A Participatory Process to Engage Appalachian Youth in Reducing Sugar-Sweetened Beverage Consumption

Abstract

Children and adolescents consume excessive amounts of sugar-sweetened beverages (SSBs), which are associated with adverse health outcomes. We describe a yearlong participatory research study to reduce SSBs in Central Appalachia, where excessive consumption is particularly prevalent. This study was conducted in partnership with a community advisory board in Southwest Virginia. Nine “youth ambassadors,” aged 10 to 13 years helped to systematically adapt SIPsmartER, an effective theory-based program for Appalachian adults, to be age and culturally appropriate and meet desired theoretical objectives. They then assisted with delivering the curriculum during a school-based feasibility study and led an advocacy event in their community. Satisfaction surveys and feedback sessions indicate that ambassadors found the program acceptable and important for other students. Validated surveys and focus groups suggested that theoretical objectives were met. Findings from these mixed methods sources informed curricular changes to further enhance acceptability and refine theoretical objectives. Participation in follow-up advocacy activities was tracked and described. Following the yearlong study, ambassadors reported having advocacy skills and motivation to continue reducing SSB intake in their community. Results, challenges, and lessons learned are presented to inform larger efforts to enhance acceptability of programs and inspire youth to take action to reduce health disparities in Appalachian communities.

INTRODUCTION

Excessive sugar-sweetened beverages (SSBs; soft drinks, energy/sports drinks, sweetened fruit drinks/tea/coffee/milk) consumption is an established determinant of childhood obesity and increases risk for Type II diabetes, cardiovascular disease, and poor oral health outcomes (Malik, Pan, Willett, & Hu, 2013; Tahmassebi, Duggal, Malik-Kotru, & Curzon, 2006). U.S. children and adolescents consume approximately 155 kcals/day, representing 8% of their daily caloric intake (Kit, Fakhouri, Park, Nielsen, & Ogden, 2013). Given this, SSBs have been the target of various intervention strategies across the socioecological spectrum for over a decade (Lane, Porter, Estabrooks, & Zoellner, 2016; Vargas-Garcia et al., 2017).

Many strategies have shown promise (Lane et al., 2016; Malik et al., 2013; Vargas-Garcia et al., 2017); however, few have been translated to low-income and rural children/adolescents, who consume disproportionate amounts and are at increased risk for obesity-related diseases (Lane et al., 2016; Wang, Bleich, & Gortmaker, 2008). These subgroups experience unique challenges that may preclude implementation of effective strategies to reduce SSBs. Youth participatory methods, which engage children/adolescents in formative development, implementation, and evaluation of initiatives, can address these challenges (Langhout & Thomas, 2010; Millstein & Sallis, 2011). This article describes a participatory research project with middle school “youth ambassadors”, in a Central Appalachian county in Southwest Virginia.

BACKGROUND

Health Disparities in Central Appalachia

Central Appalachia includes parts of Kentucky, Tennessee, West Virginia, and Virginia and is disproportionately affected by poverty, low educational attainment, and limited access to medical care (Halverson & Bischak, 2008; Health Resources & Services Administration, 2011; Pollard & Jacobsen, 2017; Robert Wood Johnson Foundation, 2016). When compared to non-Appalachian counties, Appalachian counties of Virginia experience disproportionate rates of poor oral health, heart disease, diabetes, and childhood obesity (McGarvey, Leon-Verdin, Killos, Guterbock, & Cohn, 2010; Pollard & Jacobsen, 2017; Robert Wood Johnson Foundation, 2016). The county where this study occurred ranks 129 of 134 in Virginia’s 2016 County Health Rankings (Robert Wood Johnson Foundation, 2016). It is a designated medically underserved area, the unemployment rate is nearly twice the state rate (9.8% vs. 5.5%), and 33% of children live in poverty (Health Resources & Services Administration, 2011; Robert Wood Johnson Foundation, 2016).

