = −1.68, p = .092).

DISCUSSION

The current study evaluated outcomes among YPAR participants before and after the program and compared post‐program outcomes with a comparison sample. Study results suggest the YPAR approach promoted increased psychological empowerment and self‐efficacy for research as well as increased opioid health knowledge and safety behaviors. Overall, Hypotheses #1 and #2 were supported, finding significant differences from pre‐ to post‐survey in the YPAR participant group and comparatively between the intervention and comparison groups. Regarding opioid knowledge, behavior, and stigma, there was a nonsignificant increase in substance use stigma among YPAR participants from pre‐ to post‐survey. Unfortunately, the stigma scale reliability was poor among the comparison group, so group comparison was not conducted. Prior research on adolescent substance use stigma has found levels of stigma shift developmentally in a curvilinear fashion, with stigma levels declining from early to late adolescence before tapering off—likely a factor in the current study (Adlaf et al., 2009). Stigma was addressed across all YPAR sites with an “Opioid 101” training. However, some sites used other approaches known to be effective in reducing substance use stigma, such as hearing from individuals with lived experience (Livingston et al., 2012). When comparing YPAR participants to the comparison group, a nonsignificant difference emerged in the likelihood of engaging in opioid prescription safety behaviors. Prior research suggests adolescents may have limited knowledge about specific opioid medications but generally have an understanding of the risk of opioid addiction and overdose (Abraham et al., 2022).

Findings align with other substance use focused YPAR program evaluations, which found increases in knowledge of alcohol and tobacco (Helm, 2015; Valdez et al., 2020) and expand this study to opioids. This study is an important contribution to the field as the pathway to opioid use may look different compared to alcohol, tobacco, or cannabis. Although some risk factors for adolescent opioid use are similar to those for other substances, there are unique risk factors, such as receiving routine medical or dental pain treatment (Nawi et al., 2021; Rahmandar et al., 2021). Adolescents who use nonmedical prescription opioids are more likely to also use other substances, including alcohol, cannabis, and methamphetamines (Bhatia et al., 2020). Therefore, using a YPAR approach to address opioids may also serve to address the use of other substances. Prior research on YPAR has demonstrated an impact on shared risk and protective factors for substance use (Valdez et al., 2020) and even the use of substances over time. Berg et al. (2009) evaluated a YPAR project across four time points and identified a significant decrease in past 30‐day cannabis use and a nonsignificant decrease in alcohol use. Although we did not measure individual opioid use, we would expect findings to align with that of Berg and colleagues such that our short‐term impact of opioid knowledge and behavior, long‐term, is likely to help reduce opioid use.

Although there was not a formal qualitative evaluation, youth shared their experience through lesson activities and other informal conversations. In response, one youth from the Central site said, “I never realized how hard recovery is. This project helped us all realize that this is not a simple issue—it's extremely complicated. I'm going to keep doing my part by helping people learn to be more compassionate and give that helping hand.”

Lessons learned

The Take‐PART team reflected on their experience in the project and identified lessons learned that contributed to its success, including (a) a project team made up of campus‐based faculty, community‐based Extension faculty, and staff across the state; (b) the importance of maintaining flexibility across sites; and (c) compensating adolescents for their role in the project.

The first lesson learned related to the project team, which featured an important partnership between campus‐based faculty with expertise in adolescent development and prevention science and community‐based Extension faculty and staff with expertise in youth development, health promotion, and program facilitation. This campus‐community partnership was instrumental in providing adolescents access to expertise and resources, including additional information and instruction from faculty in areas of medicine, pharmacology, neurobiology, and addiction. Pairing this support with community‐based Extension faculty and staff meant access to local partners (e.g., chemical dependency counselors, physicians, youth advocates) who could speak to the issues adolescents were seeing and experiencing in their own communities. These local partnerships also helped to facilitate the sharing of YPAR projects in local venues, such as farmers markets, county fairs, and local government (e.g., county courthouse), thereby enhancing the project's reach and impact.

The second lesson learned was about the importance of flexibility in YPAR program delivery. YPAR delivery across all sites took place between November 2020 and August 2021, which means varying COVID‐related restrictions were in place. Although the same YPAR approach was used across sites, there was flexibility in how YPAR was delivered to accommodate local restrictions and context. For example, the Central site convened once a week online at a time when adolescents were engaging in schoolwork at home via computer. YPAR, at this point in time, likely provided adolescents with a way to connect and engage with peers outside of school‐based work. Conversely, the Western site integrated YPAR into an existing youth leadership program, delivering it in person via 1‐h meetings 4 days a week for 5 weeks. This approach not only increased accessibility for youth but also demonstrated the practicality of implementing YPAR in a variety of settings. All sites followed the YPAR curriculum and ensured all core components of YPAR were present. This flexibility is a hallmark of YPAR—it can be used in a way that best fits the adolescents, adults, and the setting in which they are in (Malorni et al., 2022).