Furthermore, regional surveys suggest that Appalachian children consume three to four times the amount of SSBs as their non-Appalachian counterparts (Harris, 2013; Lane et al., 2017; Oza-Frank, Norton, Scarpitti, Wapner, & Conrey, 2011). This pronounced disparity is a significant but modifiable contributor to disproportionate disease rates. Appalachia’s unique SSB norms (i.e., “sipping soda throughout the day” and a preference for citric acid drinks), geographic isolation, skepticism of outside programs, and lack of medical/dental infrastructure have exacerbated disparities and limited efforts to reduce SSBs (Halverson & Bischak, 2008; Harris, 2009; Smith, Valenzuela, & Ludke, 2012). Thus, an intervention specifically targeting local SSB norms, accessibility, and behaviors among adolescents could have a significant impact on health disparities in this underserved region.

Formative Research to Inform an SSB Intervention for Appalachian Adolescents

Effective SSB interventions are sparse in Appalachia, with only one known study conducted in the region with a small sample of high school students (Lane et al., 2016; Smith & Holloman, 2014); thus, there is little evidence to guide development of an intervention for adolescents. Formative research is needed to ensure that the intervention addresses region-specific factors hypothesized to influence SSB behaviors and, as recommended for effective health promotion for adolescents, actually addresses the theoretical constructs on which it is guided (Peters, Kok, Ten Dam, Buijs, & Paulussen, 2009).

Youth Participatory Methods During Formative Research

Youth participatory research methods, which draw on expertise of both researchers and adolescent community members, can ensure that the intervention is theoretically grounded, addresses norms and behaviors and is accepted by the community (Bardwell et al., 2009; Israel, Schulz, Parker, & Becker, 1998; Jacquez, Vaughn, & Wagner, 2012; Langhout & Thomas, 2010; Millstein & Sallis, 2011; Smith et al., 2014). As adolescents interact with their peers and are in their community daily, they are best able to recognize personal and community health needs. Involving youth throughout intervention development and delivery can generate enthusiasm and buy-in. Finally, sustained youth participation can strengthen participants’ skills, capacity, and motivation to be “change agents” to reduce SSB consumption and improve chronic disease in their community (Langhout & Thomas, 2010; Millstein & Sallis, 2011).

Despite these advantages, participatory methods are infrequently used or formally evaluated. Furthermore, few studies have assessed the longer term impact of participation on adolescents’ skills, behaviors, and capacity to be agents of change (Jacquez et al., 2012; Langhout & Thomas, 2010). Two studies in Appalachia reported behavior-related outcomes of participatory research projects with high school students (Bardwell et al., 2009; Smith et al., 2014) but did not evaluate the impact of participation on students’ skills or capacity. These studies demonstrate the feasibility of using participatory methods for intervention development in Appalachia and suggest the need to describe the impact of such methods on younger, adolescent participants.

Study Purpose

This article describes a participatory process in which a group of middle school youth ambassadors (n = 9) were engaged in (1) formative development, including testing acceptability and theoretical basis, of Kids SIPsmartER (KSS), an intervention targeting SSB behaviors and (2) subsequent advocacy efforts in their school and community. It also describes (3) the extent to which engagement in these participatory efforts affected ambassadors’ perceptions of their community’s health and their role in improving it. Lessons learned, limitations, and recommendations are provided to enable replication in similar at-risk populations.

METHOD

Formative Development: Acceptability/Theoretical Basis Testing of Kids SIPsmartER

In fall 2014, a regional community advisory board (CAB) first identified the need to address the region’s SSB burden and prioritized community needs (Israel et al., 1998). Needs included school-based programming for adolescents and parents, changes to community norms, policies to reduce SSB access, and changes to oral health infrastructure. The CAB’s first step was recruiting a group of middle schoolers to help address some of these needs. CAB members asked middle school principals to refer motivated students to be youth ambassadors. Figure 1 describes ambassadors’ activities during 2015 to 2016.

FIGURE 1. time line of Youth ambassador Participation and activities during a Yearlong Participatory research Project 2015–2016.

NOTE: SSB = sugar-sweetened beverage.

Prior to student involvement, the research team adapted SIPsmartER, an effective behavioral intervention among Appalachian adults, to be appropriate for adolescents and meet CAB priorities (Zoellner et al., 2014; Zoellner et al., 2016). SIPsmartER was grounded in theory of planned behavior (TPB) and health and media literacy and included 3 small-group classes, a “teachback” call, and 11 phone calls over 6 months. A total of 301 adults in 8 counties participated in a group randomized trial. Intervention participants reduced SSB consumption by 227 kcal/day, compared to a 54 kcal/day reduction among control participants (p < .001; Zoellner et al., 2016). KSS was adapted to include shorter, more frequent lessons with age-appropriate activities that could be delivered in a classroom setting. Lessons were similarly grounded in TPB and emphasized media literacy principles, with the addition of public health literacy concepts. KSS builds skills for individual-level behavior change while supporting efforts to generate community-level changes around SSBs. The TPB posits that an individual’s intention to disengage in drinking SSBs is predicted by that individual’s SSB-specific attitudes, perceived behavioral control, and subjective norms (Ajzen, 1991; Hackman & Knowlden, 2014; Riebl et al., 2015). TPB provides foundational guidance for reducing individual SSB intake; however, it may be insufficient for community-level change. Combining TPB with media literacy and public health literacy, which encourages understanding, evaluating, and acting on information needed to make public health decisions that benefit one’s community, can provide adolescents with knowledge, skills, and behaviors to both reduce their own SSB consumption and be community “change agents” (Freedman et al., 2009). For example, KSS targeted perceived behavioral control through a discussion with students about the personal, social, and environmental facilitators/barriers that affect their sugary drink intake, then extended that discussion to include barriers/facilitators that affect their peers, family, neighbors, and community (Lane et al., 2017).

Following initial curriculum development, ambassadors were recruited by school principals to attend a 3-day summer camp and provide feedback to strengthen theoretical targets, test evaluation measures, and determine the acceptability of KSS. The camp was centrally located and transportation was provided. Ambassadors learned that they had been invited as peer leaders to help make KSS fun, engaging, and informative before it was delivered in schools. To elicit feedback on the KSS lessons, camp activities included (1) delivery of the six 1-hour KSS lessons by two researchers, which were each followed by a “debrief” session, where ambassadors gave written and oral feedback on the lesson they had just received and (2) focus groups and surveys before Lesson 1 and following Lesson 6 to evaluate theoretical constructs. During the camp, ambassadors expressed interest in continuing involvement in their school and community. Thus, a fourth activity consisted of brainstorming future events.

Acceptability of KSS was assessed by satisfaction surveys and debrief discussions after each lesson. Surveys were adapted from an existing instrument and consisted of 10 Likert-type response statements and 4 open-ended questions (Ansell et al., 2008). Participants answered the surveys individually, then engaged in a structured ~15- to 20-minute discussion based on open-ended questions (i.e., if you could change one thing about this activity, what would it be?).

The extent to which KSS targeted desired theoretical constructs (i.e., attitudes, perceived behavioral control, subjective norms, media literacy, public health literacy) was assessed through pre–post surveys with Likert-type responses and scripted, pre–post focus groups. Quantitative measures were adapted from validated surveys, and focus group scripts were developed based on TPB/public health literacy constructs (Chen, Porter, Estabrooks, & Zoellner, 2016; The Colorado Trust, 2004; Freedman et al., 2009; Riebl et al., 2016; Rogers et al., 2014; Zoellner, Estabrooks, Davy, Chen, & You, 2012; Zoellner et al., 2014). Two hour-long audio-recorded focus groups were conducted by trained researchers, with students separated by age. These focus groups were designed to be age appropriate and engage each participant by incorporating hands-on activities, such as sorting drinks into categories and drawing scenarios in which they might drink an SSB (Agar et al., 2005; Krueger & Casey, 2000).

School and Community Advocacy Activities

During the subsequent school year, the ambassadors continued their involvement with the research team to carry out activities they had brainstormed at camp. Additional measures were developed to evaluate these activities and track participation, including attendance logs, interactions with community members, and field notes.

Ambassadors’ Perceptions of Their Role in the Community

To assess ambassadors’ perceptions of their community as well as their perceived contribution to improving their community’s health after their participation, they completed an exit survey (Ansell et al., 2008) and interview conducted by a researcher who was unaffiliated with the project. Surveys and interviews were conducted after all activities were completed.

This study was approved by the Virginia Tech Institutional Review Board. Ambassadors assented to participate, and their guardians provided signed consent.