The final lesson learned was the value of compensating adolescents for their time. Each site compensated adolescents differently, but all provided monetary compensation to adolescent YPAR participants, which aligns with best practices for authentic youth engagement (Pineda, 2022). For example, the Central and Eastern sites hired adolescent YPAR participants as interns and paid them a stipend for their participation in the program. The paid internship approach benefited recruitment, retention, and role legitimization. Those sites also provided free 4‐H enrollment by covering the annual membership cost (valued at $25).

Limitations

The current study has several limitations, including the COVID‐19 pandemic, a small sample size, differences in YPAR implementation across sites, and a post‐survey‐only comparison group. Across sites, YPAR was delivered between November 2020 and July 2021. This timing coincides with the COVID‐19 pandemic and related restrictions. As a result, the program format varied by site due to public health guidance: the Central site, which started first, was primarily virtual, the Eastern site hybrid, and the Western site, which began last, was in‐person. The pandemic impacted how youth engaged in the current study and influenced the broader social‐emotional context in which youth participated. During this period, youth nationally and globally reported greater psychological distress (Gotlib et al., 2023; Panchal et al., 2023). Personnel at the Central site anecdotally reported increased recruitment interest in this series compared to previous local YPAR implementations, sharing the experience provided youth a sense of connection and belonging at a time when they faced heightened isolation. This broader social context may have influenced differences in group findings. The absence of a control‐group intervention limits the study's ability to attribute observed effects to the YPAR process itself rather than to general engagement or social interaction.

Thoughtfully engaging youth requires significant resources and time, including facilitation by adults trained in adolescent development and effective youth engagement. In the current study, multiple adult partners at each site worked closely with small groups of youth. As a result, the sample size for each YPAR site implementation was small, limiting both the generalizability of findings and the capacity for rigorous statistical evaluation. In addition, youth within each site could be more similar to one another than youth at other sites, which was not accounted for in the current study. Since YPAR is an approach and not a prescribed curriculum, each site tailored YPAR delivery to its specific context. While all sites intentionally included YPAR core components, the variability in delivery may have impacted outcomes. Comparisons between YPAR sites were not performed as the small sample size and variability in delivery may limit the ability to draw meaningful conclusions from observed differences between sites. Finally, participation in the comparison group was limited, which constrained the strength of our comparative analyses.

Future research should conduct a more rigorous evaluation with a control group to more confidently attribute changes in outcomes to YPAR participation. Additionally, further studies on YPAR focused on opioid use are warranted to evaluate implementation outcomes, such as dose, duration, setting, and specific content elements. Despite these limitations, hypotheses were supported and contributed to the broader literature on the effectiveness of YPAR on substance use outcomes.

CONCLUSION

Effectively addressing the opioid crisis will require community‐driven approaches to substance misuse grounded in evidence and a concerted focus on prevention. The current study expanded limited available information on how to engage youth and communities in the development of opioid misuse prevention efforts (Perry et al., 2023), showing the positive impacts of an opioid‐focused YPAR project on adolescent empowerment and outcomes known to protect against opioid misuse. This study identified lessons learned to support others in meaningfully engaging adolescents to address issues impacting their community. As seen in this study, YPAR is an approach that can bring together community members, positively leverage the unique developmental stage of adolescence, and create positive changes in opioid misuse‐related outcomes and fundamental mechanisms of change for both individuals and communities.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

This study was reviewed and approved by the Washington State University Institutional Review Board (approval no. 18752). Caregivers of participants provided written informed consent prior to before adolescent enrollment in the study. Youth participants provided verbal assent prior to before participation in the study.

REFEREES

(1) Emily Ozer, University of California, Berkeley, eozer@berkeley.edu; (2) Elizabeth S. Valdez, University of Arizona, salerno@email.arizona.edu; (3) Parissa Ballard, Wake Forest University, pballard@wakehealth.edu; (4) Michelle Abraczinskas, University of Florida, mabraczinskas@ufl.edu.

Weybright, E. H. , Hampilos, K. , White, A. J. , Grinstead, C. , Fees, J. , Greer, M. , Doering, E. L. , & Graham, L. M. (2025). “I never realized how hard recovery is.” A quasi‐experimental evaluation of a youth participatory action research project for opioid prevention. American Journal of Community Psychology, 76, 396–407. 10.1002/ajcp.70001

DATA AVAILABILITY STATEMENT

Research data are not shared.