Data Analysis

Quantitative data were analyzed using SPSS Version 22.0 for Mac. Descriptive statistics (means and standard deviations) described results from satisfaction surveys. Pre–post camp surveys were analyzed using paired t tests to assess changes in mean scores for theory variables. Exit surveys were also analyzed descriptively. Qualitative analysis was conducted using a deductive approach, whereby data were coded based on TPB and public health literacy constructs. Transcripts from camp focus groups and exit interviews were transcribed verbatim and entered in NVivo 11. Two student researchers were trained to thoroughly read transcripts and independently generate themes/subthemes based on the coding framework, then met to reach consensus on emerging themes (Krueger & Casey, 2000; Zoellner et al., 2012).

RESULTS

Formative Development: Acceptability/Theoretical Basis Testing of Kids SIPsmartER

Of 20 recommended students, 13 attended at least one camp activity. Four withdrew due to a scheduling conflict, and nine attended all three days (gender: six girls, three boys; age: five sixth graders, one seventh grader, three eighth graders). Students received a $50 gift card, passes to a local pool, and participation certificates.

According to satisfaction survey results, ambassadors understood and liked the lessons, felt they were important, and thought their classmates would also enjoy them (Table 1). Ambassadors felt that they were able to freely share their thoughts and opinions. They were confident that they could be role models and share what they learned with family/friends. Debrief sessions led to many curricular changes. For example, the ambassadors felt most confident when they acted out “realistic” scenarios, so a new role-play activity was added incorporating community locations where they saw high prevalence of SSBs, such as the county fair. Additionally, the health-related content was refocused to more distal disease outcomes (i.e., diabetes) due to their concern that their classmates might be sensitive about discussing weight. They also provided suggestions for clarity on survey instruments. For example, one ambassador’s confusion about “soft drinks” on the survey led to revising the term to “soda/pop.”

TABLE 1.

Youth ambassador Quantitative results: theoretical Variables, Satisfactions Surveys, and exit Surveys

Theoretical Variables (n = 9)	Precamp, M (SD)	Postcamp, M (SD)
Variable (Likert-type scale 1–5)
Attitudes	3.22 (0.37)	3.69 (0.34)*
Subjective norms	4.04 (0.54)	3.89 (0.55)
Perceived behavioral control	3.93 (0.60)	4.33 (0.60)
Behavioral intentions	3.42 (0.80)	3.50 (0.86)
Media literacy	3.83 (0.41)	4.60 (0.37)**
Public health literacy	3.24 (0.63)	4.07 (0.41)*
Satisfaction Surveys (n = 9)		M (SD)a
Questions (1 = Not at all to 5 = Very much)
During this lesson, the instructors used words I could understand.	—	4.88 (0.16)
I learned something new from this lesson.	—	4.83 (0.28)
I liked doing this lesson.	—	4.79 (0.23)
My friends and classmates would like this lesson.	—	4.40 (0.49)
I think this lesson is important for my friends and classmates to learn about.	—	4.83 (0.28)
During this lesson, I was able to share my ideas and feelings.	—	4.88 (0.16)
I feel like I can be a role model by telling people what I know about the lesson topic.	—	4.42 (0.75)
Exit Surveys (n = 5)		M (SD)
After being an ambassador … (1 = Never to 5 = Always)
I am better at standing up for what I believe.	—	4.20 (0.45)
I am more interested in community and world problems.	—	3.80 (0.84)
I feel better about myself.	—	4.00 (1.00)
I learned I can do things I didn’t think I could do before.	—	4.40 (0.89)
I believe I can make a difference in the world.	—	3.60 (0.89)
I care about making the world a better place for everyone.	—	4.80 (0.45)
It is important for me to try to make a difference in the world.	—	4.80 (0.45)
I want to use what I have learned as an ambassador to help others be healthier.	—	4.80 (0.45)

^aThis is a mean score across responses for all six lessons.

^*p < .05 (paired t test).

^**p < .001 (paired t test).

Theoretical constructs were tested through pre/post surveys and focus groups among the nine ambassadors who attended all camp activities. Ambassadors significantly improved SSB-related attitudes (p = .05), media literacy (p < .001), and public health literacy (p = .011) (Table 1). Data from the postcamp focus groups corroborate many of these findings, suggesting that desired theoretical objectives were met (themes described in Table 2). Regarding attitudes, the ambassadors indicated that they had known SSBs were not healthy but did not realize how unhealthy and had never thought concretely about the personal or community consequences. For public health literacy, all acknowledged that SSBs were a problem, but not everyone perceived it to be more prevalent in their community compared to others. They recognized environmental factors that contribute to high consumption, including excessive availability, affordability, and demand. Most thought the problem was preventable and that they could help. They perceived communicating messages about the harms of SSBs throughout their community as a means to decrease demand. Some had ideas for what these messages might say, while others did not know where to start. They also suggested environmental changes but were less sure about their role in influencing those changes. As they discussed ideas, confidence that they could make meaningful changes became more apparent.

TABLE 2.

Youth ambassador Qualitative results: camp Focus groups and exit Interviews

Construct (Definition)	Themes	Sample Quotes (Theme)
Precamp focus group (n = 13) (Barriers and facilitators)
Attitudes (Reasons why people drink or do not drink SSBs)	Health Availability/access Habit/preference Advertised incentives	“They like the taste of it.” (Habit/preference) “They’re on a diet” (Health, why don’t drink)
Perceived behavioral control (Things that might make you decide to drink sugary drinks)	Peer pressure Parent restrictions Access/availability Habit/preference	“I can’t (am not allowed to) have more than two cans of Coke or soda a day” (Parent restrictions)
Subjective norms (Reasons that family and friends drink SSBs and support drinking fewer)	Addiction Lack of rules Parent support Lack of friend support	“They (friends) would laugh at me.” (Lack of friend support) “My mommy would help, she wouldn’t buy them.” (Parent support)
Intentions (Thoughts about drinking fewer and things that might make it hard or easy)	Availability/access Preference for alternatives Addiction parental/doctor restrictions	“The rules, I’m not allowed” (Parent restrictions make it easier) “All that’s (in the store) is pop or sweet tea, you have to go to the back to get water (Availability makes it harder)
Postcamp focus group (n = 9) (Theoretical constructs targeted by the intervention)
Attitudes (New reasons why people drink or do not drink SSBs)	Knowledge of health effects Awareness of community scope	“I realized how much people drink pop and how bad it is for you, everybody drinks it” (Awareness)
Intentions (post) (Thoughts about drinking fewer and things that make it hard or easy)	Intent to change No change in perceived barriers/facilitators	“I usually drink like 2 cans of pop a day, but now I’m gonna drink one.” (Intent to change) “Because I like it, like that is probably what I’m not gonna like the most [about cutting back] … it tastes really good” (Habit/preference)
Conceptual foundations (Recognize public health problems caused by too many sugary drinks)	Prevalent public health problem Ecological perspective	“At the dollar store, at the first of the month, they’ll have a big pop sale, like buy two big bottles get one free” (prevalence)
Critical skills (Interpreting information and communicating messages to reduce SSBs)	Communicating messages Supply/demand	“They should raise the price, like $100 for a carton” (supply and demand) “I would like to go to the (principal) and ask if we can go in the auditorium and tell the whole school all these effects.” (Communicating messages)
Civic orientation (Understanding burden of SSBs and ways to take action)	Unware of disproportionate burden Perceived lack of inevitability Self-efficacy for action	“After we have made a change, I’d like to see a lot of pop (in stores) cause no ones’s buying it, and no water cause everyone’s buying it.” (Lack of inevitability; efficacy for action)
Exit interview (n = 5) (Perceptions of community’s health and their role)
Perceptions of community’s health	Prevalence of problem	“A lot of people do have diabetes and other health situations that sugary drinks caused”
Perceptions of their role in changing it	Barriers to communication Self-efficacy for communication and action	“Before, I wasn’t really heard on my opinion and no one like really cared … but after [VT] came … everyone was asking me questions, like, how am I supposed to find out how much sugar is in this drink … and now I can tell them” (Self-efficacy for communication) “With this program I’ve learnt ways that you can stop people from (drinking SSBs), or help people to stop drinking so much” (self-efficacy for action)

NOTE: SSB = sugar-sweetened beverage.

Some survey findings (Table 1) were contradicted by the follow-up focus group (Table 2). For example, survey data indicated that there were no significant changes in intention; however, most ambassadors indicated that they intended to cut back on SSBs.

Focus groups revealed TPB-related barriers/facilitators to drinking fewer SSBs to address in the intervention. Barriers included widespread availability at home and in the community, parental/peer influence, and habit/taste preference. Along with proposing community-level solutions described above, ambassadors also proposed facilitators that might make SSB reduction easier at an individual/interpersonal level, including parental restrictions and making water more easily accessible than SSBs at home (i.e., displaying water at eye level).

School and Community Advocacy Activities

During the camp brainstorming session, the ambassadors discussed various ideas to communicate knowledge and use skills they had learned (i.e., role-playing/improvisation), including helping deliver the curriculum to peers, holding a school assembly, distributing water bottles, and hosting an event in a public setting. During the 2015–2016 school year, ambassadors met approximately weekly after school to plan and carry out two of these ideas. Meeting attendance ranged from four to seven students.

First, they assisted with pilot testing after the curriculum was refined using their feedback. Pilot testing occurred at an elementary/middle school attended by six of the nine ambasssadors (Lane et al., 2017). The program was delivered to sixth- and seventh-grade science classes during the 2015–2016 schoolyear. During first semester, students received KSS or a matched-contact physical activity program once/week for 6 weeks. During second semester, they received the other program over 6 weeks. Parents received weekly phone calls to reinforce lesson concepts both semesters (12 weeks total). Students in KSS reduced SSB intake by 12.2 (SD = 25.5) ounces. Additionally, they significantly improved media (p < .001) and public health (p < .05) literacy compared with matched-contact participants (p < .05) (Lane et al., 2017).

During pilot testing, ambassadors demonstrated their communication skills to help reach students and parents in two ways (1) they helped write and record parent phone calls and (2) wrote/filmed a public service announcement (PSA) to air as an example for students during the media literacy lesson. Ambassadors recorded calls on 6/12 weeks—during the other weeks, the ambassadors did not meet or worked on other projects. The PSA featured a boy who had trouble concentrating in class until he started drinking water instead of soda. It incorporated a tangible outcome of SSB consumption (trouble concentrating), a barrier to drinking less (not liking water), a strategy to overcome this barrier (drinking it with friends), and a benefit to reducing consumption (better grades). This PSA was developed over 5 weeks. Figure 2 shows a screenshot.

FIGURE 2.

Screenshot From the Public Service announcement created and Filmed by ambassadors Participating in a Yearlong Participatory research Project 2015–2016; Final Iteration of “Stop the Sugar and go get Healthy” Flyer for community grocery Store event

Second, the ambassadors planned a community advocacy event at a local grocery store. The ambassadors guided discussions about where to hold the event and what materials to develop, while the research team took notes and facilitated discussion. Ambassadors decided on a local grocery store and designed a flyer to distribute. The research team drafted the flyer to ensure that it used accurate, evidence-based messages, then the ambassadors gave feedback on the cultural acceptability for several iterations (Figure 2). The research team developed a protocol for ambassadors to track how many individuals they approached at the event.

Seven of nine ambassadors attended the grocery store event. They distributed flyers and sugar-free hot chocolate samples and set-up a table with SSB-related activities. Tracking sheets indicated that they distributed ~90 flyers and ~50 sugar-free hot chocolate samples. Seven individuals declined the flyer, and no one declined the samples. Ambassadors were surprised at how much SSBs they observed people buying. Several had stories about talking to unfriendly customers or being ignored, but most had “success stories.”

You know what the highlight of my day was? I was talking to this lady with her daughter. They had a bunch of pop in their cart and I talked and handed her the flyer and I saw her reading it … she said her daughter had just got diagnosed with diabetes … then when I saw her later she had put back a bunch of the pop!

Ambassadors’ Perceptions of Their Role in the Community

Five ambassadors completed exit surveys and interviews (Tables 1 and 2). In general, ambassadors reported learning more about the excessive intake of SSBs throughout their community and associated SSB consumption with adverse health consequences. All stated their confidence that they could make a difference and help reduce the problem long-term. While some recalled that not all responses they received when communicating with community members or classmates were positive, all felt they had already made a difference.

They wanted to continue advocating in their school/community by communicating messages through flyers or advertising and helping with environmental changes, such as putting more water in the vending machines or making SSBs less accessible. They wanted to continue being role models for their friends/family and reduce their own intake. They felt that being ambassadors had helped them gain skills and self-efficacy to be advocates.

DISCUSSION

This study established the utility of a participatory process to engage adolescents in developing a theory-based, acceptable curriculum, which was then tested in a school and shown to reduce SSB consumption among participants. It offers methodology for involving adolescents in testing cultural acceptability and tailoring adolescent programs to fit within unique community contexts, such as Appalachia. Few studies have systematically assessed youth participation in intervention development, or the long-term impact of participation on their perceptions of their role as change agents (Israel et al., 1998; Jacquez et al., 2012). Furthermore, this study adds to a sparse body of evidence on participatory research methods for health promotion in Appalachian youth (Bardwell et al., 2009; Smith & Holloman, 2014) and provided insight into challenges to address with future studies that similarly engage adolescents in underserved communities.

This study used qualitative and quantitative measures to assess acceptability and theoretical basis of KSS. Satisfaction surveys and debrief sessions indicated that the curriculum was acceptable for this age range and informed changes to further improve acceptability. While pre/post survey and focus group findings should be interpreted within several limitations, including the short duration between pre- and poste-valuation (3 days) and the small sample size, findings align with prior diet-related TPB studies in that most, but not all, theoretical objectives were met (Hackman & Knowlden, 2014). Ambassadors significantly improved SSB-related attitudes, media literacy, and public health literacy. Furthermore, they identified key barriers/facilitators that strengthened the theoretical foundation of KSS and allowed for inclusion of better examples to address perceived behavioral control, subjective norms, and intentions.

This study also demonstrated the potential of a participatory process to build participants’ skills and motivation related to changing both individual- and community-level health behaviors. After demonstrating public health literacy skills during camp, ambassadors successfully communicated the harms of SSBs at a community location, over the phone, and via PSA. Planning and implementing these events helped them understand the depth of the problem in their community and inspired them to want to continue being advocates. Several ambassadors attended a CAB meeting in Summer 2016 to describe how participation had changed their behaviors and perceptions. CAB members remarked on the clear impact the program had on the ambassadors, which renewed their interest in sustained efforts. Thus, the ambassadors inspired CAB members to continue supporting school-based SSB programming. Our findings generated buy-in from CAB members as well as applications for funding to implement, evaluate, and sustain a scaled-up “youth ambassador” model in middle schools throughout Central Appalachia.

Lessons Learned

Challenges in this study included our inability to accomplish all of the ambassadors’ brainstormed activities due primarily to geographic distance and lack of resources. Additionally, it was difficult to engage some ambassadors after camp who attended different schools or had competing commitments. Notably, all eighth graders were lost to follow up after advancing to high school and completed few activities after camp. In contrast, all sixth and seventh graders participated in the pilot study and community event and all but one completed the follow-up interview. Future efforts should expand retention efforts to ensure that all students can continue participation.

Additionally, our uncertainty regarding the continued level of involvement of our ambassadors limited the scope of our evaluation plan for school/community activities. Future studies should establish measures a priori to assess participants’ perceptions and skills as it relates to influencing changes at a peer, family, and/or community level. This evaluation should use a mixed-methods approach to fully describe barriers, implementation challenges, and outcomes (Creswell & Plano Clark, 2010; Zoellner & Harris, 2017). Participant reach/retention should be prioritized throughout projects.

Despite these challenges, this study benefitted from productive relationships with both the adult CAB members and the ambassadors themselves. These relationships are particularly important in regions that are difficult to access and/or have unique cultural norms. Advisory boards consisting of local, invested individuals can help identify community advocacy needs and facilitate frequent, sustainable efforts to reduce obesity-related disparities (Israel et al., 1998; Smith et al., 2012). In our study, involvement of adolescents and adult CAB members enabled us to conduct the school-based feasibility study and apply for additional funding.

Conclusion

This project focused on developing a culturally appropriate curriculum designed to reduce SSBs in Appalachia by providing adolescents with the knowledge, skills, and motivation to become role models and advocates for their friends, family, and community. KSS was found to be acceptable among adolescent community members and subsequently was found to reduce SSB consumption during a pilot study. These findings have promoted local support and resource gathering and for broad uptake of the curriculum across the region. Furthermore, the process described is not specific to SSBs and can transcend health promotion efforts in at-risk populations. By providing successes, difficulties, and lessons learned, we hope to inform future efforts to empower adolescents, implement sustainable and relevant programs, and ultimately, reduce the disproportionate burden of disease in medically underserved communities.